The World

The Struggle to Vaccinate Lebanon

Beirut’s largest public hospital long embodied all the country’s institutional failures. Now it’s leading the COVID-19 response.

Director of the Rafic (Rafiq) Hariri University Hospital, Firass Abiad, takes the morning tour at the coronavirus testing centre of the hospital, in the capital Beirut, on July 28, 2020. - Abiad used to be a little-known state hospital director until coronavirus propelled him into the spotlight and restored at least some faith in Lebanon's much-maligned public sector.
Since the first COVID-19 case reached Lebanon in February, the has taken centre-stage in battling a disease that has infected over 4,550 people and cost more than 60 lives across the country. (Photo by ANWAR AMRO / AFP) (Photo by ANWAR AMRO/AFP via Getty Images)
Director of the Rafiq Hariri University Hospital, Firas Abiad, takes the morning tour at the coronavirus testing centre of the hospital, in the capital Beirut, on July 28, 2020. ANWAR AMRO/Getty Images

BEIRUT — It is a moment of triumph at Rafiq Hariri University Hospital (RHUH), a dilapidated building complex on the southern edge of the Lebanese capital and the country’s largest public hospital. Tents are arrayed to the left and right of the central courtyard, each one devoted to distributing the AstraZeneca and Pfizer COVID-19 vaccines. Inside the tents, nurses rely on a pen and paper system to track the hundreds of mostly elderly patients who arrive to receive their shots. On the day I visited, the staff briskly registered new arrivals and ushered them to a nearby booth for their shots, completing the entire process in a matter of minutes.

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Over the past 18 months, Lebanese have watched their currency lose over 80 percent of its value, one of the largest non-nuclear explosions in history destroy the Beirut port and surrounding neighborhoods, and their government’s failure to develop a plan to stop the economic bleeding. The official response to the pandemic has been similarly shambolic. The health minister attended a crowded lunch when his own regulations prohibited large gatherings, then promptly contracted COVID-19. Parliamentarians jumped the line to receive vaccinations from a World Bank-funded program; when a World Bank official criticized them, one MP mocked the official’s name, purposely mispronouncing it as the Arabic word for rotisserie chicken.

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Aided by these failures of governance, the pandemic has run roughshod across the country. COVID-19 has infected nearly 500,000 people and killed more than 6,000, and over 10 percent of local tests are still coming back positive. Although the World Health Organization does not recommend reopening unless the test positivity rate is consistently below 5 percent, the country has mostly returned to normal life. Public health experts have recently seen glimmers of hope: The test positivity rate has dropped several points over the past month, cases among health care workers have declined to near-zero, and the number of daily deaths has fallen.

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But there is still a long road ahead. Lebanon’s vaccination rates remain paltry: Only 3 percent of people have received even one shot, and less than 20 percent of the population has even registered for the vaccination program. Vaccine hesitancy also remains a challenge. When I praised the lack of lines in RHUH’s AstraZeneca tent to one of the nurses, she shrugged, saying many people had not shown up for their scheduled appointments. On some days this month, up to 30 percent of patients scheduled to receive the AstraZeneca vaccine missed appointments, with many citing health concerns as the reason for remaining unvaccinated.

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While RHUH long represented a microcosm of the state’s failures, it now offers a glimmer of hope. Five years ago, it was “penniless” and “on the brink of closure,” in the words of its manager, Dr. Firas Abiad. Today it is leading the COVID-19 response despite having far fewer resources at its disposal than its private peers.

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The hospital’s reversal of fortune is due in no small part to Abiad, a soft-spoken surgeon who serves as chairman of the board at RHUH. In some ways, he functions as Lebanon’s version of Anthony Fauci: a medical professional who offers data-driven assessments of the course of the pandemic at a time when many government officials seem asleep at the wheel. “This experience of trying to fix a public institution, this is going to be the path that will be required in all our institutions,” he said. “Because I think most of our public institutions are failing at the moment.”

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A partnership with the International Committee of the Red Cross (ICRC) was critical to Abiad’s efforts. The collaboration, which began in 2016, allowed the hospital to overhaul its infrastructure and administration. As a result, its budget deficit declined from roughly $15 million in 2014 to only $400,000 by 2019.

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But with the onset of the financial crisis in late 2019, RHUH was soon faced with an even more daunting challenge. Its revenue streams dried up, the Ministry of Public Health was unable to pay its staff, and the hospital started experiencing supply shortages because importers didn’t have enough dollars to buy products from abroad. Doctors and nurses in hospitals across the country have not been provided with proper personal protective equipment, resulting in over 2,600 healthcare workers being infected with the virus.

Faced with these circumstances, the country’s medical professionals have increasingly fled the country. Doctors’ and nurses’ salaries have effectively been slashed by the financial crisis, leading over 1,000 doctors and a similar number of nurses to leave Lebanon for jobs abroad. One doctor at a prominent private hospital described how his colleagues with financial commitments abroad were the first to leave: With their salaries trapped in Lebanese banks, it has become impossible to support children in university or pay mortgages on property outside Lebanon. A third of his department will depart by the end of the summer, and many more are pursuing opportunities abroad.

