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Jirmanus L. Victims of a broken system: a Syrian refugee family’s struggle for healthcare in Lebanon. Harvard Public Health Review. Spring 2016;9.
A day in the life of a Syrian refugee family in Lebanon offers a glimpse of a young girl’s encounter with the costly Lebanese health system. As the international community slowly responds to a crisis five years in the making, Syrian refugees must struggle for their survival daily.
On Wednesday morning, the small clinic in the southern suburbs of Beirut, Lebanon is bustling. I am seated in the office of the social worker, discussing a study protocol, when a woman arrives dressed in black. She is roughly in her mid-forties and walks in crying. She holds the hand of a small girl, about five years old. I rise to offer her my seat, but she shakes her head and insists no.
I have worked in the clinic for six months, supervising family medicine residents and seeing patients, but have never met this woman before. I learn that her name is Ameena. She is a Syrian refugee originally from Homs, once the third largest city in Syria and a major industrial center, now an opposition stronghold and the site of much bloodshed. She tells her latest story to the social worker. “Now Zeina also has a urine infection. She will also have to go to the hospital for treatment. I already have her sister in the hospital, and now this one.”
The social worker hands me a paper, the results of a urine culture. E. coli greater than 100,000 colonies, a positive culture. My eyes scan over the antibiotic sensitivities below: Ampicillin – Resistant, Cefipime – Resistant, Cefuroxime – Resistant, Cephalexin – Resistant, Ciprofloxacin – Resistant, Trimethoprim-Sulfamethoxazole – Resistant…Imipenem – Sensitive. The bacteria is resistant to first, second, and even third-line agents. Zeina has a urine infection caused by an extended-spectrum beta-lactamase producing bacteria, a multi-drug-resistant bacteria. This is the third case in six months at the small clinic of 5000 patients.
Antimicrobial resistance is on the rise in Lebanon (Araj et al., 2012; Daoud, Salem Sokhn, Masri, Matar, & Doron, 2015; Kanafani, Mehio-Sibai, Araj, Kanaan, & Kanj, 2005; Moubareck et al., 2005). Although infections with drug-resistant bacteria tend to be more common in hospitalized and chronically ill patients, isolates of drug-resistant bacteria have also been found throughout Lebanese communities (Moubareck et al., 2005). Antimicrobial resistance has long been recognized as a global public health problem, which the World Health Organization notes is principally driven by the inappropriate use of antimicrobials (World Health Organization, 2001). Lebanon has a law against the dispensation of antibiotics without a prescription (Ordre des pharmaciens du Liban, 1994), but it is not enforced. Studies have demonstrated that 42% of patients purchased medications in Beirut pharmacies without a prescription (Cheaito, Azizi, Saleh, & Salameh, 2014), and the majority of antibiotic regimens purchased were inappropriate for the condition (Saleh et al., 2015). The top two reasons cited by participants for self-medication were to save time and money (Cheaito et al., 2014).
Nearly half of the people in Lebanon are uninsured, yet the vast majority of hospital beds and primary care clinics are privatized, making access to care difficult and costly (World Health Organization Regional Office for the Eastern Mediterranean (WHO EMRO), 2010). Syrian refugees in Lebanon, like underprivileged Lebanese, must rely on the health safety net, a patchwork of low-cost clinics run by the Lebanese Ministry of Public Health and non-governmental organizations (NGOs). With 1.5 million Syrians in Lebanon, Syrian refugees now make up one-fourth of the country’s population (United Nations High Commissioner for Refugees, United Nations Development Program, & United Nations Development Group, 2015), placing an immense strain on this under-resourced safety net. The high cost of care in Lebanon even drives some refugees, at great risk to their safety, back to Syria (Amnesty International, 2014), where they can receive health care for little to no cost (World Health Organization & Syrian Ministry of Health, 2013). Once a member of a Syrian middle-class family, Zeina is now doubly vulnerable: first to multi-drug-resistant infections, and then to unaffordable medical bills.
