Conflict in the waiting room: Lebanon's healthcare sector under strain in wake of Syrian crisis

This blog is written by Lana Khattab. Last month Lana travelled to Lebanon, where she spoke with staff and patients at health centres across the south of the country. This blog was first published on the Middle East Monitor and has been translated into Arabic by the Noon Post here.

Lebanon has faced a number of crises in the recent past. The most recent wave of violence has been in the eastern part of the country where the Lebanese army is fighting militants who have crossed the border from Syria. Many Lebanese believe the threat of violence is directly linked to Syrian refugees who have settled in towns and villages across the country.

"For the past 20 years, we Lebanese got used to dealing with emergencies. They used to last for three to four months and we dealt with them quite well. But we have been in a state of emergency for over two years now; it has lasted too long," says Rajaa Abboud, head of a health clinic in Bazourieh, a village in south Lebanon.

Security is far from being the only concern associated with the refugees. Rajaa Abboud's clinic treats between 60 and 70 patients a day, of whom 90% are Syrian refugees, mostly women and young children. According to UNHCR, Lebanon currently hosts around 1.1 million Syrian refugees, although the unofficial number is rumoured to be twice as high.

Many Syrian refugees have settled in rural areas where living costs are lower than in the rest of the country and the infrastructure is poor. These areas are home to the poorest Lebanese communities, who struggle with severe electricity and water shortages. The presence of over a million refugees has put pressure on public utilities such as water and electricity, but also increased demands for jobs and accommodation, driving prices up.

The health sector is also under strain to serve an increased number of patients. Many Lebanese feel they are not treated fairly, since most of the international assistance is targeted at Syrians. Today, tensions between Syrian refugees and the Lebanese host communities in the healthcare sector are visibly surfacing. The delivery and reception of aid specifically targeting Syrian refugees has at times angered the local population, which also often struggles to cover rent, utilities and healthcare costs.

'Consider me a Syrian!'

In most cases Syrian refugees pay three to four times less that the Lebanese patients for seeing a doctor in a clinic. "Our Lebanese patients do complain a lot about the difference in consultation fees. They sometimes tell us, 'consider me a Syrian', says Rajaa Abboud. Speaking in confidentiality, a Syrian refugee woman timidly confirms: "They complain loudly in front of us and get upset. It makes me feel uncomfortable but I stay quiet."

The high visibility of humanitarian assistance to Syrians makes many Lebanese believe Syrians get 'everything for free'. In reality, however, organisations working on the ground such as UNHCR are underfunded and their capacities overstretched, and are thus unable to accurately provide for all vulnerable Syrians.

Many Lebanese believe that Syrian refugees 'abuse the system'. According to Manal*, a nurse in Bazourieh health centre, some Syrian refugees sell the extra medication they accumulate. "I walked past another health centre one day and saw some of our patients sitting in the waiting room. That way they get more medication and can re-sell it to make money."

Some Lebanese also complain about a lack of medicines, since a significant amount is reserved for Syrians. Nurses in several clinics have confirmed that medication for Lebanese and Syrian refugees are funded through different channels. If medicines for Lebanese are out of stock, clinics cannot tap into the drugs meant for Syrians. Refugees, however, also complain about the opposite phenomenon: "Sometimes we can see the medicine stocked in piles on the shelves, but the health workers tell us they don't have the medicine and we need to buy from outside, which is expensive," says a Syrian patient who frequently visits the clinic to get his medicine for hypertension.

Some health centres are now almost exclusively frequented by Syrians. Doctors and nurses are increasingly concerned about the decreasing number of their Lebanese patients, who chose to avoid a waiting room full of Syrian refugee women and children. "At the start we could not believe how many Syrian patients we received. Our waiting rooms were full. They were standing in the kitchen, on the balcony, everywhere. Lebanese neighbours would come to the centre and ask what was happening, simply because the queues were so long," recounts Rajaa.

One of the major frustrations of health workers and Lebanese patients is a perceived lack of hygiene among refugees. Mona Shaker, head of a clinic in Tyre, confirms that Lebanese patients are afraid of catching diseases from Syrians: "Lebanese don't want to be treated with the same medical equipment as Syrians and don't want to sit next to them." While health workers are generally aware of the hardships Syrians face as well as their often extremely poor living conditions, which includes lack of consistent water and sanitation facilities, they seem to align strongly with their Lebanese patients in showing a certain degree of hostility towards Syrians.

Curing the tensions, tackling the symptoms

Over the past few years, health workers have introduced some informal adjustments to keep their Lebanese patients and avoid escalation of conflict. One of them is to fast-track Lebanese patients through a mixture of queuing and appointment measures so they do not wait behind Syrians. "First, all Lebanese patients go in, then do Syrians. If a Lebanese patient comes to the centre late, we try and take one or two Syrians before fast-tracking him," says Manal.

In the nurse's view, it is important to wait for a few Syrians to pass before letting in the next Lebanese patient. This way it is not too obvious that the nurses favour their fellow Lebanese. Depending on the resources and size of the health centres, some of them have taken steps to separate Lebanese and Syrian patients within waiting areas. Again, Syrians are well aware that Lebanese patients do not like to wait with them or because of them, and that they receive preferential treatment.

With no foreseeable end to the conflict in Syria, and the number of refugees in Lebanon expected to continue rising, tensions in and around healthcare are likely to further intensify. What can be done? First, Lebanese need to be better informed of how much and what kind of aid reaches Syrians. Due to the lack of funding and rigid assistance criteria, not all Syrians in need of assistance actually receive it.

Secondly, health workers – whether they want to or not – often play the role of intermediary between the Lebanese and Syrian communities. They work increasingly long hours, serve a higher number of patients and are exposed to more tensions in the work place. Their role as conflict mediators on a daily basis needs to be acknowledged and supported, for instance through stress management and communication training.

Additionally, a dire need for trust-building exists to bridge prejudice and misconceptions between communities. In some places, that need has already been diagnosed and is spearheaded by health workers and humanitarian agencies' social workers. Mona Shaker stressed the need to engage some vulnerable Lebanese in efforts directed towards Syrians in order to make them feel included. Awareness sessions and workshops, for example on nutrition, hygiene and early marriage, provide an opportunity to reach out to both communities. "We distributed free diapers to both Syrian and Lebanese mothers and Lebanese were so happy to be included and receive something free as well. I tell all our donors: if you donate to us it will go to those most in need, no matter their nationality – Lebanese, Syrian, Iraqi or Palestinian."

*Name has been changed for confidentiality purposes

International Alert is working to strengthen the role of healthcare organisations in Lebanon by providing support to the local population and Syrian refugees in a way that does not exacerbate tensions. Find out more here.

Photo © Nadim Kamel/International Alert