This combination of pictures created on April 7, 2020, shows members of the medical staff unit in charge of patients suffering from Covid-19 at the Rafik Hariri public hospital in the Lebanese capital. Photos: AFP/Joseph Eid

If you asked any Lebanese where they would turn to for urgent care before the Covid-19 outbreak, Beirut’s neglected public hospital would likely have been last on the list, if at all.

The governmental Rafik Hariri University Hospital for years has been known as the last resort of the poor and refugees, standing in sharp contrast to Lebanon’s dominant and bustling private healthcare sector.

Those with even limited means gravitate toward private hospitals, ranging from the religious and politically-affiliated to the gleaming top hospitals of Beirut, which attract medical tourists from elsewhere in the region.

The Covid-19 pandemic has created an ironic twist.

This public hospital has now emerged as the nation’s vanguard against the novel coronavirus, caring for both rich and poor, while the private sector has remained largely on the sidelines.

Duty calls

When the first novel coronavirus case emerged in Lebanon on February 21, the Rafik Hariri University Hospital stepped forward to anchor the response.

To date, the number of confirmed cases is at 658. Eighty people have recovered and there have been 21 deaths.

Until now, testing availability has not been an issue, and masks are widely available.

Massachusetts, a US state with approximately the same population as Lebanon, six million, has now logged more than 25,000 cases and seen over 800 deaths.

There are numerous factors contributing to this disparity. Lebanon closed its borders one month ago and major supermarkets take the temperature of customers before they are allowed to enter. In the United States, social distancing rules vary from state to state, while citizens move around freely by car and plane.

But a major factor in Lebanon that cannot be ignored is the existence of Covid-19 testing and care that is public and free of charge.

Every day, the largely volunteer-operated Lebanese Red Cross transports Covid-19 patients from all over Lebanon to the public Rafik Hariri University Hospital.

“I think volunteer is a flattering word, but we consider this as a duty, a duty of all hospitals,” the hospital’s manager and CEO Firass Abiad told Asia Times by phone.

“Whenever other hospitals have a suspected patient they contact us and the Red Cross transfers them.”

In addition to its ample space for Covid-19 patients, Rafik Hariri is the reference hospital of the Lebanese Ministry of Health for large-scale programs targeting measles and influenza.

“These issues are considered public health concerns, and usually not privatized but still within the domain of the Ministry of Health,” said Abiad.

Rafik Hariri is the go-to local partner of the World Health Organization. It last year received a 37.9 euro grant from France’s development agency to undergo a modernization carried out by the International Committee of the Red Cross, something Abiad credits with making the Covid-19 response possible.

At the height of the outbreak, Lebanon saw more than 60 new cases in a single day, with 92 coronavirus patients at Rafik Hariri. In recent days, the number of new cases has fallen into the single digits.

Flattening the curve

One key to flattening the curve, Abiad says, is to control the spread so the number of cases remains below the medical sector’s capacity to treat every patient.

The other critical point, especially with Lebanon’s large refugee population, and as the country prepares to re-open, is scaling up capacity.

“We’ve been increasing the capacity of the hospital, and currently have the capacity to hold about 125 regular beds and 23 ICU beds in addition to 20 beds in a fully equipped corona emergency room,” Abiad said.

Still, it is important for other hospitals to prepare coronavirus-ready units “and thus allow us to have access to more corona beds in case it’s needed.”

To date, teams from 16 sister public hospitals have participated in preparedness workshops led by Rafik Hariri, he said in a Tweet on Tuesday.

A Red Cross volunteer in north Lebanon told Asia Times that the government hospital in Tripoli will soon begin receiving Covid-19 patients and carrying out tests. The response will then be shared geographically.

A handful of private hospitals have taken the initiative in dedicating space for Covid-19, namely the American University of Beirut Medical Center and Hotel-Dieu.

But they are not the go-to destination for the most critical health emergency facing the country.

Governing care

Omar Dewachi, a professor of medical anthropology at Rutgers University who previously co-directed the Conflict Medicine Program at the American University of Beirut, says it is hardly surprising Lebanon’s principal public hospital is leading the pandemic response.

“What the Covid-19 event has put in focus is the role of state healthcare,” said Dewachi, whose book Ungovernable Life (Stanford University Press, 2017) examines the rise and fall of state healthcare in Iraq.

When it comes to a such a large-scale health crisis, “the state is held responsible,” he told Asia Times. “That’s why state-run hospitals are so critical.”

The Rafik Hariri University Hospital was essentially built to “absorb the problems of the uninsured, and those who can’t afford healthcare,” said Dewachi.

While the themes of global health and privatizing healthcare have gained prominence over the past several decades, the scale of the current pandemic has restored focus to government infrastructures and capabilities.

When it comes to Covid-19, it is world governments being compared, not hospitals, Dewachi points out.

“The whole logic with neo-liberalizing these places was that public hospitals are corrupt, but now we’re paying the price for the last 30 years of the deregulation of state healthcare. Not only Lebanon, I think everywhere.”

US President Donald Trump, whose country now has the highest number of Covid-19 cases in the world, has preferred to pass responsibility during the Covid-19 crisis to governors, and offer praise for initiatives taken by industry leaders and healthcare executives.

The federal response, meanwhile, appears in disarray.

“At the end of the day, the problem is that if you don’t have an organized public healthcare, you’re in deep shit,” said Dewachi.

The Lebanese Minister of Health was recently compelled to warn hospitals, without naming names, that they must heed orders to receive Covid-19 patients. The ministry over the years has increasingly outsourced state-funded treatment to private hospitals, but is in arrears over payments.

Hospitals, both public and private, are also coping with a dollar shortage in the country, which has threatened their ability to import critical medical supplies and offer treatment.

Other tensions have arisen between the Lebanese syndicate of private insurers – which pledged to cover Covid-19 treatments of its clients – and private hospitals, which the syndicate head accused of jacking up fees.

The public sector hospitals have a whole host of their own problems, including delayed payments of salaries, which compelled staff at Rafik Hariri to protest outside the hospital gates mid-pandemic.

Yet in the era of Covid-19, this public hospital has garnered praise, donations and respect.

Alison T Meuse is the Asia Times Middle East editor and correspondent.