Dr Qassem Salah’s 6,500 patients include many with life-threatening conditions. His small clinic in Beirut’s Mar Elias refugee camp treats cancer patients, those in need of open-heart surgery and at least two people with acute schizophrenia.
It is operated by the United Nations Relief and Works Agency for Palestine Refugees (Unrwa), which supports up to 250,000 Palestinians in Lebanon. They are ineligible for state healthcare but priced out of the private market, says Salah: “There is no alternative for Palestinians.” Without Unrwa, he says, his most critically ill patients “surely will die”.
Palestinians in Lebanon rely on Unrwa for basic services such as healthcare and education. The decision by more than a dozen donors – which together contributed about two-thirds of Unrwa’s funding last year – to freeze payments has left the organisation’s operations facing collapse.
After Israel alleged that Unrwa staff members took part in the 7 October attacks, which killed more than 1,200 people, donors threatened to cut $450m (£350m) funding from the $880m budget, just as the need for its services in Gaza was at its peak. Cuts also threaten its activities in the West Bank, Jordan, Syria and Lebanon.
The Lebanese government is warning that the suspension of Unrwa’s services could create a humanitarian catastrophe that threatens the country’s stability. Unrwa runs 150 sites across Lebanon on a budget of about $180m a year, according to Unrwa’s director there, Dorothée Klaus.
In places such as Mar Elias, these services are a lifeline for Palestinians. In addition to the clinic, Unrwa runs a primary school for 277 pupils – at 95%, the attendance rate for Palestinians in Lebanon is higher than the regional average – and a small water-treatment facility.
It also runs waste-collection services and has helped to pave the narrow streets between Mar Elias’s colourfully painted tenements with concrete patterned to resemble flagstones.
“It’s almost like a village,” says Unrwa’s camp services officer, Ferial Kiwan. She says Mar Elias is quiet and clean, as well as being smaller and more peaceful than most of Lebanon’s 12 camps, the worst of which suffer from high crime rates and poor sanitation.
The camp was established on church grounds to host Christian Palestinians after the 1948 Nakba (“Catastrophe”), in which more than 750,000 people were displaced or expelled from their homes during the creation of Israel and the resulting Arab-Israeli war. It has since become home to 1,700 residents of different faiths, the majority of whom were born in Lebanon.
Despite its peacefulness, unemployment is rife and deprivation is high. Across the country, 80% of Palestinians live in poverty. Growing up in the camps, Kiwan says, “makes you a different person”.
Palestinians are barred from attending Lebanon’s schools, accessing state healthcare or owning property in the country. Most Palestinians in employment have low-paying jobs in the informal sector, but since the economic crisis hit in 2019, these jobs have become harder to find. A recent Unrwa recruitment drive for 30 sanitation workers received 38,000 applicants, including many with higher degrees.
Unrwa is one of the few employers offering white-collar positions to Palestinians. “It is the dream of every Palestinian to find a job there,” says Tarek Moneim, chief executive of Initiate, a programme that supports empowerment and entrepreneurship among young Palestinians in Lebanon.
Unrwa employs about 3,500 people in Lebanon; the vast majority, like Kiwan, are Palestinian. With so many of their relatives out of work, she says, “every Unrwa staff member is supporting two or three families”.
For young Palestinians in particular, Moneim says it is “super-difficult” to earn an income. Children growing up in the camps “start to lose hope and ambition”, he says, seeing few opportunities for themselves beyond emigrating to Europe or joining a militant group at home.
“Without Unrwa, I see a lot of violence inside the camps and a humanitarian crisis,” he says. “If it ever collapses, it will be a black day.”
Lebanon is already suffering from an economic crisis that has wiped out more than half its economy, and a border conflict between Hezbollah and Israeli forces that has displaced thousands of people and threatens to spread to the rest of the country.
Speaking in Beirut earlier this month, the caretaker prime minister, Najib Mikati, warned that Unrwa was critical for maintaining stability in Lebanon and that its collapse could result in “unforeseen consequences”.
The potential for unrest in the camps was made clear last summer, when three months of interfactional fighting in the Ain al-Hilweh refugee camp left dozens of people dead and many more wounded, according to reports. Gunmen from Fatah, the dominant faction of the Palestine Liberation Organisation, fought street battles with Islamist militants after the assassination of a Fatah commander. More than 2,500 families were forced to find temporary accommodation, according to Unrwa.
According to Abdelnasser el-Ayi, the director of the Lebanese Palestinian Dialogue Committee, unrest in the camps poses “a security threat for Lebanon’s stability”.
“Unrwa is a stabilising actor,” he says. “Leaving the people without any services would make people much more inclined to join the [militant] groups, who actually can offer them money and can offer them survival. They are already in terrible living conditions.”
One of Unrwa’s most effective interventions in Lebanon is the quarterly distribution of small cash payments to the most vulnerable individuals, which go to 65% of the 145,000 registered refugees. The organisation’s distribution of $50 handouts four times a year for children, elderly and chronically ill people has reduced poverty levels from 93% to 80%, Unrwa says.
But the threat of funding cuts has put this quarter’s payments in jeopardy and the people who rely on them “are already getting restless”, says Klaus.
“We’re having to see where we can still find a bit of money,” she says, “and then we will have to make some hard decisions.”
