As of this writing, the small, cash-strapped country has recorded 22 deaths from among 688 confirmed cases of COVID-19, the illness caused by the virus. The outbreak comes at a time in which Lebanon is already struggling with its worst economic and financial crisis in a generation which has had dreadful consequences on the country’s medical care system. As recent as this February, public officials, including doctors, announced that there is a shortage of lifesaving drugs and medical supplies, which can no longer be obtained from international suppliers due to Lebanon’s shortage of U.S. dollars. The rampant spread of coronavirus through developed nations with advanced health systems, has caused deep alarm in the country.
BEARING THE BRUNT
As the virus hits at a time when Lebanon is least prepared, fears are growing that refugees who have been struggling in poverty for years will bear the brunt of the pandemic. Lebanon’s refugees exist in extraordinarily cramped, fetid conditions without access to clean water or safe sanitation. A lockdown is a luxury they cannot even implement properly, let alone afford. This poses the greatest threat to not only refugees themselves, but the community at large.
“As is the case for most refugees across the world, Syrian and Palestinian refugees in Lebanon are at increased risk of contracting the disease due to the overcrowded context in which they often live, combined with poor access to basic services, which challenges their ability to apply precautionary measures such as social distancing, self-isolation and proper hand hygiene practices. The informal tented settlements and Palestinian camps in Lebanon are illustrative examples of such conditions.” Elena Dikomis, spokesperson for the Norwegian Refugee Council (NRC) in Lebanon, told Majalla.
“Additionally, refugees’ very limited access to income, including but not exclusively because of COVID-19 related movement restrictions, makes it very challenging for them to cover additional expenses in the context of the coronavirus outbreak, such as hygiene and disinfection items,” she added.
So far, there is only one public hospital being used to quarantine and treat COVID-19 patients for free – the Rafik Hariri University Hospital (RFUH) in Beirut. UNRWA, the agency responsible for Palestinian refugees in the Middle East, which is in the grips of the worst funding crisis in its history, announced that it would coordinate with the Lebanese health ministry to provide COVID-19 testing and treatment for Palestinian refugees at the Hospital. Similarly, the UN High Commissioner for Refugees (UNHCR) has said it will assist with the cost of these services for Syrian refugees.
On March 28, Lebanese Health Minister Hamad Hassan declared that Lebanon will share responsibility with the appropriate UN agencies for refugee healthcare. However, it is unclear whether access to services will be on an equal basis or if there will be discrimination in care as in the past the Lebanese government has systematically left out Palestinian and Syrian refugees from public health initiatives.
BARRIERS TO HEALTHCARE
Palestinian refugees, whose forefathers fled the creation of the state of Israel in 1948, are subject to a wide range of discriminatory laws, preventing them from accessing public education and health services, and from working in at least 36 professions, including medicine.
Syrians likewise face serious bureaucratic difficulties. According to Human Rights Watch, due to restrictive Lebanese residency policies, only 22 percent of Syrian refugees have the legal right to live in the country, leaving the vast majority to live under the radar, subject to arbitrary arrest, detention, and harassment. Their lack of legal status means they cannot move freely through the ubiquitous checkpoints that predate COVID19, have difficulty getting services such as health care or education, and find it difficult to register births, deaths, and marriages.
Given the persistent barriers with access to services and the fragmented nature of health care provision in Lebanon, it is unlikely that refugees would have adequate and equal health care services during the current health crisis.
Claudio Cordone, UNRWA’s Lebanon director, told The Independent that they were working with medical charity Medecins Sans Frontieres to turn one of UNRWA’s centres into a dedicated refugee isolation centre to treat mild cases and take the load off Lebanon’s ailing health system. “We have been given assurances from the Lebanese authorities that all residents of Lebanon would be treated in the hospitals,” Cordone said, adding: “The test will be when the healthcare system is overwhelmed and there is a choice between a Palestinian and Lebanese patient.”
Nadia Hardman, refugee rights researcher and advocate at Human Rights Watch, says that Lebanon has a “duty to ensure the health of Syrian and Lebanese residents alike, and it won’t be successful against COVID-19 unless it ensures everyone has access to information, testing, and treatment.”
Refugees themselves are raising concerns about their ability to access health care. In focus group discussions conducted on March 5 and 6 with Syrian refugees in Bekaa and Tripoli, Oxfam found that the costs associated with access to health care was a major concern. The refugees expressed fear of further discrimination and stigmatisation if they contracted COVID-19. They cited this fear as a deterrent from seeking medical care, even if they experienced symptoms.
In a recent survey by the Norwegian Refugee Council, when respondents were asked about access to health services, (not related to COVID-19 per se but rather general access), 34% stated that there were barriers such as financial constraints and transport challenges. One of the main concerns by respondents was the fear of being discriminated against in hospitals and Primary Healthcare Centers. Additionally, 80 percent of the refugees surveyed had not received awareness-raising sessions related to COVID-19 and are thus “unlikely to have accurate information on accessing testing and treatment.”
"DISCRIMINATORY RESTRICTIONS"
Several Lebanese municipalities have imposed curfews to further restrict the movement refugees because of the virus. Authorities have threatened Syrians with legal action and the confiscation of their legal documents if they violate the curfew. The restrictions do not apply to Lebanese citizens and could both undermine the country’s public health response and endanger the refugees’ health by further impeding treatment.
“You have these additional restrictions on Syrian refugees: only allowing movement between 11 a.m. and 1 p.m. In informal tented settlements, only one person, possibly two, have to be appointed to go out and get supplies for the rest of the informal tented settlement. In other places, this must be done in coordination with the municipality. In other instances, fines also and confiscation of ID,” Hardman told VOA.
HRW says that is no evidence that extra curfews for Syrian refugees will help limit the spread of COVID-19 and these “discriminatory restrictions” on refugees risk the virus spreading if Syrians are too scared to seek medical help after 1 p.m.
These sentiments were echoed by Dikomitis: “The government has been proactive in implementing social distancing and the general mobilisation which has helped to contain the spread of Covid-19, However, as highlighted by Human Rights Watch, we have seen a number of local authorities use the Covid-19 measures to impose further discriminatory measures and restrictions on refugees. This leads to unjustifiable restrictions of movement beyond what the Government is requesting, and blocks access to essential goods and services,” she told me.
A report by HRW said that at a time when trust is most needed, the Lebanese authorities are "conducting business as usual and adopting policies that fail to alleviate the refugee populations’ mistrust of the authorities. This lack of trust could easily undermine efforts to prevent control and spread of the disease.”
“The government should simultaneously push an information campaign to provide refugees with all the facts that they need to protect themselves against infection and to seek healthcare in a timely manner.”
Dikomitis told me that despite restrictions, NRC Lebanon is continuing its education and Information, Counselling and Legal Assistance (ICLA) programmes through remote modalities while taking the necessary preventative measures to minimize the risk of exposure to field staff and refugees in line with the World Health Organization (WHO) recommendations.
“For awareness raising on-site, we use vehicles with megaphones and we also spread information through phone calls, text, video and audio messages,” she said. This is combined with “follow-up phone calls to provide guidance and support and to safely refer people to other specialised organisations.”
