When the Syria conflict sent the first refugees across the border into Lebanon, many feared the violence would soon spill over. No one thought that conflict could be related to the humanitarian aid that followed. Today, three and a half years into the crisis, tensions are palpable between the Lebanese communities and the over 1.1 million Syrian refugees that have found shelter throughout Lebanon, and several recent studies have confirmed the disgruntlement of the Lebanese with the way humanitarian aid is delivered. As a Lebanese woman quoted in one of the studies says, “We, the Lebanese, feel that we are the refugees in our own country.”
There is a prevailing perception among the Lebanese that the refugees are receiving all services for free. The reality, however, is that the UN refugee agency, UNHCR, has only received 36% of the money required to cover the needs of the refugees. It was forced to restrict its support to the most vulnerable of the vulnerable, and many of the refugees rely solely on underpaid daily labour to pay for their rent, food, electricity, water, schooling and healthcare.
Amid growing hostility towards the Syrian refugees and dissatisfaction with the humanitarian response, Alert is working with healthcare providers to help them tailor their services in a way that doesn’t magnify existing tensions.
To better understand the tensions related to healthcare, Alert commissioned a study by Integrity Research and Consultancy, which looked into the conflict issues and the abilities of health actors to address them.
Health was not the main issue of concern raised by most of the respondents – rent, water and employment were. Other recent studies also confirm that tensions between the Lebanese and the Syrian refugees are mostly over access to affordable accommodation and competition for jobs. In some regions, however, such as the impoverished Akkar in the north, health is reported to be the third greatest concern after water and wastewater (OCHA/Reach Initiative, August 2014).
Integrity's assessment identified specific concerns related to the provision of healthcare that fuelled negative reactions towards the refugees. Primarily, the Lebanese complain that they have to pay more for health consultations than the Syrians. According to a survey conducted for UNHCR in July (UNHCR/La Sagesse), Lebanese paid on average 34% more that the Syrian patients for a consultation in a health clinic.
The fears of the Lebanese over the growing numbers of Syrians in their country are reinforced by the higher fertility rates among the refugees. Health clinics confirm a high usage of gynaecology and obstetrics services by the refugees. At the same time, the UNHCR support to pregnant and lactating women is seen by some as an incentive for the refugees to bear more children. Family planning on the other hand is not handled very well by healthcare workers. In many cases doctors and social workers shy away from discussing reproductive health or approach the topic without the needed sensitivity.
Lebanese health workers and patients both complain about the lack of hygiene among the refugees. With little consideration of the often sub-standard living conditions and frequent lack of water and sanitation facilities available to refugees, medical staff and Lebanese patients do not appear to conceal their disgust.
This situation often charges the atmosphere in the waiting room and makes refugees feel mistreated.
Doctors and nurses in health clinics working with refugees are additionally concerned with the decreasing number of Lebanese patients, who choose to avoid the waiting rooms crowded with refugee women and children. In an attempt to keep their Lebanese patients, clinics have introduced various measures, such as allocating different waiting areas for Lebanese and Syrian patients, making appointments in different time slots or fast-tracking Lebanese patients. These measures mitigate the immediate tension in the waiting room. At the same time, however, some mitigation measures bring a risk of institutionalising preferential practices and ultimately further damaging the relationships between the refugees and the host communities.
Alert is working with its partners in Lebanon to search for a cure for the ailing, underfunded humanitarian response. With decreasing funding and the ever increasing number of refugees in-country, UNHCR and its partners would struggle to provide equal aid to Syrian refugees and vulnerable Lebanese.
One of the biggest priorities for all humanitarian actors, including the health clinics, should be to explain to the Lebanese population what type of aid reaches the refugees. A better understanding of the conditions in which many refugees live, as well as the difficulties of providing aid to displaced populations in the absence of refugee camps, the ever more rigid vulnerability criteria and the ever decreasing percentage of refugees that receive aid, would help bring back the empathy the Lebanese had toward the Syrians in the first months of the crisis.
Medical workers can also play an important role in mitigating conflict. They should be praised for working longer hours, serving a much higher number of patients and dealing with increased stress at the workplace. Likewise, nurses, administrators and doctors need to be offered support in dealing with the stress, improving their communication and dispute resolution skills and coping with the increased administrative demands related to the humanitarian funding.
Social workers and outreach staff affiliated with both health clinics and humanitarian organisations can more actively support trust-building between communities. By becoming better facilitators, seeing the benefit of engaging mixed groups of Syrians and Lebanese in their regular activities, and creating space for dialogue between refugees, members of the host community and the humanitarian agencies’ social and outreach workers can help bring the parties closer to each other.
As one study has shown, a quarter of the Lebanese nationals and a quarter of the Syrian refugees never came into contact with one another – an indication of a growing need for supporting dialogue and engagement.
Humanitarian agencies and their counterparts from the Lebanese government remain the primary decision-makers on the modality of humanitarian aid. A conflict-sensitive response would require understanding and commitment among decision-makers at strategic levels. The first step is to see both the positive and negative, both the intended and unintended impacts of humanitarian aid.