When 77-year-old Sukaina Hodeib’s daughter died in 1997, the disabled grandmother of 12 was left homeless and destitute. With her floral hijab fastened carefully over her snow-white curls, she sits upright in bed in the room she shares with four other elderly and immobile residents at the Dar al-Ajaza al-Islamia hospital, a shelter for geriatric and psychiatric patients in Beirut’s southern suburbs, and thanks the nurses and God for saving her life.
“My other son and daughter couldn’t afford to keep me at their home and pay for my nursing and medical care,” she says. “So I came here.”
Her family, living far away in southern Lebanon, stopped visiting years ago. “This is my home now,” she says. “When I first came I couldn’t walk. I couldn’t take care of myself. Now, thanks to physiotherapy, I can make my bed, change my own diaper. I am semi-independent.”
Divorced and without a pension, Sukaina is a member of Lebanon’s growing elderly population to be housed in one of Beirut’s 11 nursing home or geriatric care facilities, which are mostly privately funded through confessional communities, and are often shared with psychiatric and other disability wards. With no access to assistance under the country’s outdated and cumbersome pension system, the vast majority of Lebanon’s elderly are left to rely on family for housing, care and support. A recent study by the international Journal of Nursing Studies on the caregiving role of family members cohabiting with older disabled relatives found that the typical caregiver in Lebanon is a 46-year-old married female, providing care to a 76-year-old frail mother with no insurance coverage.
But for those without such a daughter, “We replace the role of the family,” explains the hospital’s director Azzam Houry.
Dar al-Ajaza al-Islamia, like most such semi-private facilities, is just 40 percent funded by the Ministry of Health. “The rest is covered through donations, especially during (the Muslim Holy month of) Ramadan,” says Houry. With just under 300 beds for geriatric patients, he says, there is frequently a waiting list. That waiting list is only likely to get longer as Lebanon continues to urbanize.
Over the last century, Lebanon has witnessed a massive migration from villages to cities. Today, the capital of Beirut is home to over a quarter of the country’s four million residents. But while the governments of other countries have stepped in to help manage such demographic shifts, with public agencies supplementing the traditional caregiving role of families, a brutal 15-year civil war and decades of ensuing political insecurity have derailed reforms and arrested adaptive strategies in crisis-stricken Lebanon.
Social security is one entitlement whose reforms have fallen by the wayside. Several reform proposals have made it to parliament, but died on the vine as the country cycled through multiple governments. “Lebanon was the first country in the region to develop pensions — we were pioneers,” explains Nabil Kronfol, a professor of health policy and management and a cofounder of Lebanon’s Center for Studies on Aging. “But the concept was arrested in utero because of the civil war.”
The current pension scheme, adopted in 1964, provides for a one-off indemnity for public sector employees: civil servants, military and security personnel. The National Social Security Fund’s End of Service Indemnity System for private-sector employees also provides a one-off lump-sum payment of around eight percent of salary per working year for those who have completed 20 years of service upon retirement, offering little or no protection against poverty and the costs of deteriorating health in older age.
Meanwhile, with more than 58 percent of Lebanon’s work force either self-employed or working informal, low-paid, physically demanding jobs, large swathes of the retiring population do not have any access to social security or accumulated indemnity. Women, who make up a far lower percentage of the workforce, especially among the retirement-age population, are dependent on their spouses indemnity. This means the system covers only about 30 percent of the total workforce.
“There is a paradox with our pension fund: you pay while you are employed and when you actually need it, the money is not there,” says Kronfol.
Compounding the problem is Lebanon’s graying population. Lebanon is unique among Arab countries, with a relatively high 7.7 percent of its population over 65. This is projected to increase to 10.2 percent by 2025, given Lebanon’s decreasing birth rate and younger generations moving away. People are now also living longer — the average life expectancy in Lebanon is 77, while the retirement age remains at 64.
“The elderly in Lebanon are not looked after properly. I have no idea how they survive,” says Ibrahim Muhanna, an actuarial fund manager and pensions expert. “In developed countries, when cities grew, the government took over the control of some of the family roles where traditions were cut too quickly. But in Lebanon, the government doesn’t get involved. In this city [Beirut] we are on our own; the extended family is no longer there for us.”
Kronfol agrees. “All cultures in the world say, ‘Respect your elderly.’ But things are changing and these traditions are no longer applicable. Men and women are both working, you have one or two children instead of seven or eight. The children travel abroad. People don’t live in big houses, they are living in small apartments in Beirut. And the old are living longer.”
The biggest drawback of the current scheme, according to Muhanna, is that indemnity is paid out in one lump sum, rather than monthly installments. “The lump sum is never enough and when people do get it they spend,” he says.
Muhanna helped draft a new policy that he says will be presented to parliament, under the newly formed coalition cabinet, in the next six months. “They have crossed all the I’s and dotted all the T’s. Within the next six months parliament will start talking about this.”
In the meantime, the elderly are doing what they can to support their peers. Exasperated over the lack of political movement, Kronfol raised $30,000 to rehabilitate a vacant lot in the southern suburbs of Beirut where the elderly can come to socialize. Interaction and exercise are important components of healthy aging, he says. “I arranged for the municipality to clean it up and installed children’s slides for the grandchildren and benches for the old people, flowers and trees.” Other communities are now replicating the initiative, with similar parks and lots springing up around Beirut.
Sitting on a bench with two elderly male friends in the small Jesuit Garden park in the Christian neighborhood of Achrafiyeh in east Beirut, Jospeh Heddad, 77, plays cards, exchanging gossip and advice each morning.
A widower who lives alone and whose children migrated many years ago, Haddad credits his morning walks as life-saving.
“A walk and a little chit-chat keeps me awake and alive,” he says.
Resilient Cities is made possible with support from The Rockefeller Foundation.