Why Lebanon’s Health Sector Is Messed Up

Abdul Ra’ouf was a 4 months old baby boy and he is another Lebanese tragedy. He was refused admission to hospitals in Akkar and has passed away. I suspect Abou Faour will hold a press conference soon.

In late February, a scandal hit Hotel Dieu as the Ministry of Health, led by Abou Faour, froze its contract with that hospital over them not admitting a patient who had no other form of coverage.

Heartbreaking stories of children dying make headlines, but they don’t tell you the truth of the health sector in Lebanon. That truth is in the numbers:

Before going into what thosee numbers mean, let’s take the hypothetical scenario of a hospital with 100 beds. The beds in that hospital are divided according to coverage: those covered by insurance have the biggest chunk allocated to them (let’s say 70), while those covered by NSSF have 20 beds and those covered by the Ministry of Health have the remaining 10.

Hold that thought for a second and let’s talk about the numbers.

Half of the Lebanese population (48%) is covered by the Ministry of Health (MOH), while 23% are covered by the NSSF (daman) and only 8% are covered by private insurance. This means that about 2 million Lebanese have the MOH as their ONLY way to afford hospital care in the country.

Having half of your people covered by the ministry doesn’t seem too bad right? The truth of the matter is far less utopian.

Having half the country covered by the MOH means those 48% are entirely dependent on the MOH’s budget. The disaster is when you find out that out of all the ministries running this country, the budget allocated for the MOH to cover the needs for HALF of the country is 3%.

How The Ministry of Health’s Budget Is Divided:

16% that budget goes towards expensive drugs notably cancer treatment. Patients not covered by the NSSF have to resort to the ministry for their medication (if they can’t afford it, which is the case of  99.7% of Lebanese).

Getting the medication out of the MOH isn’t easy. Sometimes they run out of the medication and you end up having to wait until they bring it back into the country. Other times, as has happened with a friend of mine who needed a $12,000 treatment over the course of a couple of months, other people come in and take the medication that was allocated to you, sign for you and leave.

The system is rigged with wastas, bureaucracy and corruption.

80% goes to hospital care, which is where most of the people need the MOH: operations, hospital admission, etc.

So imagine ONLY having 80% of the country’s 3% budget used to essentially treat 50% of the Lebanese population. This is why the MOH has the least number of beds at the country’s major hospitals: the MOH often doesn’t pay, and when it pays, it does so extremely late.

So when you hear that a patient couldn’t find a bed at a particular hospital, it doesn’t always mean that every single bed in the hospital is full, it means that the beds for that patient’s coverage are fully occupied, and that is very easy to occur when 48% of the country gets a minimal amount of beds in the country’s major hospitals.

Does that sound harsh? Of course it does. All Lebanese are entitled to excellent care and that level of care is, sadly, rarely available outside of Beirut and its major hospitals. Why so? Because excellent care is not cheap. Those imaging equipment with fancy names you hear being thrown around on shows like House, MD and Grey’s Anatomy cost in the millions. Every time a hospital buys something to advance its level of care, they pay figures in the seven digits. Even the research that goes into advancing care is expensive.

The level of care being expensive is a big problem. The bigger problem is not having hospitals that are close to the level of those inside Beirut outside of the capital. Most of the people in the country cannot afford places like AUBMC, SGH or HDF, but they can go to public hospitals where the level of care has the potential to be excellent but is handicapped by how little funding those hospitals get.

4% of the MOH’s budget goes to help public hospitals. What you need to know is that public hospitals are not exactly under the jurisdiction of the MOH, which means that the Ministry isn’t responsible for their finances and how they run: they have a separate board of directors that is required to run them and keep them within profit margins. However, as is the case with almost all public hospitals in the country, very few (if not none) are success stories because of the lack of governmental support that goes toward them.

I rotated at one of those public hospitals not too long ago. It wasn’t an eye opening experience because I do come from a non-privileged area of the country, but it was a heartbreaking one. The hospital was in a state of near-decay. Some of the equipment didn’t work.  And all the patients were one sad story after the next.

The latest high profile example is Beirut’s Governmental Hospital which has been in the news for months now because of the lack of payment to employees. Imagine not getting your salary for months. Does it make it okay just because you’re a doctor or a nurse?

