Zero state support, much Lebanese solidarity
For a long time, pharmacy was considered an attractive career option in Lebanon. Indeed: a survey by Human Resources for Health revealed that the country boasts the highest per capita rate of pharmacists in the world. On average, there are 20 pharmaceutical professionals per 10,000 inhabitants; the global average is only five. Even though these figures are from four years ago, there is little to suggest that this picture has changed much.
It is no coincidence that the pharmacy sector is so strong in Lebanon: for a long time, the supply of medicines on the market was huge and even managed to keep pace with the ever-increasing demand. But then one day the Lebanese, spoiled by an abundance of medicines, found themselves facing empty shelves in their pharmacies.
Empty shelves and skyrocketing prices
Customers visiting pharmacies – large or small – in the Greater Beirut area were forced to confront the same sight of yawning emptiness. The initial shock, which has since been digested, was followed by the realisation that many medicines are no longer available at all. On top of that, the medicines that are still available are unaffordable of many, as they have to be bought in U.S. dollars. The vast majority of people in Lebanon, however, receive their salaries in the national currency, the Lebanese lira, the value of which is inexorably falling, day by day, minute by minute.
Abandoned by a state that has failed to stop the power of cartels and monopolies in the pharmaceutical sector, it seems the only way out of the crisis for the Lebanese people is through solidarity. Through the initiative of individuals, creative solutions have emerged that have gained traction and spread; through social media, people have been able to exchange medicines; and very often, relatives and friends abroad have been asked to provide medicines. New initiatives include Meds for Lebanon and Medonations. But for all the initiatives, it is still not easy to obtain medicines.
In a lengthy interview on the medication crisis, Manal Azhari Bashi, staff and operations manager of the Children's Cancer Center in Beirut, confirms that difficulties in the supply of medication have become much greater than she initially expected. Lebanon is "politically and economically very unstable. It takes a lot of effort and creativity to get the medicines we need."
Azhari Bashi lists a whole series of challenges that make life difficult for people: the economic crisis, inflation, lack of medicines, the COVID-19 pandemic, the consequences of the Beirut port explosion. Many people have lost their jobs and thus their material livelihoods. In addition, medical and hospital bills have skyrocketed, and these bills often have to be paid in hard currency, especially when it comes to medicines for incurable diseases. All these factors have also made the work of the children's cancer centre much more difficult – these days it can barely cover its annual operating costs (15 million USD).
Nothing works without donations
Even before the crisis, the Children's Cancer Center relied on donations – direct donations, gifts, donations in kind – for its work. Donations were collected through various fundraising programmes. Given the numerous crises in Lebanon, however, these have not been able to take place. Recently, for instance, it was the Anera Foundation that provided the bulk of funds to "ensure the treatment of about 350 children annually".
In addition, the fundraising focus has shifted to Internet campaigns and online appeals for donations. The administrative costs of the children's cancer clinic have been reduced by 30 percent. In response to the increasing need for medicines combined with supply shortages, the centre has worked tirelessly, attempting to obtain from abroad the medical supplies needed to treat its seriously ill patients. Occasionally staff have even had to travel abroad and return with medicines on the same day. It was not an option "to fall behind in the treatment of even one child. Even if we needed hard currency to do so – and that remains the biggest challenge".
At the beginning of the crisis, rumours were rife that the clinic would have to close: it was no longer able to provide medical and psychological care for the children because important medicines were not available, or it was no longer able to absorb the increased costs on all sides – from petrol to electricity to food.
Talking to Azhari Bashis, you could be forgiven for thinking that the clinic came dangerously close to closure at the time. In 2020, however, when the need was greatest, a rescue fund came to the clinic's aid. Over the years the clinic, which enjoys great trust among the population, has provided the best treatment options for almost 3,500 children with cancer. "Thanks to the centre and thanks to all the charitable donors, these children have been given a second chance at life," Azhari Bashis emphasises.
The fund was like a lifeboat in the storm, organised by Lebanese society and diaspora Lebanese. By contrast, "neither help nor a rescue plan can be expected from the crisis-ridden state in the current situation". The Children's Cancer Centre continues primarily to seek support from among the population and from Lebanese abroad. It is also increasingly making contact with people from other countries who are interested in the clinic's humanitarian mission. So far, assistance has been received from 46 countries.
With just as much commitment, but fewer opportunities than the well-established clinic, Marina el-Khawand is working with Lebanese abroad to help provide medicines for the people of Lebanon. We met the manager of Medonations in her modest office, where – amid mountains of bags – it was almost impossible to put one foot in front of the other. The bags contained vast quantities of medicines sent by Lebanese expats. Over time, they have formed something of a solidarity network for the Lebanese back home who have been affected by the crisis. The young association organises and monitors the distribution of the medicines. Although it has already helped many people, el-Khawand sees the main responsibility for ending the crisis with the Lebanese state.
The role of pharmacists
Pharmacists have also become active in the crisis. In one of the large pharmacies in the Beirut neighbourhood of Tariq el-Jdideh, we meet Marwa al-Jamal, a board member with the Lebanese Pharmacists' Union. She says that her organisation is addressing the drug scarcity issue and is working to find appropriate solutions. Our interview is punctuated by several power cuts in the pharmacy and customers constantly enter the premises, wondering why there are no medicines.
Is a digital health card the solution?
Unlike many of her peers, Marwa does not believe in individual solutions to the crisis, but sees the answer in a new digital health card, which will allow the Lebanese Ministry of Health to track the supply of subsidised medicines from the factory to the patient.
At the same time, she is convinced there is scope for the union behave with solidarity in the quest for solutions. These could include supporting local pharmaceutical production in order to reduce the need for imports.
Joe Salloum, President of the Pharmacists' Union in Lebanon, says that for the past two years there have been calls to rationalise supplies by switching, at least in part, from branded to generic medicines. This demand has only recently been met and pharmacists have not yet been able to re-stock their shelves. Moreover, patients are still unable to pay the high dollar prices due to inflation, he said. Salloum also sees the idea of a digital health card as the best solution proposed to date. To cover the costs of the new system, he explains, "would require annual financing of up to 300 million U.S. dollars by the World Bank".
The idea is that each Lebanese citizen would have a certain amount of money deposited on the card, which they could use to buy medicines at the pharmacy. The purchases would be traced via a tracking system. "This would prevent monopolies, hoarding of medicines and smuggling, and it would also be possible to control who has what amount of medicines at their disposal," says Salloum. Although his proposal seems to be based in solidarity, it is linked to conditions that a large part of the Lebanese population would likely reject. After all, the World Bank and its policies are not very popular in Lebanon.
"It is safe to say that, in the short term – say, one to two years – the digital health card is the only solution," Salloum adds. But there are still many unanswered questions about the new card system: will non-Lebanese, including the approximately 1.5 million Syrian refugees in the country, also be able to benefit from it? Which medicines will be able to be billed via the card, in view of the announced categorisation according to type of illness? Salloum recognises that the health card has its limits. Above all, however, it is an instrument to bridge the time until "the end of the dollar crisis and until the price of the currency has normalised on the market". Many pessimistic Lebanese who are currently struggling to survive are unlikely to be happy with this assessment.
This brings us back to the beginning of the article: Lebanese are facing another crisis in the midst of the crisis. How will they be able to pay the high costs when medicines become available again? In the short term, and according to many of those affected – health professionals as well as patients – it seems they currently have no choice but to support each other. Mutual solidarity seems to be the only way out of the crisis as long as there is no reliable and safe health system that does justice to a modern state.
© Goethe-Institut/Ruya 2022