Social Science & Medicine 82 (2013) 43e50

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Social Science & Medicine

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Bedouin in Lebanon: Social discrimination, political exclusion, and compromised health care
Dawn Chatty a, *, Nisrine Mansour a, Nasser Yassin b
a b

Refugee Studies Centre, Department of International Development, University of Oxford, 3 Manseld Road, OX1 9TB Oxford, UK Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

a r t i c l e i n f o
Article history: Available online 16 January 2013 Keywords: Lebanon Middle East Bedouin Access to health care Social discrimination Political exclusion Compromised health care Rural health care

a b s t r a c t
Global inequalities in health have long been associated with disparities between rich and poor nations. The middle-income countries of the Levant (Lebanon, Syria and Jordan) have developed models of health care delivery that mirror the often complex make-up of their states. In Lebanon, which is characterized by political clientelism and sectarian structures, access to health care is more contingent on ethnicity and religious afliation than on poverty. This case study of the Bedouin of the Middle Bekaa Valley of Lebanon is based on interviews with policymakers, health care providers and the Bedouin as part of a study funded by the European Commission between 2006 and 2010. The study explores the importance of considering social discrimination and political exclusion in understanding compromised health care. Three decades after the Declaration of Alma Ata (1978), which declared that an acceptable level of health care for all should be attained by the year 2000, the Bedouin community of Lebanon remains largely invisible to the government and, thus, invisible to national health care policy and practice. They experience signicant social discrimination from health practitioners and policymakers alike. Their unfair treatment under the health system is generally disassociated from issues of wealth or poverty; it is manifested in issues of access and use, discrimination, and resistance and agency. Overcoming their political exclusion and recognizing the social discrimination they face are steps that can be taken to protect and promote equal access to basic reproductive and child health care. This case study of the Bedouin in Lebanon is also relevant to the health needs of other marginalized populations in remote and rural areas. 2013 Published by Elsevier Ltd.

Introduction This paper examines the extent to which public sector health care in a middle-income country is adequate and accessible for marginalized, rural and formerly nomadic tribal populations. It describes a case study carried out in Lebanon between 2007 and 2010 to determine how and under what constraints the Bedouin accessed health care (Barbir, 2010; Chatty, 2010b; El-Kak, 2010; Mansour, 2010). Health inequality or health disparities refer to the differences in the quality of health and health care between groups of different racial and ethnic backgrounds, sexual orientations and income levels. After the initial euphoria of the 1978 Alma-Ata conference, when health for all was assumed to be possible by making free health care services available to entire populations, came the realization that severe economic difculties made free governmentprovided primary health care unrealistic.
* Corresponding author. Tel.: 44 (0)1865 281715. E-mail address: dawn.chatty@qeh.ox.ac.uk (D. Chatty). 0277-9536/$ e see front matter 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.socscimed.2013.01.003

Now, early in the 21st century, there is renewed concern for poverty and equity in health (Leon & Walt, 2001). In her statement in the 1999 World Health Report, the WHO Director-General, Dr. Gro Brundtland, wrote, First and foremost, there is a need to reduce greatly the burden of excess mortality and morbidity suffered by the poor (WHO 1999). This was followed by the eight Millennium Development Goals goals, three of which specically address poverty, child health, and maternal health. The impact of poverty on health outcomes is evident in studies across the world (Kawachi & Kennedy, 1997). Infectious diseases as well as non-communicable diseases have been linked to poverty (Marmot, 2005). Income disparities are also evident in the utilization of health services (Wagstaff, 2002). Non-economic forms of inequality and their links to health have also been investigated, including those related to social capital (Campbell & McLean, 2002) and cultural capital (Khawaja and Mowa, 2006). Much of the health economics literature does not accept the existence of a causal relationship between income and health, expect possibly through the purchase of health care (Deaton, 2003). Horizontal inequalities in health and skewed access to health care between different ethnic or cultural groups are

