Lessons Learned from the COVID-19 Pandemic: Physician Safety and Coverage in Lebanon

Similar to other countries, Lebanon experienced the challenges that the COVID-19 pandemic imposed on its healthcare system. Physicians, among other healthcare workers, felt the large toll of the pandemic. The growing number of physicians infected with the coronavirus has uncovered gaps in the policies and laws meant to protect and ensure physician safety. These include gaps in physician coverage for healthcare, disability, and death, in addition to particular vulnerabilities of trainee physicians, along with the absence of specific laws, strategies, and agencies to ensure the safety of the healthcare work environment. This paper highlights these gaps and proposes solutions to address them.

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Written on behalf of the Healthcare Delivery and Reform Group1Part of the Volunteers Outreach Clinic organization which is a registered NGO (no. 1562) that aims to provide healthcare services to the underserved, improve health awareness, and contribute to scientific and practical research.

Introduction:

The outbreak of the novel coronavirus has challenged healthcare systems worldwide. As of 8 February 2021, cases have  been documented in 219 countries.2Worldometers, "Countries Where Covid-19 Has Spread,"  worldometers.info. Lebanon documented its first case on 21 February 2020.3Global Health Institute, "Covid-19 Arab Monitor," American University of Beirut ghi.aub.edu.lb. With airport closure and a series of lockdowns, Lebanon was able to keep the number of daily new cases and hospitalizations relatively under control. However, the 4 August 2020 explosion at the Beirut port coupled with relaxed restrictions in October and December saw a massive soar in cases, reaching 4,594 new daily cases in mid-January 2021.4Worldometer, "Coronavirus Cases: Lebanon,"  worldometers.info. What is more concerning is the increase in the number of hospitalizations where ICU occupancy in the whole country approached 95% in January 2021.5Ruth Sherlock, "Lebanon’s Full Hospitals Turn Away Coronavirus Patients Amid Record Daily Cases,"  npr.org. With the meteoric rise in the number of infections and hospitalizations, concerns have arisen regarding the vulnerability and safety of healthcare workers, whose own infection rates also increased and of whom many were forced into quarantine, hospitalized, or killed because of the virus. It is needless to say that healthcare workers are at a higher risk than the general population and can amplify outbreaks in healthcare centers when infected.6Centers for Disease Control and Prevention, "Interim Operational Considerations for Public Health Management of Healthcare Workers Exposed to or with Suspected or Confirmed Covid-19: Non-U.S. Healthcare Settings,"  cdc.gov.

A healthcare worker is one who delivers care and services to the sick, either directly such as doctors and nurses, or indirectly such as helpers, laboratory technicians, or medical waste handlers. Healthcare workers also include dentists, physiotherapy personnel, students and trainees, dietary and food services staff, administrative staff, and others.7"The Importance of Covid-19 Vaccination for Healthcare Personnel,"  cdc.gov. 8World Health Organization, "The 2018 Update, Global Health Workforce Statistics,"  who.int.

In this paper, we describe the toll of the COVID-19 crisis on healthcare workers in Lebanon, particularly physicians, without discounting the crucial role of other healthcare workers. Some of the discussed points can apply to all healthcare workers, though physicians are unique in many aspects regarding their protection and coverage. The sad experience with physician hospitalization and mortality due to COVID-19 has highlighted the need to revisit laws, policies, and decrees related to health insurance coverage, and disability and mortality compensation for physicians, including those in training. The paper also presents recommendations on how best to address the gaps in insurance coverage during the pandemic, particularly for the most vulnerable among physicians.

