When an explosion ripped through Beirut on August 4, 2020, it heavily damaged four hospitals, putting them largely out of commission. More than 20 primary care facilities, serving approximately 160,000 patients, were damaged or destroyed, according to the World Health Organization.

And throughout the night, patients poured into hospitals.

“We received hundreds of patients on the night of the explosion,” recalled Dr. Firass Abiad, a surgeon and CEO of Rafik Hariri University Hospital, the largest pubic hospital in Lebanon. “A lot of the hospitals used a lot of their medical supplies taking care of the patients that night,” depleting an already compromised supply.

Now, more than two months after the blast, Lebanon’s advanced health system, already weakened by economic collapse, is low on vital medications and supplies. Patients unable to afford health care are showing up at hospitals with unmanaged chronic health issues, “in very bad condition,” said Dima Zayat, the deputy country director in Lebanon for Anera, a Middle East-based NGO.

Mental health concerns are on the rise. Covid-19 cases have flared wildly, from fewer than 200 new cases daily before the blast to as many as 1,459 on October 8. ICUs are filled with sick patients fighting the virus, even as damaged hospitals mean fewer beds are available.

Some doctors and nurses are working in damaged facilities. Others are furloughed or quarantined, brought to a standstill by Covid-19’s rapid spread. Still others – many of them Lebanon’s best and brightest – are leaving the country altogether.

“The health system is under significant, significant pressure,” said Fadi El-Jardali, chair of health policy and management at the American University of Beirut. “It has been resilient thus far, but things are getting much, much more difficult than they were before.”

Urgent Support

Immediately after the blast, Direct Relief sent a 227-pallet shipment to Lebanon, containing a wide range of medicines and supplies, including PPE and Emergency Health Kits. Shipments since then have included much-needed medicines, such as insulin, tetanus vaccinations, oncology drugs, and Survanta, a lifesaving drug for babies experiencing respiratory distress.

To meet skyrocketing needs, Direct Relief has collected mental health medications for shipment and is preparing to provide ongoing support to Lebanon’s largest psychiatric center.

In total, Direct Relief has sent or is preparing $23 million in medication and supplies to Lebanon in the aftermath of the explosion.

In addition, through a $500,000 donation from Facebook, the organization has provided emergency operating grants to 5 different Lebanese health facilities to help them meet increasing expenses.

A Shortage of Supplies

Zayat explained that Lebanon’s economic crisis has made it more difficult for the country to import a range of medications and supplies, including medications for chronic diseases.

“Even if people have the money to buy the medicine, it is not available in the pharmacies…They are rationing the quantities that are given to patients,” she said. “For chronically ill people this is very stressing.”

Lebanon’s public health care system is relatively small compared to its private sector. But many Lebanese can no longer afford a private doctor, which places additional stress on an overstretched public sector, Dr. Abiad said. “We are seeing a larger number of those people who are coming more and more to the public sector because they cannot go to the private sector.”

And many are delaying care because they simply can’t afford to seek it out. “We are seeing people at a more advanced state of their disease,” he said. “It’s feeding into the escalation of the cost of health care, because of people don’t get the preventive medicine part…then what you see is more diseases requiring more intervention and requiring more management. It’s a vicious cycle.”

Both public hospitals and primary care facilities are feeling the squeeze. A center that used to see 100 patients in a day might now accept as many as 500, Zayat said.

Losing Health Care Workers

Although El-Jardali said that access to PPE has improved since the blast, “we’re not yet at a good stage.” In particular, he’s worried that more and more health care workers are coming down with Covid-19. “Either there is not enough PPE, or they are not being trained very well, or hospitals are not working hard to ensure good practices.”

And the pressure placed on health care workers to provide high-quality care for large numbers of patients is concerning. “More pressure, more burnt out, more dissatisfaction…quality of patient care and safety will suffer as a result,” he said.

Although doctors and nurses are primarily seen as heroes by the general public, frustrations over finances and the care available have even led to reports of violence directed toward health care workers, El-Jardali said.

“Obviously the situation is not as apocalyptic as it was on the day or the week of the blast. There’s still significant shortages. They’re exhausted…They’re working overtime. They’re working with few resources. Many of them are sick,” explained Josyann Abisaab, a Lebanon-born, New York-based emergency room doctor who co-founded the NGO Lebanon Needs.

And, several sources said, many of them are responding by leaving the country altogether. “We pride ourselves on having very well-trained doctors and nurses,” Dr. Abiad said. “It wasn’t difficult for them as the situation started worsening to make a living elsewhere.”

That has consequences for the quality of Lebanon’s medical system overall. “That unfortunately is going to become another hurdle,” Dr. Abiad said. “The very well-trained doctors and nurses, the leaders in the field, will go away.”

A Growing Need

Mental health issues are widespread, Zayat said, but meeting them comes with cultural challenges. “There is still some stigma against mental health,” particularly among Lebanon’s older adults, she said. “Even when they are suffering, they will not seek mental health services.”

But it’s not just older adults. Dr. Raya Saab, medical director of the Children’s Cancer Center at the American University of Beirut, said that she’s concerned for her patients as well. “For patients and parents of children with cancer, who were already stressed, these mental health issues are of high concern,” she said.

Dr. Abiad explained that stigma around mental health has meant there is less demand for it – which has made it, in turn, a historically underfunded area of mental health in Lebanon. “A lot of people consider mental health as kind of a taboo,” he said.

But even as the blast has led to a drastically increased need, he said, fewer health workers are available to meet it. Nurses who previously were assigned to mental health treatment programs have been “reallocated” to overstretched Covid-19 units.

“As a surgeon, I’ve been trained to manage physical wounds…Mental health wounds are much more difficult to see,” Dr. Abiad said. “After all that has happened, I think they have become easy to see.”