A Chronicle of Crises and Emergencies: (Dis-)continuity of care for Syrian Refugee Children with Neglected Non-communicable Diseases in Lebanon

A Chronicle of Crises and Emergencies: (Dis-)continuity of care for Syrian Refugee Children with Neglected Non-communicable Diseases in Lebanon | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Chronicle of Crises and Emergencies: (Dis-)continuity of care for Syrian Refugee Children with Neglected Non-communicable Diseases in Lebanon Molly Gilmour, Ibrahim R. Bou-Orm This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5836496/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 May, 2025 Read the published version in Conflict and Health → Version 1 posted 11 You are reading this latest preprint version Abstract Lebanon’s recent history has been marked by intersecting crises, including a severe economic collapse, the Beirut port explosion, and the COVID-19 pandemic. Amidst this "polycrisis," the healthcare system has become increasingly reliant on international humanitarian assistance. This paper examines how these overlapping crises have affected the provision of care for children with thalassemia, a neglected non-communicable disease (NCD), within a Médecins Sans Frontières (MSF) paediatric unit operating in Lebanon between 2018 and 2023. Drawing on a single-case study design, the research explores the dynamics of power between state and non-state actors and within international humanitarian organizations and their approaches to healthcare delivery. The study employed a mixed-methods approach, including audio diaries, interviews, document analysis, and co-development groups involving 11 staff members and 18 caregivers of Syrian paediatric patients. Participants shared insights into operational challenges, decision-making processes, and the lived experiences of navigating Lebanon’s collapsing health system. Findings reveal three interconnected issues: (1) the polycrises created an unsustainable environment even for resource-rich international non-governmental organizations (iNGOs); (2) the withdrawal of humanitarian services exacerbated the suffering of structurally marginalized Syrian families reliant on no-cost thalassemia treatment; and (3) national staff experienced profound professional and personal challenges as they sought to reconcile iNGO decision-making with patients' needs, often leading to burnout and reduced well-being. The study underscores the need for a paradigm shift in the relationship between international humanitarian organizations and local health authorities. Greater equity in decision-making, grounded in shared values, is essential to recalibrate the humanitarian healthcare model. This reorientation should prioritize not only operational costs but also the population-level and individual value of healthcare, particularly for vulnerable groups. In Lebanon, a reimagined model of care is critical for addressing structural inequities and mitigating the fragility of humanitarian healthcare amidst enduring crises. NCDs in Emergencies Refugee Health Health Systems Resilience Thalassemia care Background Lebanon has been in a state of “permacrisis” for several decades and dealt with major emergencies and crises in the last five years. A prolonged and severe economic collapse started in late 2019 with the Lebanese Lira [national currency] losing more than 98% of its value by March 2023 (1). The 2020 Beirut Port explosion (or Beirut Blast) also happened during this challenging economic crisis as well as the COVID-19 pandemic, resulting in over 190 deaths and 6,500 injuries and the displacement of 300,000 residents (2). The World Bank estimated an economic cost of 8.1 Billion USD, further crippling a nation with a longstanding failure in governance and lack of political and economic reforms. These shocks were added to a protracted conflict in neighbouring Syria and the consequent presence of over 1.5 million refugees in Lebanon, of whom nearly 90% live in extreme deprivation. Similarly, Lebanese families are living in a never-ending cycle of financial instability and suffering due to the extremely weakened social systems and distrust in state institutions (3). Lebanon's health system is influenced by the neo-liberal political economy of the country, with market mechanisms and private sector involvement shaping health service delivery. Before 2019, approximately half of Lebanese citizens had health coverage either from social health insurance schemes such as the National Social Security Fund (NSSF) and/or private insurance, and the other half were entitled to state support through the Ministry of Public Health (MoPH) to cover hospital admissions, and relied on a network of non-governmental organizations (NGO) led primary care network if they cannot afford private ambulatory care. The system is fragmented, with the existence of many providers including public, private, and NGO providers. The majority of hospital beds are private and concentrated in the Greater Beirut area, and out-of-pocket payments (OOP) accounted before the economic collapse for about 35% of total health expenditures (4). The health system has further deteriorated due to Lebanon’s economic collapse, leading to heightened inequitable OOP payments (4), an exodus of skilled health workforce (5), and delayed healthcare services (6). This has exacerbated health accessibility issues, especially among Lebanese and Syrian communities living with non-communicable diseases (7, 8). More communities became reliant on the humanitarian system and non-state actors which struggle to addressing the increasing demands of communities, and often respond with unsustainable support mechanisms (9). Local and international non-state actors in Lebanon, including well-resourced organizations, face overwhelming challenges due to the triple crisis. For instance, the destruction of Lebanon's main port in 2020 has hindered the importation of essential medications, drastically raising costs and limiting access to treatments for chronic conditions like thalassemia (10). Fuel shortages in 2021 led to prolonged power outages in hospitals, reducing the ability to provide care, particularly for emergencies, as hospitals ration energy and other critical supplies (11). Additionally, medication scarcity and financial constraints have forced patients, including 29% of 253 individuals living with non-communicable diseases and participating in a survey conducted by Médecins Sans Frontières (MSF), to ration their medications even before the blast (12). These conditions have severely impacted vulnerable populations like Syrian refugees, who are further marginalized as NGOs limit their services due to resource depletion, leaving many without the needed support (9). These changes in the dynamics of health service delivery have worsened health outcomes, especially among vulnerable populations. For instance, the challenges to access health services due to and coupled with increased poverty and challenging socio-legal context led to worsened mental health among Syrian refugees, exacerbating their pre-existing trauma from the Syrian war (13). Children from deprived communities also suffer from long-term health risks including food insecurity, non-communicable diseases and developmental issues. Abou-Rizk, Jeremias (14) reported a prevalence of 30.5% of Syrian children under five suffering from anemia and moderate wasting. This paper will detail how Lebanon’s polycrisis created an untenable environment for the thalassemia programme of Médecins Sans Frontières (MSF) , a resource-rich an international humanitarian healthcare Non-Governmental Organization (iNGO), furthering the hardship experienced by families from Syria seeking refuge within its borders and mounting pressure for staff responding to these healthcare needs. It will reflect on the compounded challenges of temporal tensions in humanitarian healthcare (15), where the urgent, short-term demands for life-saving interventions often overshadow longer-term efforts to build sustainable healthcare systems. This dynamic is exacerbated by the urbanization of refugees (16), as displaced populations move into urban settings, straining already fragile infrastructure and complicating service delivery. The ethics of exit for international NGOs also come into focus, particularly regarding the right to healthcare and accountability (17, 18), raising critical questions about their responsibilities in providing care and ensuring that their departure does not further destabilize vulnerable communities. Through these lenses, this paper will critically examine how these intersecting challenges have created a humanitarian response that, despite significant resources, could have fallen short of meeting the long-term needs of vulnerable communities. Specifically, this paper addresses the following research question: What are the dynamics of power between state and non-state actors and within international humanitarian organizations and their approaches to care delivery within Lebanon's healthcare system, and how do these dynamics contribute to improving or deteriorating the impact of a polycrisis on providing care for neglected noncommunicable diseases? Specific objectives were: To explore the challenges posed by multiple shocks in Lebanon and their impact on a health programme run by a well-resourced iNGO and thalassemia care in general; To examine the experiences of staff navigating MSF decisions, the relationships with the state, and their career dynamics; To explore the experiences of loss felt by providers and carers in the face of multiple crises and the withdrawal of international support for the programme. Methods Study Design and Setting This study adopted a single-case study design, focusing on a Médecins Sans Frontières (MSF) paediatric thalassemia unit which operated in a public hospital in Zahle, Lebanon between 2018 and 2023. The unit provided the only no-cost thalassemia service in Lebanon, treating structurally marginalised children from Syria. The organisation managed operations, recruitment and logistics from a European capital, while daily coordination was manged locally. The organisation operates on the two-tier recruitment system of international staff and national staff. Target population and sampling process The study involved three primary groups of participants: i) national staff employed by MSF, ii) international staff, and iii) the carers of the paediatric patients. The recruitment of participants was done through purposive sampling, focusing on individuals who could provide insights into operational challenges and decision-making processes within the humanitarian healthcare setting. A total of 11 staff and 18 care givers of the paediatric patients participated in eight co-development groups, with a median of six per group. The staff involved in this research encompass both medical and nonmedical professions including physicians, nurses, psychologists, logisticians, human resources and finance. Other non-health personnel were also eligible to participate, including people who are underrepresented in spaces of aid such as cleaners and administration staff, in order to offer an opportunity for them to speak for and represent themselves politically, socially, culturally, spiritually, and intellectually (19). Inequitable dimensions of power are central to this article, as organisations reinforce inequalities through making distinctions between national staff, recruited in-country, and international staff traditionally recruited from Europe and North America. A second crucial factor in this context is that, in Lebanon, many providers acquire their training and professional experience in Europe or North America. As a result, national staff hold experience comparable to their international staff colleagues. Yet discrepancies in contracts, salary, staff benefits, training and voting privileges between national and international staff remain the norm, mirroring wider geopolitical dynamics (20). International staff had diverse nationalities including Brazil, Italy, the United States, Russia and Germany while national staff were typically from Lebanon, while some were Palestinian. Care givers of the paediatric patients were typically from Syria, in their thirties or forties with mixed literacy abilities. The children were typically under five years old. The families were from mixed socio-cultural and economic backgrounds – some families were Bedouin from rural Syria, while others were middle-class families from cities. The families typically lived in informal refugee settlements across Lebanon and were required to pay for and travel many hours to this thalassemia clinic. Data Collection Methods This article draws on four years of participatory ethnography-by proxy sociological research conducted with an independent Syrian researcher Belal Shukair (BS). This research examined MSF unit which treated children with thalassemia, a genetic noncommunicable blood disease which can be fatal in some cases if untreated. This research traced the medical project’s mobilisation in 2018 to its closure in 2023. Research methods included eight participatory ‘co-development groups’ with national and international staff (x4), and the carers of the paediatric patients (x4) who were mostly from Syria. These one-hour sequential sessions took place in parallel and participatory methods, such as voting and ranking of identified service improvements, were used in group sessions to explore what could be improved in the thalassemia service delivery. A total of four sessions took place per group, with six participants per group, allowing for carer turnover. This main researcher (MG) conducted one semi-structured interview with BS, the local researcher to explore the methodological process and one unstructured interview with senior management to trace operational decisions and their consequences. MG asked the participant an open-ended question: ‘What do you think I should know about the thalassemia service?’ This interview consolidated the internal and external communications which informed this study. Throughout the duration of this study, MSF staff prepared internal documents called ‘sitrep reports’ to detail meetings with local authorities, daily operational overviews, and related concerns, and to map ethical dilemmas. These documents served as a daily record written by busy project staff conveying information to headquarters. MG spent a total of six months in Lebanon between the Summer of 2019 and end of 2023. This presence in the field helped develop rapport with staff and the families at the thalassemia unit. In 2021, while working remotely due to COVID-19, MG held a weekly meeting with staff for a check-in, alongside multiple calls with BS to share progress updates. There were multiple information flows which kept the research team informed of the daily realities for Lebanese and Syrians living in Lebanon, all of which shaped our understanding of the research data. While in Lebanon, MG kept a research diary, borrowing the templates advised by Spradley (21). The research diary was transcribed electronically for organizing consolidated notes that capture the nuances and impressions and to support data protection (22). Belal also kept an audio diary while running the co-development groups documenting his experiences and reflections throughout the study period. These diaries provided real-time insights into the researchers’ observations, challenges faced, and the dynamics of the humanitarian response. Data were analysed using a participatory thematic analysis approach. All interviews and audio diaries were translated by a local interpreter who was trained on data protection. Once completed, the transcription files were transferred securely using the University of Glasgow's file transfer service, and then uploaded into NVivo 12. The analysis process followed three steps. The first step was familiarization: reading the transcripts carefully and repeatedly, and beginning the initial process of descriptive coding. This approach allowed the identification of preliminary responses to the research questions and provided a foundation for further thematic analysis. The second was coding and theme extraction. The process of coding was both iterative and reflexive. Throughout the analysis, there was continuous engagement with relevant theoretical frameworks and prior empirical studies to interpret emerging patterns. Dialogue with other researchers from the University of Glasgow and between