Lebanon Report

Scratching the surface


On the surface, Lebanon, a small, reasonably well developed country whose capital was the seaside jewel of the Mediterranean, appears to be forging ahead economically, its people content to go about their daily life – business as usual. But if one scratches the surface a more disturbing scenario of mental fatigue, or even mental disease is revealed.

This should come as no surprise considering the prolonged civil war which began in 1975, and the more recent conflict with Israel in 2006. One could hardly expect the damage to be limited to visible scars.

According to Médecins Sans Frontières (MSF) – who play a vital role in the country treating the local population as well as the large refugee populations from Palestine and now Syria – as many as one in four people in the country “meet the criteria” for a debilitating mental health condition.

It is for this reason the MSF set up a mental healthcare centre in the southern suburbs of Beirut in 2008, in the wake of the 34-day war between Hizbollah militia and Israel in 2006.

Overall, the state of health of a nation can never be divorced from wider factors such as economic development and cultural and social cohesion. It has been noted that the civil war – which stretched until 1990 – cut national output by half and destroyed Lebanon's position as a thriving Middle Eastern entrepreneurial and financial hub.

War of any sort – and a civil war in particular – is likely to lead to mental health problems, anywhere, and Lebanon, with its curious mix of ethnicity and religion living in such close proximity in a fragile, continually-tested peace, is far from immune to these.

In the mix are Christian Maronites, Sunni and Shia Muslims and the large numbers of refugees, mostly Palestinians who have been housed there for years, and now Syrians.

MSF – applauded for its contribution to humanity's health with the 1999 Nobel Peace prize – decided to focus on mental health because this was where its assessment found “a real gap” in the healthcare services provided by the state. Where there is recognition of mental illness, treatment is prohibitively expensive and it is thus available only for a small elite.

Alison Jones, MSF medical co-ordinator in Lebanon, whose Swiss arm is running the organisation’s operations in the country, estimates that a conservative fee for a session with a psychologist in Lebanon is US$30, rising to US$50 for a psychiatrist.

With a public healthcare sector overwhelmed and with Lebanon’s laissez-faire economy, the private health sector has boomed with myriad private companies, the result being that many citizens are now priced out of getting even basic treatments.

The massive treatment gap resulting from a highly privatised healthcare sector is highlighted not only by the MSF, but also the International Medical Corps, one of a number of other non-governmental organisations operating in Lebanon.

After the devastating war with Israel in 2006 that saw large parts of Lebanon’s infrastructure wrecked, an assessment found that one in six people – or around 17% of the population – were in need of psychological care. That is over 700,000 people, in a country of about 4.2 million.

But it may be worse than this. Jones told Middle East Health that a study by a local psychiatrist showed that 26% – that’s a quarter of the Lebanese population – meet the criteria for a mental health disorder. This rises to 29% for the large number of Palestinian refugees – around 400,000 – stranded in Lebanon.

Medical professionals have diagnosed depression, anxiety, psychosis and personality disorders, among other conditions, at least one of which was detected among these individuals.

While figures showing the extent of the population exposed to mental health problems are not “wildly different” to many other countries – depression has become the fourth-leading cause of disability worldwide, and is expected to be the second-biggest cause of human disability by 2020, according to the World Health Organisation (WHO). The “treatment gap” in Lebanon is stark and is worsened dramatically by a “very under-resourced” public healthcare sector, says Jones.

Mental healthcare is not seen as a priority by the government. This is the case in many countries, although highly industrialised countries have increasingly been addressing the issue in recent years, with the view that a country “cannot have health without mental health”, says the MSF staffer.

The WHO has also begun to advocate this understanding of what makes a healthy individual and thus a healthy nation. We are seeing a re-evaluation of the very concept of health in the 21st century, with a new look at the role of the human mind in the overall health of the individual.

In Lebanon there is virtually no provision at all for mental health treatment within public sector services. Then there is also the question of perception: individuals who are unaware that they have a mental illness that requires treatment, and, even worse, the negative stigma attached to mental health problems in communities.

