War Fractures Emerging Clinical Trial Infrastructure in the Middle East

Over the past few years, a series of wars and conflicts have caused immense devastation in the Middle East. The Israel-Hamas war that began in October 2023 has resulted in more than 73,000 deaths, with the count still rising each week. This has only been exacerbated by the US-Israel-Iran war that began in February 2026 and expanded the war zone into multiple countries in the Middle East. Along with nearly 2 million displaced Palestinians, strikes on Iran and Lebanon have led to millions more refugees.

This has disrupted core life necessities in the Middle East: access to food and water, housing, and healthcare. But researchers in hospitals and universities in the Middle East are also mourning the loss of research infrastructure that was painstakingly built in recent decades.

During a humanitarian crisis, as hospitals are flooded with war casualties and refugees, research becomes a secondary priority. For ongoing clinical trials, this can be a major issue, especially when it risks the safety of patients who are taking an investigational drug. As these studies have complex designs, require careful monitoring of participants, and take years to complete, clinical trials are highly vulnerable to conflict.

At this time, the US-Israel-Iran war seems to have had a limited impact on the broad clinical trial landscape in the Middle East, but a closer look reveals how researchers in highly affected countries are navigating the daily challenges of maintaining trials and patient care in a war zone. Their experience offers a blueprint for the Middle East’s incipient clinical trial infrastructure to maintain resilience in the face of conflict.

“It is painful for us to watch how this man-made event is negatively impacting the way we bring better care to patients,” said Gen Li, president of Phesi, a clinical trial analytics company. “Hopefully, the war’s impact on clinical development, for this particular episode, is relatively insignificant…but we still need to be prepared.”

The Middle East and North Africa Present a Unique Opportunity for Clinical Research

The number of clinical trials registered in the World Health Organization’s Eastern Mediterranean region—which includes the Middle East and North Africa—has grown nearly 50-fold over the past two decades. More than 7,000 trials were registered in 2025, although this still lags behind Europe, Asia, and the Americas.

External interest from pharmaceutical companies has been met with great internal interest in establishing major centers of clinical research in the resource-rich Gulf region.

“Low cost and a booming population: Those two combined together make it a great place to conduct clinical trials,” said William Soliman, the chief executive officer of the Accreditation Council for Medical Affairs and a former pharmaceutical executive.

The Middle East also presents an intriguing scientific opportunity for drug development. Drugs may work differently in people from different ancestral populations. Genetic and environmental variation can impact how a drug is metabolized, potential side effects, and whether it treats the disease effectively. Middle Eastern representation in clinical trials is hard to quantify, since they are often categorized as “white” in US-based trials, but with their distinct genetics and environmental exposures, they are an important population to include in clinical studies.

A unique feature of the Middle Eastern population is the prevalence of consanguineous marriage, or marriage between close relatives. Between 20 to 50 percent of marriages in the Middle East are thought to be consanguineous, compared to less than 1 percent in the United States, which can increase the risk of certain rare genetic conditions.¹ Some genetic diseases require two copies of a damaging mutation, and if the mutation is rare enough, it’s unlikely that two unrelated parents will both pass on the mutation. However, in consanguineous marriages, it is more likely that both parents will have the mutation because they share large portions of their genetics. This can increase the prevalence of certain diseases that are hard to study elsewhere, such as certain immunodeficiencies or blood disorders.² Dozens of disease-related genes have been identified by studying Middle Eastern families.³

“We are helping the scientific community to find new genes and from there to discover a path to medications,” said André Mégarbané, a clinical geneticist at Lebanese American University (LAU) in Beirut. “Don't forget us.”

Few But Critical Clinical Trial Sites Affected by War

In April, analysts from Phesi sifted through more than 65,000 globally recruiting clinical trials and found that more than 4,000 of those trials—6.7 percent of all the trials they analyzed—had investigator sites in the Middle East. While they don’t know how many of those trials were disrupted by war, the findings are still sobering, Li said. He pointed, for example, to the more than 2,000 clinical trial investigator sites in Israel as “an important place for doing clinical trials.”

Some countries have the infrastructure to sustain trials during conflict. For example, in October 2023, Clinical Trials Arena reported that the Israeli Ministry of Health was prepared to employ contingency plans to continue clinical trials. “Where it's going to make a difference is when the centers where the clinical trials are run don't have the staff to run the trial or the infrastructure to do it,” Soliman said.

The most affected countries are those with relatively small clinical trial footprints. Phesi’s analysis included just 53 sites in Lebanon and 69 sites in Iran, for instance, compared to more than 2,000 in Israel. In these countries, hospitals have repeatedly been damaged by Israeli missile strikes. As of June, hospitals in Lebanon had been damaged, including some that have sheltered and treated refugees. In Iran, counts of damaged hospitals range from 17 to more than 300.

The trials in these countries may be small and few in number, but they often address critical, unmet needs. In an article published earlier this year in The Lancet Haematology, a team of researchers from the American University in Beirut (AUB) described their experience of running clinical trials for thalassemia in Lebanon during the war.⁴ This genetic blood disorder is more common in people of Middle Eastern ancestry than in people of European or East Asian ancestry, partially driven by consanguineous marriage. Thalassemia trials in Lebanon therefore provide essential insights into how to treat a unique, highly affected patient population.

