In 1948, Palestinian refugees made their way into Lebanon following the Arab-Israeli war and the establishment of Israel. Nineteen years later, a second wave of refugees came to Lebanon after the Six-Day War. In 1975, Lebanon’s civil war began when tensions between Muslims and Christians turn into conflict. In April, people were killed when gunmen fire on a Christian church and later Palestinians die when a bus is ambushed. In 1978, outside forces were implemented by the UN Security Council, and their aim was to get Israel to withdraw after causing many Lebanese to evacuate their own country. Israel did not withdraw until 1983. The UN’s involvement had a goal of calling foreign troops to leave Lebanon and to issue a resolution that involved all sides to adopt a ceasefire (RCPL, 2004).
Lebanon is in the upper middle income group, Israel is in the high income group, and Syria is in the lower middle income, which was set by the World Bank (World Bank, 2017). These countries neighbor Lebanon and have a big impact on the conflict that has broken out in the Middle East. The total population of Lebanon is 5.8 million people (IHME, 2016). Life expectancy at birth is 80 years old, 22 years at age 60, and an average life expectancy of 30 years old. According to the data, women live longer than men, but both genders live longer than the expected lifespan. Women live to be 84.4 years old compared to the life expectancy of 79.4 years in 2016. Men are living until 78.8 years as compared to the life expectancy of 73.1 years (IHME, 2016). There is an observed trend of both women and men living longer than initially expected, with about 90% of deaths attributed to non-communicable diseases (IHME, 2016). The leading causes of death are mostly affecting the aging population, with nine of the top ten being non-communicable diseases and the remaining one as a disease of injury, as of the year 2016. The top three leading causes of death that fall under the non-communicable diseases category are ischemic heart disease, Alzheimer’s and lung cancer. Conflict and terror, Alzheimer’s, depressive disorders, and diabetes are higher than the mean in other countries of similar economic ranking.
According to the IHME 2016 report, ischemic heart disease is the top cause of death in Lebanon, Israel, and Syria and has been the primary cause of death for over a decade. The prevalence of ischemic heart disease is seen to increase since 2005, with a 59.4% increase in Lebanon, a 14.6% increase in Syria, and a 0.8% increase in Israel (IHME, 2016). This trend could be due to a few factors, one of which is the epidemiological transition where an increase in non-communicable diseases (heart disease) is observed, while diseased of poverty are decreasing but are still prevalent (WHO, 2006).
Following ischemic heart disease, Alzheimer’s is the second leading cause of death, with cancer as the third leading cause of death. Both diseases have remained in second and third since 2005, but an observed increase of 108.8% for Alzheimer’s, and a 64.4% for cancer is seen (IHME, 2016). Contrastingly, injuries due to conflict and terror has moved up to the tenth cause of death from seventy seventh, with an increase of 2,842.8% (IHME, 2016). This drastic increase is due to the conflicts and outbreaks of war that have occurred in the Middle East.
Conflict and terror is the leading cause of most death and disability. The crisis that started on July 12th has displaced 1 million people, with more than 150,000 crossing into Syria. Syria also experienced an increase in conflict and terror, with a rise from the mid-one hundreds to first place from 2005 to 2016. The number of people in shelters has increased, and safe drinking water and sanitation are becoming a major concern due to ongoing bombings. The destruction of infrastructure has made communication complicated and has limited access to health care. The region is experiencing an occurrence of diabetes. Between 2005 and 2016, the rate of diabetes in Syria increased by 34.5%, and in Lebanon by 57.0%. In Israel, diabetes has decreased to the fifth leading cause of death, replaced by chronic kidney disease.
In the top ten causes of death in the Middle East, lower respiratory infection remains in the top ten. The prevalence in Syria has decreased between 2005 and 2016, but the prevalence in Israel has increased (IHME, 2016). In Lebanon, lower respiratory infections are not observed in the top ten causes of death. Respiratory diseases are caused by the smoke and ash from fires indoor. People in the Middle East use indoor fires to cook food, and this constraint traps the smoke indoors, affecting the air that people are breathing into their lungs. It is seen to mostly affect women and children, due to societal factors of them remaining at home.
Air pollution, inadequate solid waste management, and water pollution are all possible causes of respiratory diseases that are due to the wars in Lebanon. In Lebanon, lung cancer prevalence increased by 64.4% between 2005 and 2016. With nine of the top ten causes of death being non-communicable diseases (including cerebrovascular disease and breast cancer), this shows a decrease in the prevalence of communicable diseases, maternal diseases, neonatal diseases, and nutritional diseases as of a 2016 report. This shows the country’ shift towards improvement of the economy and infrastructure after the wars (IHME, 2016).
