Rocco Massad was spending the evening of 4 August at his home in Lebanon, more than 50km away from the country’s capital, Beirut, when he heard what he thought was a sonic boom. “I wasn’t sure what it was,” he remembers, “but it felt big – like a small earthquake.”
Within minutes of the disturbance Massad’s phone had flooded with calls and social media notifications. Earlier that evening, the roof of a warehouse in the main working port of Beirut had caught light. Shortly after 6pm, the fire spread to the roof of the warehouse and – without the knowledge of the emergency services, who were on the ground trying to tackle the blaze – to more than 2,700 tonnes of highly combustible ammonium nitrate that had been unsafely stored inside.
Eyewitnesses described a large initial explosion, followed by a series of smaller, firework-like pops. Less than 30 seconds later came the blast – a gigantic explosion that sent a mushroom cloud into the sky and destroyed the dockside and surrounding warehouses.
The impact blew boats out of the water and left a crater about 124 metres wide and 43 metres deep at its epicentre, while a shockwave ripped through the capital, causing buildings to collapse and shattering windows within a 9km radius. Multiple reports said the blast was felt in Cyprus, more than 200km away.
At least 200 people were killed and thousands more were injured by the blast. As footage of the disaster spread around the world, Massad was trying to get hold of his family and friends living in the capital. “Phone lines were jammed because of the networks – everyone in Lebanon was trying to get hold of their loved ones, so it took me 20 minutes to even get through. They were very long minutes.”
Upon making contact he discovered that some of his family members had been injured – thankfully not seriously – so he travelled to Beirut to find out which of the city’s hospitals they were in. “It was a long night,” he says. “As you’d expect in a mass casualty [event] there were hundreds of people turning in to the emergency rooms. It was chaotic – but the medical staff were good at dealing with it.”
The following day he was contacted by UK-Med, a UK charity he works for as a logistician. “They got in touch to see if I was in Lebanon and could prepare for the arrival of the assessment team,” he says. “Thirty-eight hours after the blast, I was working.”
How to deploy in a global pandemic
UK-Med began its life as the South Manchester Accident Rescue Team (SMART), supporting rescue and ambulance services around the city of Manchester. The organisation’s first international response took place in 1988, when a team of eight Manchester clinicians travelled to Armenia to support people hit by a severe earthquake, and the charity now has more than 30 years’ experience in responding to health emergencies around the world.
The charity trains experienced NHS doctors, paramedics, midwives and other health professionals to respond to international disasters, and is a partner in the UK Emergency Medical Team (UK EMT) – the government’s front line of response to overseas humanitarian crises.
Funded by UK aid through the Foreign Commonwealth and Development Office (formerly the Department for International Development), the team comprises UK-Med, fellow international relief charity Humanity and Inclusion, the UK Fire and Rescue Service and the Palladium Group.
UK-Med’s chief executive, David Wightwick, first heard of the Beirut explosion on the news, and soon afterwards was co-ordinating with UK EMT’s core partners and the FCDO to identify next steps. “With any situation we have to decide whether to ignore, investigate, or deploy a team without questions asked,” he says – adding that in this instance, the verdict was to ‘rapidly investigate’.
“Just because there is a big explosion does not necessarily mean there is a serious health situation,” says Wightwick, who previously worked as a senior adviser in emergency response with the World Health Organization and as director of operations management at Save the Children International.
“It’s also almost inevitable that what you think the situation will be from several thousand miles away is not the situation you find [once you’re] on the ground.”
After agreeing to deploy a UK EMT team to Beirut and reaching out to Massad, who began working on logistical arrangements – “hiring cars, arranging accommodation and security, and trying to establish contact with local hospitals so we didn’t lose time when they arrived” – the charity began assembling a team of clinicians who would make an assessment of the blast site.
UK-Med runs an active roster of NHS clinicians who are on call for the UK EMT for a period of two months every year, and ready to deploy around the world within 24 hours. Lizzi Marmot, the charity’s humanitarian operations manager and emergency medical teams focal point, explains that under normal circumstances an on-call clinician would be prepared to grab a bag and be on a plane within 12 hours of being contacted by the charity – but emergency travel in the middle of a global pandemic comes with its own set of complications.
“It’s a lot of work to have 400 people on a roster and ready to go out of the door as and when you want them,” says Marmot, a former NHS clinician who began working for UK-Med as a volunteer in 2014 and is now responsible for safely deploying the best possible teams when crises arise.
“There is constant background work covering response-setting, recruitment, training, vetting and safeguarding – and a complexity we have had to deal with this year is that our core register, for which we supply a lot of the medical and operational components of crisis responses, is largely based around NHS clinicians.”
