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Is violence driving doctors in Middle East to emigrate?

January 25, 2023

Most doctors working in the region say they have experienced violence in the workplace. Since the pandemic began in 2020, reports of aggression have increased — and so have the numbers of physicians leaving their homes.

https://p.dw.com/p/4Mdnn
BG Ärzte im Nahen Osten l Ägypten, Krankenwagen mit Opfern des russischen Verkehrsflugzeugs A321
Nurses and doctors are leaving their homes in the Middle East in search of better pay and better working conditionsImage: Mohamed El-Shahed/AFP via Getty Images

In central Egypt last summer, a man attacked a doctor and hospital workers with a knife. In a hospital near the Suez canal, the husband of a pregnant woman tried to beat her gynecologist because the couple disagreed with the potential date of birth.

In southern Tunisia, patients threw a chair at a young emergency ward doctor and forced her to lock herself into her office until the police came. She had only told the patient to report to the outpatient's department rather than emergency.

In Iraq, it is traditional for families and supporters to accompany a patient into hospital. Doctors regularly report threats and violence from these groups if the patient doesn't improve. A 2021 survey of doctors at Baghdad hospitals found that 87% of them had experienced verbal or physical violence at work during the past six months. Almost all of it — 94% — was by patients or their families. 

A doctor at a hospital in Iraq's southern Dhi Qar province, examines a patient.
Many Iraqi doctors have reported threats or verbal abuse from patients' relativesImage: Asaad Niazi/AFP via Getty Images

Violence in health care widespread

These are just a few of the worrying stories about violence told by health care providers in the region.

Surveys of health care workers in countries across the Middle East found that anywhere between 67% and 80% of doctors and nurses reported experiencing physical or verbal violence while at work. Surveys also confirm that younger doctors, usually those under 40 years of age, bear the brunt of this kind of workplace harassment.

Over the past three years, the coronavirus pandemic has worsened this . According to a 2022 survey published by the International Council of Nurses, there was "a higher frequency of [violent] incidents after the coronavirus pandemic started."

In the Middle East and surrounding nations, medical authorities say the pandemic has been a tipping point, one that is leading to increased emigration of doctors.

Lebanon's hospitals fear collapse

For example, the Egyptian Medical Syndicate, or EMS, which represents thousands of doctors, recently concluded that the number of physicians resigning from the country's public sector in 2022 was the highest in seven years. Last year, 4,261 doctors left their posts and applied for certificates that would allow them to work outside of the country. 

Thousands of doctors want to emigrate

The Turkish Medical Association, or TMA, reported that in 2021 1,405 local doctors asked for certificates that would allow them to apply for jobs abroad. "Are you aware of the fact that we are losing our physicians who have to live with violence every day and cannot find rewards for their labor?" the president of the TMA, Sebnem Korur Fincanci, wrote on social media. He predicted those numbers would continue to rise.

In Tunisia, labor unions reported that around 2,700 doctors had left the country in 2022, up from 800 in 2018. Surveys of young Tunisian doctors have found that almost 40% were considering leaving.

In 2021, the World Health Organization estimated that nearly 40% of Lebanon's doctors had emigrated, and this year Lebanese medical associations reported that almost one-third of the remaining doctors plan to leave.

Similar reports regularly come out of Iraq, Morocco, Jordan, Iran and Kuwait. However, it is not just the violence or threat of violence that's causing this exodus.

A view outside the emergency entrance of a hospital in the Saudi capital, Riyadh.
Gulf states such as Saudi Arabia are a favored destination for young doctors in the region because of better payImage: Fayez Nureldine/AFP via Getty Images

Though the definition of violence and aggression in the workplace differs for each study, scientific surveys from around the world suggest that attacks on doctors and nurses are common everywhere. Many young doctors from the Middle East want to work in Europe or in wealthier Gulf countries. But there's violence there too.

For example, a 2015 survey of German doctors found that 73% had experienced "aggressive behavior" in the previous year. Just over three-quarters of respondents to a 2021 study on violence and bullying of health care workers in the United Arab Emirates and Saudi Arabia said they were abused by patients or patients' relatives.

Why are doctors being assaulted?

It's something of a vicious circle, Omaima al-Hassani, a doctor and member of the Tunisian organization of young doctors, told DW.

"When it comes to violence against young doctors, I think the main causes are the same ones that are leading to their exodus," al-Hassani  said. "It's the lack of resources, equipment and staff. Patients and their families often find themselves in dreadful situations, especially when it comes to emergency services."

All of these combine to cause the violence, she said. 

"The patient at the hospital is in a state of tension due to the poor conditions," confirmed Ahmed Elgharairi, who started practicing medicine five years ago and works at a hospital in southern Tunisia. "Verbal violence is rampant every day. I have never been beaten, but my colleague, who is older, has.

"The problem is the entire health system. The violence motivates many doctors to leave, but there are other reasons too. If I got the opportunity,I would leave without hesitation," he told DW. 

The more disorganized or ill-equipped a state clinic or hospital is, the worse things are. In some countries, doctors have complained that clinic management has been appointed because of closeness to governing political parties, not skills or medical knowledge. Others suggest that patients who "know the right people" jump the queue for treatment.

Medical staff pictured outside American University of Beirut Medical Center in Lebanon
The Lebanese Order of Physicians warns that the country's health sector is on the verge of collapse due to emigrationImage: Anwar Amro/AFP via Getty Images

This leaves other patients waiting hours for admission. They may not be able to get the right medicines or a bed on a ward. The relatives who accompanied them become upset, and this is often when altercations with hospital security staff or attending doctors start.

The more doctors emigrate, the worse conditions become in public hospitals, Yahya Diwer, an Egyptian doctor and spokesperson for the EMS based in Cairo, told DW. That means more potential for violence, but also for misinformation and damage to the reputation of local doctors, which in turn leads to more violence.

Doctor-patient communication is key

Last summer, the retired Egyptian football professional and TV personality Ahmed Hossam posted a six-minute video online detailing his attempts to seek urgent health care for his father during a holiday. "Most [Egyptian] doctors have no conscience," said Hossam, who was forced to visit several hospitals before his father was treated. The EMS filed a libel complaint against Hossam, who did eventually apologize.

There's often a lack of knowledge about what doctors can and cannot do, Diwer said. "We get patients coming in who say they don't want to be treated because the doctor said something they interpret as a bad omen," he said. A 2019 survey of young Egyptian doctors' attitudes in the Eastern Mediterranean Health Journal seems to confirm this, with only around 5% of doctors feeling appreciated by the country and three-quarters unsatisfied with their relationships with patients.

Tunisian doctors shout slogans during an anti-government demonstration in front of the Health Ministry in the capital, Tunis, on December 8, 2020
In 2020, young Tunisian doctors protested dangerous working conditions after one of their number plunged to his death down an elevator shaft Image: Fethi Belaid/AFP via Getty Images

To improve the situation in Egypt, Diwer said doctors need more training on how best to communicate with patients about topics such as informed consent, medical consequences and outcomes. 

"The reasons behind the exodus of young doctors are numerous," Tunisian physician al-Hassani said. "They leave because they aspire to a better salary but also to improve their quality of life and their work environment."

Al-Hassani hasn't given up hope that things can get better. She believes that improving public health infrastructure and salaries would be an important first step toward breaking the long-running cycle of violence against towards and nurses.

Cathrin Schaer Author for the Middle East desk.