the co-authors helped connect the data to broader theoretical constructs, particularly drawing on works such as St. Pierre and Jackson (23) to shift focus from what the data means to what it does or the effects it produces. Thematic coding evolved as key themes were identified, merged, renamed, and refined. This thematic organization was supplemented by the creation of mind maps and narrative mappings to visualize the connections and relationships within the data. Finally, the research team led the process of consultation with participants – as integral part of the process of analysis and interpretation. Feedback sessions were conducted with staff in Lebanon in 2022 and 2023, where the emerging themes were presented and discussed. These sessions provided valuable insights into the participants' perspectives, ensuring that the analysis was grounded in the lived experiences of those involved in the study. Through this participatory approach, the research not only captured the complexities of the humanitarian response but also facilitated the co-creation of meaning alongside participants, centring their voices in the interpretation of the findings. A final round of discussion between co-authors was held in 2024 to prepare this article. Ethical Considerations The research team approached the power asymmetrywith contextual responsiveness rather than a rigid application of rules and guidance offered by peers and in academic literature (24). In this research, we ought to provide ‘fair’ working conditions, informed by professionality, transparency and trust regarding their time spent on tasks and its respective payment (25). Warnock, Taylor (24) call for researchers to reduce suspicion around payment in social sciences research and instead draw on a framework centred around the ethics of care in paying local researchers. The positionality of the local researcher (BS), as a young Syrian male who is an experienced participatory research facilitator and aid worker in Lebanon, enriched this project. His experiences of migration from Syria to Lebanon, due to the Syrian war, resulted in him being well placed to navigate the social, cultural and ethical dynamics during data generation in the iNGO’s clinics with Syrian carers of service users. His contextual knowledge paired with the training he received for this research project. This allowed him to reflect, respond and facilitate discussion from congruence, or ‘collisions’, or perhaps possible false preferences that arise in discussions by posing vignettes and fictional narratives in a realistic and relevant way (26) (Fadiman, 1999). To abide by ethical principles during recruitment, posters were circulated with a participant information sheet and consent form via WhatsApp by MSF’s staff to prospective participants, staff and parents. Staff also informed prospective participants by word of mouth. Due to COVID-19 restrictions, there could be a maximum of six participants in the co-development groups. When participants arrived in the room, Belal gave them the participant information sheet, which they could keep if they chose to. For participants who could not read and write, information was discussed verbally and oral consent was obtained. All participants received a health pack for participation which included items like hand sanitiser, soap and facemasks. All participants were provided with tea, coffee, water and cake. The study received ethical approval by College of Social Science Ethics Committee at the University of Glasgow (reference number 4001900800) and the Ethics Committee of the Saint Joseph University of Beirut (reference number USJ-2019-270). Results This section first presents the rationale behind the implementation of the thalassemia programme by MSF in Lebanon’s complex humanitarian context, followed by the challenges posed by multiple shocks and their impact on the programme and thalassemia care in general. The section then examines the experiences of iNGO staff navigating the increasingly difficult circumstances in Lebanon including the port explosion, pandemic and economic collapse, highlighting their perspectives on the impact of operational disruptions, how resources were prioritised during the many shifts to healthcare service design over the four-year period of data generation. Additionally, the analysis addresses the profound sense of loss felt in the face of ongoing crises and the withdrawal of international support. Finding a niche within a republic of NGOs Lebanon endured an influx of aid and donor assistance in recent years. This influx has fragmented the healthcare system and prioritised different populations on the grounds of, e.g., gender, nationality, sectarianism and geography. This finding is corroborated by Facon (27), who calls Lebanon a republic of NGOs. Hamadeh, Kdouh (28) evidenced how this fragmentation has increased confusion for patients about eligibility and increased the complexity of referral processes and drug supply networks, leading to high levels of staff turnover and a geographically mismatched network of clinics and specialist services (28). Due to this, in discussions with interlocuters and in an unstructured interview with the senior staff member at the international humanitarian medical organisation, participants in this study described how the iNGO also sought to mobilise operations in Lebanon in 2017 due to increasing regional conflicts. In this interview with the senior staff member, who we call Charlotte, she explained that it is crucial for NGOs to avoid duplication of services and that international humanitarian NGOs must ‘find their niche’ to justify their intervention and daily operations. In Lebanon, there is one thalassemia centre for Lebanese citizens, called the Chronic Care Centre (29). It is run by a local NGO established in 1993, and it is where most Lebanese patients living with thalassemia are treated. This centre does not offer care to non-Lebanese citizens due to the economic collapse (30), despite that staff from the Chronic Care Centre considered before 2018 visiting the refugee camps to offer support. However, this service was subsequently left for other NGOs to provide (30). People from Syria who registered as refugees with the UNHCR received healthcare coverage from UNHCR through contractual arrangements with NGO-run primary care centres and subsidization of secondary care in Lebanese hospitals via a third party administrator. However, not everyone was registered with the UNHCR, in part because UNHCR stopped accepting registrations in 2015 due to pressures from the Lebanese authorities. For this reason, the organisation established the thalassemia service which treats all nationalities. Thalassemia care was the anchor for this iNGO operations, including running a Paediatric Intensive Care Unit (PICU), preparing to open an Emergency Room, and mobilising a vaccine campaign in response to the pandemic. Health programme and system resilience tested by multiple shocks The set of analysis in this subsection examines the impact of conflicting approaches from state and non-state actors on care delivery in Lebanon during the multiple crises. Staff attributed this fractured working model to the fragmentation of the health system and its impact on how to prepare and respond to the multiple shocks. Several NGO staff emphasized their efforts to collaborate with the state to improve sustainability and continuity of care, yet many components of the health system operated in silos preventing a coordinated and timely response from non-state actors. For instance, the medical procurement systems – described as rigid, complicated, and expensive – faced additional strains after the Beirut blast. The port and many surrounding areas including a main MoPH warehouse were destroyed, and the iNGO had to rely on private planes for medication imports. This affected access to essential medicines and drastically increased operational costs, leading to a significant impact on children with thalassemia and other patients. Moreover, participants in this research explained that sustainability of the thalassemia service was not adequality planned as the high treatment costs were an inherent barrier to finding project partners, either another NGO or the MPH, due to the high expertise associated costs required for the treatment. One participant highlighted the fragmentation of the healthcare system in Lebanon as a key factor exacerbating referral issues following the economic crisis. They explained that, after the crisis, public hospitals stopped receiving referrals from the medical iNGO due to the rising cost of patient care. This fragmentation led to a situation where public hospitals would only accept a referral if the NGO supplied the necessary medications for treatment, such as magnesium for post-partum conditions. This shift underscored how the disjointed system, further strained by the economic shock, hindered access to essential care and disrupted the referral process. Participants reflected on how the mismanagement of multiple shocks and the volatile socio-political environment added complexities to the ability of non-state actors to secure resources or other inputs related to their health programmes. After the economic crisis, the iNGO staff reported that the public health infrastructure became a significant obstacle, with public hospitals charging them rent to operate within their facilities. International staff participants explained that in Lebanon the hospitals were described as being ‘ run like a business’ (Research Diary, May 2022). A senior staff member reported that ‘treating thalassemia is expensive, requiring significant resources like a blood bank and generator power, with monthly treatment costs reaching up to £450’ (10). Additionally, staff were critical of the state-imposed taxes on medications and the inefficiencies of the medical procurement systems, which further hindered their ability to provide care effectively. In an interview, senior management explained that working in Lebanon is unlike working in Sub-Sharan Africa such as Chad or South Sudan, where often costs are lower as they are not charged tax, and salaries and expertise are lower. Similar scenario was reported with the COVID-19 emergency. Although there has been an acknowledgement of positive approaches to dealing with the pandemic, some staff, particularly those with international experience, reported a lack of public awareness campaigns and Lebanon’s inability to prepare adequately for emergencies. One national staff member, whom we call Muhammad, was working in Canada at the beginning of the COVID-19 pandemic. This international work experience for him was significant in how he made sense of Lebanon’s response. For him, there were stark differences in what he termed Lebanon’s ‘ level of culture and awareness in society ’; he explained ‘with all the education and health promotion in Canada, things got better, but here in the Middle East nothing changed’ (Muhammad, Staff, Co-development Group Two). He concluded that there was a failure in the Lebanese response leading to high levels of transmission. These transmission rates directly affected the ability of the iNGO to collect blood as part of the thalassemia care management. Blood donation efforts for thalassemia patients were hindered by COVID-19 restrictions and public distrust given the fear of contagion, especially in informal settlements. Similarly, efforts to secure blood donations became very difficult after the Beirut Blast due to the public's focus on helping the blast victims. The economic crisis also impacted severely both health system and programme financing, leading to a notable financial pressure on providers and communities seeking thalassemia care. Affected by the devaluation of the Lebanese currency and the quasi-collapse of all public health financing schemes, many Lebanese patients have turned to NGOs like the iNGO of this case study instead of private hospitals, which have become increasingly unaffordable. Unlike Syrian refugees, Lebanese patients do not qualify for UNHCR financial coverage, placing the entire financial burden of their treatment on NGOs. Staff members emphasized their commitment to providing equal care to Lebanese patients, adhering to the humanitarian principle of impartiality. However, staff noted a perceived lack of “humanitarian culture” within Lebanese communities – characterized by insufficient community support, volunteering, and resource sharing. This absence fuelled tensions between Lebanese and Syrian communities, particularly as Lebanese individuals face medication shortages while witnessing aid being distributed to Syrian refugees. Such disparities have sparked hostility, culminating in incidents like the burning of an informal settlement. Despite these challenges, staff recognize the inherent need for individuals to prioritize their families' well-being over their local community, which complicates the dynamics of community support in the economic crisis. In response to these increasing financial challenges, the iNGO decided to withdraw services when they perceived that the increased costs of treating a low number of children were to become unsustainable. This increased cost was caused by i) the destruction of Lebanon’s only port leading to the organisation commissioning private planes to import medication and ii) the economic collapse which led to public hospitals accepting patient referrals only if the treatment was paid for at a rate of 25% of cost for Syrian patients, due to UNHCR subsidy, and 100% for Lebanese patients (9). As cited on their website, the iNGO’s position to close the project aligned with the rationale that ‘ humanitarian actors cannot replace the healthcare system of an entire country ’ (31), and the Lebanese state was criticized for not taking enough responsibility to contribute to elements of thalassemia care, such as providing essential medicines. ‘Sadly, we do not always find ourselves able to support. The quantities in our clinics and stocks are limited and even if we manage to get an extra order it takes time, because of the importation delays. Due to the complicated and often chaotic public system, shipments of drugs are often taking eight months to reach us, which is simply too long in the context of a health care emergency […] We remain committed to delivering impartial medical care to the most vulnerable people to the best of our ability, but necessary action needs to be taken by the Lebanese authorities to ensure that essential medical services are provided to the people. They need to act so that medication, supplies and fuel are accessible in the country. Humanitarian actors cannot replace the health system of a whole country’ (31) Charlotte, a senior staff member, emphasized the utilitarian rationale behind this decision, comparing the high-cost thalassemia care in Lebanon with the low-cost treatment for malnutrition in Afghanistan. Ultimately, the organization reallocated resources to those countries. Participants in this research reported a variety of reactions and opinions when asked about project closure. Staff members, especially national staff, approached this from a need for health justice. They emphasized the importance of prioritizing vulnerable patients and ensuring equitable access to care, particularly in the face of limited resources. There was a consensus on the need to prioritise this health justice approach, which contrasts with the current focus on optimizing resource allocation within the humanitarian sector. Others blamed their organization for hesitating to promote their health services within both Lebanese and Syrian communities due to management’s fear of overwhelming limited resources. This reluctance led to unmet patient number targets, resulting in an inefficient program that eventually faced closure. ‘There was something strange. When we came our hospitals [were] empty, we used to say we need to do better communication, [but] they [management] didn't want to, they are afraid to spread the news like UNHCR, they didn't want to spread the knowledge and say there's a project here for the Lebanese as well, professionalism was lacking, they were afraid more people would come.’ (Leila, Staff, Co-development Group Three) Similar to international staff, Leila acknowledged that in Lebanon, futures are uncertain. However, this should not result in project closure when patient numbers are not realised. Patients need care, and those who are more structurally vulnerable need reasonable adjustments to attend the clinic. Prioritisation and triaging to focus on people with urgent needs and increased vulnerability is necessary when there is a high demand that exceeds the resources available. From the national staff’s perspective, rather than proceeding with a health justice approach to service provision and actively targeting vulnerable groups, the iNGO relied on their service information being shared amongst patient social networks only. In 2020, the iNGO cited in external reports that the demand for their services had reached an all-time high due to increasing poverty. People who had previously relied on Lebanon's private healthcare system could no longer afford it and turned to no-cost services run by iNGOs as a result. Yet the total patient numbers forecasted were never realised. International staff were taken aback by a second unforeseen effect of the economic collapse — the realization that Lebanese patients had a lack of acceptance towards their services. Charlotte, a senior manager, admitted staff often asked, ‘Where is everyone?’ , referring to the absence of Lebanese patients presenting at the newly opened emergency room. When speculating on why this might be in an interview, Charlotte summarised that ‘working in Lebanon, like many middle-income countries, is very difficult. It's difficult because there's a lot of actors, it's difficult for access, it's difficult for recognition and trust’ (Research Diary, May 2022). She suspected that this lack of acceptance was because Lebanese patients perceived the humanitarian medical service as cheap. As many Lebanese citizens had previously had private healthcare, this shaped their perception of the services; they would have to seek healthcare where Syrian refugees were treated. For instance, to keep costs low, aid organisations use generic drugs, such as a generic iron chelation oral medication. Charlotte detailed how Lebanese patients sought brands of drug they were familiar with and trusted. She suggested that the use of generic drugs was not acceptable to Lebanese patients and that there is a stigma associated with consuming what are seen as cheap products. This stigma limited the uptake of MSF services among the Lebanese community, despite the increased need as a consequence of economic collapse. As a result, the high costs solely came from the thalassemia unit, which treated low patient numbers, compared to an emergency room with a higher patient turnover. This unmet forecasted patient-to cost-ratio shaped headquarters’ decision to close the healthcare services. Humanitarianism in complex settings: staff experiences in Lebanon In this part of the analysis, we reflect on the dynamics of decision making and staff experiences within the humanitarian sector in volatile and fragile settings, especially in relation to short-term programmes that may not have been planned or implemented according to health needs. Participants had increasing concerns about the “pop-up humanitarianism” reflecting the temporary nature of aid responses in complex crises and the uncertainty and insecurity from the lack of long-term solutions (32). This dilemma, between the aim to provide temporary relief and dignity in adherence to the organization values, versus carefully considering the financial viability amid a lack of political and financial reforms in Lebanon created a psychological toll for the participants of this research. The research team noted increasing concerns regarding the purpose, accountability, and legitimacy of aid organizations which had an evolving nature similar to that of the UN system; citing that the iNGO was ‘ turning into the UN ’ that it’s ‘ getting too big and it's kind of past its critical phase now ’ (Research Diary, May 2022). The majority of staff shared the concern that the perspective that their voice would not be heard or considered amid institutional changes and decisions are made at a higher level. The experiences of both international and national staff in this research also highlight the precarious nature of humanitarian work, with various challenges including the demanding job nature, emotional isolation and barriers to immersion in the local culture and context. International staff often face short-term employment contracts (ranging from six to twelve months), complicating their ability to establish a sense of home or stability. The low pay (starting at £800 per month) further exacerbates their inability to maintain a permanent residence, trapping them in a cycle of redeployment and financial insecurity. The living conditions within “compound” settings of humanitarian housing – when working in remote areas – hinder the formation of meaningful relationships, leading to a sense of isolation among international aid workers. Staff like Charlotte share experiences of feeling trapped in perpetual migration for income and career advancement, alongside a yearning for belonging and purpose. This precarious lifestyle results in a lack of material welfare and emotional support networks, as colleagues come and go. Mobility, the practice of working across borders, is at the heart of much international humanitarian practice. Frequent relocation leads to a loss of contextual project knowledge, contributing to the “short-term memory” of the humanitarian sector. This phenomenon creates a divide between international staff and local populations, hindering genuine solidarity and understanding. The separation caused by language and cultural differences especially in distal areas – where most humanitarian projects operate – perpetuates harmful perceptions of “otherness,” fostering an Orientalist gaze that reinforces neo-colonial attitudes, and normalizes the superiority of Western knowledge over localized ways of understanding (33). Nevertheless, the dedication to humanitarian principles and work, despite coming at the cost of a sense of belonging, shapes the humanitarian identity. Separation from family, migrating in search of a better life, seeking a home and feeling uncertain of the future evokes feelings of uncertainty and vulnerability for international aid workers. This sense of precariousness in their unknown journeys and associated risks are similar for Syrian families, although their experiences and sense of freedom are different. Finding mutual vulnerabilities, as illustrated between staff and service users, can act as a basis for solidarity and support in moving towards health justice and more equitable forms of coexistence (34). Our data identified palpable tensions among national staff within a constant atmosphere of stress and anxiety affecting trust and morale among all staff. Moreover, national staff reported an inherent job insecurity due to the temporary nature of humanitarian projects in a failing state like Lebanon. Yasmin, a Lebanese staff member shared the affect of the project’s closure for her and the patients she works with: “This is really sad, because everywhere they know that here there is paediatric service and now we are just telling them 'we are closed'. We don't even know where to go. And in this last phase we were closing we were not even standing with the message we will support other hospitals to pay”. This precariousness negatively impacts their physical and mental health, as well as their attitudes toward their organization. This also creates vulnerability among national staff, who rely on their employers for stability in a context marked by economic decline and social unrest. This insecurity fosters feelings of anger and alienation, as highlighted by academic perspectives on the social consequences of precarity by scholars such as (Guy Standing), and diminishes their power within the organization. Finally, international staff participants explained that some Lebanese patients also had reservations about trusting this iNGO. International staff proposed that perhaps it was the stigma associated with using their services due to societal preference for private healthcare and branded medications over the generic ones provided by iNGOs, which caused complications for their operations. Moreover, due to Lebanese state constructed illegality, many Syrian families were confined to remote informal settlements, which created security and economic barriers to access. Furthermore, the absence of service advertisement many Syrian families did not know of the existence, or the eligibility, of this service. This lack of trust in the iNGO’s services reflected broader challenges of providing humanitarian aid in middle-income countries, where access and recognition for international NGOs can be fraught with difficulties. These findings highlight the importance of research using qualitative approaches. Such studies capture an understanding of challenges like trust and stigma when accessing healthcare services. Understanding and resolving these challenges can facilitate clinic access and develop trust with patients who suffer from thalassemia, providing better patient-centred care (Nouvet et al., 2016). Experiences of loss in the face of multiple crises and the iNGO withdrawal All participants in this study made sense of the multiple transitions the thalassemia unit underwent by conveying a sense of loss, revealing both shared and divergent perspectives on how the multiple crises impacted their lives in Lebanon. This included fears about the potential loss of employment, materials, relationships, and patient health due to service closures. International staff expressed feelings of loss related to various transitions within the thalassemia unit, including fluctuations in the forecasted project funding, resource reductions from headquarters, and service closures. International management staff stated in an external publication report that ‘ We wished we could do more to respond to the needs but we are limited by the very high price of the thalassemia drugs’ (Médecins Sans Frontières, 2020a). Both international staff and patients experienced spatial loss due to the closure of the programme's location within the public hospital. To avoid loss of investment, the medical equipment purchased for the thalassemia unit was handed over to the Ministry of Public Health (MoH). However, Charlotte expressed scepticism about the MoH’s capacity to maintain this treatment due to funding and expertise shortages. These challenges highlight the conceptual failures in forecasting a future in humanitarian aid. This notion of a "loss of patients" was significant across participant groups, relating to onward and return migration, preventable deaths due to lack of treatment, and the emotional impact on national staff who viewed the loss through the lens of stress and emotional burden associated with their roles. These ‘lost patients’, the failed forecasting of patient numbers, contributed to the thalassemia unit’s closure. While international staff mainly faced temporary contract issues and the prospect of moving on, national staff endured long-lasting mental health impacts from their work experiences. For instance, Leila who worked as a staff nurse explained the affect of the loss of a patient’s life and how the support her colleagues offered to parents when grieving for their lost child took its toll on staff, ‘even for us, in this hospital, we have no mental health support and we have a PICU [Paediatric Intensive Care Unit] for example ,’ said Leila; she explained that as national staff they had to cope with ‘ what is happening’ : situations that were not ‘their fault’ , caused by the structural violence that the patients at their clinic lived in. National staff expressed concerns that patients, particularly those requiring ongoing treatment for thalassemia, would face critical challenges, as the loss of services was a matter of life and death. To mitigate possible unemployment after project closure, the iNGO offered training and staff support, which most national staff showed little interest in dedicating extra time to an organisation where they saw no future. This decision to close services for which a great need remains led to national staff losing trust in their employer. Patients and carers at the lower end of the welfare continuum, including many of the families from Syria and Lebanon in this research were disproportionately affected by the eroded health system, which drove them to rely on humanitarian support. Service users expressed three forms of loss during data generation: biographical loss (e.g. what it means to be a child from Syria), the loss of a home, and the loss of family. While these intersect in many ways, the distinct ways in which they shaped how service users made sense of their health and healthcare journeys to the thalassemia unit provide an understanding of migration and the broader social determinants for humanitarian healthcare. Many participants shared how they had lost their dignity and identity since arriving in Lebanon. Maryam, a mother whose child was treated for thalassemia explained ‘At the clinic, it's the same, the Lebanese entered without having to stand in the queue. They were expelling us as if we were animals and we were not human in front of them. We notice prejudice and indifference to the Syrian people’. Many participants in this study detailed the ways in which they felt disregarded or mocked by healthcare professionals when they presented with an illness. Another illustration was that one participant's child was turned away from a healthcare service, and subsequently died. The consequences of these experiences for many participants were an overall loss of trust in public health institutions. Participants shared stories of their children being bullied in the camp for having thalassemia. Zahra detailed that ‘ Whenever my son goes out to play with the kids at the camp, the kids bully him, saying, “He's sick, let's not play with him”. They don't know what the illness is, they think it's contagious’ . Parents narrated the ways their children were losing out on their childhood due to their illnesses, for instance Jamal shared the difficulties he experiences with his daughter: ‘She always asks me, “Dad, why is it just me?” She cries every time I take her to the hospital and says, “Don't take me; take my other sibling instead’. For children who have already endured the hardships associated with fleeing war and the violence of growing up in a state where they are illegalised, the consistency of care from thalassemia staff they trust and family support is essential in mitigating further harm. Parents detailed the implications of losing a house that provided them with safety from snow, rain, the cold and heat. Their homes in Syria were away from pollution, a quiet space with privacy. Zahra summarised that ‘if the society you're living in is good, then you are good, if it's not, then you're not’. A home evokes a sense of connection, both a material and socialised space, a sense of belonging that is integral to a person’s wellbeing (35). Participants identified that living in informal settlements or overcrowded, and squalid housing often created sickness and hindered their recovery process. Hense, migration itself was a determinant of health. Participants highlighted the loss of family support and the impact it had on their health; Umm Mohammad explained that she felt that she could cope due to the support of her family, whereas Jamal was ‘totally alone’ as a single parent caring for his children. Families share the burden of one member’s ill health. Yasmin, a mother summarised that ‘For me, the most important thing is my children's wellbeing, that they get cured of the disease that affected the life of the whole family’ . Many parents had originally planned for more children, but due to the hardships they experienced caused by their child’s thalassemia, they decided not to have any more children. Jamal explained, ‘ If having children is related to finding a blood donor and going through all of this, then I prefer not having children anymore’ . Many parents suffered from the deaths of their children caused by thalassemia, including Amira, who lost her elder daughter to thalassemia. The suffering and loss experienced by service users were narrated in the past, present, and future illustrating the necessity for long term care for people subject to the global asylum system. These resultant losses, for both present and future patient care, reflect broader issues within the humanitarian aid framework, evidence the need for a more sustainable and trustworthy approach to healthcare