A health worker dressed in a protective outfit walks in an alley at the Wavel Palestinian refugee camp in Lebanon's eastern Bekaa Valley, on April 24, 2020. (Photo by -/AFP via Getty Images)

No Funding and No Policy: Lebanon’s Refugee Population amid COVID-19 and an Economic Crisis

07/23/2020 . By Diana Rayes and Kareem Chehayeb

Though refugees constitute a small percentage of the nearly 3,000 confirmed cases of COVID-19 in Lebanon, cases are on the rise among Lebanon’s vast refugee population. In April of this year, the first case of novel coronavirus (COVID-19) was identified in a Palestinian refugee camp in eastern Lebanon’s Bekaa region. Since then, at least 30 cases of COVID-19 have been confirmed among Lebanon’s Palestinian refugee population, including 10 cases recently identified by the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) in Rashidieh Camp in southern Lebanon. Among the Syrian refugee population, a total of 15 cases have been identified in camps alongside the Syrian-Lebanese border, and 227 cases have been reported among Syrian refugees living in urban areas. Chronic food insecurity, unemployment, rampant discrimination, and uncertainty about the future, exacerbated by Lebanon’s deteriorating economic and financial situation, have added significant stress on Lebanon’s refugee population and the humanitarian agencies and non-governmental organizations aiming to support them.

Hampered response compounded by economic woes

Lebanon is currently home to roughly 1.5 million documented and undocumented Syrian refugees, as well 200,000 Palestinian refugees. It is also host to smaller refugee populations from Ethiopia Iraq, Sudan, and Egypt. About 38 percent of refugees registered in Lebanon live in crowded, informal settlements in the Bekaa Valley, and over half of Syrian refugee families in Lebanon live in temporary or substandard housing. Crowded settlements in the Bekaa Valley are particularly vulnerable to the spread of COVID-19, particularly due to lack of access to clean water and sanitation, limited access to testing, and pre-existing health conditions among refugees.

Concurrently, Lebanon is facing the worst economic crisis in its history, with its local currency devalued by approximately 80 percent. A recent International Labour Organization report revealed that 60 percent of Syrians in Lebanon were laid off following the onset of COVID-19, compared to 39 percent of Lebanese citizens. Close to 92 percent of Syrian refugees in Lebanon are experiencing some sort of food insecurity; and 66 percent live in poor standard conditions. Critical economic challenges have left significant numbers of refugees in Lebanon without employment, and therefore, unable to pay rent, healthcare, and food. The Lebanese government also continues to implement austerity measures, including a seven percent budget cut on state-run healthcare, which includes support to NGOs which are critical to maintaining cash assistance, health services, and humanitarian aid to over 1 million Syrian and Palestinian refugees in Lebanon. Given the largely privatized nature of the Lebanese healthcare system, these cuts to public facilities will greatly impact access to healthcare for refugees in Lebanon, who almost entirely rely on public services.

Nine years of conflict in Syria and decades of refugee resettlement in Lebanon have led to chronic donor fatigue, hampering efforts by medical agencies and the UN Refugee Agency (UNHCR) to guarantee the provision of medicine and medical services to refugee populations. Consequently, smaller-scale initiatives have since faced a greater burden. Endless Medical Advantage, co-founded by Syrian doctor Feras Alghadban, provides primary healthcare services using a van-turned-mobile clinic in the central Bekaa region—where almost 40 percent of UNHCR-registered Syrian refugees reside. Alghadban says that it has been difficult to implement social distancing and other necessary measures to mitigate the spread of COVID-19 in Lebanon’s refugee camps. “People weren’t wearing masks and sanitizing wasn’t ultimately helpful,” he explained, adding that it was an ardent task to convince refugees to stay confined to their cramped shelters. Though 69 percent of registered Syrian refugees live in residential structures, almost 60 percent live in shelters that are overcrowded, below humanitarian standards, and/or in danger of collapse, according to the UNHCR.

About half of Palestinian refugees in Lebanon live in one of 12 UNRWA-administered refugee camps. The UN agency provides a range of basic services includingUNRWA-run schools, medical facilities, and other social services. Palestinians in the overcrowded camps, already living in dire conditions with sub-par infrastructure, continue to face rampant poverty and unemployment. Lebanon’s economic crisis has further exacerbated these issues, with the agency saying that unemployment has shot up from around 65 percent to 90 percent at the camps. The agency added, during a webinar on COVID-19, that homelessness and the inability to pay for rent and other primary costs has pushed many Palestinians to request shelter in UNRWA schools and facilities. Trying to mitigate the crisis during the COVID-19 pandemic, UNRWA struggled but ultimately managed to provide one-time cash assistance.

Testing, medical access, and restrictions on movement

Access to COVID-19 testing has proven to be a difficult task for refugees in Lebanon.Though government-run Rafic Hariri University Hospital in Beirut provides free testing for symptomatic individuals, its Bekaa counterpart, the Elias Hrawi Hospital, does not. According to Dr. Alghadban, polymerase chain reaction (PCR) tests used to diagnose COVID-19 at the hospital cost 150,000 Lebanese liras—roughly $100 prior to the economic crisis, a price that may have been inflated. He added that this was especially a concern for emergency patients, who have to take PCR tests before being admitted. “It takes two days for the result to come out, but if this is an emergency case, how can they wait for two days?” Dr. Alghadban asked. This is compounded by persisting fears among members of the refugee community of seeking treatment for COVID-19, thus attracting the attention of Lebanese authorities who may flag their irregular status or lack of paperwork and risk being deported.

