The dismissal of experienced doctors for providing medical care to injured protestors in the wake of the 2011 popular uprisings in Bahrain, coupled with the hiring of foreign medics and poor hospital management, are contributing to a low standard of health at Al-Salmaniya Medical Complex (SMC), the country’s largest public hospital. The government of Bahrain needs to reinstate dismissed doctors to their previous positions at SMC, hire qualified nurses, and adopt appropriate administrative measures toward the full realization of the right to health.

In a 2015 survey, 94% of participants indicated that the quality of health services at SMC has deteriorated. Bahrain’s National Health Regulatory Authority (NHRA), a body responsible for the licensing and regulation of health care professionals, received 116 complaints in 2014 compared with 86 in 2013, 41 in 2012, and 24 in 2011. In September 2012, a sickle cell patient and her unborn child died at SMC due to medical negligence. In September 2013, a 12-year-old girl was pronounced clinically dead when “an unqualified” doctor mistakenly inserted a tube into the esophagus instead of the trachea. In May 2016, a 65-year-old patient died in May 2016 after he was given a dose of a chemotherapeutic agent ten times the amount he was originally prescribed. On 26 May 2015, a medical device fell on a child who is diagnosed with cerebral palsy, causing swelling to his eye.

Medical errors are now the third leading cause of death in Bahrain, claiming one hundred lives every year.  Dr. Maha Al Kuwari, president of the Bahraini Medical Association, said in a statement, “Doctors cannot be solely responsible for medical errors… one must look at management and work environment at Salmaniya.”

High Patient Turnover & Poor Management:

High patient turnover is contributing to a low standard of health at SMC – the only public hospital in the Shiite-majority kingdom that receives cases from all health centers in all five governorates. The hospital receives an average of 950 to 1,050 patients every day and has approximately 1,000 beds. SMC employs around 5,000 people, of whom 1,300 are doctors. The hospital’s Emergency Department alone receives close to 1,100 patients a day. SMC’s nephrology clinic has only two rooms for dialysis and sixteen beds. Meanwhile, the maternity yard has only twelve beds. This number is low considering that there were 5,116 births at SMC in 2014 alone. Further, the hospital’s Obstetrics and Gynecology unit has only eight beds and no isolation rooms. In 2015, three patients, diagnosed with infectious diseases were placed with the rest of pregnant women due to a lack of isolation rooms. Additionally, sickle cell anemia patients complained to a local newspaper about the limited number of hospital beds at SMC’s Accidents and Emergency Department, “We were surprised by the lack of beds in Room D of the Emergency Department. Fifteen beds were placed in the room that can only fit eight beds. Beds were also placed in the hallways.”

On 9 November 2015, the Directory of Human Resources at Bahrain’s Ministry of Health (MOH) reduced the limit of on-call hours from 156 to 70 hours per month for SMC doctors as part of new austerity measures. The regulation failed to take the needs of each department into account. Dr. Mahmoud – whose name was changed to protect his identity – said his salary decreased by 30% as a result of the new policy. He, along with other medics, is working beyond the 70 hours monthly limit without pay. “I cannot just walk away,” he said, “these patients need me and I have to attend to their needs even if I’m not paid for that time.” Dr. Mahmoud sees close to 80 patients a day and is under more pressure to clear the cases he receives.

Since the regulation went into force on 1 December 2015, the number of patients at some departments, especially at the Accidents and Emergency Department, the Department of Anesthesiology, and the Department of Obstetrics and Gynecology, increased due to the insufficient number of doctors on duty. Those who are on duty receive an increasingly higher number of patients. The new policy has also delayed the delivery of medical care for countless patients. Furthermore, most of the medics Defenders for Medical Impartiality spoke to, said that a higher number of nurses are being transferred from their primary departments to other ones that are outside their area of expertise.

Dismissal of Medics:

Dr. Taha Al Derazi, a neurosurgeon, works in the private sector after being asked to retire from his position at SMC in 2012 for treating injured protestors. He told Defenders for Medical Impartiality that the removal of medics from their positions in the wake of the 2011 uprising weakened the overall performance of SMC’s medical team.

In 2011, SMC became a focal point of the popular uprising. On 16 March 2011, Bahrain security forces cleared protesters from the Pearl Roundabout in the capital, Manama, and subsequently surrounded and took control of SMC. Forces prevented ambulances, patients, and medical staff from entering or leaving the hospital, and fired teargas, rubber bullets, and pellet guns at the windows and entrances. Security forces created “interrogation chambers” within the hospital to interrogate and torture doctors that treated injured patients. Bahraini authorities claimed that security forces took over SMC because anti-government protesters and rioters were holding hostages, preventing access to healthcare services and storing weapons at the hospital.

