A study on
The health reality of the Palestinian camps and gatherings in Lebanon
An executive summary
Ever since the early 1970s, the Palestinian refugees in Lebanon continue to suffer from intolerable living conditions that are contradictory to human rights and their basic liberties, such as the rights to work, ownership, medical treatment and hospitalization. By way of its defense of human rights and its description of the human reality of Palestinians in Lebanon, and during the period extending from Dec. 2008 to Feb. 2009, the Witness Association for Human Rights has conducted a fact-finding study aimed at uncovering the truth about the health care situation of the refugees in Lebanon, and at seeing first hand the repercussions of deprivation in health and hospitalization to which the Palestinians in Lebanon of all backgrounds are subjected. The study included a random sample of 967 persons from 12 camps and communities of Palestinian refugees in Lebanon. In addition to the opinion poll, the study included the preparation of a health card for each Palestinian camp, containing basic information about the health situation of the camp, such as the prevalent diseases, health-care institutions, environmental health and mental health. The study also included frequent meetings with dedicated groups that gave precise description of the overall health reality in the camps. In addition, the study used information and figures from the United Nations Relief and Works Agency (UNRWA) about the state of its medical institutions. This supplementary information confirmed the results of the opinion poll.
The study has revealed several worrisome indications about the health and health-care of Palestinian refugees from all backgrounds. It shows that the Palestinian camps suffer huge health problems and that the infrastructure is in need of rehabilitation and repair. The study also reveals that the health condition of Palestinians in Lebanon has not received sufficient media coverage and the required attention from the concerned parties.
The most important finding of the study is the decline in UNRWA's health services, in spite of the fact that UNRWA – in its capacity as the primary health-care provider - is the first refuge and the most important destination for Palestinian patients. Indeed, 60% of the sample members reported that they frequently visit its clinics in the camps, but that they are not satisfied with the quality of services they offer. And so 38.5% of those surveyed evaluated UNRWA's services as average, while 18.1% considered them good.
The care that the patient receives is absolutely insufficient, for the clinic receives daily more than one hundred patients, and this number rises in many clinics to more than 150, as is the case in the clinics of Ein al-Hilweh and al-Beddawi camps. And if we take into account that the working hours at the clinics start at 7:15 AM and ends at 2:45 PM, we discover that each patient gets to see the doctor for three minutes. And if we reduce the time during which the doctor examines patients (by one hour at the beginning of the working schedule and another before its end), the examination time becomes shorter still. The question inevitably arises: are two or three minutes sufficient to ask a patient about his medical history, examine him, make a diagnosis and prescribe the appropriate medicine for him? And consequently, was the patient really treated or did he just have his symptoms tended to? And was he prescribed the wrong medicine? That's why negligence in treating the disease from its beginning may lead to grave complications. And so 42.7% said that they underwent surgery as a result of negligence in treating the illness upon its discovery. And in spite of the fact that UNRWA provides the medicines available to it free of charge, there are many types of drugs that are unavailable, and so the patient is obliged to buy them, not to mention that many of the existing drugs are ineffective in treating diseases. Maybe this justifies the ratio of 59.4% of those surveyed who buy medicines at their own expense compared to 41% who always get their medicines from UNRWA; knowing that UNRWA secures the medicines that it doesn't have at only one location, namely through its contract with al-Rayyan pharmacy in al-Beddawi camp.
Regarding the laboratories at UNRWA clinics, they carry out routine tests, such as (CBCD, FBC, and Urinalysis.)
As for specialized tests such as (culture, hormones), these laboratories lack the technical resources and skills needed to carry out these complex tasks. And so once again the patient is compelled to undergo these tests in private laboratories, with all the heavy expenses that entails.
Furthermore, most UNRWA clinics lack a diagnostic radiology department. For example, in the Tyre area only one such department exists in the clinic of al-Bus camp. Therefore, the patients from other camps (al-Rashidiyah, Bourj al-Shemali, and other Palestinian communities) who need this kind of radiation have to go to al-Bus camp clinic, which is not feasible for emergency cases, knowing that this radiology department has only an X-ray section, while the machines for (ultrasound, MRI, CT) are unavailable. Moreover, there are no specialized doctors working in UNRWA clinics except in certain areas (gynecology, obstetrics, ophthalmology, and cardiology). And these come to the clinic once a week at most, as if it is up to the patient to choose his illness and the time to get sick with it. And what would become of the one who gets afflicted with a disease of the lungs, the liver, the urinary tract, or the nerves?
