Lebanese authorities have shown a callous disregard for the protection of healthcare workers at the front lines of the Covid-19 pandemic, Human Rights Watch said today. The country has had an alarming surge of cases that is threatening to overwhelm the healthcare system.

Government institutions, including the Health Ministry, National Social Security Fund, and security agencies such as the military and Internal Security Forces, owe private and public hospitals large sums of money. Their failure to meet their financial obligations severely restricts hospitals’ ability to maintain sufficient staffing levels and protect staff from infection. The authorities have also failed to stop violent attacks against healthcare workers. The pandemic has had a significant mental and emotional toll on the workers.

“Healthcare workers are the backbone of the country as Covid-19 cases rage across Lebanon, but the government has shown a callous disregard for their health and safety,” said Aya Majzoub, Lebanon researcher at Human Rights Watch. “If the government wants the health system to withstand this crisis, it should pay hospitals their dues and ensure that health care workers have the protection and support they deserve.”

Human Rights Watch interviewed two high-level hospital officials, five doctors – including the head of the Order of Physicians – and ten nurses across the country, including the head of the Order of Nurses. Most of the healthcare workers asked that their names not be used for fear of jeopardizing their jobs.

Lebanon’s economic crisis predates the pandemic. The national currency has lost more than 80 percent of its value in the past year. Poverty rates have doubled, unemployment has skyrocketed, and inflation exceeded 100 percent.

The economic crisis has had a devastating impact on the healthcare sector. Medicines and medical supplies, most of which are imported, are in short supply. The value of nurses’ and doctors’ salaries has declined rapidly, triggering a mass exodus. The pandemic then placed an additional strain on a healthcare sector already in crisis. Hospitals’ capacities have been stretched, their costs have risen, and yet the government is not disbursing the funds it owes them.

The state owes the governmental Rafik Hariri University Hospital (RHUH), Lebanon’s biggest Covid-19 treatment center, around 20 billion Lebanese Pounds (US$13.3 million at the official exchange rate and around $2.5 million at the unofficial market rate) in unpaid bills for 2020, the hospital’s CEO, Dr. Firass Abiad, told Human Rights Watch. “We have some money from internationals like the United Nations refugee agency and the International Committee for the Red Cross,” he said. “If not for those, we would be in trouble.”

The government also owes over 120 private hospitals 2,500 billion Lebanese pounds – $1.6 billion at the official exchange rate and around $300 million at the unofficial market rate –, according to Sleiman Haroun, the head of the Syndicate of Private Hospitals. Haroun said that in 2020, the Finance Ministry has only disbursed 8.5 percent of the amount owed. He added that they have not yet seen a penny of the additional credit line in the 2020 budget of 450,000,000 Lebanese pounds that parliament created for hospitals in April.

Dr. Georges Ghanem, the chief medical officer of the LAU Medical Center – Rizk Hospital, one of Lebanon’s largest private hospitals, told Human Rights Watch that the government owes the hospital around 22 billion Lebanese pounds ($14.5 million at the official exchange rate and $2.8 million at the unofficial exchange rate), creating a “very tough situation.” “There is no transparency whatsoever in how the money is allocated to hospitals,” he said.

In April, the World Bank allotted $40 million to help Lebanon respond to the Covid-19 pandemic, including to protect healthcare workers. Abiad said his hospital has not received any money from this loan yet. Ghanem said that “nobody has been able to tell us how this money was spent.”

Most doctors are compensated by fees from clients’ private or public insurance rather than salaries. Dr. Sharaf Abou Sharaf, the head of Lebanon’s Order of Physicians, told Human Rights Watch that around 20 percent of the dues owed to hospitals are doctors’ fees, some from as far back as 2017. Mirna Doumit, the head of the Order of Nurses, said that since the economic crisis began in late 2019, 40 percent of nurses across public and private hospitals have been dismissed from their jobs, increasing pressure on the remaining workforce. She said hospitals have also slashed nurses’ salaries. The currency’s rapid depreciation over the past year has resulted in an 80 percent decline in workers’ real income.

Both Abou Sharaf and Doumit said that some public and private hospitals were not providing their staff with adequate quantities of personal protective equipment (PPE), resulting in growing numbers of infections among doctors and nurses. As of December 6, 1,792 healthcare workers had been infected with Covid-19, including about 10 percent of the country’s nurses. Six doctors and at least one nurse have died.

