Lebanon has been historically renowned for its healthcare system; Lebanese physicians have staffed hospitals in the Middle East and North Africa (MENA) region, while travelers have flocked to Beirut for medical tourism. For years, high class facilities and training among the country’s university medical centers enabled international standards to prevail and created a trusting and respected environment. This applied to both Lebanon’s public and private hospitals and was also demonstrable through their performance during various infectious disease challenges.
Lebanon has experienced several infectious diseases including influenza, tuberculosis, hepatitis A, typhoid fever. The most recent global health pandemic, Covid-19, saw Rafic Hariri University Hospital (RHUH) at the forefront of the country’s fight against the infectious disease. With the public healthcare system overseen by the Ministry of Public Health (MoPH), the country’s coronavirus response initially centered on state healthcare. RHUH is the largest mental health facility, and has not been without its problems: material and logistical issues, poor maintenance, and unsatisfied staff. Yet despite these setbacks, during the pandemic it transformed into the leading public hospital in the fight against the disease. Though, it should be noted that Lebanon’s healthcare system is dominated by the private sector: the country has 157 private hospitals and only 29 public hospitals, according to the MoPH. The public healthcare system is funded by the government and provides free or low-cost healthcare services, while private healthcare is often expensive, making it inaccessible to many people, particularly those who are uninsured or have low incomes.
Lebanon’s fight against Covid-19 began with the MoPH’s operational plan which was implemented in March 2020, a few weeks after the first recording of a positive test detected in a woman who had travelled from Iran, where an outbreak was flourishing. As the government sought to contain just a handful of positive cases, restrictive measures were rapidly introduced. Universities, schools, nightclubs, bars, restaurants were ordered shut, and then in a dramatic move, the country’s land, sea, and air borders were closed and there was an implementation of a state of emergency. Citizens who had corona-like symptoms; headaches, sore throats, or fevers, were told to stay at home and avoid mingling with others. Severe cases were to be treated in hospitals. During that period, the government’s quick reflex in implementing containment measures was widely lauded.
Led by now caretaker Health Minister Firass Abiad, RHUH played a vital role in caring for coronavirus patients and leading the crisis response. As a 430-bed public hospital, RHUH needed to step up to the challenge and ensure its services could meet those most in need. A collaboration with the World Health Organization (WHO) boosted its services, thanks to the provision of technical support and training to staff, as well as through medical supplies, including personal protective equipment, and creating public awareness campaigns. Despite this external support, the hospital, alongside other public hospitals, was suffering from the country’s dollar shortage – a ramification of the economic crisis – which was hindering the ability to import medical supplies.
Human Rights Watch (HRW) reported in March 2020 that the government had only paid 40 percent of the dues owed to RHUH from the previous year and was yet to make any payments for 2020. Public hospitals in the north of Lebanon also said they had not received all their reimbursements from the government. Private hospitals, though not at the full mercy of the state, were not exempt from dealing with it. The government owed private hospitals an estimated $1.3 billion worth of unpaid bills since 2011, HRW noted in the same report. The financial imbalance meant the hospitals were struggling to maintain quality services just as the pandemic took hold.
In fact, this precarity was just the start of a long decline in the quality of the health sector. One of the major impacts of the economic crisis has been the dearth of drugs. Despite the government’s subsidy policy, basic painkiller tablets to cancer medication have been at times impossible to source. There have been widespread reports of patients and their families scrambling to find alternative sources for drugs; reaching out over social media, scouring the black market, or asking friends and relatives abroad. These stories epitomized the broken state of the health sector: a population left with no alternative but to resort to private initiatives to meet needs.
With this in mind, Lebanon’s ability to address infectious diseases like Covid-19, as well as cholera, tuberculosis, typhoid or hepatitis A, is dependent on state finances or the involvement of external aid. This was tested last October, when cholera, an acute diarrheal bacterial illness, was detected in Lebanon for the first time since 1993. It was considered a major regression in public health and was believed to have crossed the border from Syria, where an outbreak was underway. Cases were quickly identified in Akkar, the Bekaa valley and the Baalbek-Hermel regions, mainly in Syrian refugee camps, where living conditions are squalid and access to clean water is not guaranteed for the many thousands of families living there.
