Fleeing the violence in Syria
Syrian refugees in Lebanon

Acronyms

3

List of acronyms
ICRC

International Committee of the Red Cross

IDMC

Internal Displacement Monitoring Center

HRC

Higher Relief Council

MSF

Médecins Sans Frontières

NFI

Non Food Items

NGO

Non-Government Organisation

PRCS

Palestine Red Crescent Society

UN

United Nations

UNHCR

Office of the United Nations High Commissioner for Refugees

UNRWA	United Nations Relief and Works Agency for Palestine Refugees
in the Near East

Médecins Sans Frontières

Contents

Table of contents

A region in turmoil

TURKEY61, 450

AleppoMEDITERRANEAN
SEA

Idlib

SYRIA
Hama

Homs
Wadi Khaled
TripoliLEBANON
Beirut

Saida

BEKAA
VALLEY41
37, 5

In November 2011, Médecins Sans
Frontières (MSF) expanded its
activities in Lebanon to respondto the crisis in Syria. Now, theorganisation is running activities infour areas of the country, providing
primary healthcare, psychologicalcare and distributing relief items.
In Jordan, Lebanon and Iraq, MSF
has been providing medical caremainly to Palestinian, Syrian andIraqi refugees, and teams in thesecountries are prepared to deal withneeds arising from the conflict in
Syria. In Lebanon, MSF has prepositioned emergency medical
stocks and relief items for 10,000
people in case a possible declineof the situation in Syria triggers amassive influx of refugees.
MSF remains ready to assist
all victims of the conflict andcontinues to expand its activities
in Syria and neighbouring
countries. Despite difficulties
accessing the country, MSF has
been working in Syria for the past
two months, trying to provide
humanitarian assistance topeople affected by the conflict.
As of mid-August, MSF has
admitted more than 300 patientsto this facility and surgeons havecarried out 150 operations.

List of acronyms

3

Map of Lebanon

4

Executive Summary

8

Background
Lebanon’s medical support to Syrian refugees halted

1010Syria’s crisis impacts Lebanon

11

Findings of the study
I. From Syria to Lebanon

12
12

42

, 93

96

IRAQ

12

II. Lebanon: a struggle to survive12a) Assistance at breaking point

12b) Major gaps in healthcare provision

12

More hospital care needed

12

Gaps in treatment for chronic diseases

12

Access to primary healthcare centres

15

Limited pregnancy care

15

Vaccination

15

Reported medical conditions

15c) Registration posing problems

16d) Living conditions: a dire lack of shelter and proper housing

16e) Shelter and water

16f) Financial and housing constraints

19g) An uncertain future

19

III. Conclusions

15
,0

11

Objectives of the Studya) Conflict and lack of medical care: two reasons to flee

* T he figures on this map represent the
number of Syrian refugees that haveregistered in the neighbouring countries
of Lebanon, Iraq, Jordan and Turkey.
Figures were sourced from the UNHCR
in mid-August 2012. See http://data.
unhcr.org/syrianrefugees/regional.php
for updated figures.

Damascus

Daraa

5

19

Annexes

20

Study Methodology

20

Tables22

Assistance to Syrian refugees across borders
Other MSF activities in Lebanon

28
28

4

JORDAN
Médecins Sans Frontières

“We used to have a nice life. I can’t
understand how, in few months, thesituation has changed. Everybody is
becoming able to kill. It all happened
too fast to be understood.”
Female patient, 28“They tortured me to the extent thatwhen they asked me if I preferred or
wished that my mother or father could
take my place and suffer from the pain,
I replied “yes.””
Young man, 27

Right: A Syrian family gathers in the home of Lebanese hosts in the
Wadi Khaled area, northern Lebanon, after fleeing the Syrian townof Tall Kalakh, near the Lebanese-Syrian border. © REUTERS/Omar
Ibrahim, courtesy the Thomson Reuters Foundation – Alertnet

Executive Summary

8

Executive Summary© REUTERS/Jamal Saidi, courtesy theThomson Reuters Foundation – Alertnet

As the crisis in Syria intensifies
daily, with thousands continuing
to flee to neighbouring countries
to search for safety, humanitarianneeds inside and outside thecountry are escalating rapidly. The
situation is desperate, thousands
have been killed and wounded, andmedical assistance in Syria is not
only limited but has itself become atarget of the regime. Since the crisis
began in March 2011, the ability
for international organisations,
including Médecins Sans Frontières(MSF), to provide aid inside Syria
has been severely restricted. MSF
has therefore strengthened its
response to the refugees who are
flowing across the Syrian borders
into countries such as Lebanon,
Jordan and Iraq.
In November 2011, MSF expanded its
response in Lebanon to provide urgent
assistance to the influx of thousands ofSyrian refugees. The organisation has
opened new medical projects in thenorth of Lebanon in the Wadi Khaledarea, in Tripoli, and also in various
locations in the Bekaa Valley. In order todevelop a comprehensive understandingof the refugees’ health conditions
and living situations, and to adapt its
programs accordingly, MSF carried out
a study at the end of May 2012. In thesethree locations, representatives of 889
families were interviewed.
In the face of a rapidly declining
humanitarian context, the study