In their account, the researchers described the challenges of continuing a clinical trial that involved regular patient visits and investigational drugs when travel was limited, infrastructure was damaged, and supplies were scarce. Medical ethics always came first, as well as the wellbeing of the staff, who were themselves living through a crisis. “Even under fire, the pursuit of healing and knowledge endured,” they wrote.

Prioritizing Patient Survival and Safety

When Sola Aoun Bahous, a nephrologist and dean of the medical school at LAU in Byblos, launched her clinical trial in 2024, she did not know that a full-blown war would soon disrupt her work. But she knew the process was likely to be rocky. “We had been living in a crisis, even when we started enrolling,” she said. Fighting had already begun along the Israel-Lebanon border, and south Lebanon endured nearly daily airstrikes.

The war “further destabilized Lebanon's already fragile health-care system,” the AUB researchers, led by hematologist Ali Taher, wrote in The Lancet Haemotology article.⁴ Lebanon has been in an economic crisis since 2019, marked by steep inflation and decline of public services such as electricity and water. In parallel, the healthcare infrastructure had been challenged by multiple mass casualty events: the COVID-19 pandemic; a 2020 explosion in the Beirut port that killed more than 200 people and displaced 300,000; and the 2024 pager and walkie-talkie explosions intended to target Hezbollah that injured thousands of civilians.

Aoun Bahous’s clinical trial had been in development throughout this turmoil. In 2020, she had published a case-control study where she observed that people with migraines had stiffer arteries and were somewhat more likely to be deficient in vitamin K2.⁵ To test whether addressing this deficiency could be a pathway to treatment, she initiated a trial to test whether vitamin K2 supplementation can reduce the frequency and intensity of migraines.

Compared to other trials, her intervention is a relatively low-risk one: Vitamin K2 is well tolerated and has minimal side effects. Nonetheless, her study protocol includes monthly phone check-ins with study participants to ensure that they are taking the medication—either vitamin or placebo—and that they aren’t experiencing any concerning side effects. Patients come to the LAU hospital periodically for blood tests and measurements of migraine scores, arterial stiffness, and body mass index.

When attacks on Lebanon began escalating, Aoun Bahous was in the midst of recruiting patients for her trial. She had to refocus her efforts. As dean of the medical school, she had a large student body to think of, as well as medical and research staff. “In times of crisis, we tend to prioritize what is most important for us at this moment,” she said. “Survival and safety are much more important than conducting research or being enrolled in a research project.”

Aoun Bahous’s team at LAU instead focused on ensuring patient care, treating casualties, and maintaining hospital operations. Occasionally, during periods of relative normalcy when the strikes abated, her research team would resume patient recruitment. But these efforts were tinged with uncertainty. “You never know when war will end,” she said. “We could not predict or even understand how things are going to evolve.”

This mindset can be seen in other countries throughout the Middle East as well. Ahmad Al-Bitar is a medical student in his final year at Damascus University in Syria. He is training to become an oncologist, a specialty where there is great unmet need in his country. Syria only recently began to emerge from a 15-year civil war that has devastated the country’s economy and medical infrastructure.

Although the US-Israel-Iran war hasn’t directly affected Syria, Al-Bitar is skeptical that clinical trials are currently attainable in Syria’s fractured healthcare system. In 2025, he conducted a survey-based study of cancer patients to better understand their attitudes toward clinical trials.⁶ He found that 99 percent of participants did not know what a clinical trial was, and even once they learned more, transportation and costs were obstacles to participating.

“Clinical trials need a complete system and cooperation to make the trial successful,” Al-Bitar said. “Here, we still lack basic medications. Clinical trials are a luxury.”

“Experts in Times of Crisis”

Patient safety is always of paramount importance in clinical trials, but during war, the researchers have additional considerations. Lebanon, for example, is a fairly small country—slightly smaller than Connecticut—and Beirut is located at the midpoint of its western coast. People drive to Beirut for medical appointments from different regions of Lebanon, which allows researchers in Beirut to recruit trial participants from all across the country.

During the war, however, roadblocks and unpredictable missile strikes made such travel dangerous. When the war began, Aoun Bahous’s research team changed the study protocol to minimize the need for participants to travel to and from Beirut. Instead of asking them to come to the hospital once a month to replenish their supply of the investigational drug, the researchers gave them three-month supplies. Participants were only asked to come to Beirut for blood tests and other measurements; if participants felt unsafe traveling, they left the study. Aoun Bahous knows that these missing data will affect the results of the study, but she is certain it was the right choice to avoid putting participants at risk.

Monthly phone calls served as a replacement for the in-person visits, allowing the study staff to still check in on the participants and make sure they were taking the medication as instructed. Aoun Bahous’s team prioritized outreach to patients who had been displaced, and these calls also took on a new purpose: a way to connect with patients human-to-human, check on their wellbeing, and provide some comfort.

