ADF Fellow Ziad Abu-Rish takes a deeper look at COVID-19’s spread in Lebanon and how it intersects with the country’s ongoing crises
By Ziad Abu-Rish
Lebanon has faced an avalanche of devastating developments since 2019: chronic budget deficits, economic stagnation, rising poverty and unemployment rates, infrastructural breakdown, a banking crisis, currency depreciation, political paralysis, and the August 2020 Beirut port explosion. These compounding and intersecting crises have made it difficult for outside observers and many local residents to keep tabs on and make sense of the overall trajectory of the COVID-19 pandemic in the country. This article draws on insights from local public health researchers, journalists, and activists to highlight the nature of the pandemic’s spread, the government response, and how they intersect with other critical dynamics in the country.
Lebanese authorities announced the country’s first confirmed case of COVID-19 on February 21, 2020 and its first confirmed related death less than two months later, on March 10. As of June 1, 2021—fifteen months into the pandemic in Lebanon—the Ministry of Public Health claimed there were a total of 540,630 cumulative confirmed cases, 12,422 of which remain active, and another 7,735 that resulted in death. Among those active cases in Lebanon, 244 people were hospitalized, with 135 of those patients in intensive care units. The average 14-day positivity rate for the last two weeks of May was 2.6% (compared to 11% for the last two weeks in April).
Such statistics are staggering in absolute terms, but also in relative terms. With an estimated total population of 6.5 million people, that means about 8% of the total population has caught the virus. Yet political jockeying, systematic corruption, and ineffective monitoring have combined to render problematic record keeping in the country. These government statistics in fact belie a different, and direr, reality. First, there is far more information about the pandemic’s spread among Lebanese citizens than among refugee and migrant worker populations. Constituting more than two million of the roughly 6.5 million population count, refugees and migrant workers often live in more crowded spaces with less access to clean water, medical services, and personal protective equipment (PPE). They have been more vulnerable to COVID-19 outbreaks and have died at a higher rate. Second, a large number of potentially infected persons across the country could not secure access to COVID-19 tests due to either the expense or the long waits.
Beyond the issue of misleading statistics, assessing the effects of the COVID-19 pandemic in Lebanon cannot be reduced to a simple count of incidence and/or mortality rates. Such an assessment must factor in the country’s multiple pre-existing and overlapping crises: infrastructural, developmental, fiscal, and financial crises, to name the most prominent. While the COVID-19 pandemic did not cause these crises, it revealed their mutually-reinforcing nature. In some cases, it has exacerbated them.
Perhaps the best example is the public health care system in Lebanon. Public health policies in the latter years of the Lebanese Civil War (1975–1990) and its aftermath featured a dramatic increase in government reliance on the private sector and an abandonment of the more equitable pre-war public healthcare system. In 2017, the four major public health insurance schemes in Lebanon accounted for only 44.8% of the population’s total healthcare expenditure, while private insurance and NGO programs accounted for another 22.1%. The remaining 33.1% were out of pocket. Furthermore, public health insurance schemes heavily rely on sub-contracting private health care institutions for preventative, diagnostic, and treatment care. In 2019, the 28 public hospitals accounted for roughly 36.7% of government-subsidized hospital visits and the same percentage of government-subsidized admitted patients. That year, the Ministry of Public Health contracted with 118 private hospitals. Such trends are in keeping with broader dynamics, especially when one considers public-private bifurcation of utilities such as electricity, water, telecommunication, and internet service, to say nothing of capital investment, employment, and other developmental trends.
