A year since the Beirut seaport explosion, on the riverbank, Adonis is still bleeding.¹ This is not a slow ooze. Topical antifibrinolytics are no longer working. A few transfusions of platelets and plasma via time-limited foreign aid are not cutting it. The Lebanese healthcare system is in full-blown hemorrhagic shock with copious bleeding, internal and external, from all its vessels – nominate and innominate. External bleeding, through the medical brain drain, and visceral bleeding, mediated by the ongoing corrupt systems, have crippled the vital organs of the nation with ischemia in nearly every sector. Microthrombosis and paradoxical bleeding in every sector are paralyzing the function of the political system, the healthcare sector, and the financial apparatus. For both of us as hematologists/oncologists, the scenes are so absurd and so overwhelming that the closest pathophysiological process to this reality would be a state of hemorrhagic shock complicated by disseminated intravascular coagulation in the setting of decompensated liver cirrhosis, a state of chaos, where factors are missing, some vessels are clotting while others are bleeding, the hospital is out of blood products, the lab results are artifactual, and the medical staff is burned out.

In the political arena, the country has been without a government for over a year. The different factions, religious sects, and political parties are at a stalemate. Many are calling for the fragmentation of an already small state into a patchwork of smaller states that are not even geographically continuous as individual entities. The political and judiciary systems have not concluded investigations regarding those responsible for the port explosion that killed hundreds, injured thousands, and made hundreds of thousands homeless in August 2020. The financial system has been witnessing one of the worst economic crises our world has met in a century.² The banking sector, a matrix that stabilized the mesh of the economy by pegging the Lebanese lira at a set exchange rate for three decades, has been cleaved into inactive monomers and shredded into dysfunctional fibrils.

The healthcare sector, a previous hub for innovation in the Middle East and Eastern Mediterranean, has lost some of its most essential coagulation factors that would abort a hemostatic stress to its system. This past year has seen the most precipitous and most substantial brain drain among healthcare professionals in decades and a scarcity of medical supplies to levels unprecedented in years.^3-5 The American University of Beirut Medical Center (AUBMC), a medical center that has been at the forefront of medical education and clinical care in the Middle East and North Africa region, is facing unparalleled challenges in acquiring and retaining talent. Physicians with practices maintained and reputations developed over decades are spending at least some of their time outside the country to be able to support their families as the economic whirlpool continues to cloud every aspect of life. Many Lebanese physicians, who had temporarily left the country for specialty medical training and returned to work and serve the country's institutions, have changed their career plans and headed back to North America or pursued opportunities in the Arab Gulf countries. Some physicians and nurses who had never thought of building their careers elsewhere are finding themselves up against insurmountable financial and social stressors that are pushing them out of the country. Pharmacists are now rationing medications, selling drugs in individual leaflets rather than sealed boxes, and prioritizing patients with certain conditions over others.⁵ One of us (Dr. Ali Taher) is the director of the Naef K. Basile Cancer Institute at AUBMC – a cancer center providing 80 infusions of systemic anticancer therapy, 100 outpatient clinic encounters, and tens of hospital admissions daily. The cancer center is experiencing historically low inventory numbers and shortages of chemotherapy medications.⁵ To help mitigate drug shortages, the cancer center has been collaborating with numerous non-governmental organizations, local suppliers, and local and regional partners in healthcare. The cancer center leadership has modified practices to circumvent the shortage of certain medications while keeping patient safety as an immaculate guiding principle and continuing to innovate amid the turmoil. Despite these efforts, AUBMC and other institutions are still treading water. The need for constant innovation, the limitedness of resources, and the lack of sustainability of those solutions make the operational process an uphill battle every single day. Establishing reliable supply chains and maintaining other operational processes, which are tasks typically revisited every several months or years, are now quests that must be tackled on a weekly, and sometimes daily, basis.

We see the anxiety and despair those difficulties foster in our patients living with a diagnosis of cancer and other conditions that could be life-threatening if left untreated. Hearing about or seeing those frustrating realities every day, feeling helpless, and being unable to procure assistance make us, physicians with ties to Lebanon, rethink the main reason we do what we do. Whether in research, education, or clinical care, preserving human life and alleviating suffering are key tenets of our mission. However, we often find ourselves deprived of the tools needed to serve the suffering and the drugs needed to soothe their pain. To fulfill our duties and help our patients, we are in dire need of medications and medical supplies. We need a reliable supply of electric power. With the fuel shortage, operating rooms in rural hospitals have changed their operation schedules around the availability of electricity. At AUBMC, power conservation measures have been implemented, and backup plans have been instituted. Nonetheless, we remain extremely concerned as we look to our colleagues caring for patients in hospitals outside the capital Beirut and our larger cities.

