The Lebanese government should uphold its commitment to ensure that everyone living on its territory has equitable access to Covid-19 vaccines and is included in the national vaccine program, regardless of their nationality or residency status, Human Rights Watch said today. It should also swiftly address gaps in its strategy to inoculate the population just weeks before the vaccine drive is slated to begin.

The caretaker health minister, Hamad Hassan, announced that the first batch of Covid-19 vaccines will arrive in Lebanon by mid-February 2021. The government needs to make public which body will oversee and coordinate the campaign, how the plan will be carried out and communicated to hospitals and to the public, and how the vaccine will be distributed to vulnerable groups. These should include front-line health workers and other essential workers, older people, and those with underlying health conditions, as well as migrant and undocumented workers, refugees and asylum seekers, and detainees who fall into those priority categories.

“The government’s stated commitment to an inclusive vaccination strategy is positive, but the real test will be translating the plan into action,” said Aya Majzoub, Lebanon researcher at Human Rights Watch. “It is critical for leaders to clearly communicate the government’s vaccination strategy, ensure that vaccine access is not determined by political connections or socio-economic status, and apply transparent, evidence-based distribution criteria equally to everyone in Lebanon.”

The Health Ministry should increase transparency about its national vaccination strategy. It should ensure that its plans are accessible to the population and communicated effectively to raise awareness about the benefits of vaccination, respond to vaccine hesitancy, and dispel misinformation, said Human Rights Watch.

On January 27, Hassan announced the outlines of the government’s strategy, saying that everyone in Lebanon, regardless of nationality, will be eligible for the vaccine.. Lebanon has an estimated 1.7 million refugees and asylum seekers, and 400,000 migrant workers.

Hassan said the plan aims to vaccinate 80% of the population by the end of 2021. However, the government has so far only stated its intention to purchase 6.3 million doses, enough for just under half the country’s population.

In the first stage, the strategy prioritizes healthcare workers and those over age 75, followed by those over 65, and then those over 54 who suffer from certain underlying health conditions. Residents will be able to register on a Health Ministry platform, he said. On January 25, the Health Ministry released a list of 42 designated vaccination centers.

However, hospital officials told Human Rights Watch that they had not yet received any instructions from the government on how to operationalize the strategy. Dr. Georges Ghanem, the chief medical officer of the LAU Medical Center-Rizk Hospital, one of Lebanon’s largest private hospitals and one of the 42 vaccination centers, said that “we don’t have a clear operational roadmap for the vaccination campaign. We have this broad plan which is a plan of principles, but not an operational, on-the-ground plan.”

Ghanem said that they still do not know what software vaccination centers will use to register and schedule appointments and when staff members will be trained to use it. Nor do they know how the private sector, which the government said will be allowed to import vaccines, will fit into the national program.

“We have so far not received an implementation plan,” said Dr. Hassan Wazni, director-general of the Nabatieh Governmental Hospital in south Lebanon and one of the vaccination centers. He said the Health Ministry had not yet provided lists of people prioritized for vaccination, the number of vaccines the hospital will receive and the number of expected recipients, which vaccine it will receive first, and whether the vaccine will be stored in Beirut or at the hospital.

The director of a public hospital in north Lebanon, who did not want to be named, described a similar situation. “We are currently filling forms and questionnaires with information about our capacities,” he said, but added that they have not received any information beyond the fact that they are a vaccination center.

Hospital officials also raised concerns about the lack of nation-wide awareness campaigns. “Whether people will accept the vaccine is a major concern,” said Dr. Firass Abiad, the head of Rafik Hariri University Hospital, Lebanon’s biggest public hospital and one of the vaccination centers. “If people refuse, you are still looking at a group of people where the virus can still spread and run the risk of mutation. So my question is, with the vaccine arriving within three weeks, where are the awareness campaigns?”

Finally, hospital officials said they still do not know which body will oversee the vaccination campaign and receive queries and complaints, such as reports of adverse reactions, vaccine shortages, discrimination or corruption within the program, or misinformation from third parties. “This was lacking during the pandemic and for this reason we failed dramatically to have clear leadership and clear accountability,” Ghanem said. “I’m scared. I’m scared that when there is no leadership, no planning and anticipation, and no transparency, there will be a vacuum filled by predators.”

