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Lebanese nurses at a ward where the first case of coronavirus in the country was being treated, at the Rafik Hariri University Hospital in the southern outskirts of Beirut, on February 22, 2020.  © 2020 Anwar Amro/AFP via Getty Images

(Beirut) – Lebanon’s financial crisis has resulted in a scarcity of medical supplies necessary to deal with the COVID-19 outbreak, Human Rights Watch said today. Hospital staff and nurses have raised concerns about the failure of the government and hospitals to adequately staff hospitals and protect staff from infection. The Lebanese government is obligated to ensure everyone’s right to health, including access to essential medical care and treatment of disease.

The country’s financial crisis has caused a dollar shortage that, since September, has restricted the ability of medical supply importers to import vital medical supplies, including masks, gloves, and other protective gear, as well as ventilators and spare parts. The government has also not reimbursed public and private hospitals for bills, including from the National Social Security Fund and military health funds. This has made it harder for them to purchase medical supplies, hire additional staff to reduce the burden on overworked nurses, and provide necessary protective gear.

“The COVID-19 outbreak has placed additional strain on a health care sector already in crisis,” said Joe Stork, deputy Middle East director at Human Rights Watch. “The Lebanese government has taken swift and broad measures that bought it time, but its ability to manage the outbreak will depend on how it uses this time to secure necessary supplies and provide health care workers with the resources they need.”

Between March 16 and 19, 2020, Human Rights Watch interviewed 6 high-level hospital officials, 2 hospital staff members, a medical equipment importer representative, and 2 epidemiology specialists.

A source at the public Rafik Hariri University Hospital (RHUH) in Beirut, the leading COVID-19 testing and treatment center in the country, said that the government has paid only 40 percent of the dues it owes the hospital from 2019 and has made no payments for 2020. Public hospitals in Halba and Akkar also said they have not received all their payments from the government. The government owes private hospitals an estimated US$1.3 billion in unpaid bills since 2011, according to Sleiman Haroun, the head of the Syndicate of Private Hospitals.

Salma Assi, the spokeswoman for the medical equipment importers, said that they have not been able to import medical equipment since September due to the dollar shortage and the absence of government regulations that would prevent banks from arbitrarily restricting money transfers outside the country. “Some very vital items are missing for the coronavirus response,” Assi said, including almost all “disposables” like gloves, masks, and gowns. Importers have not been able to bring in ventilators or spare parts for faulty ones.

Assi said that since September, importers have only been able to bring in equipment worth $10 million – less than 10 percent of the country’s needs. “For three months now, we have been saying that we are running out of disposables and sounding the alarm,” she said. “Meanwhile, the Central Bank and the commercial banks have been playing a game of ping pong and deflecting blame.”

Officials at private and public hospitals in Beirut and north Lebanon said that the lack of funds as well as the shortage of medical supplies was impairing their ability to respond to the COVID-19 outbreak. A source at RHUH said that “the more our system is tested by a larger number of cases, the more we will struggle to cope.”

Officials at hospitals that are not treating COVID-19 cases said that they also need to take precautionary measures, as their staff may come into contact with an infected patient. “We are suffering,” said Dr. Mohammad Khadrin, the director of the Abdallah al-Rassi public hospital in Halba in northern Lebanon. “We need to at least secure protective gear – today before tomorrow.” Khadrin said that the hospital has shortages of gloves, protective suits, and respirators, and has had to buy them at inflated prices on the black market. Khadrin added that the small payments they receive from the Health Ministry can barely pay salaries, let alone equip the hospital to deal with the outbreak.

Ali Fakih, a member of the infection control committee at the Sir al-Dinnieh Public Hospital in northern Lebanon, said that the hospital had trouble getting medical supplies before the COVID-19 outbreak, but the situation now is worse, as gloves and masks “have disappeared.”

