Lebanon: Precarious living conditions make daily life a struggle

© Dina Debbas

Since the end of 2008, MSF has been running a mental health programme for the most vulnerable Palestinian and Lebanese people in and around Burj el-Barajneh camp in Lebanon. Over the past two years, more than 1,000 people have been treated in the programme, which is based on a community approach, bringing together psychiatric and psychological care with social and community support to foster good mental health.

 
© Dina Debbas Palestinian refugees:
Shut out from society


There are 4.7 million Palestinian refugees registered with the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA), the agency set up to provide assistance to them. Under their definition, Palestinian refugees are those who lived in Palestine under the British mandate but lost their homes and livelihoods as a result of the 1948 Arab-Israeli conflict, as well as their descendants.

In Lebanon, Palestinian refugees have no legal protection, owing to the Lebanese state’s refusal to sign the 1951 Convention Relating to the Status of Refugees. Palestinian refugees are banned by law from practising in more than 20 professions, including as doctors, lawyers, engineers and accountants. Their social and civic rights are non-existent in Lebanon, and their access to public health services and education is limited. The vast majority of Palestinian refugees in Lebanon rely on UNRWA for education, health and social services.

Millions of Palestinian refugees still live in camps, where - more than 60 years after being forced to leave their homes - they face a future of seemingly unending exile. More than 200,000 Palestinian refugees are registered in Lebanon, about half of whom live in a dozen camps dotted around the country. Some 60 percent of Palestinian refugees are unemployed and a similar number live below the poverty line, according to figures from UNRWA.

Squeezed between the airport and Beirut’s southern suburbs, Burj el-Barajneh camp is the capital’s most densely populated area, home to some 18,000 people living in a space of just one square kilometre.  

When the state of Israel was created in 1948, hundreds of thousands of Palestinians were forced into exile. The Burj el-Barajneh camp, set up by the League of Red Cross Societies, took in refugees mainly from Galilee. Since then, the camp’s population has expanded year on year, with the arrival of migrants from elsewhere in Lebanon, as well as refugees from Syria, Egypt and Iraq.

A community-based approach
MSF’s community-based mental health programme, which opened in December 2008, has been alone in offering free consultations in the refugee camp and its vicinity. Since then, the services have also been provided inside the facilities of the main health providers in the camp: the Palestinian Red Crescent Society (PRCS) and the United Nations Relief and Works Agency.  

By breaking the taboos associated with mental health issues, and by giving individuals support and lending them a sympathetic ear, people are beginning to bring their troubles out into the open. A team made up of international, Lebanese and Palestinian staff is providing psychological, psychiatric and social support to the most vulnerable people, regardless of their gender, nationality or religious and political convictions.

In 2009 and 2010, more than 1,000 patients had consultations with MSF’s psychologists and psychiatrists, the majority of them Palestinian and Lebanese women aged between 25 and 40 (60 percent).  

Many of the camp’s residents have been deeply affected by successive wars and conflict, their prospects for the future are bleak, employment is hard to come by, and most suffer difficult living conditions and a precarious socio-economic situation. In such an environment, depression is very common, affecting almost one-third of patients seen, while others are affected by anxiety (22 percent of patients), psychosis (14 percent of patients), bipolar disorders (10 percent of patients) and personality disorders.

“MSF always tries to set up a community-based and multi-disciplinary approach,” said Pierre Bastin, MSF’s mental health advisor in Geneva. “This means that we do not limit ourselves to prescribing drugs, but try to provide comprehensive bio-psycho-social care.

“We like using this model. As the factors behind the illness are of a biological, psychological and social nature, so the treatment must also address these three issues. In practical terms, this means that the biological factor will be treated with drugs by the psychiatrist, and the psychological aspect will be treated by the psychologist working with the patient and possibly relatives. As for the social side, there are also social conditions that must be addressed to help the patient improve.”

 
© Dina Debbas

The lingering effects of war
Although the July 2006 Lebanon War is in the past, its effects are still very real. During the conflict, MSF discovered, to its concern, that one in six people in the country were in need of psychological care, in a country where the provision of mental healthcare was extremely limited.

According to a national survey published in the Lancet in 2006, mental disorders are no more common in Lebanon than they are in Western Europe, but the number of people not receiving treatment is far higher in Lebanon than in the West. The Lebanese healthcare system is dominated by the private sector, and treatment is expensive. Mental healthcare is available mainly for children, whilst adults - and especially refugees - can rarely access the treatment they need.

According to MSF’s head of mission in Lebanon, Fabio Forgione, “The people we wish to reach with our mental health project are Palestinian refugees from the Burj el-Barajneh camp. Precarious living conditions make daily life a struggle in Burj el-Barajneh, the main reason being that Burj el-Barajneh is one of the most densely populated and deprived camps in Lebanon.

“Although there have been slight improvements in terms of working opportunities - since a law decree approved by the Lebanese Parliament on  August 17, 2010 - general conditions for Palestinian refugees in Lebanon remain deplorable. Policies still applied towards the Palestinian refugee community are restrictive in terms of access to health, education, employment, social services and property ownership. All of this has a serious impact on people’s emotional stability, and there is a huge demand for psychological support.”

 
© Dina Debbas

Precarious living conditions

Residents of Burj el-Barajneh have mostly sought refuge in the camp from a difficult economic, political or social situation. Some left their homes and countries more than 60 years ago; others have just arrived. The stress of living in these surroundings compounds the feelings of trauma and isolation already experienced by so many of the camp’s residents.

“Life is a daily struggle in Burj el-Barajneh. Social exclusion, coupled with the extremely poor living conditions experienced by its residents, remarkably increases the degree of precariousness, exposing many refugees to a dire, traumatic and discouraging daily life,” said Fabio Forgione. “MSF’s operational decision specifically to target the adult population is based on the exposure of this population to past and repeated traumatic experiences of conflict and displacement, on the denial of their basic rights and on their struggle to cope with the permanent nature of what should be a temporary situation.

“This is why the multi-disciplinary approach of the MSF team has made, and continues to make, a difference. Besides the delivery of mental healthcare, the MSF team is engaged in identifying social, legal and economic support among a broad network of partner organisations, which can enable patients to tackle the root causes of their burden of suffering.”

In the camp, water and power are available for only a few hours a day. Despite the water shortages, the alleyways are often flooded, because inadequate drainage systems mean that excess water from tanks and rooftops sits stagnant in the streets. Tangled skeins of electric cables hang between buildings, and the average room is shared by four people. Rain in the winter and scorching heat in the summer add to the problems of these overcrowded living conditions.

 
© Dina Debbas

No health without mental health
Good mental health is the cornerstone of an individual and community’s wellbeing. MSF’s medical teams offer care and social support through home visits as well as consultations in its consultations rooms and clinic. Visits to the specialised mental health clinic are constantly increasing, while MSF also ensures that mental healthcare forms part of the primary healthcare on offer in medical facilities throughout the camp.

This approach is helping to spread the idea that good mental health is an essential part of general physical health - because of its influence on the way people behave, perceive the world and interact with others. MSF’s psychologists and psychiatrists have given 8,023 consultations and provided mental healthcare for 1,160 patients since the project in Burj el-Barajneh began.