Although the government announced that the vaccination campaign will cover everyone in Lebanon, regardless of nationality, other health officials have previously publicly stated that refugees and asylum seekers would be excluded and that United Nations agencies would be responsible for ensuring that refugees in Lebanon are vaccinated. Members of some political parties, including the president’s party, have publicly argued that vaccines should be given to the Lebanese “exclusively,” which is likely to inflame xenophobic and nationalist sentiments. Such pronouncements resulted in a trending Twitter hashtag that translates to “the vaccine for the Lebanese first.”

Discrimination on the basis of national origin or residency status is contrary to international law, and in particular would violate Lebanon’s obligations under the Convention on the Elimination of All Forms of Racial Discrimination (CERD) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). Any differential treatment based on national origin or immigration status can only be justified as nondiscriminatory if it pursues a legitimate aim and is proportionate to its achievement.

Given the overwhelming public interest and public health goal of ending the pandemic, excluding or limiting certain groups’ access to the vaccine on the basis of national origin or residency status, which would undermine those aims, would not be justifiable or proportionate.

In its general guidelines, UNHCR, the UN Refugee Agency, maintains that “national authorities are responsible for public health responses and COVID-19 vaccination drives” and that “the delivery and administration of the vaccines to refugees…will be coordinated by national health authorities.”

Lebanon reported over 114,000 active Covid-19 cases and 2,477 Covid-19 related deaths as of January 27 The health sector, already in crisis before the pandemic began, is on the brink of collapse as hospitals fill up and scramble to redirect resources to fight Covid-19. Lebanon is under a strict lockdown and 24/7 curfew until February 8.

“The economic crisis and the pandemic have pushed Lebanon’s health sector to the breaking point,” Majzoub said. “Lebanon needs to urgently slow the transmission of the virus, and this can only be done by ensuring that everyone in the country – including refugees, asylum-seekers, migrant workers, and detainees – is included, and treated equally, in the vaccine rollout.”

Vaccines Expected

On January 17, the Health Ministry said that it finalized a bilateral deal with Pfizer-BioNTech to secure 2.1 million doses of their vaccine. The health ministry’s strategy stated that Lebanon will receive 250,000 doses in the first quarter of 2021, 350,000 doses in the second quarter, 800,000 in the third quarter, and 700,000 in the fourth quarter.

The president also announced on January 15 that Lebanon had reserved 2.73 million vaccine doses through the COVAX Facility, a global pooled procurement system that aims to provide lower-income governments with enough doses for 20 percent of their populations by the end of 2021. Hassan said on January 27 that Lebanon was also in negotiations with Oxford-AstraZeneca for another 1.5 million doses. The government has not yet announced when Lebanon is expected to receive its share of these vaccines. The government will distribute all three vaccines to the public for free as part of Lebanon’s national vaccine strategy.

The World Bank announced on January 21 that it approved the reallocation of $34 million from an ongoing health project to support Lebanon’s vaccination plan, the first World Bank-financed operation to fund the procurement of Covid-19 vaccines. Lebanon has already paid a $4 million deposit to Pfizer-BioNtech. It has also paid two deposits to the COVAX Facility: $4.3 million and 26.4 billion Lebanese pounds ($17.53 million at the official exchange rate or $2.9 million at current market rates) on January 17.

Recommendations for Equitable Vaccine Distribution

Lebanese Authorities

Lebanese authorities have an obligation to fully respect the human rights of refugees, asylum seekers, and people without legal documentation within their borders, including their right to health, Human Rights Watch said. The government should include migrant workers, including undocumented migrants, refugees, and asylum seekers, in its vaccination plan in keeping with WHO recommendations.

The WHO recommends that countries “ensure that vaccine prioritization within countries takes into account the vulnerabilities, risks, and needs of groups who, because of underlying societal, geographic or biomedical factors, are at risk of experiencing greater burdens from the Covid-19 pandemic…[this includes] Low-income migrant workers, refugees, internally displaced persons, asylum seekers, populations in conflict setting or those affected by humanitarian emergencies, vulnerable migrants in irregular situations, nomadic populations.”

The Lebanese authorities should take immediate steps to build public confidence in vaccines by ensuring that the public has access to full and accurate information about the vaccines available and the government’s vaccination strategy, Human Rights Watch said. The government’s public awareness campaign should include information about clinical trial data and possible side effects, counter misinformation, and underscore the public health importance of including everyone within its borders in its vaccination plan to counter the heated nationalist and xenophobic rhetoric calling for Lebanese nationals to be prioritized.

