Okay. >> Hi, Rima. Thank you so much for joining us today. Professor Rima Afifi, who's Professor of Health Promotion and Community Health at the American University of Beirut, but is joining us today from North America. Where I gather you're sitting in your brother's office, who we have to blame for the skeleton in the cupboard in the corner. But Rima, thank you so much for taking your time out. I'm aware of your particular interest in working with Palestinian young people, who are marginalized due to their refugee status. And to start with, I wondered whether you would be able to share with our global adolescent health students something of the context in which you've been working with refugee young people. >> Certainly, I just wanted to say thank you for giving me this opportunity to share some of what we have been doing and to perhaps bring forth the voices of young people in settings that are difficult and conflict-ridden. So, as you said, I work in Lebanon. And, most of the work that I've been doing has been with young people that are refugees. Now, Lebanon is a unique context in that we have a variety of waves of refugees. So we have had refugees from Palestine since 1948. We've had refugees from Iraq since 2003. We've had refugees from Syria since 2011. And in-between we've had a bunch of internal displacements as a result of a variety of wars with Israel. So there's a lot of potential for people to be exposed to difficult circumstances. Most of my work has been in the context of the most protracted refugee crisis, which is the refugee crisis, the Palestinian refugee crisis. And so we've worked a lot with young people between the ages of 11 and 25 that live in refugee camps in Lebanon. >> Okay, and in terms of that, and I think you've painted that picture, I think, in relationship to the number of waves of refugees that there have been. But we also know that in terms of the picture of health, there are also some critical challenges that tend to accompany the experience of displacement, and in particular, typically from conflict zones as well. Are there any particular health challenges that accompany the experience of being a refugee and as a young people? Because, clearly there are some physical health issues that come to mind but certainly mental health concerns I could imagine would be particularly problematic. >> Yes I think definitely those physical and mental health concerns are problematic for all refugees, including young people. But I think that we sort of have to broaden the lens of that question. So what our understanding of social and political determinants of health have made us realize is that in fact it's the broader challenges that affect health. So really any challenge that a refugee is faced with, whether it's around education or employment or housing or any of those other challenges actually affect their health. So we could we could be looking specifically at health challenges, but I think in order to understand the wider complexity of the context that they're in we need to really broaden that lens and look at challenges that affect health. And that allows us, I think, much more effectively to understand their situation and also to solve the situation, and to help them interact or cope with the situations that they're in. Because that would allow us to actually consider an intervention that helps them access education as a health intervention, no only those interventions that are within the health system, per se. >> Well I think that very nicely leads on to the next sort of thought in terms of well, we know that some, there are such complex social determinants of health. And as your saying, it's not just the perhaps a past experience of conflict or the current situation of displacement, but so much the interference if you like of that context of all of those social determinants. But in terms of the, as you're saying, the amelioration, the restitution, how is it that when we have such large numbers, particularly with the Syrian crisis most recently that you've been describing that I know is overwhelming Lebanon, the accompanying countries as well and increasingly in Europe. What are your thoughts then about what are some of the strands that can be taken on board to try and modify the experience and to reduce the impacts as much as possible on health outcomes for young people? >> That's really a good question. And if I had the perfect answer, I think we wouldn't any of us be where we are in terms of any of the humanitarian crises that we have around the world. But I think just from experience, there's a few thematics perhaps that I'd like to suggest and one I think has been talked about a lot so not all of them are only specific to adolescents. I think a lot of these sort of strands or thematics apply to any person in a refugee crisis but I think adolescents have been to great extent in a sense ignored during a crisis. So one of the issues is that whenever there's a crisis whether and protracted are a little different than acute. But particularly in acute crises the response of the sort of humanitarian NGOs, INGOs, the UN agencies, the humanitarian machine is a very acute response. That looks at sort of solving the immediate needs. And although that's important, I think that from experience, that sort of builds a dependency which is not at all helpful for refugees which are going to be in protracted refugee situations. And many of those, at least in the Arab world are either there or will be. So, as we know, the Palestine issue is a long-term issue that's been going on for over 60 years. The refugees in Lebanon have been there for now over three generations. Iraqi refugees are now, again, protracted. They've been out of their countries for over ten years. And it doesn't look like we're going to solve the Syrian crisis any time soon. And even if we do, I'm not sure that there's much for those refugees to go back to. And many of them have given up everything in terms of livelihood to move to wherever they've had to move and so there's really nothing to go back to. So in those types of situations I think we need to be thinking a little differently about how is it that we can both respond to the immediate need. But in a way that supports communities to be independent in the places as much as possible and the places where they're at to be able to negotiate and interact with each other in a way that takes into account that they're going to be there for a long time. And to think sort of outside the box in terms of perhaps it's development at the same time as we're doing relief. So relief and development together. And this is