RESPONSE INTERNATIONAL IN LEBANON 1996 TO PRESENT

We have been successfully implementing programmes in Lebanon since June 1996, funded first by Irish Aid and then by the European Union. Throughout this time we have liaised with government ministries, local NGOs, community groups and military factions in order to operate safely in this sensitive area and to ensure the maintenance of a neutral humanitarian stance. The ‘Grapes of Wrath’ campaign marks the beginning of our intervention and continuous presence, and our involvement continued through the more recent Israeli invasion of 2006 with an emergency Primary Health Care response. Programmes that have been successfully delivered during this period include:

• Primary Health Care, integrating Mine Risk Education, as an emergency response to the cross border incursion of the Israeli Army (2006). The IR response was made immediately upon the withdrawal of the invaders and upon access becoming possible. The project was of six months duration and served to support the country vaccination programme for children.
  
  
• Prosthetic and Orthotic Services for Disabled Palestinian Refugees in Lebanon (2006). The workshop is based in Tyre and outreached to 12 refugee camps and other gatherings. The project is sponsored by the British Government.
  
  
• Support to Palestinian refugees living within camps in Lebanon; we are developing a strong partnership with United Nations Relief Works Agency (UNRWA). Initially we helped UNRWA secure funding for the reconstruction and equipping of a dental clinic in Ein El Hilweh camp, and in 2002 provided a series of training workshops for all of UNRWA's water and sanitation engineers (see below for project outline). In 2003/4 we purchased water quality monitoring equipment to provide a badly needed service for all 12 refugee camps in Lebanon, and provided training workshops for UNRWA staff to ensure the effective use and maintenance of this equipment (see below). Both these projects were funded by the British Embassy. The reconstruction and equipping of a health centre in Beddawi refugee camp, funded by the UK’s Department for International Development; completed 2004 (see below).

• Funded by the United Nations Voluntary Fund for the Victims of Torture (UNVFVT) RI trained a group of its own nurses to provide mental health support for the former inmates of Khiam Detention Centre, their families and the wider community in the south of Lebanon.
  
  
• Funded by the British Embassy, RI implemented a major sanitation project in MishMish in the Aakkar region of north Lebanon. The area had previously experienced a serious outbreak of typhoid, centred on the village school, attributed to faecal contamination of drinking water.
  
• RI established a community nursing service in the Caza of Bint-Jbeil, using 10 of the nurses that graduated from the formal training programme. This initiative, implemented in cooperation with the Ministry of Public Health and funded by the British Embassy and St George’s Society, ran until 2006. A home nursing service was provided, to monitor and manage those with chronic diseases and the terminally ill, care for wounds, and provide ongoing health education in the target area. The nurses receive referrals from public and private hospitals and village clinics in the area, together with self-referrals from patients and their carers. Medical support is provided by doctors within the public and voluntary sectors. The nurses have established a child health surveillance programme in local schools, monitoring the growth, hearing, vision and overall development of young children. Such a programme is central to the early detection of significant problems that would otherwise impede a child’s social and academic progress. Through liaison with the village clinics we intend to expand the programme to younger age groups, as the earlier such problems are detected, particularly those impairing hearing and vision, the greater the scope for intervention.
  
  
• UK National Lotteries Charities Board (now known as the Big Lottery Community Fund) for a two year Community Nurse Training programme. This provided further training for village nurses, and enabled them to obtain a range of nationally accredited nursing qualifications. Trainees followed a nationally agreed curriculum, presented in modules that gave a sound base to clinical practice both in the hospital and the community setting. The programme was completed at the end of August 2001.
• IR provided a series of structured training sessions for a cohort of volunteer village clinic nurses in 1998/99. Many of these nurses had no formal nursing qualifications and limited nursing experience. The programme trained them in key nursing skills, including dressings, basic examination technique, care of the terminally ill, disabled and mentally ill, health education, and the management of chronic illnesses.
  
• RI managed a Hospital Nurse Development programme over a period of two years, aimed at up-grading the theoretical knowledge and practical skills of the nurses working in Tyre and Tibnin government hospitals.
  
