Published here as part of MAP's Notes from the Field.
MAP-UNRWA partnership in Ein el-Hilweh, Lebanon: the impact of increased population on camp clinics
On entering Ein el-Hilweh through its main checkpoint, the change in environment is felt immediately, viscerally. The smooth roads of Saida turn into pot-holed streets that shake the car and shudder through your body. The UNRWA Clinic is one of the first buildings on this main road, its outer wall painted with bright figures holding a sign that reads ‘Together your health is better’.
Dr Ali Dakwar, who has been driving me, is the Project Coordinator for MAP’s Maternal and Child Health initiative, and he brings me to the clinic to have a look around. Upstairs is the mother and baby section, and downstairs is General Practice. The clinic is white and clean inside, and already busy on a Thursday morning – groups are milling in reception, queueing up at the desk and waiting to see the doctors. I am introduced to Dr Mahmoud Suleiman, the Senior Medical Officer of this clinic (one of two in Ein el-Hilweh), and a tall and kindly man. He has spent the last decade working for UNRWA, and 8 of these years in the camp.
Dr Suleiman and Dr Ali, with midwives Nadine and Saria Dr Suleiman breaks down for me the running of the clinic. There are 3 full-time doctors, 1 dentist and 2 visiting specialists in gynaecology and cardiology. The two UNRWA clinics share a lab, a radiology centre and 2 ultrasound machines between them. While resources are stretched by the sheer size of the community this clinic caters for, supplies are available and equipment is good; it is manpower the clinics lack. I am shocked by how overstretched the staff here are. In the UK, a GP will see on average 30-40 patients per day; my local surgery keeps appointments to 10-15 minutes per person. In the UNRWA clinics, Dr Suleiman tells me, in February 2014 doctors saw an average of 172 patients per day, for just a couple of minutes at a time. It is difficult to overstate the limitations of these kinds of numbers. For the doctor, there is almost no time to do more than scan the patient’s file. Proper physical examination cannot take place; indeed, there is no time to do much more than jot down the patient’s symptoms and propose treatment; these highly qualified practitioners are often unable to do much more than dispense medication. For the patient, there is little time to build up trust with the doctor, to relax in their presence, to confide in him or her. With barely enough time for proper physiological care, the doctors are hard pushed to treat attendant psycho-social problems among their patients.
Before the Syrian crisis, the clinic was already feeling the pressure of numbers. Approximately 60,000 Lebanese Palestinians lived in Ein el-Hilweh, in a space just 1km square. With the influx of Palestinian Syrians into Lebanon, thousands more have found their way into the camps. Of the 172 patients each doctor treated per day this February, 27 of these were Palestinians from Syria, representing a swell in patient numbers by 15%. Crucially, Syrian patients take 2 to 3 times longer to treat, Dr Suleiman tells me, because they have no existing file with the clinic. These patients are used to certain medication, certain diets, as prescribed in Syria. Now in Lebanon, treatment may be quite different, and in the extremely poor conditions within the camp, their diet uncontrollable – most Palestinian Refugees from Syria (PRS) come with little money and few resources, and simply have to eat what they find. Patients often have little exact information about their pre-existing conditions, and as the working medical language in Syria is Arabic they have difficulty articulating technical terms in the English-dominant Lebanese clinics. The extra time taken to establish files and histories for PRS patients contributes to the resentment felt for these recent refugees within the camp by members of its pre-existing population. While there are many tales of generosity and kindness towards PRS – families welcoming others into their homes, sharing meals – reports of discrimination are rife.
Dr Suleiman stresses that the greatest impact experienced by the doctors is the absolute absence of time to build trust with a patient. PRS are less embedded in the local community, scared and unwilling to trust others, and need time to open up with the doctors. In Ein el-Hilweh, unfortunately, there is no such time. Perhaps predictably, hypertension – dangerously high blood pressure – is a frequent problem in the camp. Often caused by stress, Dr Suleiman’s careful statistics report higher rates among PRS patients, who are then at risk of stroke and diabetes. The environment in Ein el-Hilweh is significantly poorer than the camps in Syria from which many originated. Many of the PRS I met on my visit came to Lebanon from Yarmouk, in Damascus. Although Yarmouk is recognised as a camp, there are no tents or slums, and in practice it is a residential area, a suburb of the city. Refugees described to me their very journey from Syria as distressing, so arrival at Ein el-Hilweh has no doubt induced a double displacement – into both a foreign country as refugees, and into a camp where a huge proportion live below the poverty line.
The camp’s chronic overcrowding has only been aggravated by new arrivals, with an impact felt by the doctors in the clinic. Cases of scabies and Hepatitis A have risen sharply, along with other diseases that are contracted via oral-fecal means. Hygiene in the camp is generally very poor – in one section hundreds of Syrian refugees have created makeshift shelters beyond its official boundaries. The slum’s basic bathrooms are slick with mud, and hung with a permanent stench. The public kitchen consists of little more than a steel sink and a couple of hobs, servicing the entire population. A rubbish tip ferments in the heat at its perimeter. Homes are little more than tents, which flood when it rains and freeze when the temperature drops. Stone floors are masked by thin mats, and people live ten to a room in places. In such conditions, it is no wonder people fall ill. Children play barefoot in what is, effectively, an open sewer. Rigorous hygiene – crucial to a patient’s care, and central to the prevention of further infection – is almost impossible to practice. As both Dr Ali and Dr Suleiman attest sadly, the socio-economic situation of the refugees has a direct impact upon their health, and vice versa.
This is where MAP comes in. When extra funds are required for surgery, MAP’s Tertiary Care scheme shares the cost with UNRWA. While midwives and antenatal doctors are busy in the clinic, MAP’s team of midwives make regular home visits to pregnant and nursing mothers. When UNRWA needs nurses for stations all over Lebanon, MAP contributes when possible to the cost of their training. As Dr Ali puts it, MAP exists to ‘fill gaps’ on the ground. It became clear on my visit that the partnership between MAP and UNRWA is very strong, and absolutely crucial to the smooth running of health facilities in Ein el-Hilweh. The success of this partnership is facilitated in large part by Dr Ali himself, who was the Chief of UNRWA’s Field Health Programme in Lebanon for years before moving to MAP.
Both UNRWA and MAP also work to empower local agents. The Community Mothers scheme boosts the professional midwifery practice with local mothers who support their neighbours with newborn babies. I was struck continuously by the resilience and dedication of all the medical professionals I met at the clinic; and by the high standards of care patients received – and to which they themselves attest. The quality and commitment of the doctors, however, is not enough to change the conditions in which they operate – their good work is restricted by the sheer numbers of refugees, and the camp’s conditions. Though I have no doubt in the excellence and perseverance of Dr Suleiman and his team, I fear for their future. With no end to the Syrian crisis in sight, it is both unjust and counter-productive for the most marginalised and underprivileged of Lebanese and Palestinian communities to bear the brunt of its horror. In Ein el-Hilweh, and in its clinics, this is life as they know it.
Please note, the citation for the quotation about Yarmouk Camp in Damascus: Lina Sinjab, ‘Lure of the homeland fades for Palestinian refugees’, 24th August 2010, BBC News, Damascus
Thumbnail image is of Ein el-Hilweh by Stefan Christoff, published in Electronic Intifada here