Lebanon: Should I stay or should I go?

An exhausted healthcare sector

In this episode, we put Lebanon’s healthcare sector under the microscope and find out how corruption and mismanagement made the effects of the wider economic collapse even worse and left the sector on its deathbed.

Our guests are Dr. Anis Germany, a public health expert, and Nibal Dahouk, a health sector activist. We also hear from 46- year-old Wissam al-Nahhas who works at a grocery store and lives with kidney failure.

"Lebanon: should I stay or should I go?" is produced by Sowt for Context, the Thomson Reuters Foundation’s digital news platform, and it is the story of a nation's collapse as told by its own people.

This episode was produced by Layla Yammine and Basant Samhout, hosted by Nazih Osseiran. Sound Design by Siham Arous. Editorial support by Rana Daoud. The show's Executive Producer is Nada Issa. Original score is composed by Firas Abou Fakher.

Read the full transcript below or via the transcript tab above.

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Nazih: This podcast was produced before and during Israel’s military campaign in Gaza and South Lebanon.

Dr. Anis: When a patient worries about going to the hospital, when a family member watches another member of their family dying, or in pain or just suffering, this is a form of violence that stays at home that we do not see.

Wissam: You’re down and depressed and you can’t get out of it. You try, but you can’t get out.

Nibal: No matter how many initiatives you come up with. You cannot just redo a government within a government, that doesn’t work.

Nazih: Over the last four years, Lebanon, my country has suffered one of the biggest economic meltdowns the world has seen in more than a century. Our currency has lost 90% of its value. Our annual inflation in 2023 is more than 250%. As each day passes, people have less and less, while everything costs more and more; food, medicine, electricity, even water. So what are our options? Well, those who have the means to leave the country are leaving. And the rest of us? Do we wait and hope that things are going to get better? Or do we figure out how to get out of here for better opportunities elsewhere? What happens to those of us who can’t leave or have nowhere to go? I am Nazih Osseiran, Middle-East correspondent for Context, the Thomson Reuters Foundation’s digital news platform, and this is "Lebanon: Should I stay or should I go?", a podcast about how this country’s crisis is hitting its most vulnerable people, and how they’re grappling with the choice of staying here or leaving.

Nazih: One of the first casualties of Lebanon’s economic crisis was healthcare. When the banks collapsed in 2019, the value of the local currency disintegrated and depositors were locked out of their dollar accounts. To make matters worse, prices of imported medicine skyrocketed, exacerbating an already dire situation, leaving patients unable to afford their medication. Four years on proper health care services in Lebanon are now out of reach for most people. The government does not provide universal coverage, and the majority of the population does not have health insurance, resorting to out of pocket payments. Essential medicine, like heart and cancer treatments are in short supply and high demand. In 2021, the number of children who could not access health care when they needed it rose from 28% to 34%. Another study showed that today, more than 50% of families were unable to obtain the medicines they needed. Those who are able to are leaving in search of more affordable health care in other countries, but for most unable to leave, they’re having to rely on help from health care charities or support from family members living abroad. 46-year-old Wissam Al Nahas works at a grocery store. A divorced single dad of a 19-year-old daughter, he doesn’t leave his house except to go to work. Wissam’s kidneys began to fail back in 1996. He received a kidney transplant, which meant he would need regular treatment and medication. His condition makes him vulnerable, catching a cold alone could be fatal. For decades, he was able to afford his treatment and also provide for his family. But since 2019, the cost of his medication has soared. They now amount to more than his monthly salary.

Wissam: The Problem that I’m facing now is that the basic medicines that I need for my immunity system are not available in Lebanon, so I am forced to buy the drugs from abroad, which costs a lot of money that I don’t have.

Nazih: In order to stay alive Wissam says he takes 27 pills every day. They suppress his immune system and stop it from further damaging his kidneys. But with reduced immunity, even a cold could put him at serious risk.

Wissam: I caught a cold virus that caused me to have a strong fever and diarrhea. I lost the ability to feel or use my tongue. I went to the hospitals A&E they requested $3,000 to admit me. They told me I needed to pay the full sum up front or I couldn’t receive treatment. I did not have this money. Friends and family came to my aid and chipped in to cover some of the costs, but all we could afford was $1,000. My friends and family explained to the hospital that I’m vulnerable to my immune system being low, and so everything affects me drastically. They reasoned with them that if I wasn’t treated, my kidney could stop functioning and the situation would deteriorate quickly. They begged the hospital to admit me. If it wasn’t for them, I wouldn’t have been admitted or treated. I might not have made it and would not be speaking with you today.

