Cosette Bou Akar’s smile seems incongruous as she sits on her hospital bed and describes the endless anxieties of being sick in a country starved of medicine, electricity, fuel and money.

She has been undergoing treatment for leukemia at Lebanese Hospital Geitaoui – University Medical Center in Beirut, while her country has been politically, economically and socially breaking down.

As if worrying about having cancer were not enough, the 45-year-old French teacher is contending with the possibility of her life-saving medicines being out of stock.

“Every three months, I need an injection of immunotherapy,” she says in mid-October. “And, right now, I have been waiting two months to find it.

“The situation has been very negative. We can’t find medicine easily and, if we do find it, it is very, very expensive,” she says, exposing one of the many crippling impacts that Lebanon’s two-year economic crisis has had on residents.

Given the steep devaluation of Lebanon’s currency, her treatment — if available — would cost the equivalent of up to 12 million Lebanese pounds. Prior to the start of the country’s economic collapse, when the exchange rate was 1,500 Lebanese pounds to the dollar, this same treatment would have cost about 900,000 Lebanese pounds. In U.S. dollars, the treatment costs about $600.

Over the past year, shortages of essential goods also have become commonplace in Lebanon. Ignited by panic buying, as well as by suppliers who are hoarding goods, hoping to sell them later at a higher price as government subsidies are withdrawn, the Middle Eastern nation of 6.8 million people — including more than one million refugees — has been pushed to the brink.

In October 2019, when the value of the local currency started to crumble, the government subsidized medicines to ensure prices remained stable. The Lebanese pound has since devalued more than 90 percent, creating hyperinflation, crushing spending power, depleting the value of salaries and turning livelihoods upside down.

This past summer, Lebanon’s cash-strapped government began withdrawing subsidies, causing exorbitant price jumps. The crisis has pushed more than three-quarters of the once middle-income nation into poverty, according to a U.N. report on the changing face of poverty in Lebanon, published in September.

Mrs. Bou Akar is not alone in her dramatic search for life-saving medication; the share of families who are unable to obtain medicines has increased to more than half of the population, the same U.N. report estimates.

Despite her precarious situation, Mrs. Bou Akar keeps smiling, demonstrating why her nickname in the ward is “Madame Positive.”

Such strength is valued at Geitaoui Hospital, which, along with Lebanon’s entire health sector, has undergone what some consider to be a crisis more severe than the health crisis during the country’s 1975-1990 civil war.

Aside from medicine shortages, the hospital has been challenged by the COVID-19 pandemic, the exodus of skilled medical workers seeking more stable work abroad, and a major reconstruction project after the deadly Beirut port blast.

Hundreds of tons of ammonium nitrate, a highly dangerous fertilizer, caught fire and exploded on 4 August 2020, killing 218 people and injuring more than 6,000. The force — considered the most powerful non-nuclear explosion in history — ricocheted through the city, hitting the historic Christian quarters of east Beirut, where Geitaoui Hospital stands. The hospital, located less than a mile from the blast epicenter, sustained $7 million worth of damages.

However, by October this year, the 265-bed hospital was running at 80 percent capacity, thanks to a giant reconstruction effort spearheaded by CNEWA’s Beirut-based team, known throughout the Middle East as Pontifical Mission. Full restoration will be completed by March 2022.

“I never believed it would be possible to raise the hospital again, to rebuild it,” says Sister Hadia Abi Chebli, the hospital’s codirector and a member of the Congregation of the Maronite Sisters of the Holy Family, to whom the hospital was entrusted in 1927.

“I saw the end, because it was impossible to get more loans from the bank, because all our facilities were already limited,” she says.

“For us nuns, we don’t have big resources to financially assist the damage. It was a miracle, really, a miracle,” says Sister Hadia of the worldwide emergency donor support coordinated by CNEWA.

However, while great advances were made to restore the hospital, the outlook for the country has steadily worsened.

“The devaluation of our Lebanese pound is very dramatic, and many thousands, hundreds of thousands of Lebanese have left the country,” says Dr. Pierre Yared, who codirects the hospital with Sister Hadia.

One of the “many severe problems” for the hospital is the increasing cost of maintaining technical medical equipment, he explains. Outside funding is their “only hope,” he says; otherwise, the hospital could be forced to decrease its operations and furlough staff.

Maintaining equipment, such as X-ray machines, MRI scanners, freezers and air-conditioning units, costs $600,000 to $700,000 annually. Dr. Yared says he is grateful CNEWA has launched a campaign in the United States to help defray the expenses.