starting to be, I think, discussed in the humanitarian aids Let's see. Solutions or in the international aid community, but I don't think we have good understanding of what that means. Now some of the things that I think it does mean Is to actually engage refugees themselves in the solutions to some of those problems. So I think because we tend to want to help, and support people that are coming from very difficult circumstances. We often forget that they have agency, for one thing. And often, they know what works best in their communities much better than anybody else does. And in fact, within those communities, and when we're talking as you're saying about millions of people, often. There are the components of everything that we need. So there are nurses, and there are doctors, and there are teachers, and there are architects, and there are engineers within those communities that have become refugees. But instead of sort of engaging refugees that have those skills in the solution building where ever they are, we sort of tend to want to fix it or solve it for them. And I think that's a mistake because for a variety of reasons. One, we're losing on critical knowledge and skills that we need, because we never have enough people for relief. But the second is that engaging people in solutions actually helps them cope with whatever it is that they're dealing with. And I think for adolescents specifically this is important. What we've seen with sort of young persons is they seem to be, a lot of the time out of the equation. So, a lot of the interventions in disasters or whether it's person made of natural. Natural disasters focuses on water and sanitation efforts or focuses on maternal and child health, a little bit on social and reproductive health, and sort of gender-based violence, which is also important and that may be. Where there's perhaps a little more focus on adolescence but still not enough. But otherwise, nobody's really paying attention to this big group of people who are energetic, creative, have agency, are assets to their community and actually, if engaged, could be very supportive in a variety of ways to I think help the community cope at this particular time. >> So Rena are you able to share with us because I think you've painted that a very different picture, if you like, in terms of how communities themselves can engage, and contribute to solutions, rather than potentially having less than ideal solutions hoisted upon them. Although as we would all recognize that nothing is going to be ideal in this situation. But given your commentary about the opportunities for young people, and on one hand, the lack of activities for them to engage in, but the other the fabulous opportunity there is from their skills that they bring and their energy and creativity that they bring. Are you able to share a bit more explicitly some of the work that you've been doing with young people, in terms of building on those capacities of how they might be able to be harnesses to contribute to their refugee communities? >> Yeah, certainly. So I can give a few examples. I think the biggest project that I was involved in again was within the refugee camp in Beirut. And it was focused actually on positive mental health. You brought up mental health a couple minutes ago. So this wasn't at all focused on young people with identified mental health conditions. Rather sort of focused on the mental health that all of us need to function in daily life, to get up and feel like we're able to go to school, or able to do the things that we need to do. And so this project sort of looked at what are some of the intervention programs out there that are focused on skill-building around positive mental health. And created what we call an evidence-informed program, because evidence-based, suggests that you are working in the same context. And there's been very little actually well evaluated interventions that have happened in contexts like ours. There's a lot of excellent work that's happening, but the tools for effective evaluation often aren't used, so. And that's too bad, because I think there is quite a bit of really good work that's taking place, and we just need to push our think monitoring and evaluation a little more. So our program took what we knew globally about evidence-based interventions for positive mental health, and adapted it to the context that we were working in. And this was a community-based participatory research project, and so we actually spent a year and a half In the community, working with both adult residents, and young people, as well as NGOs in that community. And we had that time because, again, this is in a Palestinian refugee community. So there's nothing immediately acute about that situation. It's a a very protracted situation that they're in. And they have no rights whatsoever in Lebanon because the state just doesn't give them those rights, the state of Lebanon. So what we ended up developing with the community, and with young people is an intervention that was actually a year long intervention that happened In school, because a school is a safe place, but it happened after school hours. So we were not able to incorporate it into the school curriculum, and this is part of the evidence informed, rather than evidence based, because many of these programs in developed settings happen within a school system. But in a refugee context, often schools have double shifts, and so there's a group of kids going to school from 7:00-12:00 and another group of kids going to school from 12:30 to 4:00. There's really no place in the curriculum or in the day of the school to be able to put in anything other than what is required of them. Educate, quote unquote, education. And so the school system was very cooperative and actually gave us a lot of space in the school building. But we just did this intervention after school over the course of year. And we had, the intervention was with 11, 12 13 year olds. So fifth and sixth graders. But I think the key here that I want to focus on is that the implementors of the intervention were, what we called youth mentors. So they were 17 to 25 year olds who were from that community, paired with university students who had been trained on this curriculum that then did group sessions with these young 11, 12 and 13 year olds. And I think, for me, and sometimes I think this happens in interventions, the unexpected effect was then on that group of youth mentors. And so although the skills, the communication skills, conflict resolution, all those things we talk about that are really important for positive mental health