Médecins Sans Frontières

strongly recommends a sustained andviable assistance to be provided by
the Lebanese government and othernational and international organisations.
Although assistance was quickly
deployed in the early days of the crisis,and numerous organisations are still
supporting the aid response, clear gaps
are arising and the response must be
maintained and reinforced. Of mostconcern is the recent announcement by
the Lebanese government that medical
assistance to refugees has been cut due
to funding issues. This funding must be
urgently reinstated in order to respondto the medical needs of refugees which
will only grow as more people stream
across the border and the conflictintensifies in Syria.
Treatment for chronic diseases suchas asthma, diabetes, hypertension
and cardiovascular disease is a major
concern, with the cost of drugs required
on a long-term basis out of reach formany. Almost half of interviewees were
found to be in need of medication andtreatment for chronic diseases, however
18.7 percent are not receiving it. There
are also significant gaps in hospital-levelcare, with four out of ten interviewees
saying they were not able to access a
hospital due to reasons such as costand insecurity.
For many refugees, living conditions
are extremely precarious. According to
MSF internal estimates, over a thousandpeople are accommodated in different
villages of Wadi Khaled and the Bekaa

Valley in overcrowded shelters. Living
close to the border, they continue tofear for their safety. In Tripoli, rental
costs are high and many families haveto share apartments.
Syrian refugees in Lebanon are largely
reliant on humanitarian assistance.
Individuals within the Lebanesecommunity itself have made atremendous effort to integrate andhelp the refugees but their own
financial constraints mean they arereaching their limits in terms of theirown capacity to cope.

The number of refugees
living without help
is increasing, andaccommodation is scarce.
In addition, tensions in
Tripoli have already started
between communities.
Humanitarian relief and official support
to Syrian refugees in Lebanon and thatof their host communities has been an
important factor in avoiding a major
health crisis thus far, however theprospect of any reduced assistance willplace them in danger and could expose
them to the consequences of the Syrian
crisis once more. For this reason, ongoingsupport to the Syrian refugees and their
host communities must be provided.
© Nagham Awada

Background10

Background11

Background
Following anti-regime
demonstrations that began in
March 2011 in Deraa, Syria, whichthen spread throughout thecountry, many of the population
started to flee the turmoil andseek refuge in neighbouring
countries. Over the last 16 months,
several thousand dead have beenreported,1 and the amount ofwounded is still unknown.

has been temporarily suspended,” anofficial in Prime Minister Najib Mikati's
office said, adding that “the reason
behind the suspension is technical,
not political.” The official went on to
say that “many Syrians are coming to
Lebanon for treatment and claiming
to be displaced persons, but it is nottrue. This is causing chaos, and the
HRC needs time to reorganise
its assistance.”6

MSF remains ready to assist all
victims of the conflict and continues
to expand its activities in Syria andneighbouring countries. Despitedifficulties accessing the country,
MSF has been working in Syria
for the past two months, trying toprovide humanitarian assistance topeople affected by the conflict. As
of mid-August, MSF has admitted
more than 300 patients to this facility
and surgeons have carried out 150
operations. MSF is supporting
networks of Syrian doctors in Homs,
Derah, Hama, Damascus and Idlib. In
March 2012, an MSF team was able
to reach Idlib for a short period oftime and witnessed the terrorisationof medical workers, as well as directtargeting of hospitals and medical
facilities by armed forces. As detailed
in an MSF statement2 issued elevenmonths after the crisis began:Syria’s crisis impacts Lebanon
Like Syria's other neighbours – Turkey,
Iraq and Jordan – Lebanon has
absorbed thousands of refugees
fleeing from the conflict now raging
on the other side of the border. But
unlike the other countries, Lebanon
risks being plunged into sectarian strife,
possibly even civil war, by the strains
inflicted on its own delicate internalsituation by the Syrian crisis.7 Heavy
sectarian clashes broke out in May andJune 2012 in Tripoli, the biggest city inthe north of Lebanon, mostly between
Sunnis of Bab Tabbaneh and Alawis of
Jabal Mohsen.

“In Syria today, wounded patients anddoctors are pursued and risk tortureand arrest at the hands of the security
services. Medicine is being used as aweapon of persecution. Most of thewounded do not go to public hospitals,
for fear of being tortured or arrested.”
Faced with this ongoing situation,
thousands of Syrians are escaping tofind safe refuge elsewhere and to beable to access healthcare services.
According to the UN Syrian Refugees
Web portal,3 around 157,000 people
have been registered as refugees
in neighbouring countries. Mass
displacement within Syria itself
has also occurred, and overall, atleast 156,000 people were internallydisplaced during 2011.

Médecins Sans Frontières© REUTERS/Omar Ibrahim, courtesy theThomson Reuters Foundation – Alertnet

Recently, there has been a dramaticincrease in this number, with the Syrian
Arab Red Crescent and the UNHCR
placing the current figure at 1.5 million.4
Inside Syria, humanitarian assistance isstill very limited, with the Syrian ArabRed Crescent the main provider ofassistance to the population. In May
2012, eight international NGOs5 werepermitted to extend their activities for
Iraqi refugees to the rest of the civilian
population inside Syria’s borders.
Medical assistance is however still
very scarce.

