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
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
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
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
been addressing the issue in recent years,
with the view that a country “cannot have
health without mental health”, says the
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
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
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,
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
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
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
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.
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
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
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 upload: 26th Jul 2012