The spread of COVID-19 in Lebanon coincided with an acute state budget crisis, an economy characterized by a foreign currency shortage, local currency depreciation, and a banking sector that has effectively confiscated residents deposits made in U.S. dollars (approximately 75% of total bank deposits). In this context, the public-private “partnership” revealed the very limits and inequalities its critics had long lambasted. As the government failed to meet its financial obligations vis-à-vis public hospitals, public healthcare workers threatened strikes and work stoppages. In December 2019, at least two major public hospitals reported not receiving any of their budgeted funds for that year, including for salary payments. That same month, private hospitals claimed they were owed an outstanding balance of 1.3 billion U.S. dollars for services rendered on behalf of the government during 2011–19. Consequently, private healthcare institutions threatened to close their doors to individuals on public health insurance plans. The dramatic spike in unemployment, first in the wake of the financial crisis and then intensifying during the pandemic, meant an increased burden on both the public health insurance scheme and the few public healthcare institutions that existed. This was all compounded by the shortage in foreign currency, which dramatically decreased and slowed down the import of medicines, medical equipment, and related supplies. This is to say nothing of the decrease in the number of healthcare workers as a function of intensified emigration and massive layoffs by private hospitals since 2019. In October 2020, several health officials and professionals were sounding the alarm on the shortage of COVID-19 designated regular and ICU hospital beds. By the following January, the reported occupancy rates exceeded 80% and 90%, respectively, and the healthcare infrastructure risked an impending collapse. Since then, much has been made about how the budgetary and financial crises in Lebanon prevented the private sector from “stepping up” and the state from “stepping in.” Lost in such rhetorical gestures was the fact that the public-private healthcare partnership was justified over the past three decades, in part, with reference to the private sector’s alleged ability to quickly adapt to changing circumstances. This is to say nothing of the fact that the current multiple crises in Lebanon are themselves partially a result of a particular type of public-private partnership.
During the early months of the pandemic, many regional and international observers praised the Lebanese government for what they viewed as swift and effective lockdown measures. (These began in March 2020 but were increasingly rolled back beginning two months later in May of last year.) The lockdowns affected borders, schools, hospitality and entertainment establishments, government offices, and public spaces. Yet such praise belied two important realities. First, these lockdown measures came in the wake of historic mass mobilizations that erupted in October 2019 and showed signs of a potential resurgence in spring 2020. The government simultaneously carried out a wave of investigations, arrests, and prosecutions—both criminal and military—of participants in protests prior to the pandemic and those who sought to be active during the pandemic. Second, once the government effectively demobilized the threat of mass protests, it did not implement any serious or effective lockdown measures until January 2021, when the pandemic in Lebanon reached “crisis” proportions. The government also failed to provide any meaningful social safety net for income earners affected by the pandemic.
Between May 2020 and January 2021, the government prioritized attracting visitors (and thus foreign currency) and encouraging local spending at the expense of a prudent and targeted lockdown program. With the exception of an ineffective two-week lockdown in August 2020 and a series of short-lived municipal-level lockdowns in different parts of the country, the government overwhelmingly abdicated its responsibility. The ever-shortening intervals between major milestones in the numbers of confirmed cases and related deaths is perhaps the best indicator of this fact. According to one tabulation, it took 283 days to reach the first 1,000 COVID-19 deaths in Lebanon, whereas it only took an additional 52 days to reach 2,000 and 16 more days after that to reach 3,000. It wasn’t until strict lockdown measures were imposed in January 2021 that confirmed infection and death rates started to decline. Yet such downward trends only began to manifest in earnest this April, and the Ministry of Public Health has apparently and for inexplicable reasons decreased the frequency and amount of data it has published since then. So we cannot yet say with any certainty if Lebanon has permanently turned a corner after reaching the precipice.
With COVID-19 vaccine production in full swing, Lebanon has now entered the National Deployment and Vaccination Plan for COVID-19 Vaccines. The overall plan calls for an immunization rate of 80% or higher among the population of Lebanon, irrespective of citizenship status. So far, it has entered into vaccine-purchasing contracts to begin targeting the first 35% of the population through the combination of the World Health Organization-affiliated COVAX initiative and a bi-lateral purchasing contract with Pfizer. The plan is admittedly confusing: it does not specify if the plan targets 80% of the entire population or of those eligible (i.e., aged 16 years and older); it identifies several phases and sub-phases; and it has been changed several times since being launched in January 2021. For example, media workers (including journalists) recently became eligible for vaccination under the elaborated definition of “persons essential for the functioning of society.” This is ironic given how much of media infrastructure in Lebanon is tied to dominant political parties, while the few independent media workers and outlets in existence have been subjected to a barrage of government-led and/or politician-led intimidation, threats, and even prosecution. At the same time, as one colleague noted to me, it is troubling that many adults with two or more co-morbidities will not be vaccinated until the late summer while healthy adults in their fifties or media workers in their twenties have already been vaccinated.