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The departures are placing great burdens on those who decide to stay. The doctor said he has been on call virtually non-stop since last July. Meanwhile, the hospital has also laid off the secretaries who answer the phones, meaning that patients often try for weeks to reach him in order to make appointments. “Everybody is angry about it, everybody is frustrated, everybody is tired,” he said. “And honestly, I don’t know how long it is going to last.”

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Abiad said that the Beirut port explosion “demolished any hope” many had that the situation would improve, and many had now finalized their plans to depart.

“The financial offers they are getting [abroad], there is no way we can match it,” he said. “The only thing you can resort to is non-financial incentives: You can bet on their patriotism, or their sense of duty to family, society, community [keeping them in Lebanon].”

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RHUH must also still care for the non-COVID patients streaming through its doors. As people’s savings evaporated, they increasingly turned to the public hospital for care. Private hospitals have increasingly turned away patients on state insurance or demanded large up-front payments, pushing the burden onto the underfunded public hospitals. And because of the pandemic, patients have often waited until their conditions grew severe before seeking treatment.

The board of directors resisted a government attempt to have it care exclusively for COVID-19 patients, instead opting to “cut the hospital in half,” in Abiad’s words, to care for both groups of patients.

RHUH “is the hospital of last resort” for many Lebanese, Abiad said. “If we had turned into a complete COVID hospital, the damage that would have happened to those patients… would probably be worse than what was happening with COVID.”

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While Lebanon’s private hospitals have long been considered the best in the Middle East, its public hospitals have been systematically marginalized and underfunded. The Ministry of Public Health exists mainly as a mechanism to funnel money into the private hospitals’ coffers: 80 percent of its budget, the third-largest of all ministries, is devoted to reimbursing private institutions for care of those with state-backed insurance. A meager 2 percent of the ministry’s budget, meanwhile, goes to public hospitals.

Despite this divergence of resources, RHUH was asked to bear the brunt of the COVID-19 response at the onset of the pandemic, when it was the sole hospital in Lebanon treating patients infected with the virus. Private hospitals, meanwhile, negotiated with the Ministry of Public Health for higher rates of reimbursement before agreeing to treat COVID-19 patients.

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“I don’t want to use a harsher word, so let’s use this word: “[The private hospitals] drove a hard bargain with the ministry,” said Abiad. “Once they reached a price they wanted, that’s when they said OK. Now I have my own issues with bargaining in such dire times, but anyway, this is what happened.”

Many Lebanese who would happily use harsher words to describe such behavior. The fact that Abiad chooses not to reflects his low-key public persona. His Twitter account has become the best source of information about the spread of the pandemic from a sitting public official: Every day, he offers detailed information about the progress in the vaccination campaign, the strain being placed on the country’s hospitals, and what the country’s citizens can do to stem the spread of the pandemic. But his criticisms of the government response to COVID-19 are couched in medical facts rather than the settling of political points.

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Abiad frames his use of Twitter as a way to combat widespread cynicism among Lebanese about their government’s pandemic response. As the state absents itself from daily life, many simply ignore its regulations: The government proclaimed one of the world’s tightest lockdowns earlier this year, requiring citizens to register via an app for any excursion out of their homes. In reality, highways were often packed with cars as people simply ignored the regulations, and the government made little effort to enforce them. “I really believe that patients have the right to have full information in a very transparent way,” he said. “And I felt that this was not happening.”

The question of how to reform the country’s broken institutions remains even more daunting. While Abiad speaks in glowing terms about the international partnership that allowed RHUH to revive its operations, he says that it was successful because the ICRC established a regular presence in the hospital to collaborate on administrative and financial reform. It is no easy task to convince other public hospitals—let alone other public institutions—to agree to such partnerships. Abiad worries that gifts of money or equipment absent such oversight will “backfire,” comparing them to the international aid that has flowed to Lebanon for years, cementing the current status quo. “And we all know where that got us.”

Last week, Abiad tweeted an excerpt from Joseph Heller’s novel Catch-22, the story of how an absurdist bureaucracy—in this case the US military—traps its victims in paradoxes that inexorably lead to disaster. In the passage he posted, a doctor, Doc Daneeka, explains to the protagonist, Yossarian, why he can’t get out of flying bombing raids: He must be crazy to continue flying dangerous missions; but applying for excusal demonstrates one’s sanity, and thus he must continue flying.

Abiad said that he submitted his resignation four times prior to the current crisis. And yet he, too, has not been able to escape his mission. Those who remain in Lebanon rarely express much hope that there is a way out of the country’s downward spiral, and yet somehow, they press on.

“Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle,” the quotation posted by Abiad concludes. “‘That’s some catch, that Catch-22,’ he observed.”

“‘It’s the best there is,’ Doc Daneeka agreed.”

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