Thursday, April 28, 2016

Perspectives from an Urban Slum in Beirut, Lebanon Entry 2

Lara Jirmanus, MD, MPH
Second-year Global Women’s Health Fellow, Brigham and Women’s Hospital

April 6, 2016
Carrying trays of pastries and bottles of juice, my research assistant Micheline and I walk into the offices of the non-governmental organization (NGO) for a community meeting to discuss the trash.  A pile of waste sits at the top of the street near the clinic. Garbage was a primary health concern of residents in this slum, but we eventually discovered that the issue was fraught with local politics and conflict.
When we asked women in focus groups in March 2015 about causes of childhood illness, we expected to hear about asthma and diarrhea. But the first response was always the garbage.  The discussion would then take a negative tone, with people describing the problem as hopeless and blaming it on their neighbors. The Lebanese women would blame the Dom families, who lived in the worst conditions in the alleys below the clinic. The Syrian refugees reported being harassed and cursed at about the trash, and even having their children intimidated into taking out their neighbors’ garbage. Most of all participants would say that the trash problem cannot be solved without cooperation of all in the neighborhood. “’Eid wahad ma bi za’if,” or “A single hand cannot clap,” was a frequent phrase heard in the focus groups.
Underlying this lack of collaboration was another story, which only surfaced after I spent months building trust and conducting individual interviews with residents. In 2014, a landlord in the neighborhood removed the government dumpsters, to build two buildings, which he now rents to shop owners. The dumpster served the immediate neighborhood around the clinic.  Every morning, the government trash company, Sukleen, collected the trash from the dumpster, providing the only government service in the slum. While the neighborhood residents have no dumpster nearby, the landlord now collects rent from the land, which previously hosted the community dumpsters. The Sukleen truck still comes every morning to collect the trash from the informal pile on the street, which remains strewn with bits of waste, as residents have even stopped using garbage bags.
Over a year ago the Tahaddi NGO attempted to tackle the trash issue, recruiting support of the local government. The municipality was willing to place garbage cans around the neighborhood, but the residents were unable to agree upon where the cans would be placed. No one wanted a trash can to be near their home for obvious reasons, such as the smell and the mess. But resentment also plays a role. Allowing a trash can near one’s home would be tantamount to consenting to the initial injustice of having the dumpsters removed. While the current reality urgently begs a solution, with summer coming and a child in the neighborhood who was recently bitten by a rat, the resentment that an individual is profiting from rental properties, which instigated the local trash problem, remains a formidable obstacle.
It has been interesting to reflect upon the local trash crisis in this single slum, in the shadow of the national garbage crisis, which emerged over a year later. Lebanon’s garbage crisis has made international headlines since August 2015, when residents of the village of Naameh, where the national dump has been long overfilled, refused to allow any more trash to be deposited.  After national protests over the failure of the state to collect the trash, the Lebanese government eventually began depositing the waste in a makeshift dumps in Beirut suburbs. Residents of these areas keep their windows closed to shield themselves from the foul smell of rubbish. In March 2016, the Lebanese government negotiated an agreement to reopen the Naameh landfill for 2 months. Now as trucks now transport waste across the city, the sweet smell of rotting waste intermittently wafts through downtown Beirut, carried by the spring breeze.
The local problems in Hay el Gharbeh echo the national situation. In both cases the political leaders fail to make the needs of the population their top priority, privileging the interests of friends and allies.  Thus a spirit of non-collaboration trickles down to even the most mundane of issues, with real public health consequences. With these obstacles before us, one can see why it may be difficult to resolve a seemingly simple problem, such as the dumping of waste on the street.
Although in the beginning of the study in March 2015, conversations in the trash felt hopeless, by June, participants seemed more ready for action. I visited the members of the community board, in order to gain a sense of whether they would support a local trash initiative in June 2015, and people became enthusiastic about the idea of having someone come door to door to collect the trash. I then had to leave to return to my clinical position in Boston, but one of the men in the neighborhood approached the NGO after my departure with the intention of starting a local trash collection initiative. The NGO afterward noticed that the immediate area around the clinic was cleaner than it had been in months, in spite of the national trash crisis.
Upon my return, however, I learned that no trash collection initiative had begun, but rather two women, Rim and Nisrine, whom I mentioned in my previous post, had been sweeping the neighborhood. In addition one of the neighbors of the clinic receives daily payment from the Tahaddi clinic for sweeping the area. During my previous trip in January, Tahaddi contacted an international NGO, which agreed to help organize a local cleanup of the neighborhood. The purpose of our community meeting would be to create a plan for keeping the neighborhood clean, after the neighborhood cleanup scheduled for April 21.  
The meeting was attended by some 12 people in total, including Issam, one of the local Lebanese landlords, and women from each of the three social groups, Lebanese, Dom and Syrian refugees, as well as the Medical Director and Health Program Director of the Tahaddi NGO.  While in previous meetings side conversations had emerged with conflicts between Syrian and Lebanese participants, this conversation was perfectly civil and completely focused on the trash.  Furthermore, the Dom participants spoke in this meeting, although in previous meetings they sat silently. One of the secondary objectives of my study in the neighborhood was to foster collaboration among the various social groups, which is complicated in a neighborhood where they often find themselves in competition over limited resources.
After an hour or so of debate, the participants agreed that Issam, the landlord, would hire a man to collect the trash. He would go door to door and would take 5000LL or about $3 per month from each household to collect the trash twice a day. The NGO would furnish the initial cart, and all participants in the program would receive trash bags when they initially sign up and then they could go to Tahaddi NGO would supply them with used plastic bags to throw out their trash.
I then presented the plastic bag dispensers, which were sewn by women in the neighborhood. I demonstrated their use and announce that everyone who collaborates with the program would receive plastic garbage bags as well as a bag dispenser to store plastic bags which they can bring to Tahaddi to refill (See Image2c_Jirmanus). The eyes of the participants lit up.  Rima, a Syrian woman, whispered to the woman beside her, “I made that one.” Someone pointed and said, “I want the one with the Tahaddi badge.” There were three colors, blue plaid, red plaid and a pink one with flowers on it.
After the meeting adjourned, Issam excused himself and returned with two men, who agreed to help with the trash initiative. One would help to collect names and the other would collect the trash. As people left the atmosphere was hopeful. Everyone left carrying a bag of trashbags and a plastic bag dispenser.

A few days after my return to the US, I received an update from the Tahaddi Health Program director about our meeting.  Unfortunately, neighborhood residents who weren’t at the meeting were unwilling to pay for door-to-door trash collection, and the program never got off the ground.  Furthermore, the international NGO, which had offered to help with a neighborhood clean-up withdrew because of “security concerns.”

The area we work is not a war zone. The residents of Hay el Gharbeh live the daily violence of poverty. The violence of waking up in the morning and not knowing whether you will be able to feed your children. Of sending your sick child out to work or to beg because it’s the only way to make ends meet. Of not being able to fix the hole in the wall that the rats crawl in. Of not knowing whether your child will be caught up in an armed scuffle on the way home to a neighborhood where the police rarely set foot. Not as striking as bombs and guns, social and economic marginalization is insidious. Paul Farmer calls our work “the long defeat,” a never-ending struggle to promote the health of those that live at the edges of our societies.  But this phrasing fails to capture the joy of this work, the proud smiles of the women at the community meeting to see their sewing put to good use, the appreciation of focus group participants at the chance to reflect on their own needs and priorities, and the inspiration of working with dedicated colleagues, like the Tahaddi Health Program Director who regardless of setbacks, still wrote in her last communication: “Sorry for the bad news but we will keep on trying and trying. I haven't given up!”   

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