All the hospital officials and doctors interviewed said that personal protective equipment is available in the market – in contrast to the early months of the pandemic – but that the main limiting factor was its price. They said that many necessary items, including gloves and surgical masks, were not subsidized by the state and that their prices have increased drastically due to the national currency’s depreciation.

Both Ghanem and Abiad said that after the August 4 port explosion, their hospitals received large amounts of protective equipment from international donors. But assistance channeled through the government since the beginning of the pandemic rather than to the hospitals directly found its way to the black market, Ghanem said, and sold at inflated prices. Human Rights Watch has not been able to verify these allegations, but there have been other substantiated cases in which the government has not distributed international aid as intended.

Under the International Covenant on Economic, Social, and Cultural Rights, which Lebanon has ratified, Lebanon is obligated to minimize the risk of occupational accidents and diseases, including by ensuring workers have health information and adequate protective clothing and equipment. This means providing healthcare workers and others involved in the COVID-19 response with appropriate training in infection control and with appropriate protective gear. In the context of the right to life where a lack of adequate PPE creates a foreseeable life-threatening situation, failure to provide adequate PPE to health workers exposed to Covid-19 may violate states’ obligations to protect life.

The Finance Ministry should urgently disburse the funds owed to hospitals, Human Rights Watch said. Given credible allegations of corruption in the healthcare sector and the continued failure of the Lebanese authorities to address the economic crisis endangering peoples’ access to healthcare, international donors should channel emergency medical aid directly to hospitals to the greatest extent possible.

“If the Lebanese government doesn’t put coordinated and effective policies in place to address the economic crisis, hospitals may soon be unable to provide life-saving care,” Majzoub said. “The Lebanese government needs to urgently pay hospitals and relieve the pressure on health care workers.”

Lebanon has had an exponential increase in Covid-19 cases and related deaths since October. Multiple full or partial lockdowns have been poorly enforced and have not stemmed the rise of Covid-10 cases, in large part due to the lack of an emergency social safety net that would enable working people to stay at home. Critics have accused the government of not having a cohesive, long-term strategy to deal with the pandemic.

The Lebanese authorities have also failed to address the economic crisis that has endangered people’s basic rights. The World Bank said that the “deliberate lack of effective policy action by authorities has subjected the economy to an arduous and prolonged depression.” The World Bank said that this lack of action is likely to cause Lebanon’s economic crisis to be “deeper and longer than most economic crises.”

Overworked and Underpaid

The Covid-19 pandemic has placed additional strains on a healthcare system already in crisis due to the government’s failure to address the economic crisis and pay hospitals their dues. Various public sector entities, including the Health Ministry, National Social Security Fund, Internal Security Forces, and the army cover some medical costs for their personnel or residents covered under certain health insurance schemes, but the government has not disbursed a large share of those payments to hospitals.

The hospitals’ precarious economic situation forced many to lay off significant numbers of staff in 2019, making them ill-prepared to face the Covid-19 pandemic. On top of that, the delay in paying doctors and nurses, the 80 percent decline in the value of healthcare workers’ real income, and the lack of faith in the government’s ability to address the multiple crises Lebanon is facing, have prompted an exodus from Lebanon of doctors and nurses – many of whom were among the most qualified.

Sharaf Abou Sharaf, the head of the Order of Physicians, said that 400 doctors emigrated this year. A doctor in Tripoli, one of the most impoverished cities in the country, said that a significant percentage of the doctors in the Tripoli chapter of the Order of Physicians left the country this year due to the economic crisis and that those who have not yet left were making plans to go.

Mirna Doumit, the head of the Order of Nurses, also said that nurses were migrating “en masse.” This exodus, in addition to the large number of healthcare workers infected, has placed an additional burden on the remaining workforce, many of whom have had to work additional shifts and longer hours.

Doumit said that in some hospitals, there is one nurse for 20 patients, though the Order of Nurse’s guidelines stipulate a ratio of one nurse for eight patients in regular wards. One Covid-19 ward nurse said that her hospital had only one nurse for every six-seven patients in the Intensive Care Unit, violating the hospital’s own standards and the Order of Nurse’s guidelines, which stipulate a one nurse to two patient ratio in Intensive Care Units.

“The big[gest] problem we have is the shortage in staff members,” said an emergency room nurse at a private hospital. “To be blunt, they [hospital management] are just trying to save money. We have a heavy load of patients in the ER…[Typically] I have to go [to the hospital] three to four times a week. But sometimes now, I end up going five to six times. Even on Saturdays, which is my time off. Sometimes from the morning until the evening even though I have the night shift.”