As previously mentioned, non-communicable diseases are more prevalent than diseases of extreme poverty or any communicable diseases, including but not limited to congenital defects and neonatal premature births. Congenital defects are seen to fall from the second leading cause of death to the fourth, with a decrease of 12.8% from 2005 to 2016. Similarly, neonatal premature births are seen to fall from the third cause of premature death to the tenth cause of premature death, with a decrease of 21.9% in a little over a decade. Maternal mortality rate happens to sixty-four out of one hundred thousand people, and under-five mortality rate happens thirty-two out of one thousand live births. Neonatal preterm birth is the birth that happen before 37 weeks of gestation. With an increase in public health interventions, these diseases have a significant observed decrease in prevalence. These public health interventions include trained health personnel attending 88% of all births (WHO, 2006). The next two causes of premature death are conflict and terror and lung cancer, rising from sixty first and fourth in 2005 to second and third in 2016.
With a decrease of 12.8%, congenital defects falls from second to the fourth position. Alzheimer’s rises from the eighth to the fifth position, but is seen with a great increase of 88.6%, followed by cerebrovascular disease which falls from the fifth position to the sixth position with a minor increase of 10.2%. There is an observed positive trend regarding the leading causes of premature death for Lebanon’s health, with a decrease from four non-communicable diseases, and a decrease in maternal diseases, with road injuries, breast cancer, and lymphoma falling from sixth, seventh, and tenth to seventh, ninth, and eleventh respectively. Diseases such as polio and TB are less prevalent and are being replaced by non-communicable diseases like Alzheimer’s and diabetes. There is an observed a shift in the prevalent diseases in Lebanon from 2005 to 2016. With broad data such as this, it may inadvertently disguise the regional disparities with under-five mortality reaching up to 52.2 in Northern Lebanon, which is a rural area (WHO, 2006). The main causes of child morbidity in these areas are respiratory infections, which was seen as a premature cause of death, as well as diarrhea, which is a common cause of premature death, especially in children.
In the rural areas of Lebanon, people have limited access to quality health care as compared to the urban areas. Health problems also vary from rural citizens to urban citizens, however the data does show improvement and changes in prevalence over the last decade. This is due to various public health interventions, and a change in living conditions. The diseases are still fluctuating, but improvements are observed with both non-communicable and communicable diseases.
The utilization of health services in Lebanon has been steadily improving. The percent immunization for measles in Lebanon is 79%, and the WHO region is 78%. The percent smear-positive TB treatment- success is 71% in Lebanon and 87% in the WHO region (WHO 2007). During the war, the private sector developed, which allowed for rapid growth in the number of hospitals. During the last decade, the number of physicians has increased by 8.3% each year. However, the geographical distribution is unequal, but with a higher population closer to the available hospitals. The nursing and paramedical services remain understaffed, which is problematic during times of conflict and emergency.
The high percentage of life lost due to disability is attributed to mental health, which often receives less attention in the world of public health. From 1990 to 2010, the percent change of the leading causes of DALYs has increased 50% for anxiety disorders, and 62% for major depressive disorders (GBD compare, 2010). Stress factors that arose from the war negatively affected the health of families. A study was done by the Beirut Health Survey in 1993 on the impact of war on mental health of Lebanese families for the past 12 years (Farhood, et al., 1993). The stress from wars, specifically the Lebanese civil war, has had an impact on health outcome. Reduction in food consumption was one of the outcomes of psychological and physical stress. Psychological symptoms are at high levels in Lebanon, mostly due to the war conditions. At least one symptom of psychological distress was reported from 8.3% of a sample that was surveyed, with females reporting higher symptoms than men. People with higher levels of income and education have less depressive symptoms, and this is mostly seen in women.
Anxiety and depression do not have a conclusive cause, however, there are many factors that elevate levels of anxiety and depression in people and place them at a higher risk. Depression is a genetic disease, and familial background plays a huge role in determining who will inherit it. A study that was done pointed to familial inheritance. The study concentrated on family as a social “unit”. The study investigated Lebanese families after their exposure to stress factors from the war. The risk of disease occurrence also increases with gender, with females from ages 40-59 were more likely to develop symptoms than any other subgroup of the study, with a 13.8% depression rate. Depression stems from stress, so high rates of stress lead to an increased chance of developing depression. When examining Lebanon’s socioeconomic factors, the level of poverty and unemployment rates are very high. These factors all contribute to stress, which increase the chance of depression in the country.
