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Fatima Al-Sayah, PhD, Public Health Researcher, University of Alberta, Canada


June 2020
What Is Missing in Lebanon’s COVID-19 Exit Strategy?

The Lebanese government extended its general mobilization against COVID-19 on 5 June, pushing it until 5 July. This extension came after a rise in cases during the last week of May, which was expected to happen following the easing of public health measures and diminished public compliance with social distancing measures. To date, the highest number of new cases was recorded during the month of May with 495 cases, compared to 262 in April, and 456 in March. Although the number of daily new cases had been relatively low over the last two weeks, with the exception of yesterday, the total number of recorded cases in June (to date) is 383, suggesting that the outbreak is still ongoing and several public health measures should continue to be followed.
 
As of 22 June, there were 1,602 recorded cases in Lebanon, after the first case was confirmed on 21 February. The Lebanese government’s response, led by the Ministry of Public Health (MoPH), employed containment measures in a timely manner and proved successful in containing the outbreak to date. Containment involved various public health measures that were implemented progressively as the outbreak evolved. These included closure of schools and academic institutions, public spaces, businesses, the airport, and almost all non-essential services, as well as transport restrictions (with an alternate circulation policy) and nationwide night curfews. The socio-economic impact of these containment measures in Lebanon has not been short of catastrophic, particularly amid an unprecedented economic and financial crisis that has worsened over the past year.
 
Over the last few weeks, several countries have started implementing strategies to lift lockdown measures and transition into the “new norm”, which is likely to last until a vaccine or a successful treatment for COVID-19 is available. On 24 April, the Lebanese government announced a phased-out plan to relax the national lockdown and reopen the country through five phases.
 
  • Phase 1: Set to begin on 27 April, and included reopening of various government services, hotels, small businesses, car rental companies, health services, some factories, and the agricultural sector.
  • Phase 2: Set to begin on 4 May, and included restaurants (at 30% capacity), playgrounds, salons and barbershops, mechanics, and other factories.
  • Phase 3: Set to begin on 11 May, and included nurseries for children under 3, as well as Casino Du Liban, car dealerships, and services for individuals with special needs.
  • Phase 4: Set to begin on 25 May and intended to allow universities to resume classes, and letting students who have International Baccalaureate exams go back to school. Malls and shopping centers could also restart operating.
  • Phase 5: Set to begin on 8 June, and involved reopening of schools, public transportation, travel, nightclubs, gyms, beaches, museums, theaters, places of worship, and other public spaces.
 
According to the plan, the reopening of all sectors of the economy was planned with restrictions in terms of capacity and hours of operation. The plan also indicated that large social gatherings such as festivals and conventions—or protests—would not be permitted; this, however, did not stop people from protesting the dire socio-economic collapse in the country, without getting arrested.
 
The government proceeded with phases 1 and 2, and increased testing capacity including random testing in rural areas. During the second week of May, an increase in the number of cases was observed, and on 13 May, the government reinstated a total lockdown for four days. This lockdown was neither evidence-informed nor necessary. The increase in the number of cases was largely due to lack of compliance with self-quarantine of those returning from abroad, and most of these cases were clustered (as in the cases of Barja and Akkar regions). A lockdown of certain communities may have been justified to control local transmission, but a national lockdown was surely unjustified.
 
Despite the announced dates of reopening various sectors, the plan has not been followed as intended due to several factors. For instance some sectors identified in phases 1, 2, or 3 have reopened with restrictions, as well as malls from phase 4 and nightclubs and beaches from phase 5, yet schools, universities and other institutions remain closed. As such, it is difficult to assess which phase Lebanon is currently at. Additionally, it is not clear whether the government has updated the exit plan, and if so, what the updated plan entails; such information has not been publicly announced or shared.
 
Since the announcement of this plan, there seems to be a discrepancy between what is intended in the plan and its implementation. This is partly due to lack of clarity on how the plan is implemented, enforced, and evaluated, and is partly due to carelessness and lack of compliance with physical distancing and other restrictions among the public. The successful implementation of COVID-19 exit-plans requires ample cooperation between governments and the public, which was evident in countries like New Zealand. In Lebanon, the decades-long mistrust of the government, incompetence, corruption, and the current debilitating economic circumstances complicate and impede the implementation of this exit strategy.
 
Overall, the government plan seems in line with exit plans employed in other countries, and largely complies with the recommendations of the World Health Organization, particularly around the allocation of sectors to reopen in certain phases, generally based on the risk level of virus transmission and how essential a certain sector is. One of the shortcomings of the plan was announcing specific dates for each phase given that lifting the measures is likely to be gradual, tentative, and based on how the outbreak develops, something not possible to predict. Additionally, the short timeframe from phase 1 to 2 and from phase 2 to 3 does not permit proper evaluation of the impact of reopening on the number of cases, which requires at least two weeks based on the current estimate of the incubation period which ranges from 1 to 14 days.  
 
The health system capacity and preparedness to detect, isolate, test, and treat every case and trace every contact—an essential element in COVID-19 exit plans—is still questionable. The government has increased testing capacity in terms of numbers of tests and testing sites: From an average of 815 tests/day in April (total 24,434 tests) to 1,324 tests/day in May (total 41,025 tests) to 1,541 tests/day in June (total 30,812 to date). It also broadened testing into rural areas. However, the criteria for testing and contact tracing strategy have not been clear. Additionally, testing at the current rate is still insufficient; at least 2,000 tests/day are needed, particularly at this stage given the importance of case identification in informing the epidemiological pattern of the outbreak and guiding government action throughout the implementation of the exit plan.
 
