As part of a roundtable discussion organized by the Institute for Development, Research Advocacy and Applied Care (IDRAAC) during the annual congress of the St Georges Hospital University Medical Center, Ms. Mireille Girard, representative of the United Nations High Commissioner for Refugees (UNHCR) in Lebanon, revealed that 88 per cent of the Syrian refugees in Lebanon want return to their home country, explaining that the reasons why they are hesitant are essentially not related to political settlement or reconstruction issues, but to practical obstacles, including property concerns, identity documents and personal status documents, and their legal situation back home.
The roundtable titled: “Supporting a Good Environment for Refugees: Between Empowerment and Settlement” also hosted Professor Richard Mollica, Director of the Harvard Program in Refugee Trauma (HPRT) of Massachusetts General Hospital and Harvard Medical School, and one of the leading international researchers in the field of mental health care of survivors of violence and trauma.
The discussion was moderated by Dr. Elie Karam, psychiatrist, mental health researcher and President of IDRAAC.
The roundtable discussion tackled the situation of refugees in Lebanon from different angles, including their mental health standpoint as well as ways to improve their quality of life and their implication on the Lebanese society and the intention of refugees to return to their homeland.
Karam
While moderating the discussion, Dr. Karam asked: “how comfortable should refugees be in the country they moved to? This is more serious when they were not invited in… worse if many of them represented in many ways former enemies… or if they are bound to stay forever and no chance to go back to their home country… or if they come from a neighboring country, the present power of which, they now see as their enemy…”.
He also added: “We are not sure that there are answers that satisfy us to the same degree if only some of these, let us call them, risk factors exist such as refugees going to Europe or the USA from this part of the world. Especially that in those instances, refugees see the country of their destination as a permanent settlement in which they plan to integrate and grow and prosper in spite of the huge cultural differences.”
Karam also noted that: the Lebanese “experience with the Armenian refugees was a huge success that enriched Lebanon and in the eyes of all, the Armenian community was and still is a major purveyor of the diversity and wealth of Lebanon. The same cannot be said alas about the Palestinians whose name is associated not only with the erosion of the power of the state but also with the break out of the Lebanon wars that ruined the country.”
He also added that “this picture is still in the mind of most Lebanese and it is in this context also that we are called on to examine our positions towards the help we provide to the huge influx of Syrian refugees.”
Dr. Karam concluded by welcoming Professor Mollica and Ms. Girard and thanking them for their participation in a discussion which will bring the audience “closer to the truth”.
Girard
Ms. Girard started her speech by stating that: “the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. There are currently 68.5 million displaced inside their countries or in other countries. “
“Experiences of displacement due to armed conflict, persecution, or disasters put significant psychological and social stress on individuals, families and communities. The ways in which refugees experience and respond to loss, pain, disruption and violence vary significantly and may in various ways affect their mental health and psychosocial wellbeing or increase vulnerability to develop mental health problems.”
She also noted that: “adults and children affected by war and displacement experience a substantial and diverse range of mental illnesses” such as PTSD and others. In addition, “the living environment of refugees contributes to a further deterioration of their mental health, due to uprootedness, abandonment, and lack of access to health services.”
Ms. Girard also mentioned that: “despite extensive psychosocial programs (10 NGO partners, 4 UN agencies) and recent efforts to improve mental health care in Lebanon, limited access to formal mental health services and diagnostics are still a challenge facing both refugee and host population. In 2017, a total of 43,111 subsidized mental health consultations were provided by health partners whereas in 2018, the average of mental health consultations were 4,300/month.”
In addition, according to “an assessment done in 2017, of all surveyed households, 2.5% reported one or more family members requiring care. Of this group, 38% were reported to have received the required care, while 62% did not.”
Ms. Girard also added that: “healthcare and other types of assistance are sometimes perceived in the current context as maintaining refugees in exile in Lebanon and therefore as a disincentive to return. This leads to a debate as to whether it is advisable to address the existing gaps in mental health and other sectors in Lebanon whether these should on the contrary be addressed in the country of origin.”
“Healthcare is not an incentive either for refugees to remain in Lebanon or for them to return earlier to their country. Other considerations prevail for such decisions.”
