Dalia* is a cardiologist in her thirties who works at a major public hospital administered by the east Cairo division of the General Authority for Health Insurance. In 2015, she fell sick with a bacterial infection rarely seen outside of those who are immunocompromised or work in places of high exposure to bacteria, like healthcare facilities.
“I understand that I’m always prone to infection because adequate protective measures are not in place,” she says. It is an awareness that enables her to manage her fear of contracting the novel coronavirus, COVID-19.
“I contracted the bacterial infection while resuscitating a patient whose heart had stopped. He almost died of pulmonary congestion. I had to intubate him: insert a tube into his airway,” says Dalia. “The patient hurled bodily fluids out of his mouth and onto my face. Because I wasn’t wearing a face mask, I was infected. I had to work quickly to finish the procedure, only having a matter of seconds, because, once the heart stops, death isn’t far behind.” Dalia underwent intensive treatment for four months before she was able to stamp out the infection.
This kind of risk is commonplace in the healthcare sector. But the conditions in which medical professionals operate at public healthcare facilities make it substantially worse. They are neither properly trained nor adequately guided in the necessary steps to mitigate the risk of infection. And when they do contract something in the line of work, the financial compensation they receive is not on par with the risks involved in their jobs. These factors have pushed many to leave the public sector.
Now, with Egypt facing the highly contagious COVID-19 virus, the circumstances healthcare workers have faced for years has taken on more complexity. At least 26 medical practitioners reportedly have contracted the virus, and the Doctors Syndicate has received complaints from a number of government hospitals inside and outside of Cairo regarding a lack of personal protective equipment, such as N95 masks and sterilization equipment. Healthcare workers are thus faced with the imperative to continue to treat patients, risking both their own personal wellbeing and a potential outbreak among a crucial labor force.
Constant risk of infection
In 2003, the Health Ministry launched an infection control program. Its stated objective to control infection in hospitals and during the provision of health services. “Infection control departments were established at every hospital,” says Alaa Ghanam, the director of the Right to Health Program at the Egyptian Initiative for Personal Rights (EIPR). “They were tasked with providing guidelines on measures to be followed, based on infection control policy, monitoring execution and making regular assessments of their hospitals and units’ adherence to policy. The program was placed under the jurisdiction of the ministry’s preventive medicine division.”
According to the program’s 2016 infection control guide, which is the most recent edition, personal protective equipment includes “gloves, gowns, aprons, face masks and eye protection — which prevent contact between infectious substances and a healthcare professional’s skin, mucous membrane and respiratory system.”
The guide also mandated that healthcare facilities are required to provide protective equipment.
Despite the guide’s proscriptions, things have played out differently in practice. Many doctors have died of infections that they contracted at their workplaces. During one month in 2014, four doctors at Mansoura University Hospital died from respiratory infections. In November 2019, a medical intern at Cairo University’s Faculty of Physical Therapy died from a respiratory infection that she contracted at work. Other smaller-scale incidents happen all the time.
Despite the risks that they face, doctors are not offered adequate compensation when they contract an infectious disease. The Doctors Syndicate filed and won a lawsuit against the government before the Court of Administrative Justice in an attempt to raise the LE19 medical staff receive per month as compensation for diseases they may catch while on duty to LE1,000.
Mona Mina, the former deputy chairperson of the syndicate, tells Mada Masr that the matter was referred to the Finance Ministry, which wanted to negotiate the compensation payment down to LE38.
“It was ridiculous. We had to end the negotiations, obviously,” she says. But the stalemate was broken when the government filed and won a countersuit that effectively threw out the administrative court’s ruling on the grounds that the matter of compensation was outside its jurisdiction. “The syndicate turned to the Cabinet and Parliament, repeatedly seeking a resolution, but to no avail,” says Mina.
A large swath of doctors has been driven out of their public sector jobs by these conditions. They either take jobs in the private sector or relocate to other countries. The rate of doctors resigning from public hospitals soared in 2018. Health Minister Hala Zayed admitted at the time to a significant shortage of doctors at government hospitals, citing the government’s inability to pay competitive wages. In fact, 60 percent of Egyptian doctors are in Saudi Arabia, Zayed said.
What is different during the COVID-19 pandemic?
With this being the norm, emergencies—such as the ongoing COVID-19 pandemic— only aggravate the situation. Doctors are vulnerable to additional risks now, Mina explains, as they may be exposed to COVID-19 patients without even a natural immunity to help their bodies combat the illness. “The Health Ministry has been blocking all leave applications, including for sick and unscheduled leave,” Mina says. “So, if a doctor is suffering from a condition that compromises their immune system, they are being forced to take on the risk of contracting COVID-19, as they may treat a patient who happens to be an unknowing carrier.”
The infection control guidelines state that infection may occur at healthcare facilities as a result of “an increase in the number of hospitalizations and recipients of care, which would allow for less time and room to properly follow infection control measures.”
Ismail* is a pulmonologist who asked Mada Masr not to disclose the name of the public hospital where he works. For him, the real problem is “the overcrowding and the pressure.”