Lebanon’s medical support to
Syrian refugees halted
In early July 2012, after MSF conducted
this study, the Higher Relief Council(HRC), the humanitarian branch of thePrime Minister’s office, announced
that due to a lack of funding, it would
have to shut down most of its Syrian
refugee-related operations. The HRC
stopped covering the cost of secondary
healthcare and limited other typesof aid distribution such as fooditems. As Agence France-Presse (AFP)
reported at the time: “Assistancethrough the Higher Relief Council

The influx of Syrians to Lebanon
has increased as the conflict has
intensified in recent months: almost
60 percent of the refugees MSF
surveyed arrived between Januaryand June 2012. According to the
UNHCR office of registration, there
are currently approximately 37,000
Syrian refugees in Lebanon, althoughsome are not yet registered, andsome are choosing not to register atall. Statistics are also quite difficult torely upon: the most recent updatefrom the UNHCR says the agency
is providing aid such as food andmedical supplies to “some 30,000”
Syrian refugees, a constant figure
since the beginning of May. A study
conducted by the Gulf-funded Islamiccharity Al-Taqwa reports that there
are around 58,000 refugees in the
country, while a separate estimate
from the Bashaer charity, a Lebaneseorganisation, places the number at
52,000 people.”8 People have directly
reported to MSF staff that they areoften afraid and would therefore notapply for official registration. They
feared being targeted by security
services or were anxious of thepotential repercussions for their own
families in Syria.
The economic and political situationin Lebanon continues to be severely
affected by the crisis in Syria. Overthe last months, Lebanon has
experienced an economic decline,with its service-oriented economy
highly sensitive to political events in
the region. The Economist Intelligence
Unit predicts that as the Syrian unrest
continues, economic growth could
stall even further, and any flare-up
in inter-communal violence could
also drag down Lebanon’s economy.9
These economic and political frailties
mean that the Lebanon‘s capacity tocope with such an influx of refugees
in the long term could be constrained.
While over the last year thesolidarity displayed by the Lebanesecommunity has been impressive, it
is feared that resources will soon dry
up, and that the situation for the hostcommunity as well as the refugees
will only worsen.

“Here in Lebanon, we are ina big jail: we are not allowed
to cross any checkpoint, weare afraid to go out because
anybody might catch us.”
Young man, 21
Objectives of the Study
MSF’s objective in carrying out thisstudy was to better understand theconditions facing Syrian refugees
living in Lebanon. With the aim ofadapting the organisation’s responseto the evolving situation, teams
collected information and testimonies
specifically focused on the healthsituation of refugees and influencing
factors such as shelter, sanitation andtheir journey from Syria.

Already present in Lebanon providing
mental health projects for Palestinian
refugees as well as vulnerable
Lebanese in Bourj-el-Barajneh andEin-el-Hilweh camps, MSF has been
providing humanitarian assistanceto Syrian refugees in Lebanon sinceNovember 2011. In response to thecrisis in Syria and the influx of refugees
into Lebanon, MSF further expanded
its activities to the areas of Tripoli,
Wadi Khaled and different locations in
the Bekaa Valley.
The study was conducted in June 2012
in Saadniyel, Jdeide and Aarsal (Bekaa
Valley), Tripoli as well as in several villages
in Wadi Khaled, including the so-called‘collective shelters.’ A significant number
of Syrian families continue to live inthese shelters – normally old schools,
mosques or abandoned buildings – dueto an increasing shortage of properaccommodation.
1 5,000 according to IDMC; 17,000 according to
the Human Rights Syrian Observatory
2 MSF Press release, 8 February 2012.
3 data.unhcr.org/syrianrefugees
4 Syria. A full-scale displacement and humanitariancrisis with no solutions in sight. IDMC. 31 July 2012.
5 International Medical Corps (IMC) and theDanish Refugee Council (DRC), in collaboration
with the Syrian Arab Red Crescent (SARC), havebegun distributing hygiene supplies, medical
assistance and other essential items. The IMC is
supporting SARC to operate two health clinics
in Damascus (Sayyeda Zainab and Mazkeh
Barzah), two Mobile Medical Units in Rural
Damascus and four SARC health posts. The DRC
has completed a field mission to Dar’a and aims
to distribute 10,000 hygiene kits (supporting
50,000 people) in the governorate, with the firsttranche (3,000 kits) to be provided in early July”,
in http://reliefweb.int/sites/reliefweb.int/files/
resources/Full%20Report_822.pdf
6 Lebanon suspends aid to Syrian refugees: PM
office / AFP / 11.07.12
7 Syria crisis: Lebanon sucked into Syria crisis / BBC/ 29.07.12 http://www.bbc.co.uk/news/worldmiddle-east-18655845
8 Number of Syrians aided by UNHCR stagnates,
inaccurate / Daily Star /09.06.12/ http://www.
dailystar.com.lb/News/Local-News/2012/Jun09/176244-number-of-syrians-aided-by-unhcrstagnates-inaccurate.ashx#axzz230zkoJ9K
9 Economist Intelligence Unit. Country Report,
Lebanon, July 2012.

Médecins Sans Frontières

Findings of the study

12

Findings of the study
The major issues currently facing
the refugee population in Lebanon
are housing, food, water andsanitation, health and security.
As the refugees are settling inprimarily lower socio-economic
regions of Lebanon, additionalburden is being placed on alreadyoverstretched resources. Gaps areappearing in refugees’ access to
medical care, particularly in theiraccess to hospital-level care andtreatment for chronic diseases.
I. From Syria to Lebanona) Conflict and lack of medical care:
two reasons to flee
Just over three quarters of the
respondents, 75.6 percent, reported
insecurity as the main reason forleaving Syria. The remaining 24.4
percent reported that they left due to a
combination of insecurity and a lack ofaccess to medical care.
Nearly half of the respondents, 43.5
percent, reported that one of theirfamily members had died in the past six
months, with 92.9 percent stating thisloss was due to the violence in Syria.
Particularly affected were refugees
from the Homs governorate close to
the Lebanese border, from where mostof the respondents originate.
II. Lebanon: a struggle to survivea) Assistance at breaking point
Since the very beginning of the crisis
in Syria, Lebanese government bodies
such as the HRC, and other nationalorganisations, have been involved inproviding assistance to refugees. They
have provided food and non-fooditems, shelter, primary and tertiary
medical care, education assistanceand psychosocial support.10 Howeverin early July 2012, the government
announced that a lack of funding was
forcing it to stop providing medicalcare to refugees.
In response to the crisis, someinternational organisations such as
MSF and the ICRC11 have expanded
their existing activities in Lebanon toprovide direct support to the refugees.
Additionally, and despite