The Ministry of Public Health claimed, as of June 1, that 513,694 people (10.8% of those 18 years or older) had received a first dose of the COVID-19 vaccine. Of these, 167,461 received their second dose. The government has primarily facilitated Pfizer (with some AstraZeneca) doses as part of its national COVID-19 vaccination program. The Lebanese government also recently received a donation of 90,000 doses of the Chinese-made Sinopharm vaccine and announced it would distribute 50,000 to the armed forces and earmark the remaining 40,000 for public sector employees, media workers, and health insurance sector workers.
Similar to other dynamics of the pandemic in Lebanon, the present moment promises to reflect the structural inequalities and institutional dynamics of Lebanon more so than it does any qualitative relief or meaningful public health strategy. While the national vaccination program is meant to be available to all, there is a disconnect between the demographics of those registered (registration in the program is required for vaccination) and that of the broader population. For example, the proportion of persons registered from each governorate is not reflective of those governorates’ respective shares of the population. Similarly, over 88% of those registered identify as Lebanese nationals, while less than 5% identify as Palestinian or Syrian, communities with COVID-19 infection fatality rates three and four times the national average, respectively. As of early June, less than 5% of vaccines doses went to non-Lebanese, even though non-Lebanese make up nearly 30% of the population.
Relatedly, in late February and early March the Lebanese government tentatively agreed to allow the private sector to import an estimated one million vaccine doses (Sinopharm and Russian-made Sputnik V) directly or purchase others (AstraZeneca, Pfizer, Sputnik V) through the Ministry of Public Health. The fate of this agreement is currently in question. More recently, the government apparently reached a deal with universities, private companies, and professional syndicates for an estimated 750,000 doses of the Pfizer vaccines to administer to their constituencies and their families. All of these arrangements reflect a privatized component of the government plan to eventually vaccinate “80% of the population.” One could claim that these are necessary measures in light of the public deficit that has rendered the government unable to shoulder the cost of purchasing and administering all the vaccine doses necessary to reach the plan’s target. But these measures are also part and parcel of a longer history of chosen public-private “partnership” and a broader pattern of unequal access based on economic and political privilege. For example, a scandal erupted this February when it was revealed that sixteen parliamentarians received their first vaccine doses despite the country officially being in a vaccination phase for which several of them were ineligible. Additional examples abound. According to the International Federation of Red Cross and Red Crescent Societies, 40% of vaccination centers breached the priority order in the first week of roll out. More recently, Prime Minister-designate Saad Hariri appears to be maneuvering to donate vaccine doses to particular constituencies. These and many more dynamics continue to raise questions that we are only beginning to consider. Finding out the answers will depend on the continued diligence of independent journalists and healthcare researchers in Lebanon.
Despite the death, illness, and various forms of dislocation the pandemic has produced in Lebanon, those in positions of power and authority have approached the pandemic like they approach most everything else that should rightly be considered a matter of public good, public benefit, and public safety. Only time and, unfortunately, the deepening of Lebanon’s multiple crises will reveal the lengths to which these political and economic elites are going in order to maintain their authority, privilege, and networks. That being said, it is worth noting a shift in the public discourse on public health services. On one hand, the pandemic has forced the government to invest more money directly into public hospitals than it has since the end of the civil war. On the other hand, the combination of the pandemic and other crises has reoriented many people away from private hospitals and to public ones. This has resulted in a significant increase in first-time visits to some public hospitals. These changing patterns of public investment and seeking out public healthcare might—despite everything—help reconstitute the balance of power for a greater and more meaningful role of the public sector.
Ziad Abu-Rish was a 2020-2021 American Druze Foundation Fellow at CCAS. He is also Director of the MA Program in Human Rights and the Arts at Bard College and Co-Editor of Arab Studies Journal and Jadaliyya e-zine.
This article is part of the Spring/Summer 2021 CCAS Newsmagazine, which is illustrated with art from Lebanese artists.