Lebanon is located within a region that continues to face protracted conflict, from the 1948 Arab-Israeli conflict to the disaster currently unfolding in front of our eyes. The displacement of millions of citizens into neighbouring countries has become common place in the region and Lebanon has been – and continues to be – host to many people seeking safety, with the highest number of refugees per capita in the world. Adding insult to injury, conflict and marginalisation affect ‘host’ populations and refugee communities, with the effect that individuals are often overlooked by Lebanon’s already weak social protection network.
If we consider international definitions, the Lebanese situation is a unique case in the realm of host–refugee relations. The Israeli-Arab conflict has led to over 450,000 Palestinians seeking refuge in Lebanon since 1948. The Palestinian community in Lebanon is now entering its fourth generation, challenging the notion that these camps are ‘temporary’. Over 40% of Palestinian refugees (PR) in Lebanon reside within the 12 official camps, despite their inadequate conditions, which include insufficient infrastructure, overcrowding and increased health risks. Housing conditions are poor, with damp, leaks when it rains, and poor ventilation being common. However, the camps do offer security to unidentified PR, as Lebanese forces do not patrol them.
Refugees in Lebanon, of all nationalities and origins, are ineligible for state services, including health services. Even the minority of refugees who find employment in the formal sector and contribute 23.5% of their wages to the National Social Security Fund remain excluded from sickness funds and subsidies. Refugees are therefore reliant on international organisations, including the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), and NGOs to subsidise their healthcare payments. These organisations cover a substantial amount of such payments, but as a result of the economic crisis facing the country, as well as the dollarisation of health expenses, many still find it difficult to cover the remaining share. Thus, many refugees engage in healthcare avoidance.
Those Palestinians in Lebanon who are neither registered with the Lebanese government nor with UNRWA are considered ‘unidentified refugees’. These are people who have been displaced to Lebanon from their initial country of refuge, and have passed this status down through generations. There are over 4,000 such unidentified PR in Lebanon, who face barriers to accessing healthcare. One such barrier is geographical accessibility: checkpoints are installed around the Palestinian refugee camps to control entry and exit, and these are known sites of persecutory practices, in some cases leading to forced confinement. With hospitals out of reach, many of those excluded in this way prefer safer options, such as healthcare provided by the Palestinian Red Crescent or UNRWA within the relative safety of the camps. However, this includes only primary healthcare services, not secondary or life-saving services. Even if refugees are able to cross through the checkpoints, entry to healthcare institutions requires proof of ID, which unidentified refugees do not have.
The Lebanese government does not consider itself responsible for unidentified PR in the country. The government’s Lebanese Crisis Response Plan (LCRP) shifts the responsibility for healthcare for these people onto its partners, whether international organisations, charity organisations, or NGOs. At the same time, the Lebanese government claims to be working towards a ‘more inclusive and equitable system’. However, the only observable change is a continuous decline in refugees’ health status, and their decreasing access to healthcare.
While the continuous demand for more funding made by Lebanese government officials at international conferences is legitimate, there is no tangible evidence that this is leading to concrete improvement in the health status of refugees: rather, there continues to be a denial of responsibility towards unidentified refugees. This warrants a review of the funding provided. Targeted approaches are necessary to improve the livelihoods of these refugees, who suffer from systemic neglect and marginalisation by the Lebanese social protection system. Funding should be allocated to decrease the current high level of discrimination in healthcare access, between registered and unidentified refugees, especially in regard to UNRWA services. The 1951 and 1961 conventions relating to statelessness, to which Lebanon is not a signatory, could be a starting point for obtaining official acknowledgement of responsibility for unofficial refugees in Lebanon. Humanitarian agencies can help end statelessness in the country; to do so, it is essential that they work alongside the Lebanese government to ensure the adoption of the conventions’ directives.
The continuous decline in the health status of unidentified PR in Lebanon is troubling, including as a result of the mental and physical toll caused by the experience of statelessness and open-air confinement within the Palestinian camps in the country. The normalisation of the misery and suffering of these refugees, and the acceptance of their current state, contravenes and violates fundamental human rights and refugee health resolutions within the United Nations system, and necessitates immediate state and international attention.
About the authors: Yazan Farhat, MSc candidate in Global Public Health and Policy at Queen Mary University of London; Policy Associate in Healthcare Recovery and Reform at the Queen Mary Global Policy Institute.
Dr Jonathan Filippon, MSc, PhD; Senior Lecturer in Health Systems in the Centre for Public Health and Policy at Queen Mary’s Wolfson Institute of Population Health.
Competing interests: None
Handling Editor: Neha Faruqui