In Tunis, Tunisia, young people gather freely, returning to the days of sipping coffee in cafes as crowds of shoppers and onlookers enjoy the now bustling city center. No longer locked inside, Tunisians have become the fortunate few who are able to enjoy weddings, restaurants, and Friday prayers without fear of contracting COVID-19.
Elsewhere in the Middle East, public health responses have not been as effective. Movement restrictions remain in place in Kuwait and Oman while many other Middle Eastern borders remain closed to all travelers. As Iran, Saudi Arabia, and Qatar grapple with some of the largest per capita outbreaks in the world, other countries in the region have effectively limited the threat of the virus. With the international telescope trained on the responses of the United States, Brazil, and China, it is important to examine potential successes in the fight against COVID-19 whose successes have gone overlooked by the international community.Animation of Bar Graphs:
MENA Cases and DeathsAnimation of Bar Graphs:
MENA Cases and Deaths Per Million
In early March, while the virus spread through Northern Italy unchecked, many Middle Eastern countries were laying the groundwork for the closure of borders and suspension of regular life. The Middle East and North Africa, a region often referred to by the acronym MENA, has been plagued by political instability and strife since the 2011 uprisings known as the “Arab Spring,” Weak institutions, poor governance, already strained healthcare systems, and often unsustainable population density make the region a veritable powder keg for the spread of virulent disease. But the data suggests that historically unstable political regimes have offered some of the most effective responses to the threat posed by COVID-19.
Since mid March, as the COVID-19 pandemic entered the global consciousness, five MENA countries, Lebanon, Tunisia, Jordan, Morocco, and Israel have each faced unique challenges in their responses to the pandemic, but each one of them acted quickly and effectively. The data suggests that, remarkably, these five nations, despite facing vastly different economic considerations, possessing varying levels of social and political stability, and operating under fundamentally different systems of government, have had success in containing the virus.
Since October of 2019, Lebanon has seen millions take to the streets in popular demonstrations against new proposed taxes, the collapse of the Lebanese Pound, and mass unemployment. On the verge of economic collapse, and amidst skyrocketing prices, Lebanon reported its first case of the novel Coronavirus on the 21st of February. Tied to Shia’a pilgrims returning from the holy city of Qom in Iran, the introduction of the virus threatened to re-ignite the sectarian tensions that have loomed large in Lebanese political memory since 1990, the end of the 15-year civil war. Instead, on February 28th, with only seven confirmed cases in the nation, educational institutions were shuttered. Only one week later, while the United States, now the world leader in both COVID-19 cases and deaths, had reported only one hundred confirmed cases, Lebanon had already closed theaters, cinemas, gyms, and nightclubs, issuing warnings about public gatherings.
As of July 14th, 2020, Lebanon, a country of 8.1 million, reports only 960 active cases and 36 deaths, giving it one of the lowest per-capita caseloads in the region. Still facing dire economic challenges, data suggests that Lebanon’s response to the COVID-19 pandemic has been a success at least in terms of per capita deaths and cases.
Tunisia, the country that saw the first uprising in 2011, has reported similar successes in combating the spread of the virus. On March 18th, Kais Saied, only the second democratically elected president of Tunisia, acted in concert with the armed forces to impose a severe lockdown. With fewer than 30 confirmed cases in the nation, Tunisia rapidly closed land and sea borders, shuttered mosques and restaurants, and implemented a strict curfew to curtail public gatherings.
Between June 2nd and June 9th, Tunisia reported no new COVID-19 cases. Since then, they have joined the select few nations around the world who consistently report few or no new cases of the virus. On June 14th, Tunisia ended internal movement restrictions and allowed all businesses to resume normal operations. Seeing few new infections following eased lockdown measures, and in an attempt to make up for lost tourism revenue, on June 27th, they opened international borders to travelers from select countries. For Tunisians, who have seen a total of 1,188 cases and 50 deaths, life has now returned to normal.
Tunisia’s young democracy and Lebanon’s fraught sectarian political structure have each managed to unite behind a single cause; the containment and mitigation of the COVID-19 pandemic. In the coming weeks and months, it will be important to observe if these governing coalitions that allowed for their successful responses to the virus can be rallied to face the impending recession and to revitalize the economies of the two nations.
Examining the triumphs of Tunisia and Lebanon, we find that institutional strength and social stability are not perfect indicators of the efficacy of pandemic responses. Ultimately, the results speak for themselves.
It is important to recognize that democracy does not offer the only answer to COVID-19 in MENA. Two of the region’s oldest ruling dynasties, the Alaouite dynasty, who have ruled Morocco since 1666, and the Hashemites, Muslim rulers since the 10th century and rulers of Jordan since 1921, have presided over containment of the virus in Morocco and Jordan.