“We are in a desperate situation — all around us, the people, families, doctors, nurses. We are not fine.”

“I can’t imagine the Lebanese government will help us,” he says. “If the government does help, it will help the public sector. It’s normal.”

Lebanon’s public health sector constitutes 20 percent of all health care in the country, leaving the rest of the health sector dependent on international donations.

“I think the future will be more serious, more severe,” Dr. Yared adds. “About three months ago, we lost power to our MRI scanner … and had to pay $40,000 ‘fresh’ [to repair it]. It was very, very, difficult for us. … We received help for that.”

“Fresh dollars” has become a colloquial term in Lebanon, which emerged amid a shortage of cash in U.S. dollars — yet another impact of the economic crunch — when Lebanese banks restricted withdrawals in U.S. funds. Lebanese use “fresh dollars” to refer to cash funds in U.S. currency, often procured through international fund transfers or on the illegal market, which many suppliers are requiring for the transaction of goods.

Lebanon’s Central Bank pegged the Lebanese pound to the U.S. dollar in 1997, but over the past two years the pound has tumbled to record lows against the dollar on the illegal market, which dictates day-to-day pricing.

In the current situation, an average doctor’s monthly salary in Lebanon has fallen in equivalent value from $2,300 in 2018 to $175 in 2021. Such a dramatic fall in living standards has pushed almost 40 percent of medical doctors and nearly 30 percent of registered nurses to leave Lebanon either permanently or temporarily, the World Health Organization said in September. The brain drain is depriving the country of skilled professionals, threatening the quality of health care and hampering long-term economic recovery.

According to Dr. Yared, 24 physicians and 75 nurses left Geitaoui Hospital for opportunities abroad in the past 14 months.

At the Rosary Sisters Hospital in Gemmayze, just a few blocks away, 15 personnel left for work abroad in about the same period.

The Congregation of the Sisters of the Rosary has been running the nonprofit hospital since 1986. Nine sisters work there, alongside the general director, Sister Nicolas Akiki. Over the years, they transformed it from a 50-bed facility to a thriving 200-bed hospital, only for their efforts to be undone in seconds by the port explosion.

“It was so, so hard for us,” Sister Nicolas says, tears welling in her eyes. “But we have to say, we have faith in God. We must not say stop. If I am still alive, God needs me to continue.”

CNEWA played a crucial role in funding the refurbishment of four floors of the hospital, as well as overseeing the reconstruction plan and ensuring resources were used effectively.

While corridors gleam with new floorboards, and private rooms overlooking the port feature fresh furnishings and new equipment, the challenges remain endless.

The threat of losing more personnel becomes more tangible each day and Sister Nicolas says she has resorted to asking donors to support staff salaries, which are paid in Lebanese pounds. With about $15,000 to $16,000 a month, the salaries of her doctors, nurses and administrative staff could be secured, she says.

The hospital budget has been strained by the dramatic rise in the price of diesel oil needed to fuel three generators. Over the past six months, Lebanon’s state electricity grid has provided barely two hours of power a day. As the government’s foreign currency reserves for fuel imports dried up, it created a rush for generator diesel, which has become expensive and scarce.

Power blackouts threaten life-support machines and jeopardize patient safety, leaving management with no choice but to ask donors for additional funding. Before the crisis, Sister Nicolas says, the hospital paid $10,000 to $15,000 each month for diesel.

“Now, I pay $2,000 per day,” she says.

The current trials are a far cry from a time when Lebanon boasted of its high-ranking health sector and many people from other Middle Eastern countries flocked to Lebanon for medical care. The decline has left local practitioners, including Dr. Pierre Mourad, struggling to believe better days lie ahead. The pulmonologist and managing director at the Rosary Sisters Hospital admits he is in the process of making emigration plans to France, where he studied medicine.

“To tell you the truth, we are in a desperate situation — all around us, the people, families, doctors, nurses,” Dr. Mourad says. “We are not fine.”

Before October 2019, which is widely considered the start of the crisis, when a popular uprising demanded the downfall of a ruling class deemed corrupt and negligent, it was usual to find two or three doctors for each specialty in every hospital, Dr. Mourad explains. Now, there is only one doctor to cover each specialty and that doctor might stretch their expertise to multiple clinics.

Patient numbers are down, but not because the population is less sick.

“The Lebanese people don’t have enough money to go to the hospital,” says Dr. Mourad.

“We have faith in God. We must not say stop. If I am still alive, God needs me to continue.”

