How war sets the stage for epidemics

A cholera outbreak in Iraq is the latest in a long line of conflict-induced epidemics

For centuries, war has catalyzed the spread of infectious diseases, creating the ideal conditions for bacteria and viruses to tear through armies and civilian populations. In September 2015, a cholera epidemic began in Iraq, becoming the latest in a long line of diseases to bring war-torn populations to their knees.

Combat-fueled epidemics can be traced back to ancient Greece: the Plague of Athens, which is thought to have been epidemic typhus, returned three times during the Peloponnesian War, in 430 BC, 429 BC and 427-6 BC. Typhus has made an appearance in several wars since, notably during the English Civil War, the Thirty Years’ War and the Napoleonic Wars. Famously, more soldiers died of typhus than were killed by the Russians during Napoleon’s retreat from Moscow in 1812. Epidemic typhus also killed hundreds of thousands of people during World War II, infecting prisoners in Nazi concentration camps.

Cholera is also notoriously infectious. Starting in 1817, the disease travelled along the Ganges in India, killing hundreds of thousands of people; the British army alone reported 10,000 deaths. The disease had been carried port to port in kegs of water and the excrement of infected people. A decade after the epidemic started, cholera had become the most feared disease of its time.

During the American Civil War, 600,000 soldiers died, two-thirds of whom succumbed to infectious diseases. According to a review of medical records kept during the war (Bollet, 2004). Bad sanitary practices were to blame for the spread of disease; one commander dismissed inspectors’ complaints, saying “…an army camp is supposed to smell that way”. Doctors persevered and eventually their plea for better sanitation resulted in a decrease in the incidence of enteric diseases later in the war.

Although much has changed over the centuries, some constant aspects of warfare mean that conflict still provides the ideal conditions for epidemics to occur. Sanitation is one contributing factor, especially in refugee situations, where hygiene may not be ideal in camps. Infrastructure is often damaged, making it more difficult for people to seek medical care. The widespread deforestation and damage to infrastructure that occurred during the Vietnam War is thought to have led to a plague epidemic in the 1970s.

Movement of people also has a major impact on disease epidemiology. Soldiers move around, carrying equipment and diseases with them. Displaced people and migrants who move because of conflict can also hasten the spread of disease, either by taking disease with them to new places or by contracting diseases they have no immunity to. Today’s widespread migrations are only serving to facilitate the spread of infection, the results of which are all too apparent in Iraq.

Cholera outbreaks in Iraq

On 15 September 2015 the WHO received notification that there were confirmed cases of cholera in five Governorates in Iraq: Baghdad, Babylon, Najaf, Qadisiyyah and Muthanna. One week later the number of laboratory-confirmed cases had risen to 120. As of 8 October, this had risen to more than 1,200 cases of Vibrio cholerae 01 Inaba, which is thought to be spreading in the water, across 15 Governorates in the country.

This epidemic is not the first time Iraq has been hit by cholera. In 2007, there were more than 4,500 cases of cholera in Baghdad, with three deaths. The infectious agent was confirmed as Vibrio cholerae 01 Inaba. Complicating the epidemic further, the strain was resistant to trimethoprim-sulfamethoxazole.

In a paper published in the Eastern Mediterranean Health Journal (Khwaif & Yousif, 2010), epidemiologists noted the connection to sanitation and called for action: “Efforts are needed in Baghdad to establish safe drinking-water and proper sanitation as limited availability of tap-water and sewage contamination probably contributed to the spread of the disease.” Yet five years on, a new epidemic is threatening to reach similar levels.

One of the reasons for this is the sustained conflict in the country and the lack of coordination in the effort to improve health. In the article “Living conditions in Iraq: 10 years after the US-led invasion,” Rawaf et al. note that in the decade since the US invaded Iraq, the country has deteriorated in terms of people’s health, among other things. “In the early 1980s, Iraq was a middle-income and rapidly developing country with a well-developed health system,” said the authors. “A few decades later – after wars, sanctions and a violent sectarian upsurge – child and maternal health indicators have deteriorated, its poverty headcount index is at 22.9% and diseases such as cholera have remerged.”

Despite efforts to improve the health system in Iraq, political deadlock and complex economic challenges meant that health indications are not improving. According to the authors, the only way to make strides is to mount a “resounding and synergistic effort in other aspects of life affecting health: the social determinants of health”.

Iraq’s humanitarian needs are in danger of going unfunded, with the Humanitarian Response Plan for July to December 2015 being funded for only 40% of its cost of around $500 million. Such underfunding means, among other things, that basic hygiene needs are not being met – broken down water supply systems and insufficient chlorine to clean the water are fueling the cholera epidemic.

Responding to the epidemic

By the end of September, more than 1,700 people had reported to hospitals for cholera treatment. Such a rapid rise in cases requires a concerted effort to halt the spread. According to a report issued by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), emergency responses are focusing on eight areas: protection; water, sanitation and hygiene; health; shelter and non-food items; food security; camp coordination and management; education; and logistics.

To contain the epidemic, the WHO’s Global Outbreak Alert and Response Network (GOARN) is now working closely with the Ministry of Health (MoH) Cholera task force, which has set up a Cholera Command and Control Centre to lead the response. Additional camps have been set up for civilians who have been displaced from their homes. Preparedness has also been stepped up to improve water hygiene throughout the country: more bottled water, hygiene kits and chlorine tablets are being distributed and water distribution points are being set up.

Since sanitation is one of the major factors contributing to the spread of cholera, there is a focus on improving sewage systems, with septic tanks being disinfected, water treatment plants being fixed and solid waste disposal being improved. Public health messages are also vital in the control of an outbreak. The control teams are using social media, radio, text messages and even door-to-door campaigns to share information about how to prevent cholera infection.

Years of war and neglect in Iraq have resulted in broken water and sanitation systems and a deadly epidemic. Ultimately, control efforts can only go so far; as long as conflict continues, people are displaced and infrastructure is broken, the conditions will be ideal for outbreaks of diseases like cholera.

Unfortunately, if the people in power do not recognize and address the problems contributing to the spread of disease, a permanent solution is unlikely to be found. Speaking to Reuters, Health ministry spokesman Rifaq al-Araji proposed that the outbreak was caused by low water levels in the Euphrates, which supplies local people with water for drinking and farming, and floods that contaminated the water with sewage. “If treatment is received within the first 24 to 48 hours of infection, there is no peril to the patient,” he commented.


Cholera is caused by the bacterium Vibrio cholera, which is transmitted via water; poor sanitation and unclean water supplies mean cholera can spread through populations quickly. Cholera is an extremely virulent acute diarrhoeal disease that can kill adults and children within hours of infection. There are several different serogroups of V. cholera, two of which – O1 and O139 – can cause outbreaks.

There are an estimated 1.4-4.3 million cases every year worldwide, causing 28,000-142,000 deaths. Around 80% of people infected do not develop symptoms, but they are able to shed the bacteria in their faeces and contribute to the spread of the disease.

Despite its virulence, cholera can be prevented with provision of clean water and good sanitation. Following infection as many as 80% of cases can be treated successfully and simply, using oral rehydration salts. Oral vaccines are also available against cholera, and some countries have vaccinated high risk populations. However, the WHO recommends that more long-term actions are taken: “In the long term, improvements in water supply, sanitation, food safety and community awareness of preventive measures are the best means of preventing cholera and other diarrhoeal diseases.
Lucy Goodchild van Hilten

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