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gaining more attention among scholars. Nazroo, Falaschetti, Pierce, and Primatesta (2009) have shown how inequalities exist between ethnic groups in England in terms of their access to hospital and dental care. Yet limited attention has been given to the impact of social discrimination and political exclusion on health and access to health care, particularly in middle- and low-income countries. This merits specic consideration of these factors, specically on the ways in which ethnic identity and citizenship status e including the lack of citizenship e inuence health outcomes and access to health care. This case study of the Bedouin in the Bekaa Valley of Lebanon examines the impact of social discrimination and political exclusion e through lack of nationality e on health and access to health care. It argues that unequal access to health care, particularly reproductive and child health care, as seen among the rural Bedouin in Lebanon, is less related to issues of income or poverty and is more closely linked to issues of social discrimination, political exclusion and ethnicity. The case study is framed around three general issues: 1. Access to and use of health care facilities 2. The perception and experience of discrimination 3. The resilience and agency of Bedouin in accessing adequate health care What emerges in this study and what is detailed below is the recognition that the long history of social discrimination and the lack of nationality and a political voice have profoundly impacted how the Bedouin access acceptable health care, particularly reproductive and child health care, in Lebanon. Case study of the Bedouin of the Bekaa Valley Background The term bedouin [bedu] is derived from the Arabic word badia, the semi-arid and steppe land that covers much of Northern Arabia. The Bekaa Valley is the western-most nger of the badia. Numerous Bedouin tribes have moved into and out of the Bekaa Valley during their yearly seasonal migrations (Burckhardt, 1822; Chatty, 1977; Cole, 2003). There are accounts of the Bedouin presence in the Bekaa Valley as early as the 13th century (Oppenheimer, 1939, p. 325) (Map 1). During the establishment of their League of Nations Mandate over Greater Syria in the early 1920s, the French created the predominantly Christian country of Lebanon primarily by attaching the Bekaa Valley to Mount Lebanon. They began collecting statistical records in 1926 and conducted the rst and only census of the population in 1932. Many Bedouin were not registered in this count, either because they happened to be migrating in the badia or because they refused to be registered to show their opposition to the French colonial presence. Large swaths of pastoral land in the Bekaa valley were divided and redistributed for agricultural use. The majority of the Bedouin in the Bekaa Valley were not able to purchase land, nor did they have access to education and public health care. By the mid-20th century, many Bedouin found themselves relegated to marginal areas within this rapidly developing area of agricultural production. Some Bedouin diversied and developed multi-resource agro-pastoral economies. The Bedouin who could not afford the investment in agricultural machinery or transportation sought employment in the rapidly diversifying agricultural sector in the Bekaa. Throughout the region, the governments of the Levant regarded nomadic pastoralists as anachronisms; throw-backs to a past era (Chatty 1986, 2006, p. 1) and worked hard to settle them or pushed them to the margins of the state (Chatty, 2006, 2010a). In
Map 1. Map of Lebanon and the Bekaa valley.

Lebanon, the Bedouin pastoral sheepherders were largely excluded from the benets of nationality or citizenship, including joining the civil service or the states armed forces, access to free education in public schools and national university, and access to hospitalization and the National Social Security Fund (NSSF). Several categories of nationality apply to the Bedouin and other groups (e.g., the Kurds): full citizenship and two categories of statelessness. The rst is citizenship under study (qayd al dars), and the second is without records (maktum al qayd). The few Bedouin who were registered in the French census of 1932 were granted full citizenship. In 1958, the Lebanese government issued a type of amnesty and permitted the Bedouin without citizenship to register. These individuals were categorized into the citizenship under study or qayd al dars group. In 1994, the government granted approximately 10,000 Bedouin with qayd al dars documentation full citizenship, the full benets of which would come into effect after a 10-year waiting period. However, an appeal by a Maronite party has extended the waiting period indenitely, and the children of the Bedouin with citizenship under study (qayd al dars) papers are considered stateless without documentation (maktum al qayd). Although there is no census data more recent than 1932, the election rolls for 2009 showing Bedouin voters in the districts of the Bekaa Valley included approximately 15,000 voters. A guestimate of the number of individuals with voting rights (and thus full citizenship) is approximately 40e50,000. Those with qayd al dars papers also number approximately 40e50,000, and those with no papers or who are stateless comprise the last third (approximately 50,000) of the Bedouin in the Bekaa Valley. Of a total of approximately 150,000 Bedouin in Lebanon, the majority does not have full citizenship (Chatty, 2010b), and is thus excluded from all government social and health service provisions (Table 1). By the early 1970s, researchers in Lebanon became interested in understanding the impact of sedentarization on Bedouin society.

