The Challenges of a Public Health Approach to COVID-19 Amid Crises in Lebanon

An eerie silence pervaded the usually car-filled, noisy streets of Beirut in the post- revolution, COVID-19 era. But on March 29 at 8 pm the silence was momentarily broken by the sound of clapping in support of Lebanon’s healthcare workers—widely seen as the unsung heroes of this crisis.

Just a few months earlier, people banged kitchen pots at 8 pm from the same balconies, but for different reasons. They were showing solidarity with the street protests that erupted across Lebanon on October 17, 2019. An unprecedented outpouring of anger and frustration brought together people from all social classes, generations, localities, political parties and sects in this divided country. People called for an end to corruption, economic mismanagement, inequality and the lack of political accountability that has plagued Lebanon for decades.

Yet, these revolutionary calls for social justice did not always make explicit the connection to health. As elsewhere in the world, the COVID-19 pandemic is revealing the deficiencies of neoliberal policies that fail to make the public’s health and well-being a priority. Lebanon stands out in the region for its market-led approach to healthcare provision, which has resulted in the expansion of for-profit curative care based on the ability to pay, not on health needs. The effects of this pandemic illustrate how public health measures can reduce the need for individual medical care. Lebanon’s long-term and chronic underfunding of public health, primary health care and preventive services has put healthcare workers, and most citizens, in a precarious position. Who gets sick and how societies react to illness is shaped by political and economic factors. The disproportionate impact of the coronavirus on vulnerable populations is finally drawing more of the public’s attention to these social determinants of health.

The New Government Responds

The street protests in the fall of 2019 led to the resignation of Prime Minister Saad Hariri in October and the appointment of Prime Minister Hassan Diab on January 21, 2020. This new government was tasked with addressing the demands of protesters and implementing reforms to address the worst economic crisis since the end of the civil war in 1990. Just one month later, the first coronavirus case was reported in Lebanon on February 21, 2020—a woman who had recently traveled from Iran. On February 29, with only four cases reported, Minister of Education Tariq Al Majzoub closed schools and universities initially for a week, before there was any evidence of community (not travel-related) transmission. Schools and universities are currently expected to re-open on May 25.

On March 15, the government declared a public health emergency and announced a national mobilization plan against COVID-19. Criticized for acting late, on March 18 it stopped all flights from highly affected countries, including Iran and Italy, and closed its sea and land borders except for essential goods. Temperature checks, and testing, were introduced at Beirut’s international airport. A nightly curfew was imposed and non-essential workers were encouraged to stay home as of March 21, with the (aspirational) recommendation to the private sector to offer paid leave to employees. All but essential functions of government offices stopped and banks closed. The service sector, which sustains Lebanon’s economy, was badly affected and unemployment soared further, with few signs of compensation to workers (there is no system for unemployment benefits). The government’s plan for opening the country in phases started on May 4, and will loosen the lockdown a little more each week.

One of the government’s first responses to the pandemic was to convert a section of the Rafic Hariri University Hospital in Beirut, one of the country’s 29 public hospitals, into a testing service, as well as an isolation and management center for all confirmed cases. Preparations began at other hospitals to accept COVID-19 patients as well, although private hospitals—which are by far the majority at 131 out of a total of 160 hospitals in the country—were initially reluctant to do so. Even before the coronavirus hit Lebanon, public hospitals were underfunded and private hospitals in crisis due to the government’s failure to pay its bills, including money owed to hospitals by the National Social Security Fund and military health funds. Underfunding combined with the deterioration of the unofficial exchange rate resulted in a greatly reduced capacity to buy imported equipment and supplies, including medicine, and to pay salaries to healthcare workers.

In mid-March, the Ministry of Public Health developed and made public their Coronavirus Disease 2019 National Health Strategic Preparedness and Response Plan. Drawing on the expertise of its Epidemiology Surveillance Unit, founded in 1995 with World Health Organization (WHO) support, the ministry began extensive isolation and contact tracing of all COVID-19 cases. It also engaged in an active risk communication strategy in collaboration with civil society groups, including mass text messages with videos explaining the latest COVID-19 trends by the director general of the Ministry of Public Health, Walid Ammar, and, more recently, a 24/7 hotline.

