Navigating Collapse in Lebanon’s Covid-19 Response

Nearly 2,500 new Covid-19 cases are confirmed each day in Lebanon, an untenable number in a country reeling from concurrent economic, political, and security crises and still recovering from the August 2020 Beirut port explosion. Just weeks after emerging from one of the most extreme lockdowns in the world, the Lebanese government ordered yet another one on April 3, 2021—Easter weekend. For many Lebanese, this most recent lockdown was the most challenging to date. Two of the country’s four main power generation plants shut down after running out of oil, leading to daily power outages of up to 22 hours. Ever since the prime minister resigned in August 2020, negotiations for the formation of a new cabinet have stalled, and the caretaker government has languished. A complex web of state, nonstate, and international actors exert influence over daily life in Lebanon.

These challenges make Lebanon one of the most difficult places in the world to manage a Covid-19 response and vaccination effort, and the country is in dire need of additional support. However, because Lebanon is classified as a middle-income country—a classification that does not account for its recent economic collapse—it is ineligible for many forms of international health and humanitarian aid. Complicating matters further, the Ministry of Public Health is effectively under the control of Hezbollah, a designated foreign terrorist organization, so the United States is unable to provide direct support to the government-led Covid-19 response in Lebanon. Many Lebanese harbor deep mistrust of authorities and outside actors, including the United States, which creates additional obstacles.

The stakes are high: the humanitarian and economic crises are intensifying, and security risks are growing. The United States should expand its technical and financial support to the international agencies filling critical gaps in the Covid-19 response in Lebanon, and it should work with its European allies to support the Ministry of Public Health as it oversees the Covid-19 vaccine rollout. A successful vaccination effort will save lives, alleviate suffering, and help to prevent further deterioration in a country on the verge of collapse.

A Confluence of Crises

Lebanon faces cascading crises. Its financial crisis has caused the Lebanese lira to lose more than 90 percent of its value on the black market since December 2019. After draining its foreign reserves, Lebanon is increasingly struggling to import food, fuel, and agricultural equipment, and is cutting subsidies on basic food items. The risk of countrywide food insecurity is growing—more than 50 percent of Lebanese households now live in poverty. Meanwhile, the country hosts the highest number of refugees per capita in the world, including more than 1 million Syrians and hundreds of thousands of Palestinians. The August 2020 Beirut port explosion—widely blamed on government negligence—caused $4 billion in damages and left tens of thousands homeless.

Security conditions are also deteriorating. The acting interior minister stated in March 2021 that the army is no longer able to perform 90 percent of its tasks, saying the security situation “has broken down, all possibilities are open.” Intercommunal violence between Lebanese and Syrians has recently spiked and mass anti-government protests have spread across the country. The Biden administration’s intention to revive the Joint Comprehensive Plan of Action (JCPOA) could generate additional instability in Lebanon. The recent assassination of Lokman Slim, a vocal critic of Hezbollah, has led some to fear that Hezbollah may increase its violent activities to build Iran’s leverage as it considers renegotiation of the nuclear accord.

Lebanon’s once robust health system has buckled under the weight of the economic collapse and Covid-19. Hundreds of healthcare workers have fled the country in “a mass exodus,” unable to withstand the chronic shortages in staff, basic medical supplies, and pay. The August 2020 port explosion damaged 292 health facilities. As the economy has deteriorated and poverty has risen, private healthcare has become unaffordable for many, increasing the strain on the depleted public health sector. The result is a health system that is under resourced, understaffed, and overwhelmed, compromising not just the Covid-19 response, but access to quality healthcare more broadly.

The caretaker government’s response to the pandemic has been chaotic and haphazard. The health system reached a breaking point over the winter holidays, when the government—against the guidance of public health officials—allowed nightclubs, bars, and restaurants to reopen for New Year’s Eve. Covid-19 cases spiked dramatically in the following weeks, with more than 5 percent of the population infected at the peak. More Lebanese died of Covid-19 in January 2021 than in all of 2020 combined. The caretaker government then imposed a severe national lockdown, closing all businesses, including grocery stores, for several days. Economic pressures forced the government to reopen the country in March 2021, but after a spike in cases, the caretaker government instituted another lockdown ahead of the Easter holiday.