for chronic illness patients. Layla, a Lebanese nurse remarked on the project closure by summarising that that: When the NGOs came to Lebanon, things weren't that bad but after they leave Lebanon, the situation is going to be worse than ever”. Discussion This paper explores the dynamics between the MoPH and humanitarian healthcare organisations, highlighting the implications for both healthcare providers and the patients they serve. There are three primary, interconnected findings of this research for the MoPH and state relations, for staff and for the patients they serve. First, the polycrises in Lebanon led to an untenable operational environment for one of the most resource-rich iNGOs; secondly, their withdrawal of services compounded the hardship families from Syria experienced, and thirdly, staff felt "stuck" in their efforts to navigate both iNGO decisions and the mounting challenges faced by patients leading to decreasing well-being of national staff. Lebanon's healthcare system is fragmented and under significant strain, operating through a mix of public, private, and NGO-provided services. This structure results in a segmented system, where access to care is often determined by factors such as nationality, residency status, and religion, creating disparities in treatment across different population groups. This fractured health system was caused by the conflict-affected state enduring compounded shocks on decades of state neglect, insofar as in 2021 MSF described it as a context comparable to a conflict setting (Doctors Without Borders, 2021). As a result, Lebanon’s health system became reliant on international humanitarian healthcare, a sector which prioritises primary care in favour of secondary or tertiary healthcare due to the comparatively higher costs and necessary continuity care. Moreover, to prevent duplication of efforts in a saturated NGO environment, iNGOs had to ‘find their niche’ to justify intervention and continued presence. For this reason, MSF mobilised a thalassemia treatment clinic, a neglected NCD which families from Syria were in desperate need of. The economic collapse, COVID-19 pandemic and port explosion intensified the expensive and intricate operational costs imposed by the Lebanese state and caused frustration between medical NGO and the MoPH. This expensive operational environment, coupled with the absence of any foreseeable changes, ultimately shaped MSF's decision to withdraw. They defended this decision by stating that ‘Humanitarian actors cannot replace the health system of a whole country’ (Doctors Without Borders, 2021). At the inception of the humanitarian sector, prominent aid actors asserted they were not meant to provide a structural solution but instead they adopted a temporary approach. This temporary approach is what Pallister-Wilkins (32) calls ‘ pop up humanitarianism’ , aid in response to informal settlements, state withdrawal of access, or service closure. The emergency modus operandi which governs the operation of medical NGOs, decontextualises future health care needs in favour of being stuck in the present (15). Taken together, this creates uncertainty and insecurity, as all actors are prevented from planning for the future and pursuing long-term goals. This has subsequently shaped employees' understanding of their purpose (Brun, 2016). For humanitarian staff who speak out against this approach, Charlotte admitted that MSF is ‘ turning into the UN’ . She explained that she felt the established humanitarian healthcare organisations are resistant to change, and staff feel that alternative voices are not considered and therefore the sector is ‘past its critical phase’. The escalating cost of essential goods and the withdrawal of services by international NGOs were key themes in discussions throughout this research. This study supports evidence from research conducted by Fakih (36) which found that in order to continue to feed themselves, households were giving up on the quality of what they eat, on education or health care, and are even skipping some meals, as approximately 85% could no longer afford to buy basic foodstuffs (36). Through the theme of loss, this article narrates how the scarcity of resources fuelled tensions between Lebanese and Syrians and resulted in conflict, negative stereotyping, and a decline in the quality of healthcare. Carer participants detailed how limited food and medication supplies were prioritized for Lebanese individuals, creating fear, a distrust of medical services, and societal tensions, which negatively impact well-being. This finding is consistent with that of Spiritus-Beerden, Verelst (37) who found that emergencies and their aftermaths give rise to discrimination towards refugees due to increased fear, resulting in stigmatisation. The families who participated in this study relied on their informal networks to secure resources and for support, exacerbating their distress and leading to a higher risk of negative health outcomes. For the paediatric patients, the impact of poverty, lack of education, malnutrition, and untreated medical conditions are likely to impact their families for generations to come. Evidence from the Dutch Hunger Winter (1944–45) and the Chinese Famine (1959–1961), shows the association between early life malnutrition and adult body size, schizophrenia and type 2 diabetes (38–40). There is an increasing likelihood of an intergenerational transmission of illness and chronic poverty for the families who participated in this research, rather than the transmission of positive assets and capital such as land, livestock, status, education, and kin group (41). During data generation, it became clear that staff who worked closely with these families on a daily basis had a deep understanding of how the project’s closure would impact their child’s health and the precarious tactics they would resort to in order to secure thalassemia care. Lebanon’s polycrises had profound impacts on daily operations and patient care, with detrimental consequences for the wellbeing of staff working at the thalassemia unit. An importatn finding in the data from this study was the "invisible labor" of decision translation that national staff were compelled to undertake while working for MSF. They were responsible for translating the difficult operational decisions made by the organisation in response to Lebanon's polycrises, helping to explain these challenges to the patients and their families under their care. For instance, they would the challenges in obtaining blood or medications to paediatric patients after the port explosion, alongside policy changes in response to the Covid-19 pandemic. Moreover, they translated the increasing hardship families were experiencing back to senior management (42). (43) terms this role as ‘switchers’ and details the complex subtle systems of power that these switchers hold in shaping the power making systems. This echoes the findings of James (44), who documented the significance national staff have in the success of humanitarian action due to their central role of what she calls the politics of humanitarian fixing and brokerage. In this research, there are clear parallels between the consequences of the ‘burn out jobs’ and increasingly neo-liberal model of many global healthcare systems (45). At times, national staff are subject to similar conditions as patients, and as this research has demonstrated, national staff conduct exhausting translation work between patients, their parents, and senior management. To make the necessary improvements in the working culture of international humanitarian aid, there must be greater communication from headquarters to project staff regarding service design to increase trust, accountability, and morale in humanitarian healthcare provision. Taken together, the loss articulated by staff and patients in this study align is consistent with the literature, as it evidences the limits of humanitarian health responsibilities, emphasizing the need to allocate necessary care and promote health justice across intersecting social issues (46). Aid provides respite and a sense of dignity for those living with uncertainty, as is illustrated in the experiences of families in this research. However, there comes a point when aid institutions deem it no longer proportionate to allocate funds for a medical project (20). The organisation’s decision to withdraw was based on a careful deliberation between the project’s financial cost, and the cost to the institution’s values, and perhaps the aid sector as whole. In adherence to humanitarian principles, MSF could not justify continuing to fund operations if the state was not reforming, and the organisation identified a more pressing humanitarian crisis elsewhere, ‘where they are needed most’. Conclusion The intersecting political and economic crises in Lebanon shaped public health in a myriad number of ways, including increased food insecurity, reduced availability of medicines and services, and further fragmentation and verticalization of the health system. Humanitarian medical organisations mobilised to support Lebanon’s health system on a temporary basis, with the expectation of health system reform and wider reforms in the meantime. The state failed to meet this criterion and some organisations had to close operations amidst mounting crises. This paper concludes that there is a necessity for paradigm shift in working relations between international humanitarian medical organisations and local health authorities, to recalibrate the inherent power inequity within the humanitarian medical system and to reorient the values underpinning the model of care of those organizations. Value systems should be determined by the cost of the operations but also the relative value of the healthcare both at a population health level and for what it means - the value - for the individuals and their families (46). Declarations Ethics approval and consent to participate: The study protocol and questionnaire were reviewed and approved by the ethics committees of the University of Glasgow (reference number 4001900800) and the Saint Joseph University of Beirut (reference number USJ-2019-270). All study participants provided an informed consent to participate in this research. Consent for publication: Not applicable Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: This study was funded by the University of Glasgow’s Lord Kelvin Adam Smith Interdisciplinary Doctoral Scholarship. We also acknowledge the contribution of ReBUILD for Resilience (R4R) for supporting the publication cost. Authors' contributions: M.G. conceived the study and developed the study protocol and the tools. M.G. coordinated the data collection and analysed the data with support from I.R.B. All co-authors (M.G. and I.R.B.) contributed to the interpretation of data, prepared the manuscript after critical revisions of previous versions, and approved its final version. Acknowledgements: We would like to acknowledge Belal Shukair for his role in data generation and analysis in the Doctoral Research Project ‘How can humanitarian medical care be strengthened in Lebanon?’, which forms the basis for this paper. We would also like to thank Médecins Sans Frontières and the research participants for their commitment and willingness to participate in this project. Thank you to Professor Chris Bunn, Professor Mia Perry and Professor Kate O’Donnell for their invaluable guidance during the PhD research which forms this article. References Khalife D, Elia R, Yammine C. What are the Financial Causes of the Lebanese Economic Crisis and How Can it be Resolved or Avoided in the Future? Journal of Law and Sustainable Development. 2023;11(6):e1221-e. Abouzeid M, Habib RR, Jabbour S, Mokdad AH, Nuwayhid I. Lebanon's humanitarian crisis escalates after the Beirut blast. The Lancet (British edition). 2020;396(10260):1380-2. Bosqui T. 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Conflict and Health. 2011;5:1-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 May, 2025 Read the published version in Conflict and Health → Version 1 posted Editorial decision: Revision requested 26 Mar, 2025 Reviews received at journal 13 Mar, 2025 Reviewers agreed at journal 28 Feb, 2025 Reviewers agreed at journal 28 Feb, 2025 Reviews received at journal 18 Feb, 2025 Reviewers agreed at journal 22 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviewers invited by journal 21 Jan, 2025 Editor assigned by journal 16 Jan, 2025 Submission checks completed at journal 16 Jan, 2025 First submitted to journal 15 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5836496","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":402980171,"identity":"3150f5a6-8913-4f9e-a02e-a81f7c2b8561","order_by":0,"name":"Molly Gilmour","email":"","orcid":"","institution":"University of Glasgow","correspondingAuthor":false,"prefix":"","firstName":"Molly","middleName":"","lastName":"Gilmour","suffix":""},{"id":402980172,"identity":"85e28c52-5d7d-4fe3-9f8f-9f30efdc9438","order_by":1,"name":"Ibrahim R. 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A prolonged and severe economic collapse started in late 2019 with the Lebanese \u003cem\u003eLira\u003c/em\u003e [national currency] losing more than 98% of its value by March 2023 (1). The 2020 Beirut Port explosion (or Beirut Blast) also happened during this challenging economic crisis as well as the COVID-19 pandemic, resulting in over 190 deaths and 6,500 injuries and the displacement of 300,000 residents (2). The World Bank estimated an economic cost of 8.1\u0026nbsp;Billion USD, further crippling a nation with a longstanding failure in governance and lack of political and economic reforms. These shocks were added to a protracted conflict in neighbouring Syria and the consequent presence of over 1.5\u0026nbsp;million refugees in Lebanon, of whom nearly 90% live in extreme deprivation. Similarly, Lebanese families are living in a never-ending cycle of financial instability and suffering due to the extremely weakened social systems and distrust in state institutions (3).\u003c/p\u003e \u003cp\u003eLebanon's health system is influenced by the neo-liberal political economy of the country, with market mechanisms and private sector involvement shaping health service delivery. Before 2019, approximately half of Lebanese citizens had health coverage either from social health insurance schemes such as the National Social Security Fund (NSSF) and/or private insurance, and the other half were entitled to state support through the Ministry of Public Health (MoPH) to cover hospital admissions, and relied on a network of non-governmental organizations (NGO) led primary care network if they cannot afford private ambulatory care. The system is fragmented, with the existence of many providers including public, private, and NGO providers. The majority of hospital beds are private and concentrated in the Greater Beirut area, and out-of-pocket payments (OOP) accounted before the economic collapse for about 35% of total health expenditures (4). The health system has further deteriorated due to Lebanon’s economic collapse, leading to heightened inequitable OOP payments (4), an exodus of skilled health workforce (5), and delayed healthcare services (6). This has exacerbated health accessibility issues, especially among Lebanese and Syrian communities living with non-communicable diseases (7, 8). More communities became reliant on the humanitarian system and non-state actors which struggle to addressing the increasing demands of communities, and often respond with unsustainable support mechanisms (9).\u003c/p\u003e \u003cp\u003eLocal and international non-state actors in Lebanon, including well-resourced organizations, face overwhelming challenges due to the triple crisis. For instance, the destruction of Lebanon's main port in 2020 has hindered the importation of essential medications, drastically raising costs and limiting access to treatments for chronic conditions like thalassemia (10). Fuel shortages in 2021 led to prolonged power outages in hospitals, reducing the ability to provide care, particularly for emergencies, as hospitals ration energy and other critical supplies (11). Additionally, medication scarcity and financial constraints have forced patients, including 29% of 253 individuals living with non-communicable diseases and participating in a survey conducted by Médecins Sans Frontières (MSF), to ration their medications even before the blast (12). These conditions have severely impacted vulnerable populations like Syrian refugees, who are further marginalized as NGOs limit their services due to resource depletion, leaving many without the needed support (9).