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Round the World

From Our CorrespondentsLebanon

MEDICAL RELIEF

LEBANON has been crossed by armies for countless generations:but the war this summer was seen around the world on television.

Many international agencies, and the United Nations Relief andWelfare Agency, which has been responsible for Palestinian

refugees since Israel was created in 1948, worked to provide relief,especially during the siege of West Beirut. This is a brief account ofthe political history of the area and of some of the health care prob-lems encountered by a medical relief team working in Lebanon.

HistotyOn June 4, 1982, Israel bombed the Palestinian suburbs of Beirut.

Two days later, the Israeli Defence Forces invaded Lebanon,seeking to destroy Palestinians whose military strength had grownin the south of Lebanon since the 1975-76 civil war and who had

created, in Lebanese eyes, "a state within the state". Israel,supported by the right-wing Lebanese Christian Phalangist party,rapidly occupied south Lebanon up to the Beirut-Damascus road,where they faced Syrian forces. They entered East Beirut withPhalangist help, but were stopped at the "green line" between theeast and west of the city by the Palestinian army and leftist Muslimmilitias. The six-week siege of half a million people in West Beirut,during which the Israelis cut off water, fuel, food, and even medicalsupplies, and made many bombing raids, was raised on Aug. 12 aftera ceasefire treaty negotiated by the United States.During the next three weeks over 10 000 Palestinian fighters were

safely evacuated from Beirut. Then on Sept. 14, the LebanesePresident-elect was assassinated. Israel broke the ceasefire

agreement and moved into West Beirut, meeting only limitedresistance. However, when it was learnt that Israel had let

Phalangist militias into the suburbs of Sabra and Shatilla andhundreds of undefended Muslim Palestinian and Lebanese familieshad been killed, the United States forced the Israeli troops towithdraw from the whole of Beirut. An international force ofAmerican, Italian, and French troops supervised reestablishment ofLebanese Army control, under the new President, Amine Gemayel,throughout the capital. Elsewhere in Lebanon, Israeli, Palestinian,and Syrian forces remain in occupation, with occasional skirmishes:negotiations for their eventual withdrawal may depend on theUnited States itself investing a substantial peace-keeping army inLebanon.

Health Care during the WarLebanese newspapers in early September quoted the Government

as estimating that 38 000 people were injured and 6000 killed in thebattle of West Beirut, of which about 9000 and 1000, respectively,were Palestinian fighters. The figures are imprecise because few ofthe emergency treatment centres kept good records, there weretransfers of patients between centres, and nobody knows accuratelyhow many people were buried under collapsed buildings, whichcould not be cleared because of the continued fighting. However,they do give an approximate view of the medical task. An estimated1500 people were killed during the massacre of Sept. 15-18.The war injuries were broadly of two kinds-burns and trauma.

Although many burns were severe, particularly the effects of

phosphorus bombs, the wounds recovered surprisingly well, evenunder the unsterile conditions of emergency care. In contrast,abdominal wounds and limb trauma usually led to more compli-cations, especially compound fractures, which often becameinfected, could not be stabilised, and became problems for long-termtreatment. Adults playing with their guns and children playing withunexploded bombs remained a source of injuries after the war hadceased. Rehabilitation and prosthetic needs remain to be defined,although much experience had been gained during the civil war.The health of the displaced families was surprisingly good. The

Red Cross and UNICEF efficiently organised food supplies from

local centres. Clinic staff saw no malnutrition, nor were seriousinfectious diseases, such as polio, tuberculosis, or diphtheriaevident. The many skin diseases were related to lack of water duringthe siege. People sensibly burnt their rubbish in large piles and inonly a few places were drains damaged sufficiently for sewage toflow in the open streets.There has been civil war in Lebanon for seven years, and the

health services were attuned to dealing with it. Equipment andsupplies were stockpiled before June and some hospitals werespecially built to withstand damage. Yet many Lebanese doctors andnurses left West Beirut during the siege and most of the private hos-pitals closed. Two large hospitals, the American University Hospi-tal and the Islamic Makassed Hospital, remained open throughoutthe bombing, and fourteen first-aid centres and emergency hospitalswere opened, in garage basements, apartment blocks, schools, anddance halls. The Palestinian Red Crescent Society’s three hospitals,Haifa, Akar, and Gaza, in the southern suburbs continuedemergency work. All the hospitals suffered from bombing damageand lack of supplies, especially fuel, until the siege was lifted.