Médecins Sans Frontières

having limited resources themselves,individuals within the Lebanesecommunity have been very much
involved in providing assistance.
Among the respondents, 86.1 percent
received assistance in Lebanon fromdifferent NGOs12 such as relief items,
food, healthcare, money and fuel. Of
those not receiving assistance, theymentioned that they were reliant on
relatives living in Lebanon, on ‘good
people’, on God, on their husband’s
income (for female respondents) andtheir savings from Syria (see table 5).
b) Major gaps in healthcare provision
More hospital care needed
There is a significant lack of accessto hospital care for the refugee
population. Among the interviewees,
21 percent reported that they neededhospital-level care. Of these, 61.6
percent were able to go and 39.2
percent of them were able to receive
treatment free of charge. However,
38.4 percent of those who said theyneeded treatment were not able toaccess a hospital.

70%

Access to hospital
61.6

60
50
39.2

40
30
21
20
10
0

In need of
hospital

Able toaccessFree ofcharge care

With a higher number of hospitals in
Tripoli, refugees living there have abetter chance of accessing the carethey need. In Tripoli, 88.4 percent ofrespondents reported receiving freehospital treatment, as opposed to only
20–25 percent in the Bekaa Valley andin Wadi Khaled. Of those who were notable to visit a hospital, 65 percent said
they were unable to pay for the care.

Hospital: need, access and cost
200

%
88.4

150

20

100
25.8

91.1

69.2

43.2
50

0

22.5

18.8

19

Wadi
KhaledBekaa

Tripoli= Free of charge care
= Able to access hospital= In need of hospital

Gaps in treatment for chronic diseases
Among the respondents, 47.4 percent
were taking medicines in Syria forchronic diseases such as high bloodpressure and diabetes, asthma, anaemia
and rheumatoid arthritis. Of these, 81.3
percent are still receiving their treatment
in Lebanon. This implies howeverthat 18.7 percent are not receiving thetreatment they started in Syria.
Additionally, 51.6 percent are now paying
for drugs. Only 18.9 percent are obtaining
drugs free of charge, and 7.9 percent said
it was dependent upon drug availability
at health centres. Overall, almost 68
percent stated that they are ‘doing well,’although 10.3 percent reported they are
in need of free medicines which are notavailable at the primary healthcare clinic.
Refugees also said that drugs were much
more expensive in Lebanon.
There were 22 percent who reported
the need for specialists such as
gynaecologists, dentists, and urologists,
as well as for financial coveragefor surgeries. In Wadi Khaled, therespondents asked for mobile clinics
to be provided due to the remotelocation of the areas in which they aresometimes forced to stay for lack ofbetter and more viable alternatives.
© Nagham Awada

Findings of the study

15

Drug availability

currently no significant treatment gap
at the primary healthcare level.

are breastfeeding and only 8.3 percent
are enrolled in postnatal care.

For the refugees who were unable toaccess a primary healthcare centre when
they needed it (5.8 percent), they mainly
cited transportation problems and lackof money. They also mentioned thatdrugs were not available at the clinics.
Some said they preferred not to go due
to security restrictions, while others said
the fact that they were not registeredas a refugee meant that they could notaccess health services for free.

Vaccination
Only 60 percent of children are reported
to be vaccinated, but just 27 percent of
the respondents were able to show theirvaccination card. The best vaccination
rates were in Tripoli, where 40 percent
were able to present their card.

= 51.6%
Paying for drugs

Reason for not accessing Primary
Healthcare Centre= 18.9%
Receiving free drugs= 7.9%Receiving drugs upon availability= 1.9%Receiving drugs with people’s help

25

%
22.5

20

15

20

15
12.5

Access to primary healthcare centres
The vast majority of refugees, 94
percent, said that money is an obstacle
to access healthcare services,13 andthat this was the main reason fornot seeking medical care. As shownin the graph below, 77.4 percent ofrefugees said they needed access tobasic healthcare. Of these, 94.2 percent
were able to access it, and 69 percent
received care free of charge. Thesefigures demonstrate that there is

100

80

%

Access to Primary
Healthcare Centre (PHC)
94.2

77.4
69.7

60

40

20

0

© Nagham Awada

In need of
PHC

Able toaccess PHC

Free ofcharge

10

10

5

0

= Don't know locations= No transportation= No money or drugs not available= Unregistered with HRC= Security reasons

Limited pregnancy care
Pregnancy care is not being widely
accessed: 12.3 percent of respondents
said there was a pregnant woman
in the family but only 49 percent ofthem are enrolled in antenatal care (seetable 4).14 Among the women who had
already given birth when the survey
was carried out, 15.7 percent deliveredin Lebanon: 72.3 percent experienced
a normal delivery and 27.7 percent
underwent caesarean section. Sixteen
women surveyed delivered at home. Of
the women who delivered, 58 percent

