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.
Epilogue
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!”