Private hospitals also face severe supply shortages, further exacerbated by the government’s failure to make payments. Assi said that private hospitals owe medical suppliers $350 million, accrued over the last 2 years. Haroun said on March 12 that “we have an acute shortage…. If there are no imports of fresh [medical] supplies, we will not be able to manage for more than a week.”

Dr. Naji Aoun, head of the COVID-19 response committee at the Clemenceau Medical Center in Beirut, and a source at a private hospital outside Beirut both said that they face shortages in gloves, suits, and goggles, although both added that part of the problem lies in the global shortage.

Hospital staff and nurses interviewed raised concerns about working conditions amid severe supply shortages and funding shortfalls. Mirna Doumit, head of the Order of Nurses, said that due to the economic crisis many hospitals laid off nurses in December, causing an unsustainable workload for those remaining. “In some hospitals, you have up to 20 patients per nurse,” she said. “This is unacceptable.” She said that some hospitals are not paying nurses or are slashing their salaries. “Now on top of that, even though nurses are on the front line, if any nurse is suspected of having coronavirus, they are being asked to self-quarantine without pay,” she said.

Doumit also raised concerns about hospitals providing nurses with the necessary equipment to protect themselves from infection. She said nurses at the RHUH have the necessary support but nurses in other hospitals do not: “The risk that they come into contact with an infected person is high, even if the hospital is not a coronavirus treatment center.” As of March 17, there were 12 confirmed COVID-19 cases among nurses, Doumit said.

Administrative staff at the RHUH expressed their concern about what they viewed as insufficient measures to protect them against the risk of infection. “They have not disinfected our offices yet, nor given us masks,” said Samer Nazzal, a finance administrator and employees’ committee member there.

“Unless Lebanon urgently takes measures needed to import vital medical supplies, there is a risk of the virus overwhelming the already struggling health care system,” Stork said.

Lebanon’s COVID-19 Containment Efforts

As of March 23, the Lebanese Health Ministry had registered 267 COVID-19 cases and 4 deaths. The RHUH has been receiving and treating coronavirus patients. On March 20, the head of the health parliamentary committee, Issam Araji, announced that they have equipped 12 additional public hospitals to treat coronavirus patients. A number of private hospitals have also begun preparing to receive coronavirus patients, though the head of the Syndicate of Private Hospitals stated that even the biggest private hospital will not be able to provide more than 20 beds to receive coronavirus cases.

On February 28, Lebanon introduced travel restrictions for non-residents from countries with large COVID-19 outbreaks, including China, Italy, South Korea, and Iran. The next day, Education Minister Tarek Majzoub ordered all schools and universities to close. On March 6, the ministerial committee tasked with combating the virus ordered all entertainment venues, such as cinemas and nightclubs, to shut their doors temporarily, and, a few days later, the measure was expanded to include restaurants.

On March 15, President Michel Aoun announced a “medical state of emergency,” and the government ordered all non-essential public and private institutions to close, except those needed to fulfill vital needs, such as bakeries, pharmacies, supermarkets, and banks. The government also announced that it would immediately suspend travel from countries with serious COVID-19 outbreaks, including Iran, Egypt, Iraq, Syria, Italy, Germany, France, Spain, the United Kingdom, China, and South Korea, then closed all air, land, and sea borders on March 18.

Prime Minister Hassan Diab on March 21 called on citizens to observe a “self-imposed curfew” and instructed security forces to step up measures to ensure that citizens remain at home.

Dr. Salim Adib, professor of epidemiology and public health at the American University of Beirut and a consultant to the Health Ministry, stressed the need to stop “importing cases” and urged the government to ensure that people on the last buses and planes coming into Lebanon before the nationwide lockdown began on March 18 are rigorously tested and quarantined. “This is the make or break,” Adib said.

The source at the RHUH said that the government’s recent measures bought time and prevented the health care system from being overwhelmed, but that Lebanon’s ability to weather the crisis will depend on what they do with this time. “Will they increase the health care system’s capacity and make sure that the social distancing measures are enforced, or not,” he said.

