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Down and Out in Beirut and Boston

By Dr. Brandon Green
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I am wrapping up an elective rotation thousands of miles from my residency in Boston, in the far away land of Lebanon.  An invited guest of the School of Medicine at Lebanese American University (LAU), I have been living on the west side of Beirut, but crisscrossing the city day by day to work in various clinics, the main LAU teaching hospital, and present lectures to staff and medical students.    Back before medical school I called Lebanon home for a couple summers while studying Arabic and teaching English. So it’s been a much anticipated reunion for me, and I have been pleased to see ubiquitous signs of progress with new roads and buildings springing up everywhere.

I have always found Lebanon beautiful and compelling. It intrigues me with its east-meets-west character of modern secular society in the setting of ancient religious heritage and modern religious conflict.  Among its rock hewn churches and stately mosques, you find spectacular wealth and grinding poverty, great potential and great challenges.  This place remains at once exotic and familiar, but perhaps even more familiar now that I return as a physician who sees so much of his own country in this place.   

My time here has exposed me to a wide gamut of both safety net and for-profit health care.  The system  is mostly administered by the private sector, paid for with a patchwork of employer based insurance, social security, separate military coverage, and a small slice of charitable donations.  So as you can imagine, I am struck by how much in common our non-system in the US has with Lebanon’s.

Like us, the Lebanese have every right to be proud of their advanced health care infrastructure.  They have lots of physicians, well trained both here and abroad – too many in fact, according to my colleagues here who lament the overly competitive environment that forces many of their peers to immigrate to Europe and the US to find work.  Moreover, they have plenty of medical gadgetry, MRI/CT scanners, modern operating suites, etc…so much so that Lebanon has even become a major hub for plastic surgery tourism with patients coming from all over the Middle East to have face lifts and nose jobs, provided in an all inclusive package as if they were planning a cruise or any other high-end vacation.  

And like us, they have vast populations of poor people who are effectively shut out of this fancy system.  These are not just poor Lebanese (though as many as 40% of citizens are thought to be uninsured), but also tens of thousands of Palestinian and Iraqi refugees who have little–to-no access to the insurance regime and generally lack the means to pay out-of-pocket.  They mostly rely on charitable health care through the United Nations or various non-governmental organizations. 

So even though Lebanon is considered a middle income country, they have the same dilemma as us: they have an advanced but fractured and expensive health care system that leaves too many people out.

Consider Layla, a 60-year-old Palestinian woman who has lived her whole life in Lebanon.  She’s a regular patient at LAU’s free clinic in the Shatila refugee camp south of Beirut, one of the places I have had the privilege to work during my time here.  Layla has been coming to this free clinic for years, and like many of the clinic’s other patients, she gets adequate care for her hypertension and high cholesterol as monitored by volunteer medical students, residents, attendings, and pharmacists using donated medicines.  Also like many other patients there, she has other serious conditions that are beyond the clinic’s resources and scope.  Layla has thyroid cancer.  For years now her volunteer doctors have helplessly watched masses in her neck slowly grow and spread up her lymph nodes.  At one point, money from a UN agency allowed for a CT scan, the results of which were consistent with malignant neoplasm, but the work-up stopped there.

 In the few years since this problem came up she would have likely already had definitive diagnosis and treatment if she weren’t poor, if she weren’t stateless, and she could be watching her grandchildren grow up without the obvious specter of this cancer.  But instead she can’t afford a biopsy, and why should she save up the money for it, when the subsequent surgery and chemotherapy is certainly beyond her means to pay? The clinic staff has searched for a surgeon who will agree to take her case at an affordable rate, but have been unsuccessful, and so the slow motion train wreck continues.  By now her cancer is likely incurable, but the tragedy remains that in a modernizing country like Lebanon, the means exist to have intervened and likely cured her at the outset.  That’s what wealthy Americans and Lebanese expect when it comes to their own health care.  

Back in the US, early in the Republican Primary Debates, Ron Paul suggested that, rather than uphold any civil responsibility to provide all citizens with health care, countries like the US should rely on charities to fill in the gaps left by our for-profit system.  The audience showed even less compassion, hooting that the uninsured should be allowed to die when disaster strikes.   That is what is happening in Lebanon everyday in slow, excruciating fashion, even while they have surplus beds and physicians.  And it’s been happening in the US for a long time, as anyone who has followed the health insurance reform debate knows all too well.

So what should this mean to us Americans?  Do we not aspire to lead the world in all arenas? What does it mean that our health care system is plagued with the same sort of injustice and inefficiency seen in the Middle East?  For both our countries it is a failure of our values, not to mention simply bad economic policy.  But for America in particular it is a failure of our leadership for human rights. 

Dear Lebanon, I love you, and am happy to see that your prosperity continues despite the instability all around you.  But of course, with your prosperity comes a rich country’s burden of making just use of your great resources.  If you figure that out, please let us know, for we also have much to learn.  

       

(Top:  Shatila Refugee Camp. Bottom: New high rise apartments and yacht club in Beirut)

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