COVID-19 Among Healthcare Workers

The number of infections among healthcare workers increased by more than 50% during the month of September 20209Global Health Institute. and steadily increased after that to reach 2,429 cases by the beginning of February 2021.10Lebanese Ministry of Public Health, "Monitoring of Covid-19 Infections in Lebanon- "  moph.gov.lb. Ideally, we would compare this number to the total number of healthcare workers, obtain the number of physicians infected, and compare it to the total number of physicians actively practicing in Lebanon in order to obtain a better indicator of how much the workforce combatting the coronavirus is affected. However, these numbers are difficult to accurately ascertain since many physicians may still be registered as active members of the Lebanese Order of Physicians (LOP) but are not currently practicing in Lebanon. The LOP estimates this number to be around 8000 physicians.11Member of the Lebanese Order of Physicians Council, February 7, 2021.  An estimate from a large medical center in Beirut shows that 26% of the hospital staff had been infected with the coronavirus as of late January.12Chief of Staff at St George Hospital Beirut Eid Azar,  twitter.com. As this paper is written, 26 physicians have died due to the coronavirus.13Member of the Lebanese Order of Physicians Council. The head of the LOP recently sounded the alarm at the increasing number of coronavirus infections among medical personnel and called upon insurance agencies and providers to cover 100% of the hospital bills for hospitalized physicians, and upon hospitals to ensure protective measures are taken to prevent infection.14El Nashra, "Abu Charaf: The Numbers of Coronavirus Infections among Medical Personnel Is Rising and Ensuring Protection Is a Must,"  elnashra.com. It is fitting here to also mention the heavy toll that the pandemic has exacted on healthcare workers’ mental health, as a recent study showed that half of the participants were at high risk of acute stress.15M. Bizri et al., "Psychological Distress Experienced by Physicians and Nurses at a Tertiary Care Center in Lebanon During the Covid-19 Outbreak," J Health Psychol  (2021).

Regarding physician protection, it has been shown that the adequacy of personal protective equipment (PPE) and the clinical setting have a role in determining the risk of healthcare worker infection.16Long H. Nguyen et al., "Risk of Covid-19 among Front-Line Health-Care Workers and the General Community: A Prospective Cohort Study," The Lancet Public Health 5, no. 9 (2020).  Globally, there is a shortage of  PPE available, along with an increase in prices.17T. Burki, "Global Shortage of Personal Protective Equipment," Lancet Infect Dis 20, no. 7 (2020). Lebanon depends entirely on imports for its supply of N95 masks and ventilators18Petra Khoury, Eid Azar, and Eveline Hitti, "Covid-19 Response in Lebanon: Current Experience and Challenges in a Low-Resource Setting," JAMA 324, no. 6 (2020). , making it difficult to ensure adequate supply from an already-strained global market. This challenge is further intensified by the financial crisis that the country has been facing for more than a year, making foreign currency needed for importing PPE and medical supplies scarce and expensive, at around eight times the old exchange rate. The central bank tried to remedy the issue by supplying 85% of the required foreign currency at the old low exchange rate. However, many suppliers still put cash restraints on hospitals for the delivery of medical supplies.19Elnashra, "Haroun: Let the Government Put Its Hands on Hospitals by the Emergency State Law,"  elnashra.com. This led to a shortage of PPE in the beginning that was experienced by all healthcare workers, which prompted the head of the LOP to urge hospitals to provide doctors with protective equipment to help stop the spread of the virus among medical teams.20El Nashra, "Abu Charaf Urges Hospitals to Provide Doctors with Protective Equipment,"  elnashra.com.  Even though PPE is now more available than it was earlier in the pandemic, there still is no strategy in place to ensure Lebanon does not face a shortage again, should it come under strenuous circumstances.

Rights and Duties

Physician Healthcare Coverage and Compensation for Death and Disability.

Practicing medicine is considered a “free profession,” physicians are thus not employees and their relationship with the hospital they practice at is dictated by the contract each doctor signs. Physicians can also hold private practices and thus have no contractual relationship to any hospital. By law, a physician should be registered with the LOP to practice medicine.21"Article 3 of the Regulations of the Lebanese Order of Physicians,"  app.lopbeirut.org. Through the LOP, a physician can buy a health insurance policy with a group-priced premium. They can also enroll in the healthcare fund of the National Social Security Fund (NSSF), which would further reduce their premium. The LOP, since 2004, has been covering co-pays required by insurance policies or the NSSF.22Lebanese Order of Physicians, General Assembly, May 5 2004. On the other hand, should a physician who is a member of the LOP, become temporarily disabled or kept out of work for a long time due to COVID, the order pays up to LBP 1,200,000 (equivalent to USD 150 at the current market rate) per month in disability coverage.23Member of the Lebanese Order of Physicians Council. In cases where physicians pass away after contracting the coronavirus, the LOP has to pay their families a sum of LBP 50 million (equivalent to USD 6,250 at the current market rate).24Member of the Lebanese Order of Physicians Council