Reported medical conditions
The main medical conditions reported
from MSF projects providing medicalcare to Syrian refugees, in the Bekaa
Valley, in Tripoli at dar Al-Zahra Hospital,
and in Wadi Khaled, are listed below.
Out of a total of 1,896 new cases inJune in all of the Bekaa Valley locations,25 percent were chronic diseases(diabetes, hypertension, asthma,other cardio-vascular diseases),followed by upper respiratory tract
infections, gynaecological-obstetriccases, musculoskeletal problems, skindiseases and eye infections. The latterare reported to be linked to poor
living conditions. There were also
83 patients who consulted with ourmental health team.
In Tripoli, in the dar Al-Zahra
Hospital, from March until the endof June, 1,140 consultations werecarried out by MSF. The majorityof the consultations were forrespiratory tract and ear, nose andthroat infections, musculoskeletal
problems, diarrhoea, and chronic
diseases (diabetes, hypertension,
asthma). Some scabies cases
were detected and treated. MSF
teams also carried out antenatal
and postnatal consultations, andvaccinations. Among the mental
health consultations, depression
represented 50 percent of cases andanxiety accounted for 25 percent.
Some patients reported having been
tortured and raped.15
Among the interviewees, 35.7 percent
reported their general health as ‘very
good’, and almost the same percentage
as ‘good.’ There were 63.7 percent who
reported that at least one of their family

Médecins Sans Frontières

Findings of the study

16

members has a medical condition. For
women, reported conditions wereslipped disc, blood pressure issues,
joint pain, diabetes, gynaecologicalproblems, migraine and anaemia. Many
reported suffering from more than one
medical condition.
Among men, reported medical
conditions included slipped disc, bloodpressure issues, rheumatism or joint pain,
stomach pain and ulcers, bullet wounds(one in Wadi Khaled and four in Tripoli).
Many men also reported suffering morethan one medical condition.
The highest reported diseases
among children were respiratory
problems, followed by diarrhoea
and mental distress, vision problems
and skin allergies. Additionally, sometuberculosis cases were reported.
Psychological issues for men, womenand children were also reported, withcases being more prevalent in Wadi
Khaled than in other areas.
c) Registration posing problems
Seventy-five percent of respondents
were registered with the UNHCR and/or
partner organisations to the UNHCR.16
There are fewer registered Syrians in
Tripoli than in Wadi Khaled and in the
Bekaa Valley, as registration has not yet
been properly implemented in Tripoli
due to security issues within the city.
Thirty percent of respondents wereregistered one to two weeks after theirarrival, 27.2 percent after one month,and for 19.3 percent, the process took
between two to three months.
For those registered, the process meant
they were provided with healthcare, relief
items, money, rent, medications and food.
However, 28.2 percent reported they
were not provided with anything, and22.7 percent reported only receiving food.
Some refugees were not registered: theycited reasons including that they did notknow where to go (mainly those in Wadi
Khaled), that they did not see the benefit
of being registered, that they were
not informed about the possibility of
being registered, or that they just feared
registration would have consequenceson their families back in Syria.

Médecins Sans Frontières

Registration according to region
100

%
87.7

83.2

80

60
48.8
40

20

0

Wadi Khaled

Bekaa

Tripoli%

The remaining refugees are living within
host Lebanese families in the Wadi Khaled
and Akkar areas, while in Tripoli, refugees
are mainly renting houses, flats or rooms.
Syrian refugees are mainly residing withhost families who are not necessarily theirown relatives. These families also facedifficult circumstances, living in some ofthe poorest areas in the country.

30
27.2

Percentage ofrefugees living alone

25

20

Dr Philippa Boulle, MSF emergency medical
coordinator, February to May 2012

The figure below shows that in Tripoli,
more refugees are renting their own
places, while in Wadi Khaled and Bekaa
Valley, they are sharing houses or livingwith host families.

Length of registration
30

The highest rate of overcrowding is in
Wadi Khaled, as people are living incollective shelters. Only 29 percent ofrespondents in Wadi Khaled mentionedthat they live alone in their space,compared to 70 percent in Tripoli.

“There were many cases where parents
initially felt they couldn't get adequate
care for their kids, or take them to a
hospital. There was one family with adisabled 4-year-old boy, living in a tent.
This young boy wasn’t able to sit up
properly, and he was getting recurrent
respiratory infections and asthma. We
gave him treatment, and hospitalised
him on two occasions.”

19.3
80

%
72.2

15

70

12.5

57.8

60

10
12.5
5

50
40

0

30

= Directly20= 1–2 weeks

10= 1 month0d) Living conditions: a dire lack ofshelter and proper housing
Around 90 families are currently living
in collective shelters located in different
villages of Wadi Khaled, and 112 families
in the Bekaa Valley are living mainly inmosques where they are receiving aid
from different organisations.17
Nearly 50 percent of respondents aresharing their living space with otherfamilies. There is an average of 3.32
families per room per house,18 meaningaround seventeen people are living ineach house in very crowded conditions.