\u003c/p\u003e \u003cp\u003eThese changes in the dynamics of health service delivery have worsened health outcomes, especially among vulnerable populations. For instance, the challenges to access health services due to and coupled with increased poverty and challenging socio-legal context led to worsened mental health among Syrian refugees, exacerbating their pre-existing trauma from the Syrian war (13). Children from deprived communities also suffer from long-term health risks including food insecurity, non-communicable diseases and developmental issues. Abou-Rizk, Jeremias (14) reported a prevalence of 30.5% of Syrian children under five suffering from anemia and moderate wasting.\u003c/p\u003e \u003cp\u003eThis paper will detail how Lebanon’s polycrisis created an untenable environment for the thalassemia programme of \u003cem\u003eMédecins Sans Frontières (MSF)\u003c/em\u003e, a resource-rich an international humanitarian healthcare Non-Governmental Organization (iNGO), furthering the hardship experienced by families from Syria seeking refuge within its borders and mounting pressure for staff responding to these healthcare needs. It will reflect on the compounded challenges of temporal tensions in humanitarian healthcare (15), where the urgent, short-term demands for life-saving interventions often overshadow longer-term efforts to build sustainable healthcare systems. This dynamic is exacerbated by the urbanization of refugees (16), as displaced populations move into urban settings, straining already fragile infrastructure and complicating service delivery. The ethics of exit for international NGOs also come into focus, particularly regarding the right to healthcare and accountability (17, 18), raising critical questions about their responsibilities in providing care and ensuring that their departure does not further destabilize vulnerable communities. Through these lenses, this paper will critically examine how these intersecting challenges have created a humanitarian response that, despite significant resources, could have fallen short of meeting the long-term needs of vulnerable communities.\u003c/p\u003e \u003cp\u003eSpecifically, this paper addresses the following research question: What are the dynamics of power between state and non-state actors and within international humanitarian organizations and their approaches to care delivery within Lebanon's healthcare system, and how do these dynamics contribute to improving or deteriorating the impact of a polycrisis on providing care for neglected noncommunicable diseases?\u003c/p\u003e \u003cp\u003eSpecific objectives were:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo explore the challenges posed by multiple shocks in Lebanon and their impact on a health programme run by a well-resourced iNGO and thalassemia care in general;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo examine the experiences of staff navigating MSF decisions, the relationships with the state, and their career dynamics;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo explore the experiences of loss felt by providers and carers in the face of multiple crises and the withdrawal of international support for the programme.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy Design and Setting\u003c/p\u003e\u003cp\u003eThis study adopted a single-case study design, focusing on a \u003cem\u003eMédecins Sans Frontières (MSF)\u003c/em\u003e paediatric thalassemia unit which operated in a public hospital in Zahle, Lebanon between 2018 and 2023. The unit provided the only no-cost thalassemia service in Lebanon, treating structurally marginalised children from Syria. The organisation managed operations, recruitment and logistics from a European capital, while daily coordination was manged locally. The organisation operates on the two-tier recruitment system of international staff and national staff.\u003c/p\u003e\u003cp\u003eTarget population and sampling process\u003c/p\u003e\u003cp\u003eThe study involved three primary groups of participants: i) national staff employed by MSF, ii) international staff, and iii) the carers of the paediatric patients. The recruitment of participants was done through purposive sampling, focusing on individuals who could provide insights into operational challenges and decision-making processes within the humanitarian healthcare setting.\u003c/p\u003e\u003cp\u003eA total of 11 staff and 18 care givers of the paediatric patients participated in eight co-development groups, with a median of six per group. The staff involved in this research encompass both medical and nonmedical professions including physicians, nurses, psychologists, logisticians, human resources and finance. Other non-health personnel were also eligible to participate, including people who are underrepresented in spaces of aid such as cleaners and administration staff, in order to offer an opportunity for them to speak for and represent themselves politically, socially, culturally, spiritually, and intellectually (19).\u003c/p\u003e\u003cp\u003eInequitable dimensions of power are central to this article, as organisations reinforce inequalities through making distinctions between national staff, recruited in-country, and international staff traditionally recruited from Europe and North America. A second crucial factor in this context is that, in Lebanon, many providers acquire their training and professional experience in Europe or North America. As a result, national staff hold experience comparable to their international staff colleagues. Yet discrepancies in contracts, salary, staff benefits, training and voting privileges between national and international staff remain the norm, mirroring wider geopolitical dynamics (20).\u003c/p\u003e\u003cp\u003eInternational staff had diverse nationalities including Brazil, Italy, the United States, Russia and Germany while national staff were typically from Lebanon, while some were Palestinian. Care givers of the paediatric patients were typically from Syria, in their thirties or forties with mixed literacy abilities. The children were typically under five years old. The families were from mixed socio-cultural and economic backgrounds – some families were Bedouin from rural Syria, while others were middle-class families from cities. The families typically lived in informal refugee settlements across Lebanon and were required to pay for and travel many hours to this thalassemia clinic.\u003c/p\u003e\u003cp\u003eData Collection Methods\u003c/p\u003e\u003cp\u003eThis article draws on four years of participatory ethnography-by proxy sociological research conducted with an independent Syrian researcher Belal Shukair (BS). This research examined MSF unit which treated children with thalassemia, a genetic noncommunicable blood disease which can be fatal in some cases if untreated. This research traced the medical project’s mobilisation in 2018 to its closure in 2023. Research methods included eight participatory ‘co-development groups’ with national and international staff (x4), and the carers of the paediatric patients (x4) who were mostly from Syria. These one-hour sequential sessions took place in parallel and participatory methods, such as voting and ranking of identified service improvements, were used in group sessions to explore what could be improved in the thalassemia service delivery. A total of four sessions took place per group, with six participants per group, allowing for carer turnover.\u003c/p\u003e\u003cp\u003eThis main researcher (MG) conducted one semi-structured interview with BS, the local researcher to explore the methodological process and one unstructured interview with senior management to trace operational decisions and their consequences. MG asked the participant an open-ended question: ‘What do you think I should know about the thalassemia service?’ This interview consolidated the internal and external communications which informed this study.\u003c/p\u003e\u003cp\u003eThroughout the duration of this study, MSF staff prepared internal documents called ‘sitrep reports’ to detail meetings with local authorities, daily operational overviews, and related concerns, and to map ethical dilemmas. These documents served as a daily record written by busy project staff conveying information to headquarters.\u003c/p\u003e\u003cp\u003eMG spent a total of six months in Lebanon between the Summer of 2019 and end of 2023. This presence in the field helped develop rapport with staff and the families at the thalassemia unit. In 2021, while working remotely due to COVID-19, MG held a weekly meeting with staff for a check-in, alongside multiple calls with BS to share progress updates. There were multiple information flows which kept the research team informed of the daily realities for Lebanese and Syrians living in Lebanon, all of which shaped our understanding of the research data. While in Lebanon, MG kept a research diary, borrowing the templates advised by Spradley (21). The research diary was transcribed electronically for organizing consolidated notes that capture the nuances and impressions and to support data protection (22). Belal also kept an audio diary while running the co-development groups documenting his experiences and reflections throughout the study period. These diaries provided real-time insights into the researchers’ observations, challenges faced, and the dynamics of the humanitarian response.\u003c/p\u003e\u003cp\u003eData were analysed using a participatory thematic analysis approach. All interviews and audio diaries were translated by a local interpreter who was trained on data protection. Once completed, the transcription files were transferred securely using the University of Glasgow's file transfer service, and then uploaded into NVivo 12. The analysis process followed three steps. The first step was familiarization: reading the transcripts carefully and repeatedly, and beginning the initial process of descriptive coding. This approach allowed the identification of preliminary responses to the research questions and provided a foundation for further thematic analysis. The second was coding and theme extraction. The process of coding was both iterative and reflexive. Throughout the analysis, there was continuous engagement with relevant theoretical frameworks and prior empirical studies to interpret emerging patterns. Dialogue with other researchers from the University of Glasgow and between the co-authors helped connect the data to broader theoretical constructs, particularly drawing on works such as St. Pierre and Jackson (23) to shift focus from what the data means to what it does or the effects it produces. Thematic coding evolved as key themes were identified, merged, renamed, and refined. This thematic organization was supplemented by the creation of mind maps and narrative mappings to visualize the connections and relationships within the data.\u003c/p\u003e\u003cp\u003eFinally, the research team led the process of consultation with participants – as integral part of the process of analysis and interpretation. Feedback sessions were conducted with staff in Lebanon in 2022 and 2023, where the emerging themes were presented and discussed. These sessions provided valuable insights into the participants' perspectives, ensuring that the analysis was grounded in the lived experiences of those involved in the study. Through this participatory approach, the research not only captured the complexities of the humanitarian response but also facilitated the co-creation of meaning alongside participants, centring their voices in the interpretation of the findings. A final round of discussion between co-authors was held in 2024 to prepare this article.\u003c/p\u003e\u003cp\u003eEthical Considerations\u003c/p\u003e\u003cp\u003eThe research team approached the power asymmetrywith contextual responsiveness rather than a rigid application of rules and guidance offered by peers and in academic literature (24). In this research, we ought to provide ‘fair’ working conditions, informed by professionality, transparency and trust regarding their time spent on tasks and its respective payment (25). Warnock, Taylor (24) call for researchers to reduce suspicion around payment in social sciences research and instead draw on a framework centred around the ethics of care in paying local researchers.\u003c/p\u003e\u003cp\u003eThe positionality of the local researcher (BS), as a young Syrian male who is an experienced participatory research facilitator and aid worker in Lebanon, enriched this project. His experiences of migration from Syria to Lebanon, due to the Syrian war, resulted in him being well placed to navigate the social, cultural and ethical dynamics during data generation in the iNGO’s clinics with Syrian carers of service users. His contextual knowledge paired with the training he received for this research project. This allowed him to reflect, respond and facilitate discussion from congruence, or ‘collisions’, or perhaps possible false preferences that arise in discussions by posing vignettes and fictional narratives in a realistic and relevant way (26) (Fadiman, 1999).\u003c/p\u003e\u003cp\u003e To abide by ethical principles during recruitment, posters were circulated with a participant information sheet and consent form via WhatsApp by MSF’s staff to prospective participants, staff and parents. Staff also informed prospective participants by word of mouth. Due to COVID-19 restrictions, there could be a maximum of six participants in the co-development groups.\u003c/p\u003e\u003cp\u003e When participants arrived in the room, Belal gave them the participant information sheet, which they could keep if they chose to. For participants who could not read and write, information was discussed verbally and oral consent was obtained. All participants received a health pack for participation which included items like hand sanitiser, soap and facemasks. All participants were provided with tea, coffee, water and cake.\u003c/p\u003e\u003cp\u003e The study received ethical approval by College of Social Science Ethics Committee at the University of Glasgow (reference number 4001900800) and the Ethics Committee of the Saint Joseph University of Beirut (reference number USJ-2019-270).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis section first presents the rationale behind the implementation of the thalassemia programme by MSF in Lebanon\u0026rsquo;s complex humanitarian context, followed by the challenges posed by multiple shocks and their impact on the programme and thalassemia care in general. The section then examines the experiences of iNGO staff navigating the increasingly difficult circumstances in Lebanon including the port explosion, pandemic and economic collapse, highlighting their perspectives on the impact of operational disruptions, how resources were prioritised during the many shifts to healthcare service design over the four-year period of data generation. Additionally, the analysis addresses the profound sense of loss felt in the face of ongoing crises and the withdrawal of international support.\u003c/p\u003e \u003cp\u003eFinding a niche within a republic of NGOs\u003c/p\u003e \u003cp\u003eLebanon endured an influx of aid and donor assistance in recent years. This influx has fragmented the healthcare system and prioritised different populations on the grounds of, e.g., gender, nationality, sectarianism and geography. This finding is corroborated by Facon (27), who calls Lebanon a republic of NGOs. Hamadeh, Kdouh (28) evidenced how this fragmentation has increased confusion for patients about eligibility and increased the complexity of referral processes and drug supply networks, leading to high levels of staff turnover and a geographically mismatched network of clinics and specialist services (28).\u003c/p\u003e \u003cp\u003eDue to this, in discussions with interlocuters and in an unstructured interview with the senior staff member at the international humanitarian medical organisation, participants in this study described how the iNGO also sought to mobilise operations in Lebanon in 2017 due to increasing regional conflicts. In this interview with the senior staff member, who we call Charlotte, she explained that it is crucial for NGOs to avoid duplication of services and that international humanitarian NGOs must \u003cem\u003e\u0026lsquo;find their niche\u0026rsquo;\u003c/em\u003e to justify their intervention and daily operations.