The Lebanese Healthcare Sector: The Point of Exsanguination
Authors: Antoine N. Saliba, Ali T. Taher
Journal: American Journal of Hematology (2021)

A year since the Beirut seaport explosion, on the riverbank, Adonis is still bleeding.1 This is not a slow ooze. Topical antifibrinolytics are no longer working. A few transfusions of platelets and plasma via time-limited foreign aid are not cutting it. The Lebanese healthcare system is in full-blown hemorrhagic shock with copious bleeding, internal and external, from all its vessels – nominate and innominate. External bleeding, through the medical brain drain, and visceral bleeding, mediated by the ongoing corrupt systems, have crippled the vital organs of the nation with ischemia in nearly every sector. Microthrombosis and paradoxical bleeding in every sector are paralyzing the function of the political system, the healthcare sector, and the financial apparatus. For both of us as hematologists/oncologists, the scenes are so absurd and so overwhelming that the closest pathophysiological process to this reality would be a state of hemorrhagic shock complicated by disseminated intravascular coagulation in the setting of decompensated liver cirrhosis, a state of chaos, where factors are missing, some vessels are clotting while others are bleeding, the hospital is out of blood products, the lab results are artifactual, and the medical staff is burned out. In the political arena, the country has been without a government for over a year. The different factions, religious sects, and political parties are at a stalemate. Many are calling for the fragmentation of an already small state into a patchwork of smaller states that are not even geographically continuous as individual entities. The political and judiciary systems have not concluded investigations regarding those responsible for the port explosion that killed hundreds, injured thousands, and made hundreds of thousands homeless in August 2020. The financial system has been witnessing one of the worst economic crises our world has met in a century.2 The banking sector, a matrix that stabilized the mesh of the economy by pegging the Lebanese lira at a set exchange rate for three decades, has been cleaved into inactive monomers and shredded into dysfunctional fibrils. The healthcare sector, a previous hub for innovation in the Middle East and Eastern Mediterranean, has lost some of its most essential coagulation factors that would abort a hemostatic stress to its system. This past year has seen the most precipitous and most substantial brain drain among healthcare professionals in decades and a scarcity of medical supplies to levels unprecedented in years.3-5 The American University of Beirut Medical Center (AUBMC), a medical center that has been at the forefront of medical education and clinical care in the Middle East and North Africa region, is facing unparalleled challenges in acquiring and retaining talent. Physicians with practices maintained and reputations developed over decades are spending at least some of their time outside the country to be able to support their families as the economic whirlpool continues to cloud every aspect of life. Many Lebanese physicians, who had temporarily left the country for specialty medical training and returned to work and serve the country's institutions, have changed their career plans and headed back to North America or pursued opportunities in the Arab Gulf countries. Some physicians and nurses who had never thought of building their careers elsewhere are finding themselves up against insurmountable financial and social stressors that are pushing them out of the country. Pharmacists are now rationing medications, selling drugs in individual leaflets rather than sealed boxes, and prioritizing patients with certain conditions over others.5 One of us (Dr. Ali Taher) is the director of the Naef K. Basile Cancer Institute at AUBMC – a cancer center providing 80 infusions of systemic anticancer therapy, 100 outpatient clinic encounters, and tens of hospital admissions daily. The cancer center is experiencing historically low inventory numbers and shortages of chemotherapy medications.5 To help mitigate drug shortages, the cancer center has been collaborating with numerous non-governmental organizations, local suppliers, and local and regional partners in healthcare. The cancer center leadership has modified practices to circumvent the shortage of certain medications while keeping patient safety as an immaculate guiding principle and continuing to innovate amid the turmoil. Despite these efforts, AUBMC and other institutions are still treading water. The need for constant innovation, the limitedness of resources, and the lack of sustainability of those solutions make the operational process an uphill battle every single day. Establishing reliable supply chains and maintaining other operational processes, which are tasks typically revisited every several months or years, are now quests that must be tackled on a weekly, and sometimes daily, basis. We see the anxiety and despair those difficulties foster in our patients living with a diagnosis of cancer and other conditions that could be life-threatening if left untreated. Hearing about or seeing those frustrating realities every day, feeling helpless, and being unable to procure assistance make us, physicians with ties to Lebanon, rethink the main reason we do what we do. Whether in research, education, or clinical care, preserving human life and alleviating suffering are key tenets of our mission. However, we often find ourselves deprived of the tools needed to serve the suffering and the drugs needed to soothe their pain. To fulfill our duties and help our patients, we are in dire need of medications and medical supplies. We need a reliable supply of electric power. With the fuel shortage, operating rooms in rural hospitals have changed their operation schedules around the availability of electricity. At AUBMC, power conservation measures have been implemented, and backup plans have been instituted. Nonetheless, we remain extremely concerned as we look to our colleagues caring for patients in hospitals outside the capital Beirut and our larger cities. The Lebanese healthcare system is exsanguinating. We would like to think that we have reached a point so low that an inflection is bound to happen. While our hopes remain high in the face of so much devastation and our faith in the strength of the Lebanese people remains steadfast, we are calling for help - any help - because human lives are at stake. We are calling on the Lebanese diaspora, international non-governmental agencies, and the United Nations to send any help possible in the form of essential medications – directly delivered to hospitals. With cancer care spanning chemotherapy, immunotherapy, surgical supplies, and supportive care medication (antiemetics, analgesics, growth factor support), we call for a concerted effort to maintain the resources patients need with continued accountability. We are not promoting the need for a massive transfusion protocol for an exsanguinating healthcare sector in Lebanon without any accountability – at least at the institutional level as public oversight remains disjointed. We vigorously support the need to assess and address the underlying causes of statewide losses and corruption. We remain cognizant of the challenges leading institutions may still be up against in the setting of the collapsing political and financial systems. We are equally worried about our patients who are concerned they will not have their chemotherapy medications next week. We share their pain as we sit with them in clinic. We see their faces overcome by sadness as they receive their therapy in the infusion unit. We hear the pain in their voices when we check on them by phone. What keeps us going is that glimmer of hope in their gloomy eyes, their stout faith that things will be okay, and their resolute desire to be with family for as long as possible. What keeps us going is a shared humanity that no explosion, monetary devaluation, or loss will take away from us. We need to act for them and advocate on their behalf. The crisis in Lebanon is projected to last for years, and the recovery is estimated to take close to a decade.2, 6 In the meantime, while some of us need to be involved in the rebuilding of the political infrastructure, many of us are called to patch the leaks and ensure there is a sufficient supply of anticancer and other drugs for next week and next month. Some maintain that what has propagated this state of political and financial corruption in the country is short-sighted and reactive policy. Indeed, long-term strategic planning and thoughtful policymaking are certainly needed. But, when there is a human acutely suffering, healthcare professionals roll up their sleeves and dive right in, elbow deep. Some parts will be messy, but we hope you will join us in reversing at least part of this exsanguination. Reach out. Let us think and act together. The authors declare no conflict of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.