Another category of physicians includes trainee physicians. Trainee physicians are those who have obtained their medical degrees and are pursuing further specialty training. They sign a contract with a teaching hospital and receive their training and a regular salary from that hospital. Many trainee physicians do not register with the LOP due to their inability to pay the registration and annual fees. Although by law, only those who register with the LOP can practice medicine,25"Article 3 of the Regulations of the Lebanese Order of Physicians". trainees exceptionally practice under the license of their supervising physicians, who are held legally liable for any errors. While supervising physicians are held legally liable for medical errors and malpractice, they are not responsible for the trainee physician’s healthcare and safety coverage, as the trainee’s contract is with the hospital and not with the supervising physician. Without being registered with the LOP, trainees and their families are not entitled to compensation from the order. Since they should be salaried by the hospitals, by law, the cost of hospitalization for any work-related injury is the responsibility of the employer.26"Legistlative Decree Number 136 Regarding Work Emergencies Enacted on 16/09/1983." In case of death due to a work-related injury, it is the responsibility of the employer to compensate the family of the deceased with a sum, the value of which depends on the salary last earned by the deceased.27Ibid. Trainees also have the right to receive the same wage from the hospital for up to 9 months, if their disability is caused by a work-related injury.28Ibid.

Gaps Uncovered by the COVID-19 Pandemic:

Physicians who contract the virus and require hospitalization are being treated by the hospitals they work with. However, when beds are no longer available for them at their hospitals or in cases where physicians work at hospitals with no COVID units or do not work at hospitals at all, they are treated like any other patient and given no priority. The Ministry of Public Health (MOPH) helps with some of the costs, just as for all other citizens. While the LOP does cover the deductibles required by the NSSF and insurance policies, certain parts of the hospital bill, are not covered for physicians, as is the case with other patients, leading the head of the LOP to urge hospitals to cover 100% of the bill for physicians being treated for COVID.29El Nashra, "Abu Charaf Urges Hospitals to Provide Doctors with Protective Equipment".

One major gap in compensation and coverage concerns trainee physicians.  While a few teaching hospitals adhere to the law and ethical ideals and offer their trainees healthcare coverage, others do not offer any compensation. In fact, many trainee physicians do not receive any payments or benefits during their training. There is also no standard contract for trainees, which leaves room for huge disparities among different training centers.

Physician Protection

Lebanese law clearly states that it is the responsibility of the employer to provide all that is needed to ensure the safety and health of employees in all areas where they perform their employment duties. It is also the employer’s responsibility to take all necessary measures to protect all those employed and to maintain their health while providing their services.30Article 647 of the Law of Obligations and Contracts. 31Article 67 of the Labor Law 32Law Number 183 Date Enacted on 25/5/2000. Furthermore, failure to meet such responsibility can lead to the application of penal code statutes penalizing employers.33Article 604 of the Penal Code

These laws are legally binding in the relationship between employer and employee as specified in the law of contracts and obligations where the employee is the one who puts their work under the direction of the employer. This is the case of employee healthcare workers, and trainee physicians. Non-trainee physicians who work at hospitals are not considered employees, which is the same for physicians with independent practice.

The World Health Organization, through its constitution34International Health Conference, "Constitution of the World Health Organization. 1946," Bulletin of the World Health Organization 80, no. 12 (2002). and the Alma Ata Declaration,35"Declaration of Alma-Ata," WHO Chron 32, no. 11 (1978). has stressed the need to protect the healthcare professionals during their work through taking precautions against workplace dangers and combatting those dangers.

Failure to provide adequate PPE puts healthcare workers at risk while performing their duties and would be a violation of these laws and principles. Endangering the lives of healthcare workers at this juncture compounds an already-ailing system with a disastrous action. The consequences would be catastrophic, especially in light of the economically driven exodus of physicians and nurses from the country.

It is important to note that physicians should not be and are not held liable if they deny a patient urgent care when the provision of care exposes the physicians to danger.36"Article 567 of the Penal Law ". Based on that, a physician cannot be held liable for not providing care to a coronavirus patient if necessary PPE is not available.

Policy Suggestions

The coronavirus pandemic is an exceptional time and has put physicians in a strenuous situation. Unfortunately, the law is silent as to what should be done in such situations as there are no laws that cover exceptional circumstances.  The non-inclusion of physicians under labor laws is also an important gap. Amending labor laws and LOP regulations to cover emergency or exceptional situations can remove ambiguity and clarify rights and duties. Moreover, legislations that are specific to healthcare worker protection and compensation due to COVID-19 can clarify roles and ensure better protection and fairness to healthcare workers.