“At an unusual time like this, the Health Ministry should have advised the public to refrain from visiting hospitals and outpatient clinics unless necessary,” he says. “We can’t have people coming to hospitals during a pandemic for a simple cough that can be cured with natural remedies, for example.”
Additionally, a severe shortage of protective equipment hinders healthcare workers’ ability to adhere to the guidelines, which warns against the risk to themselves if they fail to wear the proper gear. At the Dalangat Central Hospital, in the Beheira Governorate, the hospital administration submitted an application to the local health directorate for face masks and rubbing alcohol, but the directorate responded to the request by saying that they were completely out of stock. The hospital administrator then escalated the matter to the deputy health minister in a letter dated March 18.
“[These healthcare facilities] cannot buy protective equipment themselves,” says EIPR’s Ghanam. “The Health Ministry’s purchasing process is centralized. Strategic items, such as medical devices, are bought through public tender. This is meant to stifle the possibility of corruption, as it gives the Central Auditing Authority better oversight than it would have over remote hospitals.” Hospitals are still allowed to buy other medical supplies, such as face masks, says Ghanam. “But they end up having to ask their local health directorates for more because their annual budgets are limited.”
With the onset of the COVID-19 pandemic, “some protective equipment items are not being distributed rapidly enough and infection control measures have not been standardized,” the Doctors Syndicated the Medical Syndicate stated in a letter sent a few days ago to the Health Ministry.
Moreover, the syndicate petitioned the ministry to send out instructions to all healthcare facility administrators to ensure that all infection control supplies are always available in order to protect healthcare professionals and limit COVID-19 outbreaks in healthcare facilities.
Yet Dalia reports no changes to her daily workplace routine. “There is no additional stock of protective equipment, especially face masks. Neither the hospital administration nor the Health Ministry gave us clear information on whether the available equipment is adequate as protection from the new infection.”
It is even more dire in remote areas. Ali*, a doctor in his twenties, works at a healthcare unit in an Aswan village. He tells Mada Masr that he is very worried about the possibility that he might contract COVID-19 because of the severe shortage of protective equipment at his unit, a situation he has tried to remedy by buying supplies out of his own pocket.
Ali says his unit has seen a surge of patients coming in with fevers in the last week. “I see dozens of cases with a temperature above 40°C, a sign that they may be COVID-19 positive. I have been examining them all without a face mask or gloves, let alone disinfectant.”
Ali says that he asked the health authority to provide supplies, but he was told that the health directorate is out of stock.
No short-term fixes for a limited budget
For Mina, in light of the current danger to healthcare workers, the compensation paid out in case of infection should have been raised to reflect the dangers doctors and other care providers face.
In a statement issued a few days ago, the Doctors Syndicate said they raised the issue with the president. The amount paid as an allowance against infectious disease “has been the same for 25 years, during which the cost of living increased several dozen-fold,” the statement asserts
The syndicate has repeatedly called for the provision of protective equipment, according to Mina. But the board, she says, is often unable to accurately assess the shortage of supplies, as a lot of doctors are reluctant to file complaints regarding the lack of necessary medical supplies against infection, “possibly because they don’t expect any change,” Mina says.
“The well-equipped medics who appear in photos are usually quarantine staff tending only to confirmed patients or potential patients. This is not available to other doctors who may treat patients that are infected with COVID-19 but are asymptomatic,” says a prominent syndicate member who was at the forefront of doctors’ mobilization efforts for years.
“Hospitals have a stock of protective equipment in storage,” says Doctors Syndicate Secretary-General Ehab al-Taher. “But they aren’t issuing enough to doctors because they are afraid they might run out and will have to buy more.”
Member of Parliament Sami al-Mashad, who sits on the Health Affairs Committee, acknowledges that the allowance against infectious disease that doctors are currently paid is too little. “But raising it would require an overhaul of the civil service law,” Taher says. The MP, however, notes that doctors only come under the jurisdiction of the civil service law where administrative affairs are concerned. Financial affairs, on the other hand, fall under the Law on the Regulation of Affairs for the Members of the Medical Profession. Therefore, he argues, all that is needed to raise the allowance is either an amendment to this law, or an executive order by the prime minister — pointing out that the current allowance amount was promulgated by an executive order from a former prime minister.
A more effective approach, Mashad believes, would be “what the Health Ministry is seeking to do through amending its own bylaws to give doctors bonuses, which would be indexed to a target of minimum hours — thus incentivizing doctors to join public hospitals.” Although Mashad has not read the bylaws himself, he asserts that the new bonuses are very high. He does not say how big they are or how much the cost would be, but he affirms that the president is behind the new bonus and has pledged to allocate enough funds to cover it. The new bylaws are not legislation but an administrative decree. Therefore, they will not have to pass through Parliament. “But the Health Ministry told [members of the Health Affairs Committee] that they would allow us to review [the new bylaws] once they have been finalized,” says Mashad.
The Health Ministry could not be reached for comment. Ministry spokesperson Khaled Magahed, ministry preventative medicine officer Alaa Eid and deputy minister Hossam el-Khatib would not take our calls.
*The names of doctors who spoke to Mada Masr have been changed for their safety.