All the healthcare workers interviewed said that one main reason for stress was seeing the value of their salary decline so much that it was barely enough to afford basics, including rent and bills. “You can have more patients to treat, but we no longer have an actual income,” a pulmonologist in south Lebanon said.

A doctor’s consultation fee costs between 100,000 and 150,000 Lebanese pounds, which was previously worth $67 – $100. However, due to the currency’s devaluation, it is now worth $12 - $19 at the actual market rates.

“The salary is no longer enough with the depreciation,” said an emergency room nurse on Beirut’s outskirts. “It’s paid in Lebanese pounds. So one million Lebanese pounds is now barely $200.” This salary was previously worth $667.

“Everything is becoming more and more expensive and the salaries can’t keep up,” he said. “There was no adjustment, no bonuses, nothing at all.”

Only one nurse interviewed said that she received a slight “Covid salary bump” at the private hospital she worked at.

Private and public hospitals have adopted cost-saving measures that have negatively affected their staff. Some have slashed salaries or forced staff to work half time. Others have started treating overtime hours as regular hours, instead of paying time and a half for overtime, as Lebanese labor law stipulates. Still, others have switched from paying their staff in US dollars to Lebanese pounds either at the official exchange rate or at a slightly higher rate that is considerably less than half the unofficial market rate.

Two nurses who work in Covid-19 isolation centers said that they are working without contracts and without benefits, including social security benefits or paid time off, and that they have not been paid since October. One nurse said that when he complained, the hospital coordinator told him, “If you don’t like it, you can leave.”

Lack of Personal Protective Equipment

The failure of the government to pay hospitals their dues has made it difficult for them to purchase adequate supplies of personal protective equipment, prices for which have increased drastically due to the national currency’s depreciation.

Doumit, the head of the Order of Nurses, told Human Rights Watch that there are no national guidelines for the provision of personal protective equipment, but that each hospital sets its own standards. While four nurses and doctors interviewed said that their hospitals were providing them with the PPE that they needed, six described severe shortages, especially of respirator masks. Four said that they had to buy their own, including a doctor and a nurse who work in a Covid-19 ward and an emergency room.

An emergency room doctor in Mount Lebanon said that his private hospital faced severe shortages during some periods, including gloves, respirator masks, and surgical masks. At one point, he said, the hospital gave them flimsy, clear plastic gloves that are commonly “used to make sandwiches,” instead of the standard latex gloves for medical use. He said that he has had to buy his own N95 respirator masks, which cost 55,000 Lebanese pounds ($36.70 at the official exchange rate).

The head nurse of the Covid-19 unit at a private hospital outside Beirut, where six nurses and one resident tested positive for the virus within ten days in September, said that the hospital gave them masks that were not designed for medical use and had not been approved by the United States Food and Drug Administration. “That was the end for me,” she said. “I resigned because I gave up. At the beginning [of the pandemic], I wasn’t very scared. But when the breakout happened in the hospital, I became very scared. I was scared to transmit the virus to my 65-year-old parents.”

Another nurse, in a Covid-19 isolation and treatment center in southern Beirut, said staff is only allowed to use two gowns a day. “This is impossible,” he said, as he deals with about ten admissions per day. He also said that the quality of the PPE provided decreased over time. He said that some of the boxes of gloves were defective and had a missing finger or were torn. He also said that the gowns tore easily and that the surgical masks they were given only had one layer, as opposed to three, as they had at the beginning of the pandemic, which he felt provided better protection.

Both Ghanem of Rizk Hospital and Abiad at RHUH said that through careful planning, as well as direct donations in the aftermath of the Beirut port explosion, they were able to ensure that all their staff was adequately protected. They acknowledged that this may not be the case in smaller or more remote hospitals that were even more strained for resources.

The World Health Organization (WHO) has issued interim guidance on Covid-19 concerning the rights, roles, and responsibilities of healthcare workers. Employers and managers should provide workers with infection prevention and control masks, gloves, goggles, gowns, hand sanitizer, soap and water, and cleaning supplies in sufficient quantity such that workers will not have to incur their own expenses. Workers have the right to remove themselves from a situation that they have reasonable justification to believe presents an imminent and serious danger to their life or health, and to be protected from any resulting retaliation.

