With the Syrian crisis entering its fifth year, Lebanon currently hosts over 1.1 million Syrian . This high intake of refugees has increased political tension but also vastly strained the already limited resources and infrastructures of a country with 4.5 million people.

In January, Lebanese authorities announced new visa for Syrians crossing the border into Lebanon, making it practically impossible for refugees to enter the country.

International organizations and United Nations agencies have been delivering humanitarian assistance and attempting to fill gaps where possible. That includes providing food and cash assistance for refugees, as well as supporting the Lebanese government to respond to increased demand in the several sectors such as health care.

The capacity of the Lebanese health care sector to deal with the demand is vastly overstretched. Today, several years into the Syrian refugee crisis, conflicts around health care provision are visibly surfacing, most notably in health clinics.

With a large part of the international assistance directly targeted at Syrians, many Lebanese feel unfairly treated and left behind, since they also often struggle to cover the rising rent, utilities and health care costs.

These rapid developments over a short time-span have brought about a number of changes and challenges for health workers across Lebanon.

Juggling Tension and Workload

“Since the Syrian refugee crisis started, the stress levels at work have increased a lot,” says Safa, a receptionist and administrative assistant at the Makhzoumi Foundation’s health clinic in Beirut. “Instead of arguing with ten patients a day, I now argue with 30.”

As clinics across Lebanon have seen an increase in the number of Syrian refugee patients, frontline staff such as receptionists and nurses have often found themselves exposed to a new set of challenges in the workplace.

© Nadim Kamel

“The number of patients we get has increased over the past few years. I often don’t get a break during the day anymore,” says Safa.

But aside from the increased workload, health care workers are also faced with tension between Syrians and Lebanese.

“As we were getting more Syrian patients, the waiting rooms would fill up quickly. When our Lebanese patients would step in and find no place to sit or stand, they would often leave,” mentions Safa. “Lebanese don’t always want to wait with Syrians.”

A common solution adopted by health clinics is to segregate Syrian and Lebanese patients. Safa says this used to happen at her clinic until she came up with a new system: “Syrian patients would come and accuse me of letting Lebanese jump the queue, and the latter would come and accuse me of favoring Syrians over them. To avoid more tension, I developed a new numbering system. Now everyone knows whose turn it is to see the doctor.”

Nonetheless, she admits this has not solved all problems. Lebanese patients often call and take appointments in advance, to avoid waiting with fellow Syrian patients.

The most significant point of contention, however, is the specific targeting of assistance toward Syrians. Syrian refugees registered with the UN Refugee Agency (UNHCR) pay three to four times less for a consultation fee at health clinics than Lebanese patients. Mirna, a certified nurse and colleague of Safa, explains: “A lot of issues happen around the differences in fees. Our Lebanese patients get upset and ask us why they don’t receive support as well.”

While health workers explain that the UNHCR covers part of the fee for Syrian refugees, they are often left vulnerable to patients’ frustrated comments and questions.

“Lebanese seem to think that Syrians get everything for free but while that is not true, some Syrian refugees also think that and then accuse us of taking advantage of them,” adds Mirna. “Most of my energy is spent explaining, clarifying and mediating between both sides.”

Finding Ways to Deal With Tension

So far, frontline health care workers have had to cope with these new challenges in a mostly improvised manner. As it seems unlikely that those Syrian refugees already in Lebanon will be able leave the country anytime soon, an urgency exists to solve some of the pressing issues in the health care sector. While some short-term solutions are, to some extent, being used across Lebanese health clinics — such as segregation or prioritizing Lebanese patients — they may harm long-term cohesion between host and refugee communities. Health care workers as frontline staff play a pivotal role in bridging gaps and alleviating tension between both sets of people.

© Nadim Kamel

“For a good while I was chronically stressed,” says Safa. “I would get home after work and not want to speak to my family. I became very snappy and avoided going out to meet friends. I then realized that the constant interaction with people at work has tired me out and the stress was affecting my private life.”

Mirna has found another way of dealing with the difficult working conditions. She says: “I have started blocking my emotions toward the stress and conflict and am using humor to get me through the day. I laugh a lot and even sing at work, my colleagues find it amusing.”

Some organizations have included stress management in their technical trainings for medical staff. International Alert, however, is the only organization that has focused on tension arising from the presence of Syrian refugees in Lebanon.

As part of three-day trainings for health care staff held across Lebanon, over 120 nurses, receptionists and social workers met and discussed the issues they face at work. Using discussions and role-plays, health care staff learned and practiced how to communicate better with their Lebanese and Syrian refugee patients and prevent escalation.

Safa was very positive about her participation. “I was surprised to see that everyone is facing the same challenges,” she says. “I now feel much more confident in taking the responsibility away from myself when it really is not my fault. We cannot change the structure of things, but I can change my attitude in communicating better with patients and in not letting stress at work affect me. We really need more practical assistance to help us deal better with the changed working conditions.”

*[Note: International Alert’s work on reducing tension between Lebanese communities and Syrian refugees related to health care is funded by the European Union, through the United Nations High Commissioner for Refugees, and implemented under the leadership of the Ministry of Public Health of Lebanon.] 

The views expressed in this article are the author’s own and do not necessarily reflect 51�Թ�’s editorial policy.

Photo Credit: Nadim Kamel

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The post Lebanon’s Health Care is Under Strain Over Syrian Crisis appeared first on 51�Թ�.

In attempting to shed light on the increasingly complex developments in Syria, more and more analyses, such as Dr. Josef Olmert’s  for 51�Թ� in May 2013, have placed sectarianism at the heart of the current power struggle. The overemphasis on the sectarian factor does not constitute an analysis of reality, but rather a depiction of reality.  

