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Too Little Too Late: A Timeline of Lebanon’s Response to COVID-19

Hussein Mahdi

Promo-Too Little Too Late: A Timeline of Lebanon’s Response to COVID-19

In early August 2020, Lebanese citizens followed a televised debate between the Minister of Health, Hamad Hassan, and the Minister of Interior, Mohamed Fahmy. The Health Minister announced the requirement of “exceptional approvals” to hold weddings during the lockdown period due to the increasing number of cases. The Interior Minister, on the other hand, opposed his colleague and reprimanded a recipient of exceptional approval, causing confusion about what appropriate measures should be taken to tackle COVID-19.

This wasn’t the first time the government response to COVID-19 sparked widespread confusion in the country. In fact, a lack of communication, delayed response and power conflicts have characterised the Lebanese government’s response to the pandemic since the country’s first recorded case in February.

The government and its ministers had previously boasted about their implementation of the World Health Organization’s (WHO) guidelines and their ability to follow best practice in tackling the pandemic. These praises were echoed internally by ministers, officials and politicians. However, reality on the ground reveals an entirely different truth.

At the end of June, the government decided that a gradual return to ‘normal life’ was necessary, and lifted the state of emergency. This meant that tourism and commercial facilities, including the airport, were allowed to reopen. The only explanation for this decision was the government’s desire to boost the economy through foreigners bringing US dollars into the country. But these relaxed measures led to a rise in the number of COVID-19 infections, and by July 27, 3,879 cases had been confirmed.

The government responded by reinstating a country-wide lockdown from July 31 to August 3, and again from August 6 to August 10. This decision was widely criticized as there was no warning or explanation behind the selection of non-consecutive days, which coincided with Eid al-Adha, an Islamic holiday.

By August 9, the number of recorded cases had doubled to reach 6,517.

This investigation documents the timeline of government decisions and actions, most of which were reactive instead of preemptive or preventive. It highlights the government’s failure to adhere to and apply an already existing legal framework which facilitates preventative actions.

Where it All Began

On February 21, 2020, the country’s first COVID-19 case was recorded when a Lebanese woman returning from Iran tested positive. Prior to this, on February 4, the committee tasked to address the virus met for the first time to discuss preventive measures and procedures. A WHO representative was present, yet no action followed the meeting.

The representatives from the relevant departments, which formed the committee and were tasked with developing contingency plans for facing disasters, were content with simply presenting their proposed actions and strategy in the event of a crisis. Yet, in practice, the strategies and mechanisms allegedly developed were neither announced nor implemented.

Immediately after the first case was announced, the Lebanese government demonstrated their lack of preparedness by failing to take swift and effective action to prevent the spread of the virus. In retrospect, it’s clear that they saw the virus for its security threat, rather than its health or societal dimensions. As such, the committee was headed by the Secretary General of the Supreme Defense Council, and the majority of its representatives were from other military bodies, instead of the appropriate medical bodies.

The first action taken by the government was to halt the export of medical personal protective equipment, and other tools that prevent contagious diseases. But this decision was not taken preemptively. Rather, it coincided with the announcement of the first recorded case, and after at least 4 million medical masks (both N95 and regular) had already been exported. These masks were sold for more than 30 times their original purchase price, according to the Medical Equipment Importers Association.

According to a pharmacist speaking on the condition of anonymity in the southern city of Nabatieh, pharmacies used to buy a pack of 50 masks for between $2.5-$3.5, while five masks were sold for 1,000 Lira (less than a dollar). But once the first case was announced, masks disappeared from pharmacies, only to reappear a few days later with a ___% markup.

At the beginning of the crisis, merchants sold masks to pharmacies for an amount ranging between 35,000-55,000 Lira (approximately $23-$35). At that time, the consumer price for one mask ranged between 2,000-5,000 Lira ($1-$3). According to the same sources, merchants were allowed to manipulate the mask market without government intervention by holding back stock and selling masks that were imported before October 17, and sitting in their warehouses. Despite the price increase, the Internal Security Forces were strict in imposing fines for those not wearing masks and gloves.