The AUB researchers employed similar strategies to sustain their thalassemia trials. These trials involved investigational drugs that needed to be moved and stored in places that could be more reliably accessed. They relied on telehealth for recording data and sharing information and enlisted local labs and hospitals to conduct lab tests.

These strategies were informed by lessons that researchers learned navigating other past crises, Aoun Bahous said. From COVID-19, they learned how to leverage remote patient monitoring. From past mass casualty events, they learned about the importance of supporting staff and patients’ mental health.

“Each crisis presents a different challenge, and we learn something different,” she said. “We have become experts in times of crisis.”

The Growing Cost of Doing Research

When Aoun Bahous designed her clinical trial, the goal was to recruit 160 participants. Currently, she has recruited 127 participants, but nearly one-third of them have dropped out. This dropout rate is much higher than the 10 to 15 percent rate that she typically sees in studies, and it will necessitate more recruitment than what she initially budgeted for and will extend the timeline of the study.

This is just one of many new costs that clinical researchers in the Middle East face during conflict. Mégarbané studies rare genetic diseases found among Middle Eastern populations. Although he has participated as an investigator in international clinical trials of drugs for genetic diseases in the past, he is not currently running any clinical trials because it is too costly. This is in part because of the economic crisis in Lebanon, which has caused the currency to drop in value and made it prohibitively expensive to buy research supplies from outside the country.

Currently, he is conducting a clinical study in partnership with Weill Cornell Medicine’s Qatar branch to explain the high rates of breast cancer in Lebanon. He collected more than 350 blood samples from patients but then faced a dilemma: how to get the samples to Qatar.

Beirut and Doha, Qatar, are around 2,000 kilometers apart, a distance easily traversed by a three-hour flight. But for the first few months after he collected the samples, the shipping company told Mégarbané that they were not flying in the region due to the dangerous airspace. Eventually, they agreed to send the samples but not directly: He would have to ship them first to Europe. From there, the route to Qatar was uncertain, potentially requiring stops in Kuwait and Saudi Arabia.

Mégarbané paid an extra fee for faster shipment, but the shipping company still offered no estimates of when the package would arrive: It could take anywhere between 24 hours and a week, they said. For precious patient samples needed for a carefully controlled study, this was a huge risk, and Mégarbané also felt he was disappointing the study participants.

“Patients call me sometimes to ask if I have any news about their sample, and I have to say, ‘Sorry, we didn’t start processing the samples because of this war,’” he said.

Building Resilient Clinical Trials

Despite the challenges she has faced in her current clinical trial, Aoun Bahous is optimistic about the future of trials in Lebanon.

“This is the first time that I’ve seen this international interest in what's happening in the area,” she said, pointing to the increased scientific investment in studying the diverse Middle Eastern population. Al-Bitar has also seen growing support for Syrian doctors and researchers from the global Syrian diaspora.

Aoun Bahous recognizes, however, that running clinical trials in the Middle East will require local and global investment to rebuild the infrastructure. Country-level efforts have emerged to expand healthcare infrastructure. Iran, the United Arab Emirates, and other countries have their own registries of patients with rare diseases. Saudi Arabia launched Vision 2030, an initiative to modernize the country’s healthcare system. Part of this initiative is a push to grow clinical trial capacity by building infrastructure linking doctors and patients to companies seeking to run trials.

But running clinical trials in the Middle East may feel like a risky proposition for companies at the moment, Soliman said. “The status quo is shifting, and I think now, for pharmaceutical companies that are operating in the Middle East, there's definitely more instability,” he said. The need to spend extra money on logistics, extra recruitment, and other costs incurred by trial disruptions may disincentivize companies in search of the lowest-cost setting for a trial.

“From the sponsoring pharmaceutical companies’ point of view, each and every one of those trials are enormously expensive,” Li said. “Sometimes we encourage them to proactively prepare themselves for this type of thing.”

But war can be unpredictable, and there are limits to how much researchers can realistically prepare for its fallout, Soliman said. Every war or conflict comes with new disruptions, and research is a slow process that requires substantial planning years in advance.

Mégarbané was recently invited to run a clinical trial site in Lebanon for a Duchenne muscular dystrophy study initiated by a pharmaceutical company. It was a tempting proposition: Not only would his efforts add patient data from Lebanon and Syria to the evidence base for the drug’s effectiveness, but it was also an opportunity for his patients to get free access to a drug that might otherwise be out of reach.

However, when he read the investigator agreement form, he paused. The form asked him to attest that he could ensure patients received the investigational drug at a specific cadence, under specific conditions, over the next two years. As the airspace above Lebanon remained closed due to bombing, blocking his shipments, he had also heard from his patients about the dangers that they faced as they tried to travel to the hospital for medical care. “I couldn’t commit,” he said. “I prefer not to give my patients hope if I cannot continue after a month. If I start, I need to be serious.”

The silver lining for Lebanon’s clinical research infrastructure is that it is battle-tested, Mégarbané said. “We are used to facing such situations, unfortunately,” he said. “Lebanese people are very resilient.”