We have an early pick-up for the twenty-minute drive to Shatila refugee camp, in constant lane-swapping-honking-traffic. We pass under a metal arch adorned with pictures of leaders and flags of one of the many political factions that operate in the camp.
People and motorbikes weave around each other in the narrow winding streets and passageways which are draped in a spider-web-tangle of cables. We turn down an alleyway barely wider than our van to a dusty parking-lot surrounded by residential blocks strung with
laundry. My colleagues tell me that at night, extra floors are built onto existing structures, haphazardly and illegally, to accommodate the estimated 40,000 people now living in an area of about one square kilometre.
We walk past collapsed hulks of rusted cars and stray animals scrounging rotten food from rubbish bags. We step over a grill-covered open sewer and pass by open-fronted shops. Through a dim passage and up several flights of stairs we arrive at the clinic.
At 8am there are a few early patients already sat in the chairs in the downstairs reception area. There are health posters in Arabic sellotaped to the red-and-cream-coloured walls.
The people of Shatila
Lebanon has the highest number of refugees per capita in the world. Shatila was established as a camp for Palestinian refugees in 1949. It is now also home to the many Syrian refugees who have arrived since the onset of their civil war in 2011.
The camp community is very divided. Even fourth-generation Palestinian refugees continue to live on the margins of Lebanese society, with limited citizenship, employment and property rights, but Syrians and those from other minorities experience even worse discrimination, exclusion and lack of protection.
There is no formal government provision of healthcare in the camps and MSF is a major provider of the limited free healthcare here.
Non-communicable diseases (NCDs)
The MSF team opened the clinic here in 2013 in response to the influx of Syrian refugees. Our main activity is looking after patients with non-communicable diseases - the leading cause of mortality worldwide, especially in low and middle-income countries.
Non-communicable diseases include hypertension, diabetes, coronary heart disease, asthma, chronic obstructive pulmonary disease, hypothyroidism and epilepsy. Patients who do not have access to care are at risk of acute and chronic complications.
For example, about once a week we have a medical emergency - often a young diabetic with ketoacidosis (dangerously high levels of sugar and ketones leading to confusion and possible coma). They are promptly treated by our doctors and nurses with intravenous fluids and insulin whilst the nursing and social work team manage the complicated process of arranging transfer to hospital.
For patients, managing their illness is yet another challenge to add to poverty and hardship, past traumas and losses, and ongoing stressors in their daily lives. Most of them have more than one illness and have often seen several different doctors.
There is little oversight of the highly privatised, fee-for-service system here, and patients arrive at our clinic with a jumbled pile of handwritten medical papers, often with no formulated diagnosis but a list of drug combinations which make little sense clinically.
We try to review these lists so that when they leave us patients do not spend money buying unnecessary medications that are of no benefit and may be potentially harmful.
Many patients would benefit from psychological support, especially those who disclose domestic violence. However, our mental health team only have capacity for those whose issues are significantly impacting their day-to-day lives and ability to manage their own self-care
The morning’s clinic quickly becomes busy. When I am not diverted to help the doctors managing more complicated conditions, I try, with variable daily progress, to arrange trainings, ensure protocols are followed, revise the role of the nurses, manage telemedicine cases, improve patient file documentation, arrange audits and work through my scribbled tasks-to-do-list.
We see an angry and depressed man with epilepsy who is stigmatised because of his illness and pressurised by his family as the only breadwinner.
We try to encourage an older woman to stop her heavy smoking, until we learn that she is desperately waiting to hear from her son since he deserted from the Syrian army three months ago.
We need the social worker to find out how a single mother who will soon need chronic dialysis for her worsening kidney failure can get the right support and funding for this to happen.
A Syrian woman is being treated for epilepsy, but it slowly becomes clear that she has a condition called ‘non-epileptic activity disorder’, related to her witnessing the aftermath of a bombing seven years ago. One of our psychologists sees her regularly and her antiepileptic medications are being slowly stopped. Hopefully, she will learn to control the triggers to her ‘seizures’ and not be restricted in her life-choices due to the stigma of her illness.
Later we hold a multi-disciplinary meeting to discuss how we can help an 11-year old diabetic boy. His father died in prison because of his diabetes and his grandmother became his carer when his mother re-married left. His grandmother despairs because she doesn’t know how to get him to eat healthily and inject his insulin regularly. The boy grins a sheepish grin as he stands at her shoulder. I wonder about his chances for a future that will be any better than his father’s.
In the nurse’s room a diabetic patient is having a dressing on their chronic foot ulcer. Many patients struggle to come as often as they should for repeat dressings and their ulcers are slow to heal. Several patients end up with an amputation because of osteomyelitis (infection in the underlying bone) or gangrene.
The financial crisis and COVID-19
The issues already faced by our patients are exacerbated by the political and financial turmoil the country has faced since mass anti-government demonstrations in October 2019. The Lebanese pound has been devalued by 85%.
We hear repeated stories of patients not having enough money for food or rent. An elderly diabetic man needed management of his high blood sugar as watermelon was the only thing he could afford to eat. Other diabetic patients report that they have no electricity for their fridge and struggle to keep their insulin cool.
It’s hard for the team to be constantly exposed to the daily struggles for basic needs in the lives of our patients.
On top of all of this is COVID-19. With their underlying illnesses, we are worried that COVID could be very serious for many of our patients. We have brought in new infection prevention and control measures, and worked to educate the community, but the potential for rapid spread is high in the overcrowded camp.
The end of the day
By the time we close at 4.30pm the last patients are leaving and our wide-smiling cleaners have swept and mopped the floors ready for tomorrow’s influx.
I am now home and have time to write this blog during lockdown in the UK. Meanwhile the amazing team I have left behind continue with their daily battle to try to do the best they can for each of our patients, whilst also coping with their own tough lives in a country facing so many challenges.