Updated: Sep 5, 2021
Rasha Al Saba
Minority Rights Group International
Recent years have seen a real transformation in the way we treat patients and maintain the health of populations. Among these developments are advances in medical diagnostics technology, broadly understood as equipment and supplies that allow clinicians to measure and observe an individual’s health to form a diagnosis.
Such testing is particularly crucial at every stage during a disease outbreak, as it allows for the mapping of who has a disease as well as who is at risk of becoming infected. Without diagnostic testing, it is impossible to strategize responses effectively.
The current Covid-19 pandemic demonstrates this clearly. The disease, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first emerged in Wuhan, China, in late 2019 before spreading rapidly across the world. By 11 March 2020, it was declared a pandemic by the World Health Organization (WHO). With governments racing to slow the spread of the virus, most recognize that access to testing is a key measure that must be at the core of their responses. This is an approach backed by Tedros Adhanom Ghebreyesus, Director General of the WHO, who stated: ‘Our key message is: test, test, test’, during a press briefing on 16 March 2020.
Across the world there have been different barriers to putting this into practice, not only technical barriers but also social, political and economic ones. These issues are especially evident in Lebanon. Though it hosted significant numbers of Palestinian refugees before the outbreak of the Syrian conflict in 2011, since then its refugee population has risen substantially. According to the United Nations High Commissioner for Refugees (UNHCR), there are more than 1 million Syrian refugees registered in Lebanon, though different agencies estimate the true number to be in the region of 1.5 million. As a result, Lebanon is now the country with the highest per capita refugee population in the world. The large Syrian refugee population, many of whom are unregistered, were already struggling with the effects of years of discrimination before the outbreak of the Covid-19 pandemic.
Covid-19 in Lebanon
Lebanon recorded its first case of Covid-19 on 21 February 2020 and went into partial lockdown after three weeks, closing schools, shutting its borders, and banning new arrivals by air, land and sea. It also introduced restrictions on movement, only allowing people to leave their houses to get essential goods or to perform some forms of key work, including food production, agriculture and health care delivery.
The Covid-19 pandemic hit Lebanon during one of its worst economic crises in decades. The country has long struggled to finance its health care system, following the end of the civil war and subsequent years of privatization. As a result, the national health system now finds itself under-resourced and insufficiently funded, struggling to maintain a proper supply chain of medicines and equipment at a time when the need could not be more acute. Lebanon has focused its Covid-19 response on providing testing for individuals who present symptoms, as well as conducting random community testing. The government announced that testing would be available to everyone for free at Rafik Al-Hariri hospital, the country’s main public hospital, located in Beirut. While resources in the state’s health system dwindle, private facilities – which make up more than 80 per cent of the sector in Lebanon – have been able to deploy their resources and expand testing services successfully. For example, the Lebanese American University hospital in the capital is running mobile clinics to provide testing for people living in remote areas. Another private hospital has gone further and developed robots to facilitate Covid-19 testing to prevent health workers from having direct contact with patients, thus reducing their risk of infection.
However innovative and effective these measures may be, the cost of accessing the services is a barrier for many in the country. One Covid-19 test from the private sector can cost between 100,000 and 200,000 Lebanese pounds, equivalent to US $66–130 before the devaluation of the Lebanese pound. With the current economic crisis and unprecedented unemployment levels, purchasing a test is simply not an option for many. Moreover, the health system response to Covid-19 has failed to adequately incorporate the health needs of vulnerable groups, including refugees and migrants, people living in poverty and people living with disabilities.
Disproportionate risks and impacts for refugees
As in many other countries, refugees and migrants in Lebanon face higher risks of contracting Covid-19 for a number of reasons, including inadequate living conditions, limited access to services and higher poverty levels.
In alignment with Lebanese government policy, no formal refugee camps have been established in Lebanon in response to the influx of Syrian refugees in 2011. Around one-third of those registered as refugees live in informal settlements or ‘non-residential structures’, where it is common for more than one family to live together in a single tent or unit. Sharing living spaces with families is also a common practice among refugees living in residential structures.
Living in overcrowded conditions in these residences, the risk posed to refugees sharply increases, particularly for those who live in informal settlements. This is mainly because access to sanitation facilities and adequate water is limited or lacking, and following certain public health measures to prevent the spread of the virus, such as social distancing, hand washing and self-isolation, has proven to be nearly impossible. Unfortunately, living conditions for most refugees have dramatically deteriorated of late, with a survey by UNHCR indicating that the number of Syrian refugees living in sub-standard conditions has increased significantly. Many are seeking more affordable options, but this usually entails even poorer quality housing.
Health care delivery
The way that health care is delivered to Syrian refugees is heavily influenced by where and in what setting refugees are staying in Lebanon. Generally, basic health care for registered refugees is subsidized and facilitated by the UNHCR in Lebanon. Some non-governmental organizations (NGOs) also provide health care, either through their own established health facilities or by subsidizing health care provided by the existing Lebanese public health facilities. In some cases, NGOs also provided some health services in camps, including health education and promotion.
However, during the coronavirus outbreak, the imposed lockdown measures and the additional restrictions on Syrian refugees put in place by some municipalities have had a huge impact on their access to health care. NGOs reported their inability to deliver medication or provide medical consultations due to the outbreak response measures, putting many vulnerable refugees with underlying health conditions at additional risk.
During crises, refugees and migrants are among the first vulnerable groups to suffer job losses and health insecurity. Lebanon is no exception. Even before the financial meltdown in Lebanon, Syrian refugees had become more economically vulnerable. They are permitted to work only in a limited number of low-skilled jobs, and only if they are sponsored by a Lebanese national; a 2019 UNHCR assessment found that just a third of Syrian refugees had regular employment while almost three-quarters(73 per cent) lived in poverty.