As for the referrals given to patients who need hospital treatment, they are few in numbers and are disproportionate to the large number of patients. For UNRWA has contracts with some hospitals for a determined number of nightly hospital beds each month; and this number is often exhausted before the middle of the month. Also UNRWA has contracts with hospitals for a certain sum of money per bed per night; which means that the patient receives the treatment proportional to the amount set for him. And so if the cost of treatment is more than this amount, either the patient is denied treatment or is compelled to pay the additional funds from his own pocket. The survey results came to confirm that, for they showed that UNRWA paid the expenses of surgery for only 39% of those surveyed, while 26% paid for it themselves. Moreover, some of the hospitals that have contracts with UNRWA are located far from the camps, and reaching them requires effort and time, as is the case with the patients of al-Jaleel camp in Baalbek who need more than one hour to reach al-Nassrah Hospital in Bar Elias. Also some patients need to be transported in ambulances in view of their serious state of health, and ambulances are not available at UNRWA in any of the camps.
As for the Palestinian Red Crescent, its services have deteriorated and its role has diminished dramatically from what it was in the past. This led to loss of confidence in it on the part of the patients, as only 35.8% of the surveyed sample stated that they visit it when they get sick, in spite of its presence within the camps; while 38% of them rated its services as average.
The role of many of the Red Crescent hospitals in many camps has deteriorated in favor of the five main Red Crescent hospitals, which are (al-Hamshari Hospital in Sidon, Balsam Hospital in al-Rashidiyah camp, al-Nassrah Hospital in Bar Elias, Safad Hospital in al-Beddawi camp, and Haifa Hospital in Bourj al-Barajenah camp). This led to turning the dispensaries in the other camps to clinics that offer emergency services and fist aid. Many of these dispensaries became deficient in funds and in medical supplies, and have no ambulances to transport patients; not to mention that the salaries of the Palestinian Red Crescent workers have become very low, that is below the minimum wage in Lebanon, the host country.
This deficiency and flaw in the services of both UNRWA and the Palestinian Red Crescent created a need for other institutions, such as private dispensaries and clinics, to carry out a supplementary role in looking after the refugees' health. And as these health institutions exert commendable effort, they too suffer deficiency in their equipment, specialty and funding, allowing the refugees’ health needs to increase, especially at night when these institutions close their doors.
As for the pharmacies in the camps, they came into being as a result of the scarcity of the medicines provided by UNRWA. However, the employees of most pharmacies are not professional pharmacists; they are nurses and graduates of trade schools. This may not be a problem if the matter is confined to dispensing to the patient the medicine that the doctor had prescribed for him. It becomes a problem when we know that many patients go to the pharmacy to buy drugs without consulting a physician. Then the pharmacist takes on the role of a physician in prescribing the appropriate medicine!! Moreover, these pharmacies are not subject to supervision and lack many types of drugs.
Also there appeared in the camps private medical laboratories, most of which conduct only routine exams. However, they have contracts with private labs to conduct tests at reduced prices.
If we examine the environmental reality, it is just as bad as what we have already mentioned. For drinking water, 58.3% of the survey sample said that, for them, its source is the camp's water tank run by UNRWA, which in turn takes charge of disinfecting the water and examining it periodically. Still in many camps the water is undrinkable, which is maybe due to old fixtures or to overlapping with the sanitary drainage systems.
And in spite of the fact that they were renewed in most camps, these systems are always subject to obstruction, due to throwing solid trash in them, which causes the drainage water to spill out of its canals and sewers and into the streets and homes. Also in some camps the sanitary drainage system remains exposed.
As for trash, the sanitary workers collect them every morning from the front of apartments. However, the lack of cooperation on the part of residents, their negligence in observing collection time, and the camps' crowdedness, lead to their accumulation in alleys and streets where foul odors rise from them, cats and rats toy with them, and rodents and insects gather; which makes them a source of disease. In addition, some trash containers are placed near important facilities, such as in the case of al-Rashidiyah camp where they are found near schools, or in Bourj al-Shemali camp where they are placed across the street from the UNRWA clinic.
