The Covid-19 pandemic came on the heels of a deep economic, social, and political crises in Lebanon, amounting to an existential threat to the integrity of the country. Despite Lebanons record of public mismanagement, the country seems to have so far responded effectively to the pandemic. The government and the people themselves acted quickly and succeeded in slowing the pace of progression of the novel coronavirus. As of 6 May 2020, there were 750 confirmed cases and 25 deaths. Lebanon is doing fairly well compared to its neighbours when measured by the time it takes for Covid-19 death cases to double, which is now happening every 10 days with a fairly low plateau (figure 1).

Figure 1. Total confirmed COVID-19 deaths, rate of progression, 1 May 2020. Source: European CDC and Our World in Data.

But several challenges await Lebanon. There are lingering questions about the countrys ability to test and treat a future outbreak in refugee communities. The country has also failed to adopt measures to mitigate the economic impact of the crisis, which means that confinement measures are increasingly unsustainable as many people feel obliged to return to work to provide for their families. At a cost of only about 0.3% GDP (safety net and expanded health care budget combined), the governments response has been extremely subdued - ten times less than Jordan or Tunisia. The question then becomes: how sustainable are Lebanons efforts to contain and mitigate the virus? Can it prepare itself for a possible second wave? Can it devise a socio-economic plan to mitigate the economic impact of the pandemic on an already marginalized population?

The first case of the novel coronavirus was diagnosed on 20 February 2020. A few days later under mounting popular pressure, the government decided to close borders with the countries where the epidemic was becoming worrisome (especially Iran, where the first Lebanese case originated, as well as Italy, South Korea, and China). Since then, the government initiated several measures to try to contain the progression of the virus (closure of schools, day-care centres, universities, bars, restaurants, pubs, shops, malls, and finally ports of entry). Further containment strategies, like curfews and an alternating traffic system, were put in place in an attempt to slow down the progression of the virus.

The strategy seems to have worked, so far. The daily number of new Covid-19 confirmed cases has dropped and Lebanon seems to have flattened its curve. Since 13 March, the case-fatality rate has been stable at 3% (the World Health Organization estimates the global average at 3.4%). In terms of health performance (figure 2), Lebanon is interestingly behaving like Greece, it is performing better than Egypt and Algeria but worse than the Gulf countries or neighbouring Israel.

Figure 2. Total confirmed cases of COVID-19 vs. deaths due to COVID-19 per million, 18 April 2020. Source: European CDC and Our World in Data.

Some have raised concerns about the accuracy of official numbers for several reasons. The number of confirmed infections (the denominator used to assess various indicators) is probably underestimated given that recent serological studies have found that the rate of infections may be 50 to 85 times higher than official figures. Indeed, less than 1% of the population have been tested for the virus. At the beginning of the outbreak, Lebanon was conducting 50 tests per day, and has recently reached 1,500 tests per day but remains below the 2500 target set by the Ministry of Public Healths (MOPH). As of 7 May, Lebanon has carried out around 40,000 tests. The number of tests per one thousand population (4-6.67 depending if the population is 6 million or 10 million) is still far below its neighbouring countries, especially but not only the rich Gulf countries (for example, Israel 47.77, Qatar 39.21, and Saudi Arabia 11.19 - all as of May 5, 2020). Lebanon, however, still fares better than Tunisia (2.13 as of May 4, 2020), a similar middle-income country, which is likewise struggling financially (figure 3).

Figure 3. Total COVID-19 tests per 1,000 people, 6 May 2020. Source: Our World in Data.

Besides the underestimation of the number of confirmed cases due to lack of massive testing, some have cast doubts on the official numbers for a different, more political, reason. The Shiite party, Hezbollah, is managing the crisis in parallel to the Lebanese state with its parallel healthcare infrastructure, which includes one hospital and thousands of medical personnel. Moreover, Rasul al-Azam hospital, which is owned and run by Hezbollah, is not listed among the governments emergency plan. Sayed Hashem Safieddine, who heads Hezbollah executive council, has recently reported that the party has monitored 1,200 people who had returned from Iran, including pilgrims and 220 students who had been studying at Qom, a centre of Shiite learning, without saying if any tested positive and/or if these numbers are regularly reported to the MOPH.