In June, the World Health Organization said that medical masks should be worn by all healthcare workers interacting with Covid-19 patients and that respirator masks should be worn by those conducting aerosol-generating procedures. The Centers for Disease Control and Prevention states that regular face masks do “not provide the wearer with a reliable level of protection from inhaling smaller airborne particles and [are] not considered respiratory protection,” and recommends that health workers wear respirators where possible.

Attacks on Healthcare Workers

During the pandemic, some healthcare workers have become targets of violent attacks by patients and their families, especially as hospitals were no longer able to admit new patients. Abou Sharaf, the head of the Order of Physicians, estimated that there is at least one serious attack on a doctor every month, amid “judicial laxity” in holding the attackers – often people with “political backing” – accountable.

In one case, Abou Sharaf said that a patient’s family attacked a doctor at a public hospital after he asked them to wear a mask, which they considered “an insult.” The doctor suffered a broken jaw, a broken bone near his eye, and a concussion. Abou Sharaf said that the assailant was released two months later.

Four out of the 15 doctors and nurses interviewed said that patients or their families subjected them to verbal or physical abuse while they were doing their job, and others said that they knew healthcare workers who had suffered such abuse.

An Emergency Room doctor at a private hospital in Saida said that now that their Covid-19 ward is full, staff members have been on the receiving end of verbal abuse on a regular basis. She also said that on several occasions, patients’ families have attacked healthcare workers or damaged the intensive care unit because they were not allowed to visit their sick family member.

In one incident, people broke the unit’s glass barrier and attacked healthcare workers. She said the security forces were informed and recorded the accounts by hospital staff, but added, “Of course they won’t be able to do anything.” In another incident in November, the doctor said, a family threatened to bring 200 men to “break the hospital” if they did not admit their family member.

Mental Health Toll

The pandemic, its unrelenting spread across the country, and the failure by the government to adequately respond to the pandemic and support healthcare workers, has taken a mental and emotional toll.

Several healthcare workers said that since the disease began spreading in Lebanon, they have developed symptoms of depression and anxiety. “This experience makes you experience feelings of depression, especially when you see death on a daily basis,” one Covid-19 ward nurse said.
A nurse at a Covid-19 ward who quit her job after working at the hospital for over a decade spoke about burnout and feelings of being unprotected and unsupported:

“They [hospital management] treated the Covid-19 unit staff like people who are plagued...We [nurses] are not appreciated like you see in the media…the effort we made was double and even triple that of normal days. I left my job after 14 years, it’s a very tough decision to make. But I couldn’t anymore. I was tired. The stress of Covid-19 and dealing with staff and administrators who are uncooperative. I’m putting myself in danger, and for what? If I died, all they would do is put a medal on my coffin.”

An ER doctor described the impact that the economic crisis, fatigue, and frustration was having on his psychological well-being:

“I started taking anti-depressants. I noticed that I had become more anxious, more irritable… Remember I work 16 to 24 hours sometimes in the ER. I come back home devastated. I started using antidepressants three months ago. And look it’s not just me. I’m sure most colleagues are using them. The stress hit us in three phases. First, there was the economic crisis. My income dropped in a horrible way. Five thousand US dollars suddenly became $900. Then came Covid-19 – and then the country closed down. You can no longer go out, do things you like to do, to change your mood. Add to that, I have a lot of responsibilities, family duties. I can no longer meet my families’ needs like I used to because of the economic crisis. We’ve all turned into pessimists.”

To lower the risk and protect their loved ones, some health care workers have decided to socially distance themselves. A nurse at a Covid-19 isolation and treatment center said he had decided not to see his at-risk parents and that he has even distanced himself from his child:

“I haven’t seen my parents for the past six months. I can’t go to the village and see them. Just by phone. I think I’m strong. But I’m stronger when I see my parents. I have an 8-year-old son and I have to take precautions around him. I taught him not to run toward me to hug me when I come back home. I sometimes feel I have depression. But things feel better the second day.”

This significant disruption in social support in an effort to protect others has a significant impact on health workers’ well-being, Human Rights Watch said.

Both Ghanem and Abiad acknowledged that burnout and the mental health toll were huge concerns at their hospitals, but both said that they were putting programs in place to support their staff. Most of the healthcare workers interviewed, however, had no support from their hospitals. “We have more serious problems,” a doctor in Tripoli said, laughing, when asked whether his hospital was providing staff with mental health and psychosocial support.

The Lebanese government should act urgently to support healthcare workers during the pandemic by improving access to rights-respecting, community-based mental health services and psychosocial support, and by destigmatizing mental health problems, Human Rights Watch said.