Lara Jirmanus, MD, MPH
Second-year, Global Women’s Health Fellow, Brigham and Women’s Hospital
March 28, 2016
I walk down the familiar street in Hayy el Gharbeh, a few steps from the clinic of the NGO partner for my Community Based Participatory Research Project. For the last two years, I’ve been traveling back and forth to this site, working with the Tahaddi NGO, which runs a clinic and an education center in the urban slum, less than a mile from Beirut’s international airport.
In 2014, I worked as a chief resident in the family medicine program at the American University of Beirut. I worked in the Tahaddi clinic and began brainstorming ideas about community health programs we might do with the NGO and a professor at the American University of Beirut. We initially hoped to design a community health worker program and in March 2015 we performed an assessment of health beliefs and practices with women in the neighborhood in the hopes of designing a program tailored to their needs.
The Tahaddi NGO was initially developed to serve all in the area, with a special focus on the Dom, the Middle Eastern Roma, who have a 77% illiteracy rate in Lebanon, as compared to the 10% illiteracy rate in the Lebanese population. The Dom in the neighborhood live on less than a dollar a day, well below the Lebanese minimum wage of $450/month. Now the neighborhood is also inhabited by poor Lebanese families and increasingly by Syrian refugees.
The living conditions are squalid at best. In winter rainwater turns the dirt roads into mud, which mixes with open sewage. In summer the heat rots the garbage, and brings the rats. The Lebanese government doesn’t service this neighborhood, which is classified as illegally occupied government land, and so residents dig wells, which bring in salty water, and build their own sewage pipes or septic tanks beneath their homes.
In focus group discussions we asked about the children’s health and were told what we might have guessed. Mothers identify their living conditions as the greatest obstacles to children’s health: open sewage, trash-strewn dirt roads, drafty homes with zinc roofs, and a state of chronic insecurity, both physical and economic.
After we reported back our results to the neighborhood, some of the local women became inspired and began to clean up. I returned to ask them about their intervention, which they did without my prompting. I found Rim and Nisrine (names changed for the purpose of confidentiality) sitting on the wall across from Rim’s one-room shack. They explain to me that they started sweeping the road in front of their homes and the clinic for a month after our last community board meeting. Inspired by the collective voices of the Lebanese, Syrian and Dom women stating that the environment was the greatest cause of childhood illness, they took it upon themselves to clean the neighborhood. The NGO staff saw such a difference they thought the neighborhood had organized a door to door trash collection service.
Nisrine looks discouraged as she explains. “Sure, we were sweeping and cleaning up. But you know how it is around here. No one helps. It was just the two of us, and after a month we gave up.” Indeed, there doesn’t seem to be any noticeable difference. The ground is strewn with empty potato chip bags and candy wrappers, pieces of a cracker mixed with dirt and pebbles. A women whom I don’t know approaches to listen in, followed by her three-year-old daughter. The woman watches disinterestedly as her daughter leans down to pick a dusty piece of cracker off the ground.
“Don’t eat that,” says Nisrine to the child, “it’s dirty.” She nonchalantly rises to grab a broom and sweeps the crumbs and dirt to the side of the alleyway. Neither Nisrine, nor the child’s mother stops her from eating the first piece. I think back to one of our first community board meetings. We had food at all the meetings and focus groups, and I recall the first time a child picked a pastry off the floor. I opened my mouth to say, “Throw it away, it’s dirty,” but held my tongue as she stood between her mother’s legs, eating it happily, her mother smiling down at her. Some of the children wouldn’t have had breakfast, if it weren’t for our meeting.
I reflect on the women’s responses to our focus group questions about how people keep their children healthy. Participants would mention hand washing and hygiene. But what about when the social conditions prevent you from doing what you know to be correct? What about when you don’t have water to wash your children’s dirt-caked hands? At times we, as public health practitioners and physicians find ourselves teaching people to “keep themselves healthy” by making recommendations that they are unable to follow. These interactions may bring shame, or just a feeling of being completely misunderstood by a well-meaning doctor who knows nothing of their reality. In either case the physical environment looms insurmountable, perhaps to the point that it feels pointless to remove a dusty piece of cracker from a child’s fingers.