What Happens When The MOH Freezes Its Contract With A Hospital:

As a response to HDF not admitting the patient (who wasn’t a case of emergency in which case the hospital is required by law to take care of a patient), Abou Faour decided to put his ministry’s contract with the hospital on hold. I suppose he thought that was punishing the hospital enough, and you thought he was defending your rights in doing so.

What freezing that contract means is that those 10 beds in that hypothetical hospital are no longer allocated to patients covered by the MOH. Freezing a contract with a hospital affects the patients, not on the hospital.

Hospitals And Doctors Can Also Be Greedy:

There are a lot of hospitals and doctors in the country that are greedy, and the system permits the perpetuation of that greed.

The most relevant story to that regard is of someone I knew who required a major surgery. That person’s community tried to intervene by raising the funds. Eventually a high profile charity heard of that person’s problem and donated. In doing so, they forced the hospital in question to lower their required fees by a decent amount, because that charity needed the invoices to be audited abroad.

A lot of this goes on behind closed doors. The lack of regulations means that you don’t know which part of the money is going where.

The Media Doesn’t Help:

Out of all sectors in the country, medicine and healthcare are the juiciest to be spoken about in the media, and the way the media talks about hospitals and about patients dying is ignorant.

A couple of weeks ago, Marcel Ghanem shared a story on his show about a woman who died at a hospital in Jbeil because they didn’t give her some covers from the cold. People were outraged. Were those nurses seriously watching Yasmina and not giving the woman a blanket? What an atrocity!

The truth is very different.

That patient was a cancer patient. As a result of her chemotherapy (which she was able to afford!), her immunity was immensely suppressed, rendering her unable to defend against infection. The patient presented to the ER of that hospital with what we call “neutropenic fever,” which is fever in the background of immensely suppressed immunity. Why did the patient die? Because she ended up in septic shock, a condition with extremely high mortality.

But that doesn’t sound too media-appropriate. The problem with Lebanese media isn’t that they talk about stuff that go wrong in hospitals. They should, and they should do it more. It’s that the angle they often use is useless, leads to zero changes and doesn’t highlight the real problems here: inequality, lack of funding, lack of coverage, etc.

My Own Sensational Story:

She was such an adorable 4 year old when she walked into the doctor’s clinic in Beirut, coming all the way from Tripoli. What’s your name, we asked. Farah, she answered in a barely audible singsong voice.

Farah was there for further reparative surgeries for a congenital defect she had. A tube was sticking out of her neck to allow her to breathe. The doctor offered to do the operation pro-bono, but the hospital had no beds available for her.

I saw her father weep. I have already lost two daughters, he said, by settling to hospitals in the North because I couldn’t afford Beirut. I don’t want to lose her too. And in a corner of the room, I saw my colleague tear up.

Farah is 48% of the Lebanese population.

My colleague then approached me and said: this is something you need to write about, and so I did.


How Lebanon Is Bracing Itself For Ebola

Earlier today, my phone buzzed with a breaking news notification about a patient being investigated for Ebola at a, as of now, unnamed Beirut hospital. An hour or so later, as I had figured, the patient turned out to have malaria. But that didn’t stop people from freaking out about the disease’s possibility of invading Lebanese territory. I mean, it’s only a matter of time anyway as Ebola is the only thing, possibly, that hasn’t strutted across our borders yet.

At an almost 30% chance of having Ebola spread to it, Lebanon is not at bay. 30% is a lot in medical terms. However, that isn’t to say that nothing is being done regarding the issue or that it’s being ignored as we’ve ignored almost every other pertinent matter that could potentially affect this country. I guess when it comes to health, people pay more attention.

In a matter of weeks, Ebola has become something that we, as medical professionals (or soon to be medical professionals), had to keep at the forefront of our minds as we saw patients in ERs or in any other setting for that matter for patients who have fever or a constellation of indicative symptoms.

Back in the old days, we’d start by asking about associated symptoms to try and draw a picture of a syndrome, a viral illness or any possible etiologies that made sense give the season, the condition of the patient, etc. Nowadays, we start by asking: have you had any recent travel history, sir?