  
• An adult literacy programme, that involved the training of local volunteers as trainers. Women were specifically targeted, and this successful initiative has continued with an ever increasing number of classes throughout the target area.
  
• A programme in which a number of local people received basic training in mental health assessment, counselling skills, group facilitation and criteria for referral to specialist mental health services. These trained counsellors are now actively working within their own local communities.
  
  
• Installation of desperately needed emergency medical equipment at Tyre and Tibnin government hospitals and the training of technicians in its use and maintenance; infrastructural changes and repairs to allow for greater utilisation of the emergency department, especially during periods of high use.
  
• Provision of a mobile primary health care clinic to villages adjacent to the border with the former Israeli Controlled Area. The clinic was operational for three years (from 1996) and served seven villages. Responsibility for the patients seen in the mobile clinic was handed over to the Lebanese government and local NGOs at the end of 1999.
  

Future Directions
In the coming years we wish to further develop our support of the Palestinian refugees, focusing on water/sanitation within the camps, primary health care, disability and mental health services. These are key concerns for the refugees. Detailed needs assessments have been completed, in conjunction with UNRWA and local NGOs, for mental health (funded by the Karim Rida Said Foundation click here for report) and prosthetics services (funded by the International Arab Women’s Council click here for report), with training and service delivery programmes to follow.

Emergency Response to Invasion, South Lebanon 2006
Sponsored by International Development and Relief Foundation (IDRF) an Emergency Health Care Provision in the South of Lebanon for the benefit of  Lebanese citizens (estimate beneficiary population 31,500) affected by the recent conflict. The village of Quleileh was chosen to be the base of the project with surrounding villages covered by an outreach service.

All activities addressed the priorities identified in the National Strategy for Early Recovery of the Health Sector in Lebanon. The unit was placed/ positioned in order to complement damaged pre-existing health facilities and to support, rather than replace, those facilities.

• Delivered primary healthcare services, managed all acute and chronic health problems in the target population, and referred/ transported the seriously ill to available secondary care/specialist services;
• Outreach service, accessing isolated communities with a mobile clinic on a regular (at least weekly) basis;
• Data collection and reporting systems, including the weekly completion and submission of the WHO/MPH approved Disease (EWARNS) System form;
• Introduced oral polio vaccine and other elements of the Expanded Programme of Immunisation (EPI), for the South, for children, as full cold chain was re-established (facilitated by RI’s provision of the necessary equipment). 
• Rapid assessment of numbers, age/sex distribution, immediate problems and nutritional status of target population was problematic. Initial assessment indicated that the main problems were: existing chronic illness, accidents, mental health issues, and problems related to UXO (unexploded ordnance);
• Conducted rapid review of public health issues (food, water, shelter and sanitation), with subsequent review and revision of planned activities; done with reference to the work of other agencies and actors;
• Initiated immunisation and vitamin A supplementation for children aged greater than six months (in accordance with the MPH policy for the region);
• Mine Risk Education (MRE) training.  Project manager and a member of staff attended United Nations Mine Action Service UNMAS briefing sessions and cascaded contents to other staff members.  Experience gained in MRE in other RI projects was used to disseminate the warning messages to beneficiaries using groups, posters and computer images.  The message was also given as part of School Health activities.

Mental Health:
During and following the outbreak of the conflict in the region, high levels of stress factors faced the civilians (especially the vulnerable groups - children, women and elderly). Basic counselling interventions and advice are given using a normalisation approach.  Referrals were made when necessary to other agencies for more in-depth counselling and treatment. In mild/moderate cases of anxiety, depression and somatisation disorders, referrals were not necessary due to the availability of qualified doctors and nurses who were able to manage the cases visiting the clinics. On the other hand, a considerably high percentage of patients with severe mental health problems (self harm, high suicidal risk and psychotic illness) did not follow up on the referrals made, mainly due to the ill preconception of psychological therapy in the community. Further involvement was not possible considering the delicacy of the problem which intervenes with our resources and project duration.  

