Can you integrate a migrant population? Lessons from refugee camps in Lebanon – interview with Dr Rita Issa

Rita I met at a “meet-up” group for humanitarian workers in London that she had organised. Not that I would call myself as a humanitarian worker but, in the name of curiosity and potential promotion of the JIC, I went anyway. She had worked for MSF in Lebanon so was clearly on my hit list for interviewees. It’s taken some time to pin her down as she seems to be doing endless talks and presentations that she seems to fit around her GP training but we’ve finally managed it.

We’re in Lebanon – where Rita’s parents emigrated from in the 1980s – which is home to an estimated 260-280,000 Palestinian and 1.5 million Syrian refugees. A large proportion of this population live divided in several camps and gatherings that were set up in 1948 following the partition in the Middle East.

“I was working in an old refugee camp which is in the suburbs of Beirut itself. It’s been there since the 1940s and it’s an old Palestinian camp called Shatila – I think it’s quite well-known because there was a massacre of the Palestinians there during the Lebanese civil war [1982]. The camp itself is not a tented setting. It’s been there for so long – it’s got concrete structures, water, electricity – that it feels like a favela.”

Approximately 85% of the Palestinian Arab population, who lived on the land that eventually became Israel, were displaced in 1948 as a result of the Palestine War.  It is thought that Palestinian refugees make up 10% of Lebanon’s population and are more likely to face poverty due to the restrictions on their status. The civil unrest in Syria, which followed the Arab Spring in 2011, in still ongoing with 191,369 killed at the last count (UN statistics, 2014) with one in three Syrians being displaced – the majority to Lebanon, Iraq, Jordan and Turkey. “After the start of the Syrian civil war, people were leaving for Lebanon and they were subsidised by the UN to rent property because Lebanon didn’t create camps for the incoming Syrians. So the cheapest place to rent was in these pre-existing camps. The camp itself is a kilometre squared and the population has gone from 10,000 residents to 20,000 residents and that influx was mainly Syrian refugees.”

During her first role with MSF, Rita was ensuring that refugees in the camp were safely accessing higher level care. “The Lebanese government was very protective over Lebanese health services and so, as an NGO, we weren’t able to provide secondary or tertiary level care. So my main role was that, if anyone needed escalation to secondary care – be that acute or for some time in the future – I would arrange that to happen. I would travel with them and provide clinical support for them in the ambulance and transfer them to hospital. Most of the time I was arranging women who needed C-sections a time and a hospital to go to as so many had C-sections previously and that was a contraindication to vaginal delivery in our clinic. Part of the difficulty of that was that a lot of Lebanese hospitals were reluctant on taking Syrian refugees, even though we were covering all the costs of their care – so I would be ringing from anywhere between five and fifteen hospitals to find a bed that could take a critical patient. It could be quite difficult at times and quite upsetting.” 

This will not be something unique to Lebanon. Resistance by local populations to the integration of refugees is well-documented and often never achieved. Fears of public health compromise and communicable disease break-outs as well as concerns about stolen jobs often perpetuate a sense of otherness. Just think of “the Jungle” in Calais and, certainly, we’re not without blame with our detention centres and our new laws limiting access to healthcare to migrants. Even though the patients from Rita’s clinic were fully funded by the UNHCR and MSF, these prejudices are hard to overcome.