Speaking of the diseases that are widespread in the camps, many of them are linked to the difficult conditions endured by the refugees, such as narrow alleys, proximate housing, humidity, and absence of green areas. Thus we find that diabetes, hypertension, heart diseases, and psychological illnesses afflict large numbers of camp residents. Also in some camps genetic diseases, such as Thalassemia, proliferate, and all the while UNRWA refuses to take responsibility for the treatment of this disease.
Moroever, camp residents have to contend with anti-social behavior, such as smoking, whose ratio reached 33% of the surveyed sample, in addition to verbal and physical abuse of children.
The survey showed that 87.7% of refugees lack health insurance, also that 34.7% of the sample members don't know how to deal with injuries, and most of them don't know what to do in case of burns (54.7%) or fractures (80.6%), while (81.7%) of them don't have a first aid kit at home. These statistics reveal a lack of awareness and knowledge of how to deal with emergencies, and the absence of the roles of UNRWA and the Palestinian Red Crescent, being the two parties responsible for public health and for educating and giving good guidance to the refugees by teaching them how to deal with emergencies.
This state of affairs conflicts with many local and international legal standards related to a person's right to a healthy body. For the first paragraph of Article 25 of the Universal Declaration of Human Rights stipulates that "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control".
It also conflicts with Article 12 of the International Covenant on Economic, Social and Cultural Rights that calls for the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, working for the prevention, treatment and control of epidemic, endemic, occupational and other diseases, also the creation of conditions which would guarantee to all medical service and medical attention in the event of sickness.
The state of health of Palestinians in Lebanon also conflicts with the reasons for which UNRWA was established in December 1948, according to Resolution No. 302 of UN General Assembly, when many observers expected that UNRWA's mandate would not extend beyond a few years. Yet the years of suffering persisted, and so did UNRWA. The UNRWA agency is directly responsible for the relief and work of Palestinians until their return to their cities and villages from which they were forcibly driven out in 1948 and then in 1967, and it directly represents the international community.
The Witness Association for Human Rights, as it publishes this study, strongly sounds the alarm bells and calls all responsible parties before their legal and moral obligations, so that the Palestinian refugee would not fall victim to diseases and epidemics, become subject to begging from welfare societies and in front of mosques, and so that his ever-increasing human needs would not become his only worry, turning him away from his greatest cause, that of his right of return.
Based on all of the above, the Witness Association for Human Rights recommends the following:
1. The suffering of Palestinians in Lebanon is a direct product of the "Catastrophe” of 1948. The world community bears political and humanitarian responsibility towards them. For over a period of 62 years, it remained powerless to force Israel to implement the UN resolutions related to the right of return. Furthermore, it retreated dramatically from fulfilling the ever-increasing human needs of the Palestinian society. UNRWA always offers an excuse for its retreat, that of the deficit in its budget. Also UNRWA's health institutions need more support. They also need supervision and follow-through in a way that agrees with the prevalent health standards. Also the Palestinian camps are no longer fit for habitation; they are in need of larger areas to meet the continuous increase in population.
2. Successive Lebanese governments have not given the Palestinians enough of a chance to live in dignity. This has had an extremely adverse human impact. The government health institutions don't offer their services to the Palestinians in Lebanon, in the same way that they do to Lebanese citizens. Also the Lebanese government is called upon to allow the expansion of the camps' areas, in coordination with UNRWA, the Palestinian factions, and the Palestinian civil society, and to issue decrees guaranteed to improve the life of the Palestinian individual.
3. The institutions of the Palestinian Red Crescent need real support that would allow them to carry out their humane duties toward the Palestinian refugees, and equip them with the knowledge and resources to face the escalating health-related challenges. These institutions have become flaccid and are in need of transparency and supervision. There is also an urgent need for the Palestine Liberation Organization (PLO) to dedicate appropriate attention and resources to the health sector, the same as it does to the institutions of the Palestinian Red Crescent in the Palestinian occupied territories.