Prosthetic and Orthotic Services for Disabled Palestinian Refugees in Lebanon
A two year project, start July 2006.

Background
The 405,000 Palestinian refugees in Lebanon face specific problems. They do not have social and civil rights, and have very limited access to the government's public health or educational facilities and no access to public social services. The majority rely entirely on the United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA), supported by local and international NGOs, to provide education, health, relief and social services. All 12 official refugee camps suffer from serious problems - living conditions are characterized by high population densities and inadequate basic infrastructure, with open sewers, limited supplies of clean water and unsatisfactory drainage systems which make flooding commonplace in the often harsh winters. In addition, the years of conflict and hostilities, and the feeling of an insecure future all affect the health of the refugees.

High rates of congenital abnormality, trauma, vascular disease, and the complications of diabetes mellitus, all increase the prevalence and incidence of disability requiring prosthetic (artificial limbs) and orthotic (foot, leg and spinal supports) services. However, our survey of these services in early 2005 revealed: poor coordination; little access to rehabilitative services or planned follow-up; no programme of in-service training or continuing professional development for orthopaedic technicians (who make and maintain the prostheses and orthoses); no central register of the disabled to facilitate follow-up; no user involvement in the delivery of care; no form of quality control; and consequently poor uptake of services, poor compliance and poor outcomes for the disabled.

Target Group: The immediate beneficiaries will be the estimated 600 disabled Palestinian refugees in Lebanon (300 amputees and 300 others with disabilities) currently requiring prosthetic and orthotic services, together with the 120 new beneficiaries arising each year. Many of these beneficiaries are adult males supporting families, so if their quality of life and

RECONSTRUCTION AND EQUIPPING OF THE HEALTH CENTRE AT BEDDAWI REFUGEE CAMP, LEBANON
Completed September 2004
Background

Beddawi camp is situated on the outskirts of Tripoli in the north of Lebanon. The current camp population is approximately 25,000, but the figure is rising every year. As in all the Lebanese camps problems include: a deteriorating infrastructure; overcrowding; poverty and unemployment; with a high percentage of refugees registered with UNRWA's "special hardship" programme.
The camp experiences frequent outbreaks of water, food and vector-borne diseases; causing death and disability among the most vulnerable members of the refugee community. Malnutrition also contributes to unacceptably high death rates for young children and women of child-bearing age.
The present health centre was originally built as an emergency feeding centre, serving Palestinian refugees living both in the camp and adjacent areas. The existing structure has 15 rooms supporting 19 medical and ancillary staff. The building has become increasingly unsafe, with a recent structural survey recommending extensive repair work or demolition. However, it is also unable to meet the needs of its increasing number of patients.
Plans have been developed to demolish the existing building, and replace it with a purpose-built health facility capable of supporting a full range of general medical, maternal and child health, dental, laboratory and specialist services. The existing furniture and equipment needs to be supplemented; and that which is outdated or irreparable needs to be replaced.

Objectives
1. To demolish the existing health centre.
2. To rebuild and re-equip the health centre.
3. To enhance the provision of all health services, but in particular to reduce the unacceptably high maternal and infant mortality rates in the camp.

Implementation
On approval of a grant to support this project we will request UNRWA to tender for Palestinian contractors for the construction work. The works and installation of equipment is expected to take between nine and twelve months. During this period all health services will be relocated to leased premises near the existing health centre. Provision for the continuity of service is within the scope of this proposal. The leased premises are not ideal, but will ensure the continuity of services throughout the project.
The furniture and equipment has all been sourced in Lebanon and is readily available within country. Response International will be responsible for: project development, site supervision, purchase and installation of equipment, project monitoring/evaluation and narrative/ financial reporting.

Sustainability
UNRWA will act as Response International's implementing partner. Their Field Engineering and Construction team will be responsible for the ongoing/ long-term maintenance of the health centre, and their health budget will sustain the equipment and human resources required to deliver services. UNRWA will be responsible for contracting local maintenance support that will cover all of the Centres medical equipment.