“I can think of one case that really sticks out for me. We had a premature neonate brought in by his parents to the primary health centre. He was skin and bones, completely yellow, heart rate through the roof, peri-arrest, very very unwell. We just needed to get him somewhere that could provide some better clinical care and I was calling up these hospitals. Everybody was saying ‘yes, we have some space’ and when they get some more details and they realise that I’m calling from MSF, they would change their minds and say ‘oh no we don’t’ have any beds left’. The fact that they would suddenly change their status was really frustrating. So what we ended up dong in this case was that I just got in the ambulance with the baby and we just drove to the nearest hospital and walked in. The finance  manager met us at the door and asked ‘where’s you paper work? Can you prove that you can pay?’ and I had this dying baby with oxygen on my back and trying to keep it alive. I ended up just walking past him, walking into A&E and finding the nearest doctor, who was at first reluctant to see this baby then saw it – you know when you can just tell it’s a really critical case? Then we called down the paediatrician and we started resuscitation but the baby died. I feel that this would have been the outcome that would have happened anyway because the baby was so unwell when they arrived to us in the first place. But just having to jump through all those hurdles and being told by people that you can’t come in, that you have to show your card or your ability to pay is a really frustrating thing to go though.”

Being a British GP, I am feeling thankful that I have never once had to think about my patient’s ability to pay and that clinical need always comes first (although this may change with these new law changes). I cannot imagine the heartache of having to turn someone away in such an emergency. At the current moment, primary care services and A&E are free, as is treatment for STIs and communicable diseases, family planning services and treatment for certain conditions arisen from torture of violence. The full list is here.

I asked her how her family perceive these camps. Balancing family concerns with the desire to put yourself in “dangerous” situations is an interesting challenge and is often only underpinned by personal concern arising from public perception. Through my interviews I have realised that the perception of danger is often more significant than the actual experience but it doesn’t stop loved ones from fretting. “All my family would be very concerned about me going in there [the refugee camp]. They would never go because it was deemed to be super dangerous and I think they were a bit confused as to why I would want to work there. For them, there’s multiple issues with it. It was historically a contested place and there was a massacre there before and when things kick off in Lebanon it usually started in one of these camps and they were concerned for my safety. It was just somewhere where they would never go. I actually really loved it there and it’s a really close-knit community where I would get the bus in and I would go and get my breakfast pizza every day. I had a really nice time. That said, town planning was a nightmare – with electricity cables and water pipes precariously running side by side. When I was there there were a couple of car bombs and they were both within a kilometre from where the clinic was and once on a night shift someone fired some shots just outside our door, so the area is still pretty unsafe on multiple levels.”

Our conversation turns to the second project that Rita was involved in. Having spent her first three-months in a non-clinical role, she moves onto a project-planning role managing longer-term health outcomes of the population. “So the second project that I ended up working on was more for the Palestinian refugees in a slightly different camp further down the road called Bourj el Baraineh and was solely an NCD [non-communicable disease] project.” 

Non-communicable diseases are slowly gathering recognition in the humanitarian sector. What makes this area different to other conditions is that required care is often lifelong; the condition requires screening, monitoring and continuity of care including health promotion; and it is often associated with complications that may require acute treatment in higher-level care. This is what we take for granted in the UK and what is challenging about managing it in a make-shift setting. “I guess it was slightly different for our Palestinian and Syrian population because they had different health needs and expected length of stay in that area. A lot of the work that we were doing were under the presumption that the people would be staying in the area for a while and we didn’t do much to facilitate longer term follow up for people in transit. People did have a little health document so that, if they were to move, they would have their medication and recent blood test results so at least they had that with them but we weren’t able to do more than that I’m afraid. I think there is a real need for health information that moves with patients as they move. So being able to track populations on the move and track some continuity of care.”

“We worked with another local organisation who had just lost its funding but had employed five nurses from the camp who had grown up in the camp and were trained in the camp to check [point-of-care] HbA1c and blood pressure. There was an NCD doctor who would prescribe accordingly and do once a month visits and over the space of six months we were able to improve all of their parameters significantly.”