I look at the little girl. She stands almost too still, her hand on the corner of the desk, looking down. I review the urinalysis results. It does appear to be an infection as opposed to bacteria in the urine without symptoms, which would not need to be treated. “Does it burn when you pee?” I ask the girl. She is too shy to respond. Ameena, her aunt, confirms that she indeed has symptoms of a urinary tract infection, an uncommon infection for her age.
“I can’t afford this,” pleads Ameena. “Her sister is already in the hospital and last week my brother collapsed in front of the house with a heart attack.” The social worker presses her lips together in thought, looking down at her desk. She has heard this story before, from this woman and many others in the neighborhood.
According to the United Nations High Commissioner for Refugees (UNHCR) Guidelines for Referral Health Care in Lebanon, Syrian refugees are only eligible for coverage of secondary and tertiary care if a physician determines “life or basic functions are at stake.” Furthermore, barring exceptional circumstances, the UN only pays 75% of the hospital bill, while refugees are expected to pay the remaining 25% (UNHCR, 2015). This 25% is often beyond the means of refugee families who struggle to make ends meet in Lebanon where there are no formal refugee camps1 , and refugees face the difficult choice between buying food or paying the rent (Amnesty International, 2014).
The social worker promises to work on the case and Ameena and her niece step out. She explains further. “This family is in such a difficult situation. There are two brothers. Her brother who collapsed, Mohammad, was a lawyer in Syria but he can’t find work here. Her brothers were both prescribed cholesterol and blood pressure medicines by the doctor here, but they were too ashamed to tell us that they couldn’t afford it, so they would split one box of pills for the month between them. Mohammad was having chest pain and needed a catheterization, but the UN determined it was not immediately life threatening. He is only forty-five years old. And then, last week, he collapsed in his house with a heart attack. Then he was hospitalized for three days.”
Chronic illness is best managed with continuity of care. Such care lowers mortality rates and reduces the number of subsequent hospitalizations (Nyweide et al., 2013; Wolinsky et al., 2010). However, the overwhelmingly privatized and costly Lebanese health system makes it difficult for Syrian refugees to access medical care, necessary tests, and medicines. Mohammad was unable to afford a monthly supply of simvastatin, a generic cholesterol-lowering medication. The least expensive option available in Lebanon is about eight U.S. dollars for twenty-eight tablets of simvastatin (Lebanese Ministry of Public Health), which was still too costly for this Syrian family. In the United States, this common medication is available at about a third of this price (Drugs.com, 2015). The UN attempts to curb health expenditures by restricting refugees’ access to secondary and tertiary care and not providing free chronic disease medications. However, in some cases this may lead to increased future healthcare spending. Mohammad’s situation resembles that of his niece Zeina. He is doubly a victim of a failing healthcare system, which first prices an essential medicine out of reach, and second forces him to struggle to pay an expensive hospital bill.
Leaving the clinic, I encounter Ameena chatting with a neighbor in the waiting room, and she invites me to her house for coffee. I follow her to her home, located steps from the clinic. Her sister and sister-in-law are seated on the carpet and rise to greet me. The apartment is sparse, but clean; it consists of two rooms furnished with only a couple cushions and mattresses.
“We are always arguing with the neighbors,” Ameena says. “They won’t let us go upstairs to check the water tank, when there is no water.” “Look,” she says, as I follow her into the closet-like kitchen. There is barely enough room for the two of us to stand. The sink and limited counter and floor space are packed with glass and plastic bottles filled with water. She opens the faucet. Not a drip. “We pay $200 a month for rent, water, and electricity, but the power rarely comes and you see, we haven’t had water for a month.”
Ameena explains that she fills water jugs at the tank up the road, which is trucked in a few times a week by an international NGO. “But sometimes, the Lebanese won’t let us fill water. It is not their tank to decide, but there is a shop owner, or sometimes even just a boy, less than ten years old, who stands there and tells us, ‘No, you can’t fill today.’”
