Lebanon has been in the midst of social and political turmoil since October, 2019. In response to proposed tax hikes on common goods, the country’s population has held repeated protests and demonstrations against the ruling government and prevailing elites, condemning wide-spread structural inequalities which increasingly challenge the ability of citizens to live their lives with dignity.
The protests and demonstrations mark a turning in the country’s history. Across sectarian divides, persons of all ages are coming together to issue a bottom-up request for rebuilding Lebanon’s governance and way of life. Unfortunately, multiple protests and limited confidence in the local government have precipitated the emergence of an economic crisis, deepening the existing fragility that the country had already exhibited. Challenged by corruption and limited transparency, as well as the sudden need to accommodate a forcibly displaced Syrian population, Lebanon had already struggled with fragility in its social, political and economic life.
As a Global Health Research Unit on Health in Situations of Fragility, we work and live in settings exhibiting substantial fragility. We have been active in Lebanon since 2017, and have focused our efforts on unpacking how country level fragility circumstances manifest and impact health, specifically in relation to mental health and non-communicable diseases. Recently, our researchers had been involved in studies in Beirut and the Beqaa, focused on understanding primary care level service delivery for vulnerable Lebanese citizens and Syrian refugees. As a result of instability, field work has been delayed on several occasions. Following the October 2019 protests and road blocks for instance, field work was suspended to avoid any potential risk and harm to the research team.
In the following months, further challenges emerged. Representatives from the Lebanese Ministry of Health announced that, given the current economic crisis, service cuts and primary care center closures were necessary. We adjusted our research processes and protocols to the emerging situation yet again; however, noted with increasing concern how such developments affected not only the populations we studied, but also our own researchers. In team meetings, both our students and colleagues spoke of the inability to focus when, all around them, society was actively reshaping. Our team members themselves called for change, however also acknowledged that any government contact was now widely viewed with suspicion. Our own ability to study publicly provided health services was therefore suddenly viewed through a new lens. Even during this, sticking to the timeline assigned to deliver tasks and meeting the various reporting and research deadlines of funders was a priority.
In the increasingly unstable ‘stable’, data collection finally resumed in clinics in late February 2019, at least for a few weeks. We followed the news of China and Italy with concern; however, were hopeful that the necessary measures would be undertaken to prevent and prepare the system for the emergence and spread of COVID-19 in Lebanon. As case numbers grew, data collection was promptly interrupted again in order to safeguard our data collectors and research teams. In a completely new situation now, we ask ourselves: what research can and should be conducted, not only to inform national systems’ response and priorities, but also to address the lived experiences of the communities we have worked with and for?
Health research in fragile settings requires several adaptations in order to both safeguard research teams and be effective in conducting research in such settings. Based on our experience, we distinguish several recommendations that researchers, organizations and institutions such as funders may find helpful.
At the individual level: All researchers must be encouraged to follow strict safety protocols and procedures, adjusted as necessary for the conditions in which they are conducting the work. For example, for settings in which conflict and civil unrest is common, this means actively monitoring conditions and allowing researchers to adapt as needed to the perceived security situation encountered within an area is pivotal. This may mean collecting data in teams, or not engaging in in-person data collection at all if the situation is deemed too insecure. Similarly, individuals should follow existing condition-specific guidelines or advice when in the field, and evaluate whether the risk of in-person data collection is warranted. For example, in the case of communicable diseases, researchers should follow distancing rules or wear protective equipment as needed.
All research teams must think carefully about the risks and benefits of in-person data collection and be encouraged to actively think of alternative strategies, in case the latter is no longer possible. In situations of fragility, security and safety are frequently compromised, so teams should always design their research with several alternative strategies in mind for completing their work.
At the organizational level: We recommend that ethical review boards be flexible and agile in granting initial research approvals (e.g. in cases where a threat such as Sars-CoV-2 emerges) as well as allowing amendments as needed as security and safety concerns emerge. As aforementioned, it is frequently the case that alternative methods for data collection will be necessary. For this reason, review boards must allow researchers the flexibility of switching track, both to safeguard participants as well as research teams.
At the institutional level: Funders frequently adjust expectations when notified of emerging challenges in specific settings; however, in the case of research explicitly conducted in situations of fragility, unexpected situations and delays are the norm and not the exception. Funders should have clear processes for identifying likely challenges in specific settings at research outset and adapt expectations accordingly. Systems for frequent monitoring of research activity and ‘live’ notifications of delays should be set in place so that teams do not simultaneously worry about both completing research activities within assigned timelines, and compiling detailed reports on setting specific challenges.
 Project Coordinator, Global Health Institute, American University of Beirut, Lebanon
 Research Fellow, Institute for Global Health and Development, Queen Margaret University, UK
 Research Assistant, Institute for Global Health and Development, Queen Margaret University, UK
 Chehayeb, K. & Sewell, A. (2020), Why Protesters in Lebanon Are Taking to the Streets, Foreign Policy, Retrieved at: https://foreignpolicy.com/2019/11/02/lebanon-protesters-movement-streets-explainer/
 Hubbard, B. (2020), Lebanon’s Economic Crisis Explodes, Threatening Decades of Prosperity, The New York Times, Retrieved at: https://www.nytimes.com/2020/05/10/world/middleeast/lebanon-economic-crisis.html
 Kranz, M. (2020), Poverty set to deepen with Lebanon’s economic crisis, Al-Jazeera English, Retrieved at: https://www.aljazeera.com/news/2020/01/poverty-set-deepen-lebanons-economic-crisis-200101093225897.html
DISCLAIMER: The views and opinions expressed in this blog are the author's, and do not reflect the views of the Global Health Institute or the American University of Beirut.
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