“I think the places that we are getting refugees from now, like Syria, had a mixed burden of disease so they was a large mix of pre-existing condition. There’s something quite interesting about the Syrian population in that there was a national health system beforehand. I was really expecting a lot of infectious disease and aside from things like diseases that emerge from living in crowded conditions like scabies. But we didn’t see that many communicable diseases aside from childhood respiratory illnesses.” Forced displacement has been happening for many decades and Syria’s status as a middle-income country prior to the civil unrest has made this exodus feel different. We can try to compare this crisis to that affecting the Rohingya in Myanmar of which there is woefully little coverage. A population that has been made stateless since the 1980s (with more poverty, lower levels of literacy and reduced access to healthcare) before the current exodus. Which only teaches us that we need to ensure that we don’t paint all refugees with the same brush and that we do our needs assessment properly.

“It made me really learn the need for proper thorough planning before throwing money at it. I guess with humanitarian work its’ a balance right between sufficiently planning things whilst also not holding back because nothing ever gets done. The humanitarian sphere is changing and more and more projects are becoming longer term and with longer-term conditions there needs to be a change in the way these projects are planned. They don’t necessarily need to happen tomorrow if you’re setting up a NCD project but making sure that whatever is being set up is good rather than having to go back and make a change when after a month you realise it’s not working. Health needs are really important but that’s all in the context of the wider issue – which is usually the social determinants of health – and should we as health professionals should be influencing all these other factors that lead to ill health in populations.”

I have to say that I admire the work that MSF do but there is always a tinge of indignation when I think about the fact that there is still a need for them to fill. These camps have been around for 70 years and yet there is a reliance on NGOs and volunteer workers to give fundamental healthcare. The WHO estimates that one in seven people on this planet are displaced. That is one in seven who may not have access to education, healthcare and financial stability. Dr Tedros Adhanom said at a recent UN General Assembly “Firstly, we need better policies that promote migrants’ right to health, address their health needs, and integrate them into their host societies. Secondly, we need health systems that are sensitive to the needs of migrants. This means services that are in the right language, and that pay attention to unique health problems, including reproductive and child health, mental illness, and trauma from injuries and torture. Thirdly, we need good health monitoring and data on health needs, so that we can set realistic priorities. And finally, we need collaboration between countries and sectors. This is essential to manage the health needs of refugees and migrants of this magnitude”. 

infographic

With children growing up in these camps, there is always a concern for education, health and well-being which will impact on their future prospects – something that should be nurtured when you consider any possibility of post-disaster reconstruction. (On a side, I recommend you watch the award-winning War Child Holland advert and the incredible Save the Children video for which now they’ve made a sequel). When we know that social determinants of health has such a huge impact on long-term outcomes, it is difficult to address chronic conditions without inspecting their social wellbeing. I’m afraid I don’t have the answer and I suspect it’s not an easy one to address. Before I descend into a world of doom and gloom, I’ll leave you with some wise words from Rita.

“In my time out of training, I learnt that there are many global health opportunities, but it often takes leaving the UK to find them. However, by the end of my time with MSF I realised that I wanted and needed to come back into training if I was going to better serve such populations in the future. Whilst in the camps, I worked alongside some brilliant Syrian doctors and midwives. My time with them called into question what I was really adding, that couldn’t be offered by the local population, which in this case was highly-educated. Why should I be given a job ahead of someone else who needs a job more than I do, and could probably do it better? I didn’t think it was fair on the populations that I was working with that I was delivering care in this setting, yet I wasn’t a fully independent practitioner in the UK. So I’ve returned to complete training in London and am keeping up global health interests on the side: campaigning against charges in the NHS with Docs Not Cops; volunteering with Medical Justice; and getting involved with migrant health research. My lesson for next time: what can I bring, and am I good enough?”

Rita is a GP trainee at the Royal London Hospital. She has a policy not to take photos whilst at work but has sent me some links to some official MSF photos

Kids walking under water pipes 

MSF health promotion in Shatila 

Home based care in Bourj el Barajneh 

Reading and video recommendations from me

I shall not hate: A Gaza Doctor’s Journey on the Road to Peace and Human Dignity” by Dr Izzeldin Abuelaish

Being a refugee is not a choice: Carina Hoang TEDxPerth (I may have balled my eyes out watching this TED talk)

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