On March 12, the government allocated a $39 million World Bank loan that was awarded before the COVID-19 pandemic to prepare and equip public hospitals to confront the outbreak. The World Health Organization (WHO) has shipped personal protective gear to doctors in Beirut. The Chinese government has also provided Lebanon with equipment, including temperature monitoring machines and goggles, to combat the virus, and on March 15, the Chinese ambassador to Lebanon stated that China will offer more donations to Lebanon.

The Dollar Shortage

Lebanon’s economy has long depended on a regular inflow of United States dollars, and the Central Bank has pegged the Lebanese pound to the US dollar at an official exchange rate of 1,507.5 Lebanese pounds since 1997. Over the last 10 years, as economic growth slowed and remittances from the Lebanese diaspora decreased, the quantity of dollars in circulation declined. A lack of confidence in the stability of the Lebanese pound in 2019 and concerns about the stability of the banking sector led depositors to withdraw from dollar accounts, making dollars increasingly scarce and causing the unofficial exchange rate to reach more than 2,600 Lebanese pounds to the dollar at the end of February.

Assi said that Lebanon imports 100 percent of its medical supplies. Suppliers must pay for imports in dollars but receive hospital payments in Lebanese pounds. Around July, Assi said, medical importers started facing problems exchanging Lebanese pounds to dollars at banks due to the dollar shortage, and resorted to converting to dollars at private exchange brokers at rates higher than the official rate, losing significant sums in the process.

On January 21, the Central Bank issued a decision guaranteeing 85 percent of the dollars medical suppliers need for imports at the more favorable official rate, leaving them to obtain the remaining 15 percent at the market rate. But Assi said that the bank has not acted on its announcement. Some international companies have given Lebanese importers longer grace periods for payment, she said, enabling them to bring in shipments “here and there,” but she underscored that this arrangement was not sustainable.

Without formal capital controls by the Central Bank, banks have set their own policies restricting depositors’ access to funds in their current dollar accounts and the transfer of money abroad, making it harder to finance imports, including of medical equipment and medicine, and importers have stated that banks were refusing to allow them to transfer dollars already in their accounts to manufacturers abroad.

Lebanese banks have also imposed severe restrictions on lines of credit, and some foreign suppliers are now demanding full payment prior to delivery because insurance companies have refused to cover shipments to Lebanon.

International Obligations

Lebanon is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which requires state parties to take steps to achieve “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Under the covenant, state parties must ensure “[t]he creation of conditions which would assure to all medical service and medical attention in the event of sickness.” According to the UN Committee on Economic, Social and Cultural Rights, the international expert body that monitors implementation of the ICESCR, this includes:

the provision of equal and timely access to basic preventive, curative, rehabilitative health services and health education; regular screening programmes; appropriate treatment of prevalent diseases, illnesses, injuries and disabilities, preferably at community level; the provision of essential drugs; and appropriate mental health treatment and care

The right to health includes access to “timely and appropriate health care” and requires that “(f)unctioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party.” Any state “which is unwilling to use the maximum of its available resources for the realization of the right to health is in violation of its obligations” under article 12 of the Covenant.

Although the Covenant recognizes that constraints due to the availability of resources and the right to health is subject to progressive realization, the committee has held that it also imposes on states obligations which are of immediate effect, including an obligation to take steps towards the full realization of the rights to health. Such steps must be deliberate, concrete, and targeted toward the full realization of the right.

Under the covenant, states are required to adopt appropriate “legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of the right to health.” States should also ensure that progress toward ensuring the right to health does not regress – e.g., that people are denied essential medicine they previously had access to.

A state’s failure to take all necessary measures to safeguard people within their jurisdiction from infringements of the right to health by third parties or to regulate the activities of individuals, groups, or corporations so as to prevent them from violating the right to health of others also constitute violations.

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