AKKAR, Lebanon: They file into the makeshift clinic – a small, weary woman surrounded by barefoot children, from the chubby toddler variety to teenagers with gangly arms and legs.
“What, have you 10 children?” the doctor sounds slightly incredulous.
“And are they all sick?” he asks, more incredulous.
The fact is the woman – let’s call her Attiya – has eight children with her, and, yes, they are all in need of medical attention.
It’s Friday morning. Dr. Mahmoud Abdul-Razzak is heading up a mobile medical team visiting a Syrian refugee inhabited informal tented settlement in Qoubbet Chamra, north Lebanon.
Today, however, the adapted bus usually used as a mobile clinic has broken down, so Abdul-Razzak and his team of a nurse and a health educator have instead loaded their supplies into a smaller van and are now operating out of a cleared space inside a refugee family’s tent.
Outside the door the Syrians, mainly women and children – most barefoot – wait patiently to see the doctor. Inside, the family that has given up half their home looks on from the side they still hold jurisdiction over. The younger members appear enthralled. Perhaps this is the most entertainment they’ve had in a while.
Abdul-Razzak diagnoses three of Attiya’s children with bronchitis and doles out medicine to treat it. The remainder all have infected wounds, mostly on their feet and caused by insect bites. One adolescent girl limps badly.
The doctor can offer little help. He can give antiseptic cream, but he makes clear that without changes in the environment of the camp such infections will persist. He expects to see the same children presenting with the same issue when he visits next Friday.
The Qoubbet Chamra settlement comprises 28-30 families, or 150 people, living in makeshift tents on either side of a dirt track close to the coast about 25 km north of Tripoli.
Everywhere there are flies. The air is full of hovering black dots. The floor underfoot crawls with the germ carriers. They alight on children’s faces. That the bugs aren’t immediately brushed away suggests that battle has been fought and lost, and now the infants have become used to surrendering their skin to the insects.
“It used to be worse,” Ali Aoun says of the bugs.
Aoun explains that the municipality has already sprayed the area once with insecticide but adds that more is needed. Aoun is the health area manager for the north with International Medical Corps, the non-governmental organization overseeing the mobile medical unit.
Aoun also emphasizes the need for more water and sanitation interventions in the settlement, pointing out that the refugees say their water is sourced from a nearby, slightly salty water body and the filters, distributed by an aid agency to improve its quality, have not been replaced in over six months. According to directions on the label, the filter should be replaced every six months.
He also points out that “there are only three bathrooms for 150 people.”
Abdul-Razzak continues with his consultations. Usually he sees between 50 and 80 patients here each Friday.
A young woman, clearly feeling fragile, complains of vomiting and diarrhea. An elderly lady has arthritic pains. There are more infected bites and cuts and cases of bronchitis.
Aoun explains that one of the main purposes of the mobile medical unit is to identify patients in need of referral to either primary health care clinics or secondary health care hospitals.
Recently referrals to the latter from this particular site have been few: one case of hypertension, where the patient’s blood pressure was twice what it should have been, and several cases of the leishmaniasis skin disease.
Spread by the sand fly, leishmaniasis causes angry-looking sores. Cases of the illness must be referred to one of two government hospitals in the northern governorate, where the Public Health Ministry treats them for free, Aoun says.
Fortunately, there are no cases of leishmaniasis at Qoubbet Chamra Friday, but there is one patient that needs a referral to a primary health care clinic.
The doctor and his team must pack up and relocate to her tent to examine 18-year-old Boutheina, who sits wincing with her lower thigh exposed. While cooking the previous evening, the young woman burned herself badly. Tears stream down her cheeks as she replaces the cloth of her dress over the burn after the doctor’s examination.
Abdul-Razzak doesn’t have the materials to dress the wound, so he refers Boutheina to a clinic 2 km away. Immediately this referral presents a problem: How will she get there?
The main forms of transportation available to the community are either the motorcycles some members own (obviously not very suitable in the case of a severe leg burn) or service taxis, which are expensive. Aoun says that in order to reach the clinic, it is necessary to take not one but two services.
Back in the tent with Boutheina, Aoun gets on the phone to arrange a vehicle to take her to the clinic.
The lack of “feasible transportation” is one of the main reasons mobile medical units are such an important element of the humanitarian response in the health care sector, IMC’s Country Director Colin Lee tells The Daily Star by phone.
Without the units, minor health problems would be likely to become serious issues as financial limitations keep patients from static clinics.
According to the United Nations High Commissioner for Refugees, there are more than 250 informal tented settlements nationwide, with 109 listed in north Lebanon.
Lee also describes the efforts of mobile medical teams as “invaluable” in helping contain an outbreak of lice and scabies earlier this year.
The mobile team’s second stop Friday takes it to Aarqa in Sahel Akkar, an agricultural region. With just 8-10 related families from Hama, Aarqa is smaller than Qoubbet Chamra. It also feels more contained and there are fewer flies. There are more children with shoes on here too.
Hamdou Nashaadi, whose tent is commandeered by the medical team, quickly turns the second room of his makeshift dwelling into a waiting area. A line immediately forms.
Again, the cases are similar: bronchitis, bites and arthritis.
As Abdul-Razzak works, Nashaadi, wearing a pair of opened-toed high-heeled sandals presumably borrowed from his wife, shows The Daily Star around the settlement.
He is proud of the concrete shower areas and the accompanying drainage systems the community has installed in each tent. Yet the runoff water sits in stagnant holes between the rows of tents, around which flies buzz.
Nashaadi also leads The Daily Star to the settlement’s single toilet – a ceramic bowl set in the ground inside a small hut about 10 meters across the field from the tents. Again, flies buzz here.
The surface of the field, like the surface of the road at Qobet Chamra, is dried dirt. One can imagine the muddy swamp it is likely to become once winter rains begin to fall in earnest.
Back in Nashaadi’s tent, Abdul-Razzak has come upon a case of leishmaniais. Khalid, aged 10, has the telltale raised and blistering sores up his right arm from elbow to shoulder. He will have to go to the government hospital for treatment the following day. In this case, the family members say they can arrange his transfer themselves.
Snapping off yet another pair of latex gloves at the end of the visit, Abdul-Razzak stresses the importance of improving the living environment in order to improve health.
“They need to kill as much [of the flies and insects] as they can,” he says, adding that by wearing shoes the opportunities for insect bite infections could be reduced.
Ultimately though, Aoun says repeatedly, the entire living environment of these refugees in terms of sanitation needs serious attention.