Discussion

As the protests in Lebanon on October 17, 2019, started suddenly with no warnings, health-care providers had to react with minimal knowledge of what to expect. This study is the first to reflect on experiences, perceptions, facilitators, challenges, and recommendations of these health-care providers responding to physical injuries and psychological complaints requiring medical attention in Beirut’s protests. Notably, the uniqueness of the Lebanese experience was not reflected in similar previous studies and necessitated the emergence of new original themes. Our study constitutes the first step toward gaining a better understanding of the needed health services at times of unplanned mass gatherings, to further advance the Lebanese health-care system.

Our findings shed light on the absence of a clear protocol to follow, and the scarcity of resources and limited funds needed for adequate care provision. Funding deficit was not only limited to the purchasing and storing medical supplies but also to the logistics such as setting up the tents, which were often destroyed by vandalism. Another main issue was the lack of communication, driven mainly by the lack of any central body on a macro-level; thus, each group of volunteering medical providers, paramedics, and personnel present on ground had to create their own system, decreasing the effectiveness of care provision. The adopted mechanism in medical response to mass gatherings was found to be unorganized and based on individual efforts. It lacked a unified protocol that would confer coordination, guidance, and funding. Notably, there were no differences in answers between health-care providers according to gender. The interview questions did not address the political or ideological affiliations of the medical personnel volunteering to help.

Our results are consistent with previous studies of mass gatherings, in terms of the most common cases seen. ^{Reference Krul, Sanou and Swart15,Reference Braga, Nhantumbo and Nhambomba16} Some challenges common to other contexts include lack of preparedness of health-care providers in dealing with cases in the field, and the absence of a unified protocol that would be implemented in an emergency situation. ^{Reference Krul, Sanou and Swart15,Reference Civaner, Vatansever and Pala17} In the short-term, some of the suggestions implemented in other events and documented include the use of smart-phones in documenting cases described by McConnell and Memish, ^{Reference McConnell and Memish18} and the use of online standardized surveys which are proven beneficial on the field, used in the 9th National Cultural Festival in Mozambique. ^{Reference Braga, Nhantumbo and Nhambomba16} We further suggest the need to create funds and platforms that could be social-media-based, for volunteerism, as well as establishing better communication tools between volunteers; however, these actions are not sustainable.

To provide a better service on the long-term, a government-funded task force is essential. It would focus on formulating protocols, rapidly receiving field information during emergencies, and ensure more efficient use of resources through effective communication between different providers. ^{Reference Memish, Zumla and McCloskey4} The task force should reach a network of health-care workers who respond accordingly at the onset of any mass gatherings. This task force would have representatives from different health-care organizations involved in first aid (professionals, Red Cross personal, NGOs, and others) to optimize communication and cooperation. These recommendations are supported by the guidelines documented in the published literature to allow for timely management and offer ways for adequate referral, transport and resource distribution. For on-site measures, we recommend having an average of 6 health-care providers for every 10,000 attendees, including first aid providers, along with nurses who have event-specific training on advanced life support. ^{Reference Krul, Sanou and Swart15} These providers would be working based on unified common protocols for triage and management of the common injuries and problems presenting on-site. ^{Reference Krul, Sanou and Swart15} As for documentation, a real-time data collection of health encounters using tablets and smart phones is applicable. ^{Reference Braga, Nhantumbo and Nhambomba16} Results would be directly seen and analyzed by a central task-force coordinator. As such, based on the profile of injuries recorded, the health sector would plan strategies and take actions customized to the commonalities encountered. ^{Reference Braga, Nhantumbo and Nhambomba16} To achieve better predictability and resource allocation, recourse models can be developed, based on the models used in the FIFA World Cup 2010 event, which was later validated by Smith et al. ^{Reference Smith, Tuffin and Stratton19,Reference Smith, Wessels and Naicker20} These models would help stratify the gatherings into levels that could give decision-makers insight on the quantity and quality of providers and recourses needed in a specific gathering.

The strength of our study stems from the fact that information was gathered in real time, minimizing any recall bias. Interviews were diverse including personnel from different volunteering organizations present. Physicians of different specialties, psychologists, and volunteers were all interviewed. Moreover, there are minimal articles documenting or gathering data about mass gatherings in Lebanon and the region.