Training in Water Quality Control and the Use of Water Quality Monitoring Equipment for UNRWA Palestinian Refugee Camps in Lebanon
Completed June 2004

Background
Both UNRWA and Response International are keen to build on the success of last years course by organising follow-up practical sessions during which new skills can be imparted to the participants. In discussion with the Field Sanitary Engineer and others, it has become clear that one area of continuing weakness is Water Quality Control. The supply of equipment and training in this field would do much to improve the operation and maintenance of existing water supply networks and allow recipients to maximise the benefit of the newly constructed networks as they are commissioned.

All water distributed for public supply needs to be routinely tested to ensure it is of potable quality and will not adversely effect public health. At modern water treatment plants, telemetry systems continually monitor output for various parameters, and alarms sound and valves close automatically when any particular parameter is exceeded. Such systems are very expensive and could never be justified for refugee camps. With wells often located in unsewered areas and the problems caused by negative pressures effectively providing interconnection between water and sewage systems, the monitoring of water delivered to consumers is vital for the maintenance of good public health. Several camps are located on the coast and monitoring is also required to check if pumping is inducing saline intrusion.
Samples are collected by the UNRWA operators and taken to the public laboratory in the adjacent municipality for analysis. The locations within the camps from where samples are taken may not accurately reflect the overall condition of the distributed water. Sampling techniques, storage and transport do not always conform to recognised ‘Good Practice’. The number of samples taken at each camp, and the frequency of sampling do not follow standard procedures designed to provide representative results.

The municipal laboratories analyse the UNRWA samples free-of-charge, and although this service is much appreciated, samples may be stored during busy periods, often for longer than is permitted under ‘Good Practice’ procedures. When analyses are completed quickly, the time taken for UNRWA to receive the results, interpret them, and initiate action where contamination is identified is unacceptable for the maintenance of good public health. It is likely that UNRWA will have to pay for analyses in the future.

It is therefore proposed that UNRWA sanitation staff be taught the importance of Water Quality Control and be trained and equipped to take samples, undertake their own analyses, report and interpret the results in accordance with internationally recognised ‘Good Practice’, and to take action in time to prevent poor quality or contaminated water reaching consumers.

Basic tests required daily would be undertaken in each camp, those required weekly or monthly in Area offices, while control and longer-term analyses would be carried out in the Lebanon Field Office (LFO) in Beirut.

Objectives
1. To improve the operation and management of existing water and sanitation networks within Palestinian refugee camps in Lebanon.
2. To prepare the water plant operators and their supervisors within the camps where new construction will be undertaken for improved operation and efficient management of the new networks.
3. To generally improve the public health of all refugees in the camps.

Sustainability
The proposed training has been designed in collaboration with senior UNRWA staff. It will provide the necessary skills and equipment to undertake water quality control in both the existing networks and the new systems to be provided under forthcoming EU-funded construction.

UNRWA have confirmed that existing and previously agreed future staffing arrangements will be sufficient to manage, operate and maintain the equipment; that suitable facilities are available for the use of the equipment in each of the locations in which it is housed, and that the on-going cost of replacement reagents and other consumables can be met from within present sanitation budgets.

The custodians of the equipment will be the Area Sanitation Officers in the camps and Area offices, and the Field Sanitary Engineer in the LFO.

Training Course for Water and Sanitation Operators in UNRWA Palestinian Refugee Camps in Lebanon
Delivered September 2002

Background
Following the establishment of Israel in May 1948, the United Nations General Assembly created UNRWA, the United Nations Relief and Works Agency for Palestinian Refugees in the Near East, in 1950 to manage camps that had been established in Jordan, Syria, the West Bank, Gaza and Lebanon.

The camps in Gaza and the West Bank are now included within the Palestinian Authority, and refugees have the same degree of self-determination as other inhabitants. In Jordan and Syria, the refugees have, to varying degrees, been assimilated into their adopted country and they are allowed to take employment within their adopted country. Although these camps remain under the control of the Agency, they have been substantially redeveloped, with many infrastructure services now supplied and managed by appropriate national utilities.