Nazih: It’s not only people like Wissam. Hospitals are also crumbling. State hospitals are derelict, lacking in supplies, resources and maintenance. Private hospitals are absolutely unaffordable because most people here now live in poverty. In fact, 80% of Lebanese people are living in multidimensional poverty. This means they don’t have money to be able to afford basic things like education, food, electricity, clean water, and of course, a visit to the hospital. To understand the state hospitals are in, I spoke to Doctor Anis Germany, an internal disease and public health expert.

Dr. Anis: Even before the crisis, the system was extremely fallible. Afterwards, it became harsher and more brutal, for sure. It’s an extremely segregated system in terms of the public funds that used to cover at least half of the population, or around 48% before before the crisis. Now, the numbers are disastrous because most of these funds are completely bankrupt.  

Nazih: For people like Wissam, the situation has become desperate.  

Wissam: Every month, I need around $350 to pay for my medicines, and the price changes every time. It’s like the stock market. Sometimes you find the drugs for $140. This is the cheapest, which is already unaffordable on my salary and I need two packs a month. Sometimes I find it costs $150 and other times $165, so there is no set price. Pharmacies and hospitals can control the cost, leaving people like me constantly being priced out. My monthly salary is less than this amount.  

Nazih: So then how were you able to pay for the medication?

Wissam: I am in a great deal of debt which I cannot pay off.

Nazih: How were you managing before?

Wissam: This was not the case before because medication was available anywhere in the country. We faced challenges for sure, but I did not struggle like this. Back then I would order the medication from the pharmacy and the next day I’d collect it. Then I’d submit the receipts to the National State Security Fund Department at the Ministry of Health, and I’d receive a partial refund. That’s how it worked. So it was just about manageable.

Nazih: With bankrupt institutions, a crippled economy and an absentee government, ordinary people began to step in to help their communities. Grassroots groups popped up hoping to support the most vulnerable and needy. I traveled to Gharife Village in Mount Lebanon, almost an hour’s drive from Beirut. Here I met Nibal Dahouk, a 45-year-old teacher and mother of two. Nibal lived in Dubai for several years, holding a steady job as a head teacher and making a decent salary. Then in 2019, the family returned to Lebanon so their children could go to university. Lebanon was witnessing its biggest protest in years. Tens of thousands were coming out into the streets of Beirut, demanding the downfall of the ruling political elite, whom they accused of corruption and graft.

Archive/SOT: Translation: Demonstrations- Our demands are common sense, equality, bread, and freedom, and a revolution in all the towns!

Nazih: Nibal joined the demonstrations. Since then, she’s been volunteering with a group of young women working to provide life saving medicine to their communities that have absolutely no assistance from the state and its institutions.

Nibal: Our initiative was mainly three girls started an initiative in our village. It basically came from the need for people to get the medication that was not there. We had to intervene. People started coming together using their knowledge and using our skills. So everybody put whatever is a strength in him into this initiative to make it happen.

Nazih: Nibal and the group visited the village sick and elderly. They created a database of the medication each household required and logged when repeat prescriptions were needed. She told me some people have gone for months without their medication for insulin, cholesterol and painkillers, but they were too embarrassed to ask for help.

Nibal: It was sad to see so many people suffering in silence. Breaking this idea of shame was a very big challenge. We had to be delicate in approaching the people. We treated them with respect, kindness, but we always kept reminding them that the situation they found themselves in was not their fault. It was really difficult to see because on several occasions when we knocked on doors and we discovered that some people were literally on the brink of collapse, unable to find their medication, mind you, pay for them. They were too proud to ask for help. They were suffering alone. Quietly. There were cases where people might have died, others their conditions worsened due to lack of treatment. So we tried to save people when the state was absent and uncaring. And this is why community and grassroots works matter. It’s all that we have. No one else will come and save us. We have to be there for each other. We reached out to more and more people. Both of them were people in Lebanon, people in the diaspora, and those all over the country who could find medication that people needed. We visited pharmacies, corresponded with those abroad who could find or buy or send medication.

