Social Science & Medicine 272 (2021) 113699 Available online 21 January 2021 0277-9536/© 2021 Elsevier Ltd. All rights reserved. Confronting Structural Inequities: The Limits of Participation when Developing a Community Health Intervention with Syrian Refugees and Host Communities in Lebanon Lara Z. Jirmanus a, b, c, * , Micheline Ziadee d , Jinan Usta e a Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, 75 Francis, St. Boston, MA, 02115, USA b Department of Family Medicine, Cambridge Health Alliance, 1493 Cambridge, St. Cambridge, MA, 02139, USA c FXB Center for Health and Human Rights at Harvard University, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA d Department of Sociology, Anthropology and Media Studies, American University of Beirut, P.O.Box 11-0236, Riad El-Solh, 1107 2020, Beirut, Lebanon e Department of Family Medicine, American University of Beirut Medical Center, Wassef and Souad Sawwaf Building, 4th foor, P.O. Box: 11-0236, Riad El Solh, 1107 2020, Beirut, Lebanon A R T I C L E INFO Keywords: Community based participatory research Refugee health Lebanon Syrian refugees Dom/Roma Middle East Global health Social determinants of health ABSTRACT Lebanon is one of the most unequal countries in the world, whose economy, social welfare and public health system struggle to meet the needs of the Lebanese and over one million Syrian refugees. Researchers applied Community Based Participatory Research (CBPR) methodology in collaboration with a non-governmental or- ganization (NGO) in an underserved Beirut neighborhood from 2014 through 2016, aiming to address health inequities, build social cohesion among refugees and host populations, and empower community members to develop a community health intervention. We recruited a community advisory board (CAB), conducted six focus groups and sixteen individual interviews, and held several community meetings. In response to the study fnd- ings, NGO staff, researchers and community members agreed to work together on a trash collection initiative as a community health intervention. Ultimately, we found the CBPR toolkit to be insuffcient to the empirical reality: a series of structural challenges due to entrenched local and national hierarchies, ineffective political processes, and inter- and intra-group confict driven by competition over privatized social services. Together these resulted in a lack of trust in the collaborative process wherein study participants solicited researchers for aid in return for their involvement, mirroring the Lebanese patronage system. Ultimately, the most expedient path toward change was not through empowerment of oppressed community participants, but through the action of already powerful local individuals. In conclusion, structural inequalities limit the participatory and emancipatory possibilities of CBPR research. Power mapping exercises, which are often used in community organizing, offer an important opportunity to assess viability and lay the groundwork for CBPR projects. Academic and popular media in the Middle East often focus on religious, sectarian confict; however, in our study confict both between and among social groups was driven by competition over material resources more than cultural or religious differences. 1. Introduction In October 2019, the small country of Lebanon erupted in revolution, with millions in the streets demanding an overhaul of a sectarian po- litical system and the overthrow of the ruling elite, who have governed the nation for decades. Lebanon is one of the most unequal countries in the world (Alvaredo et al., 2019), and these inequities have been exacerbated as the COVID-19 pandemic and the recent explosion of 2700 tons of ammonium nitrate plunged the struggling economy further into crisis (Al-Khalidi, 2020; Doherty and Sullivan, 2020; Mounzer, 2020). The revolution and economic crisis take place against the backdrop of the Syrian refugee crisis, the largest displacement crisis of our time, with 12 million Syrians displaced. Lebanon has one of the highest ratios of refugees per capita in the world, where approximately one in four residents is a Syrian refugee (United Nations High Commissioner for Refugees, 2016). The majority of Syrian refugees have settled in un- derserved host communities, rather than in refugee camps (United * Corresponding author. Department of Family Medicine, Cambridge Health Alliance, 1493 Cambridge, St. Cambridge, MA, 02139, USA. E-mail addresses: ljirmanus@challiance.org (L.Z. Jirmanus), michelinekz@gmail.com (M. Ziadee), ju00@aub.edu.lb (J. Usta). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: http://www.elsevier.com/locate/socscimed https://doi.org/10.1016/j.socscimed.2021.113699 Received in revised form 14 December 2020; Accepted 10 January 2021