\u003c/p\u003e \u003cp\u003eIn Lebanon, there is one thalassemia centre for Lebanese citizens, called the Chronic Care Centre (29). It is run by a local NGO established in 1993, and it is where most Lebanese patients living with thalassemia are treated. This centre does not offer care to non-Lebanese citizens due to the economic collapse (30), despite that staff from the Chronic Care Centre considered before 2018 visiting the refugee camps to offer support. However, this service was subsequently left for other NGOs to provide (30).\u003c/p\u003e \u003cp\u003ePeople from Syria who registered as refugees with the UNHCR received healthcare coverage from UNHCR through contractual arrangements with NGO-run primary care centres and subsidization of secondary care in Lebanese hospitals via a third party administrator. However, not everyone was registered with the UNHCR, in part because UNHCR stopped accepting registrations in 2015 due to pressures from the Lebanese authorities. For this reason, the organisation established the thalassemia service which treats all nationalities. Thalassemia care was the anchor for this iNGO operations, including running a Paediatric Intensive Care Unit (PICU), preparing to open an Emergency Room, and mobilising a vaccine campaign in response to the pandemic.\u003c/p\u003e \u003cp\u003eHealth programme and system resilience tested by multiple shocks\u003c/p\u003e \u003cp\u003eThe set of analysis in this subsection examines the impact of conflicting approaches from state and non-state actors on care delivery in Lebanon during the multiple crises. Staff attributed this fractured working model to the fragmentation of the health system and its impact on how to prepare and respond to the multiple shocks.\u003c/p\u003e \u003cp\u003eSeveral NGO staff emphasized their efforts to collaborate with the state to improve sustainability and continuity of care, yet many components of the health system operated in silos preventing a coordinated and timely response from non-state actors. For instance, the medical procurement systems \u0026ndash; described as rigid, complicated, and expensive \u0026ndash; faced additional strains after the Beirut blast. The port and many surrounding areas including a main MoPH warehouse were destroyed, and the iNGO had to rely on private planes for medication imports. This affected access to essential medicines and drastically increased operational costs, leading to a significant impact on children with thalassemia and other patients. Moreover, participants in this research explained that sustainability of the thalassemia service was not adequality planned as the high treatment costs were an inherent barrier to finding project partners, either another NGO or the MPH, due to the high expertise associated costs required for the treatment.\u003c/p\u003e \u003cp\u003eOne participant highlighted the fragmentation of the healthcare system in Lebanon as a key factor exacerbating referral issues following the economic crisis. They explained that, after the crisis, public hospitals stopped receiving referrals from the medical iNGO due to the rising cost of patient care. This fragmentation led to a situation where public hospitals would only accept a referral if the NGO supplied the necessary medications for treatment, such as magnesium for post-partum conditions. This shift underscored how the disjointed system, further strained by the economic shock, hindered access to essential care and disrupted the referral process.\u003c/p\u003e \u003cp\u003eParticipants reflected on how the mismanagement of multiple shocks and the volatile socio-political environment added complexities to the ability of non-state actors to secure resources or other inputs related to their health programmes. After the economic crisis, the iNGO staff reported that the public health infrastructure became a significant obstacle, with public hospitals charging them rent to operate within their facilities. International staff participants explained that in Lebanon the hospitals were described as being \u0026lsquo;\u003cem\u003erun like a business\u0026rsquo;\u003c/em\u003e (Research Diary, May 2022). A senior staff member reported that \u003cem\u003e\u0026lsquo;treating thalassemia is expensive, requiring significant resources like a blood bank and generator power, with monthly treatment costs reaching up to \u0026pound;450\u0026rsquo;\u003c/em\u003e (10). Additionally, staff were critical of the state-imposed taxes on medications and the inefficiencies of the medical procurement systems, which further hindered their ability to provide care effectively. In an interview, senior management explained that working in Lebanon is unlike working in Sub-Sharan Africa such as Chad or South Sudan, where often costs are lower as they are not charged tax, and salaries and expertise are lower.\u003c/p\u003e \u003cp\u003eSimilar scenario was reported with the COVID-19 emergency. Although there has been an acknowledgement of positive approaches to dealing with the pandemic, some staff, particularly those with international experience, reported a lack of public awareness campaigns and Lebanon\u0026rsquo;s inability to prepare adequately for emergencies. One national staff member, whom we call Muhammad, was working in Canada at the beginning of the COVID-19 pandemic. This international work experience for him was significant in how he made sense of Lebanon\u0026rsquo;s response. For him, there were stark differences in what he termed Lebanon\u0026rsquo;s \u0026lsquo;\u003cem\u003elevel of culture and awareness in society\u003c/em\u003e\u0026rsquo;; he explained \u003cem\u003e\u0026lsquo;with all the education and health promotion in Canada, things got better, but here in the Middle East nothing changed\u0026rsquo;\u003c/em\u003e (Muhammad, Staff, Co-development Group Two). He concluded that there was a failure in the Lebanese response leading to high levels of transmission. These transmission rates directly affected the ability of the iNGO to collect blood as part of the thalassemia care management. Blood donation efforts for thalassemia patients were hindered by COVID-19 restrictions and public distrust given the fear of contagion, especially in informal settlements. Similarly, efforts to secure blood donations became very difficult after the Beirut Blast due to the public's focus on helping the blast victims.\u003c/p\u003e \u003cp\u003eThe economic crisis also impacted severely both health system and programme financing, leading to a notable financial pressure on providers and communities seeking thalassemia care. Affected by the devaluation of the Lebanese currency and the quasi-collapse of all public health financing schemes, many Lebanese patients have turned to NGOs like the iNGO of this case study instead of private hospitals, which have become increasingly unaffordable. Unlike Syrian refugees, Lebanese patients do not qualify for UNHCR financial coverage, placing the entire financial burden of their treatment on NGOs. Staff members emphasized their commitment to providing equal care to Lebanese patients, adhering to the humanitarian principle of impartiality. However, staff noted a perceived lack of \u0026ldquo;humanitarian culture\u0026rdquo; within Lebanese communities \u0026ndash; characterized by insufficient community support, volunteering, and resource sharing. This absence fuelled tensions between Lebanese and Syrian communities, particularly as Lebanese individuals face medication shortages while witnessing aid being distributed to Syrian refugees. Such disparities have sparked hostility, culminating in incidents like the burning of an informal settlement. Despite these challenges, staff recognize the inherent need for individuals to prioritize their families' well-being over their local community, which complicates the dynamics of community support in the economic crisis.\u003c/p\u003e \u003cp\u003eIn response to these increasing financial challenges, the iNGO decided to withdraw services when they perceived that the increased costs of treating a low number of children were to become unsustainable. This increased cost was caused by i) the destruction of Lebanon\u0026rsquo;s only port leading to the organisation commissioning private planes to import medication and ii) the economic collapse which led to public hospitals accepting patient referrals only if the treatment was paid for at a rate of 25% of cost for Syrian patients, due to UNHCR subsidy, and 100% for Lebanese patients (9). As cited on their website, the iNGO\u0026rsquo;s position to close the project aligned with the rationale that \u0026lsquo;\u003cem\u003ehumanitarian actors cannot replace the healthcare system of an entire country\u003c/em\u003e\u0026rsquo; (31), and the Lebanese state was criticized for not taking enough responsibility to contribute to elements of thalassemia care, such as providing essential medicines.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Sadly, we do not always find ourselves able to support. The quantities in our clinics and stocks are limited and even if we manage to get an extra order it takes time, because of the importation delays. Due to the complicated and often chaotic public system, shipments of drugs are often taking eight months to reach us, which is simply too long in the context of a health care emergency [\u0026hellip;] We remain committed to delivering impartial medical care to the most vulnerable people to the best of our ability, but necessary action needs to be taken by the Lebanese authorities to ensure that essential medical services are provided to the people. They need to act so that medication, supplies and fuel are accessible in the country. Humanitarian actors cannot replace the health system of a whole country\u0026rsquo; (31)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Charlotte, a senior staff member, emphasized the utilitarian rationale behind this decision, comparing the high-cost thalassemia care in Lebanon with the low-cost treatment for malnutrition in Afghanistan. Ultimately, the organization reallocated resources to those countries.\u003c/p\u003e \u003cp\u003eParticipants in this research reported a variety of reactions and opinions when asked about project closure. Staff members, especially national staff, approached this from a need for health justice. They emphasized the importance of prioritizing vulnerable patients and ensuring equitable access to care, particularly in the face of limited resources. There was a consensus on the need to prioritise this health justice approach, which contrasts with the current focus on optimizing resource allocation within the humanitarian sector. Others blamed their organization for hesitating to promote their health services within both Lebanese and Syrian communities due to management\u0026rsquo;s fear of overwhelming limited resources. This reluctance led to unmet patient number targets, resulting in an inefficient program that eventually faced closure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;There was something strange. When we came our hospitals [were] empty, we used to say we need to do better communication, [but] they [management] didn't want to, they are afraid to spread the news like UNHCR, they didn't want to spread the knowledge and say there's a project here for the Lebanese as well, professionalism was lacking, they were afraid more people would come.\u0026rsquo;\u003c/em\u003e (Leila, Staff, Co-development Group Three)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilar to international staff, Leila acknowledged that in Lebanon, futures are uncertain. However, this should not result in project closure when patient numbers are not realised. Patients need care, and those who are more structurally vulnerable need reasonable adjustments to attend the clinic. Prioritisation and triaging to focus on people with urgent needs and increased vulnerability is necessary when there is a high demand that exceeds the resources available. From the national staff\u0026rsquo;s perspective, rather than proceeding with a health justice approach to service provision and actively targeting vulnerable groups, the iNGO relied on their service information being shared amongst patient social networks only.\u003c/p\u003e \u003cp\u003eIn 2020, the iNGO cited in external reports that the demand for their services had reached an all-time high due to increasing poverty. People who had previously relied on Lebanon's private healthcare system could no longer afford it and turned to no-cost services run by iNGOs as a result. Yet the total patient numbers forecasted were never realised.\u003c/p\u003e \u003cp\u003eInternational staff were taken aback by a second unforeseen effect of the economic collapse \u0026mdash; the realization that Lebanese patients had a lack of acceptance towards their services. Charlotte, a senior manager, admitted staff often asked, \u003cem\u003e\u0026lsquo;Where is everyone?\u0026rsquo;\u003c/em\u003e, referring to the absence of Lebanese patients presenting at the newly opened emergency room. When speculating on why this might be in an interview, Charlotte summarised that \u003cem\u003e\u0026lsquo;working in Lebanon, like many middle-income countries, is very difficult. It's difficult because there's a lot of actors, it's difficult for access, it's difficult for recognition and trust\u0026rsquo;\u003c/em\u003e (Research Diary, May 2022). She suspected that this lack of acceptance was because Lebanese patients perceived the humanitarian medical service as cheap. As many Lebanese citizens had previously had private healthcare, this shaped their perception of the services; they would have to seek healthcare where Syrian refugees were treated. For instance, to keep costs low, aid organisations use generic drugs, such as a generic iron chelation oral medication. Charlotte detailed how Lebanese patients sought brands of drug they were familiar with and trusted. She suggested that the use of generic drugs was not acceptable to Lebanese patients and that there is a stigma associated with consuming what are seen as cheap products. This stigma limited the uptake of MSF services among the Lebanese community, despite the increased need as a consequence of economic collapse. As a result, the high costs solely came from the thalassemia unit, which treated low patient numbers, compared to an emergency room with a higher patient turnover. This unmet forecasted patient-to cost-ratio shaped headquarters\u0026rsquo; decision to close the healthcare services.\u003c/p\u003e \u003cp\u003eHumanitarianism in complex settings: staff experiences in Lebanon\u003c/p\u003e \u003cp\u003eIn this part of the analysis, we reflect on the dynamics of decision making and staff experiences within the humanitarian sector in volatile and fragile settings, especially in relation to short-term programmes that may not have been planned or implemented according to health needs.\u003c/p\u003e \u003cp\u003eParticipants had increasing concerns about the \u0026ldquo;pop-up humanitarianism\u0026rdquo; reflecting the temporary nature of aid responses in complex crises and the uncertainty and insecurity from the lack of long-term solutions (32). This dilemma, between the aim to provide temporary relief and dignity in adherence to the organization values, versus carefully considering the financial viability amid a lack of political and financial reforms in Lebanon created a psychological toll for the participants of this research. The research team noted increasing concerns regarding the purpose, accountability, and legitimacy of aid organizations which had an evolving nature similar to that of the UN system; citing that the iNGO was \u0026lsquo;\u003cem\u003eturning into the UN\u003c/em\u003e\u0026rsquo; that it\u0026rsquo;s \u0026lsquo;\u003cem\u003egetting too big and it's kind of past its critical phase now\u003c/em\u003e\u0026rsquo; (Research Diary, May 2022). The majority of staff shared the concern that the perspective that their voice would not be heard or considered amid institutional changes and decisions are made at a higher level.