Nazih: Lebanese living abroad were tasked with sourcing and sending medicines home. Nibal and the group were then sort and deliver them in the village, but as the crisis worsened, the number of volunteers began to shrink.

Nibal: Many of our volunteers have left the country. They felt they had no other option and we can’t blame them. But this means we don’t have the same resources anymore. The demand is still high, but there are so few of us on the ground able to help. It’s also made things harder. Harder to raise funds as there’s less people and those left simply cannot afford it. But this is all the more reason I have to stay. I can’t go back to the security and stability of Dubai when my country is falling apart.  

Nazih: While Nibal is still determined to stay and help her community, Wissam tells me he dreams of leaving to a place where hospitals don’t turn you away if you’re poor and medicine is available to all. Have you ever tried to leave Lebanon?

Wissam: I can’t do it because of my physical health. Unless I was able to secure my medical care abroad.

Nazih: What if there was an opportunity to leave?

Wissam: Yes, yes, I would leave if I could. I am now in a state of despair. I feel like there is no going back from the situation we are in. But I don’t have a visa to leave, and I have no one abroad who can help me get out.

Nazih: Doctor Anis, who has been working in Lebanon’s hospitals for almost a decade, knows this despair all too well. He says the very hospitals that he is all too familiar with are putting profit before people.

Dr. Anis: It is a system that is based on violence, constant daily violence, abuse of patients, abuse of family members. When they call you and they tell you your significant other has to have this surgery, come up with a couple of thousand dollars or watch them die. Very abusive.

Nazih: And is there violence towards medical staff too?

Dr. Anis: When you look at the staff, the medical staff, most hospitals are understaffed. Nurses are overworked. People who work in the paramedical field are extremely badly treated. Even physicians, they put on the forefront. So when patients and their family members cannot afford treatment, they become aggressive. They take it out on physicians. Physicians have no say in the pricing of hospitals, even though I do believe that they should. They have a political responsibility to organize and to start controlling these payments. But as it stands today, they do not. So, yeah, it is absolutely a system of violence.

Nazih: A system of violence. Doctor Anis explains this violence is not limited to financial issues. He claims hospital staff, from administration to medical teams, also discriminate against people they don’t like and rarely face any repercussions.

Dr. Anis: After the crisis, there was a trans patient who showed up to a private hospital. She attempted suicide by overdosing on Captagon. She was spastic, couldn’t breathe. Her oxygen levels were low. We treat her. She wakes up. Then the ER staff abuse her. They started screaming at her, telling her you’re a man. Why do you identify as a woman? How dare you? This is against nature. The poor woman, she wakes up, she’s in tears. She attempted suicide. She begged me to end her life.

Nazih: According to Doctor Anis, this kind of abuse based on discrimination happens all the time in state hospitals and private ones. He says marginalized groups like LGBTQ+ people or the poor are especially susceptible to abuse and neglect.

Dr. Anis: I was working in a governmental hospital. There was this migrant worker who is literally thrown by the Red Cross. No identification. She is not cooperative. She is barely aware of her surroundings. I go to the ER. After she was thrown there, I realized she wasn’t being given any treatment. She was spastic, probably having seizures. Everybody across the whole ER staff was just watching her. I asked them what have you done to this patient? They tell me, yeah, we called the cops and they still haven’t showed up. People who don’t do not have money do not access it. Definitely the abuse of minorities, mishandling queer people, trans people and even migrants.

Nazih: So in a health care sector, rife with soaring prices, abuse based on all sorts of discrimination and little to no accountability, what happens to people like Wissam?

Wissam: I have had to stop taking my medications many times for a while now so I can afford doing certain tests, for example, or x-rays or anything related to my kidney. Then when I am able to buy them again, I do.

Nazih: Wissam tells me that he can find locally made generic drugs, but he’s decided not to take them on his doctor’s advice. For starters, there are not much cheaper than the original brands. And then there’s the question of quality. The government’s regulation policy is ineffective and outdated. The Health Ministry uses quality control methods that date back to the 80s. Many also worry about the prevalence of counterfeit drugs and expired medication.