Managing the COVID-19 Crisis

The active efforts of the Ministry of Public Health, despite constraints, seem to have been effective and drew international praise. According to official Ministry of Public Health statistics, there were 725 confirmed cases (and 24 deaths) as of May 1. Given Lebanon’s population of 6.8 million, this is a low proportion—106 cases per million population—compared to the United States where it is over 3000 per 1 million population. Reported cases are distributed across the country, but Mount Lebanon accounts for more than half, and Beirut less than one fifth. Numbers of cases have been much lower than expected, and hospital capacity was not overwhelmed as some predicted it would be.

But the lack of widespread testing means that, as elsewhere, a full sense of the pandemic—and particularly the asymptomatic, undetected cases—is difficult to glean; recent promises to scale up access to PCR testing (used to detect the presence of the COVID-19 virus) made by the minister of public health may change this situation. While free testing is available for the symptomatic at Rafic Hariri University Hospital and other public hospitals, it is available only for a fee of 150,000 Lebanese lira (or $100 at the official, not black market, exchange rate) at university hospitals and private labs, which were licensed to test on condition that they provide results to the ministry.

Predicting the potential extent of the epidemic is challenging. Some factors could provide grounds for optimism that Lebanon’s society and healthcare system will continue to manage the COVID-19 crisis. The fact that the population is generally younger than those in Western Europe, for example, will serve as a protective factor. By the standards of many low and middle-income countries, Lebanon has a relatively large and well-trained health workforce and accessible (if expensive) healthcare, although more than half of the population is not covered by health insurance. As a small country with privatized health care and an oversupply of doctors, hospital beds are widely available (there are over 2,300 intensive care beds in the country and nearly 12,000 inpatient beds, according to the Ministry of Public Health).

In general, calls for social distancing and lockdown have been taken seriously, though with huge economic consequences in a society teetering on the brink of financial collapse. With the partial lifting of lockdown in May—badly needed both economically and politically—and with plans to re-open the airport in June, it remains to be seen whether Lebanon will be able to insulate itself from a second wave of infections. Access to affordable testing at an expanded scale will be critical to containing the spread of the virus. The recent decision by the US government to de-fund the WHO will have implications for countries such as Lebanon that rely on its support for help in expanding access to testing and strengthening the response to the virus. In the future, that support will also be needed for scaling up a vaccine when it is eventually developed.

Lebanon has a mountain of challenges to address and both the United States and Gulf countries are turning a cold shoulder to what they view as its one-sided government (referring to the fact that it is aligned with Hizballah and Amal but not with other political parties with whom the United States and the Gulf states have closer ties, including the Future Movement, the Lebanese Forces and the Progressive Socialist Party). Pledged funding by international donors at the 2018 CEDRE conference to aid Lebanon remains undelivered and contingent upon reforms. The government announced a long-awaited economic reform plan on May 1, and officially requested assistance from the International Monetary Fund to deal with the country’s financial crisis, its inability to pay debts and the plummeting value of the currency.

Social Inequalities Increase with Further Economic Collapse

Economically, the pandemic and the associated lockdown spell disaster for many sectors. As everywhere, the epidemic will be filtered through, and will in turn exacerbate, existing social inequalities. Prime Minister Diab announced in March that 40 percent of the Lebanese population will likely be below the poverty line soon. His government put forward a 1.2 trillion Lebanese lira social support fund, but implementation challenges in disbursing funds to impoverished families quickly emerged. In late April, protests erupted in Tripoli—a city that had already suffered from massive unemployment before the COVID-19 crisis—as the unofficial exchange rate approached an unprecedented 4,000 Lebanese lira to the dollar. The official rate remains at 1,515 lira to the dollar, but with banks imposing capital controls, withdrawals in dollars are no longer allowed, forcing people and businesses to purchase them on the black market. An official devaluation seems likely, especially with the IMF involved.

Lebanon currently hosts approximately 1 million Syrian refugees, as well as a longstanding and largely impoverished population of Palestinian refugees. Although the United Nations Relief and Works Agency (UNRWA) serves the Palestinian refugees, its ability to provide aid and needed employment has been significantly reduced by the Trump administration’s elimination in 2018 of all support for the agency. Refugees living in camps and informal settlements are particularly at risk of infection, due to poor water and sanitation facilities, crowded living conditions and, for Syrian refugees, poor access to healthcare. Moreover, Syrian refugees suffer from a high level of non-communicable diseases, which increases the risk of severe illness for those who contract COVID-19.