“Lack of access to mental health may on the contrary be a factor delaying solutions. Persons affected by mental health and their families may not feel in control of their futures and too dependent on assistance.” She also stressed that “resolving mental health issues empowers refugees to project themselves in the future and take charge. In UNHCR’s experience, vulnerable individuals are always the latest to return to their country.”
As part of the discussion with the audience, Ms. Girard stated “three quarter of the Syrian refugee population are living under the poverty line (4 dollars a day), more than a half of the refugee population are living under the extreme poverty line which means less than 3 dollars a day. However, they still have hope in the future and 88 % of the Syrian refugees want to go back home. Our role is to try to make this intent possible.”
“Refugees in Lebanon pay an average of $200 of rent per month. Because the Lebanese economy was affected by the war in Syria, there are not enough unskilled labour opportunities, so if a Syrian refugee is lucky to work, he would work two weeks a month. He would earn around $170 a month, not even enough for the rent.”
“Healthcare in Syria is subsidized, so it’s much cheaper. So why people would not be attracted to go back? It’s cheaper there and they don’t have a rent to pay.”
She also added: “the more obstacles are removed, the more of the refugees here will feel confident to return.”
“They’re ready to reconstruct themselves. It is not the level of destruction that is keeping people here. People who are returning now are returning to destroyed houses. They’re not waiting for their houses to be rebuilt by any humanitarian organization.”
She continued by saying that: “88% of Syrian refugees tell us that they want to return to their country, and since it is our responsibility to try to put an end to the displacement problem, we asked them about the reasons that make them hesitant to go back. The obstacles that make people not return are very practical. It’s not about political settlement, and it’s not about rebuilding houses. They are asking: will I have to fight if I go back? Do I recuperate my home? Is my house still my house? Will I be punished for being a refugee? Will I recover my documents? These are the questions, and these are exactly the things that we are working on with the authorities in Syria, but here also in Lebanon, getting death certificates or marriage certificates.
She ended her discussion stating: “beyond return, the crucial point also is about reconciliation after return. There is a need to heal wounds. The social fabric has been affected and we have to contribute to rebuilding it.”
Mollica
As for Professor Mollica he mentioned that “millions of refugees in the Middle East and around the world are waiting to return home”.
He said that what is needed is “ a different way of thinking about refugees: we have to move away from the approach of food, water and shelter, to an approach that has to do with people being restored to wellness after being damaged by terrible violence and atrocities. So our approach needs to be a restoration approach, not only the basic needs.”
He also added that studies related to refugee mental health has shown that: “in any refugee community in the world there is 66% of depression and 33% PTSD.”
He presented studies on refugees in Turkey, Jordan and Lebanon as well as Palestinians where “every study has shown trauma, war trauma, PTSD, depression, and anxiety among refugees”. He also noted “the relationship between trauma, war trauma, violence and chronic diseases and the high rate of mortality as well as the impact of violence in creating physical illness and mortality where trauma can later causes diabetes, heart attack, stroke, etc.”
Professor Mollica added that despite the lack of research on repatriation results, some studies showed that: “the mental health status of refugees worsened after their return to their home country with an increased rate of mental health disorders due to the difficulties they faced when returning, such as lack of work or adequate housing.”
“Mental health disorders are especially apparent in those who have stayed for a long time in the hosting country, or when forced to return.”
“On the other hand, other studies show a decline in the rates of mental health disorders among returnees, compared with the period during which they were refugees.”
Professor Mollica insisted that “successful repatriation to the refugee’s country of origin is the gold standard, but unfortunately, the return to safe environments is the exception to the rule.”
Finally, he introduced “a new concept of “home” as an organizing principle to replace standard operational repatriation policies and procedures.”
“This model in which we activate people from the time they distress to self-actualize themselves to go home, to have a job, to have a skill… since day 1 and not after years of displacement”.
As part of the discussion, Professor Mollica insisted that refugees are in fact “like invitees to your home. They have obligations to respect your environment and to treat you well.” And he acknowledged that this is quite important adding that “on the other hand, for the host country, it will be cheaper to get the refugees to feel well and this naturally to want to go home” than trying in much more expensive ways to make life difficult for them.