The ongoing Nakba: Sickness and health among Palestinian refugees in Lebanon

A Palestinian woman from Nahr al-Bared collects a bag full of basic supplies like soap, household cleaning items and toilet paper in Shatila refugee camp where her and many others are currently staying after fleeing the violence in Nahr al-Bared. She shouts to those around that the aid is not enough for her and her family who left Nahr al-Bared with nothing and are unable to work and provide such basic necessities for themselves, 9 August 2007. (Matthew Cassel)

Public health expert Michael Marmot underlines the relation between health and two fundamental human needs: autonomy and full social participation, adding that “deprived of a clean safe neighborhood, meaningful work, freedom from police harassment and arrest, and freedoms from violence and aggression, it is harder to have control over one’s life or be a full social participant.” [1] The values Marmot describes are ones that camp refugees in Lebanon — like Palestinians in many other places — do not have. That such conditions should be allowed to continue by the international community is in clear contravention of the first principle of the 1992 Rio Declaration: “Human beings are at the center of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature.”

Before looking at health, we must therefore look at politics. The two main factors that structure the situation of Palestinians in Lebanon — the majority who hold refugee IDs, and live in the camps — are insecurity and poverty. Local, regional and international forces combine to create a situation characterized by absence of autonomy, participation and hope. There has been no improvement on any aspect of well-being since 1982.

To keep refugee numbers to a minimum, the Lebanese state employs direct and indirect methods somewhat similar to the “silent transfer” system that Israel uses against Palestinian Jerusalemites, starting with insecurity of residence rights. Lebanon does not guarantee Palestinians this right until a solution to their problem as do most other Arab host countries; and the Ta’ef Accords of 1989 explicitly exclude them from permanent settlement. Long-term projects exist to demolish the camps. [2] In the south, Lebanese army checkpoints prevent materials for house construction or repair from entering the camps. The threat of demolition is always imminent, awaiting only an appropriate political moment.

Palestinians from Lebanon working abroad have been struck off the register of those entitled to residence. Palestinians who marry Lebanese women do not gain naturalization routinely as do other foreigners. Another point to note is the way any crisis in Lebanon rebounds negatively on Palestinians, politically and economically. Soon after the beginning of the Hizballah demonstration in December 2006, the Lebanese Forces issued a statement against towteen (a disguised way of attacking Palestinians). The economic impact of the crisis on camp households is becoming increasingly severe. [3]

Insecurity of Palestinians is also achieved through their exclusion from civic rights, the most basic being the right to work. [4] From the beginning the “free professions” have been closed to them (except by default within camp limits), as well as employment in public bodies. Most medium and even low-skilled jobs (for example guarding buildings) have been added to those prohibited to them. [5] When the state recently sought workers for the “public’ ” garbage-collecting company Sukleen, after the Israeli war of July/August 2006, Palestinian applicants were turned away. For all salaried employment, work permits are obligatory, and since 1982 few of these have been issued to Palestinian refugees. Denial of normal work rights is, of course, a major cause of refugee poverty.

Though the FAFO survey of 1999 reported only 17 percent of the Palestinian labor force as “unemployed” critics maintained that this figure was obtained through using inappropriate ILO measurements. [6] Taking into account the exclusion of most Palestinians from regular salaried employment the critics said that a more realistic estimate of unemployment is 80 percent. Some FAFO findings are clearly indicative of Lebanon field particularities: i) significant levels of “under-employment;” ii) highest unemployment among young adults; iii) the tendency of men from age 45 to drop out of the labour force, either because of disablement (33 percent), or having lost hope of work (17 percent).

In the area of income, FAFO researchers also found a huge difference between the refugees and the national population, with only six percent of Lebanese making less than LL3,600,000 ($2,400) per year compared with 44 percent of Palestinians in camps and gatherings. A majority of 70 percent of refugees fall into the bottom two income brackets compared with 20 percent of Lebanese. Only 2.5 percent of Palestinian households reach the higher levels (more than LL19,200,000 pa, $12,800) as against 25 percent of Lebanese. [7] Another indicative finding was that 35 percent of all camp households fall below the “poverty line” (LL 350,000 pa, $233.3), while 15 percent fall into the “ultra-poor” category (LL170,000 pa, $113.3). [8]

Woman-headed households are also most likely to be among the 15 percent of camp households classified as “ultra-poor.” Such households depend entirely on social aid, forming an extremely poor start for children, especially in terms of education and health.

Poverty has a direct impact on health, since it affects nutrition and all other aspects of the quality of life. But we should also consider the effects on health of the camps as habitat. The state excludes Palestinian camps from infrastructural services such as clean water, electricity, sewage disposal, garbage collection, street surfacing and lighting. The FAFO survey found that 14 percent of households had no sewage connection, and that seven percent lived in milieus where sewage lies in open ditches. Though the UN agency for Palestinian refugees UNRWA provides a basic minimum of hygienic services, the fact that the government has not allowed camp sewage and drainage networks to be linked to those serving municipalities causes constant back-up problems.