D. Chatty et al. / Social Science & Medicine 82 (2013) 43e50 Table 1 Lebanese citizenship categories and legal status. Type of ID papers Lebanese nationality ID prior to 1994 Lebanese nationality ID post 1994 Signicance Full rights of citizenship Requires 10-year waiting period before rights to birth registration, land ownership, employment and voting rights take effect; the waiting period extended indenitely as a result of the 2000 appeal by the Rabita al Marouniya Nationality under study; recognition of birthplace in Lebanon; rights not yet guaranteed Nationality unknown; no recognition of birthplace as Lebanon

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Qayd al dars Maktum al Qayd

The health-related literature was concerned with the nutritional impact that sedentary life had on Bedouin children in Lebanon (Babaae, Shaarb, Hamadeh, & Adrad, 1991; Dagan et al., 1983). This research mirrored similar work with the Bedouin in other regions of the Middle East, such as Foreman and Hundts work in the 1990s in Gaza and the Negev (1995) and Neil Spicers work in the early 2000s in Jordan (2005). More recently in Lebanon, Susan Joseph has turned her attention to the changing patterns of fertility among the Bedouin, showing a drop in fertility from the high during the French mandate era Joseph (2007). Health care in Lebanon The current health system in Lebanon is characterized by heavy reliance on the private and non-prot sectors. State bodies provide systematic coverage through national health programs to approximately 45% of the population. The remaining 65%, who are composed mainly of disadvantaged segments of the population, resort to non-systematic subsidies provided by the Ministry of Public Health and the NGO sector. Lebanese nationals, who are mostly employed in the informal economy (e.g., as microbusiness people, farmers, and shermen), are not covered by any of the above schemes and rely on the Ministry of Public Health subsidies to cover hospitalization costs at private and non-prot hospitals. However, these subsidies are not systematically approved, and patients need to go through an approval process on a case-by-case basis, often using wasta (connections) to wield political and sectarian inuence within the Ministry of Public Health (Gilsenan, 1985; Inhorn, 2004). As a result of the Lebanese civil war legacy and insufcient state health subsidies, Lebanon has a thriving private and non-prot health sector that caters to the unsponsored 65% of the population. During the 1975e1990 civil war, a wave of secular and religious non-governmental health providers emerged. The various militia groups and warring parties set out to create state-like health services. Examples include the health facilities of the Palestinian Liberation Organization (PLO), the Hariri Foundation, and Hizbollahs health facilities, in addition to the Lebanese Red Crescent, the Palestinian Red Crescent, and the Lebanese Red Cross. They have all expanded their activities to include primary and secondary health care in rural areas with disadvantaged populations. Methods This study was part of a European Commission-funded research project to examine the health care access and quality of health care for marginalized rural people in Lebanon and Jordan that took place between 2006 and 2010 (Chatty, 2010b; Hasna, Lewando Hundt, Smeiran, & Alzaroo, 2010; Lewando Hundt, Alzaroo, Hasna, & Alsmeiran, 2012). This study focused on the Bedouin in Lebanon

and sought to understand how they accessed reproductive and child health care and to explore the barriers to access. The study employed a range of research methods: a review of clinical records of utilization, facilities and stafng; ethnographic observations of health practitioners interactions and health management practices with the Bedouin and other patients; structured questionnaires, semiformal interviews, in-depth interviews and focus group interviews with policymakers, practitioners and the Bedouin. Prior to commencing the study, the PI, who had conducted ethnographic research with this community, returned to the Western Bekaa Valley after a 30-year absence to identify possible Bedouin communities, to meet with Bedouin tribal leaders to gain their support for the study and to identify possible partners and potential eld study clusters. After an agreement to conduct the study had been reached with the local Bedouin and a local female Bedouin liaison ofcer had been appointed, the Minister of Public Health was also approached for permission (which was granted) to conduct medical audits and ethnographic observations in some of the countrys rural health clinics. The studys mixed methods were conducted in stages over a period of 18 months, starting with the formal quantitative tools and concluding with the more participatory and qualitative ones. Health clinic audits took place in six one-week data collection sessions. Six rural health centers were identied in the heart of the study area: two governmental centers, two private centers, and two NGO-afliated health units. These clinics were purposively selected because they were all located in areas with a high density of unofcial Bedouin settlements. The one-week engagements at each clinic involved two researchers who carried out a medical audit checklist, administered a questionnaire to the clinical staff, and conducted ethnographic observations related to Bedouin health care delivery at the clinic. A short socio-economic survey was conducted with 20 Bedouin women visiting each of the six health facilities. These informants were selected purposively at predetermined intervals during the week of the ethnographic observations to capture a representative range of users, taking age, economic status (reported family income) and sub-ethnic afliation into account. The next stage of data collection focused exclusively on qualitative data from semi-formal interviews with health practitioners (7) and policymakers (9), in-depth interviews with Bedouin women (42) and key rural men (6) and focus discussion groups with health practitioners (2) and Bedouin women (2). The semi-formal interviews with health policymakers and service providers were conducted to develop an understanding of current health provisions as well as attitudes and perceptions regarding the Bedouin. The in-depth interviews were conducted with a sub-sample of the Bedouin women who had been surveyed at the health clinics. The PI conducted in-depth training with the research team, honing their interview skills, paying close attention to possible reexivity, preconceptions, and potential interview bias (Malterud, 2001). These interviews explored household care-seeking behavior, the medical histories of their children and reproductive histories of the women, their immediate health concerns and their movements over the past year while seeking medical care (Table 2). These semi-formal and in-depth interviews were all transcribed and translated into English by the bilingual researchers themselves. The interviews were then entered into QSR Internationals NVivo7 software to conduct a computer-assisted analysis of ndings. The interviews were read independently by two researchers to identify emergent themes. After discussions with the larger research team, a coding template was created and used by one of the researchers (NM) to code the interviews. The interviews were organized in such a way that it was possible to pool the document sets from policymakers, health care practitioners and the Bedouin to analyze the stakeholders separately as needed. The survey results were input