Without reliable numbers about the trend in overall mortality in Lebanon, especially during this pandemic, and without accurate demographic information (last official census was in 1932, and current estimations are impressionistic at best, ranging from 4 million to 10 million for the overall population including refugees), the assessment of the crisis can only be partial. However, even if we assume that official numbers are inaccurate or underestimated, Lebanon seems to have been spared the worst of the pandemic. Possible causes that may explain the relatively low numbers of confirmed cases may include one or more of the following causes that have been advanced: a lack of dense urban centres, lack of public transportation, the relatively young demographic profile (7% of the population is above 65 year old vs. 19.82% in France or 21.69% in Italy), cultural behaviours (the elderly tend to live with their families and not in nursing homes where most deaths occurred in Europe), climate, and even genetic predisposition.

There are three settings with overcrowded conditions that need to be closely monitored. The first is the crowded settlements of refugees. Lebanon hosts the largest number of Syrian refugees per capita, with an official estimate of 1.5 million refugees. It also hosts an additional 18,500 refugees from various countries, as well as more than 200,000 Palestinian refugees under the mandate of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). Since the beginning of the outbreak, the UN agency and its partners have mobilized in raising awareness about Covid-19 and distributing soap and other hygienic and sanitation materials to refugees. UN agencies are also helping the government expand existing capacities for hospitalization, testing, and intensive care.

While there are only a few confirmed cases among refugees to date, the situation is unpredictable. It is also important to note how prevalent stigmatization and discrimination against refugees are in Lebanon as these may pose obstacles to contain the spread of the virus. Since January 2020 and before the government declared a nationwide curfew on 26 March, some 21 municipalities had taken discriminatory measures against Syrians in their efforts to fight the spread of the virus imposing curfews and restrictions on their movements. Human Rights Watch has criticized these measures for contravening Lebanons international human rights obligations and Lebanese domestic law.

The second crowded setting of concern is prisons. On March 17, riots erupted in Lebanons two largest prisons in Roumieh and Zahle with prisoners demanding their release over fears that the epidemic would rapidly spread among them. Lebanon has notoriously overcrowded prisons; 10,000 inmates distributed among 25 prisons and 261 detention facilities. Unlike other countries, such as Iran or Turkey, which have released thousands of prisoners in an attempt to halt the epidemic, Lebanon instead adopted preventive measures, such as suspending all activities and reducing family visits. In an additional attempt to reduce anxiety and fear among prisoners, the United Nations Office on Drugs and Crime (UNODC) has provided mobile SIM cards for inmates to maintain contact with their families.

The third vulnerability is the crowds that will eventually form when more protesters will go back to the street. Since 17 October 2019, widespread protests have raged across Lebanon, demanding an end to the economic and political mismanagement of the country. These protests were in reaction to the rapidly deteriorating economic and financial conditions unleashed by a financial crisis of historic proportion, with significant impact on the standard of living. Lockdown measures have slowed down the protest movement but in recent days protesters have gone back to the street demanding an end to systemic corruption, which they believe to be the source of Lebanons economic and political bankruptcy.

Since the outbreak started, the MOPH has published an emergency framework and kept the public informed about cases, mortality, and preparftness. It presented its strategy of flattening the curve given the limited numbers of ICU beds and ventilators identifying four lines of hospitals (public and private) that will be activated as the need arises. The first concerns 12 hospitals, including the main governmental hospital, which is currently treating patients, Rafic Hariri University Hospital; the second will involve another 12 public hospitals, which will be dedicated to Covid-19; the third involves yet another 17 public hospitals; and the fourth line will involve the remaining 29 public hospitals, in addition to all private tertiary hospitals.