Space deprivation is another environmental hazard with clear consequences for health. In Lebanon camp space is restricted by the state’s prohibition of expansion, collective poverty, and the law against private ownership which prevents even the better-off from moving outside. Diminishing space-to-people ratios mean narrow streets, lack of light and ventilation. UNRWA schools are mainly rented buildings outside camps, and have minimal play space for children. The FAFO survey reported interviewees complaining of dust, humidity, noise, pollution from cars and industry. Rats and cockroaches are visible in camp alleys.

Housing quality is another environmental factor with implications for health. The 1999 FAFO study reports that housing conditions in the Lebanon field are the worst in the region. Most dwellings (96 percent) are built of concrete and light-weight materials, poor in insulation. Furthermore, 58.8 percent lack safe and stable drinking water; 13.9 percent lack sanitation, 45.7 percent lack electricity or a stable connection, 67.2 percent have a poor indoor environment. Most interviewees said their homes are cold in winter, hot in summer, and lack light and ventilation. A quarter of households use charcoal or wood for cooking and heating. There are obvious implications here for health — especially the health of those who spend most time at home, i.e. women and children. Women are likely to develop arthritic pain at relatively young ages, and children to suffer from respiratory problems. The continued use of charcoal fires and Primus apparatuses for cooking also carries health threats.

Lebanon must be set in the regional and international framework that produced and maintains the expulsion of the Palestinians when considering the specific conditions of Palestinians in this host country. US policy in Lebanon aims at reinforcing its hegemony over the region and guaranteeing Israel’s security, supporting the sector of the population that points to the camps as “islands of insecurity.” [9] What the Israelis and the Lebanese Forces failed to achieve in 1982, i.e. the elimination of the Palestinians as an oppositional force, the US continues to work for through other means, such as pressure for the disarmament of Hizballah.

The international framework has other kinds of negative impact. Since 1982 international donors have reduced their support for refugee communities outside the Occupied Territories. This reduction is most serious for camps in Lebanon because of their dependence on international aid. Another example of aid-reduction is that East European countries no longer offer low cost university training to Palestinian students. Emigration no longer offers an escape, since countries which once accepted Palestinian asylum-seekers have closed their doors.

On the regional level, the closing off of work migration to the oil-producing countries has impacted more severely on Palestinians from Lebanon than elsewhere because of their relative exclusion from the Lebanese labor market. Travel for Palestinians from Lebanon to any other part of the Arab menfah is impeded through prohibitions and the high cost of entry and transit visas. Aid from public Palestinian sources has also declined since Oslo.

International, regional and local forces thus combine to create a situation where autonomy and participation are distant dreams. The refugees are trapped between a host country that rejects them and an outside world that refuses them entry. The health implications of such a situation clearly go beyond available statistics concerning health service provision, demographics and morbidity.

Health services

Camp refugees depend on UNRWA as main health service provider. From the perspective of its users the problem with UNRWA is its fluctuating health budget, and the fact that it cannot cover hospital treatment or the more expensive medical procedures. For hard cases such as cancer, people have to knock on the doors of NGOs, charities, and patrons. The Red Crescent Society provides hospital care in some camps, but a low budget limits its scope and professionalism. NGOs offer a gamut of medical services, such as remedial therapy, help to drug-takers, and mobile clinics, but though such plurality increases service availability, it remains uncoordinated and under-funded, so that there is little development of services to fill gaps or meet new needs. In spite of accumulated war-stress, there is still no psychological counseling such as exists in the West Bank.

Because of its cost, no comprehensive survey of refugee morbidity has been carried out. A number of partial studies exist including the FAFO survey of 1999, based on 4,000 households, and using self-assessment. This and other smaller studies are valuable in conveying refugee perceptions of health, sickness and health providers, but are limited as to kinds and incidence of ill-health. [10]

Yet grassroots health campaigns are a positive sign of growing community self-care. In late March 2007 the Women’s Humanitarian Organization (based in Bourj al-Barajneh camp) animated three days of activities centered on breast-feeding and health foods resurrected from the traditional Palestinian rural diet.

Major health problems

The FAFO survey reports that the refugee health situation in Lebanon is characterized by a higher incidence of health failure and more mental distress than in Jordan. [11] Sixteen percent of interviewees in Lebanon assessed their health as “bad” or “very bad” in Lebanon compared to five percent in Jordan. The relationship between war and bad health comes out clearly here, with 19 percent of Lebanon interviewees reporting prolonged or chronic illness due to war, and nine percent reporting war-caused disability. Low-quality dwelling was found to correlate strongly with distress, especially for women. Women reported more stress symptoms than men. Another significant finding was that 11 percent of interviewees had suffered an acute illness in the two weeks before the interview, while 53 percent of children under five included in the survey were reported as having been acutely ill in the same two-week period. Members of poor households were three times likelier to report poor health.