Besides being badly hit by the economic crisis, Syrians have faced further hardship as a result of the restrictions on movement related to the Covid-19 response. Despite being regarded as essential work during the lockdown, jobs in agriculture and food production have not been accessible to refugees due to additional limitations on their movement imposed by local authorities, depriving many of an essential source of temporary income to meet their basic needs. Refugees who, before the pandemic, were already making ends meet by cutting their expenditure on food, health and education, are now struggling to survive in the face of further economic hardship. Recently, humanitarian agencies have warned that the risks of starvation facing Syrian refugees in Lebanon could even exceed the risks of Covid-19.
Barriers to refugees’ access to Covid-19 testing
While testing plays a central role in managing the spread of Covid-19, Syrian refugees face considerable difficulties in accessing this service. These are rooted in their long-term marginalization in the country, the impacts of discriminatory treatment by local officials and a wider failure to communicate effectively with refugees — a reflection of the government’s reluctance more generally to develop a more inclusive approach to the Syrian population in Lebanon.
At the beginning of the outbreak, it was unclear how Syrian refugees could access coronavirus testing and treatment. The government announced that the test was available for free for everyone with coronavirus-like symptoms, without stating whether refugees were included in this service. Later in April, UNHCR stated that any refugee who needed to access Covid-19 testing and treatment must first go through Ministry of Health screening via a hotline dedicated for this purpose. After the screening, a referral to Rafik Al-Hariri hospital (the main public hospital dealing with Covid-19 patients) might be possible, where the testing has been offered for free. Furthermore, UNHCR announced that it would cover the cost of treatment for Syrian refugees who contract the virus, but only if they have passed the ministry’s screening. Yet some refugees expressed their fears over seeking testing or treatment for a variety of reasons. For example, it is unclear what type of information the ministry will collect through this screening process. As many refugees have been forced to live in Lebanon without residency permits, given the difficulties in securing them, many are concerned that testing could put them at risk of harassment.
Refugees and migrants are often the first to be stigmatized and are often unjustifiably blamed for spreading viruses. A number of Lebanese local officials and even some civilians have made the link, without evidence, between the outbreak and refugees. In a wider context of social exclusion, misinformation and anti-refugee sentiment have led to the introduction of discriminatory restrictions on Syrian refugees, especially those residing in rural areas and small towns. Some locals reported that they received messages from their local council to report the arrival of any new Syrian family, on the suspicion they might have fled from the camps to escape the spread of the virus. One local council even ordered residents not to let available flats or houses to any refugees coming from outside the town.
Some even went further and performed ‘surveillance’ of refugees residing in their areas, with activists reporting that a Syrian family was evicted after being suspected of contracting the virus. This came after the town’s pharmacist reported to the local council that a member of a Syrian family, a young boy, purchased paracetamol tablets for his sick father. The family was evicted from their home and was in danger of becoming homeless without even being given the chance to check the validity of the accusation or to perform a coronavirus test. Unfortunately, this behaviour could easily result in other refugees choosing in future to avoid seeking medical help and treatment, with life-threatening implications for vulnerable individuals and for the country’s public health as a whole.
Discriminatory restrictions on movement
In addition, local authorities in some regions of the country have introduced further restrictions on the movement of Syrian refugees that do not necessarily apply to Lebanese residents. According to Human Rights Watch, at least 21 Lebanese municipalities have applied discriminatory restrictions on Syrian refugees. For example, a municipality in Bekaa has allowed Syrian refugees only four hours per day to leave their homes to perform essential tasks, while Lebanese residents are entitled to much more time to perform the same tasks. The local council deems these measures necessary in order to prevent the spread of Covid-19.
However, tight restrictions on the movement of Syrian refugees, such as curfews, existed even prior to the Covid-19 outbreak and as a result of increasing social tensions and anti-Syrian sentiment in the country. Sadly, these practices have been exacerbated during the coronavirus pandemic. Many refugees have not even been given the chance to escape overcrowding and seek better quality housing conditions.
Towards an inclusive public health response to Syrian refugees in Lebanon
The Covid-19 pandemic, like other public health emergencies, has brought long-standing social inequalities to the surface across the world — and Lebanon, with its large refugee population, is no exception. Simply from the perspective of effectively containing the spread of the virus across the country, the importance of a national response that is collective and inclusive is clear. This means it is vital to ensure that everyone in Lebanon with Covid-19, including Syrian refugees, can access testing and treatment. This will be difficult, however, until Syrian refugees can be sure of receiving these services free of charge and without fear of being penalized for doing so.
This will require a concerted effort from the government to reverse the long-standing marginalization of Syrian refugees in the country, as well as a more positive engagement with communities. This should include more effective dissemination of accurate and relevant information regarding the prevention and transmission of Covid-19, while at the same time challenging broader misinformation that seeks to link refugees with the spread of the virus. Lebanese authorities will also need to address the underlying issues that put Syrian refugees at greater risk of contracting the virus, from lack of water and sanitation to overcrowding and inadequate housing. Any restrictions on the rights of refugees, such as curfew, should be legal, necessary, proportionate and non-discriminatory, in line with international human rights law.
More broadly, a more effective Covid-19 strategy will also require a move towards a stronger rights-based approach to the treatment of Syrian refugees in the country. Greater service provision, improved resources, better access to information and a wider move away from discriminatory surveillance to inclusive support will not only help protect vulnerable Syrian refugees from the threat of the virus, but also benefit the country as a whole.
Source: Minority Rights Group International, 2020