The U.N. estimates the portion of households deprived of health care in Lebanon has jumped by 24 percent since 2019, and 55 percent of the population now lacks health insurance.

The surge in vulnerable Lebanese has pushed many individuals for the first time into the waiting rooms of primary health care centers. Consultations at such centers can cost 3,000 Lebanese pounds. Pre-crisis, this sum was equivalent to just below $2. Now, with the pound’s collapse, it is hardly a few cents.

The Howard Karagheusian Center is a medical and social center in the bustling municipality of Bourj Hammoud, just outside Beirut. In a predominantly Armenian Christian community, the center welcomes a wide demographic of displaced Syrians, Iraqis and foreign workers from Africa and Asia.

However, the number of Lebanese benefiting from its services has swelled, says Serop Ohanian, the center’s field director. For the first eight months of 2021, the center received 33,238 Lebanese patients, compared with 13,366 patients for 2018.

The CNEWA-funded center offers mental health care, social case work, employment assistance, and skills and language development, among other services.

Zainab al Hajj has been bringing her 6-year-old son to a speech therapist at the center for the past six months. A local resident, she has always known about the center, but recently began visiting as her finances became critical.

Describing her financial situation, Al Hajj laughs and says, “Yaani” — an Arabic filler word — which best translates as “neither bad nor good.” She is grateful the center remains open to all.

“I feel at ease with everybody here and my son loves the therapist. Everyone is so kind,” she says. Other patients at the social center reported how their health was improving and spoke of the warm atmosphere among the staff and visitors.

Among Lebanon’s pile of crises is its huge refugee population. Since the start of the war in neighboring Syria a decade ago, Lebanon has welcomed more than a million Syrian refugees, becoming the country with the highest ratio of refugees per capita in the world.

The situation has placed immense pressure not just on state infrastructure, but also on local non-governmental organizations, such as St. Anthony’s Health Care Community Center.

Adhering to the motto “Religion is for God and the dispensary is for all,” the primary health care center caters to some of the country’s most vulnerable populations.

The center is in a socioeconomically depressed area just outside Beirut, between the Maronite Catholic neighborhood of Jdeideh and the Shiite area of Roueissat. The center is of great importance to the Congregation of the Good Shepherd Sisters, which has been serving there since 1998, nurturing harmony in the area as well.

On a weekday morning, the center, perched on the side of a rough road between grassy wasteland and a mosque, is holding a midwifery session and many veiled women cradling babies are queuing up to attend. One woman holding a baby is making the uphill journey on foot, the hot sun beaming down on her black clothing.

Sister Antoinette Assaf, the center’s director, reflects on the rollercoaster of the last decade in Lebanon, describing it simply as: “Crazy, real chaos.”

There was the refugee crisis and then the coronavirus pandemic, she enumerates.

“Now, the crisis with a lack of medicines, people not able to afford to pay, doctors and nurses leaving the country,” she adds. “Oh, it doesn’t stop!”

The sisters took on the management of the health center in 2004, after the death of Toni Abbas, a local lay leader who established the center 20 years prior for “the poorest of the poor.” He entrusted the center to the sisters to continue his efforts.

To ensure the dispensary produces the same quality of care as private health care facilities, the sisters have built up partnerships with international organizations, including CNEWA, and with the faculty of medicine at St. Joseph University in Beirut, linking doctors with the center.

Sister Antoinette explains appointments in other dispensaries last barely five minutes.

“We said the consultation [here] should last at least 20 minutes, because this is the right of the poor, to have the same quality … of health care,” she says.

CNEWA has been critical in supporting the center’s obstetrics and gynecology service, as well as its polyclinic that provides dentistry, ophthalmology and social services.

“Without international aid, it’s really very difficult for Lebanon to keep going — those who are staying cannot survive.”

Sister Antoinette wants to extend opening hours to cater to the new wave of patients triggered by the crisis, but with capacities stretched and staff growing weary, the center cannot cope without additional funding.

“We need more resources, more nurses, more doctors, more admin workers,” she says. “Nowadays everything is so expensive. The salaries are really increasing too much, [there is] not enough money.”

She cites the center’s contribution to the lives of individuals and the cohesion of the multifaith community as proof of the value of such international support for the health sector.

“Without international aid, it’s really very difficult for Lebanon to keep going,” she says. “To be realistic also, for sure, without international aid, those who are staying cannot survive.”

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Rosabel Crean is a British freelance journalist based in Beirut. She reported for the local paper The Daily Star and currently writes for the Catholic weekly The Tablet.