An Unavoidable Sectarian Fate? 

The conflict in Syria, including the political involvement of regional actors, has increasingly been explained through sectarian affiliation. Broadly speaking, Iran, Iraq and Hezbollah are argued to stand beside Bashar Al-Assad’s brutal regime, supposedly based on their shared "Shi’ite" identity, while Saudi Arabia and the Gulf states are claimed to be supporting the Free Syrian Army because of their "Sunni" identity.

Although the sectarian element is not always identified as the sole motivation, most analyses reference it as a key to understanding the dynamics of the conflict. Olmert, among other like-minded analysts, claims that at the very core of the conflict in Syria lies a "Shi’ite-Sunni War."

Calling the Syrian conflict "sectarian" implies that people’s sectarian affiliation is their primary marker of identity and defines their political interests. By highlighting sectarian affiliation as the main motivation for political actions, sect is often considered in isolation from other important factors, such as the socioeconomic class, geographic location or political affiliation of an individual. What often follows is an uncritical blurring of definitions between sect and religion.

The interchanging of religion and sect is an easily made, yet fundamental, mistake. While religion refers to a specific system of beliefs and practices, sect is a sociological phenomenon relating to the organization and dynamics of the groups concerned. In other words, religion is a doctrine with a fixed set of assertions, while sect is a fluid and constantly changing category. Sunnism and Shi’ism appear to become historical actors independent of the people who adhere to them. Clouding the differences between religion and sect only reinforces the idea that sectarian identities are immutable and the boundaries between sects natural.  

The Creation of a Reality

In his article, Olmert employs precisely such a misleading understanding of the term "sect." In assessing Hezbollah’s support for the Syrian regime, he draws on a so-called "Shi’ite-Alawite connection." Olmert cites Imam Musa al-Sadr’s 1973 fatwa, which declared Alawites as part of Shi’ite Islam, to somehow "prove" the sectarian basis for the Hezbollah-Assad alliance.

By assuming an immutability of sectarian identities based on uncompromising differences, Olmert explains the political behaviour of Hezbollah and Iran as naturally supporting Assad’s government. However, there is nothing natural or inherent about this political choice. Rather, the decision to support Assad’s regime is influenced by a myriad of factors, including strategic, economic and military interests. A regime change in Syria would, for instance, complicate the flow of money and other resources to Hezbollah in Lebanon. Olmert’s Orientalist argumentation is less analytical than judgmental. The overemphasis on sectarian identity seems to point towards a backward Middle East, where religious violence is presented as an inherent expression of primordial ties.

Rather than presenting an objective reality, Olmert’s piece, along with others such as Patrick Cockburn’s  published in The Independent last year, is in fact creating a certain reality. Does that mean that sectarianism does not exist? No, sectarianism has to some extent become a reality on the ground. However, it has been presented as not only a factor to take into consideration, but seemingly the main factor in explaining the conflict today. These articles consciously frame reality in a way that stresses one element over many others, such as regime oppression or economic grievances.

Unfortunately, the more the Syrian conflict is depicted as a sectarian one, the more likely it is to actually turn into one. By referring to sectarianism as the "elephant in the room" and claiming that Arab statesmen, intellectuals and civic leaders avoid recognizing sectarian differences as the basis of their divergent opinions and interests, Olmert magnificently reinforces the notion that sectarianism is simply inherent to the region.

Remember Two Years Ago?

From the very beginning of the Syrian uprising, which took the form of peaceful marches and rallies, protesters were aware that their struggle could be exploited on a sectarian basis. Consequently, the majority of peaceful protesters made the conscious decision to reject not only sectarian explanations for the uprising, but also sectarian language itself.

This decision was linked to the Syrian regime’s attempt to paint the uprising as a sectarian encounter. In an effort to fuel fears among the Syrian population at home and abroad, Assad  that armed gangs and extremist religious groups were behind the attacks and destabilization of the country. The Assad regime used sectarian language as a cover up for its suppression of peaceful demonstrations.  

What we are seeing today is the materialization of a sectarian discourse which was first rejected by many, and has now — after over two years of struggle and conflict, tragedy and destruction, and violence and militarization — become a reality on the ground. Considering the intense brutality from the regime’s side and the deteriorating situation, it is not at all surprising that the initial struggle for dignity and freedom has morphed into something ugly and perverse, which is now given names such as "Shi’ite-Sunni War."

Rejecting Sectarian Language

The strength of sectarian language lies in the fact that it allows only a very limited scope for nuance and contestation. Once trapped within sectarian language, it becomes extremely difficult to critique it without reinforcing it in return. For instance, condemning the actions of Sunni extremists can quickly lead to justifying Hezbollah’s support of the Assad regime on the basis of sect, and vice versa. The only way of getting past this distortion is in rejecting sectarian language and moving beyond it.

Considering the state of the Syrian conflict today, is this argument useful? Is it not too late to turn around the clock? The answer is simple: The more time passes, the more difficult it will become to move beyond sectarian language. Like a self-fulfilling prophecy, sectarian language will only solidify sectarian identities, deepen mistrust and increase polarization. After more than two tragic years, one should not be surprised that sectarian affiliations are increasingly correlated with violence.

A primordial "Sunni-Shi’ite" discord does not lie at the core of the Syrian conflict, but rather an ensemble of powerful interests and discourses, which increasingly amplify sectarian identity as a political factor. Syria has become a regional sectarian battleground, not because it was a ticking sectarian time bomb, as Olmert and others are eager to claim, but because its fragility was exploited on a sectarian basis. 

The views expressed in this article are the author's own and do not necessarily reflect 51�Թ�’s editorial policy.

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