Vaccines Raise Hope and Concerns

In a country with an intensifying humanitarian crisis and a weakening healthcare system, Covid-19 vaccines could help stave off further disaster. Despite severe economic constraints, Lebanon has signed agreements to secure 6.3 million Covid-19 vaccine doses, largely due to unprecedented support from the international community. Still, Lebanon’s confirmed procurement deals will not be enough to vaccinate 80 percent of the country’s 6.8 million people in 2021, the target set forth in the national vaccination plan.

On January 21, the World Bank announced that it would reallocate $34 million from its Lebanon Health Resilience Project to finance the procurement of vaccines for the country. These funds will pay for 2.25 million doses in Lebanon’s bilateral deal with Pfizer-BioNTech (an additional 600,000 will be donated by Pfizer), and may cover future agreements made by the caretaker government that meet World Bank standards. The Ministry of Public Health also successfully negotiated a bilateral deal for 1.5 million doses of the Oxford-AstraZeneca vaccine, although it is unclear how this deal will be financed. In early March, the Chinese ambassador to Lebanon announced that China will donate 50,000 doses of the Sinopharm vaccine to the country.

Because of its long-standing middle-income classification, Lebanon is participating in COVAX—the global procurement effort devoted to expanding access to Covid-19 vaccines—as a self-financing country, paying in full for 2.73 million doses. COVAX delivered its first shipment of 33,600 AstraZeneca doses to Lebanon on March 24, but given COVAX’s funding and manufacturing constraints, it may take months to deliver the full order.

More recently, vaccines have begun entering the country through private networks. The Lebanese company Pharmaline announced in mid-March that it would purchase 1 million Sputnik V vaccines, which would be available for purchase by private institutions in Lebanon to provide to their employees. The first shipment of 500,000 Sputnik V doses arrived on March 26.

But as has been seen in countries around the world, procuring vaccines is only half the battle. In Lebanon, procuring and distributing the vaccine quickly and equitably will be a gargantuan task.

A Weak Health Ministry Leaves Gaps

The Ministry of Public Health is overseeing vaccine distribution in Lebanon. With support from the World Health Organization and the World Bank, the Ministry developed a robust national vaccine distribution plan, and it established an official registration portal and an online dashboard that tracks registration and administration. The World Bank has also partnered with the International Federation of Red Cross and Red Crescent Societies (IFRC) to monitor every step of the national rollout, from arrival in Lebanon to delivery and administration at the Ministry’s 42 vaccination centers. Lebanon launched its vaccination campaign on February 14 and had administered over 290,000 shots as of April 12.

Despite this progress, the Ministry of Public Health lacks the resources and the staff to fully operationalize and implement the national plan. As the Ministry struggles to manage vaccine distribution, a range of private and nongovernmental actors are scrambling to fill the gaps. The result is a vaccine rollout that is exacerbating existing issues of inequity, distrust, and corruption in Lebanon.

In late February, public outrage soared when 16 members of parliament and five parliamentary staff received Covid-19 vaccinations, jumping ahead of health workers in clear violation of the national prioritization plan. More recently, Prime Minister-designate Saad Hariri made extra doses of vaccine available in the municipality of a political ally. While Lebanon is certainly not the only country where the rich and powerful are cutting the line, in an environment of intense public anger at the corruption of the political elite, these scandals are particularly damaging.

The proliferation of private vaccination networks—including the recent Sputnik V deal—risks the creation of a parallel market giving preferential access to the wealthy and connected, rather than the most vulnerable and at-risk prioritized under the national plan.

According to the national plan, all residents of Lebanon, including both Lebanese and non-Lebanese citizens, should have equal access to the vaccine. But the reality is that the country’s vulnerable non-Lebanese populations—including more than 1 million Syrian refugees, hundreds of thousands of Palestinian refugees, and hundreds of thousands of foreign domestic workers—are being left behind. Syrians and Palestinians have been disproportionately affected by Covid-19 in Lebanon, dying at a rate four and three times above the national average, respectively.

With the Ministry of Public Health in charge of vaccine distribution and administration, the World Bank, UN Relief and Works Agency (UNRWA), UN Refugee Agency (UNHCR), UNICEF, and International Organization for Migration (IOM) are all working to build vaccine confidence and demand within the populations they serve. But non-Lebanese communities are especially hesitant to register for the vaccine through the government portal, fearing arrest, deportation, or unaffordable payments. As of April 12, Syrians accounted for just 1.9 percent of individuals who had registered for a vaccine, despite constituting about one-fifth of the population.

