An informal dispensary visit in Majdal Anjar
Victims of a broken system: a Syrian refugee family’s struggle for healthcare in Lebanon
5 December 2023
Dr Lara Jirmanus [opens a new tab] was formally an instructor and residency program director at American University of Beirut – the ReBUILD for Resilience Partner in Lebanon. During the development of this article (originally published in HPHR journal – opens a new tab), she was supervising family medicine residents in a facility hosting healthcare provision for refugees. In that piece – which dates from 2016 but is still very relevant – she describes the daily struggle for survival of Syrian refugees in Lebanon. This edit focuses on their experiences of the fractured health system. Since publication, Lebanon has undergone a series of crises, including an economic collapse, and the challenges described have been amplified and multiplied. Vulnerable Lebanese families have now also joined the cohort of people for whom the formal health system fails to meet basic health needs.
On Wednesday morning, the small clinic in the southern suburbs of Beirut, Lebanon is bustling. I am seated in the office of a social worker 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, her niece, who is about five years old. Ameena is a Syrian refugee, originally from Homs. She explains, “Zeina 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 result of the urine culture shows that the bacteria involved is resistant to first, second, and even third-line agents. Zeina has a multi-drug-resistant bacterium. This is the third case in six months at the small clinic of 5000 patients.
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 – opens new tab). Lebanon has a law against the dispensation of antibiotics without a prescription but it is not enforced. Studies have demonstrated that 42% of patients purchased medication in Beirut pharmacies without a prescription (Cheaito et al., 2014 – opens new tab), and the majority of antibiotic regimens purchased were inappropriate for the condition (Saleh et al., 2015 – opens new tab). The top two reasons cited by participants for self-medication were to save time and money (Cheaito et al., 2014 – opens new tab).
Syrian refugees in Lebanon, like underprivileged Lebanese, must rely on the health safety net, a patchwork of low-cost clinics supervised by the Ministry of Public Health and non-governmental organizations (NGOs). The high cost of care in this network 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 – opens new tab). 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.
The little girl stands almost too still, her hand on the corner of the desk, looking down. Ameena pleads, “I can’t afford this. 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. She has heard this story before, from this woman and many others in the neighbourhood.
According to the United Nations High Commissioner for Refugees (UNHCR), 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%. This 25% is often beyond the means of refugee families who struggle to make ends meet in Lebanon where there are no formal refugee camps, and refugees face the difficult choice between buying food or paying the rent (Amnesty International, 2014 – opens new tab).
The social worker promises to work on the case and Ameena and her niece step out. The social worker explains further. “This family is in such a difficult situation. There are two brothers. The one who collapsed, Mohammad, was a lawyer in Syria but he can’t find work here. The 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.”
The overwhelmingly privatized and costly Lebanese health system makes it difficult for Syrian refugees to access medical care, necessary tests, and medicines in a sustainable way. Mohammad was unable to afford a monthly supply of simvastatin, a generic cholesterol-lowering medication. The least expensive option is about 8 USD, which was still too costly for this Syrian family. In the USA, this common medication is available at about a third of this price.
The UN attempts to curb health expenditure by restricting refugees’ access to secondary and tertiary care and not providing free chronic disease medications, however, 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 who 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 200 USD and provide several documents, including a signed pledge not to work and a rental agreement from their landlord (Holmes, 2015 – opens new tab). Lebanon is not a signatory to the 1951 UN Convention Relating to the Status of Refugees (United Nations, 1951, – opens new tab) and as such does not even formally recognise Syrians as refugees.
“How can we pay the 200 USD 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. As host countries and international NGOs do their best to provide services, it is the individuals like Ameena, Zeina, and Mohammad who must battle daily for survival in the face of seemingly impossible odds.
Image: An informal health facility in Beqaa, Lebanon, 2023
The ReBUILD team visited two health centres (dispensaries) in Beqaa, Lebanon during the 2023 consortium workshop. The two systems, which serve both refugees and Lebanese people, are compared and contrasted here.