Our cut-off to rule out Ebola in someone who presented from an endemic area, few as those people are, is about 3 weeks. I’ve seen people panic that they’ve encountered someone who visited Lebanon from Nigeria 3 months ago and are currently presenting with fever. No, it doesn’t work that way.

The Ministry of Health, in its capacities, has circulated memos to Lebanon’s hospital to educate employees, nurses and doctors about Ebola and about the proper ways to handle patients suspected with the disease. I have taken pictures of the memo in question, which you can find as follows:

When it comes to our airports, however, the story is entirely different. Sure, there’s probably not a massive influx of Lebanese coming from West Africa, but even with the global worry regarding the virus, there’s been basically zero measures at our airport to screen passengers or attempt to keep ebola in the back of their minds, just in case, especially in passengers from Sierra Leone, Guinea and Liberia. I guess there are more important airport-related issues at hand, such as fixing that A/C.

The media, on another hand, isn’t doing a terrific job either at spreading awareness regarding the virus or educating people on it in order to decrease mass hysteria and help catch suspected cases earlier, in case they happen to be there as unlikely as that is.

In a way, Lebanon is better prepared for Ebola than it is for any of our average crisis. Our hospitals are well equipped and can handle such cases extremely well. We have excellent equipment and doctors and, believe it or not, excellent medical management – at least at Beirut’s major hospitals that is.

The status of Ebola and Lebanon can be summarized as follows: there are more people in Lebanon that have been attacked by MP Nicolas Fattouch than have had Ebola.

Vaccinate Your Children Against Polio Starting Tomorrow

The Lebanese ministry of Public Health is starting a massive polio vaccination campaign tomorrow. As I’m currently rotating in pediatrics, I’ve seen a lot of parents who are unaware of the vaccine, who are having second thoughts about giving it to their children and who have not given the vaccine much thought to begin with.

Why You Should Care:

With the increasing influx of Syrian refugees, Lebanon is at an increased risk of a resurgence of diseases that we thought had long died off in the country, second to successful campaigns, such as polio.
Because the Syrian refugees in the country are uncontrolled, we cannot ascertain the disease load they’re bringing with them as as such we have to be extra careful with our children’s well being.

Poliomyelitis is a viral infection that can leave your kid paralyzed. Why take the risk?

Why You Should Spread The Word:

Polio vaccines are in two forms: an oral form and an inactivated injectable form. Both have 100% efficiency. The latter has no side effects while the former has a side effect that happens at about 1 in 2.4 million. The form that will most probably be employed in the campaign is the oral form and this provides the country with something that is called herd immunity and is actually able to help the children that have not be vaccinated.


Herd immunity is basically the following: when people in a setting are all incapable of catching a disease and therefore spreading it, those who are not vaccinated will be protected by default. In case of the oral polio vaccine, the vaccine gets excreted by the child and can be transferred to other children. Therefore, the more you spread the word and the more children get vaccinated, the more the country will be protected.

Consult Your Pediatrician:

Your doctors are there to help you. Many of you have most probably had their children take the polio vaccine already but if you have any doubt on the matter, consult your pediatrician and ask them what to do. They will be more than helpful given that they are active components of the campaign set forth by the ministry of health.

I know this isn’t the regular stuff you’d expect from this blog but I find this matter of utmost importance and I hope you find that is the case as well.

How Lebanese Women Can Save Their Lives

Almost a year ago, my October turned pink as my mother got news that she had breast cancer. After the initial shock of the matter subsides, you’re left with one of two options: you either think rationally and fight or succumb to your emotions and crumble. It was a tough year, that’s for sure. My mom wasted away because of the chemo. She lost her hair, vomited anything she’d eat. But she’s getting better now.

My mom, however, is not your typical breast cancer patient: she doesn’t have a family history that would cause anyone to be more vigilant. The other risk factors associated with breast cancer do not apply in her case. And yet, there she was getting a needle stuck in her central IV line. My mother fell through the statistical cracks of medicine, like so many other people out there.

October may be breast cancer awareness month but I figured I’d shed some light on other cancers that aren’t discussed often and which might be prevented with some careful attention.

