A few years back, walking through the narrow trail at Mar Elias Camp, I wasn’t able to process the telltale signs. Today, crouching under the looming entangled electrical wires and jumping across dirtied waterbeds snaking around makeshift houses, I understand the importance of rethinking health initiatives put forth in my country, Lebanon. This was especially highlighted, when I recently visited a young girl, a refugee who I once taught, with bright eyes and a quick wit, Asma. I realized matters were worse than when I had last seen her; Asma was unable to pursue her education.
Unfortunately, the turbulent events plaguing Lebanon and the region prevent refugees from having a fair childhood. But to understand the tragedy of a child unable to pursue an education, a chain of events and subsequent policies are brought to light.
Lebanon’s devastating civil war imparted long-lasting repercussions well beyond its years (1975-1990). The public health sector was adversely affected, which was reflected with a weakened primary health sector. This contrasted with the booming private health care sector. The government relied thoroughly on private facilities, to the extent of having the Ministry of Public Health allocate most of its budget towards them. At the same time, the involvement of a network of religious, domestic and international non-government organizations has led to parallel systems and poorer coordination. This highly fragmented system does not provide robust centralized healthcare to tackle the ever-increasing humanitarian crises.
For the Lebanese, health is covered as part of a social protection scheme. However, these services for Lebanese citizens do not cover displaced individuals sheltering from the destruction of war including Syrian refugees and the already inhabiting population of Palestinian refugees. These vulnerable populations lack a robust and integrated healthcare system supervised by the state to ensure fairness.
Almost nine years into the Syrian civil war, there are 1 million refugees registered by UNHCR (United Nations Higher Commissioner Relief) in Lebanon, while it is estimated that the total number who reside in the country reaches 1.5 million. Additionally, approximately half a million Palestinians are registered with UNRWA (United Nations Relief and Works Agency). UNHCR aims to prioritize accessible primary care over more costly expenditures in order to cover the whole refugee population. Yet, the fragmented and pluralistic health system in Lebanon is an inequitable one. The needs of this large and vulnerable population are not being met by the actual services resulting in out of pocket expenditure, long commuting hours, and lack of preventative services.
More recently, Lebanese citizens took to the streets on October 17, 2019 to voice their distrust in the ruling, sectarian class which has adamantly held on to power since the civil war and has exacerbated the stifling economic crisis.
Presently, the novel coronavirus pandemic spreads through the world, whilst Lebanon stands at 677 cases and a mortality count of 21 (as of April 22nd) amid a nation-wide lockdown. The number of identified cases per day are now leveling, but some Lebanese have said they would rather try their chances with the coronavirus than to live through unbearable economic and social turmoil. Yet, these identified cases could be an underestimation with the limited amount of tests administered. More so, displaced communities have limited testing, and so they need to seek alternate ways to defend themselves against Covid-19. Today, matters look more ominous as a Palestinian woman from the crowded Bekaa camp has just tested positive for the coronavirus.
The predicament of Asma and many other refugee families in Lebanon
When I went back to visit Asma, I sat on the only couch available in the small apartment. When I asked her where she is now in her studies, she only feigned a smile and nodded her head backwards, testifying she indeed had stopped going to school. Her father interjected pointing to the two other children crammed beside me, Asma’s younger sisters, who have also been pulled out of school.
Asma’s father suffers from Kidney Hemodialysis; he must visit the nearest hospital for which the cost is subsidized for Palestinians. A trip back and forth from Beirut to Hamshari Hospital in Sidon costs him almost 20 dollars, and he is obliged to do that twice per week. Additionally, although the expense of the bed is covered for him, he must still pay for the blood transfusions and vitamin injections, as well as the heart medications he also needs for his own cardiac complications. The straining finances were evidence enough of the reason behind Asma and her sisters pulling out of school.
“I sat all my children down,” he elaborated, “and explained to them how I simply couldn’t keep them all in school. It’s either that or their father’s health.”
Two undeniable rights, education and health, in competition with each other. In Lebanon, Palestinian and Syrian refugees still struggle to attain what the World Health Organization constitution decrees as the “enjoyment of the highest attainable standard of health [as] one of the fundamental rights of every human being without distinction of race, religion, political beliefs, economic or social condition.”
In such a frail system, refugees are not only struggling with the feeble healthcare systems, poverty and overcrowding, but must also survive, mostly alone, with the knowledge that Coronavirus is spreading. The state has no formal plan for fighting the novel coronavirus for refugees, nor do the refugees have the ability to deflect it, as social distancing in such populated places is almost impossible. It remains to be seen whether the most vulnerable, the refugees that have again been marginalized, can withstand another layer of hardship. In this context, universal health coverage in Lebanon seems a far off dream.
The road to equitable health care needs far more lobbying for (and voicing the concerns of) underserved communities. In Lebanon, refugees’ access to healthcare should be a focus of the new cabinet and the new Parliament if hopes of equitable, accessible and efficient healthcare are to become a reality. International efforts should focus on supporting refugee education, but also advocate for health system reform that reduces the fragmentation, out of pocket costs, and access issues, all of which undermine universal health coverage and inhibit refugee access to basic healthcare.
Health is a right not a privilege: a peaceful productive Lebanese society depends on more equitable and accessible healthcare for all, including Palestinian and Syrian refugees, and vulnerable Lebanese. In the year 2020, no family should have to choose between education or health – in ordinary as well as Covid-19 times.
Acknowledgment: Thanks to Kristof Decoster, Dr. Steph Topp, and Dr. Kerry Scott for their support, guidance and feedback on the article.
Welcome to the SHAPES article series, hosted by IHP. SHAPES is a thematic working group within Health Systems Global, which facilitates discussion, debate and collaboration around social science approaches for research and engagement in health policy & systems. In the months leading up to the 6th Global Symposium on Health Systems Research in Dubai (Nov 2020) SHAPES members will be blogging about the Symposium's theme of "re-imagining health systems for better health and social justice" through a social science lens.View entire SHAPES series