The twelve camps in Lebanon have never been afforded such improvements, the refugees have not been assimilated into the community and they are not allowed to work outside the camps. They therefore continue to rely upon the Agency to provide basic infrastructure services such as water supply, sewerage and drainage, solid waste disposal, education, health care and social welfare. The existing population of these camps is some 350,000.

Existing Infrastructure Whilst some camps were originally established as tented encampments, others made use of redundant buildings from the French Mandate era. Today, all twelve camps in Lebanon comprise single and two storey blockwork shelters with some three or four storey buildings. Some roads are wide enough to permit vehicular traffic, but access throughout the majority of camps is via narrow, poorly surfaced, pedestrian alleyways. Institutional facilities include schools, clinics, mosques and UNRWA offices and food distribution centres. Development has been piecemeal and infrastructure services such as water supply, sewerage and storm water drainage are difficult to operate and require high maintenance.
The majority of camps obtain water from their own boreholes. Discharge is chlorinated at the wellhead and either pumped into elevated reservoirs for onward distribution or directly into supply. Many reservoirs were originally constructed to serve as water collection points and are not of sufficient capacity, nor provide adequate head to efficiently feed pressurised distribution systems. There is often no inflow control and the reservoir full condition can only be determined by inspection. Because most boreholes have been constructed with steel pipe perforated by flame-cut slots in place of proprietary well screen, many produce substantial quantities of sand and reservoirs need frequent cleaning. Distribution networks comprise galvanised steel pipelines laid on the surface or at very shallow depths. At convenient points, tappings connect to a manifold from which narrow diameter, flexible or galvanised steel pipes snake their way through alleyways and along open sewer ditches to individual shelters. Control facilities are generally absent and looped distribution systems are rare. Given the poor condition of storage facilities and much of the distribution pipework, losses are more than 20%. Hence there is severely suppressed demand and the water available at consumers’ taps is often below that recommended for good public health.

All shelters have inside toilets and although many are of the non-flush variety they are usually fitted with a U-bend to reduce odour. Most camps have some sub-surface sewers, usually combining foul and storm water flows. Only one camp has separate systems for sewage and surface drainage; two have no sewerage system, and others have substantial unsewered areas, in which foul flows are disposed of into soakaways while ‘grey’ water drains to the open channels provided for storm runoff. Again, pipes are laid at shallow depths, where they are frequently damaged. Gradients are shallow, self-cleansing velocities cannot be maintained, and blockages are common. Drainage laterals from individual shelters are often poorly connected at manholes and there are on-line connections. In several camps, some manholes have to be cleared daily.

The majority of camps have some provision for storm water drainage; either the same open channels as take ‘grey’ water or to the sub-surface foul sewerage system. The combined systems are of insufficient capacity to take the runoff from heavy storms and flooding of shelters is regularly experienced at several camps.

Household refuse and other solid waste is collected by hand or wheel barrow from the pedestrian alleyways and temporarily stored at locations with vehicular access, from where it is collected by compactor lorries and taken to disposal sites outside the camps. During temporary storage there is much hand sorting by camp residents to remove anything that may be recycled. When vehicles break down, refuse quickly builds and residents frequently revert to dumping solid waste in manholes and drainage channels. As in normal communities worldwide, there is a continuing problem of fly-tipping on vacant plots and around the perimeter of the camps.

Objectives
1. To improve the management and operational maintenance of existing water and sanitation systems within Palestinian refugee camps in Lebanon.
2. To prepare the water and sanitation operators within these camps for the benefits new construction will bring.

Social and Environmental Impact
Water, sanitation and refuse collection systems have a major impact on living conditions and the health of populations. Although reliable data are difficult to obtain, all 12 camps in Lebanon experience frequent outbreaks of water, food and vector-borne diseases, causing death and disability among the most vulnerable members of the refugee community: children; the elderly; and women of child-bearing age. Health improvements resulting from a reduced incidence of communicable diseases would be reflected in the improved social, educational and economic development of individuals and whole communities.