Breast Cancer:

I’m especially happy at the response I got after writing about my mother’s diagnosis, with many readers coming up to me to tell me that they got their mother to go get tested as well and they’re relieved she has nothing or, in the case of some unlucky few, had a very early stage of the disease. A lot of research and money has gone into breast cancer. We’re at a stage, medically, where early detection is almost synonymous with cure.

Early detection happens by personal observation first and foremost. If you feel any difference in the shape of your breast or any odd sensation that wasn’t there before, make sure you consult a gynecologist who will do a breast exam. Don’t worry, though, the exam is not painful. It consists of very careful inspection of the breast for any masses as well as how any potential mass might be affecting shape, texture, etc.

Seeing as October is free mammography month, there’s absolutely no reason for every woman aged 40 and above not to get one. If you have a family history of breast cancer, mammographies should have started by age 30-35. The sad part is that despite mammographies being either free or at a greatly reduced price during October, Lebanon’s medical community has had trouble in getting the message to some sectors of Lebanese women.

Make sure the women you know get tested this month. Make sure you haven’t had any changes. They might sound like small steps but they can go a long way in saving the lives of the women you love.

Cervical cancer:

The thing about cervical cancer is that there’s a quick screening method for it called a pap smear. It’s recommended to do the pap smear annually until you’re 30, with the test starting preferably by the age of 21. It’s a screening exam so it cannot give you a diagnosis.

The other thing about cervical cancer is that there’s a vaccine which could cut your risk of getting it by about 90%. Why so? Because the main causative agent of the cancer is a virus that’s called HPV, which is acquired by sexual intercourse. It’s preferable  to get the vaccine prior to your first sexual relation. However, even if you have had a sexual relation without taking the vaccine, you can still take it and have your risk reduced dramatically.

A lot of Lebanese women don’t take the vaccine or do a pap smear for the following reasons:

  • They believe it’s a taboo to take a vaccine for something that’s related to sex,
  • The vaccine itself is quite expensive, especially since doctors charge quite a hefty sum to administer it,
  • Many women don’t trust vaccines to begin with,
  • Having a gynecologist is, to many, only a matter that should happen after marriage.

The HPV vaccine, however, has proven itself to be very efficient. With its introduction into the medical field, cervical cancer deaths have drastically decreased. So in case you haven’t taken the vaccine or done a pap smear yet, consider this a sign that you should do so.

Ovarian Cancer:

Ovarian cancer is sometimes called the silent killer of women. It’s currently the leading cause of gynecological cancer deaths among women. It’s so inconspicuous that its diagnosis usually happens at a very advanced stage, when the disease has already metastasized. Less than 20% of women survive an advanced stage of some types of ovarian cancer. This cancer metastasizes to the lungs, liver, bowels, among other organs. The operation required to resect and manage the spread is considered a marathon and often only buys a little time for treatment, which is usually very harsh.

Ovarian cancer doesn’t have screening methods or vaccines. It requires you to be vigilant. A yearly visit to your gynecologist who does a pelvic examination should suffice. If there’s any suspicion, your physician will order an ultrasound to guide any possible diagnosis.

Your Life Matters:

My mother, like many other women, took her health way too lightly. She paid the price for it. Don’t let that happen to you or the ones you love because your health and life matter. There are other types of gynecological cancers than the aforementioned that affect women. The common denominator is not to treat any sign that your body might be telling you lightly, not to have a sense of immortality or denial imprinted on you despite all forms of common sense and, most importantly, not to so shy as to no seek out a gynecologist for any possible reason. On the contrary, make sure you find a gynecologist who proves to be the best fit for you, with whom you can be comfortable and with whom you feel free to discuss whatever’s making you worry.

The Ultimate Lebanese Medical Taboo: Mental Health, Not Demons. Psychiatry, Not Exorcisms

“Tell me I have cancer please,” she said as I stood next to her in the Emergency Room. “Tell me I have cancer,” she repeated again as if repetition would make it true. “I have cancer, yes I do. But I’m not insane.”

1 out of 5 Lebanese will have a mental disorder during their lifetime. This is in sync with international averages, which is interesting given the proficient history that serves as precipitating factors galore that we’ve had. But be sure of this: we all know someone who has or will have a mental disorder.