In the same context, and on March 17, the government decided to pursue efforts to reduce the prices of sanitizers and disinfectants. Adding to the dramatic increase in market prices, tests and studies conducted by the Industrial Research Institute, revealed that three out of 10 hand sanitizer brands on the market do not meet the required specifications.

On March 19, after the number of cases reached 149, efforts were made to identify and source the equipment needs of local hospitals for one month, also aiming to supply medical personnel with personal protection. This included gathering information on potential isolation centers located across the country.

However, until March 20, the number of required medical devices and hospital beds had not been determined. On the same day, a message outlining the general directives related to the virus was circulated to governors by the Minister of Interior Affairs. This action was taken 10 days late, according to the National Coronavirus Response Plan, and 28 days after the first confirmed case in Lebanon.

The National Plan: Wait for an Outbreak

The National Plan, approved on March 10, predominantly relies on awareness campaigns and waiting for Lebanon to reach the "fourth stage" or a full virus outbreak, in order to start implementing preventative measures.

Meanwhile, a discrepancy appeared in the number of cases recorded by the Ministry of Health and the Disaster Management Unit. The former recorded 52 cases and the latter, 58.

This discrepancy continued until March 13, the same date the National Plan predicted Lebanon would enter the third phase of COVID-19; the stage of virus containment.

The most prominent measures stipulated in the plan for the third phase are:
1- Monitoring land, sea and air borders by measuring the body temperature of arrivals to the country and asking them to provide information regarding their potential exposure to the virus.
2- Banning travel to affected places.
3- Conducting laboratory tests for suspected cases.
4- Adopting a “track and trace” methodology by investigating those who have come into contact with positive cases. This procedure had no specific instructions for implementation until after the announcement of a lockdown on March 15. In those five days, the number of confirmed cases had jumped from 58 to 99, according to the Ministry of Health.
5- Utilizing the resources of other non-health related institutions to support the Ministry of Health, especially in implementing public health measures.
6- Evaluating the capacity of government hospitals to house and treat COVID-19 patients.

The plan also indicates that, at this specific stage, awareness campaigns should be implemented to educate people on appropriate preventative health measures. Additionally, the plan called for the media’s involvement in keeping the public informed.

On March 30, a memo was issued by the Ministry of Health on how virus-infected corpses should be handled.

The memo emphasized the importance of “avoiding exposure to the deceased's fluids and the proper use of protection during the preparation and shrouding of the body.”

“Additionally, if the corpse requires washing, an insulating robe covering the entire body must be worn with arms, goggles or a mask, a muzzle and gloves. Further, the corpse must be wrapped in a sealed, insulated plastic bag, and all surfaces, equipment, and transport vehicles used must be cleaned, sterilized and decontaminated. During the burial, it is imperative for family members to avoid touching the body of the deceased and the ceremony should be restricted to the immediate family. Condolences should be communicated over the phone or through online social media platforms,” it read.

The aforementioned communication was 20 days late considering the first death was recorded on March 10. To date, the number of coronavirus-related deaths have reached 11.

Airport Activity and the Selective Suspension of Flights

The Lebanese government, like many governments around the world, began to control air traffic in the early days of the pandemic –– especially between countries with high casualties. Iran and Italy were both exempt from this rule to allow Lebanese citizens to return to Lebanon. Both countries, however, had already reported a high number of casualties (300 in Italy and 100 in Iran). Given the risk of possible transmission, travel to and from these countries should have also been controlled.

As for measures taken to mitigate the risk of infection in arrivals at Rafic Hariri International Airport from Iran and Italy, they were limited to temperature checks and the completion of health forms. Later, it was found that the health forms were actually intended for Ebola, but, according to information circulated to the flight crew, they were told that the form “also applies to the coronavirus”. On board some flights, these forms were neglected, as documented by the investigator through testimonies.

Until March 18, when the airport in Beirut fully closed (to all countries including Italy and Iran), Italy had recorded 28,710 cases, and Iran 10,516.

