25% to 30% is the percentage of doctors who have "officially" emigrated after obtaining certificates from the medical syndicates in Beirut and Tripoli. This figure is not final, as registered numbers do not reflect reality in conjunction with a parallel emigration of doctors who left without informing their syndicate, and because the exodus continues, especially with the increasing reasons leading to the option of emigration. Nevertheless, the figure, despite its enormity, may appear ordinary compared to the question: who emigrated? The answer reveals a deadly gap in the specialized and rare fields that Lebanon used to excel in, which is now affecting its services, warning of an end to a sector long associated with Lebanon as the "hospital of the Arabs."
The crisis of doctor emigration continues to grow, nearing a systematic exodus, according to observers. Amid the deep-rooted reasons driving more doctors to emigrate, Lebanon is expected to enter a state of medical emergency with the onset of this third wave of emigration. Observers note that Lebanon has surpassed two waves of emigration between 2019 and 2021, and is currently experiencing the third wave prompted this time by bank procedures. Following the financial crisis that caused a collapse in living standards, the initial decision to "flee" was taken, then the Beirut port explosion further intensified the desire of many doctors to leave, and now arbitrary bank decisions and ill-considered government actions are pushing more towards emigration. Banks treat doctors, like other depositors, under a "I'm your lord" principle, inventing special procedures in dealing with any depositor based on guaranteeing their survival from "their pockets."
Due to a series of other blows, additional reasons have made emigration the only option. In this context, the President of the Medical Syndicate in Beirut, Youssef Bkash, discusses the "catastrophe" stemming from successive collapses, whether in the national currency or in institutions and guarantee funds. The latter has its share in the equation, as although there have been attempts to amend medical fees and doctors’ charges, these did not match the scale of the ongoing collapse. While the National Social Security Fund raised its rates approximately two-and-a-half times, and the Ministry of Health nearly sevenfold, and similarly for the State Employees' Cooperative, none of these increases remotely matched the minimum threshold for the soaring dollar.
Doctors did not protest against these increases, knowing that this is the best they could procure from collapsing institutions. They accepted whatever is offered reluctantly, even if it is a "illusion," according to Bkash, on the grounds that funds do not reach them directly but are transferred to banks. Here begins the whirlpool: banks that might accept the deposit and others that won’t… And if they do accept it, they might not disburse it. When they do, it will be subject to specific ceilings, and even if doctors receive it, "it will equate to nothing, considering the value difference between the deposit period and the disbursement period."
As a result of the arbitrary banking policies, some doctors have started asking patients for differential payments in fresh currency, either in local currency or US dollars, "to secure minimum continuity," but the government’s unstudied policies dashed their hopes. This issue manifested itself in the approval of a set of tax measures that "did not take into consideration how a doctor can earn a living," says Bkash. The irony, according to him, is that the state shares with doctors and "still-standing" institutions their livelihood at a time when it overlooks many tax-obligated entities that do not pay. He asks: Are the money changers who caused the state collapse paying taxes? Then he answers: Certainly not. These contradictions lead to the conclusion that "there is no state with justice today."
For all these reasons, the list of those seeking to emigrate is growing. In this third wave of emigration, the number of applicants for certificates of good conduct and performance from the Beirut Medical Syndicate has reached nearly 3,500 doctors. In other words, this figure represents 25% of the total number of doctors in Beirut, which is approximately 14,000. However, this is not a final tally, as an essential reason lies in that a considerable number of doctors emigrated without requesting certification because some countries do not require it, such as several Gulf states, and some have not left yet, awaiting responses from the places they contacted. These two reasons lead to the same result: the emigration door has not yet closed.
This situation also applies to the northern region, which is also losing many doctors. According to the Deputy President of the Tripoli Medical Syndicate, Salim Abi Saleh, emigration there has surpassed 35% (the number of registered doctors in Tripoli is about 2,500) across various specialties, with rare specialties experiencing the greatest loss. Abi Saleh mentions some specialties that are beginning to disappear in the north, like pediatric heart surgery, anesthesiology and intensive care, and cerebral artery specialists, noting that "the last specialty now has only two doctors in all of the north, which has 33 hospitals!" Furthermore, specialties that "had an abundance are now witnessing greater emigration, with even a new kind of migration emerging, which is neither permanent nor temporary, as many doctors divide their clinic hours between Lebanon and abroad."
These withdrawals have impacted various medical specialties, as "none of them was safe," Bkash decisively states; all have been affected by shortages. However, some specialties have been more severely impacted than others, either due to the limited number of doctors in them originally or because they were "sought after abroad." While it is not easy to count the shortages across all specialties due to the complexity, and currently, one of the UN-affiliated organizations is preparing a detailed study on doctor emigration in Lebanon to provide accurate statistics, some examples can be highlighted. For instance, there is a critical shortage of pediatric cardiac surgeons today, with only one doctor supposed to "serve" the entire Lebanese territory. The same situation holds for cerebral artery surgery, which currently has only one doctor, according to Bkash.
