Go and pave the ocean.
- Traditional Lebanese saying
Going just over the month mark with my time in Beirut, I’ve been lucky and privileged enough to spend much of my week serving unique communities throughout the country. From elderly Maronite couples living in the mountains to Iraqi refugees living on the outskirts of northern Beirut, I’ve been able to intersperse myself in clinics and home visits on both weekdays and weekends. However, my most challenging times have been while working in the Shatila refugee camp, located just to the south of Beirut. I split my week there simultaneously working at a Volunteer Outreach Clinic (VOC), staffed by faculty and students from the Lebanese American School of Medicine (where I am doing my away rotation in social medicine), and with the Palestinian Red Crescent Society (PRCS) clinic, located just around the corner from the VOC.
Though the focus of the work traditionally has been with Palestinian populations who have been living in the camps, we have been seeing a significant number of Syrian refugees from the ongoing crisis . Walk-in clinics have been filled with individuals suffering from acute illnesses, chronic diseases left unmanaged by cuts in care due to migration, and, surprisingly (or not), new diagnoses of mental illness . With little service to be provided in these understaffed and under-equipped clinics, much of our work goes towards both management of common illnesses (hypertension, upper respiratory tract infections, and diabetes) and referrals to the UNHCR or the United Nations Relief Works Agency for Palestinian Refugees in the Near East (UNRWA) for social and material supports .
The complexity of seeing this fractured machine of health provision slowly grinding away in a refugee camp is painful. Moreover, hearing about and actually seeing the bureaucratic inefficiency from both a governmental and non-governmental level furthers this feeling. From my informants both in the camp and elsewhere, it is widely acknowledged that registration with the UNRWA takes upwards of three months, which means provisions of food, clothes, and healthcare coverage (refugees are by in large without health insurance) are placed squarely on the backburner. With winter rains and cold a constant issue in the camps, the problem of adequate housing, food security, and employment are subsequently compounded . Beyond the merely structural, the issues surrounding care for both Palestinian and Syrian refugees, both in Lebanon and elsewhere, is complicated by rumor, suspicion, and fear. One informant related a story to me regarding individuals from a certain sect (i.e. religious background) who were unwilling to be registered by the UNHCR, for fear of the list falling into the hands of the Syrian regime, or worse, being used in an inter-sectarian pogrom .
One feels the sense of burnout, as if someone is telling you to “go and pave the ocean,” a Lebanese saying akin to “leave me alone,” or, more vulgarly,” fuck off.” It becomes tough to raise one’s head and to see that beyond everything here – horrible news, rough conditions, and sick patients – things go about normally. The everyday hustle and bustle of life bleeds into these areas of structural violence – children play in the streets, the owner of the fresh vegetable and fruit stall waves hello whenever I walk by, and, on Friday afternoons, rows of men gather to pray in the alleyways of the camp. This is not to turn lemons into lemonade or to take an Orientalist leaning, but to suggest that moving away from a perception of individuals living in rough situations as constantly suffering, and looking for how life continues to be led, might in fact be more fruitful (see Biehl & Locke 2010). Moreover, it forces me to ask myself, how am I characterizing suffering in my writing? How am I contributing to a knowledge of others?
I am not writing to portray a bleak life for many of the individuals – Syrian, Palestinian, or Lebanese – that I work with and for. Facts on the ground are as they are presented – one cannot change homelessness or violence by calling it another name. And yet, I am drawn to the writings of individuals like Didier Fassin, Sarah Willen, and Miriam Ticktin precisely because they call into question the very manner in which medical humanitarianism is presented, and critique how it can serve as an “anti-political” machine, rerouting old stereotypes and, in fact, preserving the status quo. All three have worked for groups advocating for immigrant and refugee rights – Fassin, himself an MD/PhD, worked for years as a board member of Medicine Sans Frontières (MSF), and, as a result, has become one of its most unique and ardent critics. The worry portrayed in all of their evocative research and writings is as follows:
If the immigrant [or refugee] is not allowed to speak as a multifaceted subject, only to exhibit injuries, a particular nation and a particular humanity also get produced in the process (Ticktin 2011, p. 107)
In essence, am I contributing to this paradox, this legitimation of a certain type of suffering, wherein the biological is uplifted over the sociopolitical? The politics of witnessing and representation become crucial in this context, both from a professional and ethical vantage point. Who speaks for whom, in what manner and to what end?
