Regional profile - Lebanon

Well on the road to healthy recovery



The standard of healthcare in Lebanon is remarkable considering the relatively short time it has had to develop following the devastation of the civil war. Middle East Health visited three key hospitals in the capital Beirut to find out more.

Lebanon and specifically Beirut is making a remarkable recovery from the devastation of the civil war. This is evident in many spheres but perhaps most visibly in the on-going fashionable reconstruction of Beirut and, what Middle East Health discovered, the high standard of healthcare available in the country.

Beirut, nestled between snow-capped mountains and the deep blue Mediterranean, is slowly regaining its former reputation as a party place of choice for travellers. Clubs and pubs on the narrow cobbled streets in the Rue Monot area see revellers partying to the early hours of the morning all nights of the week.

It takes just 45 minutes to drive up to the snow-capped peaks behind the city and the ski lifts at Mzaar. There are not many places where you can swim in the Mediterranean in the morning, ski in the afternoon and then dance the night away in a trendy nightclub.

Although largely Arabic speaking, Beirutis, many of whom also speak French, pride themselves on the European character of their city with it’s cosy coffee shops serving a distinctly Lebanese brew and al fresco dining in the chic Solidare district. Here diners eat their mezze and smoke shisha while gazing over recently uncovered Phoenician and Roman ruins.

The Lebanese people are mostly of Arab origin, although a substantial Armenian population is also present. There are some 300,000 Palestinian refugees in Lebanon and about 180,000 stateless people resident in the country (mostly Kurds and Syrians).

It is estimated that 600,000-900,000 persons fled the country during the initial years of civil strife (1975- 1976). Although some returned, the continuing instability until 1990, sparked further waves of emigration. The Beirut population is estimated at 1,185,300 and the total population, according to 2004 estimates, is 4,432,000. According to some sources educated young people continue to emigrate due to worrisome economic, social and political prospects, making "brain-drain" one of Lebanon's most imminent problems.

However, regarding Beirut, it appears as if “the city that wouldn’t die” has had a shot in the arm. Bullet-riddled derelict buildings are being turned into stylish apartments and offices. There is a new life in the city and there is and a fresh impetus for it to regain its title as the capital of the Eastern Mediterranean.

The same can be said of the healthcare industry with the return of many highly qualified doctors following the war and the rapid growth of hospitals and clinics offering hi-tech services. Middle East Health visited the capital’s three main hospitals – American University of Beirut Medical Centre (AUBMC), St George Hospital and Hotel Dieu hospital.

Taking the leading causes of death in Lebanon – cardio vascular disease and cancer – as a sign of the state of health in the country, then Lebanon is not dissimilar to developed countries around the world where these diseases are the foremost killers. According to 2004 estimates the infant mortality rate in Lebanon is 25.48 deaths per 1,000 live births. Life expectancy at birth for the total population is 72.35 years – 69.91 years for males and 74.91 years for females.

Regarding cancer in Lebanon, AUBMC’s Tumor Registry, which measures the incidence of cancer treated at the hospital since 1983, is a good indicator of the epidemiology of cancer in the country. According to the registry: in men, lung cancer, followed by prostate cancer is the most common and in females breast cancer followed by cancer of the cervix.

However, according to the Lebanese Cancer Epidemiology Group cancer incidence in males in 1993 and 1998 showed bladder cancer as the most common. In line with the Tumor Registry the group noted that breast cancer was the most common in woman in those years.

According to the Tumor Registry there was an increase in the crude incidence of all cancers in the first 20 years of data collection. However, it says this may be attributed to the period following the end of the civil war in 1990, when there was a “proliferation in the number of medical institutions and a marked improvement and modernisation of various medical diagnostic equipment.

This is reflected in the presence of a large number of MRI, CT scan, mammogram suites, colonoscopy, cytology and pathology laboratories disproportionate to the population. More over there was an increase in the number of oncology specialists in the country.”

Healthcare financing

The AUBMC’s deputy director, Dr Marina El Hajj told Middle East Health that more than 90% of healthcare was provided by the private sector adding that the government was in the process of building more hospitals “but they have a long way to go before they can be an effective substitute for private healthcare”. A large part of the population relies on government funding to pay for healthcare.

The National Social Security Fund covers more than one third of the population. There is a scheme for each of the four arms of the security forces which is funded by general tax revenues.