46 Table 2 Summary of interviews. Type of interviews Structured questionnaire/survey Total number 111 Comments

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indicated that they were stateless. A preliminary review of the data showed widespread concern over naturalization and access to health care. Thus, a desk study of Lebanese nationality categories was also undertaken. Access to and use of health care facilities Accessing health services in Lebanon is two-tiered. There is access to primary health care and polyclinics, and there is access to secondary health care, mostly hospitals. The Bedouin women largely complained that although they were permitted access to the primary health care clinics, they had to pay the full cost of treatment like other non-Lebanese groups, such as Palestinian refugees, and other newcomers, such as the stateless Kurds. With regard to accessing treatment in secondary health care hospitals, the Bedouin women were very outspoken about their general exclusion from the subsidized care that full citizens were able to access. Even though they were present in the Bekaa Valley for centuries before the creation of the modern state, the Bedouin were mostly undocumented in the civic records of the state and found their access to health care limited and unequal to the access given to full citizens. One respondent explained the problems she faced in delivering her child: When I got to my ninth month of pregnancy, I went back to see my usual gynecologist, and she told me that I needed a C-section at the governmental hospital [in the nearby city]. I went there, but the problem was that I didnt have an ID, so the Ministry [s subsidies] wouldnt cover me. [.]. So at the hospital, they said that if I gave birth at my own expense, we would have to pay 900,000 L.L ($US 600) [.]. So we went to another doctor who promised to help me deliver at [a non-governmental] hospital for less. So it ended up costing us 450,000 L.L [$US300] (BW021, 2008). Obtaining nationality so that they would be able to gain access to adequate health care was a key concern for the majority of the Bedouin. As one Bedouin respondent explained, Many people applied wrong [in 1994]. The head of the household would be registered as unmarried, for example, and he would think that he would get citizenship rst and later get it for his wife and children (RK05, 2008). Later, though, that would prove to be impossible. Another Bedouin respondent described her experience with the process as follows: All my children applied with me [to get Lebanese citizenship]. [.] An employee at the Ministry of Interior took [my sons] name out of the application le. He said that they received an order to do so. We all got Lebanese citizenship except for him (BW49, 2008). The processes used to gain equal access to government services, particularly health services, became deeply politicized. As one Bedouin respondent explained: After the 1960s naturalization wave, sectarianism started playing a role, on the basis of the sectarian balance between the Muslims and the Christians. The Christians took citizenship, while other people did not. I personally know people who were told by the civics records judges that if they converted to Christianity, they would get citizenship right away (RK15, 2008). Our interviews revealed that the stateless Bedouin had limited access to national primary health care and were excluded from the government subsidies for hospitalization. Discrimination in health care delivery and policy The inequality of access that the Bedouin face in terms of restricted citizenship and reduced health entitlements was

In-depth interviews with Bedouin women In-depth interviews with Bedouin men In-depth interviews with key male rural residents Semi-formal interviews with service providers Semi-formal interviews with policymakers Focus group discussions with service providers Focus group discussion with Bedouin women

42

4 7

2 2

Conducted at the 6 health clinics that were being audited and where ethnographic observations were being conducted. Selected from the larger sample to achieve a full range of ages, economic statuses and afliations. Opportunistic interviews using educational level and economic status as selection criteria. 2 Bedouin and 2 non-Bedouin (in a joint interview). 2 midwives, 1 obstetrician, 1 center manager, 1 nurse, 2 government ofcials. Ministry of Public Health, Ministry of Social Affairs, UNFPA, UNICEF, NGOs (3), private sector (2). Staff from two of the sampled clinics took part. Women from two of the informal Bedouin settlements took part.

