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Offensive Cyber Series: Dr Daniel Moore on Cyber Operations, Part II

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Photo Credit: Ecole polytechnique / Paris / France, licensed with CC BY-SA 2.0.

This is part II of Ed Stacey’s interview with Dr Daniel Moore on cyber operations for Strife’s Offensive Cyber Series. You can find Part I here.

ES: Thinking about alliances more broadly, what sort of opportunities and challenges do allies face when conducting joint operations in cyberspace?

DM: Allied operations on networks – I am not a fan of cyberspace – are contentious as well. They are a good measure more sensitive than any conventional equivalent that you can think of. It is not like having a joint military operation: it means putting your sensitive infrastructure and capabilities on the line alongside an ally. That is not to say it does not happen and there have been documented cases which were purportedly joint operations by multiple countries. So I think it will happen, but there are complexities involved. I know that NATO has already declared that they are together, as an alliance, bringing forward cyber capabilities that they will use jointly. I welcome that declaration, even if I am sceptical as to what it actually means.

I would tend to believe that, considering how porous NATO is as an entity and how there are varying levels of trust within NATO, truly sensitive capabilities will be kept off the table by individual member states in favour of their own arsenals and sets of strategic capabilities. This is not to say it is not possible, but it is unlikely that at a NATO level you will see joint operations that are truly strategic in nature. What you might see is allied members that are operating together. I do not think that, for example, a joint UK-US operation against a target is out of the question, especially if one brings a certain set of capabilities to the table and one brings others – somebody gives the tools, this unit has the relevant exploits, this intelligence organisation had already developed access to that adversary and so on. Melding that together has a lot of advantages, but it requires a level of operational intimacy that is higher than what you would be able to achieve at the NATO alliance level.

ES: Moving beyond the state, what role does the private sector play in the operational side of offensive cyber? Do we have the equivalent of private military contractors in cyberspace, for example?

DM: There is a massive role for the private sector across the entire operational chain within offensive cyber operations. I would say a few things on this. Yes, they cover the entire chain of operations and that includes vulnerability research, exploit development, malicious tool development and then even specific outfits that carry out the entire operational lifecycle, so actually conduct the intrusion itself for whatever purposes. In some cases, it is part of an industrial-defence complex like in the US, for example, where you have some of the giant players in defence developing offensive capabilities, both on the event- and presence-based side of things. And ostensibly you would have some of those folks contributing contractors and operators to actually facilitate operations.

But in other countries that have a more freeform or less mature public sector model for facilitating offensive cyber operations, the reliance on third party private organisations is immense. If you look, for example, at some of the US indictments against Iranian entities, you will see that they charged quite a few Iranian private companies for engaging in offensive cyber operations. The same happens in China as well, where you see private sector entities engaging in operations driven by public sector objectives. In some cases, they are entirely subsumed by a government entity, whereas in others they are just doing work on their behalf. In some cases, you actually see them use the same infrastructure in one beat for national security objectives, then the workday ends and they pivot and start doing ransomware to get some more cash in the evenings – using the same tools or infrastructure, or something slightly different. So, yes, the private sector plays an immense role throughout this entire ecosystem, mostly because the cost of entry is low and the opportunities are vast.

ES: Just to finish, you have a book coming out soon on offensive cyber. Can you tell us anything about what to expect and does it have a title or release date yet?

DM: The book is planned for release in October. It will be titled Offensive Cyber Operations: Understanding Intangible Warfare, and it is basically a heavily processed version of my PhD thesis that has been adapted, firstly, with some additional content to reflect more case studies, but also to appeal to anybody who is interested in the topic without necessarily having a background in cyber nor military strategy and doctrine. So it is trying to bridge the gap and make the book accessible, exactly to dispel some of the ambiguities around the utility of cyber operations. Questions like, how they are currently being used? What can they be used for? What does the “cyber war” narrative mean? When does an offensive cyber operation actually qualify as an act of cyber warfare? And, most importantly, what are the key differences between how different countries approach offensive cyber operations? Things like organisational culture, different levels of maturity, strategic doctrine and even just circumstance really shape how counties approach the space.