UK-Med has been on the front line of the global Covid-19 response across 10 different countries this year (see map, below), including sending a team to help establish the pandemic hospital Nightingale Hospital North West in Manchester – but with the UK’s own health service under increased demand as a result of the pandemic, the charity had to pivot rapidly to accommodate different ways of working.
“What is normally a well-resourced health service that releases capacity to fill crisis-related gaps in other health systems around the world was suddenly facing unprecedented demands,” Marmot says. Travel proved another serious operational challenge: “When I was initially trying to get out the door in March and April I had many long, lonely train rides to Heathrow only to be turned back because flights were being cancelled, airports were closing and the government was picking and choosing which countries they would allow people in from.”
Pandemic or no pandemic, the first days of assembling a team are always the busiest, Marmot says; sourcing people with the right experience from humanitarian and operational standpoints, fielding requests from the FCDO and Ministry of Health, and ensuring they can travel safely. It’s a tribute to the flexibility and responsiveness of the charity’s core team that, despite the additional challenges and complications arising from Covid-19, an initial deployment of experts and clinicians from UK-Med and its UK EMT partner Humanity and Inclusion had joined Massad in Beirut within 72 hours of the explosion.
About 40 per cent of Beirut had been affected by the blast, with collapsed buildings for a mile around the epicentre and wider areas of the city damaged by the enormity of the shockwave.
The healthcare system was badly hit – Saint George’s Hospital, which stands about 3km from the port, sustained an estimated $35m worth of damage in the explosion, and 55 more healthcare facilities were ruled “non-functional” by the WHO in the days that followed.
Despite this – and the huge number of casualties – the needs assessment team quickly realised the local health system had immediate trauma management under control.
“It’s remarkable that the Lebanese health system, which is very much an informal one, was able to deal almost immediately with 6,000 casualties and all of their families and friends that descended on the hospitals that remained,” Wightwick says.
“The resilience is staggering. People often think of places like Lebanon as countries that are less likely to have systems in place, but the reality is that the system and most of the staff working within it are very attuned to dealing with sudden-onset crises.”
Despite the chronic underfunding of many hospitals, the system is a very well-worn one, Wightwick explains. “Everyone has their ‘black book’, their phone numbers are all in each other’s phones” – a network that was mobilised by health workers within hours of the blast to rapidly redistribute injured people to hospitals around the country that were still functioning.
“You can’t imagine many better-resourced and better co-ordinated countries doing better than that,” he says. “In fact, most would do a hell of a lot worse.”
Other informal systems played a crucial role in the local response to the explosion, with communities, volunteers and local civil society groups organising and taking to the streets to search for survivors below collapsed houses, clear rubble and detritus, and start patching the city back together in the absence of structural government support.
However, as the needs assessment team visited affected hospitals, talked to the key players in the local health system, and communicated with other Emergency Medical Teams and international NGOs, it quickly became clear that the large numbers of people gathering to help had created a new challenge.
“By the time we arrived, a huge volume of casualties had been managed in an incredible fashion – but the country was now having to deal with a huge surge in Covid-19 cases,” David Anderson, UK-Med’s health adviser, emergency medicine nurse and the UK EMT’s interim health lead, explains.
Until August, Lebanon had avoided significant incidences of the coronavirus, with just 1,306 confirmed cases recorded between February and June by the Lebanese Ministry of Public Health, compared to more than 390,000 over the same time period in the UK. Two weeks after the explosion, daily recorded cases almost tripled from 209 to 605, and by mid-September the country had its first incidence of more than 1,000 new cases recorded in a single day.
“Staff were obviously tired and having to deal with a huge number of casualties, and then deal with Covid-19 at the same time – quite understandably, there was a disregard for social distancing immediately after the blast, which led to increasing rates of Covid-19, and by the time we had been on the ground for five days all of the available ICU beds in Beirut were full,” Wightwick says.
Within four days, the team, which had arrived with a potential trauma and injury response in mind, had totally shifted its approach. The charity could be most useful by supporting local health workers who were responding to the escalating Covid-19 crisis.
“The health system had been ready for cases, but had then lost three major hospitals that had been prepared to deal with the pandemic as a result of the blast,” Anderson says. “Suddenly the emphasis had to change to hospitals that had not been as well-prepared, with an impending health crisis coming their way.”
The ability to rapidly pivot in this way is one of the best things UK-Med is able to do, he adds. “That’s the joy of working with a small, agile team, which can deploy quickly and have access to skilled professionals who can make those judgement calls at speed.
“Because we’re small, we’re nimble, and can make very rapid changes. The ideas evolved in the quickest possible terms – and when you deploy alongside your chief executive, you can make a decision to change direction and he can sign it off within minutes.”
