On Cholera in Iraq – and What Prevented It from Spreading Further into the Region
Iraq, November 2015. It has already been two months since cholera broke out in the Bagdad region. Speaking with news agency Reuters, Peter Hawkins, UNICEF’s Iraq director, expresses his fear that the infectious disease might spread to neighboring countries such as Kuwait and Bahrain. Six months later Follow Up talks with Jeffrey Bates, Chief Communications Officer at UNICEF Iraq, about the reasons for these concerns. We also asked him what UNICEF did to prevent cholera from spreading further into the crisis-shaken region.
What were the consequences of the cholera outbreak that happened in Iraq last year?
We ended up with a total 3,000 cases confirmed in the national laboratory but there were only two confirmed deaths. So, all in all, the mortality rate for this outbreak was much lower than you would have anticipated given the number of confirmed cases.
Was this due to the measures that UNICEF took?
It’s always hard to say exactly what did it – maybe if we did nothing, cholera would disappear. But you can look historically at the number of cases during previous outbreaks and compare the types of response. And if you use the history to extrapolate, you would have expected a lot more cases. However, you can measure how many people were exposed to cholera prevention messages, how many people who were exposed to messages changed their behavior such as boiling water. The only thing you can say for sure at the end of that is: “We had a plan, we put it in place with the objective of decreasing or stopping cases, then cases decreased, therefore we suspect our plan was helpful in doing that.”
What did you do to mitigate the risks of the cholera outbreak?
There were a number of measures put in place within 48 hours in collaboration with agencies such as the World Health Organization and the ministries of health who had convened a cholera task force. UNICEF focused on improving water sanitation systems and providing supplies such as oral rehydration solutions and salts. We also started a mass communication campaign which helped people understand how cholera is transmitted, mechanisms for prevention, but also, early danger sign recognition. With medical interventions, such as drips, you can reduce mortality rates from sometimes up to 30% to about 1% – 2%, so it was important for people to know symptoms so they could get treatment.
“We had a plan, we put it in place with the objective of decreasing or stopping cases, then cases decreased, therefore we suspect our plan was helpful in doing that.”
Did the cholera outbreak last year come as a surprise?
No, it was anticipated. Iraq is a cholera endemic country with outbreaks happing about every three to four years. It is not known really why cholera outbreaks follow this pattern here, but most diseases do have predictable times or cycles when we expect more cases. Because the previous outbreak was in 2012, and the one before that in 2007, if we did not see cholera this year, it probably would have happened the next year.
Can you describe the typical course of the disease?
Cholera typically starts in September, peaks in October/November, and then trails out in December. And that’s exactly the epidemiological curve that we saw from last year’s outbreak. So in November, we were at the peak of the epidemic when the most people were likely at any one time to have been exposed and thus have the cholera bacteria in their gut.
One of the additional risks for the cholera to spread to neighbouring countries was Arbaeen, the Shia Muslim religious observance. There are about ten million people from different countries coming to Kerbala, south of Bagdad, every year.
The fear was that we were going to see a huge bump in the number of cases both in Iraq, but also in source countries if people carried the cholera bacteria home. But actually, we didn’t. Exact numbers are always difficult to measure but some people estimated up to 20 million came during Arbaeen. In anticipation of this pilgrimage, we put into place a lot of mitigation activities, such as mass public information messaging, a lot of key water sanitation facilities ensuring that the water people received was clean, that they had access to medical facilities. The result was that a huge number of people converged in Kerbala and left without really impacting or seeing a dramatic increase in cholera rates.
So was your fear unjustified?
The precautions were necessary as the consequences were potentially disastrous. Further, in this region, we have a lot of travel in and around the country – people travel for economic reasons, as refugees, to visit relatives. So this fear that the cholera could spread – and it did end up spreading to some neighboring countries – was very real. Fortunately, we didn’t see wide scale spreading, and the outbreak overall was smaller than previous outbreaks.
How do you monitor the course of an outbreak?
