first days in beirut

For if humanism can only constitute itself on the bodies of the dehistoricized, archetypal refugees and other similarly styled victims – if clinical and philanthropic modes of humanitarianism are the only options – then citizenship in this human community itself remains curiously, indecently, outside of history.

 – Liisa Malkki, “Speechless Emissaries: Refugees, Humanitarianism, and Dehistorization” (p. 398)

My first three days in Beirut have been the coldest imaginable – a simultaneous whirlwind of freezing rain, downpour, and snow have all tortured the city [1]. Coupled with violent winds, flooding, and power cuts – leaving heating possibilities null and void –  living in the city over the past seventy-two hours has been akin to living in the middle of a small hell. However hard I thought it was to live without electricity or warmth (and believe me, being cold in the middle of a storm is not a wonderful place to be), I was forcefully reminded today of how wonderful I had it, living in an apartment in downtown Beirut. I spent my first morning in clinic, as part of a social medicine elective, working in Shatila, one of the oldest Palestinian camps in Lebanon.

DSC_0117

Taken during a Palestinian nationalist march in late July 2010, this illustrates some the inner conditions of the camp – poor sanitation, dim lighting, criss-crossing electrical wires overhead, and the emphasis placed on Palestinian parties and leaders, such as the symbol for Fatah on the wall located on the right of the picture.

A history of Shatila in and of itself would take far too long to be fully explained in a blog post, but many others have devoted significant scholarship to this end [2]. In short, Shatila is known, sadly, as the site of a 1982 massacre, alleged to have been carried out by Kata’eb (Phalangist) party members, under the guise of Israeli control of the surrounding area [3]. Furthermore, the site was one of many areas decimated during the “War of the Camps” from the mid-1980’s until the end of the civil war in 1990, wherein different Lebanese political parties fought for control of the camps after the PLO was forced out of Lebanon in 1982. I had been to the camp in 2010 as part of working with an NGO devoted to providing maternal and child health programming to the area. Coming back after three years and one of the worst winter storms in Lebanese history, I was shocked to see that the entire camp looked exactly as it did three years ago – trash strewn across the narrow alleyways, men on scooters honking wildly as they whirr past you, concrete houses built high enough to cloud out the sun in many places [4]. However, many of the dirt streets were soaked, tin huts in some of the smaller courtyards were damaged, occupants’ belongings blown into the street to be trampled by the countless cars and pedestrians coming through.

Thinking about living in these conditions – with pirated electricity (most certainly blown out during the storm at some point), no ability to heat one’s self except for a small gas heater, no ability to divert the onslaught of rain except to watch it flood your narrow streets – was on my mind as we saw patients throughout the day [5]. Many of them have come from Syria due to the continued war, and have settled in many of the refugee camps of Beirut [6].  Seeing the compounded effects of poor housing, refugee status [7], and inefficient social safety structures on the overall health maintenance of a population, the patients I saw today – one being monitored for uncontrolled hyperlipidemia and hypertension status-post CABG (coronary artery bypass graft) and the other a poorly-controlled diabetic on triple-drug therapy – emphasized to me that access to consistent medical care (i.e. ability to get their medications, home glucose monitors, home blood pressure cuffs, and the like) must be situated in the lives of these patients themselves. Without their history – im/migration, violence, inequity (gendered, economic, political, ethno-racial) – their suffering remains consistently outside of compassion and understanding beyond the biological, as illustrated in the epigraph [8].

Speaking with another medical student today about counseling our patient with diabetes about proper diet management, we realized that issues surrounding food security, housing (i.e. having a place to cook and store food, along with needed materials in order to prepare food), and bodily health were along a similar continuum. Moreover, taking into consideration the horrible wave of storms that have hit Beirut over the past few days and the number of patients who came in with complaints that they have not taken their antihypertensives or glucose-regulating drugs due to inability to access the clinic, more questions come up regarding how to provide a good healthcare system in an area mostly forgotten by individuals in political power. How do we manage hypertension, diabetes, pregnancy, cancer, or traumatic brain injury in an area where its hard to get clean water or access to electricity? Moreover, what are we as a medical society to say when you can travel two miles away and receive those same things? The barrier to access to such services are as much sociopolitical as they are economic [9], and the “embodiment” (to use Nancy Kreiger’s term) of such inequities is found in the health outcomes of the patients I’ve seen today.