into Excel and used alongside the NVivo data sets to create a deeper and more complex prole of the 42 Bedouin women who took part in both the survey and the in-depth interviews. Ethics Formal ethics approval was sought from the central ethics committees of the Universities of Warwick and Oxford because the American University of Beirut did not have a central research ethics committee at the time. Ethics approval was granted. Consent forms were developed, respecting the ethical standards expected by all three universities, and translated into Arabic. These were read aloud to all participants, who were also advised that their informed consent had to be freely given before participating in the study. The participants were not asked to sign the consent forms. Instead, it was agreed in advance that each researcher would sign the consent forms after reading them aloud and receiving permission to continue. The researchers were encouraged to continue to seek informed consent and to advise the informants that they could withdraw from the study at any time. Informed consent was regarded as a continuous process throughout the study, and informed consent was regularly discussed with the respondents and re-conrmed throughout the course of the study. Results/ndings In total, more than 120 surveys of Bedouin women were collected, but because of irregularities and missing data, only 111 surveys were used to purposively select a representative sample for in-depth interviewing and to enrich the analysis of the qualitative data. The Bedouin women in our sample were users of a cluster of six clinics that provided health care to the rural poor of the Middle Bekaa Valley in Lebanon. The service providers interviewed were health practitioners in the local community with long-established ties to the municipalities in which they lived. The policymakers interviewed were mostly members of the educated elite of Beirut. Most of the 111 Bedouin women respondents reported that their husbands worked in the informal economy as agricultural laborers, drivers and occasionally small-scale entrepreneurs. Half of the respondents were asked about their nationality, and 50% of them

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accompanied by discriminatory attitudes among service providers and policymakers. From the interviews with practitioners and policymakers, we found that the Bedouin were viewed as a problematic social group. The largely negative prole of the Bedouin consisted of unsupported generalizations about Bedouin social practices, including presumptions of high levels of early marriage, consanguineous marriages and promiscuity. Only the policymakers presumption of high fertility appears to be supported by the survey results. In terms of the number of children, 34.23% of respondents reported having between one and three children, a gure close to the national average. The second highest gure was 24.32% with 4e 6 children, followed by 21.62% with 7e9 children and only 4.5% with 10e13 children. These ndings are also conrmed by Joseph (2007). For the most part, the ndings from our survey contested the negative generalizations about the Bedouin made by policymakers and practitioners. The survey of 111 Bedouin women indicated that 17.12% of the respondents entered their rst marriage between the ages of 13e15, 51.35% of respondents married between 16 and 20, 21.62% married between the ages of 21e25, and 9.19% married after reaching the age of 26 years. From the sample, the gures of early marriage (below 15 years) are signicantly higher than the national averages (estimated at approximately 2% by the 2009 Central Administration of Statistics). However, contrary to the policymakers assumptions, those who marry early remain a minority among the Bedouin; the majority of the sample was spread across various age brackets above 16 years of age. The results of the survey also indicated that the rate of polygamous marriages was dramatically lower than those assumed by policymakers. Of the respondents, 88.29% identied themselves as the only wife in the household. Furthermore, the survey data indicated that marriage between cousins was not as prevalent as policymakers assumed. Of the respondents, 40.54% of the respondents were not related to their husbands, while 32% were rst cousins of their husbands, and 18.2% were distant cousins married to members of the same tribe. These gures match the national estimates of consanguineous marriages (31%) reported by Barbour and Salameh (2009), but they are higher than the gures recorded in the Lebanese Ministry of Public Health Survey (1998), which reported that 21% of the marriages in Lebanon were consanguineous marriages, with 18% between rst cousins. These ndings indicate that many of the policymakers perceptions are largely unfounded. Nonetheless, these perceptions are incorporated into the ofcial policymaking discourse. For example, one policymaker working on national maternal health policies showed very little knowledge of the Bedouin inhabitants of the Bekaa and held stereotypical perceptions of them, stating that a Bedouin man can take several wives, mostly from his clan, because the aim is to increase the number of children. (PM03, 2008). The Bedouin were not featured in any national health policy priorities. Until recently, immunization campaigns excluded Bedouin children and did not target the informal settlements where they resided. These settlements were unrecognized by the state and did not appear on any geographic or administrative maps. The residents lacked basic government services, such as water, electricity and waste collection. Furthermore, public health campaigns did not include these unrecognized settlements. School immunization programs also tended to miss Bedouin children because they were often pulled out of education early to work in factories and at harvest time. One Bedouin parent who felt no entitlement to government services gave an indication of how deeply rooted this social discrimination has become. She explained: There was an announcement in the local mosque about an immunization campaign, but we thought it was only for Lebanese citizens, and thus, we did not take our children there (BW121, 2008).