\u003c/p\u003e \u003cp\u003eThe experiences of both international and national staff in this research also highlight the precarious nature of humanitarian work, with various challenges including the demanding job nature, emotional isolation and barriers to immersion in the local culture and context. International staff often face short-term employment contracts (ranging from six to twelve months), complicating their ability to establish a sense of home or stability. The low pay (starting at \u0026pound;800 per month) further exacerbates their inability to maintain a permanent residence, trapping them in a cycle of redeployment and financial insecurity. The living conditions within \u0026ldquo;compound\u0026rdquo; settings of humanitarian housing \u0026ndash; when working in remote areas \u0026ndash; hinder the formation of meaningful relationships, leading to a sense of isolation among international aid workers. Staff like Charlotte share experiences of feeling trapped in perpetual migration for income and career advancement, alongside a yearning for belonging and purpose. This precarious lifestyle results in a lack of material welfare and emotional support networks, as colleagues come and go.\u003c/p\u003e \u003cp\u003eMobility, the practice of working across borders, is at the heart of much international humanitarian practice. Frequent relocation leads to a loss of contextual project knowledge, contributing to the \u0026ldquo;short-term memory\u0026rdquo; of the humanitarian sector. This phenomenon creates a divide between international staff and local populations, hindering genuine solidarity and understanding. The separation caused by language and cultural differences especially in distal areas \u0026ndash; where most humanitarian projects operate \u0026ndash; perpetuates harmful perceptions of \u0026ldquo;otherness,\u0026rdquo; fostering an Orientalist gaze that reinforces neo-colonial attitudes, and normalizes the superiority of Western knowledge over localized ways of understanding (33). Nevertheless, the dedication to humanitarian principles and work, despite coming at the cost of a sense of belonging, shapes the humanitarian identity. Separation from family, migrating in search of a better life, seeking a home and feeling uncertain of the future evokes feelings of uncertainty and vulnerability for international aid workers. This sense of precariousness in their unknown journeys and associated risks are similar for Syrian families, although their experiences and sense of freedom are different. Finding mutual vulnerabilities, as illustrated between staff and service users, can act as a basis for solidarity and support in moving towards health justice and more equitable forms of coexistence (34).\u003c/p\u003e \u003cp\u003eOur data identified palpable tensions among national staff within a constant atmosphere of stress and anxiety affecting trust and morale among all staff. Moreover, national staff reported an inherent job insecurity due to the temporary nature of humanitarian projects in a failing state like Lebanon. Yasmin, a Lebanese staff member shared the affect of the project\u0026rsquo;s closure for her and the patients she works with: \u003cem\u003e\u0026ldquo;This is really sad, because everywhere they know that here there is paediatric service and now we are just telling them 'we are closed'. We don't even know where to go. And in this last phase we were closing we were not even standing with the message we will support other hospitals to pay\u0026rdquo;.\u003c/em\u003e This precariousness negatively impacts their physical and mental health, as well as their attitudes toward their organization. This also creates vulnerability among national staff, who rely on their employers for stability in a context marked by economic decline and social unrest. This insecurity fosters feelings of anger and alienation, as highlighted by academic perspectives on the social consequences of precarity by scholars such as (Guy Standing), and diminishes their power within the organization.\u003c/p\u003e \u003cp\u003eFinally, international staff participants explained that some Lebanese patients also had reservations about trusting this iNGO. International staff proposed that perhaps it was the stigma associated with using their services due to societal preference for private healthcare and branded medications over the generic ones provided by iNGOs, which caused complications for their operations. Moreover, due to Lebanese state constructed illegality, many Syrian families were confined to remote informal settlements, which created security and economic barriers to access. Furthermore, the absence of service advertisement many Syrian families did not know of the existence, or the eligibility, of this service. This lack of trust in the iNGO\u0026rsquo;s services reflected broader challenges of providing humanitarian aid in middle-income countries, where access and recognition for international NGOs can be fraught with difficulties. These findings highlight the importance of research using qualitative approaches. Such studies capture an understanding of challenges like trust and stigma when accessing healthcare services. Understanding and resolving these challenges can facilitate clinic access and develop trust with patients who suffer from thalassemia, providing better patient-centred care (Nouvet et al., 2016).\u003c/p\u003e \u003cp\u003eExperiences of loss in the face of multiple crises and the iNGO withdrawal\u003c/p\u003e \u003cp\u003eAll participants in this study made sense of the multiple transitions the thalassemia unit underwent by conveying a sense of loss, revealing both shared and divergent perspectives on how the multiple crises impacted their lives in Lebanon. This included fears about the potential loss of employment, materials, relationships, and patient health due to service closures.\u003c/p\u003e \u003cp\u003eInternational staff expressed feelings of loss related to various transitions within the thalassemia unit, including fluctuations in the forecasted project funding, resource reductions from headquarters, and service closures. International management staff stated in an external publication report that \u0026lsquo;\u003cem\u003eWe wished we could do more to respond to the needs but we are limited by the very high price of the thalassemia drugs\u0026rsquo;\u003c/em\u003e (M\u0026eacute;decins Sans Fronti\u0026egrave;res, 2020a). Both international staff and patients experienced spatial loss due to the closure of the programme's location within the public hospital. To avoid loss of investment, the medical equipment purchased for the thalassemia unit was handed over to the Ministry of Public Health (MoH). However, Charlotte expressed scepticism about the MoH\u0026rsquo;s capacity to maintain this treatment due to funding and expertise shortages. These challenges highlight the conceptual failures in forecasting a future in humanitarian aid.\u003c/p\u003e \u003cp\u003eThis notion of a \"loss of patients\" was significant across participant groups, relating to onward and return migration, preventable deaths due to lack of treatment, and the emotional impact on national staff who viewed the loss through the lens of stress and emotional burden associated with their roles. These \u0026lsquo;lost patients\u0026rsquo;, the failed forecasting of patient numbers, contributed to the thalassemia unit\u0026rsquo;s closure. While international staff mainly faced temporary contract issues and the prospect of moving on, national staff endured long-lasting mental health impacts from their work experiences. For instance, Leila who worked as a staff nurse explained the affect of the loss of a patient\u0026rsquo;s life and how the support her colleagues offered to parents when grieving for their lost child took its toll on staff, \u003cem\u003e\u0026lsquo;even for us, in this hospital, we have no mental health support and we have a PICU [Paediatric Intensive Care Unit] for example\u003c/em\u003e,\u0026rsquo; said Leila; she explained that as national staff they had to cope with \u0026lsquo;\u003cem\u003ewhat is happening\u0026rsquo;\u003c/em\u003e: situations that were not \u003cem\u003e\u0026lsquo;their fault\u0026rsquo;\u003c/em\u003e, caused by the structural violence that the patients at their clinic lived in. National staff expressed concerns that patients, particularly those requiring ongoing treatment for thalassemia, would face critical challenges, as the loss of services was a matter of life and death. To mitigate possible unemployment after project closure, the iNGO offered training and staff support, which most national staff showed little interest in dedicating extra time to an organisation where they saw no future. This decision to close services for which a great need remains led to national staff losing trust in their employer.\u003c/p\u003e \u003cp\u003ePatients and carers at the lower end of the welfare continuum, including many of the families from Syria and Lebanon in this research were disproportionately affected by the eroded health system, which drove them to rely on humanitarian support. Service users expressed three forms of loss during data generation: biographical loss (e.g. what it means to be a child from Syria), the loss of a home, and the loss of family. While these intersect in many ways, the distinct ways in which they shaped how service users made sense of their health and healthcare journeys to the thalassemia unit provide an understanding of migration and the broader social determinants for humanitarian healthcare.\u003c/p\u003e \u003cp\u003eMany participants shared how they had lost their dignity and identity since arriving in Lebanon. Maryam, a mother whose child was treated for thalassemia explained \u003cem\u003e\u0026lsquo;At the clinic, it's the same, the Lebanese entered without having to stand in the queue. They were expelling us as if we were animals and we were not human in front of them. We notice prejudice and indifference to the Syrian people\u0026rsquo;.\u003c/em\u003e Many participants in this study detailed the ways in which they felt disregarded or mocked by healthcare professionals when they presented with an illness. Another illustration was that one participant's child was turned away from a healthcare service, and subsequently died. The consequences of these experiences for many participants were an overall loss of trust in public health institutions.\u003c/p\u003e \u003cp\u003eParticipants shared stories of their children being bullied in the camp for having thalassemia. Zahra detailed that \u0026lsquo;\u003cem\u003eWhenever my son goes out to play with the kids at the camp, the kids bully him, saying, \u0026ldquo;He's sick, let's not play with him\u0026rdquo;. They don't know what the illness is, they think it's contagious\u0026rsquo;\u003c/em\u003e. Parents narrated the ways their children were losing out on their childhood due to their illnesses, for instance Jamal shared the difficulties he experiences with his daughter: \u003cem\u003e\u0026lsquo;She always asks me, \u0026ldquo;Dad, why is it just me?\u0026rdquo;\u003c/em\u003e She cries every time I take her to the hospital and says, \u003cem\u003e\u0026ldquo;Don't take me; take my other sibling instead\u0026rsquo;.\u003c/em\u003e For children who have already endured the hardships associated with fleeing war and the violence of growing up in a state where they are illegalised, the consistency of care from thalassemia staff they trust and family support is essential in mitigating further harm.\u003c/p\u003e \u003cp\u003eParents detailed the implications of losing a house that provided them with safety from snow, rain, the cold and heat. Their homes in Syria were away from pollution, a quiet space with privacy. Zahra summarised that \u003cem\u003e\u0026lsquo;if the society you're living in is good, then you are good, if it's not, then you're not\u0026rsquo;.\u003c/em\u003e A home evokes a sense of connection, both a material and socialised space, a sense of belonging that is integral to a person\u0026rsquo;s wellbeing (35). Participants identified that living in informal settlements or overcrowded, and squalid housing often created sickness and hindered their recovery process. Hense, migration itself was a determinant of health.\u003c/p\u003e \u003cp\u003eParticipants highlighted the loss of family support and the impact it had on their health; Umm Mohammad explained that she felt that she could cope due to the support of her family, whereas Jamal was \u003cem\u003e\u0026lsquo;totally alone\u0026rsquo;\u003c/em\u003e as a single parent caring for his children. Families share the burden of one member\u0026rsquo;s ill health. Yasmin, a mother summarised that \u003cem\u003e\u0026lsquo;For me, the most important thing is my children's wellbeing, that they get cured of the disease that affected the life of the whole family\u0026rsquo;\u003c/em\u003e. Many parents had originally planned for more children, but due to the hardships they experienced caused by their child\u0026rsquo;s thalassemia, they decided not to have any more children. Jamal explained, \u0026lsquo;\u003cem\u003eIf having children is related to finding a blood donor and going through all of this, then I prefer not having children anymore\u0026rsquo;\u003c/em\u003e. Many parents suffered from the deaths of their children caused by thalassemia, including Amira, who lost her elder daughter to thalassemia. The suffering and loss experienced by service users were narrated in the past, present, and future illustrating the necessity for long term care for people subject to the global asylum system.\u003c/p\u003e \u003cp\u003eThese resultant losses, for both present and future patient care, reflect broader issues within the humanitarian aid framework, evidence the need for a more sustainable and trustworthy approach to healthcare for chronic illness patients. Layla, a Lebanese nurse remarked on the project closure by summarising that that: \u003cem\u003eWhen the NGOs came to Lebanon, things weren't that bad but after they leave Lebanon, the situation is going to be worse than ever\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper explores the dynamics between the MoPH and humanitarian healthcare organisations, highlighting the implications for both healthcare providers and the patients they serve. There are three primary, interconnected findings of this research for the MoPH and state relations, for staff and for the patients they serve. First, the polycrises in Lebanon led to an untenable operational environment for one of the most resource-rich iNGOs; secondly, their withdrawal of services compounded the hardship families from Syria experienced, and thirdly, staff felt \"stuck\" in their efforts to navigate both iNGO decisions and the mounting challenges faced by patients leading to decreasing well-being of national staff.\u003c/p\u003e \u003cp\u003eLebanon's healthcare system is fragmented and under significant strain, operating through a mix of public, private, and NGO-provided services. This structure results in a segmented system, where access to care is often determined by factors such as nationality, residency status, and religion, creating disparities in treatment across different population groups. This fractured health system was caused by the conflict-affected state enduring compounded shocks on decades of state neglect, insofar as in 2021 MSF described it as a context comparable to a conflict setting (Doctors Without Borders, 2021). As a result, Lebanon\u0026rsquo;s health system became reliant on international humanitarian healthcare, a sector which prioritises primary care in favour of secondary or tertiary healthcare due to the comparatively higher costs and necessary continuity care. Moreover, to prevent duplication of efforts in a saturated NGO environment, iNGOs had to \u0026lsquo;find their niche\u0026rsquo; to justify intervention and continued presence. For this reason, MSF mobilised a thalassemia treatment clinic, a neglected NCD which families from Syria were in desperate need of. The economic collapse, COVID-19 pandemic and port explosion intensified the expensive and intricate operational costs imposed by the Lebanese state and caused frustration between medical NGO and the MoPH. This expensive operational environment, coupled with the absence of any foreseeable changes, ultimately shaped MSF's decision to withdraw. They defended this decision by stating that \u003cem\u003e\u0026lsquo;Humanitarian actors cannot replace the health system of a whole country\u0026rsquo;\u003c/em\u003e (Doctors Without Borders, 2021).