Running head: EFFECTS OF DISPLACEMENT ON HEALTH 1

The Syrian Crisis: The Effects of Displacement on Health

Amber Blankenship, RN

Western Washington University

Nursing 452: Global Health

Hilary Schwandt, Ph.D. MHS

August 14th, 2017

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The Syrian Crisis: The Effects of Displacement on Health

Before the start of the civil war, Syria was an attractive tourist destination comprised of

Ancient Roman ruins, chapels, Islamic Mosques, and a landscape of mountainous farmlands and

Mediterranean beaches. In 2010, Syria drew in more tourists than Australia (United Nations

Refugee Agency, 2017). It was home to 22 million people of various religions. Today,

aggressive and immoral political affairs have devastated the ancient country. More than 250,000

Syrians had lost their lives by 2016, and more than 11 million were displaced, producing the

largest refugee crisis since World War II (Rodgers, Gritten, Offer, & Asare, 2016). Historic

buildings, homes, and health care facilities have been converted to rubble.

The physical complications and disabilities for the Syrians who had survived traumatic

injuries are what draws the greatest media attention to this crisis. What is forgotten, are the less

direct and obvious impacts of war on health. Many are without access to clean drinking water

and nutritious foods, including those who have sought refuge abroad (Medecins Sans Frontieres,

2016). These refugees live in overcrowded accommodations which place them at greater risk for

violence, exploitation, and communicable and vaccine-preventable diseases. The care of chronic

and infectious diseases was disrupted due to a broken health infrastructure and depleted drug

supply. Although the physical traumas of war take precedence, as the crisis becomes extensive,

with no end in sight, and access to safe healthcare diminishes, it is important neither to neglect

the needs of the population's chronic and preventable conditions nor to be ignorant of the

potential exploitation of the most vulnerable.

The Crisis
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The revolution began in March 2011, in protest against the arrest and torture of nearly a

dozen teenage boys, 15 years old and younger, for painting "The government must go" on school

walls (Rodgers et al., 2016). During this protest, government officials opened fire on

demonstrators, harming innocent civilians. The public demanded the resignation of President

Basar Al-Assad, but he refused and persisted with his aggressive militant tactics. Oppositionists

were forced to acquire weapons to defend their homes and families against government forces.

Syrian soldiers, whose ethics were not in line with those of the Assad regime, began to leave to

join the oppositionists (Rodgers et al., 2016). The war intensified and grew more complex as

oppositional groups became divided both on ethics and tactics, paving the way for terrorist

organizations such as the Islamic State of Iraq and Syria (ISIS) to take control of

sections of the country. As the air force bombed roads, moving cars, homes, and hospitals,

Syrian civilians were compelled to seek safety (Mdecins Sans Frontires, 2016). Some have

chosen to remain in their own country, whereas others have fled internationally to seek asylum.

Roughly 6.5 million Syrians are displaced within the country, and over 5 million have

fled to the neighboring countries of Lebanon, Jordan, Iraq, Turkey, and across the Mediterranean

Sea to Greece and onto Europe. This number only reflects those refugees registered with the

United Nations Refugee Agency (UNHCR). However, it can take weeks after their arrival

for them to become registered, and not all refugees seek asylum for fear of reprisal from local

governments due to their illegal entry into the country (El-Khatib, Scales, Vearey, & Forsberg,

2013). Lebanon, Turkey, and Jordan have the heaviest burden of hosting refugees. As of October

2016, Lebanon was home to 1,001,051 registered Syrian refugees, Turkey

was home to 3,106,932 and Jordan was home to 660,582. Nine percent live within refugee

camps, where 91% live in urban, peri-urban, and rural sites (UNHCR, n.d.). Both areas suffer
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from poverty and overcrowding, leading to unsanitary conditions, inadequate nutritional intake,

and fostering the spread of infection.

Healthcare access

Within Syria, relentless bombings and shootings have destroyed vital infrastructures,

cutting off energy sources and demolishing hospitals, causing hazards to any Syrian seeking

medical care and likewise presenting dangers for the care providers themselves. In the few

medical buildings left standing, medical equipment has been damaged and medications depleted.