Volunteer health staff came from many countries, individually orthrough national groups, expressing solidarity with the plight of theLebanese and Palestinians. Christian Aid sent 20 British doctorsand nurses to join an international team of over 70 working for theMiddle East Council of Churches. First members of the MECCteam arrived in Beirut two days before the ceasefire. They helped inthree temporary hospitals, in the American Hospital, and in Akarand Gaza Palestinian hospitals. Community health staff visiteddisplaced families in temporary refuges of cinemas, schools, andempty office blocks in Ras Beirut, and set up clinics in the southernsuburbs and Palestinian camps as the families returned home.There were also requests for help elsewhere in Lebanon. The

MECC team supported local staff at three government hospitals inthe Beqaa valley in the east of Lebanon, three hospitals in the southrun by independent health organisations, and two clinics in Sidon;and they assisted nuns in East Beirut caring for 35 mentallyhandicapped children whose home had been destroyed by thebombing.The expatriate volunteers worked mainly within existing services

rather than creating any themselves. However, during the Israeliinvasion of West Beirut and the massacre, the foreign staff were vitalin sustaining health care for the Palestinians and poor Lebaneseuntil, some weeks later, it was politically stable enough for the localstaff to return. Their presence, under protection from theInternational Red Cross, was not only a practical but also a moralsupport during frightening days.ReconstructionThere has been no full census in Lebanon for many years. The

seats in Parliament at independence in 1943 were allocated 6,5 5 infavour of Christians over Moslems, and a further census is thereforepolitically sensitive. The United Nations estimated Lebanon’s 1980population as 3,1 1 million with 40% aged over 45 and 75% living intowns. Life expectancies are near European rates, with the samecauses of death in adult life, particularly coronary heart disease.The main health care provision in Lebanon is private. The last

available Ministry of Health statistics of hospitals were for 1971:there were 21 public hospitals with 1546 beds, compared with 122private hospitals with 9149 beds. In Beirut the disparity wasgreater, only one public hospital of 200 beds in contrast to 49 privatehospitals with 3016 beds. These differences have probablyincreased over the past ten years.Government hospitals have low status in the eyes of the public

and of medical staff. The administrator of one government hospitalin the Beqaa claimed not to have been visited by a Ministry officialfor five years. At another, the medical director had opened a 100-bedhospital 10 km away and rarely attended the government hospital.The problems include poor administration and lack of cash to payfor necessary equipment or supplies.Government health insurance schemes cover a minority of the

population, mainly urban salaried families. There is no tradition forfree health services, and most people have to pay first and then seekreimbursement from government or charitable funds. In 1977 morethan 60% of the Ministry of Health budget went to private hospitals.

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Doctors are profit-oriented and rich; nurses, who are almostalways women, have low status and poor pay.The new Minister of Health is a gynaecologist, with considerable

political experience, and is president of the Lebanese FamilyPlanning Association. Apart from revitalising the hospital sector hewill need to develop programmes of primary health care,

adjusted to the contrasting local conditions of urban and ruralLebanon. The Health Sciences Faculty of the American University,the Middle East Council of Churches, and UNICEF are makingproposals for some pilot schemes.Yet the most pressing issue is the welfare of the Palestinians,

whose homes and economic life have been devastated. Pressurefrom Israel in the south has prevented the United Nations Reliefand Welfare Agency rebuilding the Palestinian camps near Tyreand Sidon; the tents the Israelis have provided have been derisivelyburned by the Palestinians. UNRWA provides only a basicmaternal and child health service in the camps. Hospital and clinictreatment used to be provided by the Palestinian Red CrescentSociety, which is now banned in the Israeli-occupied south andawaits the new government’s decision for its survival in Beirut, Inthe meantime Palestinians get inadequate or no health care.The Lebanese government has estimated the total costs of