So I tackle four case studies – Russia, the US, China and Iran – and each one of those countries has unique advantages and disadvantages, they bring something else to the table and have an entirely different set of circumstances for how they engage. For example, the Iranians are incredibly aggressive and loud in their offensive cyber operations. But the other side to this is that they lack discipline, their tools tend to be of a lower quality and while they are able to achieve tactical impact, it does not always translate to long-term success.

The US is very methodical in its approach – you can see, taste and smell the bureaucracy in every major operation that it does. But that bureaucratic entanglement and the constant tension between the National Security Agency, Cyber Command and other involved military entities results in a more ponderous approach to cyber operations, although those organisations obviously bring a tonne of access and capability.

With the Russians, you can clearly see how they do not address cyber operations as a distinct field. Instead, they look at the information spectrum more holistically, which is of pivotal importance to them – so shaping what is “the truth” and creating the narrative for longer-term strategic success is more important than the specifics. That being said, they are also one of the most prolific offensive actors that we have seen, including multiple attacks against global critical infrastructure and various aggressive worms that exacted a heavy toll from targets. So for Russia, if you start looking at their military doctrine, you can see just how much they borrow, not only from their past in electronic warfare but also their extensive past in information operations, and how those blend together to create a broader spectrum of information capabilities in which offensive cyber operations are just one component.

And finally, the Chinese are prolific actors in cyber espionage – provably so. They have significant technical capabilities, perhaps somewhat shy of their American counterparts but they are high up there. They took interesting steps to solidify their cyber capabilities under a military mandate when they established the Strategic Support Force, which again – like the NCF – tried to resolve organisational tensions by coalescing those capabilities. But they are largely unproven in the offensive space. They do have an interesting scenario on their plate to which cyber could and may play a role, which is any attempt at reclaiming Taiwan – something I look at extensively in the book and how that shapes their offensive posture.

So the book is a combination of a broader analysis of the significance of cyber operations and then how they are concretely applied by different nations for different purposes.

The next interview in Strife’s Offensive Cyber Series is with Amy Ertan on AI and military innovation. It will be released in two parts on Thursday 17th and Friday 18th June 2021.

Offensive Cyber Series: Dr Tim Stevens on Offensive Cyber in the 2020s, Part I

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Photo Credit: AirmanMagazine, licensed under CC BY-NC 2.0

On Wednesday 3rd March, Strife Interviewer Ed Stacey sat down with Dr Tim Stevens to discuss the state of play in offensive cyber in the 2020s. As part one of Strife’s Offensive Cyber Series, Dr Stevens introduces the topic and offers his thoughts on a range of topical debates, from the utility of offensive cyber capabilities to questions around international law and ethics and the UK’s recently avowed National Cyber Force.

Ed Stacey: Tim, as you know, this interview series is all about offensive cyber. This is quite a slippery term, so could you perhaps kick us off with a working definition?

Tim Stevens: You will be unsurprised to hear that there is no working definition, or at least no consensus on definition, about what offensive cyber is. Obviously, it is a term that attempts to draw some kind of analogy from other capabilities that can be used for offensive purposes – one of which is obviously weapons, another would be munition. But actually, offensive cyber is a lot more difficult to pin down because it is not kinetic in any conventional sense: it is not something that you can throw, shoot or drop on someone to cause damage.

But what offensive cyber tries to get at is the idea that through computer code, so little packets of software that can be sent through computer networks, you are going to attempt to deny, degrade, disrupt or even destroy something that your enemy holds to be of value. This principally could be data itself or it could be the computer systems and computer networks that data is held on.

Now offensive cyber is also being used not just in a military context but an intelligence context too, so it has some relationships with espionage or at least the covert activities of intelligence agencies. It could conceivably be used not in the kind of military break things sense but in the more inflected activities of intelligence, like subversion or sabotage, that occupy a slightly weird space and do not look like acts of war, for example.

ES: Terms such as cyber war, cyber attack and cyber weapons are used quite loosely in public discourse. Do you think we need to be more precise with our language when we are talking about offensive cyber?

TS: I think it would help if we had in common discourse some understanding that perhaps we are overhyping some of the phenomena that were describing, and using heavily militarised language like cyber war really does not help. Cyber attacks are usually nothing of the sort and cyber weapons usually cannot be classed as weapons, for example.