There are several ways that we do what we call “surveillance”. The primary health services in the village would record how many people come in with acute watery diarrhea, the main cholera symptom. There are normal expected incidence rates, which will increase during a cholera epidemic. If someone exhibits the signs, then you would count it as a likely cholera case. But the only way you can say for sure is if you get a laboratory confirmation. We have laboratories in Iraq at the governorate level, and there are 18 governments. They will send some samples to the national laboratory to verify them. So the ultimate verification is the national level laboratory because it has the highest control standards.
Are these laboratories working well, considering the unstable political situation in Iraq?
In Iraq we have a wide scale security crisis. In certain areas these laboratories might not be fully functional so surveillance results might not be accurate. So we can’t say for sure, particularly in areas that aren’t under government control, what was happening with the outbreak. We can only say for sure the numbers of cases in areas that we had access to laboratories, or could verify through laboratory confirmation.
The precautions were necessary as the consequences were potentially disastrous.
What role does money play for your work?
Money plays a very pivotal role because all of UNICEF’s activities have expenses related to them. Iraq is typically thought of as a middle to high-income country because of its oil exports. But the ongoing crisis and the conflict in Iraq have drained a lot from the economy. Also the lowering oil prices on the global economic market have really crippled the ability of the national government and regional governments to invest in these types of social activities.
Where do UNICEF’s resources come from?
For UNICEF, and the other UN agencies, we rely on donors to provide funding. The scope and the scale of what we’re facing requires immense investments. We just recently put out a call for over $500 million for the entire UN humanitarian response of which we’ve only so far gotten about 16% funded. Some of our major donors are the United States, the government of Germany, the government of Japan and the government of the United Kingdom. We have over 30 individual donors but these are some of our biggest ones. We also get funding from foundations or from private industry and civil society. However, their funding usually can’t reach the levels that governments can provide.
What is the health situation like in Iraq right now?
Cholera really is no longer a threat this year. However, we’re seeing huge numbers of people displaced in the current crisis – there are almost three and a half million people who have been forced to flee their homes and take up residence in other parts of Iraq where they don’t have access to facilities, and they don’t have access to the types of resources that they had at home. In many cases people had to flee their homes with only the clothes and what they could carry.
So in some areas we’re seeing an increase in malnutrition or micronutrient deficiency. We’re seeing, in some cases, children who are out working and being exposed to higher levels of hazards. The government and humanitarian workers are putting responses in place, but with such as large and prolong crisis, poor access to resources including food, along with the chronic stress of being displaced, is starting to take a toll, especially on the children – they’re much more vulnerable in these circumstances. So UNICEF and partners are trying to monitor growth rates, see if we have acute malnutrition in the form of a wasting, or chronic malnutrition in the form of stunting. And unfortunately, we are starting to see some indication that both of these are happening.
So is the danger of cholera gone now?
When you have an outbreak in the fall in Iraq, it’s often followed in the spring by a smaller-scale outbreak. So, the agencies and ministries of health were on the lookout for cholera cases this spring, which fortunately, we haven’t really confirmed for this season. April, May are the months that we would expect something to come up if it were to come up. And we’re in May right now and we haven’t had it. We are not out of the woods yet but it’s getting closer to the end of the period where we might see the spring outbreak. However, for the next couple of weeks, we have to maintain vigilance and our surveillance and be able to react and respond very rapidly if we do see an outbreak. Cholera will certainly happen again. So we need to be as ready as we can be to reduce the impact of that is what we’ll strive for.
We are not out of the woods yet.
At the end of April, there was an IS terrorist attack which killed almost 20 people. Protesters stormed Iraq’s parliament. How do political tensions affect your work?
We anticipate these sorts of things happening, so UNICEF has security measures in place to ensure all of our national and international staff are safe, and hopefully things will remain peaceful. Working in Iraq can be stressful, when you’re working in chronic crisis situations and the need to respond consistently situations which you might not be able to predict. There are a lot of people, nearly 10 million, who need humanitarian assistance, so we have to be in a position to respond to their needs while also keeping ourselves healthy. But people come here knowing that this is a very intense job, and we try to ensure that we monitor staff well-being and see how they’re doing and ensure people get rest as they need.