Reflections on what we gain from talking to colleagues who live and work in challenging contexts
By Karen Daniels, Health Systems Research Unit at the South African Medical Research Council
I recently had the enormous privilege of visiting Beirut for the first time. My colleagues Etienne V Langlois, Elie Akl and I have begun work on a methods reader for systematic reviews of health policy and systems research on behalf of the Alliance for Health Policy and Systems Research, and this was our first face-to-face meeting.
My closest previous experience of the Middle East has been a holiday to Istanbul and airport layovers in Dubai, so I was very excited by the prospect of meeting in Lebanon. However, in the week before I left there were attacks in Tunisia and Kuwait, and I became concerned, questioning the wisdom of what I had agreed to. To make matters worse, I received a highlighted email from the travel insurance company asking me to call a UK number to check Lebanon’s safety before departure. None the less, after talking to a colleague who had recently been to Niger, off my textbooks and I went. After all, I told myself, my colleagues live there every day, the insurance company doesn’t. And I am so glad I did.
Beirut is nothing like the depressed, hopeless television images of the Middle East, we’re constantly fed. Elie suggested that I choose a window seat on the left hand side of the aeroplane. As I flew in at midday I saw both the intense beauty and the intense pain of this city – the raggedy cliffs of the shoreline and the war wounds of the bomb blasted buildings, surviving amidst the buzz of new development.
Elie, together with Fadi El-Jardali (Heath Systems Global Board treasurer), runs The Center for Systematic Reviews on Health Policy and Systems Research (SPARK) at the American University of Beirut (AUB). Knowing that my colleagues at SPARK had been doing a systematic review on health care for refugees and given the recent media focus on boated refugees in the Mediterranean, I was interested in learning about doing research on health systems preparedness for refugees. What I didn’t anticipate hearing was that Elie started life as a baby refugee on a boat with his grandfather, while his mother, was fleeing on a different boat. This story, and the people Elie introduced me to, (the Syrian car guard who will never return home, and Dr Fouad M Fouad, a Syrian doctor), reminded me that life doesn’t happen out there. The events that are happening in the world are happening to us. And what is happening to us shapes the questions we ask.
It was clear to me, that as with Elie, Fouad’s understanding of regional health systems issues has been shaped by his own experience of displacement. He impressed upon me that the current response to the health needs of refugees, is lacking. From him I understood that we need to shift from thinking that refugee health care should be treated as a short term emergency, to asking how our health systems can be better orientated to accommodate the long term movement of displaced people. More importantly, that there is a political obligation on health researchers to show the health impact of displacement, so as to try and stop it happening in the first place.
Both Lebanon and South Africa take on high numbers of displaced persons, migrants and refugees. According to the UNHCR Global Trends for 2014, Lebanon hosted the largest number of refugees in relation to its national population in 2014, while South Africa registered the sixth largest number of new asylum applications. As a health policy and systems researcher, I have however not paid that much attention the issue of migrant and refugee health, focusing instead on the on-going need to correct the wrongs of apartheid. My visit to Beirut has made me rethink the limitations of this focus.
Currently the South African Constitution offers the right to health to all, not just citizens, but the extent to which this is really afforded to all remains uncertain. Furthermore, xenophobia continues to be a problem and our health system exists within this context, not outside of it, as do I. So the questions I am left with are “how do I use my skills as a researcher in contributing to the creation of a people-centred health system that is truly universal and not just limited to our country’s citizens?”; and “how can I as a citizen of the world speak out more strongly against the forces that lead to displacement in the first place?”.
Visiting Lebanon opened me to new ways of thinking and new ways of questioning, not only about the Middle East, but also about my own work and my own context. There is so much to learn from the authentic insider perspective of colleagues who live through what they are studying. While visiting each other’s home countries is a luxury, we need to find creative ways (such as harnessing the potential of social media) to foreground this insider voice in building the health policy and systems research community.
