The Litani river winds its way through the open plains of the Bekaa Valley, Lebanon’s agricultural heartland. For centuries, farmers there relied on it to irrigate their crops. But in recent years, the river has become a dumping ground for an unfettered flow of raw sewage, industrial waste and chemical fertilisers. Grey and fetid, it emits a pungent smell that wafts over nearby farms and envelops the refugee camps that dot the river banks.

“The Litani is worse than a sewer,” said Firas Aboud, a 28-year-old Syrian farmhand who lives in one of the informal camps near the city of Zahle.

“I wouldn’t let my worst enemy wash in it.”

But with Lebanon’s fragile water systems increasingly unreliable, some people are forced to use the river for their household needs and to irrigate their crops. The absence of affordable clean water is one factor behind a recent cholera outbreak, the first since the disease was eradicated in Lebanon more than three decades ago and a sign of the widening implications of the country’s compounding economic and financial crises.

Experts have been warning for years of a looming water catastrophe, the result of chronic under-investment in infrastructure, bad management of existing resources and climate change. “Unfortunately, it took the arrival of cholera for people to start taking Lebanon’s water crisis seriously,” said Ettie Higgins, Lebanon’s deputy representative for Unicef, the UN’s children’s charity, which sounded the alarm bell in a 2021 report on the country’s water woes.

Lebanon’s cholera outbreak can be traced back to one in neighbouring Syria, where upstream damming in Turkey exacerbated an already acute water crisis. Lebanon is home to an estimated 1.5mn Syrian refugees, and porous borders between the neighbouring countries helped the disease spread.

Since the first cases emerged in Lebanon in early October, there are now more than 4,700 — 45 per cent of them children under 15 years old — and 20 deaths according to the country’s health ministry.

Cholera is a diarrheal disease contracted by ingesting contaminated food or drinking water, or coming into contact with a sick person. It can prove fatal unless treated quickly. Lebanon moved rapidly to secure supplies of an oral vaccine through the World Health Organization, but there is a global shortage due to a record number of outbreaks this year driven by conflict, poverty and climate change.

Although efforts to combat the spread have been robust, health officials are worried that decades of infrastructure neglect will lead to a wider spread among the country’s roughly 6mn people. “Decaying water systems help propagate cholera and other waterborne diseases,” said interim health minister Firass Abiad.

Some areas are entirely disconnected from water systems, including refugee settlements, and after more than a decade of under-investment, “we have a concern that we could see more outbreaks in the future”.

Although Lebanon’s snow-capped mountains once guaranteed abundant freshwater, resources are now severely strained, said Lebanese environmental expert Nadim Farajalla. Over the past 30 years, the nation has fallen below the water stress threshold of 1,000 cubic metres per capita per year, according to UN data. Lebanon’s crisis brought with it a new set of problems: its financial system collapsed in 2019, hitting healthcare hard and leading to a dangerous collapse of its electricity sector.

“Electricity is vital to maintaining clean and safe water flows. Without power you can’t have water; everything breaks down,” Farajalla said. The rising costs of fuel imports have nearly eliminated the government’s ability to provide regular power or subsidised fuel for generators to run the country’s water pumping and sewage treatment plants. None of Lebanon’s 31 wastewater treatment plants are functioning properly, Higgins said.

Neither are most of the country’s 1,000 water pumping stations. Without electricity, taps across the country have run dry and untreated wastewater is discharged into rivers and groundwater, contaminating them further. Lebanon’s embattled residents are used to an absentee government and have found ad hoc workarounds: households now depend on water trucked in by private companies. A 2021 study showed 21 per cent of household budgets is spent on privately supplied water.

The average cost of 1,000 litres of trucked water has increased almost sixfold since 2019, according to Unicef data, as has the price of bottled drinking water. An average apartment in Beirut pays between $120-150 a month for household water, according to several companies surveyed by the Financial Times, while drinking water can run to $30-50 a month. Many Lebanese are now surviving on salaries equivalent to $50-$100. The booming private water business is also poorly regulated.

One employee at a private water company servicing luxury buildings in Beirut told the Financial Times that their water had routinely failed lab tests, which found unsafe contaminates.

“My bosses just doctor the tests when clients ask.” Conversely, “the fear of contracting cholera has been an effective tool to mitigate its spread,” Farajalla said. Supermarkets have slashed prices of local leafy greens, noting a drop in sales since the outbreak began. And households that can afford to are stocking up on chlorine tablets and bleach. Back in Zahle’s refugee camps, residents dump much of their untreated wastewater into the Litani, as do neighbouring municipalities

. Some crops are also irrigated with wastewater, which penetrates the area’s porous limestone and makes its way into the water table. Frustrated that contaminated water could affect agriculture near Zahle, Erica Accari, the 28-year-old co-founder of Turba Farms, is building compost toilets that use earthworms to break down waste.

“This way, wastewater stops getting thrown into the river and seeping into the area groundwater,” she said. But without government-led solutions, experts say Lebanon is heading for disaster. “Things are coming to a head,” said Higgins, adding that aid agencies could not afford to plug financial holes indefinitely.

“The next few months are going to be critical to see if we can contain cholera or if it’s going to become endemic.”