29.9

Wadi Khaled

Bekaa

Tripolie) Shelter and water
Based on interviewers’ observations,64.3 percent of houses are generally ingood condition in terms of hygiene, and20.2 percent of houses are rehabilitated.
Housing conditions are the worst in
Tripoli, with only 27 percent saying they
have access to drinking water (see table5). Those living in the Bekaa Valley appear
to have twice as much access to drinking
water, meaning it is likely they purchaseit, adding burden to already limited
finances. It is important to note that the
majority of people in Lebanon buy water
as the tap water is not drinkable.
© REUTERS/Jamal Saidi, courtesy theThomson Reuters Foundation – Alertnet

Findings of the study

19

Living conditions
80

%
27.9

70
60
50
40

49.3
25

30

5
26.2

20
10
0

14

Wadi
KhaledBekaa

Tripoli= Housing rehabilitated= Access to drinking waterf) Financial and housing constraints
The five main problems reported byrefugees are rental costs, housing
quality, lack of employment
opportunities leading to dependency
on external assistance, poor quality
water, and lack of money. The highcost of living in Lebanon, comparedto Syria was a concern, as was the low
availability of drugs, and psychologicalstress. Lack of electricity was alsomentioned as an additional burden.
g) An uncertain future
The future seems very grey for the vast
majority of the refugees. Only 16.6
percent are expecting a ‘good’ futureand 11.9 percent think it’s totally ‘out of
their hands,’ aggravating a feeling ofhopelessness. There were 16.2 percent
who believe that a future does notexist for them in Lebanon, and 13.5
percent said the same about Syria.
Thirty-two percent predict a ‘vague
and insecure’ future.

© Nagham Awada

III. Conclusions
Three quarters of refugees fled Syria
due to the high degree of violence,
and around 40 percent have sufferedlosses within their families linked
to this violence. For most of theinterviewees Lebanon is not a safe
haven. The country’s own instability
as a result of the crisis in Syria, as
well as its proximity to the borderwith frequent shelling, bombing
and incursions, does not provide areassuring place of refuge.

With several men, women andchildren experiencing psychologicaldistress, mental healthcare is acontinuing need. Availabilityof adequate psychological andpsychosocial services is hence
seen as paramount within all areas
where refugees are living. Feelingsof alienation, hopelessness anddiscrimination, difficulties in adapting
to a new environment, as well as
security related fears are widespreadamong the refugees.

The vast majority of refugees – 90
percent – see their future as highly
precarious and they do not know whenor if they will be able to return to Syria.
Feelings of hopelessness and alienation
are widespread and pervasive. Added
to this, living conditions, due tothe constant flow of refugees into
Lebanon, are also deteriorating. There
are overcrowding problems in Wadi
Khaled, high rental costs in Tripoli, andsignificant security issues in the Bekka
Valley and in Wadi Khaled.

As refugees continue to flow into
Lebanon, the capacity of the local
population to cope is at breaking
point. Most of the areas where therefugees are currently living are among
the poorest in Lebanon. While the
Lebanese community’s solidarity
with Syrian refugees is clear, resources
have reached their limits. It is crucial
that support is provided to the hostcommunities in order to reduce thisburden, and that proper housing is
allocated to the refugees to alleviatepoor living conditions for Syrian
refugees and their Lebanese hosts.

“When I felt that the soldiers
might attack us on our way
out of Syria, I got preparedto kill myself. It’s mucheasier to die than to be
attacked and taken by the
Shabiha.”Young man, 22
Basic medical assistance is generally
available and accessible. However,large gaps exist regarding treatment
for chronic diseases, with the high costof drugs leaving them out of reachfor many refugees. MSF is currently
the only provider of chronic disease
medications for Syrian refugees in
Lebanon. Hospital level care is also amajor concern, particularly with therecent announcement that funding forthis by the Lebanese government has
been halted.

10 UN Revised Syria Regional Response Plan.
June 2012.
11 Since September 2011, the ICRC has beenheavily involved in providing support
to the Lebanese Red Cross emergency
medical services to evacuate more than 500
casualties http://www.icrc.org/eng/resources/
documents/update/2012/lebanon-syriaupdate-2012-04-26.htm
12 F or an overview of the aid available in
Lebanon from international actors, refer tohttp://data.unhcr.org/syrianrefugees/country.
php?id=122
13 In Lebanon, all the health care services are
based on a cost recovery scheme.
14 The majority are enrolled in the UNHCR
Makassed centre, Hisheh in Wadi Khaled;in the MSF-supported Amel and al Farouk
dispensaries in the Bekaa Valley; and in Shifaa
Hospital, Hanan Hospital, the MSF-supported
Dar Al-Zahra Hospital and Bashaeer Hospitalin Tripoli.
15 This does not however represent a significant
amount of patients.
16 The HRC is for example registering people.
17 There are three collective shelters in Wadi
Khaled: old schools or buildings, and somemore in the Bekaa Valley.
18 An average family comprises five individuals.

Médecins Sans Frontières

Annexes

20“There were quite a few women who cameacross the border pregnant. I spoke to one
woman who told me about how she’dbeen in hiding in Homs, where it wasdifficult to access hospitals. She’d watcheda lady give birth while in hiding, and thebaby died. I imagined what it must be
like to sit there, being pregnant yourself,
watching this happen and knowing thatyour baby might not make it. They fledwhen they could.”

Annexes
Study Methodology
Design, participants and sample size
A cross-sectional survey was conductedin three regions of Lebanon where themajority of Syrian refugees are living: theWadi Khaled area and Tripoli in northern
Lebanon, and the Bekaa Valley region in
the east of the country. The study, whichlooked at physical health, demographic,socioeconomic and coping mechanism
variables, was measured using a
structured questionnaire, carried out by
trained interviewers.