The Ministry of Health funds hospitalisation for any citizen not covered by an insurance plan. “About 60% of the population have some form of health insurance whether they are with the National Social Security Fund or not,” said Dr Hajj. “Private health insurance is still quite a fragmented market. Fifteen insurance companies cover about 70% of the non-life insurance market which includes medical insurance.”

All the hospitals Middle East Health spoke to said they were having difficulty recovering money owed to them from the government funds which makes it “difficult for the hospital to cover this section of the population at the current rate of reimbursement”, Dr Hajj said. Salam Rayes, chief executive officer, St Georges Hospital in Beirut, said: “If you look at our reimbursement forms in the admission office you’ll go crazy. We bill the same institution four different forms for reimbursement.”

The spending on healthcare in Lebanon is around US$2 billion, about 10% of GDP. Of which a quarter is in hospitals 25% on medication and half on out-patients – this includes private consultations, labs, radiology and so on. Rayes said that the government had recently established a chain of government hospitals across Lebanon.

The chain is composed of around 15-20 hospitals of not more than 50-100 beds each. He also pointed out that the government had built the 500-bed Beirut General Hospital, which although construction is complete, remains vacant due to bureaucratic red tape. However, Dr Aida Yazigi, medical director at St Georges Hospital, pointed out that the Beirut Gen had recently appointed a board of directors, which could lead to this hospital opening its doors in the near future.

AUBMC

The American University of Beirut Medical Centre (AUBMC) is one of the Middle East’s leading multispecialty medical facilities with several of its departments, serving as distinguished referral centres for the region. Its status as a training, research and treatment facility is revealed in many areas including the respect it has been shown from highprofile people in the region, such as Qatar’s Sheikh Hamad Bin Jassem Bin Jabr Al Thani who recently praised AUBMC for the treatment he received at the facility.

Its status in the region is also borne out by the recent signing of a five-year collaboration agreement with Kuwait which covers a wide spectrum of health-related areas such as the exchange of healthcare information and expertise, and medical education.

AUBMC is the oldest medical institution in the Lebanon. It was established in 1867 with the Syrian Protestant College Medical School which later became the AUB Faculty of Medicine. “It had 220 beds in 1954, which was a big facility for its time,” John Rhoder AUBMC director, told Middle East Health.

Over the past 100 years the hospital relocated to three venues in the city. “The current building was built in 1970 as a 420-bed hospital,” said Rhoder. “We have a 20-year master plan. We will build a more modern and larger facility across the road.”

The hospital has a very busy ER, with about 40,000 patients a year passing through the ER doors. In total the hospital sees around 200,000 outpatients a year and admissions total about 20,000 a year. “We have about 250 active medical staff,” Dr Hajj pointed out.

AUBMC is the private, notfor- profit teaching centre for the AUB’s Faculty of Medicine. There are about 246 residents and fellows, 65 of which are Post-Graduate interns who train at the hospital. The medical training here is regarded as some of the best available in the Middle East. This was recognised in 2002 when the Faculty of Medicine received the Sheikh Hamdan Bin Rashid Al Maktoum Award for the Best Medical College, Institute or Centre in the Arab World.

“All services are available: medicine, surgery, gynaecology, paediatrics, psychiatry and so on,” said Rhoder. The centre offers comprehensive healthcare services, extensive tertiary resources, medical, nursing and paramedical training. “We do fairly sophisticated surgery such as open heart and transplant surgery.

The hospital is also well known for it neo-natal intensive care unit and critical care units. “One of our key specialties is paediatric oncology and this department [the Children’s Cancer Center of Lebanon (CCCL)] is affiliated with St Jude Children’s Research Hospital in the United States,” said Rhoder.

The CCCL has an outpatient clinic and inpatient facility. Dr Hajj pointed out that oncology was one of AUBMC’s core competencies, “both adult and paediatric”. AUBMC’s Naef K Basile Cancer Institute has a multidisciplinary adult oncology programme that includes a bone marrow transplant unit.

In the radiotherapy department the medical centre has two linear accelerators for the targeted treatment of cancer. AUBMC is also recognised for its cardiology services and neuroscience programme. “Actually all our specialties are of exceptional quality, although some are more fully integrated than others,” said Dr Hajj. “Many of our physicians who left during the war are now coming back.

