COVID-19 and the Blast: A Response Amidst Multiple Crises

The COVID-19 pandemic has challenged health sectors across the globe, placing tremendous pressure particularly on systems in low resource settings. In Lebanon, just as the country was about to resume lock-down to contain a rise in cases after border re-opening, Beirut witnessed an explosive blast on August 4^th leaving more than 175 dead, 6000 injured and almost 300,000 displaced. The events that followed further exacerbated the challenges that Lebanon was facing in responding to the pandemic effectively.

Lebanon went into the pandemic amidst an economic and banking crisis that led to a newly appointed government assuming the COVID-19 response. The initial challenges were common to many low resource settings: the country’s fragmented health system is highly privatized and concentrated in urban areas; neighborhoods are densely populated with multigenerational households;[i] and supply-chain is highly dependent on imports.[ii] The August 4^th blast strained the system further: six major hospitals were severely damaged[iii]; the density challenge was potentiated with thousands displaced; and, finally, the resignation of the governmental cabinet jeopardized the credibility of the response effort and its ability to mobilize the various sectors.

Initially, the approach Lebanon followed was one of aggressive containment to build its health sector capacity. It closed schools, daycares, pubs, gyms and malls, with full lock-down of borders and stay at home orders when case counts were still at 99. In spite of successfully containing the outbreak initially, with a case positivity rate of 1.5% and only 251 cases per million prior to border re-opening, imported cases soon started driving community clusters¹. Following the blast, which occurred amidst a second lock-down, the positivity rate spiked from 2.1% on July 25^th to 10.5% on August 22^nd, quickly overwhelming the designated COVID-19 inpatient beds.

The challenge today remains one of mobilizing the predominantly private health sector to care for COVID-19 patients, at the cost of significant financial burden for hospitals that step up: the equipment needed, facility standards and personal protective equipment (PPE) for COVID-19 care are costly; most third-party payers continue to exclude care of COVID patients; and lost revenue from elective cases who may avoid COVID-designated hospitals is an additional financial disincentive. As such, the care of COVID-19 patient has shifted to public hospitals, in spite of the overwhelming capacity of the private sector. With multiple COVID-designated hospitals either totally non-functional or with reduced capacity from blast-related damages, the few hospitals that have stepped up are even more strained post-blast. Rethinking the resourcing of public hospitals is necessary for future planning, as is providing incentives and support for the private health sector, including working with third party payers to address COVID-19 exclusions.  

An additional challenge, exacerbated further by the blast, is the heavy reliance on foreign supply chain where low/middle income countries have little leverage to compete for critical resources.[iv] With continued disruptions to this supply-chain, multiple initiatives have started locally including some efforts towards designing and producing ventilator machines and basic PPE.[v] In addition, health facilities have quickly had to resort to crisis standards for reuse of supplies and PPEs. Post-blast, Lebanon has seen an influx of donations of supplies, field hospitals and PPE. However, most donations have not taken into consideration more long-term needs beyond those of acute trauma care. In addition, the flood of donations and the logistical challenge of matching supplies to the different needs has exposed the need for a centralized national disaster response unit that would coordinate efforts and which was missing in Lebanon pre-blast.

Finally, while Telehealth use has become widespread in many parts of the world with clear practice standards, its absence in Lebanon was acutely felt during the pandemic, especially post-blast as case counts rose and workload of damaged hospitals spilled to others. In countries where it is available, Telehealth not only reduced exposure of staff and patients to COVID-19[vi], but it also compensated for some of the lost professional fee revenue from reduced in-person visits for many practices. A few health centers in Lebanon began to offer formal Telehealth services during the pandemic. Practice standards and the legal framework remain unclear however. In addition, lack of coverage of Telehealth services by third-party payers continues to be a major limitation to its widespread use.

Along with COVID-19 came the opportunity to rethink health care in low resource settings where historically entrenched practices and policies exposed vulnerabilities that need to be addressed to survive this and future health crisis.