For Dr. Ibrahim Bou Orm and Professor Michele Kosremelli Asmar, both members of the Higher Institute of Public Health at Saint Joseph University of Beirut (USJ), the Covid-19 pandemic reveals the strengths, but also the limitations of the Lebanese healthcare system.

Have the authorities been slow in taking the necessary measures to deal with the health crisis?

The government has been slow in taking certain actions, since maintaining direct flights from highly affected countries, such as Iran or Italy, was rather a political decision. Had it stopped these flights earlier, we could have gained an additional two to three weeks to prepare for the inevitable pandemic in Lebanon.

That said, the Ministry of Health began its surveillance efforts rather quickly, conducting case detection and epidemiological investigations, which helped prolong the first phase of the epidemic. Today, Lebanon is in a second phase, that of “community transmission”, in which the new infections are not linked to contact with known cases of Covid-19, or infection from abroad. The containment of the population then becomes essential to stem the epidemic, to reduce its peak; that is to say “flattening the curve”.

Why is it absolutely necessary for Lebanon to “flatten the curve”?

Consider the following scenario: the first wave of the epidemic affects 100,000 people - detected or not - 20,000 cases (20% of them) will require hospital admission and 5,000 (5%) will need intensive care, possibly ventilators. Treating these 5,000 cases within a short period will be difficult, if not impossible. It is therefore imperative to “flatten the curve” of the first wave, and the new waves in the months to follow. The situation is critical, because we know, on the one hand, that there will be no vaccine in the short term - we are talking about a year to manufacture the first vaccine- and on the other hand, we know that the hot season will not have a tremendous effect on slowing the transmission of the virus. Added to that, Lebanon is under the constraints of a severe economic crisis, with the poorest households being the most affected.

What if the curve takes a more reassuring trend in the coming weeks?

We will then need to review the lockdown strategy, and this may mean relaxing or modifying certain measures nationally or in certain geographical areas while monitoring the short- and medium-term effects. The government and the Ministry of Health must act quickly to set up a plan for the next six or twelve months and begin to consider future steps.

Do you think the measures taken at this stage are enough?

The interruption of all non-essential production activities and the decision to place the country in a state of health emergency show that the government realized the seriousness of the situation. The ministry's decision to reserve hospital beds for severe and critical cases and to isolate mild cases at home also goes in this direction.

More testing of Covid-19 is necessary, because the number of cases detected each day depends on the way testing is organized. We believe that it is necessary to increase the number of free tests and make them available to symptomatic people throughout the country for early detection of positive cases and generation of reliable data to better guide public health policies.

Does Lebanon have enough testing kits?

Currently, the number of testing kits is enough for the next few weeks given the declaration of the government about ordering over 20,000 more. However, the issue of “Who pays" must be resolved. At the moment, only the Rafik Hariri University Hospital is carrying out those tests free of charge. In the four private laboratories approved by the ministry, the tests are being done with out-of-pocket payments (100 dollars at the official rate). The National Social Security Fund covers the costs of the diagnostic test and there are discussions going on with the Ministry of Economy for the reimbursement of tests by private insurance companies.

Several dozen molecules which could be used to treat Covid-19, have been identified and they include Chloroquine. Could these early possible treatments change the course of the epidemic?

It is still very early to say. Chloroquine and its derivatives are in fact presented by some as a “potential remedy” against the pneumonia caused by Covid-19, because it can reduce the viral load.

However, extreme caution is still required: although initial clinical studies are being carried out on this medicine (as well as on others), many experimental phases are still necessary before confirming or refuting its efficacy. For example, the Marseille study , whose results have been widely circulated, was conducted on a very small number of patients (36 with only 20 treated with Chloroquine) and this is only a first step in the clinical research process to follow. It should also be noted that Chloroquine - if it turns out to be effective - does not act as a preventive treatment. The virus will therefore continue to spread.

For hospitals, this changes nothing; this medication could be given only to those in severe conditions, meaning those who in any case require hospital treatment and constant medical monitoring. Moreover, the medication can have severe side effects. Self-medication is therefore dangerous.

Is the healthcare system able to absorb the shock?

As everywhere, the epidemic highlights the strengths and weaknesses of the healthcare system. We are lucky: Lebanon regularly appears in the top tier of many studies. To name one: the country ranked 31st out of 195 countries, according to the Healthcare Access and Quality Index analysis published in 2018 by The Lancet, the British biomedical journal, at the same rank as Portugal and Estonia. This “satisfying” ranking is mainly due to the quality of the health infrastructure and the availability of competent and qualified health professionals in our country.

The epidemic could also expose the weaknesses of Lebanon’s health system. Among the most obvious: increasing [access and healthcare] inequities. The poorest are indeed more exposed to the Covid-19 epidemic - think of delivery workers - while their access to care is more limited.

Although Lebanon spends 8% of its GDP on the healthcare sector, similar to some European countries, the government only contributes to 30%. Public and private health funds cover 34% of the national health bill, and 32% are paid by the patients themselves (out-of-pocket payments). This share should not exceed 15 to 20% to reduce inequities.

It should be noted that half of the Lebanese population does not have formal health coverage, whether public or private. For them, the ministry plays the role of a safety-net and only covers hospital care. Under these conditions, can everyone be treated? It is not certain.

Do you think the plan put in place with the help of the World Bank to equip government hospitals is a wise move?

It was necessary to put forward such a plan, but its success depends on the good allocation of financial resources. However, public hospitals, which are at the heart of the system to combat the epidemic, have been the subject of political interference for decades hindering their functioning, despite the existence of a law recognizing their official autonomy. We have a real opportunity here: to change, once and for all, the strategy of the Ministry of Health concerning the regulation of all hospitals. Hospital contracting should be based on performance in order to promote positive competition between all private or public hospitals.

Can we count only on public hospitals?

Given the gravity of the situation, all hospitals, and especially private hospitals which represent more than 80% of the available beds, must join the national fight against Covid-19. Some have already started: they receive only patients in need of urgent care in order to free up more beds and human resources; they are also setting up or have already set up specific centers for this “battle”. All other hospitals, especially in disadvantaged areas, must adopt the same strategy, because the epidemic will not spare any region.

What are the urgent decisions that should be taken by the government?

In practice, the government must ensure continuity of supply of Covid-19 testing kits and personal protective equipment (PPE) to all hospitals and in all regions. It must then release the funds to pay its dues to private hospitals so that they, too, may be able to diagnose suspicious cases quickly and dedicate a building (or ward) for COVID-19 patients, and increase intensive care capacities. The government must finally decide who pays for COVID-19 care: will it be covered by the ministry and for everyone? Otherwise, it must decide to impose COVID-19 as an eligible disease for coverage by all health funds.

This seems difficult when the 2020 budget stipulates a 7% cut in the health budget ...

Obviously, austerity measures should not be applied on the health sector. On the contrary, it is necessary to review the state budget, readjust the budgets of inefficient sectors like the “Électricité Du Liban” and redirect them to the health sector. It seems illogical for us to pay $2 billion to subsidize the electricity crisis and only $700 million for the Ministry of Health and other public health funds. For now, all efforts must be focused on health. It is an extreme emergency.