In contrast to these examples, numbers in most other remaining specialties have dropped by half; for instance, kidney specialists have decreased from 130 to 76 doctors, and similarly for emergency, intensive care, anesthesiology, radiology doctors, and those specializing in oncology radiology, where now there is "one radiologist for every 4 or 5 centers," says Bkash. Those who remain cannot cover the needs of all hospitals, and this is why some hospitals and medical centers have had to close some of their departments due to the absence of medical and nursing staff as well and the reduction of bed capacities to below 50%, though another reason here is the soaring costs of hospitalization today.
Additionally, the loss has exposed patients' lives to danger, particularly those in critical conditions, as these "usually do not reach surgical services in time," especially in the peripheries, where most rare specialties were already concentrated in the capital. In this context, Abi Saleh points out that "it has become common today for certain hospitals to schedule surgeries on the days when anesthesiologists are present, something we face today as obstetricians where we have to postpone some surgeries to the days when the anesthesiologist is on duty." Even more critically, there’s a shortage of intensivists "where the treating physician has to follow the patient in intensive care, knowing he is legally forbidden to do so, as he lacks expertise in intensive care."
The other crisis stemming from this root issue is that emigration is no longer limited to specific age groups. While it initially targeted younger physicians aged 35 to 45 between the "October Uprising" and the August 4 blast, it now affects most age groups, including recent graduates receiving offers and scholarships to continue their studies abroad. However, what differs since the beginning of this emigration until now is that Lebanese doctors no longer have an advantage over others. The financial crisis has led to "negotiation" about doctors' salaries, and has become a reason for the new "escapers" to accept offers lower than what Lebanese doctors used to receive. The larger crisis here is that many are content with what the settlements impose, as Doctor Mohammad Jawad Khalifa states, while others return to Lebanon due to the periodic change in contracts, especially in Arab countries, according to Abi Saleh.
A Critical Shortage in Specialized Fields
"The important thing is not how many emigrated, but who emigrated," says Khalifa. In his opinion, the absence of one doctor may cause a crisis, while the absence of others, even if they number 100, may not have the same impact, emphasizing the danger of "the absence of specialists in sub-fields, meaning specialization within a specialty," as Lebanon's medical system is "not a general system but an ultra-specialized medical system."
He gives the example: "It may be easy to find an orthopedic doctor, but it is difficult to find a doctor specializing in joint or knee surgery; it's easy to find a general surgeon, but hard to find a surgeon for specific arteries in the head." The most significant repercussions of this situation manifest in major university hospitals more than in regular hospitals, as major hospitals adopt complex interlinked medical systems that require an integrated team "in the manner of an orchestra." This means that if one link in the chain is lost, the system may falter. Therefore, Khalifa points out that the malfunction today lies in the fact that the absence of this category of doctors "disrupts the existing medical system based on that theory."
It is true that smaller and medium-sized hospitals also suffer from shortages, according to Khalifa, but "the extent of the disruption affecting each hospital is measured by the number of doctors, especially in treatment areas that depend on physicians rather than just one doctor, and this is more evident in larger hospitals."
The other aspect of the catastrophe is that the health system in Lebanon is based on "local competence," which distinguished it, as 90% to 95% of those working in this system are based on Lebanese competencies "not a random assembly," and this has recently impacted the nature of the system due to emigration. However, Khalifa does not consider that the system has completely malfunctioned, as there are "several institutions that have maintained the quality of the system and attempted to enhance it, in contrast to other places where this has failed, although it can be salvaged." The salvage operation here could happen in only one way: the state must abandon its indifference in dealing with this category and work on finding solutions before it’s too late.
The Crisis is Material
The crisis of doctor emigration revolves around a singular theme: "the financial problem," says the President of the Private Hospitals Syndicate in Lebanon, Suleiman Haroun, pointing out that this is a fundamental reason for doctors leaving their clinics, even some after a long period of establishment. Haroun nearly asserts that "99% of those who emigrated had financial reasons," which implies that "if they find that matters return to normal, they may come back." So far, there is no hope that could support this scenario, as doctors awaken to complete collapse realizing that their savings in banks have become worthless, while they have children and commitments. Moreover, what they earn rarely covers their operational costs. For this reason, they prefer to flee rather than stay.
There have been some attempts to pressure the central bank to release the doctors' frozen funds, including efforts made by the Tripoli Syndicate where requests were sent to the Central Bank of Lebanon to consider doctors' dues as payable immediately, but "we have yet to receive a response," Abi Saleh says. Adding to the distress is "that some donor entities and international institutions used to cover doctors' fees in dollars, but a considerable number of hospitals have opted to fix the funds coming in fresh dollars from those entities in Lebanese lira, and some still receive them based on an exchange rate of 1,500 lira to the dollar," continues Abi Saleh. Nevertheless, he notes that "in the absence of any hope for improvement, we are working to resolve the issue of international dollars and have succeeded in some places, and we are currently trying to win our battle in others."
