Public health imperatives in countering drug related health threats and vulnerabilities in contemporary Palestinian refugee camps.

Viewpoint

Since the start of the Israeli-Palestinian conflict in 1948, a large number of Palestinians were displaced. Subsequent chapters of violence, conflict and wars in the Near and Middle East region, stretching up to the most recent Syrian war continue to contribute an increasing Palestinian refugee population. Current United Nations (UN) estimates indicate that 5.2 million Palestinians are displaced internally in Gaza and the West Bank (including East Jerusalem), and externally into neighbouring countries of Jordan (2175,000 registered refugees living in ten camps), Syria (552,000 in nine camps), and Lebanon (504,000 living in 12 camps). Complexities in defining Palestinian refugee status (for example legal status and registration with the United Nations Relief and Work Agency for Palestinian Refugees, UNRWA) has fuelled inherent difficulties in quantifying exact numbers and location of Palestinian refugees. UNRWA is a temporary UN body, working on improving health and education, and supporting reconstruction and social services. It is funded almost entirely by voluntary contributions from the UN Member States, and has been severely affected recently by funding cuts. Further, the ‘Peace to Prosperity’ plan that promises economic support to Palestinian refugees and their hosting countries is hampered by its prerequisites that seemingly stand against the Palestinians “right of return”, a key integral issue to the Middle East process. Amidst such political complexities and challenges, Palestinian refugees are in danger of being left behind.

They are exposed to an excessive burden of disease caused by the consequences of trauma, conflict, violence, occupation, displacement, poverty and environmental determinants of health (congested living space, poor sanitation) which jeopardize their health outcomes and wellbeing (Habib et al., 2012; Habib, Hojeij, Elzein, Chaaban & Seyfert, 2014; Habib, Hojeij, Elzein & Chaaban, 2019; Kitamura et al., 2018). Reported multi-morbidities experienced by Palestinian refugees include high rates of chronic illness such as hypertension, cancer and diabetes, mental health (including substance use) and respiratory disorders, malnutrition and blood borne viruses (HIV/Hepatitis C) (Al‐ Krenawi, Lev‐Wiesel & Mahmud, 2007; Al-Afifi, Sakka, Shehada & Afifi, 2015; Habib et al., 2014). Nevertheless, despite making up (at times) a relatively significant proportion of the domestic host population, externally displaced Palestinians. are generally denied full rights to political, economic and societal integration (employment, property ownership), are restricted access to public education, public health care and social services, and consequently experience acute socio-economic deprivation (Habib et al., 2012; Kitamura et al., 2018). Further to the political insecurity, complicated by the impending angst around the ‘right to return’, Palestinian refugee communities in the drug transit and drug production countries of Lebanon, Jordan, Syria, West Bank and Gaza are reported to increasingly experience camp insecurity and drug related health threats and vulnerabilities (Thabet & Dajani, 2012; UNRWA/UNICEF, 2018; Massad et al., 2016; Al-Afifi et al., 2019; Damiri, 2019; Syam et al., 2019; Van Hout et al., 2019; Wazaify et al., 2020). These conditions inside camps, along with tensions with the outside or host communities collectively increase their risk of substance use and high-risk drug use (Afifi et al., 2019; Anera, 2019). Limited access to safety and justice, lack of governance and infiltration by radical Islamist groups and criminal networks in some camps has played a vital role in the targeting of youth by drug dealers, the spread of drug abuse, trafficking and violence (Damiri et al., 2018; UNHCR, 2016; Yamout et al., 2012). Young disenfranchised Palestinian refugees, particularly males, and those living with the trauma of displacement and conflict, are extremely vulnerable to drug related risk behaviours including exploitation in drug trafficking by cross border criminal networks (Al-Afifi et al., 2019; Al-ghzawi et al., 2014; Elbedour et al., 2007; Van Hout et al., 2019; Wazaify et al., 2020). Internal efforts by Palestinian communities, NGOs, and CSOs strive to counteract this threat to communal existence and safety in the refugee camps.