In Lebanon, 36-38% of residents live in poverty, as compared to the U.S. where there is 14.5% poverty (Royal Oak Interactive, 2017). These factors mentioned are social determinants of health, however they are directly influenced by the policies set by the government. The GDP in Lebanon is a quarter of that in the U.S. A significant amount of loans is paid off by GDP, which means safe environments and the career industry do not receive the amount required. Structural violence is occurring in Lebanon as a result of the wars, as well as the government. These factors increase the chance of getting depression for those living in poverty.
Using a biosocial approach, the biological, social, and political determinants of health that affect Lebanon’s depression problem can be solved. Improvements in the health system that focus on mental health, such as identifying and treating citizens suffering from depression can lessen the depression problem. Depression can be treated through psychological therapy and the administration of the proper drugs. Treatment of depression can decrease the chances of developing depression later in life. If depression is treated at an earlier stage, this would significantly lower the double-burden of disease that is seen in Lebanon. Policymaking such as increasing the amount of jobs available and decreasing crime rates would decrease the prevalence of disease in Lebanon, especially the 23.68% chance of being more likely to be murdered in Lebanon than the U.S. Health system and changing how the medical system and how society views and treats depression would also decrease the occurrence of disease. Both social and biological changes must be made to efficiently lower the occurrence of disease, and to control for the double-burden of disease that is seen.
The healthcare system in Lebanon is run by The Ministry of Public Health which aims to improve the performance of the Lebanese health system. The healthcare system in Lebanon is coordinated and managed by The Ministry of Health. The Ministry of Health has six branches that are publicly managed employment based social funds: National Social Security Fund (NSSF), General Security Forces (GSF), Army, Special Security Forces (SSF), Internal Security Forces (ISF), Civil Servant Cooperative (CSC), and the Ministry of Public Health (MOPH). These divisions all organize and distribute health care across the country through their individual management systems that provide primary, secondary, and tertiary care (WHO, 2012). In the 2000 World Health Report, Lebanon’s health system was ranked 91st (WHO, 2000). The health system supplies primary care through 165 public and private institutions distributed throughout Lebanon and covering medical and surgical specializations within a linked system of primary care, hospital care, and tertiary care. Due to the presence of heart diseases, especially with ischemic heart disease being the leading cause of death, the health care system has focused on providing quality care and access to cardiologists.
The two main insurance funds are the MOPH and NSSF. In 2010, the MOPH covered 4,038 heart surgeries (WHO, 2012). The MOPH’s coverage is 100% for some expensive procedures, while the NSSF covers 90% of open heart surgeries. Work place injuries are covered by the MOPH, but not the NSSF. The NSSF covers the younger population, while the MOPH covers the older and poorer populations of Lebanon. The MOPH primarily covers health emergencies like natural disasters, attacks, or epidemic outbreaks (WHO, 2012). Higher hospitalization rates and average length of stay are more complicated and expensive interventions are to be expected. Despite high spending levels and funding for health care, health indicators are below the average of countries that have a similar spending and economical level (Ammar, 2009). The problem with the Ministry of Health is that 80% of their budget goes towards hospital car. Unfortunately, care is very limited outside of Beirut, Lebanon’s capital.
Rural areas have limited medical facilities, as compared to the facilities in urban areas that are much more advanced and offer more resources. According to the Pacific Prime’s statistics, approximately 87% of the population lives in urban areas (Pacific Prime, n.d.). This being said, there is 13% of the population that is not getting adequate access to health care. Hospitals in Beirut, however, offer some of the highest levels of medical care in all of Lebanon, and these medical facilities are similar to the healthcare and the standards put forth in the U.S. and Europe. Lebanon’s health care system is expected to improve given the audit of primary healthcare facilities done by the Accreditation Canada International (IMTJ, 2011). This project began with a small group of medical centers that underwent an assessment of their services to identify areas of improvement to provide quality care to the population.
Lebanon receives a mix of private funding, public funding, and foreign donors. In 2005, public funding was 28.98%, private was 70.99% and international donors made up the remaining 0.03% (WHO, 2012). The public funding comes from employment-based social insurance funds. Overall, the financing plan administered in Lebanon aims to meet the needs of the population while remaining cost-effective. Insurance in Lebanon is available through mostly private insurance companies. The number of active insurance companies however has decreased by 15% from 2001 to 2010 (WHO, 2012).