A nation of nearly 10 million people, Jordan has suffered only ten deaths from COVID-19. Considering the world average death toll average sits at 69.5 deaths per million, this figure is staggering. Between March 17th and April 19th, Jordan’s containment strategy ranked among the most stringent across the globe. Based on their lockdown restrictions, Oxford rated the Jordanian Government’s response 100 out of 100 on their COVID-19 Government Response Stringency Index. Jordan implemented almost total lockdown measures on March 17th, banning nearly all commercial and social activities and placing more than five thousand Jordanians in government enforced hotel quarantines.
Morocco confirmed their first case on March 2nd, and on March 15th, with only 28 confirmed cases in the country, all international flights were suspended. Morocco quickly moved to implement quarantine and social distancing measures, declaring a state of medical emergency less than a week after the suspension of international travel. Mobilizing the nation’s national security apparatus, authorities prevented all citizens from leaving their homes without explicit written authorization. Quickly engaging the legal tools at their disposal, authorities offered harsh responses to those who violated the emergency measures, regularly stopping, fining, and arresting those suspected of breaking quarantine.
Following consistent decreases in new cases following a peak in mid-May, and recognizing that their mortality rate of 1.6 percent is less than half of the world average, authorities moved to lift restrictions on primarily rural provinces. Morocco reopened 59 provinces on June 9th, following soon after by liberalizing movement and most commerce in many major population centers. While case counts have remained consistently low since June 9th, some experts fear a spike in infections as commerce and international travel resume. In early July, authorities in the city of Safi reinstated lockdown measures across the city following a spike in infections tied to an outbreak in a fish processing factory. Other outbreaks, largely tied to the reopening of factories and agricultural processing facilities have threatened to delay Morocco’s plans to lift restrictions.
Israel, a significant political, demographic, and economic outlier in the MENA region, had similar success in their early containment of COVID-19, but is now seeing a resurgence of the virus. The state experienced a year-long political crisis between April of 2019 and April of 2020. With three elections yielding no clear governing coalition, and with allegations of political corruption against Prime Minister Benjamin Netanyahu, Israel experienced significant political turmoil in the weeks and months leading up to the COVID-19 pandemic. As early as January, as the virus began to emerge in China’s Hubei province, Israeli lawmakers took the threat seriously. On January 26th, Israel established restrictions on travelers from China, following soon after with bans on travelers from Thailand, Hong Kong, Macau, and Singapore. Israel followed a containment strategy similar to that of South Korea, which is heralded as a model nation for their response to the virus, and leveraged their national security apparatus to carry out a swift and centralized COVID-19 response.
On March 11th, Israel enacted significant, mandatory, social distancing orders and, on March 19th, Prime Minister Netanyahu declared a national state of emergency and established a legal stay at home order. On March 17th, Israel’s Parliament, the Knesset, allowed the Israel Security Agency (ISA) to access retrospective cell phone location data of individuals diagnosed with COVID-19 to identify exposed individuals and instruct anyone who came into contact with the infected patients to quarantine for 14 days. Anticipating many Jewish Israelis would travel in preparation to celebrate for the Passover holiday, on April 8th, Israel declared a three day internal travel ban and imposed limits on travel that prevented excursions of more than 100 meters from one’s home.
Starting in early May, Israel began to see a decline in new COVID-19 cases, and began to lift restrictions on movement and businesses. Many public health experts now argue that this move was premature and that Israel is entering a second wave in the pandemic. On July 14th, Israel reported 1,962 new cases, a record high for the country. What has been termed as a premature re-opening has been met with criticism from the top official in the Ministry of Health, who resigned in protest.
When taking a step back from the data, it is important to recognize the possibility of reporting biases. A lower case count could indicate that a country is under testing or underreporting positive cases. One visual way to see the potential for bias is to examine an individual nation’s COVID-19 mortality rate. Qatar, whose mortality rate is the lowest in MENA, also happens to have the most cases per capita, while Yemen has the highest mortality rate and one of the lowest case counts. This could indicate that Yemen is only testing the worst cases or that Qatar is under reporting COVID-19 deaths. Further evidence of data bias can be seen in the spread between the world mortality rate, which sits at around 4.6 percent, and the mortality rate of other countries in MENA. One way to reconcile the differences in mortality rate is by taking into account differences in demographics, healthcare system capacities, and governmental responses. Further, the world mortality rate is skewed by data from countries where the pandemic rages out of control, such as the United States and Brazil. Simply put, while data incongruities are a possibility, it is hard to tell how they shift our findings. Countries with a robust free press may have a greater likelihood of reporting accuracy.
While the international community focuses on the failures of the United States and Brazil, an examination of unexpected successes in the Middle East and North Africa yields important and interesting lessons about effective responses to the COVID-19 pandemic. Future research into why these MENA countries were able to mobilize a rapid and serious response to effectively “flattened the curve” could include demographic comparisons and an analysis of how the respective countries’ economies, education, and healthcare systems have been affected.