Despite such efforts, there has been little progress in activating a joint public health and security response matching the level of needs within the Palestinian refugee camps in these countries. Most recently, the 2020 Middle East and North Africa Harm Reduction Association (MENAHRA) situation assessment of drug use and harm reduction in the region has highlighted refugees as key population, alongside the impact of displacement of drug injecting related infectious disease (HIV, Hepatitis C) and the varying degrees of access by refugees to harm reduction measures (MENAHRA, 2020). Efforts to provide integrated HIV and other health services for displaced populations have been enhanced by the 2018 Global Fund grant to support HIV, TB and malaria services in humanitarian setting in Syria, Iraq, Jordan, Lebanon and Yemen. Refugee numbers have however stretched domestic responses to substance use and related harms in the region (MENAHRA, 2020). Countries hosting Palestinian refugees also differ in terms of the level of harm reduction response. In Palestine NSP and condom provision was initiated in the West Bank by local NGOs, but is currently not provided for, with exception of a small programme in East Jerusalem. Lebanon provides harm reduction and treatment responses largely driven by civil society organisations (CSO), and provide free HIV services to refugees regardless of settled status. In contrast, whilst both Syria and Jordan note PWID as a key population in their National AIDS planning, there is no operationalization of harm reduction in Syria, and whilst NSP was provided on a small scale in Jordan, there has been a decline in the important of some health programmes, particularly the national AIDs programme, with domestic resources are currently diverted to refugee support initiatives. Community groups continue to report concern around the hidden nature of drug use, the stigmatising treatment of drug users as criminals by law enforcement, and lack of harm reduction and drug treatment provision accessible near to the camps (Al-Afifi et al., 2019; Glick et al., 2018; MENAHRA, 2020; Van Hout et al., 2019; Wazaify et al., 2020). Efforts are also reported to be coming from within, for example in Lebanon where in 2014, a group of young people living in Burj Barajneh camp converted an old prison building into a drug rehabilitation centre. The lack of policy driven by evidence is underpinned by camp security and governance aspects which hamper efforts to collect routine surveillance data, resulting in lack of informed policy (MENAHRA, 2020; Wazaify et al., 2020).

Hence, there remains an urgent need to activate robust remedial measures to prevent overcrowded camps becoming hotbeds for drug abuse, and to respond to the specific needs of Palestinian refugees affected by substance use and abuse. Research in humanitarian and conflict affected settings elsewhere (for example Thailand, Afghanistan, Pakistan, Kenya) underscores that whilst displacement and conflict affected populations are uniquely vulnerable to harmful patterns of substance use and related harms (for example HIV, Hepatitis C), the epidemiology of refugee substance use is limited and challenged by poor measurement and inconsistent reporting, with their health outcomes worsened by displacement experiences, and limited access to or exclusion from relevant host population prevention and treatment services (Ezard et al., 2011; Kane & Greene, 2018). Guidelines for humanitarian assistance refer to actions to address substance in refugee settings, but practice remains limited by the lack of evidence on effectiveness and limited implementation of substance use interventions (Greene et al., 2019). Operational research on navigating implementation barriers such as stigma and service provider capacity, and devising effective models for service integration and delivery and generating robust evidence to inform policy and resource allocation is in its infancy (Greene et al., 2018; Greene et al., 2019). Recommendations therefore centre on the need to standard measurement and reporting of substance related outcomes, and utilise existing guidance and adapt interventions implemented in refugee populations in other countries (Ezard et al., 2011; Greene et al., 2018; Greene et al., 2019; Kane & Greene, 2018), train UNRWA social and health workers (for example mhGAP substance-use training) in brief and family interventions, community behaviour change and harm reduction, and design and evaluate prevention and treatment interventions for substance misuse specific to outcomes relevant to displaced Palestinian communities.

There is an urgent need to activate contextual and age and gender appropriated evidence-based preventive measures to address vulnerability, build the resilience and promote protective factors against substance use. This is further to the response to attend to the needs of those already affected by co-morbidities, substance use and problematic use (including their parents, siblings and children) using a stepped care approach (Kane & Greene, 2018). This calls for an imperative need to quantify and address the issue, through a strengthened holistic approach of health, social and legal measures, in line with the UNODC and WHO standards and Guidelines. These include, the UNODC and WHO International Standards for Treatment of Drug Use Disorders (UNODC/WHO, 2020) and the International Standards on Drug Use Prevention (UNODC, 2018). Intervention-orientated qualitative rapid assessment and response methods are warranted (Ezard et al., 2011; Greene et al., 2018; UNHCR/WHO, 2008; Greene et al., 2019) to inform a culturally and contextually relevant response. Such responses should focus on preventive measures including promoting parental and family skills, youth social and emotional skills, enforcing environmental policies including the loose regulations around pharmacy dispensing of habit forming drugs in the camps; and preventing the exploitation of youth by criminal networks and for radicalisation. Moreover, they should also include context specific, targeted and comprehensive packages covering measures to reduce harm, integrated HIV/HCV/STI screening, and treatment of care for people with substance use disorders within Palestinian refugee settings. Such packages of assistance are paramount to prevent further exacerbation of the social and health conditions within the camps and should be inter-linked within the surrounding community social and health services as they carry impact and are related to the domestic context around such camps. We further note the impact of the COVID-19 carries an unproportionate effect on this vulnerable population. This effect is either direct due to the stress caused by the pandemic or indirect due to policies applied to deal with it (including lock down), or its economic consequences. The health vulnerabilities of Palestinian communities living in congested poorly sanitised camps, notwithstanding the heightened risks of those engaging in harmful drug use during this time of even more difficult access to health services begs more than ever for concerted public health responses to counter the drug related health threats and vulnerabilities in such settings.

Declarations of Interests

No conflict of interest declared.