Camp dwellers and medical personnel interviewed by Giulia El Dardiry (2005) perceived a rise in the incidence of serious, non-contagious diseases, especially heart and kidney problems, diabetes, cancer, and hypertension.

Asked to assess their own health on a scale of five, 16 percent of the FAFO interviewees said “bad” or “very bad.” Between 17 and 61 percent of the population stated that they had suffered from at least one symptom of psychological distress in the week preceding the survey, and roughly a quarter said that they had experienced feelings of “hopelessness about the future.” In addition 27 percent had said that they were bothered “quite a bit” or “very much” by between five and seven symptoms of distress.

El Dardiry points to the elderly as suffering from loneliness and depression. She quotes from an elderly speaker in Wavell camp:

It is very cold in winter and this is very hard for the elderly. It is hard to go to the bathroom and wash because of how cold it is. Most elderly just stay in their beds and cover themselves with blankets the whole winter. It is also dangerous because it rains and snows and we have to be careful not to slip on our way to the bathroom.
Another unusual finding of the El Dardiry report is that depression is given as a cause of death: “Depression — people thinking they have no home, because this land is not theirs.” An interviewee in Wavell camp told her, “The political situation is killing us. There is no hope. Life is shorter because there is no reason to live.”

Even with the limited data we have, it is evident that the health of certain categories in the camps in Lebanon are especially at risk, particularly children, the elderly, and adolescents. Children’s health status needs special research attention, first because of decline in income and nutrition standards, then because of the strain put on family relations by harsh conditions. Very young children in camps have been found sniffing glue, supplied by barrows that sell cheap toys and cassettes. Adolescents and young adults are especially likely to suffer depression caused by hopelessness about the future. Drugs and self-mutilation are a problem with this age group.

What can be done to improve health conditions? Asked this question by El Dardiry, camp people’s responses in order of frequency were:

  • make medication free;
  • provide funds for costly treatment;
  • improve UNRWA services;
  • create jobs.
  • Better coordination between the different service-providers in Lebanon, as well as in Palestine, would be an inexpensive first step. More research is clearly needed, and could be directed first towards social categories particularly at risk. Public education campaigns targeted at the Lebanese on the refugees’ equal rights to health might ease the isolation of camp communities. Yet of course the real solution is political, i.e. an end to Palestinian insecurity and poverty through repatriation.

    Rosemary Sayigh is an anthropologist and oral historian living in Beirut, author of Palestinians: From Peasants to Revolutionaries (1979) and Too Many Enemies: The Palestinian Experience in Lebanon (1994).

    This article originally appeared in Al-Majdal, a quarterly magazine published by the BADIL Resource Center for Palestinian Residency and Refugee Rights, Issue No. 34 (Summer 2007).

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  • Endnotes
    [1] Michael Marmot, “Status Syndrome: A Challenge to Medicine” Journal of the American Medical Association, vol 295 (11), 15 March 2006.
    [2] Camps near Beirut and in the south are the ones specially targeted. In the case of Bourj al-Barajneh camp, a freeway has been built along the northern edge of the camp, causing the demolition of around 40 homes and destruction of playing space for children. There are long-standing plans to expand facilities for the Sports City on land currently occupied by Shatila camp.
    [3] “Cash-strapped Palestinians see livelihoods decimated by security crisis,” United Nations Office for the Coordination of Humanitarian Affairs - Integrated Regional Information Networks, 22 April 2007.
    [4] See Petter Aasheim “The Palestinian refugees and the right to work in Lebanon,” University of Lund, 2000; and Souheil Natour “The Legal Status of Palestinians in Lebanon,” Journal of Refugee Studies vol 10 (3) 1997. A recent Lebanese law (2002) forbids Palestinians from buying any kind of property.
    [5] In late 2006, a resigning Minister of Labor lifted the ban from some jobs. But the necessity for work permits remains, and of paying social security from which Palestinians cannot benefit.
    [6] FAFO survey results are reported in Ole Ugland ed., Difficult Past, Uncertain Future: Living Conditions Among Palestinian Refugees in camps and Gatherings in Lebanon, Oslo: FAFO, 2003.
    [7] Ugland p. 159-160.
    [8] Incomes within camps were found to be highly skewed, with the upper tenth earning 32 percent of total income, and the poorest tenth earning just one percent of total income. Two in every ten households relied on transfers and social aid as the main source of income (Ugland p. 158).
    [9] This phrase is not intended to mean that the camps are insecure for their residents but that they threaten the citizens and political stability of Lebanon.
    [10] See Giulia El Dardiry “Between Personal Experience and Communal History: Health Perceptions and Attitudes Towards Health Services in Two Palestinian Refugee Camps in Lebanon,” Institute for Community and Public Health, Birzeit University, 2005, for a comprehensive list of health studies.
    [11] Age A. Tiltnes “Health and Health Services” in Ugland op cit, p. 75.