Like the coronavirus, the cholera outbreak was another instance of the country’s reliance on external organizations, such as the WHO. Due to the WHO’s involvement, the cholera outbreak was able to be monitored and controlled, and vaccines were brought in by the WHO and distributed among refugee communities. But such measures have been simply band-aid responses, and health experts have warned that without a thorough reform of Lebanon’s water system and improved sanitary measures, there remains a risk of future disease outbreaks. The crisis also highlighted that without this external support, the government alone would struggle to contain the disease.
Dr Aline Mouchaham, a specialist in regenerative medicine, says disease outbreaks could become more common: “The lack of adequate funding and resources has resulted in a shortage of medical supplies, equipment and testing kits,” she tells Executive. Mouchaham also says that disease outbreaks are likely to occur in areas where there is conflict, inadequate waste-water management, contaminated water, and accumulations of garbage. These conditions are often prevalent among Lebanon’s poorer communities, who live in overcrowded and unsanitary conditions, which can increase the chance of infections spreading rapidly, she says. The situation is worsened by the lack of access to health services for these communities. “It is not surprising that Lebanon experienced a cholera outbreak when large numbers of displaced individuals lack access to clean water, proper hygiene, and healthcare,” Mouchaham says.
The blind spot: the lack of scientific research
“It is disheartening and astonishing to witness individuals prioritizing their personal beliefs over scientific evidence and expertise, especially in times of crisis,” Dr Tamara El Zein, the secretary general of the National Council for Scientific Research, tells Executive. El Zein points out that the lack of awareness and access to reliable information about diseases can have significant implications for public health. In the context of infectious diseases, this can lead to delays in diagnosis and treatment, and ultimately contribute to the spread of disease.
“For example, during the Covid-19 pandemic, there were concerns about the accuracy of information being disseminated on TV and social media, which may have contributed to confusion and mistrust among the population,” El Zein says. The debate in Lebanon about the Covid-19 vaccine, which was warped by fake news and disinformation campaigns, highlighted a broader issue in public health about the importance of access to safe and reliable information. “Some people believe that vaccines can cause harm or are part of a larger conspiracy to control the population,” El Zein says, before adding: “However, these beliefs are not supported by scientific evidence, and it is important to look at the history of infectious diseases in Lebanon and the lessons learned from past experiences.” El Zein touches upon a concern for the MOPH to tackle public misinformation and the need to place greater resources on awareness and information campaigns.
Past disease outbreaks in Lebanon have surfaced from a variety of factors, including poor vaccination coverage, inadequate health infrastructure, and a lack of importance placed on vaccination and disease prevention. “Without a connection between scientific research and society, individuals are limited in their ability to educate themselves about the advancements in science, particularly with regards to vaccines and their benefits,” El Zein says.
Prioritizing scientific research that matches the challenges is essential, according to El Zein. More targeted and impactful research can lead to the development of expertise and knowledge in specific areas. “For example, Lebanon now is facing a high incidence of cancer cases; it would be more beneficial to invest in research that focuses on cancer treatment rather than research on artificial intelligence,” El Zein says, noting how research can have a direct benefit to the population’s wellbeing.
Strengthening the scientific culture in Lebanon can have a positive impact on the status of the public health system. For example, through the promotion of science education and “encouraging scientific inquiry and supporting research institutions.” This can be achieved through partnerships between academia, industry, and government, as well as promoting interdisciplinary collaboration, El Zein says. In addition, supporting development of research infrastructure and increasing funding for research can enable the scientific community to address the challenges posed by infectious diseases. “By prioritizing scientific research and promoting a culture of evidence-based decision-making, Lebanon can better protect its citizens from infectious diseases and build resilience against health threats,” El Zein says.
The Covid-19 pandemic brought to light the importance of community awareness, engagement and response in public health campaigns in responding to infectious diseases. Taking recent infections as examples, one of the main drivers of cholera and coronavirus’ rapid spread was the lack of communication and awareness among the population. “This is a reminder that we need to be ready to respond to outbreaks at all times, and that means investing in things like clean water and adequate healthcare facilities,” Mouchaham says.
Regarding community engagement, Mouchaham notes: “It involves educating the public, clarifying any doubts or misunderstandings, and engaging community leaders and organizations in response.” Individuals must also do their part by practicing good hygiene, wearing masks, and social distancing. Infectious diseases can be spread easily and quickly, and each person has a role to play in preventing their spread. If individuals take responsibility for their own health and wellbeing, it can ultimately help to reduce the burden on the healthcare system. “Outbreaks can be stressful and challenging but is important to remain focused on the goal of protecting public health and working together to overcome the challenges,” Mouchaham says.