To date, the health system has been able to provide care to all cases requiring hospitalization, and MoPH has frequently stated that the healthcare system has the capacity to deal with the COVID-19 cases requiring hospitalization. Yet, the strategy to expand capacity and the numbers of general and intensive care beds (and ventilators) that are available for COVID-19 patients across public and private hospitals in Lebanon are still unclear.
 
Other ambiguous elements in the exit plan are the strategies and measures that will be used to implement it, as well as guidelines for the safe reopening of various sectors. A complete lockdown may be an effective measure at the beginning of an outbreak despite weak evidence supporting this; however, it is not as useful during the reopening stage. And a rise of cases was expected when the lockdown was lifted, as there are more interactions between people. Lockdowns may delay any progress in developing population-level behavioral changes. During the exit stage, the government’s approach needs to be more participatory and engaging, and should aim to create an environment conducive to change to facilitate the adoption of new behaviors by the general population.
 
Containment measures, including physical distancing, wearing a facemask, and frequent sanitizing and hand washing, entail behavioral changes at the population level that is required to last until a vaccine or cure for COVID-19 is found. There are several models of behavioral change that we can use to guide the development and implementation of COVID-19 exit strategies. Of relevance in this context is the social ecological model, which emphasizes on multiple levels of influence such as individual, interpersonal, organizational, community, and public policy.
 
There are many factors that influence people to change their behavior in times of a pandemic such as threat perception, communication, leadership, social context, as well as individual and collective interests. In Lebanon, a number of system-level and structural issues have imposed challenges in the response to COVID-19, including a largely privatized and fragmented healthcare system, lack of comprehensive national epidemiological surveillance networks, no effective and transparent communication, low public trust, and significant political polarization. These issues require calls for action in the future.
 
Early and transparent communication by public health authorities is critical to build trust and ensure credibility of public health advice. The level of trust people have in both the government and the healthcare system plays a significant role in how people react, behave, and cooperate with public health measures. The communication strategy of the Lebanese government during the COVID-19 outbreak has included a mix of media outreach and social media engagement; but it could have been more comprehensive, more effective in communicating risk, and more tailored to the Lebanese public. For instance, surveying the general public about their knowledge of COVID-19 precautions, perceptions of risk, behavioral changes, and other related factors would have increased public engagement and enhanced the prioritization of public health messages and tailoring it to the local context. Additionally, the government should be clear on how the level of threat is assessed as the outbreak progresses, and provide explanations for instating or lifting certain public health measures accordingly, as well as clearly communicating to the public the metrics that will be used to evaluate the impact of these measures.
 
At the early stages of the COVID-19 outbreak in Lebanon, there was a relatively high degree of political and public consensus on the need for a strict lockdown. Over the course of the outbreak, consensus has considerably withered due to several factors including political polarization that has exacerbated by the worsening economic crisis. Political polarization leads to further decrease in public’s trust, privileging partisan labels over policy information, believing false information and fake news, and detrimental effects on social and public health.
 
Despite various shortcomings, the measures taken by the government have been successful in “flattening the curve” and controlling the outbreak in Lebanon. The current phase involves the introduction of a new norm of public life with continuing social distancing measures and is more challenging than the mitigation phase. Given the need for a population-level behavioral change, insights from social and behavioral sciences can be used to enhance the implementation of exit strategies and continued response to the pandemic. Here are some suggestions for public health experts, policymakers, and community leaders to consider:
 
  • Emphasize a sense of shared purpose and goal, and encourage acting and cooperating for the common good of the whole society.
  • Designate a MoPH official (such as a chief medical officer) alongside the Minister of Public Health to provide frequent updates about the government strategy and status of COVID-19 outbreak in the country. A non-political medical and scientific figure could communicate public health messaging to the public more effectively.  
  • Engage and cooperate with scientific and medical experts as well as religious and other community leaders who could be viewed as more credible and trustworthy sources of information in certain communities or groups to share and promote public health messages.
  • Ensure and highlight non-partisan support for COVID-19 public health measures via various sources and media platforms.
  • Promote cooperative and pro-social behavior (such as emphasizing how one’s behavior is not only to protect oneself, but also to protect others in our community), and positive framing of information, by reporting for instance the number of people who recovered, those who experience mild symptoms, and stories of people in self-quarantine or isolation.
  • Identify and correct misinformation (such as the widespread speculation around the effectiveness of the malaria drug hydroxychloroquine as a preventative measure and treatment for COVID-19 that was promoted by US president Trump, or that pets could contaminate humans), as well as misperceptions (e.g., conspiracy theories around the origin and spread of COVID-19), in a timely manner and via trusted medical and scientific figures.    
  • Develop targeted public health information campaigns especially within marginalized communities such as refugee camps and impoverished neighborhoods.
 
This is a new terrain, and fighting this pandemic requires large-scale cooperation among all components of a society and across societies. In the early stages of the outbreak, the Lebanese government took early action to respond to COVID-19 and the public complied with restrictions and guidelines. This, however, has considerably diminished with the premature reporting of having the outbreak under control and the withering public compliance. Enhancing coordination of efforts across sectors and levels within government institutions and with key stakeholders, expanding outreach and engagement of the wider community, and ensuring transparent communication are highly needed in the continued fight against this pandemic.
 






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