Vaccine hesitancy is a growing concern as a steady stream of Covid-19 misinformation reaches Lebanese and non-Lebanese populations increasingly distrustful of government and the national vaccine rollout. A recent survey found that just 33 percent of over 65-year-olds in Lebanon plan to get a vaccine, and as of April 12 fewer than one in six people in Lebanon had registered on the government portal.

The inequitable distribution of vaccines could trigger more widespread intercommunal conflict at a time when tensions are high and desperation is growing. Perceptions that Syrian refugees receive more assistance than vulnerable Lebanese from the international community are prevalent in Lebanon. Any initiatives that exclusively target non-Lebanese populations run the risk of exacerbating anti-Syrian sentiment, which has already motivated arson attacks on informal Syrian settlements.

The U.S. government is highly constrained in its ability to support the Covid-19 response in Lebabanon because the Ministry of Public Health is under effective Hezbollah control. The U.S. government has thus focused on providing indirect support for the response through international agencies and nongovernmental organizations. This support totaled $54 million in FY 2020 and included food assistance to counter food insecurity exacerbated by the pandemic; support for water, sanitation, and hygiene programming to prevent the spread of Covid-19; training of health staff at nongovernmental health centers; and the provision of personal protective equipment.

More International Support Is Needed

As the Ministry of Public Health struggles to get vaccines into arms, the situation is deteriorating and time is running out. New variants are spreading, leading to massive surges throughout Europe and threatening to reduce vaccine efficacy. There is a humanitarian and health security imperative to shore up the vaccine distribution effort in Lebanon and bring the Covid-19 crisis under control as soon as possible.

A successful vaccine rollout in Lebanon that circumvents the country’s usual networks of patronage could boost faith in the state at a time when it is at an all-time low. If a new government forms in which Hezbollah does not designate the minister of health, the United States should be ready to provide swift support. But while cabinet formation continues to stall, Washington should pursue multilateral avenues to ensure that the vaccine rollout is rapid and equitable.

The Biden administration’s first National Security Memorandum calls for strengthening the global Covid-19 response and global health security. It includes a directive to “review existing United States and multilateral financial and economic sanctions to evaluate whether they are unduly hindering responses to the Covid-19 pandemic.” Lebanon is a clear case where fears of violating sanctions on Hezbollah prohibit the provision of desperately needed aid to the government agency overseeing the Covid-19 response. Recognizing the intense political and security challenges that complicate this case, the administration should review its policy toward Lebanon’s Ministry of Public Health and explore the possibility of establishing a humanitarian waiver and necessary oversight mechanisms to facilitate the provision of aid.

Because such a review will be fraught and time-consuming, and a policy change would likely face steep opposition in the U.S. Congress, this is not a short-term solution. The Biden administration should simultaneously engage with its European allies, particularly France, Germany, and the United Kingdom, to expand their support to the Ministry of Public Health, as they have more political latitude for such a policy change.

The United States should also join with these and other partners to increase financial and technical support to the many organizations working to fill the gaps left by the Ministry of Public Health and meet the needs of vulnerable populations. This includes but is not limited to the World Bank, UNRWA, UNHCR, UNICEF, IOM, ICRC, and Doctors Without Borders (MSF). This support could come in many forms: direct financial support, vaccine donations for their health and field workers, and technical assistance to inform the complex vaccination effort. These agencies will also need additional resources to combat misinformation and build vaccine demand, particularly as vaccine supply increases and vaccine hesitancy becomes a major barrier to reaching high vaccine coverage.

This expanded support should be accompanied by a call for increased transparency and adherence to the national plan, including the equitable vaccine distribution among Lebanese and non-Lebanese populations.

In a country where so much has gone wrong, the Covid-19 vaccination campaign provides an opportunity to get something right—and prevent further deterioration in a country teetering on the edge. The United States faces particular restrictions in the aid it can provide to Lebanon, but it can and should lead in galvanizing its allies and multilateral partners to ensure the rapid and equitable vaccination of all people in Lebanon. 

Anna McCaffrey is a fellow in the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Will Todman is a fellow in the CSIS Middle East Program.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

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Will Todman
Deputy Director and Senior Fellow, Middle East Program

Anna McCaffrey