To take the cyber war example. When we think about cyber war, these days it usually means some kind of state of hostilities operating between two states, in which they are battering each other with cyber weapons of some description or another. Now apart from the fact that we have not seen this, it is also unlikely that we will see it. I think if two states are to be in a declared or actual state of cyber hostilities, there will be other issues – other types of operations in other domains – that are going to be just as relevant. So this idea of a standalone cyber war is not helpful.

Cyber warfare, on the other hand, is helpful because that is what militaries and intelligence agencies arguably are involved in at present – they are fighting, conflicting and contesting cyberspace as an operational domain. And they are doing that through offensive cyber, in part, but also through other activities that they can bring to bear on that domain. So cyber warfare has some utility; it is a form of warfighting or conflict through cyber means.

Cyber attacks, well that is just used to denote anything that you do not like. Whether it is an attack in any kind of conventional or attenuated sense is really irrelevant. If your adversary – whether they are a criminal, terrorist, state or proxy – has done something to your networks that you do not like, you call it a cyber attack, even though it might be nothing of the sort. It might be one of billions of automated pings or bots that confront your networks everyday as a matter of course. Or it could be a cunning, socially-engineered and sophisticated cyber operation against something that you hold of value. The two are clearly not the same, but they are all being called cyber attacks in popular discourse, and the media are just as guilty of this as politicians and occasionally academics and civil society too. So I do think it is important to make these distinctions.

The issue with cyber weapons is whether these types of capabilities can actually be described as weapons, and again there is no consensus. Conventionally weapons have to have the capacity to hurt by virtue of, say, ballistics. If you think about discussions around chemical and biological weapons, people are sometimes unconformable calling them weapons in any conventional sense too. And the thing about cyber weapons is that, as of yet, no direct physical harm has been caused by any of those capabilities. Instead, what happens is that there is attenuated secondary harm that would be caused when, for example, you change the 1s and 0s in an incubator in an intensive care unit and as a result of that someone dies, but it does not directly harm that person. So that is the kind of debate that is being had about whether these capabilities are weapons or not.

ES: Thinking about the utility of offensive cyber, why are states developing these types of capabilities and what do they offer that other capabilities do not?

TC: To think about the broader utility or the framing of these capabilities is, I think, to return to the [revolution in military affairs] of the late 1980s and early 1990s, then going on in subsequent decades in western military affairs. So the suggestion that we are shifting towards informationalised, precision strike, stand-off warfare that prioritises our own force protection and the ability to cause effects hundreds, if not thousands, of miles away.

Clearly, if you are sitting at a computer in one part of the world and you wish to attack another computer on the other side of the world, it is much easier to do that through computer networks than it is through conventional means: the mode of operation, the platform and the technology is much easier to get hold of. And if you can create the same effects remotely than if you were standing a hundred yards or half a mile away, then why would you not? You do not have to put your troops, or indeed your intelligence agents, in harm’s way. If you do not have to put a human asset into a foreign country to achieve an effect, why would you? These are the kind of attractions that states are finding in these sorts of capabilities.

Another one, of course, is that it is relatively cheap. It is much easier to hire people to develop these kinds of capabilities than it is to develop a new weapon system. Essentially, if the weapon system you need is, if not quite an off the shelf computer system but something existing that can be adapted, it is much cheaper than trying to develop a new line of fighter jet, precision guided munition, helicopter or battleship of any description. So that is attraction there.

Another thing is this idea of effects. As I mentioned previously, if you can create some kind of effect that generates, mainly operational or strategic but also tactical, advantage over your adversary through the use of computer networks, that has to be attractive. If it is cheaper, if it does not put your troops in harm’s way and, importantly, does not immediately escalate to something that looks like a conventional shooting war. Because if people are not being directly harmed, but yet you are causing your adversary to change their mind or behaviour in some fashion, that is incredibly seductive for a commander or state that is looking to improve, enhance or extend their operational and strategic toolbox. So that is the general idea behind why these capabilities are attractive.

ES: Looking at the other side of things, what are the limits of offensive cyber?

TC: That is a good question and an open one too. These kinds of capabilities may be attractive to countries and their militaries and intelligence agencies, but the jury is out on how effective they actually are. Because it turns out, for various reasons, that it is actually quite difficult to get your adversary to do what you want through cyber means. Partly this is because they are not as easy to control as we might think, and partly it is because, as I mentioned earlier, causing kinetic effects to actually change someone’s mind in a visceral sense is very difficult.