Improving Physician Healthcare Coverage and Compensation

          A. Non-Trainee/Senior Physicians

The laws in place for healthcare coverage and compensation are not specific for physicians; they are for employees in general. Since medicine can be an independent practice, physicians are not always covered by employment laws. These gaps are true cracks in the system where many physicians fall and should be addressed to ensure fairness.

The compensation for disability or death given by the LOP (for both COVID-19 and non-COVID-19 related illness) is a fixed amount for all physicians. A value calculated based on declared income or potential income would be a fairer alternative. This may require the LOP to avail registered physicians of a broader spectrum of coverage options based on a scale of registration fees adjusted to declared income or based on optional purchase of additional coverage at a group negotiated rate. In addition, experience during the pandemic raised questions as to what is covered by the NSSF and other agencies on the treatment bill and what is not. A clear written protocol should therefore be put in place to specify how such decisions ought to be made.

          B. Trainee Physicians

Another major gap to be addressed are protections for trainee physicians, particularly those working with hospitals or institutions that do not offer healthcare coverage. Many of them receive little or no income and live below the poverty line, placing them in the most vulnerable category of healthcare practitioners. Addressing their plight involves a multi-pronged approach:

First, the LOP can facilitate their induction into the order by creating affordable categories of membership for trainees and medical students, thereby providing them with necessary healthcare coverage and disability compensation. This membership status can be time limited by age or number of postgraduate years. After that, the ‘young member’ would become a full member and pay regular membership dues. Recently the LOP made it possible for trainees to pay membership fees over 24 installments using a bank loan, with the LOP covering the interest due.

Second, the LOP and the MOPH can push to set minimum standards for the contractual relationship between the trainee and the teaching hospital. These standards would include full healthcare, disability, and death coverage of the trainee physician, as well as minimum compensation for their work during training. Non-compliance with these standards would put the hospitals at risk of losing their academic and training credentialing, and potentially losing their accreditation by MOPH.  Trainees should also be made aware that they are entitled to NSSF enrollment by virtue of their status as university affiliated trainees.

Ensuring better Safety in the Workplace

In general, practicing physicians are not covered by labor laws, and there are no regulations for their protection in the workplace. As for salaried physicians, including trainee physicians, the Lebanese law places responsibility on employers to ensure the protection of their workers. This has put hospitals in a predicament in light of the current difficulties in procuring PPEs. Simply penalizing hospitals is not a solution to ensure the adequate availability of PPE. Adequate policies and measures should be implemented by governing bodies in order to ensure protection of healthcare workers and subsequently the survival of the healthcare sector. These policies could also set the standards against which hospitals can be held accountable. Provisions that are specific to healthcare worker protection from COVID-19 must be enacted promptly to ensure standards are set for all to follow. To implement and enforce these provisions, the MOPH, in collaboration with the Ministry of Labor, should establish a national program/agency that is specific to healthcare worker protection with a mission to develop these provisions and oversee their implementation nationwide.37World Health Organization, "Keep Health Workers Safe to Keep Patients Safe: Who,"  who.int. A good example to emulate would be the Occupational Safety and Health Administration (OSHA) created by the US Congress to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education, and assistance.38Occupational Safety and Health Administration, "Safety and Health Topics, Healthcare, Standards,"  osha.gov. This can include senior physicians who work in hospitals but are not employees, as well as those with independent practice. Physicians in independent practice are at a disadvantage with regards to PPE procurement as they are responsible for their own PPE. They do not benefit from bulk discounts on PPEs that hospitals can negotiate and have a hard time procuring PPE during shortage periods. Open bids for medical supplies and group negotiated prices by the LOP can help independent physicians procure their practice needs, including PPE, at more affordable rates.

Adequate Availability of PPE

It has been shown that adequate availability of PPE and the quality of PPE decrease the risk of infection by COVID-19, while the re-use of PPE might confer increased risk. Ensuring the quality and availability of PPE should be the goal of any policy. Calculators that can forecast the quantity needed for PPE have been developed and tested in Lebanon. These calculators also show the dependence on stringency in social distancing policies, where the more stringent the policies are the less the need for PPE; conversely, relieving restrictions is associated with a higher need for PPE.39A. A. Kamar et al., "The Challenge of Forecasting Demand of Medical Resources and Supplies During a Pandemic: A Comparative Evaluation of Three Surge Calculators for Covid-19," Epidemiol Infect  (2021).

