In a freezing classroom in Arsal, an isolated Lebanese town perched 1,500 metres above sea level near the Syrian border, one by one children line up for their cholera vaccine — taken orally, a quick gulp down the throat.
The teacher marks their hands with a pen, and now the jacket-clad children have an extra layer of protection against Lebanon’s first cholera outbreak in three decades.
Arsal, a largely Sunni Muslim town in the north-eastern reaches of the Baalbek-Hermel governorate, is one area of Lebanon that has been a focal point of the cholera spread — and efforts to fight the disease.
A poor, overcrowded town where informal settlements sit alongside houses, it’s the perfect place for the disease to take hold.
And while Lebanon is — at the moment largely successfully — countering cholera, there are fears that the looming winter could isolate Arsal, where the proportion of Syrian refugees is double that of the Lebanese population.
By the end of November nearly 450,000 vaccines had been administered. Since the outbreak in early October, there have been about 4,600 suspected or confirmed cases and 20 deaths.
The cholera strain found in Lebanon is similar to the one in neighbouring Syria, itself struggling with a much larger outbreak.
The World Health Organisation describes cholera as “an acute diarrheal disease that can kill within hours if left untreated”.
It can be easily treated with oral rehydration salts but in severe cases immediate medical attention is needed.
Lebanon’s economic crisis means the country lacks a sufficient supply of medicine, clean water and electricity.
Organisations such as Medicines Sans Frontiers, which recently opened a cholera treatment unit in Arsal, are going door-to-door in a bid to get people vaccinated.
One of those to take the vaccine was the family of Salah, a middle-aged Lebanese man from Arsal who lives near one of the small refugee camps that merge with the older homes.
Normally the family gets their water from lorries and a nearby well.
“You never know. Waste management is not properly functioning, so you never know if this water is clean or if the water in the well is clean,” he said.
Salah said waste management and infrastructure were already in a bad state before a series of crises hit Lebanon, including a devastating economic crisis that first became apparent in 2019 and an influx of refugees fleeing the war in nearby Syria that began more than a decade ago.
“It became worse with overcrowding but it was already bad,” he added.
For now, suspected and confirmed cholera cases are somewhat stable — and are even potentially going down slightly, according to government statistics.