I turn my final thoughts towards Boston, where I am headed in a matter of a few weeks. Coming back to friends and colleagues working at BMC – with our unique patient considerations mirroring many of those I’ve seen here – I think about how we can better equip our language to both convey the sense of urgency in the social and economic inequality we see everyday with the biological suffering we are trained to keep an ear out for as physicians. Put another way, the challenge in representation (and there will always be a challenge) is to know when, crudely, the body needs to stop talking and the person needs to begin. Moreover, the act of listening is highly political, and must not necessarily conform to the standards we have set for ourselves in the medical field, i.e. the social history (see Scheper-Hughes 1995). We must emphasize the person talking and who they are – where they live, what they do, the struggles they face. This posturing makes the world of difference and can, in effect, begin the challenge of responding to the heavy critiques made by members of the medical anthropological community. Humanitarianism does not necessarily have to create a notion of a morally legitimate form of suffering, and we, as the medical community, need to take the first steps away from the contradictory and dangerous mentality that this creates.
 The term “Syrian refugee” is misleading in a number of ways that merits clarification. First, it does not distinguish “nationalities” of the refugees – are they, in fact, Syrian, or are they repatriating Lebanese? Or, more uniquely, are they the “doubly-displaced” Palestinian refugees (i.e. Palestinians displaced from Lebanon to Syria during the civil war (1975-1990), who are now returning)? Secondly, “refugee” itself is a sociopolitical term, conferred formally by the United Nations High Commissioner of Refugees (UNHCR), present in Lebanon at this time. According to the most recent reports, approximately 225,000 Syrian refugees are in Lebanon, with more than one quarter unregistered with the UNHCR. See http://data.unhcr.org/syrianrefugees/regional.php and http://www.dailystar.com.lb/News/Politics/2013/Jan-26/203858-mikati-situation-of-syrian-refugees-at-dangerous-p.ashx#axzz2J6KhOhTx
 I say surprising in this circumstance because, as to our knowledge, there are no mental health professionals (i.e. psychiatrists and psychologists) working in Shatila at this time. Many patients are presenting with symptoms consistent with post-traumatic stress disorder (PTSD) and panic disorder (i.e. panic attacks) and are being managed on anxiolytics, such as benzodiazepines. The only known mental health facility is located a short distance away, in the Bourj al Barajneh camp. Initially funded by MSF, the facility has been turned over to local hands.
 Registration with the UNRWA or UNHCR depends on whether or not you consider yourself to be of Palestinian origin. Classically, Palestinians register with the UNRWA, whereas all other refugees register with the UNHCR.
 The question of work opportunities for Palestinian versus Syrian refugees is complex. Strict labor laws enacted in 1964 treat Palestinian workers as “foreign” workers, and, subsequently, they must have their home country’s legislation fulfill reciprocal treatment for work opportunities for Lebanese. Since this cannot be fulfilled, work permits for professional organizations (i.e. physicians, lawyers, and the like) are not allowed. However, working in certain nonprofessional sectors (i.e. construction, garbage collecting, etc.) require no work permit (see Deeb et al 1997). The need for reciprocity was changed in 2010; despite the change, few work permits have been issued for Palestinians, with a significant proportion (i.e. 56%) jobless. On the other hand, many Syrians are finding work in the service sector, such as driving services (i.e. taxis), or working in construction. However, the number who are unemployed is unknown at this time.
 Fears of inter-sectarian violence, an issue made most explicit by the Lebanese civil war, continues to haunt the zeitgeist of the current sociopolitical sphere. The invocation of sectarianism in the realm of humanitarian aid, however, demonstrates, as individuals like Didier Fassin (2001, 2011) and Miriam Ticktin (2006, 2011) have done, how “neutral” humanitarianism can become subsequently politicized. Moreover, it also demonstrates the transport of a political form of government into the everyday rationality of individuals at the mercy of such a system (see Joseph 1997 for the example of “patriarchal transportation” in the Lebanese realm).
Biehl J & Locke P. 2010. Deleuze and the Anthropology of Becoming. Current Anthropology 51(3): 317-351
Chabban J et al. 2010.Socio-Economic Survey of Palestinian Refugees in Lebanon (access at: http://fafsweb.aub.edu.lb/aub-unrwa/files/AUB_UNRWA_report_final_draft.pdf)
Deeb M et al. 1997. Health Profiles of the Palestinian Refugees in the Sabra and Shatila Camps. American University of Beirut, Faculty of Medicine.
Fassin D. 2001. The biopolitics of otherness: Undocumented foreigners and racial discrimination in French public debate. Anthropology Today 17(1):3-7
———–. 2011. Humanitarian Reason: A Moral History of the Present. Berkeley, CA: University of California Press
Joseph S. 1997. The public/private: The imagined boundary in the imagined nation/state/community: The Lebanese case. Feminist Review 57: 73–92.
Scheper-Hughes N. 1995. The Primacy of the Ethical: Propositions for a Militant Anthropology. Current Anthropology 36(3): 409-440
Ticktin M. 2006. Where ethics and politics meet: The violence of humanitarianism in France. American Ethnologist 33(1):33-49 (access at: http://www.hhh.umn.edu/img/assets/28237/ticktin.pdf)
———–. 2011. Casualties of Care: Immigration and the Politics of Humanitarianism in France. Berkeley, CA: University of California Press.