Struggling over the meaning of such issues – poverty, injustice, refugeedom, and the like – keeps me thinking of what medical anthropologists have had to say about such issues. I find myself gravitating towards works by individuals like Paul Farmer, Nancy Scheper-Hughes, and Philippe Bourgois – individuals who find fault in the way suffering is structured – how “the political economy of brutality,” to use a phrase from Farmer [10] finds its way into the clinic, the refugee camp, and in everyday discussion. How these frameworks can be used not merely as critiques, but as methods of promoting solidarity, self-reflexivity, and critical praxis in the clinic and the community are avenues that I want to explore not only on paper, but with the other students, attendings, and communities I come to work with in my time here. The importance of a storm, just like Sandy and Katrina in the US, can expose a great deal of issues and inequalities both locally and globally, and can challenge us as future physicians to think about how to deal with such complex problems with even more innovative solutions.

Notes:

[1] For further information, see http://english.al-akhbar.com/content/state-shock-lebanon-surveys-storm-damage

[2] For an excellent history of the Palestinian experience in Lebanon, including in the Shatila camp, see Rosemary Sayigh’s classic Too Many Enemies: The Palestinian Experience in Lebanon

[3] Founded by Pierre Gemayel in the 1930’s and modeled after the Brown Shirts of Mussolini’s regime, the Kata’eb party emphasized Maronite hegemony in Lebanese politics, along with modeling Lebanon in a “Phoenician,” rather than “Arabic” frame. For a detailed discussion, see Robert Fisk’s Pity the Nation, [2], and Fawwaz Traboulsi’s A History of Modern Lebanon. For a film biopic from an Israeli perspective about the Sabra/Shatila massacres, see Waltz With Bashir (2008), directed by Ari Folman. In regards to the massacre itself, which group actually committed the massacre is still under debate by many historians and critics, though many agree that the Kata’eb party had ultimately perpetrated the atrocity with some form of support (implicit or explicit) from Israel.

[4] Due to the fact that the Lebanese government has not allowed Palestinian refugee camps throughout the country to gain further land acreage than that initially provided, much of the construction in the camps has increased vertically, rather than horizontally.

[5] In nearby Hey Es Sallom, where I carried out research in 2010, the Ghadir river flooded due to the storms, leaving those already destitute living in the slum homeless. For further information, see http://english.al-akhbar.com/content/ghadir-river-swallows-beirut-shantytown

[6] Some of these refugees, according to one of my advisors, are “doubly displaced” – that is, Palestinians displaced to Syria during the Lebanese Civil War now are being re-displaced back to Lebanon due to conflict in Syria.

[7] The UNRWA (United Nations Relief Works Agency for Palestinians in the Near East) has been providing food, housing, jobs, and medical care to displaced Palestinian populations since the 1950’s. Though the extent of their provisions is severely limited due to internal U.N. politics and poor funding, they nevertheless provide crucial care for many living in the camps. For example, today in the camps, we realized that the UNRWA has now begun funding laboratory tests for the incoming Palestinian refugees from Syria. This was not a service offered to other refugees in the past.

[8] Liisa Malkki, along with Didier Fassin, Stephanie Larchanché, and Miriam Ticktin, have delved into the issues surrounding how medical humanitarianism – the emphasis placed on biological suffering – can ultimately lead to the bracketing of other types of suffering – socioeconomic and political, for example. For further discussion, see Ticktin’s “Where ethics and politics meet: the violence of humanitarianism in France” and Fassin’s “The biopolitics of otherness: Undocumented foreigners and racial discrimination in French public debate.”

[9] see [2], and Jad Chabban et al’s “Socio-Economic Survey of Palestinian Refugees in Lebanon” (http://fafsweb.aub.edu.lb/aub-unrwa/files/AUB_UNRWA_report_final_draft.pdf)

[10] See Farmer’s The Uses of Haiti

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