It is also difficult because you cannot keep doing it with the same capabilities. Once you have developed an advanced offensive cyber capability, essentially you can only use it once because then your enemy will see the code, understand the vulnerability that has been exploited, patch their systems and then that vulnerability disappears. So you cannot keep holding your enemy’s assets at risk, which means that even if something happens once – and given that no computer system is demonstrably secure, it is going to happen at some point – you know that it is a one-off attack. Because you know, or at least you hope, that your adversary has not got the capability to keep punishing you in that way. So that means that if you can roll with the punches if you get attacked or exploited, you are not expecting a follow-up that is really going to double down and force you to change your mind or your behaviour.

So for all the attraction of these capabilities, there are limits. Now that is not to say that there are limits to the imagination of people who wish to develop and deploy these things, and I am not saying for a second that, with this realisation that there are limits to their utility, states are going to stop developing them, because they are not. In fact, what I think is going to happen is what you are seeing at the moment, which is that states and other actors are going to continue to experiment with them until they find some way of generating the higher-level effects that they wish.

To bring that round to a conclusion: tactically, they can be very useful; operationally, they can generate some really interesting effects; strategically, it looks very difficult to generate the effects that you want.

Part II of this interview will be published tomorrow on Friday 4th June 2021.

Challenges to the Rule of Law in Times of Crisis Series: Australia and the quest for accountability after the Brereton Report

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Trooper Douglas Birchall (Mornington, Victoria) looks back to his section commander while approaching an obstacle during a reconnaissance patrol with 2CAV in the Shoalwater Bay as part of Exercise Predator’s Strike in 2011. Photo Credit: Photo by Andrew Dakin, US Department of Defense, Public Domain

This article is part of our series on Challenges to the Rule of Law in Times of Crisis. Read the series introduction at this link.

With the impending retreat of U.S. forces from Afghanistan after two decades of armed conflict, it is time to take stock of the legacy of this seemingly never-ending war. The conflict drove not just U.S. forces into the fray, but also an international coalition of forces under the mandate of the United Nations Security Council, which in 2001 established the International Security Assistance Force to combat global terrorism. Among these forces were Australian troops.

For the past years, the alarming rumours of alleged war crimes committed by Australian Special Forces deployed in Afghanistan, documented originally by  Samantha Crompvoets, have been under investigation. The findings of this inquiry resulted in the Brereton Report, an official document released by Australian authorities on 19 December 2020. It was a day of reckoning for Australians, who were confronted with the terrible deeds of some of their most trusted and admired professionals – 39 unlawful killings and instances of cruel treatment between 2005 and 2016. In the words of Major General Brereton, Assistant Inspector-General of the Australian Defence Force and author of the Report: “We embarked on this inquiry with the hope that we would be able to report that the rumours of war crimes were without substance. None of us desired the outcome to which we have come. We are all diminished by it.” (Ch. 1.01, par. 83)

Yet, there are at least two ways in which the findings of the Brereton Report have actually diminished us all as humankind. In a moral sense, each of us will be moved by the compelling words written by the English poet John Donne in 1623: “Any man’s death diminishes me, because I am involved in Mankind.” In a political sense, as already pointed out, Australian and other foreign forces have been deployed in Afghanistan for the past two decades on behalf of the international community, complying with the United Nations mandate to stave off global terrorism. Therefore, the findings of the Brereton Report are arguably not solely the business of Australia, but of the international community as a whole.

As for its contents, the Report raises several significant normative issues, not least from a military professional ethics perspective, as well as from the standpoint of criminal law.

Concerning military professional ethics, the Report is rife with references to adequate standards that are deemed becoming of a member of a Special Forces unit and that were shamefully breached in Afghanistan. Moreover, the Report is unique as an official document in that it attaches an Annex specifically dealing with professional ethics. Indeed, Annex A to Chapter 3.03, titled “Special Operations Command: Leadership and Ethics Review,” was drafted by Prof. David Whetham, Director of the Centre for Military Ethics. King’s College London. Whetham’s conclusions are endorsed in the main body of the Report. In his judgment evidence strongly suggests that war crimes have been committed, and that soldiers who receive effective ethics education and training are less likely to commit such atrocities (par. 5). But training and educating are not enough, just as it is not enough to know the Law of Armed Conflict; according to Whetham: “Military ethics should be considered as a core competency that needs to be updated and refreshed if it is to be maintained” (par. 9).