Thus far, there has not been a major outbreak among the Syrian refugee population at large. In late May, 15 Syrian refugees in the Bekaa town of Majdal Anjar tested positive. According to the UNHCR, there was only one positive case prior. According to a UN OCHA report in June, 94 Syrian refugees living in urban areas tested positive, with “clusters of cases among the local populations,” including essential healthcare workers. In early July, a total of 133 Syrians working for Ramco, the waste management company responsible for Beirut and two other provinces, recently tested positive for COVID-19.

Night curfews and other restrictions during the COVID-19 lockdown have made it difficult for medical organizations to access refugee camps and consequently, for refugees to access medical facilities. This includes Medecins Sans Frontier and Amel Association, which said visits to facilities declined by 30 percent in March. Prior to countrywide lockdown-like restrictions and policies imposed in mid-March, at least 21 municipalities had already implemented curfews and other restrictions to freedom of movement that explicitly discriminated against Syrian refugees. These policies superseded curfews imposed at a national level, which Human Rights Watch said was not only discriminatory in nature, but also redundant to preventing the spread of the virus.

No comprehensive refugee policy

In the years and months leading up to COVID-19, there had been a demonstrated lack of comprehensive refugee policy from Lebanon authorities, exhibited by a laissez-faire approach to the refugee crisis. Khalil Gebbara, advisor of then-Minister of Interior Nouhad Machnouk, said in an interview that national policy on Syrian refugees was limited, as there was no official position on the conflict that Lebanon’s ruling political parties would agree on. The country was committed to a so-called “disassociation policy,” which would bar Lebanon from taking absolute positions on regional conflicts. In May 2015, Lebanon requested the UNHCR to suspend the registration of Syrian refugees, to which the UN agency complied. To justify these positions, Lebanon often refers to the fact it has not signed the 1951 Refugee Convention, and has sidestepped international conventions it is party to that are relevant to protecting refugees and ensuring non-refoulement. These international standards have been diluted by rhetoric used by Lebanese authorities to Syrian refugees as “displaced,” rather than “refugees,” which distinguishes between the rights guaranteed to refugee populations outlined by the 1951 Geneva Convention, including non-discrimination, non-penalization and non-refoulement versus displaced populations, more broadly.

This resistance from the Lebanese government to produce a comprehensive refugee policy is largely a byproduct of the Palestinian refugee crisis, as most Palestinians remain in Lebanon indefinitely. Nearly a decade since the start of the Syrian crisis, this is slowly becoming a reality the Lebanese government is refusing to accept. When it comes to Syrian refugees, only a handful of items have been agreed on—all restrictive in nature to refugees: no internal resettlement and naturalization, no establishment of formal camps settlements, discriminatory curfews to restrict movements, inadequate access to education and health services, and no right to permanent work. As a result, more specific regulations and policies related to Syrian refugees have been spearheaded by municipalities, civil society organizations, and international organizations, both ill-equipped technically and financially to adequately handle the issue.

Although Health Minister, Dr. Hamad Hassan, expressed that the needs of the Palestine refugees and displaced Syrians are a “shared responsibility” between Lebanon and agencies responding to the pandemic, Lebanon—now with its economic woes—will continue to depend on the sustained support of humanitarian aid agencies. A struggling UNHCR is trying to reallocate resources to provide primary aid for Syrian refugees and support local public hospitals, while Palestinian refugees in Lebanon rely on UNRWA’s hospitals and medical centers for healthcare. This is in the backdrop of major shortages in funding for prominent UN agencies operating in Lebanon. For example, UNRWA has set an appeal for $400 million, with  $270 million allocated for Palestinian refugees in Lebanon and Jordan, while UNHCR’s Global Appeal for 2020 includes $546 million, a decrease from funds allocated in previous years. While donor fatigue continues to worsen, the UNHCR’s funding gap continues to widen. While the UN refugee agency’s funding gap was already at a concerning 43 percent for both 2017 and 2018, it appears that number skyrocketed to 71 percent in 2019. UNRWA continues to function at a loss, thus far unable to recover from the impact of a full withdrawal of funding from the United States back in 2018. It ended 2019 with a $55 million shortfall and had only received 30 percent of its required funding by late May 2020.

Overall, the compounding effect of COVID-19 with Lebanon’s economic downturn and sociopolitical unrest has led to decreased donor funding and limited capacity within the health system to meet the growing needs of both Palestinian and Syrian refugee populations in Lebanon. While these gaps have been temporarily filled by the informal health sector and local civil society organizations, demands for national and international stakeholders and policymakers to fill gaps in these areas, particularly in response to COVID-19, are critical, and nothing less than life-saving.

However, major budget cuts to NGOs leading health programs for refugee populations in Lebanon, particularly those supporting Palestinian refugees, are weakening programs and resulting in less than favorable outcomes for and the potential spread and transmission of COVID-19 in these areas. As such, high-level donors and countries, including those who pledged support for the Syrian refugee response at the recently held Brussels Conference and senior European officials who have called for support for Palestinian refugees, should take heed of where these disparities lie and work in tandem with humanitarian, and particularly local organizations, to identify where needs are greatest, and prevent a catastrophe that extends well beyond the threat of COVID-19.