However, public hospitals have limited capacity (222 ventilators and 419 ICU beds) in contrast to private hospitals (1242 ventilators and 2391 ICU beds). Given that the government is running large arrears with private health providers, it is not clear if private hospitals will accept to treat patients with Covid-19 for free. Given also that not all private or public hospitals have independent wards that could treat Covid-19 patients, the total number of beds available is probably less than what is projected.

The MOPH has prepared contingency plans for two scenarios, the optimistic scenario (if 1% of the population gets infected) and the pessimistic scenario (if 10% of the population gets infected) without giving reasons or explanations for these modelling assumptions. Based on these numbers, the MOPH has identified urgent needs, such as equipping 11 public hospitals with additional ICU beds, ventilators, personnel, and protective equipment. According to the MOPH, the maximum health capacity of the country would be reached with 5,000 infected patients, of which 20% would need hospital care (1000 patients), 5% would require intensive care (250 patients), while 2-3% would need mechanical ventilation (150 patients).

The number of 5,000 infected patients could be reached during what many experts fear will be a second wave, perhaps more devastating than the first Prime Minister Hassan Diab has warned about a possible second wave by July if social distancing measures are not maintained. By flattening its curve, Lebanon has successfully managed, for now, to spare hospitals a surge in critically-ill patients but it remains to be seen if this success can be maintained when the lockdown measures will be loosened.

The Covid-19 crisis comes on the heels of a series of blows that have shaken Lebanon in recent months.

The economic crisis, the result of a sudden stop of capital inflows in late 2019 to an over-indebted economy, was already devastating. The drastic lockdown measures only made the shock worse. While the economic crisis had initially mainly hit the formal sector, which is very dependent on banking relations and imports, the Covid-19 crisis extended the shock to the informal sector, which employs much of the poor, due to the collapse in catering, retail, tourism, and transport.

Businesses are going bankrupt, and unemployment is rising rapidly. Rising inflation (running now at a conservative estimate of 40% a year) and deep currency devaluation on the parallel market have sharply reduced real wages. In a matter of months, poverty has expanded dramatically with the World Bank estimating that it will reach 50% of the population by the end of 2020. With little fiscal space, the government has struggled to meet the cost of upgrading the health system and to smooth the effect of the shock on the poorer population.

The period that the country has entered is extremely volatile. The interplay between street movement and Covid-19 can, in the current fluid situation of economic, social, and political turmoil, lead to potentially chaotic dynamics.

The second wave of Covid-19 may come in Lebanon not from purely epidemiological dynamics, but from the interaction of economic collapse, revolution, and epidemic risks, which could lead to a hyper-perfect storm where each process feeds into the others, generating a generalized explosion. In recent days, protesters have been back to the street asking for the stabilization of the Lebanese pound, which is in free fall. The distributional tensions are extreme, as losses as large as twice GDP have to be distributed among the population, pitting the poor and middle class against the rich, and creating sectarian tensions. In this climate of popular insurrection, the political elites may be tempted to use the cover of the epidemic to engage in overt repression as has manifested itself with the army and security forces disbanding protesters tents. At the same time, street action is likely to only intensify in the coming weeks, leading to a faster spread of the virus, especially among the poorest in dense urban centres where hunger is a bigger worry and threat than the virus.

More optimistically, there is also a possible salvation pathway of cooperation and solidarity in the face of national adversity. This may be too much to expect in the current circumstances, where many protesters believe that the current government is hopeless because of its dependence on the existing political class. But that pathway could use the relative success in managing the Covid-19 crisis to rebuild trust between the citizens, the state, and the elites. In the same vein, the risk of the pandemic spreading across society may be more threatening than the risk of social and economic division, pushing the Lebanese across class and sect to work together in finding a solution to the historic economic challenges that both divide them, but that can also only be addressed successfully through national cooperation. Perhaps then, paradoxically, it may be the second wave that will initiate the serious soul-searching that Lebanon requires to allow it to navigate these troubled waters and invent the new social contract it urgently needs.

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Lebanon: Managing Covid-19 in the Time of Revolution -