He also points to a worrisome sense of exceptionalism among Special Forces (par. 22), as well as the development of a deleterious “warrior mentality,” as opposed to military professionalism (par. 29). Staggering behaviour was ultimately normalised as a result of this gradual erosion of professional standards (par. 65). An analogous sustained decline of professionalism has led to other dark passages in military history, such as the My Lai massacre, as pointed out by Philip McCormack.

Whetham’s final recommendations include more ethics education, espousing dissenting narratives among Special Forces that lead to healthy ethics discussions, and accountability for wrongdoing (pars. 68-73). Admittedly, much more research is needed in this area, and specialized literature on ethical standards tailored for Special Forces might ground further critical studies inspired by the findings of the Brereton Report.

As to legal accountability, it is worth mentioning that the released version of the Report is heavily redacted precisely because of potential criminal prosecutions that might ensue in the following years. In that sense, it is certainly salutary that a week before the Report was released, the Australian Prime Minister appointed a special investigator to look into possible criminal prosecutions under Australian law. Admittedly, the ‘culture of silence’ decried throughout the Report promises to pose a formidable challenge to such internal inquiries.

Still, since the misconduct of Australian forces are also the concern of the international community, the applicability of international criminal law is also worth considering. Some preliminary ideas in this regard have already been noted by Prof. Douglass Guilfoyle from the University of New South Wales. In his analysis, Guilfoyle raises a few interesting legal issues, such as the conceptual gap in command responsibility between Australian criminal law and the Rome Statute of the International Criminal Court (ICC). In a word, the standard of conviction for command responsibility is much lower in the Rome Statute than under Australian criminal law. Guilfoyle also flags the problem of the alleged complicity of military lawyers in the covering up of misconduct, a phenomenon that is gaining increasing interest.

There is another issue specifically concerning Australia-ICC relations that is not touched upon by Guilfoyle’s analysis: complementarity. Pursuant to the Rome Statute, the ICC is to operate in a complementary capacity whenever the domestic jurisdiction of states fails to prosecute international crimes (preamble, arts. 1, 17). It is in this subsidiary nature where lies the ultimate strength of the ICC to take root and flourish amidst the dense vegetation of the Westphalian system of sovereign states.

Now, complementarity can be either positive or negative. We talk of positive complementarity when the ICC renders assistance to a state for it to exercise its own criminal jurisdiction. Negative or ‘classical’ complementarity kicks in whenever the state is unwilling or unable to exercise its ius puniendi, under the conditions spelled out in art. 17 of the Rome Statute (for instance, if there is a failed state or mock trials are conducted).

It is worth noting that the Office of the Prosecutor (OTP) of the ICC is already conducting an investigation on possible war crimes and crimes against humanity perpetrated in Afghanistan, albeit at this stage the investigation refers only to actions by US personnel and Afghan nationals, and the Brereton Report styles itself a ‘significant obstacle’ to an ICC inquiry, precisely on complementarity grounds (Ch. 1.12, par. 51). Yet, there is no legal impediment for the OTP to expand the scope of its survey to include conducts detailed in the Brereton Report, as both Afghanistan and Australia are parties to the Rome Statute since 2003 and 2002, respectively.

Indeed, the spectre of international involvement looms large across the text of the Brereton Report, which is adamant in that there will be no need for the ICC to intervene at all since the Australian judiciary will mete out criminal punishment where it is deserved. Although the Report claims to be fulfilling Australia’s obligations as a party to the Rome Statute (Ch. 1.01, par. 80), it confidently states that the ICC “lacks jurisdiction” (Ch. 1.10, par. 43), and that there will be no extradition unless Australia’s Attorney-General deems the state has been unwilling or unable to prosecute (Ch. 1.10, par. 51). It further reads that “the only courts current or former Australian Defence Force members may face are those established by the laws of Australia” (Ch. 1.01, par. 81). One sentence therein strikes as particularly defensive: “The conduct of this Inquiry, and a domestic prosecution, or a considered and bona fide decision by Australian prosecutors not to prosecute, denies the International Criminal Court jurisdiction” (Ch. 1.10, Executive Summary, p. 264, emphasis added). Still, the Report concedes that ‘contested complementarity’ between the ICC and Australia remains a possibility (Ch. 1.10, par. 52), and it concludes on a more conciliatory note that: “so long as Australia can satisfy the ICC Office of the Prosecutor that it is making the requisite inquiries and taking appropriate consequential action, the jurisdiction of the ICC is not enlivened” (Ch. 1.10, par. 53).