Dr. Anis: The roots of the problem lies with the Ministry of Public Health. It’s the ministry’s job to regulate the system with policy, not by buying and selling medical services. It’s by actually regulating it. They also have to regulate the prices that are issued by those private Lebanese industries that market these drugs as generics and, you know, at the same time, they also have to regulate the quality of these medications. By speaking to my colleagues, there are many who are afraid to prescribe these local, newly newly on the market generics. They’re like, "yeah, we haven’t seen the tests, we don’t know the studies around them", even though, you know, a generic is is much easier to produce because you have to do just one study. It’s called a bioequivalence study, so as long as it acts the same as the brand name drug that is already in the market, you’re fine, you’re good to go. But even that effort is practically nonexistent, and physicians only go there when they’re absolutely forced to do so. It’s still not a system that is functioning when I have a chronic patient who has diabetes, heart failure, kidney failure, cancer even, you know, I know that they only show up to me at the hospital. That means their life is in danger. So you fix that part, but then the healthcare is so much more. It is way broader than just preventing somebody’s death. It is about making them feel comfortable. It’s about telling them or teaching them the best medical choices possible, so that the patient is autonomous, that they can make their own choices themselves. It’s about preventing disease, not waiting for it to start, and then evolve to a point of no return. I think we have a very poor execution of health in Lebanon. The idea that Lebanon is the hospital of the Middle East, it has always been a myth.

Wissam: I have a sick mother at home. This means a lot more requirements. It’s true that I have my siblings that help me support her, but it’s not enough. This is putting me under more pressure and I need to be patient because I need to prioritize my mother.

Nazih: Was there ever a time when you had to withhold your own medication to provide for your mother?

Wissam: Of course, her treatment costs me around 5,000,000l, which is around $50.

Nazih: Wissam and thousands like him are in a bind. A bind that he believes has been made even worse, and a thriving black market where you can find prescription drugs that are otherwise unavailable in pharmacies. The drugs are hoarded. There’s a shortage. Demand rises, prices go up. For example, Albumin, a medication used to treat or prevent shock following serious injury or bleeding, is meant to cost $20, but at one point it was only available in the black market for more than double the price. Another medication, Colistin, an antibiotic, wasn’t available anywhere except in the black market and at an extortionate price.

Nibal: People were deprived from the right of getting the proper medication. It was a black market. There was a scam, a big scam. The prices are skyrocketing, medicine was available, medicine was stored in places and sometimes it was thrown away, whereas people needed it.

Nazih: The true scale of Lebanon’s prescription drug black market is hard to assess. But what is clear is the impact all of this has had on people like Wissam.

Wissam: My mental health really suffered, but what can I do? Any treatment will add extra costs on me and I cannot afford it. But I definitely feel that mentally I’m not doing well. You feel like there is pain everywhere in your body as a result of the constant stress. I’m not sleeping at night because of the anxiety.

Nazih: You don’t sleep at night?

Wissam: Very little. I mean, I actually wake up for work at 6:30 a.m. if I try to sleep. I would not start to feel sleepy before 1 or 2 a.m. other nights I just don’t sleep. Like last night I couldn’t sleep. I stayed up till 5 a.m..

Nazih: What do you do all night?

Wissam: I either sit or wander around the house and then I come back and lie down so I can try to sleep.

Nazih: Did the situation affect your relationship with your daughter?

Wissam: Yes.

Nazih: How?

Wissam: The problem is that I feel like I’m neglecting her. I mean, anyone who has children would want to provide the best he can for them and give them a better life than this one. And I just can’t do that.

Nazih:"Lebanon: Should I stay or should I go?" is a production of Context, the Thomson Reuters Foundation’s digital news platform and Sowt Podcasts. If you like what you just heard, subscribe to our podcast on your preferred podcast or music apps. Tell your family and friends about us, and don’t forget to leave us a rating on Castbox and Apple Podcasts. This episode is produced and written by Layla Yammine and Basant Samhout. Voiceover by Bisher Najjar. Sound design by Siham Arous with music by Firas Abu Fakher. Nada Issa is our executive producer. We’d love to hear from you. You can email us at contact@Context.news or follow us on Twitter or Instagram at Contextnewsroom. I am Nazih Osseiran in Beirut, see you next week.