Social tensions between Lebanese host communities and Syrian refugees have grown in the past few years as Lebanese and Syrian workers compete over jobs. The increased demand for rented accommodation results in rising rents, and prices of basic commodities soar in response to the injection of cash and food/cash vouchers for refugees. (International Labor Organization Regional Office for Arab States, 2014; Mercy Corps, 2013; Tan, 2015; World Bank, 2013). According to a 2014 survey, 90% of Lebanese nationals perceive Syrian refugees as threats to their economic livelihood, and two-thirds see Syrians as an existential threat (Harb & Saab, 2014). As Syrian refugees settle primarily in the poorest parts of the country, the lack of a social safety net for the Lebanese becomes even more glaring, and competition over limited resources pushes people farther apart.
Ameena’s sister Reem brings a tray with small cups and a pot of Arabic coffee to the room. As we sip the strong coffee, Ameena explains her story further: “My brother Mohammad was a lawyer in Syria. We are not beggars. He cannot work here as a lawyer, so he is working in a telephone store. But he can’t even work here legally. We have to sign a document swearing we won’t work if we want a visa now.”
Ameena is referring to a policy enacted in early 2015 by the Lebanese government in an attempt to stem the growing tide of Syrian refugees. The government now requires Syrians to obtain visas when entering the country. When renewing or obtaining residency permits, Syrians must pay a fee of two hundred U.S. dollars and provide several documents, including a signed pledge not to work and a rental agreement from their landlord (Holmes, 2015). Lebanon is not a signatory to the 1951 UN Convention Relating to the Status of Refugees (United Nations, 1951), and as such does not even formally recognize Syrians as refugees.
“How can we pay the $200, if we can’t work to make the money? Where do they think we get money from?” Ameena says. Her question echoes the fundamental quandary of the Syrian refugee crisis. The international community’s management of the Syrian crisis traps individuals in irresolvable contradictions. As European countries and the United States slowly accept Syrian refugees, a more comprehensive international approach for resettlement of Syrian refugees is needed, such as the Comprehensive Plan of Action outlined by Akram in 2014 (Akram et al., 2014). Furthermore, a serious international commitment must be made to resolve the Syrian conflict as soon as possible. It is difficult to overestimate the stakes, as the involvement of regional and international actors in the Syrian conflict already threatens the stability of the entire Middle East. The international community must support Lebanon, Turkey and Jordan to prioritize job creation and basic service provision for their own populations as well as the 4.6 million Syrian refugees. Such an endeavor is critical to the future security and prosperity of the region. The 3RP plan of the UNHCR and the UN Development Program takes an important step by integrating humanitarian assistance for Syrian refugees with support for institutions in the most impacted countries (UNHCR et al., 2015). As host countries and international NGOs do their best to provide services beyond their means, it is the individuals, like Ameena, Zeina, and Mohammad, who must battle daily for survival in the face of seemingly impossible odds.
Akram, S., Bidinger, S., Lang, A., Hites, D., Kuzmova, Y., & Noureddine, E. (2014). Protecting Syrian Refugees: Laws, Policies, and Global Responsibility Sharing. Retrieved from Boston: http://www.bu.edu/law/files/2015/07/FINALFullReport.pdf
Amnesty International. (2014). Agonizing Choices: Syrian Refugees in Need of Healthcare in Lebanon. Retrieved from London: https://www.amnesty.org/en/documents/MDE18/001/2014/en/
Araj, G. F., Avedissian, A. Z., Ayyash, N. S., Bey, H. A., El Asmar, R. G., Hammoud, R. Z., Sabai, S. A. (2012). A reflection on bacterial resistance to antimicrobial agents at a major tertiary care center in Lebanon over a decade. J Med Liban, 60(3), 125-135.
Cheaito, L., Azizi, S., Saleh, N., & Salameh, P. (2014). Assessment of self-medication in population buying antibiotics in pharmacies: a pilot study from Beirut and its suburbs. Int J Public Health, 59(2), 319-327. doi:10.1007/s00038-013-0493-y.