One policymaker justied the social exclusion of the Bedouin as a case self-exclusion. She said that the Bedouin exclude themselves from services. Whenever we try to reach out to them, they say, Dont come to us. We dont want to participate in the campaigns; we are free (PM06, 2007). Other policymakers regarded the Bedouin as foreigners or intruders, as opposed to authentic Lebanese non-Bedouin citizens. Health provisions and services for the Bedouin were mainly provided by NGOs, such as the Red Crescent and the Palestinian Red Crescent, who also catered to other disadvantaged groups, such as Palestinian refugees and other refugee communities in Lebanon. These facilities were overcrowded and understaffed. In the private and non-governmental facilities to which the Bedouin generally turned, our eldwork registered uneven service quality. The quality of service primarily depended on the attitudes of individual service providers. In most cases, Bedouin respondents reported widespread ill treatment from administrative and support staff in the form of delayed admissions to consultations and verbal abuse. As one respondent indicated: I took my son to the dispensary on a Thursday because they told me that the doctor holds clinic hours on that day. So I was standing there, not doing anything, and a woman who worked there came and started screaming at me, the doctor is not coming, dont go into the clinic waiting room because you will make it dirty. Then, two [non-Bedouin] women came after me and she let them in and allowed them to sit down. So I went to her and berated her about what she did [.] They started gossiping about me: Look, she is a Bedouin (BW060, 2008). The doctors in these clinics are subcontracted as independent practitioners. Hence, they collect the consultation fee directly from the patients, leaving only a small cut for the facility. However, the Bedouin respondents reported that although they paid the full consultation fees, the doctors kept the consultation time to a minimum and did not adequately explain the medical conditions and the treatment process to them. One respondent narrated the negative experience she had with a doctor: I took my daughter to a doctor who specialized in orthopedics. I took her two or three times, and he would just prescribe her medication. He would mock me, give me medication and tell me to go. And my daughter didnt get any better (BW109, 2008). The resilience and agency of the Bedouin in accessing acceptable health care The political exclusion and social discrimination the Bedouin face in Lebanon has impacted the strategies they use to access and utilize health services. Many Bedouin reported that they shopped around for health services that cost the least, exposed them to the least verbal abuse and discrimination, and had a good medical reputation. One respondent explained that she used the services of a particular gynecologist who helped her cut consultation costs: During my pregnancy, I had some complications, and I went to my doctor regularly. [.] Look, [the gynecologist] is good, she feels for her patients. She knew about my tight nancial situation. She would tell me stop coming to see me. Your health situation is manageable; just put the IV in and take vitamin injections, go to the pharmacy and let the pharmacist call me [.] (BW044, 2008). Some Bedouin respondents also reported traveling to Syria, where universal health care is provided. Bedouin patients crossed the border legally (or illegally if they did not have an ID) to seek free health care in Syria. The services in Syria were also often suggested to them by Lebanese doctors. In one example, a Bedouin