Dr Philippa Boulle, MSF emergency medical
coordinator, February to May 2012

According to the UNHCR database, atthe time of the assessment, the total
number of Syrian refugees in Lebanon
was approximately 26,000. Based on
UNHCR and other agencies’ figures,
we estimated that at the time of thestudy there were 1,622 families in thenorthern, central and western areas of
the Bekaa Valley; 2000 families in Wadi
Khaled; and 700 families in the two
major areas in Tripoli.
In the three selected locations (Bekaa
Valley, Wadi Khaled and Tripoli), weinterviewed 20 to 35 percent ofrefugee households leaving a total
sample size of 889 households (Table
1). All household members aged 18 orolder were eligible to participate in the
study. Some open-ended questions
were also included, addressing the
problems the refugees were facing, or
their expectations for the future.
Out of 889 households selected, 98.4
percent completed the interviews. Outof these, 44.6 percent were male and55.4 percent female.
The analysis in this report is based on
the result of this quantitative study,
and also on medical and mental
health archives from MSF clinics
located in Wadi Khaled, Tripoli and the
Bekaa Valley. Study data was enteredusing SPSS v.19 and analyzed withSPSS v.19 as well.

Médecins Sans Frontières© Nagham Awada

EthicsInclusion in the survey was voluntary,and required verbal informed consent.
All participants and non-participants
were offered information andencouraged to visit MSF clinics which
are providing free mental health andmedical support to Syrian refugees in
Wadi Khaled, Tripoli and in the Bekaa
Valley. Where requested, social service
home-visits and referrals to MSF orother organisations were also provided.

Staff training
The staff who carried out the study
received theoretical and practicaltraining on conducting the survey,
and on appropriate handling of
human subjects’ research data. Studyquestions were piloted before theactual collection. A team of two datacollectors were responsible for a
specific site in the selected three areas,
with a total of nine different teams.

© MSF

Tables

22

Tables23

TablesTable 1:
Distribution of region per total sample size

Table 3: Distribution of socio-economic
characteristics of displaced families (n = 889)

Table 3 continued:
Distribution of socio-economic characteristics of displaced families (n = 889)
Characteristic

Region# of questionnaires

Frequencies

Characteristic

Wadi Khaled

400

45%

Gender

Bekaa

229

25.8%

Tripoli

260

29.2%

Total

889

100%

Table 2:
Participant characteristics (n = 889)
Age

n

%

17–33

377

42.6%

34–50

369

41.6%

Above 50
Mean age

140
Mean: 38.22 + 12.77

15.8%
Minimum: 17
Maximum: 99

n

%

n

%

Employment in Syria

Characteristic%

Average number of sharing families per house

Female488

55.4

Doesn’t work

118

13.5

Mean: 3.32 + 3.57

Male

393

44.6

Work

635

85

Minimum: 1 Maximum:21

Marital statusn

Employment in Lebanon

Reason for leaving Syria

Married764

86.7

Doesn’t work

514

59.7

Insecurity

662

75.6

Widowed

72

8.2

Work

297

86.2

Insecurity andno medical care

214

24.4

Never married

45

5.1

Reached Lebanon with whole family

Travelling from governorate

Loss of family member in past 6 months

Yes

697

80.6

No

488

56.5

168

19.4

Yes

375

43.5

Homs

750

85.2

No

Hama

85

9.7

Living alone with family

Other(Edleb, Damascus, Dar’aa)

36

4.1

No

436

50.4

No

674

79.6

Aleppo

9

1

Yes

429

49.6

Yes

125

14.8

Other (remedialclasses, sheikhs)

48

5.7

Children registered at school

Average number of family members per room

Education
Primary568

65.1

Mean: 5.25 + 2.44

Illiterate

177

20.3

Minimum: 1 Maximum:21

Secondary

105

12

University

23

2.6

*Data are number, %, or mean (range), as specified

Médecins Sans Frontières

Médecins Sans Frontières

Tables24

Table 4:
Health status characteristics of displaced families (n = 889)
Characteristicn%General health(self-rated)

Characteristic

n

%

317

35.7

No

707

87.7

Good

311

35.1

Yes

99

12.3

Average184

20.7

Vaccinated children

Excellent

75

8.5

Yes

541

60.9

Don’t know

266

29.9

Yes

560

63.7

No

No

293

33.3

If vaccinated, have vaccination card

Don't know

26

3

No

378

42.5

Don’t know

270
241

Yes

679

77.4

Yes

No

198

22.6

Health needs in general

Able to access PHC if needed

Characteristicn%

Housing situation

Very Good

Need to access PHC

25

Table 5:
Shelter characteristics for displaced families (n = 889)

Pregnant women

Family member with medical condition

Tables82

9.2

Characteristic

Good

558

64.3

Yes

748

86.1

Bad

189

21.8

No

121

13.6

Very good72

8.3

Type of assistance

Very bad49

5.6

NFI and food

330

44.1

NFI and healthcare
and food

57

7.6

Shelter rehabilitated
No

670

76.5

Food

272

36.4

Yes

177

20.2

NFI and money and fueland food

71

9.5

30.4

Don't know

29

3.3

If no NGO assistance, method of survival

27.1

Comfortable with overcrowded situation

God’s help

40

33.1

A little bit

353

40.5

Relatives and goodpeople59

48.8

Nothing, we’rein good health

601

67.6

Not at all

291

33.4

Savings from Syria

7

5.8

15

12.4

Yes

657

75

219

25

638

94.2

Others196

22.1

Average166

19.1

Husband’s income

No

39

5.8

Need of medicines

92

10.3

Completely

61

7

Registered with UNHCR

Need to access hospital

Access to drinking water

Yes

449

69.7

No

662

74.5

Other
(only consultation is free)