To be sure, Australia is a country with a strong tradition in the rule of law, and Major General Brereton, who is a Justice of the New South Wales Court of Appeals, is a towering exemplar of such a laudable legacy. Yet, if Australians have discovered that even their most elite and professional state agents could engage in appalling acts, the logical possibility that its judiciary could also fail must at least be entertained. The ultimate test of negative complementarity should rest with the ICC, an institution envisaged to address injustice not only in Africa, but wherever it is committed.

It remains to be seen how the relationship between Australia and the ICC will unfold hereafter. Given that there is a functional and credible judicial system in place in the Oceanic country, it is conceivable that an ambiguous love-hate relation might develop whereby positive complementarity will be fostered under the threat of the Damocles sword of negative complementarity, as has been the case in Colombia. It is also certainly possible for the OTP to decide not to conduct a full investigation if the Australian legal system is working as expected for a state party to the Rome Statute, just as in the case of the UK regarding alleged crimes committed in Iraq.

Australia finally met its Abu Ghraib, its Baha Mousa, its Airborne Regiment, like the US, the UK, and Canada before it. The disgraceful events recounted in the Brereton Report will arguably damage Australia’s international reputation to an extent that remains to be seen in coming years. They may also deter Australia and other countries from engaging in international peace operations in the future.

This does not mean that war is hell and that there is nothing for it. There are rules that govern even the most brutal and trying of human experiences. This is what Just War thinkers mean by ‘war convention’. The important thing is that, whenever such rules are breached, institutional arrangements need to be in place to mete out justice, including penal measures, as appropriate. And among those arrangements, Australian authorities must not forget, there is a permanent International Criminal Court standing at the ready.

Conflict & Health in the Eastern Mediterranean Series: Lebanon in Ashes: A Looming Mental Health Crisis?

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by Loubaba El Wazir

Beirut, Capital of Lebanon. Photo Source: Flickr, licensed under Creative Commons

This article is part of our Conflict & Health in the Eastern Mediterranean Series. Read the Series Introduction.

As Lebanon navigates dark times, the country’s youth struggle to manage their mental wellbeing amid economic and political instability. The country witnessed a nation-wide revolution in October 2019 in reaction to rising taxes and projections of economic collapse. Adding fuel to the fire since has been the banking crisis, the COVID-19 pandemic, and a massive explosion in Beirut in summer 2020. In less than a year, Lebanese youth were left with a devalued national currency, skyrocketing inflation, plummeting job opportunities, and a society poised on the precipice of conflict and self-division.

While there is evidence that riots and protests substantially increase the prevalence of Major Depression and Post-Traumatic Stress Disorder[1], research on the impact of economic and political unrest on mental health in developing countries remains widely unavailable. Our understanding of the latter dynamics could alternatively be informed by the narratives and experiences of mental health practitioners. In our interview*, Dr. Joseph El-Khoury argued that youth are at a high risk of developing mental health disorders in these circumstances due to a fluctuating sense of identity, belonging, and stability. Such issues have already been documented among Arab youth who experienced demographic and political crises[2]. Based on the increasing rates of care seekers, Dr. El-Khoury predicts that if the current state of affairs persists “we could witness more chronic disorders, including depression, anxiety, insomnia, and addiction, affecting an entire generation for the long-term”.

Unsurprisingly, signs of increasing mental health problems have already surfaced. The country’s national suicide hotline managed by Embrace, a mental health non-governmental organisation, has gradually been receiving more calls throughout the crises, with calls rising from 219 in September 2019 to 565 in January 2021. Their last report shows that 58% of these were received from individuals aged 18 to 34 years. One can also observe those struggles first-hand on social media platforms, where Lebanese youth express and share their trauma. Following the Beirut explosion, many tweeted sarcastically about the symbol of Lebanon being a rising Phoenix. Others explicitly denounced resilience, which for them is equivalent to an acceptance of their agonizing reality.