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respondent explained that hospitalization in Syria was one of the regular options proposed by her doctors: The doctor told me that I had to run a scan urgently, either in Beirut or Damascus. [.]. Why did he suggest Damascus? Because he knows I can get in without papers (BW064, 2008). Others without IDs reported overcoming the citizenship requirement for hospitalization in Lebanon by borrowing ID cards from relatives or friends with full citizenship. One Bedouin respondent who was registered as a single woman in 1994 explained that she could not use her single status ID to access hospital gynecological services. Because she was not allowed to correct her marital status due to administrative bias, she could not go to the hospital to access care provided only to married women: If I need surgery, I will be an unmarried woman [as stated on her ID], and I cannot get gynecological surgery. My ID has become useless. If I need to go into surgery, I will need to use my sisters ID (BW152, 2007). Some Bedouin women have begun to confront health inequalities by recognizing the value of their purchasing power as private health care consumers. As one respondent reported: Yes [.], there is negligence in the hospital. Yes, we told [the nurse], the IV stopped, and there is something wrong with it; we dont know how to x it. Please come and make it work again. She [the nurse] said to us, "What? I am busy now; I have other things to do". [.] How do we take care of it ourselves? We are in a hospital, we paid money, and we have a receipt. How can they deny us that? (BW025, 2007). The Bedouin are also beginning to manipulate their Bedouinness along political lines. Those with full citizenship have found that they are emerging as signicant political actors who have voting power they can use to seek greater health care access via their political patrons. As one Bedouin respondent explained after a difcult delivery that entailed a ten-day hospital stay: The hospital bill was $US 5000, and the hospital staff did not want to release [her daughter] before I settled the bill. [A Bedouin leader] called the owner of the hospital, who was running in an election. He told him that he had control over hundreds of the Bedouins votes. He [the Bedouin leader] told the owner of the hospital that they had to release me without asking for any money from me. . I told him that I didnt have any money, that I wanted to leave the child in the hospital as a guarantee and that I would come back to pay and collect her when I got the money. The hospital owner said, Dont worry, you can leave (twakali ala allah). I gave him a vow that I would vote for him and also secure twenty other votes for him. I told him I would vote for him for sure, and I hoped that he would win (BW51, 2008). Bedouin leaders are beginning to capitalize on the voting power of their relatives to bargain for enhanced health care provision. Discussion In the course of conducting this case study, both interviewee and researcher bias emerged and needed to be addressed. Interviewee bias became clear during the regular monitoring of the qualitative interviewing phase. Bias was mainly manifested as social desirability bias, whereby the respondents found it hard to open up to interviewers who do not share their reproductive experiences (Fenton, Johnson, McManus, & Erens, 2001). Married Bedouin women were not prepared for an open discussion with the unmarried Lebanese researchers on the team. A third married researcher with children was recruited to conduct fresh interviews. She was

able to elicit much more detailed and intimate responses to questions regarding reproductive and child health. Therefore, in future research on similar subjects, special care needs to be taken to select appropriate researchers for such study. Furthermore, researcher bias was detected early in the interviewing phase by the PI when monitoring the transcripts of interviews with health policy-making elites in Beirut (Hochschild, 2009). One of the project researchers was well-known in government circles and a popular gure on healthrelated TV shows. In these interviews, the policymakers deferred to the knowledge of the interviewer, expressing ignorance or lack of knowledge in his presence. These interviews were conducted again by another member of the research team. In future research on similar subjects, special training in elite interviewing needs to be integrated into the preparation for data collection phase of the projects development. The complex nationality status of the Bedouin in Lebanon affected their effective entitlements to equality in subsidized health care, both for primary and secondary health care. Our interviews revealed that the stateless Bedouin were allowed to access the national primary health care facilities run by the Ministry of Social Affairs and the Ministry of Public Health. However, they were not entitled to the subsidized or free medication or treatment distributed in these dispensaries. To receive free medication or subsidized treatment, Lebanese ID cards needed to be shown. In terms of secondary health care, the stateless Bedouin, both documented (citizenship under study qayd al-dars) and undocumented (no records maktum al qayd), were legally excluded from the governments hospital subsidies. This exclusion left the Bedouin no choice but to seek health care through private and non-governmental health care providers. In governmental and non-governmental facilities alike, our eldwork registered uneven quality in the provision of services. The quality of health care services primarily depended on the attitudes of individual service providers. In most cases, the Bedouin respondents reported widespread ill treatment and discriminatory practices, such as delayed admissions to consultations and verbal abuse (e.g., remarking publically that the Bedouin were dirty and smelly). Doctors were generally more respectful than other health care staff during encounters. Nevertheless, the Bedouin reported that although they paid full consultation fees, they felt they were treated like less deserving customers by the health care providers. Social discrimination was widespread among policymakers and service providers; these discriminatory attitudes (often including verbal abuse) were well-known among the Bedouin. Consequently, they avoided certain practitioners when they determined which practitioners to visit for particular ailments or concerns. Such discrimination is common throughout the Levant and has been recorded in Jordan, Israel and Syria, where the Bedouin are all recognized as citizens and thus have a political voice (Chatty, 2010b; Forman et al., 1995; Lewando Hundt et al., 2012). In Lebanon, however, most Bedouin do not have citizenship. Those who do are just beginning to discover the power they may be able to exercise through political engagement in local and municipal elections. The Bedouin with citizenship are being wooed by various political parties, and their votes are eagerly sought. Bedouin community leaders are beginning to use this newly developed power to demand better services, including health care, for their people. Bedouin agency with regards to demanding adequate health care is clearly beginning to impact on how they conduct their relationships in the political arena. Bedouin leaders are capitalizing on the voting power of their incipient constituency. Furthermore, political patronage is gaining ground among the disadvantaged Bedouin, and these changes are shaping Bedouin interactions and integration into the complex Lebanese political system. The ndings from our eldwork suggest that the Bedouin living in the Bekaa experience difculty accessing health care, social