Over sixty medics were arrested and tortured and the authorities dismissed 200 medics from their jobs at that time. On 6 June 2011, a security court charged 47 health professionals, most of whom worked at SMC, during a closed hearing. Some served their full sentences, some had their sentences reduced, and some were eventually acquitted. Dr. Ali Al-Ekri pediatric orthopedic surgeon, who was arrested on 17 March 2011 while he was treating a teenage boy in an SMC operating theatre, remains wrongfully detained at the time of writing. To date, at least 10 medical personnel remain dismissed, some of them having been forced into an early retirement scheme. Dr. Mahmood Asghar, a Pediatric Surgeon, and Dr. Fatima Salman Hassan Haji, Internal Medicine and Rheumatology Specialist, continue to be suspended from work. Authorities barred them from returning to SMC or working in the private sector. Bahrain’s MOH refused to reinstate Dr. Ahmed Omran, Family Physician, to his previous position as the head of the Clinical Audit Group in the Medical Review Office and the coordinator of research and studies in the MOH. Dr. Nabeel Hasan Tammam, former Chairman of SMC’s ENT Department, was suspended from work for a year, and was only rehired at half his prior salary upon his return.

Hiring from Abroad:

Almost all medics interviewed by Defender for Medical Impartiality indicated that the MOH began hiring medics from abroad following the 2011 events. According to private sources, foreigners make up twenty percent of doctors at SMC. They mostly come from countries such as Egypt, Jordan, India, the Philippines, and Pakistan. While they are paid the same salaries as locals, foreigners receive additional benefits such as housing, education, hospitalization and travel tickets. “These doctors are not necessarily qualified and many do not speak Arabic,” said Dr. Taha. The MOH is also hiring nurses from abroad, when more than one hundred Bahraini graduates with a Bachelor of Science in nursing are unemployed in Bahrain. Graduates complained that the MOH was hiring foreign nurses with a certificate in nursing. The MOH hired twelve nurses from Asian countries early in 2016 and another twelve in May 2016.

Discussion:

Poor management of SMC, together with the dismissal of qualified doctors and the hiring of medics from abroad, can be seen altogether as contributing to the deterioration in the standard of health care at SMC. These factors combined may amount to a violation of international human rights law (IHRL) and the principle of medical impartiality. Failure to deliver the highest standard of health care violates Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR). The scope of Article 12 is described in general comment 14 of the Committee on Economic, Social and Cultural Rights as “the most comprehensive article on the right to health in international human rights law.” Under Article 12, states parties, including Bahrain, ought to “recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” A violation of Article 12 of the ICESCE triggers a violation of the principle of non-interference, an essential component of the principle of medical impartiality. Under that principle, every person has the right to the highest attainable standard of living adequate for his health and well-being, including medical care.

Preference in employment for foreign medics, especially nurses, who may not be as qualified as nationals may amount to discrimination in employment by Bahrain’s MOH. The dismissal of doctors from SMC for simply providing treatment to injured protestors in the wake of the 2011 protests is also a discrimination in employment. Article 2 of the 1958 International Labor Organization (ILO) Convention concerning Discrimination in Respect of Employment and Occupation, which Bahrain has ratified, requires that State Parties pursue national policies designed to promote equality of opportunity and treatment in respect of employment and occupation. 

The poor management of SMC may also amount to a violation of Bahrain’s constitution. The right to health is enshrined in Article 8 of the country’s Constitution, which provides that “[e]very citizen is entitled to health care. The State cares for public health and the State ensures the means of prevention and treatment by establishing a variety of hospitals and health care institutions.” Furthermore, the dismissal of doctors implicated in the 2011 popular uprisings is a violation of equality and equal opportunity, both of which are enshrined in Articles 4 and 18 of Bahrain’s Constitution.

Conclusion:

Dismissing experienced doctors, hiring medics from abroad, and passing poor regulations that put doctors under more stress and extend waiting hours for patients altogether explain the deterioration in the standard of health care at SMC. The MOH needs to adopt policies in line with the ICESCR and with the principle of medical impartiality to ensure every person’s right to the highest attainable standard of health and well-being. The MOH needs to reform SMC in a manner that gives doctors and nurses enough time to care for each patient. Furthermore, doctors who remain dismissed for treating injured protestors during the popular 2011 uprisings should be reinstated to their previous positions at SMC. Finally, the government of Bahrain should initiate other public hospitals in each governorate as this will decrease patient turnover at SMC.

Recommendations:

To the Bahraini Ministry of Heath:

Abolish 2015 regulation reducing the limit of on-call hours from 156 to 70 hours per month for doctors working at SMC;

Ensure everyone’s access to a high quality and responsive health services at SMC;

Expand SMC by opening more wards;

Reinstate dismissed doctors to their positions at SMC;

Hire qualified nurses with Bachelors of Science in nursing;

Make salaries of medics equal across Bahrain’s public hospitals;

Equalize health care quality across Bahrain’s public hospitals;

Increase funding for Bahrain’s health sector;

Initiate more public hospitals in Bahrain; and

Open more wards at SMC.

 

Photo Credit: Jesse Mclean / Toronto Star File