Nevertheless, according to Dr. El-Khoury, the number of people who actually seek professional mental health services reflects a treatment gap. This was previously documented by a national study conducted in 2006 and published in The Lancet, estimating that 89.1% of mental health disorders in Lebanon receive no treatment[3]. Yet, this situation is likely further exacerbated by the economic crisis, which has led most psychologists to raise their fees. Salem, a young Lebanese who struggles with mental disorders, told me that the cost of his sessions has more than tripled since last year, jumping from 75,000 LBP to 250,000 LBP per session. This spike is caused by the banking sector’s loss of liquidity and subsequent devaluation of the national currency. While the central bank of Lebanon continues to peg the Lebanese Pound (LBP) to the USD at 1$= 1515 LBP, banks currently operate at a different exchange rate (1$= 3900 LBP) and the black market has a yet different and constantly fluctuating rate that has reached around 1$= 12,000 LBP in the past couple of months. Given that therapy sessions are priced in USD and psychologists have the freedom to choose which exchange rate to operate with, the range of therapy fees has become vast across clinics, with sessions costing between 150,000 LBP and 800,000 LBP. Not only does this situation restrict the population that is financially capable of accessing mental health care, but it also affects the general public trust in the mental health sector.

The economic crisis has also impacted mental health by diminishing resources that are vital to the sector. The main damage it caused was pushing a big portion of the health workforce abroad. In our interview, Dr. El-Khoury expressed that mental health professionals are “both providers of care and in need of care… socially”, adding that many practitioners are forced to immigrate due to inadequate working conditions and salaries. Moreover, psychiatric medications and comprehensive mental health programs have not escaped the influence of the economic crisis, with many medicines and treatments either completely running out or becoming excessively unaffordable.

This dismal situation leads us to the question of mental health access for Lebanese youth. While many foreign donors, including the United Nations and World Health Organisation, have initiated and contributed to initiatives in Lebanon, these remain limited. Dr. El-Khoury said that although certain non-governmental organisations have programs that offer free therapy sessions, their capacity is likely capped at a couple of thousands of patients. This is certainly inadequate for a population of 6 million Lebanese, 55% of whom are in poverty, and more than 50% of whom have no formal health insurance coverage. Among those who do enjoy health insurance, a very small minority get their psychologist sessions covered, given that most insurance programs only cover psychiatric, but not psychological, therapy. The National Social Security Fund plans to incorporate partial coverage for these sessions soon, according to Rabih El Chammay, head of the National Mental Health Programme. Yet, little is to be expected, given that the institution is “broke” and has a history of fragile implementation.

The ability of Lebanese youth to re-establish their mental health well-being following the recent catastrophes seems to be inextricably dependent on political, economic, and institutional reform. Particularly, it is essential to establish a rigorous national mental health system that is funded and organised by the health branch of the Lebanese government. Given that this seems like a distant prospect, it is crucial for mental health organisations to coordinate efforts across the country to ensure accessible care for the most vulnerable. Yet, we should be cautious about claiming that the NGO sector can manage this crisis alone, an idea which, in the words of Dr. El-Khoury, “washes the government’s hands from providing sustainable, free, or at least low-cost services”.

The same oligarchy that murdered and terrorised thousands of families in the 1975 Lebanese Civil War is largely responsible for the economic and social collapse happening now. While strengthening the mental health system is essential to lessen the collective psychological impact of the crisis, what the small Mediterranean country ultimately needs is political reform and accountability, now more than ever.

[1] Ni, Michael Y., Yoona Kim, Ian McDowell, Suki Wong, Hong Qiu, Irene OL Wong, Sandro Galea, and Gabriel M. Leung. “Mental health during and after protests, riots and revolutions: a systematic review.” Australian & New Zealand Journal of Psychiatry 54, no. 3 (2020): 232-243.

[2] Mulderig, M. C. (2013). An uncertain future: Youth frustration and the Arab Spring.

[3] Karam, Elie G., Zeina N. Mneimneh, Aimee N. Karam, John A. Fayyad, Soumana C. Nasser, Somnath Chatterji, and Ronald C. Kessler. “Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey.” The Lancet 367, no. 9515 (2006): 1000-1006.