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discrimination and political exclusion. The difculties with the health care system experienced by the Bedouin are distinct from those experienced by other low-income users in the area. The Bedouin population experiences less than adequate care, largely as a result of the xenophobic social discrimination they face from Lebanese political and health policy actors as well as health service providers. It is clear that the Bedouin respondents face major issues with statutory access to free or subsidized state health care. The unfair treatment in the current health system seen in the residual and mixed nature of the provision of health care is far from providing universal access to users. The current system only covers or subsidizes the cost of primary and secondary health care for citizens. In other words, access to subsidized health care is exclusionary in nature; it is restricted to those who hold Lebanese citizenship. The unequal provision of health care is crucial to understanding the extent of the discrimination faced by the Bedouin in Lebanon in terms of access to health. Thus, the indigenous but stateless Bedouin populations in Lebanon are not entitled to subsidized services. They cannot use public health facilities, register land in their names, enroll their children in state schools, register their marriages, or become employed in the public sector. The Bedouin of the Bekaa Valley get around these restrictions by registering land in someone elses name, borrowing someone elses identity card, and utilizing private or NGO health services. Conclusion This study agged the importance of recognizing a range of noneconomic factors to understand the phenomenon of unequal access to health care in rural Lebanon. These health care disparities emerge from more than low income alone; they must also be recognized as the product of social discrimination and political exclusion. In such cases, the population is left with no option other than nding the means to pay for health care that other social groups who experience less exclusion and less discrimination can access with government subsidies. The ndings from this case study indicate that most, if not all, rural health care services in Lebanon are private or NGO-operated, and this situation is unlikely to change in the near future. Lebanons other disadvantaged populations, such as those in the Akkar region, benet from substantial state-subsidized secondary health care as well as the support of a broad array of local and international NGOs. The extent of the social and political exclusion of Lebanons Bedouin population is only now beginning to be recognized. Soon, it may also be targeted by NGO activity promoted by the research project. This activity could promote greater awareness and encourage better provision of services to meet the actual health needs of the Bedouin e rather than the Orientalist perceptions of them e as well as reduce the social discrimination against them. Cultural training and sensitivity workshops have been developed for the staff at all six of the clinics that were part of this study. Furthermore, community health volunteers have been trained by the research project as liaisons between the Bedouin and health practitioners with the aim of reducing discrimination, disseminating health awareness messages, and creating greater treatment equality at these clinics. This case study extends our understanding of the phenomenon of compromised health care, particularly related to the issues of social and political discrimination against marginalized rural populations. Acknowledgments The ndings in this paper were drawn from a research project funded by the European Commission INCO-DEV Mediterranean Programme e STREP 015362.

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D. Chatty et al. / Social Science & Medicine 82 (2013) 43e50 Interview Interview Interview Interview Interview Interview Interview Interview Interview Interview Interview with with with with with with with with with with with Bedouin respondent BW49, Taanayel, 28 March 2008. Bedouin respondent BW51, Saadnayel, 07 August 2008. Bedouin respondent BW60, Mesherfeh, 12 June 2008. Bedouin respondent BW64, Faour, 17 May 2008. Bedouin respondent BW109, Saadnayel, 05 March 2008. Bedouin respondent BW121, Bahsasa, 23 February 2008. Bedouin respondent BW152, Mesherfeh, 22 November 2007. policymaker PM03, Beirut, 20 July 2008. policymaker PM06, Zahleh, 17 October 2007. key rural person RK05, Faour, 05 June 2008. key rural person RK15, Kab Elias, 01 March 2008.

Wagstaff, A. (2002). Inequality aversion, health inequalities and health achievement. Journal of Health Economics, Elsevier, 21(4), 627e641. World Health Organization. (1999). The world health report 1999: Making a difference. Geneva.

Interviews:
Interview with Bedouin respondent BW21, Bahsasa, 12 February 2008. Interview with Bedouin respondent BW25, Bar Elias, 7 October 2007. Interview with Bedouin respondent BW44, Faour, 22 February 2008.