Rebuilding Health Care After Conflicts: Lebanon as a Case Study in Failure
As the world watches what seems to be a quieting down of the war in Syria, many policymakers have begun to ask questions about the country’s reconstruction. The same can be said of Iraq or Yemen, where wars rage unabated, yet reconstruction ideas, often based around business opportunities, are increasingly being floated.
Looking to the future and studying past reconstruction mistakes was likely on the minds of those attending “Rebuilding Health Post-Conflict: A Dialogue for the Future,” held last month at the American University of Beirut, an institution which has itself survived several wars.
In opening the marathon two-day, eight-session conference, AUB President Fadlo Khoury noted the university’s role in treating the victims of successive conflicts, from opening soup kitchens in the aftermath of World War II to caring for those affected by the civil wars in Lebanon and Syria. With a medical school nearly 150 years old, AUB graduates have gone on to establish hospitals across the region, including the Arab Gulf and Iran, Khoury said.
But as Lebanon looks at rebuilding health care in other countries, local academics and policymakers may first need to look in the mirror and examine the postwar dysfunction still faced by the country’s own citizens.
In successive keynote speeches, there was little mention of the fact that the poor in Lebanon today, whether Lebanese citizens or refugees, are frequently denied access to treatments and surgery. Terminally ill patients are regularly the subject of television news stories, some allegedly dying outside the hospital doors because they cannot afford treatment. Other would-be patients are using crowd-funding to try to pay for organ transplants that the state fails to provide. A severe shortage of hospital beds and medications; a significantly underfunded health ministry; frequent charges of corruption; and unpaid doctors are among the myriad of problems.
Still, Khoury maintained that “all citizens in Lebanon and refugees deserve great health care,” adding that “in spite of the war, the health-care system the Lebanese government has developed postwar is fairly sound to go by, with access to care being relatively good.” He concluded that AUB was not limited to Lebanon but sought to offer global solutions: “We like to think we serve the whole world.”
Indeed, those attending the conference from foreign countries may have assumed that Lebanon’s health system was a model worth exporting. One panelist even went as far as showing a map of the region carved into zones of medical need across Syria, ripe for AUB’s possible expansion. The panelist, Emanuel Mikho, managing director of the construction firm Mikho Consultants (which has designed a number of big-budget hospital projects across the Arabian peninsula) then projected a map of Iraq, also carved into spheres of health influence. “Let’s be optimistic, AUB can have a role in Iraq,” he said.
It was never clear how real this proposal was, with no budget or timeline offered.
“I’m a bit surprised you are envisioning a system that is infrastructure rather than performance,” said Haroutune Armenian, professor emeritus at the Bloomberg School of Public Health at John Hopkins University. “What we need is education and health promotion, not just technology.”
That comment seemed relevant for many of the presentations, which often highlighted hardware or Internet technologies, such as providing medical examinations over Skype, drone delivery of medical supplies or vague Powerpoint presentations on the need for leadership and paradigm shifts. What felt missing were detailed case studies on how communities and their health-care systems actually cope with conflict.
“Why did we decide to expand the system rather than build capacity in the country?” asked one participant in response to the maps of AUB’s potential regional expansion.
Indeed, Lebanon’s postwar health-care system—fraught with postwar issues such as lack of planning, centralization, sectarian service provision, and the mismanagement of public-health issues such as rampant environmental pollution and unregulated privatization that keeps costs high and access low–seemed to be among the many elephants in the room.
None of these issues were specifically addressed in a presentation by Walid Ammar, the director-general of Lebanon’s public health ministry. His talk focused largely on conceptual goalposts such as public-private partnerships and capacity building, bribery among political players, and “misguided and misinformed citizens,” all leading to “white elephant projects,” with none specifically named. He leveled vague charges at private donors with “hidden agendas…who seek to manipulate academia by producing studies that fit perfectly their agendas.” Ammar concluded that “the system is resilient because the ministry of health succeeded in establishing a good kind of collaborative governance.”
Physician Kamal Mohanna was one of the few panelists who did not hold back in his criticism. “The policy in Lebanon is that there is no policy,” he said, describing public health in the country as “a scandal.”
Mohanna is the founder of Amel, one of the oldest among hundreds of nonprofit charitable organizations that offer health-care services and clinics in impoverished areas to fill the gap left by the government. He noted that nearly half of Lebanon’s population lacks health insurance and that even when covered, families are sometimes forced to pay up to 40 percent of the cost of treatment. “If you don’t have money, you can’t have health care,” he said.