Building capacity and sharing ideas
After liaising with the WHO and Lebanese government through the Emergency Medical Team control centre, the UK EMT identified which hospitals most required additional support and began implementing a programme to help local clinicians develop their knowledge and understanding of managing Covid-19.
“It’s about expertise, capacity-building and confidence,” Wightwick explains of the ongoing response, which is being funded by the FCDO as part of the UK’s initial £25m pledge to assist with the relief effort in Lebanon.
“There is no shortage of highly skilled medical staff, so our work involves deploying specific experts at particular pinch points. These revolved around three main areas: infection prevention and control; patient flow; and ITU and high-dependency care.”
A team of 11 medical and humanitarian health experts from the UK EMT are working alongside Lebanese health practitioners across three public hospitals: Baabda and Daher El Backek in Beirut, and Sidon (Saida) Hospital, situated one hour away.
The team’s expertise includes intensive care work, infection control, logistics, and risk communications. Their daily activities can cover everything from delivering training in infection control and patient flow to case management for Covid-19 (proning, intubation and ventilation) or establishing water, sanitation and hygiene (WASH) protocols.
“Infection control runs on the same processes, whether you’re in Nightingale North West or Baabda – the principles are the same, but there are nuances and differences with each hospital,” Anderson explains.
Collaborating with both local teams and other NGOs is therefore crucial to spearheading a successful health response; and for UK-Med, every deployment involves the sharing of ideas. “It makes any response so much more cohesive and well-rounded,” Anderson says, citing the partnership between the WHO and Emergency Medical Teams to deliver clear guidance on how to correctly put on Personal Protective Equipment (PPE) as an example.
“It may sound simple, but there are about 1,000 different ways to do it – by following the overarching guiding principles, there is less confusion between different organisations, which is particularly important if you have staff working in Baabda one day and Sidon the next.”
UK-Med’s work with its UK EMT partner Humanity and Inclusion, a charity that specialises in working with vulnerable and disabled people to create inclusive emergency responses, is vital. “It builds in a crucial element around protection and making sure the right steps are always taken for safeguarding – bringing a really important focus back to occasions when you can sometimes get a bit lost in clinical care,” Anderson says.
Emergency response also provides ample opportunities for informal working relationships between fellow charities, NGOs and clinicians. For Anderson, working alongside a frontline Polish EMT that reports to the WHO’s Emergency Medical Team Coordination Cell has been incredibly rewarding.
“They are an outstanding bunch of clinicians who are working hard across a different set of hospitals – we meet every week to talk things through and discuss problems and problem-solving,” Anderson says. “I think it’s the only way to do it.”
Beirut’s long term recovery from the explosion is set to be an uncertain and volatile one. The Lebanese healthcare system has been gradually eroded by continual shocks in recent years, with the country’s unprecedented economic crisis of 2019 rendering it the third most indebted nation in the world. The crash caused major damage to social cohesion and unemployment levels of 25 per cent that included large numbers of medical staff being made redundant.
“Many medical staff on the private side of the health system had not been paid for some time, and in many cases people had been laid off while others were on partial salaries or working hours,” Wightwick explains. “The health community in general was haemorrhaging people, and for many it seems the explosion was the last straw. We’ve heard of a lot of people leaving and trying to get jobs overseas.”
Massad agrees with this assessment – “everyone knows someone who is trying to get a visa for somewhere else, it’s not just medical staff” – and when a second fire broke out in the port of Beirut just one month after the August explosion, many residents left the city in panic.
“The reality is not just that the blast itself has destroyed Beirut, but that psychologically, it has really destabilised things,” Wightwick says. “There is a point at which social contracts do start to crack and break down, and I think Lebanon has witnessed a structural crack in a major social contract. Once you have a large portion of the medical profession – or indeed any other profession – starting to leave the country, you can get into quite a serious spiral.”
The UK EMT’s three-month deployment will fund UK-Med clinicians to continue their work on the ground supporting the Covid-19 response of local healthcare teams at least until November and “into flu season”, according to Anderson.
“It is a great length of time because it allows us to not only train people, but ensure the training has been embedded and can be followed through on the hospital floor,” he says. “Training in a classroom is great, but if you can work alongside colleagues who can show you how to put that machine and mask on a patient, it’s a bonus – it can be difficult to do for the first time, even if you have had all the education in the world.”
And embedded into the fabric of every emergency deployment is the mission to help build a resilient and self-sufficient healthcare systems and medical responses that local clinicians are equipped to continue delivering once UK-Med’s period of direct involvement comes to a close.
“At the core of every deployment I have been privileged to participate in is capacity-building and leaving behind a legacy that ensures we don’t need to return,” Anderson says.
“This lies in skills and knowledge-building, making sure systems that adapt and fit with local customs and culture have been embedded and can be easily delivered without you.
“That is what you leave behind – and it should effectively last for years.”