Lebanon's Crisis Reaching Into Emergency Rooms

CHIKHANE, Lebanon – On New Year's Eve, 78-year-old Linda Lahoud fell in the driveway of her daughter's modest house in Chikhane, in the mountains overlooking the coast of northern Lebanon, and broke her shinbone.

Her children took her to the nearest public hospital, expecting that she would be treated quickly. When Lahoud had fallen and fractured her ankle five years earlier, she promptly had surgery to set the broken bone and was soon on her feet again, her daughter, Mona Bou Rjeily, recalls.

But this time was different. Lebanon is in the middle of a currency crisis, and a shortage of dollars in the country and strict controls on withdrawals and transfers abroad put in place by the banks have led to difficulties in importing crucial items, including medical supplies and equipment.

"We found a hospital right away and they took her in, but the screws and the plate that the doctor puts to stabilize the bone, they didn't have them," Bou Rjeily says, sitting in the living room of her house, where her mother is recovering, lying in a hospital-style bed with her right leg in a cast and hooked up to an oxygen tank.

Over the next week, the family was bounced from hospital to hospital, visiting five facilities before they were able to find the needed supplies and get Lahoud into surgery.

"It was seven or eight days of torture for her," Bou Rjeily says.

The shortage of medical supplies and cutbacks in hospital services are perhaps the starkest effects of the country's fiscal crisis. Thanks to a scarcity of dollars in the country, the Lebanese pound, officially pegged at 1,507 pounds to the dollar, has slipped to a rate of more than 2,000 to the dollar at currency exchange shops, meaning that importers are facing a de facto price increase.

The issue has become more urgent in recent weeks as the coronavirus spreads around the globe, leaving health professionals and members of the public fearful of whether Lebanon's already struggling hospitals can deal with an outbreak. Lebanon confirmed its first case of the disease on Feb. 21. The patient is a 45-year-old woman who had returned from a trip to Iran, which is currently seeing a major outbreak of the virus. Since then, at least a dozen more cases had been confirmed in Lebanon as of Monday afternoon, all originating from Iran.

Fearing a further spread, Lebanese officials last week ordered schools to be closed through March 8. On Feb. 28, they also banned non-residents from flying into the country from China, Iran, Italy and South Korea. Some criticized the government for being too slow in acting to halt flights from Iran, which has strong ties with some Lebanese political parties, including Hezbollah.

In the wake of the diagnosis, many Lebanese rushed to buy face masks as a preventive measure, but they encountered shortages and price hikes. As it turned out, some companies had been importing face masks and then reselling them abroad, leading the Minister of Economy to announce a ban on exports of masks and other protective equipment.

But the broader issue of equipment shortages remains.

Shortage of Money, Falling Credit Rating for Country

Lebanon's Central Bank issued a decision in November intended to give medical supply importers easier access to dollars, with the bank agreeing to supply 50% of the dollars at the official rate, leaving the companies to obtain the other half at the street rate. In January, in response to ongoing supply shortages, the central bank issued a new decision adjusting the amount it would provide to 85%. While importers praised the decision at the time, a month later industry sources said it had not actually been implemented widely and importers were continuing to have problems accessing dollars.

The supply of dollars is only part of the problem. The government has also been significantly behind on paying its bills to hospitals, meaning that hospitals are often not able to pay up front for supplies. As of December, the Syndicate of Private Hospitals, an organization representing the interests of the hospital sector, said various government agencies owed its members $1.3 billion, with some unpaid bills dating back to 2011.

Meanwhile, the country's credit ratings have slipped, making international suppliers less willing to extend credit to importers.

And even when the funds are available, banks have set strict limits on dollar withdrawals and often refuse to allow transfers of dollars out of the country, says Salma Assi, spokeswoman for a group of medical supply importers.

"It's our money, and we're bringing cash money to the banks, and they are not making the transfers," she says. "If you think about it, it's unacceptable – it's insane."

Orthopedic materials are not the only supplies in short stock. Administrators and staff at both public and private hospitals say they have also faced issues in securing other basic items, including pacemakers, blood bags for transfusions, needles for anesthesia and wound dressing supplies.

Rise in Emergency Room Visits

As a result, hospitals are cutting back on non-emergency operations. Some have closed units, stopped performing certain types of surgeries and reduced the frequency of some treatments, including dialysis. Hospital staff have staged their own protests and joined with larger anti-government protests that have been ongoing in the country for the past three months.

"In the near future we will be facing a huge crisis in health care … and the few hospitals which can sustain their activity until now, these are the major university hospitals in town," says George Ghanem, chief medical officer of the private Lebanese American University Medical Center – Rizk Hospital, where staff staged a brief sit-in on Jan. 17. "They are few and they cannot cater to the needs of the whole country."

Firass Abiad, general manager of Rafik Hariri University Hospital, a large public hospital on the southern edge of Beirut, which is now treating the quarantined coronavirus patients, says the financial difficulties and supply shortages there – along with a freeze on public sector hiring – have coincided with a 25% increase in emergency room patients in recent months, with more patients in need of higher levels of care.

He attributes the increase in numbers to a shift away from private hospitals as more Lebanese are struggling financially, and the increased severity of the issues to the fact that people are putting off seeking care for the same financial reasons.

In order to cope, he says, "Orthopedics, we've really reduced the number of operations. Especially elective operations that require implants have gone down quite considerably, and we've tried to divert resources to either very basic services or life-threatening cases."

Rita Feghali, chairperson of the hospital's laboratory division, says that on two or three occasions "we ran out of blood bags completely and we were sending people to get their blood from the Lebanese Red Cross."

The hospital has had some outside assistance via a partnership it has with the International Committee of the Red Cross, which has been able to help with getting some supplies that would have otherwise been unavailable.

"We have a warehouse, and we have a limited number of items we can import," says Christina Bartalec, ICRC's senior medical officer at the hospital. "We will increase this backup program, but of course we cannot provide the whole supply for a university hospital of this size."

Skirting Regulations, Quality Health Care Materials

In some cases, the supply shortages have meant cutting corners, settling for lower-quality items, and even skirting regulations rather than denying patients needed care.

For instance, Lebanese law requires that blood used in transfusions should be filtered. Feghali, who is coordinator of the Ministry of Public Health's blood transfusion committee in addition to her role at Rafik Hariri, says a number of hospitals have asked if they can use bags without filters when filtered bags were unavailable.

"This is against the law normally, but we cannot say do not use them," she says. "Between having a patient die because of the lack of products and having a patient having a minor reaction, we say 'OK, let them have a minor reaction if it can save their lives.'"

Still, she says, the crisis is creating alarming precedents.

"In my opinion, this is very dangerous, having to say yes to things we normally don't accept."