Mohanna said Amel runs 24 centers and six mobile clinics, serving largely poor and rural areas, which he described as being on the periphery of national health services that were disproportionately located in the capital.
“Everything is in Beirut,” he said. “You can build two hospitals side by side and no one will say anything, that’s the free market. In Montreal, you have five MRI machines serving a population of five million. In Lebanon, you have 42” serving roughly the same number of people.
“Health care should be a right, and we should have a culture of rights, [but] in Lebanon we don’t have that. We have politicians that give health-care services,” he added.
Mohanna was alluding to a post-conflict detail left almost entirely out of the conference discussions: the provision of health services as a form of political patronage. Nearly all of Lebanon’s political parties and former militias run either major hospitals or clinics, offering treatment in exchange for loyalty or votes. “The provision of health care is a powerful legitimizing force, the ability to create a powerful patrimonial system,” said Ghassan Abu Sittah, professor of surgery and one of the few speakers to link health care and political power.
Abu Sittah gave the example of Iraq, where much of the government’s health budget is spent to send patients to foreign countries for costly treatments, a “quick fix” to satisfy political elites but ultimately damaging to building a local health-care system.
“The nature of power will shape the picture of how health care is provided in Syria,” he added.
Post-conflict societies will also face extensive mental-health and post-traumatic stress disorder issues, a topic broached in only one panel over the two-day conference. One quarter of adolescents in Lebanon suffer from mental health conditions and only six percent of those who need help are getting it, said pediatric psychiatrist Fadi Maalouf.
“There are only four child psychologists in Lebanon—four of us serving a population of 4 million as well as some 1.5 million (Syrian) refugees.” Lebanon also suffers from a severe scarcity of nurses, says Amel’s Mohanna. “We have 7,000 nurses in Lebanon, but we need 29,000,” he said.
Although a large number of the conference participants hailed from major universities, governments and international institutions, the most concrete suggestions for providing post-conflict health care seemed to come from smaller, local organizations that try to fill in where the government has failed to provide.
Yorgui Teyrouz, a 30-year-old pharmacist, established Lebanon’s first blood-bank network, responding to a lack of a national blood bank and daily shortages at Lebanese hospitals, often announced on the radio. The organization, Donner Sang Compter, now has a network of over 15,000 donors and runs regular blood drives across the country at universities, schools and malls. But the Lebanese government has offered virtually no support, even blocking the organization’s use of a mobile blood donation bus because the vehicle’s steering wheel was on the “wrong side” of the vehicle, Teyrouz said. Arcane government regulations also prevent the donation of blood without having the name of the patient who is to receive the blood, he added, effectively restricting donations to family or friends.
Another local nongovernmental organization, Arc En Ciel, founded a wheelchair factory, staffed by the disabled, one of the most marginalized groups in Lebanon, a country where even able-bodied pedestrians have difficulty navigating broken sidewalks, rough roads, and high curbs. Arc En Ciel lobbied successfully for legislation that now requires the government provide a new wheelchair to the disabled every five years, according to operations manager, Kim Issa. Arc En Ciel has also helped pass a law that bars hospitals from dumping untreated medical waste, which had been mixed with household garbage in landfills until the early 1990s.
As the conference drew to a close, there was much debate about the use of the term “post conflict,” with many academics casting doubt on its utility at a time when wars don’t always have clear endings. Conflicts tend to evolve rather than halt and can have lasting impacts on the populations. In Lebanon, former warlords have become politician,s and many citizens believe the battle has shifted from physical violence to economic violence, from launching mortar rounds to holding public services hostage amid political infighting over lucrative state contracts. Not only are citizens often deprived of basic services like electricity, water and garbage collection, but the resulting dumping of raw sewage across the country’s shores, the rampant burning of garbage piles and the polluting of private electricity generators have caused detrimental effects on public health, according to AUB’s own studies.
Perhaps the inability to frankly discuss issues should be added to the list of post-conflict health challenges. The preference for platitudes over critical and detailed analysis may be a sign that Lebanon has yet to reach a true post-war phase. Until it confronts its own challenges, Lebanon may not be ready to offer post-reconstruction health-care advice to Syria or Iraq.