Humanitarian actors, such as the United Nations High Commissioner for Refugees (UNHCR), UNRWA and others, have been arguing strongly for the inclusion of refugees in the government’s national preparedness plans while at the same time committing to pay the testing costs and medical care associated with infection among refugees. They have developed careful plans to avoid introducing the virus to self-contained areas populated with refugees, to provide humanitarian goods and services to the edge of such areas and to craft isolation arrangements in preparation for an anticipated outbreak. So far, a limited number of COVID-19 patients at Rafic Hariri University Hospital have been non-Lebanese residents. A first case in a Palestinian refugee camp in late April raised alarm bells, but to date further spread has been contained through isolation and contact tracing. Time will tell whether the fear of an outbreak among refugees will be borne out, and whether there could be increased tensions between refugee and host populations in gaining access to dwindling medical resources.

Another vulnerable group is the elderly, who also face social isolation during the lockdown. Lebanon’s population includes a higher proportion of people over age 60 than other Arab countries, and due to out-migration of the younger generation many live alone without social and economic support. Yet, unlike Western contexts, a limited proportion of older people live in institutionalized settings. Special measures will be needed to protect the elderly and those with underlying conditions as the country begins to open up as planned in May.

In Lebanon’s rapidly deteriorating economy, workers in the daily informal sector and low-paid private service sector, who cannot afford to stop work and stay home, are at increasing risk of exposure. Domestic foreign workers are also more vulnerable due to the falling value of the Lebanese currency and difficult work conditions. The Philippine ambassador to Lebanon, Bernardita Catalla, who was a strong supporter of the rights of domestic workers from the Philippines, died of COVID-19 in April. Catalla had been overseeing the free repatriation of the many foreign workers whose jobs were a casualty of the economic crisis.

A Weakened Public Health Sector Strains to Respond

Long-term structural deficiencies in the health system pose challenges to Lebanon’s ability to take the needed public health approach to tackling the pandemic. The Ministry of Public Health has taken active steps to contain the virus’s spread, but it has a limited ability to regulate care and coordinate the response in a highly privatized system.

For example, while the Ministry of Public Health oversees a network of 236 primary health care centers, 190 of these are operated by non-governmental organizations (NGOs). Over 85 percent of the country’s hospital beds are within private hospitals. The relatively few public hospitals were already underfunded and many are overburdened with providing care for the huge influx of Syrian refugees since 2011—even when services for refugees are subsidized by UNHCR. The diversion of healthcare resources toward COVID-19, the lockdown and the economic implications of the crisis are also likely to have knock-on consequences for other health conditions.

The shortage of dollars during Lebanon’s spiraling financial collapse has meant shortages of imported medications and supplies even before the COVID-19 crisis. The World Bank lent Lebanon almost $40 million for needed coronavirus-related equipment including more ventilators in public hospitals, and the WHO has assisted with protective gear, as has the Chinese government. Healthcare workers were already demoralized with the stringencies brought on by the ever-worsening economic situation. Desire for out-migration among nurses in Lebanon—already in short supply—was high even before the overlapping crises.

The global COVID-19 pandemic has sharply illustrated the need to support and fund public health systems and for governments to take strong public health measures at the population level to alleviate the burden on expensive, individual medical care. The difficulties of implementing public health measures in Lebanon—such as widespread and affordable testing and generating real-time data at the national level—have been constraints in detecting cases, preventing further spread and managing a fast-moving pandemic. Nevertheless, the dedication of the Ministry of Public Health staff, the small size of the country and the fact that health professionals know and interact closely with each other has helped to compensate for these structural constraints. Civil society groups in Lebanon have also filled a critical gap, with the Lebanese Red Cross, for instance, transporting suspected COVID-19 patients to hospitals.

Experiences across the globe have also shown that a key component to effectively responding to a pandemic is inter-sectoral collaboration, where multiple ministries are engaged and coordinate their response, but that has been historically weak in Lebanon. With overall infrastructure in the country collapsing from lack of investment and corruption, the gaps in the regular supply of water, electricity and the internet make controlling the spread of COVID-19 even more challenging. In the absence of governmental social safety nets in a privatized model of social welfare and under financial strain, it is close-knit families— in Lebanon and the diaspora—that will shoulder the burden of these crises.

The COVID-19 crisis has exacerbated the challenges facing Lebanon’s new government. With the curve of new infections decreasing, the government can congratulate itself on its performance so far. It remains to be seen whether the still unfolding COVID-19 crisis in Lebanon, coming as it does on top of its pre-existing economic and political problems, might precipitate larger political changes, such as those called for by its October revolution. The pandemic should also prompt a reassessment of the social contract and spur efforts to make the public’s health a higher priority.