reconstruction at US$10 billion, including the war damage and lossof commercial life. Aid agencies are offering help: USAID hascommitted$100 million and the EEC 9 million ecus. Localagencies, such as the Middle East Council of Churches, are offeringpractical help in housing, health care, and social welfare.But the basic premise of reconstruction is stability. Both Muslims

and Phalangist extremists must accept compromise under their newChristian President; foreign forces must leave the country bynegotiation and the Lebanese army take up an impartial role inpeace-keeping; and an international solution has to be found for aPalestinian homeland, based both on historic rights and currentrealities. Arab governments and the United States have agreed on aproposed Palestinian state in the West Bank. Perhaps othercountries, who have so far been onlookers, need to give theirpolitical weight to these proposals. The alternative could well befurther war.University College,University Street,London WCI6JJ MARK MCCARTHY

Senior Lecturer in Community Medicine and Coordinator of the MiddleEast Council of Churches Medical Relief Team in Lebanon, August -

October, 1982.United States

CUTS REDUCE SUPPLY OF INFORMATION

THE present Administration took office with the intent that itwould reduce Government spending. It has made massive cuts,which, it is claimed, have affected only unimportant and

unnecessary programmes. The House Government OperationsCommittee unanimously disagree, questioning whether the cutshave not been so extensive and serious as to raise questions over thewhole future of the Federal Statistical System. In this, they have thesupport of the Treasury Secretary, Mr Donald Regan, who plans toraise with the Office of the Management and the Budget questionsabout the effect of the cuts. It seems the cuts have seriously limitedthe financial information the U.S. Treasury feels is necessary to itsfunctioning. Surveys of family budgets, parts of the consumer priceindex, housing, nursing homes, health and nutrition, and energyconsumption have all been eliminated or heavily cut back.Particularly curtailed is the output of information gathered in the

last census, much of which is urgently needed by all sorts of

organisations and agencies over a wide range of Government andbusiness, from marketing surveys to the Department of Defense.Block grants to local health services cannot be properly allocatedand the situation has been reached where the Department ofEducation is allocating 1982-83 funds on the basis of the 1970census details. Moreover the Statistical Policy Branch, a small unitdesigned to make sure that the statistics available to the Governmentare reasonably accurate and coherent, has been abolished. It isevident that this Administration, and subsequent Administrations,are going to suffer from inadequate information, inadequatelyinterpreted.

NOTES FOR LANCET AUTHORS

Prospective authors are referred to the statement UniformRequirements for Manuscripts Submitted to BiomedicalJournals published in the issue of Feb. 24, 1979 (Lancet 1979;i: 428-30) and to these notes:

Units. Non-metric units should not be used in scientificcontributions, so pints, inches, and so on, and Fahrenheittemperatures will be changed editorially to metric units. Partsof the SI system are controversial or unfamiliar even incountries that have adopted the system-notably, in the matterof concentration of substance, gas tensions, blood-pressure,and radiological units. For these, authors should provide(separately from the text) explicit two-way conversion factorswhich will be printed in a prominent place in the article; if thisinformation has to be added by the Editor, the author shouldcheck accuracy at proof stage.Abbreviations. Since there is no universally accepted list of

abbreviations nor agreement on the principles on which theycan be constructed, authors should use the ones they arefamiliar with, taking care to define them at first mention andleaving the final form to house-style.

Qualifications. For the Contents page of the journal, infor-mation about full professorships and about main academic orother qualifications is needed.

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In The Lancet this particularly applies to Preliminary Com-munications (not more than 1500 words), Hypotheses (1500words), Methods and Devices (750 words), and Letters to theEditor (500 words), all these limits to be reduced if illustra-tions and/or tables are included.

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