To deal with this, MSF has been working with Lebanese authorities to integrate mental health treatment programmes into the public healthcare system, while staging shows, like theatrical performances, to create awareness of the need to recognise and confront the reality of mental illness.

Community mental health centre

MSF opened its first community mental health centre in 2008 in Burj el-Barajneh, in poorer southern Beirut and inside the neighbouring overcrowded Palestinian refugee camp swollen with over 18,000 people squeezed into a space of just oneand- a-half square kilometres.

By May 2012 MSF psychiatrists and psychologists had seen about 2,128 patients between the ages of 25 and 40, diagnosed with depression, anxiety, psychosis and personality disorders.

In April this year, MSF mental health services in Burj el-Barajneh were handed over to the local municipality, in line with MSF’s long term strategy to see mental health services integrated into primary healthcare.

The organisation continues to offer mental healthcare treatment in Burj el- Barajneh refugee camp as well as in Ein el-Hilweh refugee camp in Saida, where a community mental health project started in April 2011. MSF is working in five different health structures inside and outside the camp. Patients suffering from depression, anxiety and psychosis have been treated, with many referred to the clinics by relatives, particularly those suffering from psychosis, the second-most prevalent condition after depression.

Diagnoses vary between parts of the country as well as between refugees of different nationalities and “vulnerable” Lebanese, an MSF official said.

However, even with MSF’s commendable initiatives, a massive treatment gap remains, particularly among the Palestinians. According to an MSF study conducted in Burj el-Barajneh refugee camp in 2010, 97% of Palestinians identified as needing mental healthcare were not receiving treatment at that time.

Post-traumatic stress disorder

Leaving aside debates around diagnostic criteria, what has surprised medical professionals is the negligible extent to which Palestinian refugees are affected by posttraumatic stress disorder (PTSD), a condition common among individuals exposed to the horrors of war. MSF found that PTSD symptoms were fewer than what had been expected, or at least implied in several studies, said Jones.

Basically, “very little” PTSD had been diagnosed among Palestinians. However, those mental health illnesses that had been diagnosed were “severe”.

MSF services are by no means restricted to Palestinians, however. Over the past three-and-a-half years more than 2,900 patients have benefited from free mental health care, provided through “a multidisciplinary, community-based” approach. It has given more than 19,000 psychological and psychiatric consultations, free-ofcharge, it says.

This is all the more remarkable given the tight resources that MSF itself has been working with: one international psychiatrist and one international psychologist, supervising teams of five local psychiatrists and 19 local psychologists, says Jones.

They have been treating Iraqis, too, and more recently Syrians, who began seeking refuge in Lebanon in numbers from March 2011. An MSF staffer cites recent estimates from the United Nations High Commissioner for Refugees (UNHCR) that put the number of Syrian refugees in Lebanon at 26,000, with 17,000 so far registered. Local NGOs go higher, putting the number at about 40,000 Syrian refugees.

Points of entry for Syrian refugees are changing as the Syrian government clamps down on borders, making the job of NGOs providing health or other humanitarian services more difficult in a fast-changing environment. Initially, people entered through Wadi Khaled in north Lebanon but more recently are coming in through the Bekaa valley in the east of the country, according to a source in Lebanon.

These numbers are obviously putting pressure on the refugee camps, with running water and electricity running for only a few hours a day, and housing increasingly congested. MSF says conditions could be better.


It is a tenacious country and has recovered well considering the bombing it endured in 2006. Yet it could have done better: according to some reports, pledges of economic and financial reforms made at international donor conferences during the first decade of the millennium have largely not been met. This includes pledges made at a key donor conference in Paris in 2007.

Scratch under the surface, as MSF has done, and we see that the scars from war run deep. And then, compounding these are the insidious mental health problems that could be seen to be associated with sectarian prejudice.

The United Nations news service, IRIN, has reported a case where a young Shia who had a heart attack was refused treatment at the Rafik Hariri hospital, named after the assassinated, former five-time Sunni prime minister. This was ostensibly because the young man, named by IRIN as Hamza Sharour, aged 24, could not afford to pay the thousands of dollars of deposit demanded of him by the hospital.