50 is the approximate number of registered and licensed psychiatrists that could potentially treat these patients. 50 for slightly less than one million. We have incredible shortage and yet it doesn’t show to everyone. Why? Because we simply don’t talk about mental health.

0 is the number of local insurance companies that cover for psychiatry. People don’t care enough about the issue in order to pressure them to make it included with their healthcare bundle. It will never happen, they’d say. It only happens to other people, just like every other serious illness I suppose.

A patient my age thought she was living inside a snake on Mars. That was where she was when she presented for hospitalization with bruises all over her body.
Her family denied knowledge of those bruises at first. But they were too systematic to be coincidental. She had bruises over here wrists, torso and legs. Her parents still didn’t budge.
The patient in question was living on Mars for a few months now. She wasn’t brought in earlier because her family thought she was possessed. A religious man had tried to perform an exorcism. We live in a country where it’s more acceptable to say demons are inside a family member than to say he was admitted at a hospital and is on a few meds.

That patient wasn’t the first nor the only one I saw who had attempted many exorcisms at the hand of religious figures before finally deciding that what was wrong wasn’t, in fact, spiritual as much as it was simply biological and chemical. It’s always that way: demons, not disease. Exorcisms, not medicine.

Wasn’t it at the times of our great-great-to the power ten-grandfathers that illnesses were associated with evil spirit?
That seems to still be the case today in Lebanon, and many other countries around the world, when it comes to mental health. The way we view mental health is also that of a taboo whereby we try to hide from it, shut it away as something not to be talked about. Even the suicide of Amina Ismail, sensational as it was, didn’t turn in the media into a discussion about mental health. It was a discussion about her private life. We have it among family members but instead of looking at those family members as sick people, akin to any person with any chronic illness, we look at them as burdens who got themselves into the mess they are in. My family is no exception to the statistics. And I’ve seen both ends of the spectrum: the cancer patient is seen as the sick one. The mentally ill patient is seen as the spoiled one.

The extent that mental health is a taboo in this country is best manifested when you observe the way people act around the possibility of a mental disorder diagnosis. Some of them exchange their names with numbers as identifiers. You can name me thirteen if you want to. Others would panic when psychiatric people are called in for a consult. “I’m not crazy, get out of my room.” Few are the people who are open about the idea of possibly going to the psychiatric ward. Even fewer are those who actually present voluntarily. The least of all people are those who are open about any possible mental disorder they might have and who actually view such disorders the way they view any other illness. You should also see the reaction that doctors who are specializing in psychiatry get every time they tell people of their plans.

Then there are the diseases which have been ridiculed by people to the extent that few seem to actually see them as illnesses anymore. Schizophrenia becomes split or multiple personalities just because Hollywood says so. Substance abuse becomes an issue that doesn’t concern us because we have willpower. “Tu deprimes today?” becomes the reference for depression.

I have a friend who was diagnosed a while back depression. Treatment has greatly improved his entire lifestyle and approach. And I’ve been thinking lately how lucky my friend was to be surrounded by people who viewed his diagnosis and treatment as a true medical case, not him being a wuss. If his case had been the latter, he’d have probably never improved and he would have never known that there is a better view of life than that of a person who was always sad, who had decreased interests, decreased appetite, guilt, suicidal thoughts.

“Madness is like gravity, all it takes is a little push,” the famous saying goes. Except “madness” is nothing like gravity and it takes more than just a push to get there. It’s a collection of genetics, biological predispositions and psychological stressors – sort of like any other disease, really. A mark of the development of a society is the way they view mental health. Lebanese tell their friends who are truly depressed to suck it up. They’d rather seek out exorcisms and justify diseases with demons than with simple facts. A person who develops substance abuse is weak-minded, his abuse never seen as an actual disorder. That patient who wished she had cancer has been “living with a demon” in her house for 6 years. She had brought in a priest every month. She still doesn’t know nor does she accept that the problem is probably with her and it could have been fixed 6 years ago. I guess some people would rather find solace in demons and live in Mars in the process because society thinks a Martian habitat is better for people like them than to acknowledge the simple and yet vitally important fact that it’s mental health, not demons. It’s psychiatry, not exorcisms and voodoo.