were transferred very well to. The young people that were the participants in the intervention, it was the youth mentors who really really spoke about how much, how important this was for them, in terms of their feelings of hope, their feelings of purpose, their feelings that they were getting back to their community. Their feelings like they were able to influence their own lives and the lives of their community, and all those things related to their own mental health, which we actually hadn't planned. >> Wow. >> The other part of the that I think that was important is the young people when we were When we were doing the early needs assessment around this project. And again, the community-based participatory aspect. It was the young people that sort of said to us, please don't create an intervention that's meant to fix us, quote unquote, fix us. If you're not going to engage the important people in our lives around this intervention. So they basically said, interventions for young people that don't also include parents or also include teachers, or also include the larger community, aren't effective and unfair to young people. Because you're trying to basically, in a sense, say that they're in control of every aspect of their life, which they're not, as we all know. And so, we did include both the parents and the teachers in that intervention, and found that was very important. Because sometimes the messages that were transmitted could then be shared between children and their parents. And that was, we thought, a very important aspect of this intervention. >> Well, I can certainly appreciate the value of that just in terms of the way you’re talking about it. It is sounds a very profound experience for those young people. Finally Rema, can I ask you a visionary sort of question? If I was the Minster for youth and refugees in Lebanon and was coming to see you at the American University in Beirut, and knowing your expertise in this area. And was to ask, what do you think you could do or that I could do as the Minister for health, to most improve life chances and health of young refugees? What would you say? >> Well, I think there's a lot to say. I think one thing that we need to focus on is that as we're thinking about how to make life better for people who are in these difficult circumstances, we can't forget that we need to be thinking much broader about how to prevent these difficult circumstances from happening in the first place. And I think that's part of the concern I have around this. There's a big movement now around resilience building. And I think that's an important movement in that we're trying to ensure that people have the skills that they need to cope with difficult circumstances when they occur. But, my concern is that in all of our attention to helping people cope when difficult circumstances occur, we are then removing our energy from focusing where it needs to be. Which is to prevent those difficult circumstance from happening in the first place. And I think we need to keep on keeping on on whatever it is that we need to do to promote peace. And, I know that's a big, perhaps idealistic statement. But, I really think we need to keep that in our minds. And, I don't have the answer to that, but I think we need to keep thinking about it. In the immediate sort of okay, what do we do with young people that are now in difficult circumstances? I think the most important thing is to engage them actively in the solutions to whatever. Actually even before in the assessments of what are the issues that are taking place in their communities and the development of intervention and the solution building around that. Not only for themselves. I think it's great when we engage young people in sort of what do they need and what can we do for them. But, I think it gives them a great sense of purpose to actually also be engaged and thinking beyond that. What can they be doing for their communities? And I mean it can be very simple. It could be that if young people can actually create activities for young children. That simple. So they're just sort of engaging young children in activities, whether it's drawing, or art, or music, or anything, or tutoring around whatever it is that they can do. They actually give parents a break for whatever short period of time that is. And that break is such a needed opportunity for parents to just take a deep breath and then start again. And that may be all it takes in a day. A couple hours to just sort of take a breath before they move onto having to deal with. So it could be that simple. It could be just activities for young children all the way to. In some of the sort of conflict situations that we've had, young people have developed garbage disposal plans. They've developed all sorts of very creative ways to solve the issues that are at hand. And so, I think the first thing is to engage them actively at every stage of the process. And then, the second thing is to actually, as we engage them, give them agency, give them voice, and give them dignity. because I think that also will give them a sense of purpose that allows them to feel better physically and mentally, and also gives them skills that they'll be able to use later. And I think that's the other thing around young people in these contexts that we need to think about, and goes back to my earlier point about acute response versus thinking a little more broadly about development. How is it? How can we involve young people in a way that gives them skills that are transferable? Transferable to wherever they're going next. Whether that's another refugee camp, whether it's back to their home, whether it's to another country. But, skills that are useful for them. And so, we've had this interesting dialogue and discussion around whether or not community health workers. If we can transfer the knowledge and evidence that we have around the impact of community health workers to adolescent. So can young people community health workers? And that would be an amazing intervention I think, that both links communities to health services and systems, but also gives them skills that are completely transferable to wherever they're going next. And so, I think we just need to start thinking a little bit differently in terms of the types of interventions that we've seen with young people. >> Rena, thank you so much for joining us today. And behalf of all of our students, thank you for really the profound work you're doing in very disadvantaged situations. We wish you well, and we wish your youth mentors well. >> [LAUGH] >> Take care. >> Thank you so much, been my pleasure.