He died on the way to the Rasool al- Azam (Mighty Prophet) hospital, run by the Shia Hizbollah, in the suburbs close to the Palestinian refugee camp where MSF set up their mental health clinic.

In a poignant comment that reflects the shallow distinctions of religion when it comes to the loss of a human life, his heartbroken mother told IRIN that she wished her young son had “been a Sunni”. At least, if the Lebanese Red Cross vehicle had got him to the Rasool al-Azam on time, he may have lived. The Hizbollahrun hospital provides the family with free medical care, said his mother.

Seen in the context of a country where private medical care dominates the health sector, this goes a long way to explaining the popularity of Hizbollah, which is well known for its charitable efforts, among Lebanese Shia.

The creep of privatisation has been assisted by agreements whereby the state transfers patients from public to private hospitals, which generally provide a higher standard of healthcare

This reached a point at the end of the last millennium where 134 private hospitals had agreements with the health ministry to treat patients admitted from the public sector. In 1971, at the peak of Lebanon's golden years, there were 14 private hospitals, according to IRIN.

Under the arrangement, the health ministry is supposed to pay 90% of the bill but this has been happening less and less, according to a parliamentary committee member, leaving private hospitals with unpaid bills and pushing them to a point where they are no longer accepting transfers or patients unable to pay – as the case of Sharour demonstrates, his Shia heritage notwithstanding.

Healthcare insurance is invariably expensive. One study has found that only 27% of Lebanese people can afford it. Ongoing violence in neighbouring Syria has not helped matters and is partly to blame for slowing economic growth to 1.5% after four years of 8% average growth, which means a lot less money in the health ministry’s coffers.

Syrian refugees

In November 2011 MSF set up new health programmes in Wadi Khaled and Tripoli, in the north of Lebanon, as well as in the Bekaa valley. Because it had been in Lebanon for a few years already, the organisation says it was prepared to offer support, beginning with mental healthcare for Syrian refugees and for the local Lebanese population in these areas.

It is also providing primary healthcare and medication for the treatment of chronic and acute diseases, as well as vaccinations for children.

MSF quietly notes that its status as an independent international medical organisation “provides a guarantee of neutrality” to refugees arriving from Syria. Ominously, it adds that it is preparing for a “massive” influx of people to Lebanon, including large numbers of wounded and doubts the capacity of Lebanese public hospitals to cope.

At the time of reporting, MSF was still waiting for permission to enter Syria itself. The organisation says that for months it has been in negotiations with “all relevant authorities in Damascus” to get its medical staff into the country.

A complex country

Lebanon is a country of gross inequalities, with 28% of the population – more than one million people – living below the poverty line. (This is based on a 1999 estimate – nine years after the end of the civil war. Given the devastation wreaked by the 34-day war between Hizbollah and Israel in 2006, one would not expect the figure to have improved.)

Its problems come in layers, and exascerbating extant mental health problems are violence, human rights abuses, poverty, gender inequality and low levels of education.

Yet data provided by the WHO do not paint an entirely sorry picture: Lebanese have a life expectancy of 74 years, for men it is 71 years – compared to a global average of 66 years and the regional (Eastern Mediterranean) average of 64 years. Women live on average to 77 years, with the average female life expectancy in the region being 67, and 71 globally.

Again, leaving aside the anomaly of war, the adult mortality rate is 124 people per 1,000 adults aged from 15 to 59. This is a bright figure, way below the regional average of 188, and even the global average of 176.

Lebanon spends a lot on health care, proportionally, at least well above the Eastern Mediterranean regional average, says the WHO. By around 2008 it touched the US$600 per person mark, after seeing spending drop to around US$450 between 1998 and 2006.

In comparison, the average amount of spending per capita in the region hovered at just below the US$200 mark in 2008, the latest year for which WHO provides readily accessible data.

Out of every 10,000 people, there are just over 35 doctors. This is advanced compared with the regional average of 11 physicians for every 10,000 people.

HIV prevalence is low: per 1,000 people (aged from 15 to 49) it is a mere one, compared with a regional Middle East average of two and a global average of eight.

 Date of upload: 26th Jul 2012


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