The Lebanese healthcare system is exsanguinating. We would like to think that we have reached a point so low that an inflection is bound to happen. While our hopes remain high in the face of so much devastation and our faith in the strength of the Lebanese people remains steadfast, we are calling for help - any help - because human lives are at stake. We are calling on the Lebanese diaspora, international non-governmental agencies, and the United Nations to send any help possible in the form of essential medications – directly delivered to hospitals. With cancer care spanning chemotherapy, immunotherapy, surgical supplies, and supportive care medication (antiemetics, analgesics, growth factor support), we call for a concerted effort to maintain the resources patients need with continued accountability. We are not promoting the need for a massive transfusion protocol for an exsanguinating healthcare sector in Lebanon without any accountability – at least at the institutional level as public oversight remains disjointed. We vigorously support the need to assess and address the underlying causes of statewide losses and corruption. We remain cognizant of the challenges leading institutions may still be up against in the setting of the collapsing political and financial systems. We are equally worried about our patients who are concerned they will not have their chemotherapy medications next week. We share their pain as we sit with them in clinic. We see their faces overcome by sadness as they receive their therapy in the infusion unit. We hear the pain in their voices when we check on them by phone. What keeps us going is that glimmer of hope in their gloomy eyes, their stout faith that things will be okay, and their resolute desire to be with family for as long as possible. What keeps us going is a shared humanity that no explosion, monetary devaluation, or loss will take away from us. We need to act for them and advocate on their behalf.

The crisis in Lebanon is projected to last for years, and the recovery is estimated to take close to a decade.^{2, 6} In the meantime, while some of us need to be involved in the rebuilding of the political infrastructure, many of us are called to patch the leaks and ensure there is a sufficient supply of anticancer and other drugs for next week and next month. Some maintain that what has propagated this state of political and financial corruption in the country is short-sighted and reactive policy. Indeed, long-term strategic planning and thoughtful policymaking are certainly needed. But, when there is a human acutely suffering, healthcare professionals roll up their sleeves and dive right in, elbow deep. Some parts will be messy, but we hope you will join us in reversing at least part of this exsanguination. Reach out. Let us think and act together.

贝鲁特海港爆炸一年后，河岸上的阿多尼斯仍在流血。¹这不是一个缓慢的渗出液。局部抗纤溶药物不再起作用。通过限时外援输注一些血小板和血浆并没有减少它。黎巴嫩的医疗保健系统处于全面失血性休克状态，其所有血管 - 无名和无名血管都在内部和外部大量出血。通过医疗人才外流导致的外部出血和由持续腐败系统介导的内脏出血，几乎每个部门都因缺血而瘫痪了国家的重要器官。每个部门的微血栓形成和自相矛盾的出血正在使政治系统、医疗保健部门和金融机构的功能瘫痪。对于我们两个血液学家/肿瘤学家来说，

在政治领域，该国已经有一年多没有政府了。不同的派别、教派和政党都处于僵持状态。许多人呼吁将一个已经很小的国家分裂成一个小国家的拼凑而成的小国家，这些小国家甚至在地理上都不是作为个体实体连续的。政治和司法系统尚未结束对 2020 年 8 月造成数百人死亡、数千人受伤、数十万人无家可归的港口爆炸事件的责任人的调查。金融体系一直在见证我们这个世界所经历的最严重的经济危机之一。一个世纪。² 银行业是三十年来通过将黎巴嫩里拉与固定汇率挂钩来稳定经济结构的矩阵，但它已被分解为不活跃的单体，并被分解成功能失调的原纤维。