Lebanese nationals abroad were given a grace period to return to Lebanon before the airport’s closure. But upon their arrival they were allowed to go home without isolating in quarantine centers or following any other special procedures. The government relied on its people to self-isolate.

As expected, various returning nationals did not abide by the imposed self-isolation periods and some even continued to go to work. In one case, the virus was transmitted to a soldier working inside a military court, which led to the infection of at least 13 of his colleagues. This incident clearly indicates that necessary preventive measures were not enforced in the workplace, according to a statement issued by the Directorate of Strategy.

Expatriates made up the majority of cases recorded in Lebanon during that period and a report issued by the Ministry of Health on March 11, shows that cases were divided as follows: 37% were expatriates (from Egypt, the UK, Iran, and Switzerland); 58% were in contact with confirmed cases; and only three of these cases are under investigation.

As of March 11, the number of lab-confirmed cases reached 61. However, this is not an accurate indication of the number of cases as tests were limited to those exhibiting symptoms or those originating from countries where the pandemic had already been spread.

Further, the rate of these examinations at the Rafic Hariri Governmental Hospital’s lab was limited to approximately 74 tests per day. This strategy meant that it was up to asymptomatic individuals to self-diagnose and consequently self-isolate.

It was not until April 18, when the number of cases reached 672 and the number of deaths reached 21 that they began taking random samples from different regions to determine the actual spread of the virus and take the necessary measures. It is worth noting that the National Plan had indicated that private hospitals would not be used to treat cases until full capacity was reached in all government hospitals. This is in spite of the fact that private hospitals in Lebanon are more equipped with personnel and technical resources in comparison to government hospitals.

To justify the lack of testing, the Health Ministry invoked the country’s financial deficit. On March 16, the Ministry paid approximately 20 billion Lira ($13 million according to the official exchange rate of the Banque du Liban and $2.67 million according to the black market exchange rate) in private hospital dues. On April 22, the Parliament issued additional provisions worth 450 billion Lira ($300 million at the official exchange rate and about $60 million at the black market rate) for these hospitals.

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Nationwide Lockdown: Security Measures instead of Preventative Measures

On March 15, a discrepancy of 99 cases between the number reported by the Ministry of Health and by the Disaster Management Unit appeared. On that same day the government officially announced the implementation of nationwide lockdown.

According to the National Defense Law, the national declaration granted authorities the right to impose control over energy sources, transportation, communications, raw materials, industrial production, food supplies and regulate their import, storage, export and distribution.

The law also allowed for authorities to arrest suspected people and seize funds as they saw fit.

Following the lockdown announcement, the government decided to shut down all public and private institutions, with the exception of necessary operations; security institutions and administrations. Further, all citizens were required to stay home unless necessary.

On March 21, the Ministry of Interior Affairs began strictly monitoring and controlling lockdown violations, in light of the increasing rate of cases, with 43 new cases announced on the same day (a sharp increase from the previous 206 cases) by the Ministry of Health. However, what became clear, was the contradiction between the Ministry of Health and the Disaster Management Unit, which recorded 67 new cases (a total of 230 cases).

On March 27, a curfew was imposed between 7PM and 5AM, and on April 5, the Interior Ministry set a specific time for cars, trucks and motorcycles to travel according to plate numbers. Following this decision, curfew hours varied according to the number of recorded cases.

Just 11 days into the random testing phase, before the results of these tests were revealed and the true extent of the virus’ spread was truly understood, the government decided to gradually open the country. This action was taken in spite of the Health Minister’s reservations against the gradual resumption of “normal” activity. Shortly after, on May 13, the country was once again fully locked down.

The government based this decision on the relatively small number of new daily cases, and the fact that, on April 21, none were recorded. The government also assumed that it would be possible to transition out of lockdown because the country was at a point where the number of cases was still proportional to hospital capacities, and there was no evidence of a prospective outbreak.

However, as mentioned, the number of cases originating from those returning to Lebanon continued to increase. Thirty-four new cases were recorded on May 7, only one of which was carried by a permanent resident – the rest being expatriates. This was problematic because it led to a general increase in cases for those in contact with expats. Here, two key failures and weaknesses can be identified. Firstly, the authorities’ inability to enforce and monitor a two-week quarantine period for those returning to Lebanon. Secondly, its failure to utilise the 46 existing quarantine centres at the time.