WHO proposes a framework of three principles to ensure the availability of PPE.40World Health Organization, "Rational Use of Personal Protective Equipment for Coronavirus Disease (Covid-19) and Considerations During Severe Shortages: Interim Guidance,"  who.int. These principles are: reducing the need for PPE; appropriate use of PPE; and supply chain coordination. Reducing the need for PPE occurs through changes in patient and healthcare worker scheduling, while appropriate use of PPE is the application of PPE as per indications. Both of these principles are mostly the responsibility of the hospitals and their respective professional bodies. Supply chain coordination is the responsibility of the government where it should ensure that all parties receive their needed supply and prevent stockpiling. The government can also take all necessary steps to incentivize the local production of PPE. Transparency is important here; in this sense, the authorities should keep the public informed vis-à-vis PPE availability and distribution plans to various areas and hospitals. The government’s role is to oversee adequate procurement and distribution of the needed safety resources and to ensure both that the consumption of specific PPE (such as N95 respirators and surgical masks) is not abused and also that distribution is prioritized for healthcare use in times of shortage. Given the scarcity of PPE supply and the need to procure it from any available source, quality assurance is necessary. Unfortunately, this has yet to happen and governmental authorities need to step up and fulfill their duty in terms of quality review and certification of healthcare products.

With the imbalance between short supply and high demand for PPE, procurement could be a challenge. To decrease competition between parties over PPE supplies, WHO and Doctors Without Borders (MSF) have established a supply portal through which countries can order PPE.41Burki.  Collaborative procurement efforts have also been made between unions such as that between the African Union and the European Union.42Ibid. Starting a collaboration with other countries as part of trade deals for PPE, for example, may be a strategy that the Lebanese government can use to ensure adequate provision. Quality assurance should be taken into consideration when entering those deals. Even though there is currently enough PPE available in Lebanon, a long-term strategy should be adopted to ensure the country always has a sufficient supply to cover demanding situations, similar to what we experienced during surges of COVID-19. The gaps identified and the proposed solutions are summarized in table 1 below.

Table 1: Summary of gaps identified in physician coverage and protection and policy suggestions for each of these gaps. (LOP: Lebanese Order of Physicians, MOPH: Ministry of Public Health, PPE: Personal Protective Equipment)

Gaps Suggestions
Physician Healthcare Coverage and Benefits Trainee Physicians Facilitating LOP Enrollment
Standardizing training/work contracts
LOP Physicians Compensation for Disability or Death based on declared income
Protocol between MOPH, Lebanese Syndicate of Hospitals, and LOP on payment of uncovered parts of hospital bill
Safety in the workplace Absence of Specific Health Care Worker Labor Laws Legislating laws for specific healthcare worker hazards (e.g. COVID-19) and exceptional circumstances
Absence of Regulatory Bodies for Workplace Safety Regulatory Agency ensuring adequate standards are met
Inapplicability of Labor Law employment relationship to Physicians Inclusion of physicians in specific healthcare worker safety laws
Private Practice Physicians have to secure their own PPE Collective Bargaining for PPE via LOP.
PPE Availability Lack of National Strategy for continual availability Trade deals
Decreasing needs
Emergency supply
Quality Assurance

Conclusion:

With the rising numbers of COVID-19 cases, healthcare worker coverage and protection are critical for the survival and performance of this vital sector. There are many loopholes in the laws and regulations protecting physicians’ health and welfare. The COVID-19 pandemic has brought these gaps to light more than any other crisis before. In the absence of laws that are specific for the COVID-19 pandemic, or for exceptional situations in general, action is needed now to set uniform standards for all to follow. The LOP regulations should be adapted to facilitate trainee physician enrollment so that they can benefit from the protections that the order affords its physician members. Furthermore, policies should be enacted to ensure safety and adequate supply of safety resources (PPE) in the country, with a clear and effective national response coordinated by the MOPH. The wellbeing and safety of healthcare workers is paramount, especially in these trying times and society cannot afford exposing them to otherwise avoidable risks and uncertainties in their healthcare coverage and safety – both personal and financial. This article focused on the specific needs of physician, but similar needs exist for other healthcare workers, including nurses, as they are a crucial part of the healthcare system and have also felt the toll of the COVID-19 pandemic.

