When the Definition of ‘Life-Threatening’ Injury Undermines War Refugees’ Health Care

Nadine offers me the seat closest to the modest electric heater struggling to warm her damp living room in the Lebanese mountain town of Bhamdoun, about 12 miles east of Beirut. She sits across from me, cradling her right arm. She appears sedated, her eyes glazed over as she monotonously narrates her escape from Aleppo, Syria, almost two years ago.

By now, the Kurdish-Syrian refugee has recounted these memories hundreds of times. She lost a house, a leg, and two of her four children to an airstrike, she states matter-of-factly—too burdened, it seems, by the concerns of the present to allow herself the luxury of mourning the tragedies of the past.

(Nadine is not her real name; she's about to become an illegal resident in Lebanon and is worried about being exposed.)

She spent her first four months in Lebanon living on the streets. Missing a leg, her body riddled with shrapnel, damaged nerves and fractures crippling her arm, her husband carried her on his back from one welfare association to another, begging for medical assistance. "That's what we've become," she tells me. "Beggars."

They were eventually discovered by the NGO Basma wa Zeitouneh, which relocated them to their current apartment, covering their rent and referring Nadine to a doctor. He recommended her to the World Rehabilitation Fund, an international nonprofit that ran a six-month emergency rehabilitation program in 2014, providing disabled Syrian refugees with prosthetics, orthotics, eyeglasses, and hearing aids.

Nadine was fitted with an artificial leg, but her medical needs were far from satisfied. She also requires physiotherapy. And now, her prosthetic has widened, no longer fitting comfortably onto her knee—it needs replacing. Her arm has needed surgery for over a year. "Show it to her," Nadine's husband urges. She reluctantly lifts her sleeve to reveal a disfigured limb. A thick band of scar tissue hugging her elbow makes her forearm look like it had been severed and sewn back on. "She can barely move it," he says.

The funding for these kinds of needs is sorely lacking. "The problem is, things like prosthetics aren't seen as a life-saving priority," explains Amani Saleh, manager of the Emergency Response Fund. The body was established by the UN Office for the Coordination of Humanitarian Affairs in 2012 to respond to Syrians' most urgent needs by collecting money from donor countries and allocating them to relevant initiatives in Syria and refugee host countries.

While Nadine's injuries keep her from being able to leave the house, adequately look after her household, or take on a job, they fall outside the narrow definition of "life-threatening" that donors have adopted. A previous regional fund, the ERF, was recently de-centralized into country-based funds. "Before, it was more attractive to donors," explains Saleh. "We would receive money for Syrians in general and distribute them based on need to the different countries. Now, we have to convince donors why they should send money to Lebanon versus Jordan, for example."

Right now, winterization is the priority. Convincing donors to fund an expensive rehabilitation program in a particular country is a difficult feat. Since the beginning of 2015, Lebanon has only managed to raise $2.5 million. The WRF's 2014 program alone cost $500,000 and was only able to assist 738 people. A single prosthetic can cost up to $6,000, and hearing aids cost $280 a piece.

The problem, explains Toufic Rizkallah, Assistant Director of the WRF, is that the UN has failed to thoroughly assess the state of disabled refugees or to provide a reliable estimate of their numbers, in order to highlight the urgent need for response programs designed especially for them.

A vulnerability assessment report issued by Soldarités International in 2013 that looked at 575 of the around 6,300 households registered by the UNHCR in two districts of North Lebanon found that 13.9 percent reported a member with a disability. While the UNHCR reports that 1.3 percent of registered refugees in Lebanon suffer from some kind of disability, the WRF believes this number is a gross underestimate.

"You have to remember, a lot of people don't report their disabilities, especially if they're mental," Rizkallah explains. "According to the WHO, persons with disabilities usually form around 15 percent of a population. In a conflict, these numbers will be much higher," he says. "If we adopt the more conservative 10 percent that some countries ascribe to their population of PWDs, or persons with disabilities, and apply that figure to Lebanon, the number of disabled refugees in the country would be at least 100,000."

A 2013 report by the Women's Refugee Commission revealed that a large number of Syrians were draining their limited savings to pay for rehabilitation services. Those residing outside the camps in isolated, rural locales like tumultuous Arsal receive haphazard treatments for injuries that leave them, at best, incapacitated or, at worst, suffering from serious infections.

The tragedy, Rizkallah says, is that the Lebanese are uniquely equipped to assist disabled Syrian refugees. Fifteen years of civil war, cyclical clashes with Israel, and a landscape littered with land mines and cluster bombs have allowed them to cultivate an expertise in rehabilitation. The Nabih Berri Rehabilitation Compound, for example, has been operating since the 1990s in south Lebanon, the region of the country hit hardest by conflict. It not only offers medical treatment, but physical, psychological and vocational therapy as part of a long-term rehabilitation plan for patients.

"When the Syrians came, we were well-prepared," says Dr. Maha Gebai, director of the NBRC. As part of its program, the WRF partnered with local nonprofits like the NBRC, supplying the prosthetics while the nonprofits provided maintenance and rehabilitation for a year. But the support they received from this short-term program was quite limited, Gebai explains, severely hindering their ability to assist refugees.

Nadine's husband, a taxi driver back in Aleppo, has only been able to pick up odd jobs in Lebanon. As registered refugees, they receive $19 US per person from the United Nations—down from $30—in the form of a Visa card they can only use to purchase food from designated locations. "We can't even buy cleaning items or winters clothes," Nadine complains. They introduce me to their son, Guevara. "A strong name," Nadine's husband says. "They stopped funding his education," Nadine tells me. "I don't know why."

In a few months, they'll have to renew their residencies at $200 US per person—money they don't have. For now, all of their hopes rest on the UN approving their request for asylum. The arbitrary process can take months or years. Their priority is treating Nadine's ailments, and there's no chance of that in Lebanon, they say.

I catch a glimpse of Nadine's husband's tattoo peeking out from beneath his sleeve as he gesticulates. I think it reads "Oh God," in Arabic, but I can't be sure.

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