Lebanon provides universal healthcare to all of its population, paid for through the private insurance companies. About 26.1% of the population is covered by the National Social Security Fund (NSSF). The NSSF is the dominant source of health care coverage in Lebanon, covering primarily the population employed in the private and public sectors that are not benefitting from the Civil Service Cooperative scheme (WHO, 2012). According to the Arab Trade Union, less than half of the population (48%) benefit from insurance (ATU, 2012). The system has recently changed because there is an aim to improve the contracting system with private and public hospitals. According to the 1999 National Household Health expenditure and Utilization Survey (NNHEUS), 45.9% of the population was covered by one or more public or private insurances.
The older population suffers from chronic and non-communicable disease in Lebanon. This represents a shift from a demographic standpoint to an epidemiologic one. According to the epidemiological data of the National Tuberculosis Program (NTP) published by the MOPH, tuberculosis cases have decreased from 1995 to 2006 (WHO, 2012). Non-communicable diseases, however, are becoming more prevalent while certain infectious diseases are still common and are of public health importance.
One of the best health care systems in the Middle East is found in Lebanon, with observed health care similarities to that of the U.S. and in Europe, as previously mentioned. As far as stewardship goes, Lebanon has worked towards integrating refugees, specifically Syrian and Palestinian refugees, into their health system. The country would define quality standards and policies, regulate competition to ensure fairness and allocation of resources according to the population’s needs (Blanchet & Fouad et. al, 2016). The supply of hospital beds, for example, has enhanced the quality of care to meet the basic requirements. The MOPH’s mission is to “improve the health status of the population by ensuring equitable accessibility to high quality health services through fairly financed universal coverage and addressing economic and social determinants of health through trans-sectorial policies” (WHO, 2012). Lebanon’s reforms were set in place to improve the health system efficiency, increase coverage, and lower out-of-pocket spending. This was done by improving the quality of hospitals and refining the use of medical technologies.
The MOPH has sought to strengthen its leadership and governance functions as well. Like other health care systems, the Lebanese health care system is flawed. The Ministry of Health has spent time and funding exclusively on providing services. The MOH has not focused at all on prevention, planning, and regulation. This is a structural weakness in the health care system. The improved quality of services in the public sector has resulted in increased utilization, especially among the poor. In this case, Lebanon is a step ahead of some countries, especially the under-developed countries because Lebanon offers healthcare options for those who cannot afford it.
Lebanon’s health care system closely models that of France, which is the Bismarck Model (WHO, 2012). Both countries have systems that provide insurance plans that have to cover everyone. Operating in a non-profit manner, the main goal for the health system in Lebanon and in France is to provide universal coverage because health care is a human right. The current health system in Lebanon is quite broken, with an absent public sector due to the civil war. The integral part of the Lebanese healthcare system is the private hospital sector, accounting for 82% of the country’s population.
Lebanon has very recently undergone a period of great change, especially within the government. As a democratic republic, Lebanon employs a parliamentary system of government with a president, Michel Eoun, a prime minister, Saad Hariri, and a cabinet chosen through an electoral process (Embassy of Lebanon, 2016). This month’s sudden resignation of the Prime Minister, Saad Hariri has caused Lebanon to feel unsettled. In his resignation speech, he said that he was stepping down because of rising Iranian threats made him fearful of suffering the same fate of his father who was assassinated by a car bomb in 2005 which was believed to be related to the Iranian militant group Hezbollah (BBC, 2017). Saad Hariri helped provide a cover for the Lebanese government that was partly controlled by Hezbollah. Now that he resigned, that cover is gone, and it provides an opening for Hezbollah to exploit the government. Hariri’s announcement earlier this month increases the chance of a conflict involving Saudi Arabia, Iran, Lebanon, and possibly Israel. This political crisis does not help the country’s current standing with health care, and could lead to drastic changes within the health care system that is currently in place. Due to the sudden resignation of Hariri, there is not much information on the current standing of the government. As of now, officials are trying to figure out what the next step is for the country.
Prime Minister Saad Hariri was one of the best political figures the country had ever seen. With the current standing of Lebanon’s government and the sudden resignation of the Prime Minister, Lebanon officials are expecting another war to arise (BBC, 2017). If this happens, it could be very dangerous to the people’s health. The road conditions in Lebanon would be damaged as a result of the war, which would inhibit people’s ability to drive to get the proper health care they need. Sand and dust storms from war debris can cause ear, nose, and throat complications. People that suffer from asthma and other respiratory conditions could experience exacerbated symptoms. Another issue would be the cost of not only health care, but everything else rising.