Endnotes

Endnotes
1 Part of the Volunteers Outreach Clinic organization which is a registered NGO (no. 1562) that aims to provide healthcare services to the underserved, improve health awareness, and contribute to scientific and practical research.
2 Worldometers, "Countries Where Covid-19 Has Spread,"  worldometers.info.
3 Global Health Institute, "Covid-19 Arab Monitor," American University of Beirut ghi.aub.edu.lb.
4 Worldometer, "Coronavirus Cases: Lebanon,"  worldometers.info.
5 Ruth Sherlock, "Lebanon’s Full Hospitals Turn Away Coronavirus Patients Amid Record Daily Cases,"  npr.org.
6 Centers for Disease Control and Prevention, "Interim Operational Considerations for Public Health Management of Healthcare Workers Exposed to or with Suspected or Confirmed Covid-19: Non-U.S. Healthcare Settings,"  cdc.gov.
7 "The Importance of Covid-19 Vaccination for Healthcare Personnel,"  cdc.gov.
8 World Health Organization, "The 2018 Update, Global Health Workforce Statistics,"  who.int.
9 Global Health Institute.
10 Lebanese Ministry of Public Health, "Monitoring of Covid-19 Infections in Lebanon- "  moph.gov.lb.
11 Member of the Lebanese Order of Physicians Council, February 7, 2021.
12 Chief of Staff at St George Hospital Beirut Eid Azar,  twitter.com.
13 Member of the Lebanese Order of Physicians Council.
14 El Nashra, "Abu Charaf: The Numbers of Coronavirus Infections among Medical Personnel Is Rising and Ensuring Protection Is a Must,"  elnashra.com.
15 M. Bizri et al., "Psychological Distress Experienced by Physicians and Nurses at a Tertiary Care Center in Lebanon During the Covid-19 Outbreak," J Health Psychol  (2021).
16 Long H. Nguyen et al., "Risk of Covid-19 among Front-Line Health-Care Workers and the General Community: A Prospective Cohort Study," The Lancet Public Health 5, no. 9 (2020).
17 T. Burki, "Global Shortage of Personal Protective Equipment," Lancet Infect Dis 20, no. 7 (2020).
18 Petra Khoury, Eid Azar, and Eveline Hitti, "Covid-19 Response in Lebanon: Current Experience and Challenges in a Low-Resource Setting," JAMA 324, no. 6 (2020).
19 Elnashra, "Haroun: Let the Government Put Its Hands on Hospitals by the Emergency State Law,"  elnashra.com.
20 El Nashra, "Abu Charaf Urges Hospitals to Provide Doctors with Protective Equipment,"  elnashra.com.
21 "Article 3 of the Regulations of the Lebanese Order of Physicians,"  app.lopbeirut.org.
22 Lebanese Order of Physicians, General Assembly, May 5 2004.
23 Member of the Lebanese Order of Physicians Council.
24 Member of the Lebanese Order of Physicians Council
25 "Article 3 of the Regulations of the Lebanese Order of Physicians".
26 "Legistlative Decree Number 136 Regarding Work Emergencies Enacted on 16/09/1983."
27 Ibid.
28 Ibid.
29 El Nashra, "Abu Charaf Urges Hospitals to Provide Doctors with Protective Equipment".
30 Article 647 of the Law of Obligations and Contracts.
31 Article 67 of the Labor Law
32 Law Number 183 Date Enacted on 25/5/2000.
33 Article 604 of the Penal Code
34 International Health Conference, "Constitution of the World Health Organization. 1946," Bulletin of the World Health Organization 80, no. 12 (2002).
35 "Declaration of Alma-Ata," WHO Chron 32, no. 11 (1978).
36 "Article 567 of the Penal Law ".
37 World Health Organization, "Keep Health Workers Safe to Keep Patients Safe: Who,"  who.int.
38 Occupational Safety and Health Administration, "Safety and Health Topics, Healthcare, Standards,"  osha.gov.
39 A. A. Kamar et al., "The Challenge of Forecasting Demand of Medical Resources and Supplies During a Pandemic: A Comparative Evaluation of Three Surge Calculators for Covid-19," Epidemiol Infect  (2021).
40 World Health Organization, "Rational Use of Personal Protective Equipment for Coronavirus Disease (Covid-19) and Considerations During Severe Shortages: Interim Guidance,"  who.int.
41 Burki.
42 Ibid.