\u003c/p\u003e \u003cp\u003eAt the inception of the humanitarian sector, prominent aid actors asserted they were not meant to provide a structural solution but instead they adopted a temporary approach. This temporary approach is what Pallister-Wilkins (32) calls \u0026lsquo;\u003cem\u003epop up humanitarianism\u0026rsquo;\u003c/em\u003e, aid in response to informal settlements, state withdrawal of access, or service closure. The emergency modus operandi which governs the operation of medical NGOs, decontextualises future health care needs in favour of being stuck in the present (15). Taken together, this creates uncertainty and insecurity, as all actors are prevented from planning for the future and pursuing long-term goals. This has subsequently shaped employees' understanding of their purpose (Brun, 2016). For humanitarian staff who speak out against this approach, Charlotte admitted that MSF is \u0026lsquo;\u003cem\u003eturning into the UN\u0026rsquo;\u003c/em\u003e. She explained that she felt the established humanitarian healthcare organisations are resistant to change, and staff feel that alternative voices are not considered and therefore the sector is \u0026lsquo;past its critical phase\u0026rsquo;.\u003c/p\u003e \u003cp\u003eThe escalating cost of essential goods and the withdrawal of services by international NGOs were key themes in discussions throughout this research. This study supports evidence from research conducted by Fakih (36) which found that in order to continue to feed themselves, households were giving up on the quality of what they eat, on education or health care, and are even skipping some meals, as approximately 85% could no longer afford to buy basic foodstuffs (36). Through the theme of loss, this article narrates how the scarcity of resources fuelled tensions between Lebanese and Syrians and resulted in conflict, negative stereotyping, and a decline in the quality of healthcare. Carer participants detailed how limited food and medication supplies were prioritized for Lebanese individuals, creating fear, a distrust of medical services, and societal tensions, which negatively impact well-being. This finding is consistent with that of Spiritus-Beerden, Verelst (37) who found that emergencies and their aftermaths give rise to discrimination towards refugees due to increased fear, resulting in stigmatisation.\u003c/p\u003e \u003cp\u003eThe families who participated in this study relied on their informal networks to secure resources and for support, exacerbating their distress and leading to a higher risk of negative health outcomes. For the paediatric patients, the impact of poverty, lack of education, malnutrition, and untreated medical conditions are likely to impact their families for generations to come. Evidence from the Dutch Hunger Winter (1944\u0026ndash;45) and the Chinese Famine (1959\u0026ndash;1961), shows the association between early life malnutrition and adult body size, schizophrenia and type 2 diabetes (38\u0026ndash;40). There is an increasing likelihood of an intergenerational transmission of illness and chronic poverty for the families who participated in this research, rather than the transmission of positive assets and capital such as land, livestock, status, education, and kin group (41). During data generation, it became clear that staff who worked closely with these families on a daily basis had a deep understanding of how the project\u0026rsquo;s closure would impact their child\u0026rsquo;s health and the precarious tactics they would resort to in order to secure thalassemia care.\u003c/p\u003e \u003cp\u003eLebanon\u0026rsquo;s polycrises had profound impacts on daily operations and patient care, with detrimental consequences for the wellbeing of staff working at the thalassemia unit. An importatn finding in the data from this study was the \"invisible labor\" of decision translation that national staff were compelled to undertake while working for MSF. They were responsible for translating the difficult operational decisions made by the organisation in response to Lebanon's polycrises, helping to explain these challenges to the patients and their families under their care. For instance, they would the challenges in obtaining blood or medications to paediatric patients after the port explosion, alongside policy changes in response to the Covid-19 pandemic. Moreover, they translated the increasing hardship families were experiencing back to senior management (42). (43) terms this role as \u0026lsquo;switchers\u0026rsquo; and details the complex subtle systems of power that these switchers hold in shaping the power making systems. This echoes the findings of James (44), who documented the significance national staff have in the success of humanitarian action due to their central role of what she calls the politics of humanitarian fixing and brokerage. In this research, there are clear parallels between the consequences of the \u0026lsquo;burn out jobs\u0026rsquo; and increasingly neo-liberal model of many global healthcare systems (45). At times, national staff are subject to similar conditions as patients, and as this research has demonstrated, national staff conduct exhausting translation work between patients, their parents, and senior management. To make the necessary improvements in the working culture of international humanitarian aid, there must be greater communication from headquarters to project staff regarding service design to increase trust, accountability, and morale in humanitarian healthcare provision.\u003c/p\u003e \u003cp\u003eTaken together, the loss articulated by staff and patients in this study align is consistent with the literature, as it evidences the limits of humanitarian health responsibilities, emphasizing the need to allocate necessary care and promote health justice across intersecting social issues (46). Aid provides respite and a sense of dignity for those living with uncertainty, as is illustrated in the experiences of families in this research. However, there comes a point when aid institutions deem it no longer proportionate to allocate funds for a medical project (20). The organisation\u0026rsquo;s decision to withdraw was based on a careful deliberation between the project\u0026rsquo;s financial cost, and the cost to the institution\u0026rsquo;s values, and perhaps the aid sector as whole. In adherence to humanitarian principles, MSF could not justify continuing to fund operations if the state was not reforming, and the organisation identified a more pressing humanitarian crisis elsewhere, \u0026lsquo;where they are needed most\u0026rsquo;.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe intersecting political and economic crises in Lebanon shaped public health in a myriad number of ways, including increased food insecurity, reduced availability of medicines and services, and further fragmentation and verticalization of the health system. Humanitarian medical organisations mobilised to support Lebanon\u0026rsquo;s health system on a temporary basis, with the expectation of health system reform and wider reforms in the meantime. The state failed to meet this criterion and some organisations had to close operations amidst mounting crises. This paper concludes that there is a necessity for paradigm shift in working relations between international humanitarian medical organisations and local health authorities, to recalibrate the inherent power inequity within the humanitarian medical system and to reorient the values underpinning the model of care of those organizations. Value systems should be determined by the cost of the operations but also the relative value of the healthcare both at a population health level and for what it means - the value - for the individuals and their families (46).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study protocol and questionnaire were reviewed and approved by the ethics committees of the University of Glasgow (reference number 4001900800) and the Saint Joseph University of Beirut (reference number USJ-2019-270). All study participants provided an informed consent to participate in this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was funded by the University of Glasgow\u0026rsquo;s Lord Kelvin Adam Smith Interdisciplinary Doctoral Scholarship. We also acknowledge the contribution of\u0026nbsp;ReBUILD for Resilience (R4R) for supporting the publication cost.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eM.G.\u0026nbsp;conceived the study and developed the study protocol\u0026nbsp;and the tools.\u0026nbsp;M.G. coordinated the data collection and analysed the data with support from I.R.B.\u0026nbsp;All co-authors (M.G. and I.R.B.)\u0026nbsp;contributed to the interpretation of data, prepared the manuscript after critical revisions of previous versions, and approved its final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We would like to acknowledge Belal Shukair for his role in data generation and analysis in the Doctoral Research Project \u0026lsquo;How can humanitarian medical care be strengthened in Lebanon?\u0026rsquo;, which forms the basis for this paper. We would also like to thank M\u0026eacute;decins Sans Fronti\u0026egrave;res and the research participants for their commitment and willingness to participate in this project. \u0026nbsp;Thank you to Professor Chris Bunn, Professor Mia Perry and Professor Kate O\u0026rsquo;Donnell for their invaluable guidance during the PhD research which forms this article.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhalife D, Elia R, Yammine C. What are the Financial Causes of the Lebanese Economic Crisis and How Can it be Resolved or Avoided in the Future? Journal of Law and Sustainable Development. 2023;11(6):e1221-e.\u003c/li\u003e\n\u003cli\u003eAbouzeid M, Habib RR, Jabbour S, Mokdad AH, Nuwayhid I. Lebanon\u0026apos;s humanitarian crisis escalates after the Beirut blast. The Lancet (British edition). 2020;396(10260):1380-2.\u003c/li\u003e\n\u003cli\u003eBosqui T. 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Mental health of refugees and migrants during the COVID-19 pandemic: The role of experienced discrimination and daily stressors. International Journal of Environmental Research and Public Health. 2021;18(12):6354.\u003c/li\u003e\n\u003cli\u003eLumey L, van Poppel FW. The Dutch famine of 1944-45 as a human laboratory: Changes in the early life environment and adult health. Early life nutrition and adult health and development. 2013;3:59-70.\u003c/li\u003e\n\u003cli\u003eZimmet P, Shi Z, El-Osta A, Ji L. Epidemic T2DM, early development and epigenetics: implications of the Chinese Famine. Nature Reviews Endocrinology. 2018;14(12):738-46.\u003c/li\u003e\n\u003cli\u003eSrichaikul K, Hegele RA, Jenkins DJ. Great Chinese Famine and the Effects on Cardiometabolic Health for Future Generations. 2022;79(3):532-5.\u003c/li\u003e\n\u003cli\u003eHarper C, Marcus R, Moore K. Enduring poverty and the conditions of childhood: lifecourse and intergenerational poverty transmissions. World development. 2003;31(3):535-54.\u003c/li\u003e\n\u003cli\u003eCrain M, Poster W, Cherry M. Invisible labor: Hidden work in the contemporary world: Univ of California Press; 2016.\u003c/li\u003e\n\u003cli\u003eCastells M. A Sociology of Power: My Intellectual Journey. Annual Review of Sociology. 2016;42(1):1-19.\u003c/li\u003e\n\u003cli\u003eJames M. \u0026lsquo;Who Can Sing the Song of MSF?\u0026rsquo;: The Politics of \u0026lsquo;Proximity\u0026rsquo;and Performing Humanitarianism in Eastern DRC. Journal of Humanitarian Affairs. 2020;2(2):31-9.\u003c/li\u003e\n\u003cli\u003ePurvis K. Stigma, guilt and gaps in the system; it\u0026apos;s time for NGOs to step up on staff mental health. The Guardian. 2015;Sect. Working in development.\u003c/li\u003e\n\u003cli\u003eLeaning J, Spiegel P, Crisp J. Public health equity in refugee situations. Conflict and Health. 2011;5:1-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"NCDs in Emergencies, Refugee Health, Health Systems Resilience, Thalassemia care","lastPublishedDoi":"10.21203/rs.3.rs-5836496/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5836496/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLebanon\u0026rsquo;s recent history has been marked by intersecting crises, including a severe economic collapse, the Beirut port explosion, and the COVID-19 pandemic. Amidst this \"polycrisis,\" the healthcare system has become increasingly reliant on international humanitarian assistance. This paper examines how these overlapping crises have affected the provision of care for children with thalassemia, a neglected non-communicable disease (NCD), within a \u003cem\u003eM\u0026eacute;decins Sans Fronti\u0026egrave;res (MSF)\u003c/em\u003e paediatric unit operating in Lebanon between 2018 and 2023. Drawing on a single-case study design, the research explores the dynamics of power between state and non-state actors and within international humanitarian organizations and their approaches to healthcare delivery.\u003c/p\u003e \u003cp\u003eThe study employed a mixed-methods approach, including audio diaries, interviews, document analysis, and co-development groups involving 11 staff members and 18 caregivers of Syrian paediatric patients. Participants shared insights into operational challenges, decision-making processes, and the lived experiences of navigating Lebanon\u0026rsquo;s collapsing health system.\u003c/p\u003e \u003cp\u003eFindings reveal three interconnected issues: (1) the polycrises created an unsustainable environment even for resource-rich international non-governmental organizations (iNGOs); (2) the withdrawal of humanitarian services exacerbated the suffering of structurally marginalized Syrian families reliant on no-cost thalassemia treatment; and (3) national staff experienced profound professional and personal challenges as they sought to reconcile iNGO decision-making with patients' needs, often leading to burnout and reduced well-being.\u003c/p\u003e \u003cp\u003eThe study underscores the need for a paradigm shift in the relationship between international humanitarian organizations and local health authorities. Greater equity in decision-making, grounded in shared values, is essential to recalibrate the humanitarian healthcare model. This reorientation should prioritize not only operational costs but also the population-level and individual value of healthcare, particularly for vulnerable groups. In Lebanon, a reimagined model of care is critical for addressing structural inequities and mitigating the fragility of humanitarian healthcare amidst enduring crises.\u003c/p\u003e","manuscriptTitle":"A Chronicle of Crises and Emergencies: (Dis-)continuity of care for Syrian Refugee Children with Neglected Non-communicable Diseases in Lebanon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-20 07:33:26","doi":"10.21203/rs.3.rs-5836496/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-26T15:09:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-13T14:07:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"111404744138263864959917030393453035073","date":"2025-02-28T12:42:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195641825392222645102377652033560249531","date":"2025-02-28T05:54:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-18T06:57:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160698829566073867059419937510170616803","date":"2025-01-22T14:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124346556926206787473230620385055186040","date":"2025-01-21T22:46:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-21T22:12:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-16T11:29:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-16T11:26:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2025-01-15T17:37:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9d50316-5097-4749-bd71-92a2ad10d93d","owner":[],"postedDate":"January 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T15:59:06+00:00","versionOfRecord":{"articleIdentity":"rs-5836496","link":"https://doi.org/10.1186/s13031-025-00670-4","journal":{"identity":"conflict-and-health","isVorOnly":false,"title":"Conflict and Health"},"publishedOn":"2025-05-30 15:56:50","publishedOnDateReadable":"May 30th, 2025"},"versionCreatedAt":"2025-01-20 07:33:26","video":"","vorDoi":"10.1186/s13031-025-00670-4","vorDoiUrl":"https://doi.org/10.1186/s13031-025-00670-4","workflowStages":[]},"version":"v1","identity":"rs-5836496","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5836496","identity":"rs-5836496","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}