Daoud, Z., Salem Sokhn, E., Masri, K., Matar, G. M., & Doron, S. (2015). Escherichia coli Isolated from Urinary Tract Infections of Lebanese Patients between 2005 and 2012: Epidemiology and Profiles of Resistance. Front Med (Lausanne), 2, 26. doi:10.3389/fmed.2015.00026.
Drugs.com. (2015). Simvastatin Prices, Coupons and Patient Assistance Programs. Price Guide. Retrieved from http://www.drugs.com/price-guide/simvastatin.
Harb, C., & Saab, R. (2014). Social Cohesion and Intergroup Relations: Syrian Refugees and Lebanese Nationals in the Bekaa and Akkar. Retrieved from Beirut, Lebanon: http://data.unhcr.org/syrianrefugees/download.php?id=5807.
Holmes, O. (2015, 17 April 2015). New restrictions in Lebanon mean Syrian refugees live in fear. Reuters. Retrieved from http://www.reuters.com/article/2015/04/17/us-mideast-crisis-lebanon-refugees-idUSKBN0N819Z20150417 – CCule62OZCajsLUL.97.
International Labor Organization Regional Office for Arab States. (2014). Assessment of the Impact of Syrian Refugees in Lebanon and their Employment Profile. Retrieved from Beirut: http://www.ilo.org/…/wcms_240134.pdf.
Kanafani, Z. A., Mehio-Sibai, A., Araj, G. F., Kanaan, M., & Kanj, S. S. (2005). Epidemiology and risk factors for extended-spectrum beta-lactamase-producing organisms: a case control study at a tertiary care center in Lebanon. Am J Infect Control, 33(6), 326-332. doi:10.1016/j.ajic.2005.03.009.
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Tan, C. (2015). The Syrian Refugee Crisis: Conflicts in the Making. IEMed Mediterranean Yearbook 2015, 307-311. Retrieved from http://www.iemed.org/observatori/arees-danalisi/arxius-adjunts/anuari/med.2015/IEMed Yearbook 2015_Panorama_SyrianRefugeeCrisis_CarolTan.pdf.
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1 Although the conceptual definition of a refugee camp is debated in the literature, the words “refugee camp” often refer to a temporary settlement administered by the local government, an international NGO or the UN, where refugees are isolated from the host population, receive assistance in an organized manner, and where freedom of movement is limited. In Lebanon, the government has decided against constructing or condoning the establishment of refugee camps. Refugees have settled in informal tented settlements in rural areas of the country not formally sanctioned by the Lebanese government. In contrast, the Zaatari refugee camp in Jordan was built and is administered by the Jordanian government with the support of UNHCR. NGOs deliver services, and refugees run business inside the sprawling settlement, isolated from the Jordanian population. It should be noted, however, that 88% of Syrian refugees across the Middle East choose to live outside of refugee camps, in urban areas integrated with the local populations.
Lara Jirmanus MD, MPH is primary care physician in the Family Medicine Department at the Cambridge Health Alliance. She has been involved in grassroots organizing, advocacy and research for many years, addressing worker and immigrant rights in the US, social movements and infectious diseases in Brazil and the impacts of conflict and displacement in the Middle East. Her current research focuses on the health of Syrian refugees and host populations in Lebanon, as well as the Dom, the Middle Eastern Roma. After graduating from the University of Massachusetts Medical School, she completed a residency in family medicine at the Boston University Medical Center, a fellowship in Global Women’s Health at Brigham and Women’s Hospital, and earned an MPH at the Harvard T. H. Chan School of Public Health. Dr. Jirmanus served as chief resident in Family Medicine at the American University of Beirut in Lebanon and taught a course in global health and social medicine at the American University of Beirut Medical School.During the 2016-2017 academic year she led an interdisciplinary seminar on the Syrian refugee crisis with the Harvard FXB Center and the Middle East Initiative at Harvard Kennedy School.
She is currently engaged in a community-based participatory research project with Lebanese, Dom and Syrian refugee residents in an urban slum in Beirut, as well as a study of the quality of primary care in Lebanon.
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