Loubaba is an MSc. Social and Cultural Psychology student at the London School of Economics and Political Science. She holds a Bachelor in Psychology from the American University of Beirut. She was involved in the Lebanese October 17 Revolution and has an interest in its impact on Lebanese society. Loubaba has completed internships at the Issam Fares Institute for Public Policy and the United Nations ESCWA.

Series Introduction: Conflict and Health in the Eastern Mediterranean

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by Anas Ismail

Photo by Andrey Metelev on Unsplash

Conflict is known to affect health in a myriad of ways[1] including, but not limited to, attacks on health workers and facilities, disruption of access to health services, deterioration of water and sanitation infrastructure, and interruption of training and education for medical students and junior doctors. The more severe and long-lasting the conflict, the more significant its effects on health and the harder it will be to recover and improve health in post-conflict situations. Moreover, the impacts of conflict extend beyond the national borders in which they occur, and bleed over into neighbouring states whose governance, in the face of conflicts’ destabilizing effects and mass refugee flows, is significantly challenged.

The Eastern Mediterranean is home to one of the oldest conflicts, that between Israel and Palestine, and one of the most devastating, the Syrian civil war.

In Palestine, over five decades of occupation have taken their toll on all aspects of healthcare from medical education to patient care and life conditions, all aspects further explored in this series. In Syria, the conflict has been characterized by the weaponization of healthcare, i.e. attacking or withholding healthcare as a strategy of war. Moreover, while the parties to these conflicts suffer extensively, other countries in the region are also struggling from their spill-over effects alongside their own internal divisions and unrest. Lebanon continues to endure an unprecedented economic crisis, deep internal divisions, and lack of proper governance on the political level – all whilst hosting nearly 1.5 million Syrian refugees. These have had a significant  impact on the country’s youth whose mental health needs seems to be far from being met in a country where psychiatric and psychological services are largely neglected, with a treatment gap close to 90%. Jordan, on the other hand, enjoys  relatively stable governance and economic conditions, but it has been strained  by surrounding instability. As a result of the protracted Israeli-Palestinian conflict, it hosts 2.2 million Palestinian refugees, the most of any country, and over the past decade these have been joined by 1 million Syrian refugees, meaning that over 30% of Jordan’s total resident population are displaced peoples.

This series aims to capture various experiences of healthcare delivery and medical education in the region. The first article brings to light how medical education is being provided completely online for the first time in Gaza under settings of protracted conflict, chronic electricity shortage, and economic impoverishment. The second piece discusses the underlying causes of the looming epidemic of mental health disorders among the youth in Lebanon and how the economic crisis is impacting it. The third article illuminates the intricacies and security implications of patients in Gaza needing, and seeking, treatment abroad. In the fourth piece, the author, a Syrian doctor in diaspora, discusses how attacking the healthcare work force in Syria is affecting the provision of health and what needs to be done. The final piece describes the far-reaching impact of war-related amputations on civilians in the Gaza Strip and argues how modern warfare, such as drone attacks, are causing an increase in such injuries.

Series Publication Schedule

  • 26 April 2021 – Part I: Medical education under blockade, protracted conflict and constant warfare. By Alaa Ismail
  • 27 April 2021 – Part II: Lebanon in Ashes: A Looming Mental Health Crisis? By Loubaba Al Wazir
  • 28 April 2021 – Part III: Medical Referrals in Gaza: Uncertainty and Agony for Palestinians Patients. By Anas Ismail
  • 29 April 2021 – Part IV: How does the Syrian Civil War affect health care workers? By Abdullah Al Houri
  • 30 April 2021 – Part V: Life after traumatic amputations in the Gaza Strip. By Hanne Heszlein-Lossius

[1] Howard, Natasha, Hossain, Mazeda, Ho, Lara. “Effects of Conflict on Heath.” In Conflict and Health, 25–32. Berkshire: McGraw-Hill Education, 2012.

Anas Ismail is a medical doctor originally from Gaza, Palestine, where he received his education and training. As a citizen of Gaza, and later as a medical student, he personally lived the impact that conflict has on life in general and on healthcare in specific. This led him to an interest in global health as a means of learning more about the relationship between conflict and health.

With a joint scholarship from the Chevening Awards and the Said Foundation, Anas is currently studying MSc Global health with conflict and security at King’s College, London. He is the Production Manager for Strife Blog and a Series Editor at Strife.