Long term displacement raises new health needs

British Medical Journal,  April 17, 1999  by Pat Anderson

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What happens to health needs when refugees get stuck in camps for months or even years? Pat Anderson talks to a medical charity working with Palestinian refugees in Lebanon-Medical Aid for Palestinians-about the long term health effects of "ethnic cleansing"

At the moment, the focus for aid workers in Albania, Turkey, and other countries taking in refugees from Kosovo is on emergency measures such as providing basic nutrition, protection from the elements, and prevention of infectious diseases. These are short term, temporary measures designed to fill the gap until the refugees can go home again. But what happens if the refugees' situation goes unresolved for months, years, or even decades, and camps turn into semipermanent homes?

The experience of another refugee group who have experienced "ethnic cleansing"--the Palestinians in Lebanon--shows that refugees' healthcare needs change as time goes on and that far more than blankets and hot meals are required in the long term.

At least 300 000 Palestinian refugees are now living in and around camps in Beirut, Tyre, and Sidon in Lebanon. Some refugees have lived in Lebanon for over 50 years. The first wave of refugees appeared in 1948 when Israel came into being, and another large group arrived after the Arab-Israeli war of 1967. They are excluded from work in most occupations and are not entitled to health care provided by the Lebanese government. Some are eligible for primary health care provided by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), but many are reliant on the Palestinian Red Crescent Society (PRCS) for their healthcare needs.

The British charity Medical Aid for Palestinians (MAP) began its work in Lebanon in 1984, providing medical aid to the survivors of the massacres at Sabra and Shatila refugee camps in West Beirut. Medical volunteers, including British surgeon Pauline Cutting, brought the plight of the camp inhabitants to the world's attention.

Now, according to the charity's Lebanon coordinator Walid Abu Harb, its work has had to grow and change to help the PRCS and local hospitals to meet the changing needs of those who live in the camps. He said: "Until the peace agreement of 1991, we were providing emergency and relief work. After the peace, we began to shift the focus towards development."

Life in the camps is more stable now, and people are trying to live a normal life, working if they are allowed and, in some cases, subsisting on support from relatives in other countries. It is, however, very difficult for them to afford medicines or the cost of hospital treatment.

Health problems experienced by people living in the camps include infectious diseases linked to poor sanitation; mental health problems associated with displacement and with experiencing prolonged bombardment; intellectual and physical disability among children; poor health among pregnant women and infants; and chronic diseases such as diabetes. There have also been cases of cervical cancer and death from renal failure, which MAP is trying to address.

In Beirut, the charity has refurbished the surgical unit at the Haifa Hospital and has helped to train teams providing mother and child care and preschool screening. In Sidon, it has supported the development of maternity and ophthalmic services at the Hamsharry Hospital, and its latest project is a new department providing kidney dialysis. "This is the only dialysis service for all the Palestinians in Lebanon. In the past, people have died of kidney failure because there was nothing for them," explained Mr Abu Harb. Those in need can now have dialysis up to three times a week.

Other MAP measures to develop health services include providing training for local doctors and nurses. In 1997, it helped to arrange for trainers from Britain's Royal College of General Practitioners to provide an update in clinical skills and family medicine to 20 PRCS general practitioners working in the camps. The charity also opened the El Buss nursing school in Tyre in 1992, specifically to train Palestinian nurses because of a shortage of PRCS nurses. Since this began, 63 have graduated, and some have been given permission to work in Lebanese hospitals because of a more general shortage of nurses across the country.

MAP clinics in the Palestinian camps are attempting to provide primary healthcare services including cervical smears, advice for pregnant women on nutrition and breast feeding, and AIDS awareness training for young people.

The organisation hopes that the refugees' uncertain situation will be resolved so that they can find somewhere to live. A proportion might be able to move to the new Palestinian controlled territories, but it is unclear what will happen to the majority.

Mr Abu Hard commented: "All the attention has been diverted to Palestinians in the West Bank, but Lebanon is still an important part of our work. People say that the conditions here are worse than in the West Bank and Gaza, and the general feeling here is that we have been forgotten."