They went to very good institutions and now they are very senior people, world class physicians in their own right,” commented Rhoder. Dr Mukbil Hourani, chief of staff at AUBMC, added that the epilepsy monitoring unit was the only one of its kind in the region. “We get many foreign referrals for this unit,” he pointed out.

Dr Hourani said with regard to oncology the hospital was the first in the Middle East to use a new radioimmunotherapy called Zevalin. Zevalin is used to treat certain types of non- Hodgkin's lymphomas. Approved by the US Food and Drug Administration in February of 2002, it is the first radioimmunotherapy agent for the treatment of cancer.

Radioimmunotherapies like Zevalin are made by linking monoclonal antibodies – engineered in a laboratory to recognise and attach to substances on the surface of certain cells – to radioactive isotopes. When infused into a patient, these radiationcarrying antibodies circulate in the body until they locate and bind to the surface of specific cells and then deliver their cytotoxic radiation directly to the cancerous cells.

Dr Hourani added that AUBMC planned to develop affiliations with several medical centres in Lebanon and the region in an effort to extend a friendly professional gesture to the people of Lebanon and the region. Asked about HIV/AIDS in Lebanon Dr Hajj said the AUBMC saw a few patients with the disease, but pointed out that it was not a big problem.

She admitted, however, that there was still an inhibiting stigma attached to the disease and that it was difficult to gauge the real situation because people who were infected remained silent about their condition.

St George Hospital

The St George Hospital first opened it doors in 1878. The current hospital in Beirut was built in 1968.

Rayes told Middle East Health that the hospital would move to a new ultra-modern complex before June this year. “Our bed complement is 275 beds. In two-and-a- halfyears, when we’re finished construction it will be 400 beds.”

St George hospital is a nonprofit community hospital owned by the Orthodox Church of Beirut. “We have a board of directors composed of community members,” Rayes pointed out.

The hospital also serves as a training centre for the University of Balamand postgraduate Medical Education Programme. This was started in 1999 when the university, located in the north of the country near Tripoli, setup the programme.

The Faculty of Medicine trains residents and fellows in various specialties and subspecialties of medicine, including for example surgery, paediatrics, obstetrics, radiology and pathology “We are well-respected for open heart surgery, cardiology, orthopaedics and the paediatric department.

“We are also the only hospital in the country which has an inpatient psychiatry clinic … Cases such as depression are treated at the clinic. Difficult cases are referred to the mental hospital.” The hospital also prides itself in having the only neonatal ambulance in the country, equipped for neonatal transport.

Following the end of the civil war the hospital was able to inject new hi-tech facilities including: IVF; MRI; a transplant unit for kidney, lung, liver and pancreas; and endovascular unit; osteodensitometry; and a molecular biology lab.

Hotel Dieu

Hotel-Dieu de France, despite its misleading name is actually a well respected French hospital in the heart of Beirut.

The hospital, established in 1923, is affiliated to French language St Joseph University medical school. The hospital was originally managed by the French Hospital Association. However, starting 1984, the management of the hospital was transferred to St Joseph University.

Besides being a teaching centre the hospital also has a clinical research programme, serves as a national and regional reference centre and plays an important role in public health, Professor Patricia Yazbeck, director of medical affairs, told Middle East Health. The hospital has 395 beds, 40 of which are for the Intensive Care Unit.

The hospital receives around 14,000 admissions a year and about 20,000 ER patients a year. Joseph Otayek, the director general, pointed out that the equipment is state-of-the art with the average age of equipment no older than two-anda- half years.

“We have the Rolls Royce of linear accelerators, the Valerian, for clinical radiotherapy. “We are in the process of acquiring surgical navigation equipment,” Otayek said. Hotel Dieu has a wide range of scanning and exploration equipement including: MRI; CT; ultrasound; duplex scan; conventional radiology; mammography; and neuro-imaging among others.

Hotel Dieu has 12 operating rooms. Phycians number 106, surgeons 62, residents 120 and interns 60. “Our doctors are accredited in the US, Canada and France exclusively.

“All our 332 nurses are university graduates and the nurse to bed ratio is 0.8,” Otayek told Middle East Health. Hotel Dieu offers five-star services and gets many referrals mainly from Syria, Kuwait and Saudi Arabia. “Referrals are mainly for oncological surgery; paediatrics; echo-endoscopy; amorism surgery; and orthopaedics,” Otayek said.