Decisions about access should be transparent and made on the basis of medical and public health criteria, taking into account human rights obligations related to the rights to health, life, and an adequate standard of living, rather than political preference. The authorities should ensure that the registration process is accessible to all segments of the population, including older people and those without internet access or digital literacy skills.

The government should provide regular public reporting about the number of people vaccinated, with age, sex, occupation, nationality, district of residence, and other criteria such as an underlying health condition.

The authorities should create an independent mechanism, such as a dedicated body within the Health Ministry, to monitor the vaccine rollout and allow residents and medical professionals to submit queries about the process and lodge complaints, including about discrimination or corruption in vaccine distribution. This body should submit periodic reports to the World Health Organization.

Public health experts have noted the difficulties in developing an evidence-based and efficient vaccination response amid a dearth of demographic data in Lebanon. The country has not had a census since 1932, so estimates of the number of people in the country vary significantly, with considerable ramifications for any public health strategy. The Central Administration of Statistics estimates that Lebanon has 4.8 million people, whereas the World Bank puts that number at 6.9 million. Lebanese authorities should allow everyone living in Lebanon to register and provide relevant health and demographic data, enlisting the help of local authorities and international organizations.

International Organizations

The COVAX Facility has established a humanitarian buffer that aims to cover potential populations who may not be well served through the national allocation mechanisms for vaccines, including people living or working outside government-controlled areas or as refugees, internally displaced peoples, and asylum seekers. The volume of this buffer would be 5 percent of the vaccines supplied by COVAX, or 100 million doses by end of 2021. COVAX will use the “Global Humanitarian Needs Overview” and relevant inter-agency guidelines and data to identify target populations in humanitarian contexts.

Lebanon, UN agencies, and civil society organizations can request vaccine doses under COVAX’s humanitarian buffer, but the humanitarian buffer does not displace Lebanon’s obligation to provide vulnerable groups in Lebanon, such as refugees, internally displaced people, asylum seekers, and irregular migrants with equitable vaccine access.

Humanitarian organizations and UN agencies in Lebanon should help facilitate the deployment of vaccines to vulnerable populations. They should ensure that these groups have up-to-date and accessible information about the pandemic and the vaccine, that they can register for vaccination through the national platform, that they can safely travel to the vaccination centers, and that they can submit complaints about any discrimination or ill-treatment or side-effects they may experience.

The World Bank should ensure that its loan money is spent in compliance with fundamental human rights obligations, including the principle of nondiscrimination. In response to the World Bank Group’s announcement of a US$12 billion financing plan to help low- and middle-income countries buy Covid-19 vaccine doses, Human Rights Watch urged the bank’s board of directors to take urgent steps to address barriers to equitable vaccine access before approving the financing plan.

Relevant International Standards

Lebanon is a party to the International Covenant on Economic, Social, and Cultural Rights (ICESCR), which requires it to take steps to achieve “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” It also requires countries to take steps necessary for the “prevention, treatment and control of epidemic, endemic, occupational and other diseases.” The control of epidemics requires, among other steps, “the implementation or enhancement of immunization programmes and other strategies of infectious disease control.”

The Committee on Economic, Social and Cultural Rights has said that parties to the treaty should “respect the right to health by…refraining from denying or limiting equal access for all persons, including…asylum seekers and illegal immigrants.”

Governments also have an obligation to protect the right to seek, receive, and impart information necessary to promote and protect rights, including the right to health. The Committee on Economic, Social and Cultural Rights regards as a “core obligation” providing “education and access to information concerning the main health problems in the community, including methods of preventing and controlling them.” It is required to ensure the protection of these rights to everyone in its territory, without discrimination.

The United Nations special rapporteur on the right to the highest attainable standard of physical and mental health has stated that asylum seekers and even irregular migrants have the right to health: “States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative, and palliative health services.”

Lebanon is also a party to the Convention on the Elimination of All Forms of Racial Discrimination (CERD), and as the CERD Committee has set out in its 2004 General Recommendation No. 30, laws that treat citizens and non-citizens differently will constitute discrimination if they do not serve a legitimate state objective or are not proportional to the achievement of that objective. This applies to any difference in treatment with respect to the rights guaranteed under the ICESCR, including the right to health.