The government blamed the increase in the number of cases on the public. The Minister of Interior Affairs threatened to enforce stricter rules and increase fines for those violating the law, specifically 3 million Lira ($2,000). He also threatened to completely shut down the country if citizens continued to be non-compliant with preventative measures.

However, these threats were not accompanied by any incentives to facilitate its citizens adherence to lockdown procedures, especially given that 40% of the population may soon find themselves below the poverty line, as announced by Prime Minister Hassan Diab in a statement released on March 7.

To make matters worse, the majority of businesses cut their employees’ salaries due to the country’s economic crisis. The majority of employees now earn half or a third of their full salary, while daily-workers have almost completely lost their income. Consequently, a large proportion of the public can no longer secure or afford basic necessities such as food and housing.

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On March 17, the government decided to distribute assistance to citizens with disrupted jobs who had lost their means of income. This meant that the government would provide food rations to the families that needed it the most. However, this emergency plan was not approved until March 26, and would not be enforced before April 15 at the earliest.

A few days after the plan was approved, and specifically on March 31, the government changed its approach and decided to provide a cash transfer (400,000 Lira = $300) instead of distributing food. They also announced that the Lebanese Army would enforce these cash transfers, however a timetable of when or how this would actually be distributed and allocated was not specified.

On April 10, the Ministry of Social Affairs announced that the distribution of this aid would begin four days later. But distribution was postponed when the army’s review revealed errors in the list of beneficiaries due to the inclusion of families that did not need the assistance.

After the beneficiaries were reviewed, the government decided to provide cash assistance to families named in the Ministry's “Poorest Families Support Program”. This included those affected by mines, the families of public school students, and public transportation drivers.

Eventually, on April 22, the cash transfers were distributed by military personnel over several phases. This aid only materialized two months after people lost their income, and after the country witnessed several violent protests and clashes with security forces over Lebanon’s deteriorating living conditions.

According to the National Plan and the government’s strategy to gradually return to normal life, the end to national lockdown began on May 18. However, this was no different to previous attempts to resume normal activity and did not include new measures that would prevent a second wave.

Policemen Determine "Safe Distance"

The ways in which ministries responded to the end of lockdown were relatively varied. Some were able to apply minimal preventative measures, although this was also implemented a lot later than intended, while others completely avoided taking any precautions. The Ministries of Finance and Health, for example, did not specify any preventative measures (such as updated capacities to ensure distancing between people) inside their institutions. These procedures and preventative measures should be implemented and monitored by the government and ministries, at the very least, but such measures were instead left to the discretion of security forces, without a clear and communicated criteria.

Furthermore, Lebanese authorities did not use already existing frameworks to tackle the crisis. Instead, they attempted to confront the crisis without any legal support or procedures that could be applied and easily communicated to citizens and public administrations.

The Ministry of Health did not use their power to more actively respond to the crisis. The Infectious Diseases Law passed in 1957 gives the Ministry of Health the power to issue a decree specifying the measures that would prevent the spread of epidemics in the country. The law also outlines the delegation of authorities for each department and the measures they are required to take.

It also stipulates that all expenses for the implementation of these measures are to be covered by the government, and that major municipalities shall bear a quarter of these expenditures.

Article 10 of the same law allows the Ministry of Health to establish a “health zone” on any affected place, and prohibit, restrict or control entry to and exit from the area.

At a time when the weekly number of cases increases by more than 1,000 infections, we find that the government is unable to contain the outbreak of COVID-19. Additionally, the government is no longer capable of implementing a full lockdown due to the deteriorating condition of the country’s economy on the one hand, and weak preventive measures on the other.

If the current situation continues, the number of COVID-19 cases may exceed the government’s and private hospitals’ capacity to accommodate new patients. Overall, this crisis will continue to threaten the lives of the Lebanese people in the coming period, unless appropriate solutions are implemented.

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