“Doctors ask me to feed my kids—but how?” The Russia-Ukraine war hits Syrian refugees in LebanonBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1185 (Published 20 May 2022) Cite this as: BMJ 2022;377:o1185
Foza Cheikho, a 35 year old Syrian mother of eight children crammed in a makeshift tent in Bekaa, Lebanon, frets over what meals she can prepare for her family during Ramadan. During the Muslim holy month people usually have a feast after their day long fast ends—but no meat was served on Cheikho’s floor-turned-table, at least during the first two weeks of the festive holidays.
“Now I only put a tiny, tiny drop of oil in a pan each time I cook, and I stop adding sugar in tea for my family,” she says. Since 24 February, when Russia invaded Ukraine, the prices of cooking oil, sugar, and many other products affected by imports from Ukraine have surged in Cheikho’s neighbourhood.
She says, “Our doctor said that four of my kids don’t have enough vitamins, and the level of minerals in their blood is too low. He asked me to feed them—but how?” Cheikho already pays two medical bills: one for her 10 year old daughter, who has cerebral palsy caused by jaundice; the other for her husband, who had major depressive disorder diagnosed several months ago. Without the medicine he needs, her husband often growls out of control at home. But Cheikho says that she needs to obtain food for the family first.
Lebanon, with a population of 6.8 million, is reeling from one of the world’s worst financial crises, which has plunged the majority of its people into poverty and vulnerability since late 2019. Covid-19 has only aggravated an already dire situation, along with the chemical explosion at a Lebanese port in August 2020 that destroyed much of the nation’s grain reserve and displaced 300 000 people, followed by the collapse of its electricity network in summer 2021. The latest crisis is the Russia-Ukraine war.
Amid the global food and fuel crisis exacerbated by Russia’s invasion of Ukraine, official prices of fuel in Lebanon have increased by about 30% for octane and 60% for diesel since late February this year. As much as 80% of Lebanon’s imported wheat in 2021 was from Ukraine and Russia,1 so the Lebanese government has replaced the private sector for the first time in three decades, seeking millions of dollars’ worth of wheat a month from alternative countries. The Lebanese government is still in talks with other countries including the United States, India, France, and some other European countries to import wheat.23
The impact of this series of crises will likely force the country’s 1.5 million Syrian refugee families to cut down further their spending on healthcare. A 2021 UN report found that 94% of the population had already had to employ coping mechanisms to manage their food shortages, such as sacrificing medicines.4
Medical supply shortages worsen
“Sometimes I spend days finding insulin injection pens for my son with diabetes, as it’s very hard to find them now. I even asked someone to help look for them in Syria,” says Sabah Ramadon, a 35 year old Syrian mother who lives with five children in a one room flat in Bar Elias, western Lebanon. She tells The BMJ that after three consecutive days with no insulin available her 13 year old son’s tongue turned rough, his skin yellow, and his face pale. She asked him to go and sell perfume in the street with her husband, as she thought that the exercise might help reduce his blood sugar level.
Ramadon says, “Once I found [an insulin pen] in a local pharmacy: it was about 103 000 Lebanese pounds for just one pen. That’s already too expensive, but the price continues rising.” (At that time, this was about £55 (€64; $68) at official exchange rates or about £3.33 on the black market.) She explains that her son’s medical expenses already take up 20% of the monthly aid given by the UN Refugee Agency.
Essential drugs have been almost unaffordable, even if still accessible, for most of the population since late 2019. With the Lebanese pound dropping over 95% in value and the depletion of the government’s foreign currency reserves, in November 2021 the health minister, Firas Abiad, announced a lifting of most medication subsidies, including some drugs for chronic diseases.5
The lifting of medical subsidies, which covered 95% of drug consumption, led to a fourfold price increase for the country’s essential medicines from 2019, Amnesty International reported.6 At least 70% of the population now cannot afford the medicines that are still available, says Assem Araji, chair of Lebanon’s Parliamentary Health Committee. The country has also subsidised fuel, wheat, and other basic goods since 2020.
Yester, a Lebanese pharmacist in the Lebanon-Syria border town of Majdal Aanjar, says, “Many people who have, for example, diabetes, hypertension, or kidney problems don’t have access to medicine. Every pharmacy does not have insulin pens now because suppliers are not giving them. They’re waiting for the value of the US dollar to go up so that they can gain more profits.” Last year the country’s health minister raided a medicine warehouse that was reportedly stockpiling subsidised imports.7
Yester, who gave only her first name, says that some pharmacies are bringing medicine from Syria for patients. “People are surviving in Lebanon,” she says from the town’s major pharmacy, where the shelves are half empty. “They are survivors.”
“It’s a vicious cycle,” says Alice Baker, programme officer of Salam LADC, a non-governmental organisation based in Bekaa to support locals and refugees through humanitarian aid and education programmes. “Many families already have pronounced medical conditions, some with serious symptoms or injuries caused by conflicts in Syria.”
She adds, “The stress from the living situations in tents, such as food insecurity and high incident rates in settlements, has deteriorated both their physical and mental health conditions. The conditions are getting worse and worse.”
Baker says that her team encountered the case of a Syrian father who had experienced mental health problems for years. During a covid lockdown in late 2020 he died after setting himself on fire over a dire economic situation, leaving his now widow with eight children. Another similar story was reported by the television news channel Al Arabiya in mid-2020.
Scarce supplies of food, fuel, and medicine continue to push Lebanon’s vulnerable populations to the brink. The effects of the Russian invasion of Ukraine, says Baker, may not seem obvious but will likely increase the psychological burden among vulnerable people on top of the economic pressure.
On a sunny April morning, Ibtissam Rahil and a group of women from Syria, Palestine, and Lebanon sit together near an informal refugee camp in Saadnayel, Lebanon, chatting and making seed balls from cedar, Lebanon’s national tree.
“We all are talking about the war in Ukraine,” says Rahil, a 53 year old woman who fled to Lebanon from a Palestinian refugee camp in Syria in 2011, when the Syrian war first erupted. “Our kids and elderly people are suffering from it in all aspects, including our mental health. We can feel how the people in Ukraine feel as we live in the war.
“Nobody likes war. In fact, it affects all of us.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned, not externally peer reviewed.