医疗保健部门是中东和东地中海以前的创新中心，它已经失去了一些最重要的凝血因子，这些凝血因子会中止其系统的止血压力。在过去的一年里，医疗保健专业人员出现了数十年来最急剧和最严重的人才流失，医疗用品的稀缺程度达到了多年来前所未有的水平。^3-5贝鲁特美国大学医学中心（AUBMC）是中东和北非地区一直处于医学教育和临床护理前沿的医学中心，在获取和留住人才方面面临着前所未有的挑战。随着经济漩涡继续笼罩着生活的方方面面，几十年来一直保持着实践并享有盛誉的医生至少将一些时间花在国外以养家糊口。许多暂时离开该国接受专业医疗培训并返回工作并为该国机构服务的黎巴嫩医生改变了他们的职业计划，返回北美或在阿拉伯海湾国家寻求机会。一些从未想过在其他地方建立职业生涯的医生和护士发现自己面临着无法克服的经济和社会压力，这些压力将他们赶出了这个国家。药剂师现在正在配给药物，以单独的传单而不是密封的盒子出售药物，并优先考虑患有某些疾病的患者。⁵我们中的一个人（Ali Taher 博士）是 AUBMC 的 Naef K. Basile 癌症研究所的主任——该癌症中心提供 80 次全身抗癌治疗输注、100 次门诊就诊和每天数十次住院治疗。癌症中心正在经历历史低库存数量和化疗药物短缺。⁵为了帮助缓解药物短缺，癌症中心一直在与众多非政府组织、当地供应商以及医疗保健领域的当地和区域合作伙伴合作。癌症中心的领导层修改了做法，以规避某些药物短缺的问题，同时将患者安全作为完美的指导原则，并在动荡中继续创新。尽管做出了这些努力，但 AUBMC 和其他机构仍处于停滞状态。不断创新的需求、资源的有限性以及这些解决方案缺乏可持续性，使得运营过程每天都是一场艰苦的战斗。建立可靠的供应链和维护其他运营流程，这些任务通常每几个月或几年重新审视一次，现在是必须每周处理的任务，

我们看到那些被诊断出患有癌症和其他疾病的患者因这些困难而产生的焦虑和绝望，这些疾病如果不及时治疗可能会危及生命。每天听到或看到这些令人沮丧的现实，感到无助，无法获得帮助，这让我们这些与黎巴嫩有联系的医生重新思考我们做这些事情的主要原因。无论是在研究、教育还是临床护理中，保护人类生命和减轻痛苦是我们使命的关键原则。然而，我们经常发现自己被剥夺了为痛苦服务所需的工具和缓解痛苦所需的药物。为了履行职责和帮助患者，我们急需药物和医疗用品。我们需要可靠的电力供应。由于燃料短缺，农村医院的手术室根据电力供应情况改变了手术时间表。在AUBMC，已经实施了节电措施，并制定了备用计划。尽管如此，当我们期待在首都贝鲁特和我们大城市以外的医院照顾病人的同事时，我们仍然非常担心。

黎巴嫩的医疗保健系统正在抽血。我们认为我们已经达到了一个低点，必然会发生拐点。尽管面对如此多的破坏，我们的希望仍然很高，我们对黎巴嫩人民的力量的信心依然坚定，但我们呼吁提供帮助——任何帮助——因为人类的生命处于危险之中。我们呼吁黎巴嫩侨民、国际非政府机构和联合国以基本药物的形式提供任何可能的帮助——直接运送到医院。随着癌症护理涵盖化学疗法、免疫疗法、手术用品和支持性护理药物（止吐药、镇痛药、生长因子支持），我们呼吁齐心协力，以持续负责的方式维持患者所需的资源。我们不会在没有任何问责制的情况下促进对黎巴嫩血腥医疗部门的大规模输血协议的需求——至少在机构层面，因为公共监督仍然脱节。我们大力支持评估和解决全州损失和腐败的根本原因的必要性。我们仍然认识到，在政治和金融体系崩溃的背景下，领先机构可能仍面临挑战。我们同样担心我们的患者，他们担心下周他们将无法使用化疗药物。当我们坐在诊所里时，我们会分担他们的痛苦。当他们在输液室接受治疗时，我们看到他们的脸上洋溢着悲伤。当我们通过电话检查他们时，我们听到他们声音中的痛苦。让我们继续前进的是他们阴沉的眼睛里闪烁的希望，他们坚信一切都会好起来的，以及他们与家人尽可能长久地待在一起的坚定愿望。使我们继续前进的是一个共同的人性，任何爆炸、货币贬值或损失都不会带走我们。我们需要为他们采取行动并代表他们进行倡导。

黎巴嫩的危机预计将持续数年，而恢复预计需要近十年的时间。^2、6与此同时，虽然我们中的一些人需要参与政治基础设施的重建，但我们中的许多人被要求修补漏洞并确保下周和下个月有足够的抗癌药物和其他药物供应。一些人认为，在该国传播这种政治和金融腐败状态的是短视和反应性政策。事实上，长期的战略规划和深思熟虑的决策当然是必要的。但是，当有人遭受严重的痛苦时，医疗保健专业人员会卷起袖子直接潜入，肘部深。有些部分会很乱，但我们希望你能和我们一起扭转这种放血的至少一部分。伸手。让我们一起思考，一起行动。