105

16.3

Yes

176

21

No

90

14

Able to access hospital if needed

Taking medicine in Syria or Lebanon

Yes

106
66

No

406

46.3

No

Don’t know

234

26.7

Reason for coming to Lebanon

Yes

237

27

Proximity

485

55.5

Others(husband’s work etc)

404

45.5

61.6

No

438

52.6

No

Yes

395

47.4

If able to access hospital, free care is received

Payment a barrier to health%

Getting assistance from NGO

Yes

If able to access PHC, free care is receive

n

37.5

Yes

69

39.2

Yes

800

94

No

31

17.6

No

51

6

Other (onlyconsultation is free)

76

43.2

*Data are number and %.

*Data are number and %.

Médecins Sans Frontières

Médecins Sans Frontières

“A 25 year old woman was with her threechildren and cousin riding a motorcycle
when they were deliberately attacked bya military car. Her cousin was injured in
the feet, the eldest child was disfigured,and the second child was wounded in theleg. The third child received small injuries.
This terrible accident led their mother tobecome tetraplegic. For the last elevenmonths, she has had to remain in bed andhave ongoing surgery. She’s presenting
symptoms of post traumatic stressdisorder as well as a major depressive
disorder; she has intrusive memories of
the terrible accident, irritability, outburstsof anger, sleep disturbance, depressive
thoughts, feelings of guilt, decreased
appetite, and suicidal thoughts.
She admitted that she refuses to eat
sometimes for suicidal reasons. She
expressed her anger about her situationand displayed a lot of worry about her
children who were separated from her
temporarily. It’s hard for her to accept
her severe medical situation, and she
has a pessimistic view of the future andespecially her role among her family
and children.”
MSF psychologist

Right: An image drawn by a Syrian child of primary school age,
depicting his memory of the violence encountered in Syria.
© Nagham Awada

Assistance to Syrian refugees across borders

28“We saw lots of respiratory infections,particularly in winter, and skininfections, because people weren’t able
to look after themselves in the way
they might normally.”

Assistance to Syrian
refugees across borders

Dr Philippa Boulle, MSF emergency medical
coordinator, February to May 2012

© Nagham Awada

The widespread unrest in Syria,
which began in March 2011, madeit very difficult for MSF to continue
its work inside the country, and theorganisation was forced to suspend
its activities. MSF remains ready toassist all victims of the conflict andcontinues to expand its activities in
Syria and neighbouring countries.
However, despite difficulties accessing
the country, MSF has been able towork in Syria for the past two months,
trying to provide humanitarianassistance to people affected by the
conflict. As of mid-August, MSF has
admitted more than 300 patients tothis facility and surgeons have carriedout 150 operations.
From neighbouring countries, MSF
continues to support Syrian doctors’
work by providing them with medical
supplies and essential drugs. In Amman,
Jordan, where MSF has a reconstructive
surgery program, surgeons haveoperated on 160 wounded Syrians
since the beginning of 2012.
MSF has been providing humanitarianassistance to Syrian refugees in Lebanon
since November 2011. In response to thecurrent crisis, the organisation has

Médecins Sans Frontières

further expanded its activities.
In total, MSF medical teams havecarried out over 5,000 primary
healthcare consultations and, over 1,000
individual psychological and psychiatricconsultations, all of them free of charge.
Between January and May 2012, MSF
provided about 2,150 people in themountainous Aarsal region with relief
items, including fuel and wood forheating. In March, the organisation
helped refurbish five public buildings
to house Syrian families in the border
town of Aarsal. MSF has also donatedemergency supplies to health centres
near the border with Syria.

“I feel every day that I needto hurt myself until the
blood goes out.”
Young man, 26
Other MSF activities in Lebanon
Since 2009, MSF has been providing freemental healthcare to socially vulnerable

Lebanese and Palestinian refugees.
Mental health services have been
established within the United Nations
Relief and Works Agency (UNRWA) clinic,
in the hospital run by the Palestine Red
Crescent Society (PRCS) and within
the primary health care centre of themunicipality of Bourj-el-Barajneh. In total,
more than 16,000 psychological andpsychiatric consultations have taken place.
In April 2011, MSF extended its
community-based mental health services
to Ein-el-Hilweh refugee camp, in Saida,in south Lebanon. Seventy-five thousand
Palestinians and other vulnerable residents
are crammed into one square kilometre.
Ein-el-Hilweh is the most crowded andunstable refugee camp in Lebanon, aplace that is regularly shaken by security
incidents and clashes between politicalfactions. MSF has established free mental
health services in the two UNRWA clinics
and at the Human Call hospital inside
the camp, and also in the PRCS andgovernment hospitals outside the camp.
Between when the project began and July
2012, some 953 new patients, mainly aged
between 18 and 40, have received carefrom MSF psychologists and psychiatrists
in Ein-el-Hilweh refugee camp.
© Nagham Awada© REUTERS/Jamal Saidi, courtesy theThomson Reuters Foundation – Alertnet

www.msf.org
Report issued August 2012.
Front cover: Syrian women and children
arrive to northern Lebanon, near the
Lebanese-Syrian border. According to the
UNHCR, there are currently around 37,000
Syrian refugees in Lebanon. © REUTERS/
Omar Ibrahim, courtesy the Thomson
Reuters Foundation – Alertnet