The World Health Organization (WHO) and other non-government organizations (NGO) provide

necessary health care, emergent and preventative, and deliver medications, food, and clean

drinking water. Replacement has been challenging as militant parties have negated critical access

in hard-to-reach areas. Of the 6.5 million Syrians internally displaced, 4.5 million live in these

conflict zones (Kherallah, Alahfez, Sahloul, Eddin, & Jamil, 2012). Due to the persistent militant

threats, safety concerns have forced humanitarian efforts to retreat, leaving behind Syrian

residents within these conflict zones with inadequate care (Kherallah et al., 2012).

Inside host countries, access to health care varies depending on the nation of refuge.

Refugees living in satellite cities within Turkey are enrolled in Turkish general health insurance,

thus providing free health care; however, those living in camps within Turkey receive their

health care from humanitarian agencies(NGOs). Those registered with UNHCR and residing in

Jordan and Lebanon have access to their national public health systems and can receive limited

primary care (U.S. Department of Health and Human Services, 2016). These extra bodies place a

considerable economic strain on these countries' public health systems.

In Lebanon, public health systems feel such a burden. Those who have not been

registered with the UNHCR must pay out of pocket, a challenge for the many families without
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work and living in poverty. Due to the influx of refugees, coupled with Lebanon's own

population disparities, the overtaxed Lebanese government requested for refugee registration to

be suspended, thus denying any new colonized refugees access to their already strained public

health system since May 2015 (U.S. Department of Health and Human Services, 2016). To

address these needs, the UNHCR initiated increased efforts through the use of donated funds to

improve healthcare services for both Lebanese civilians and Syrian refugees (both registered and

non-registered). Although greater resources are provided, fees remain, and access for the poor

continues to be challenging. Thus, NGO's have subsidized where they are able. Certainly, these

efforts alleviate Lebanon's overburdened health system. However, resources are limited to

funding raised by the UNHCR and other NGOs, thus focusing care on urgent needs and less on

prevention (Abi Yaghi et al., 2016).

Health Status

Before such tragic conflicts began, Syria's population health was improving. Statistics

measured in 1970 and again in 2009 revealed life expectancy at birth had increased by an

average of 17 years from age 56 to 73.1. Infant mortality dropped from 132 per 1000 to 17.9 per

1000 infants. Maternal deaths during or after birth declined from 482 per 100,000 births to 52 per

100,000 births (Kherallah, 2012). Communicable disease control was strengthening; this was

demonstrated by data showing that only 6% of deaths were related to infectious disease. TB rates

were falling, from 85 per 100,000 persons in 1990 to 23 per 100,000 in 2011, and the country

was declared polio free in 1999 (Cookson et al., 2015; Whewell, 2014). Non-communicable

diseases such as cardiovascular disease, cancers, respiratory, diabetes, and other diseases

encompassed 46 percent of deaths (World Health Organization, 2014). However, since the rise
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in conflict such achievements have regressed, and health disparities such amongst refugees are

on the rise.

Communicable diseases are quickly spread in overcrowded, unsanitary encampments and

exacerbated by malnutrition and lack of access to clean water. A May 2015 cross-sectional study

concluded that of 1,001 Syrian children (internally displaced or seeking refuge in other

countries) illuminated that 15% lacked access to safe drinking water and 23% to sanitation. Only

16% had access to adequate nutrition, 64% had access to primary health providers, and 72% had

reduced rates of prophylactic vaccinations (Elsaeidy, Van Berlaer, Al Safadi, Pathan, &

Redrawn, 2016). Such deficiencies combined with a lack of access to preventive care increases

the risk for infectious diseases including vaccine-preventable outbreaks.

Polio, one of the most debilitating viruses, once completely eradicated from Syria,

was revived in 2013 amongst internally displaced populations (World Health Organization,

2017). It comes as no surprise that this highly infectious virus had the opportunity to reoccur

amongst this already devastated population. While Assad maintains that his government

continues routine vaccination across the country, vaccination rates in rebel-held territories

(where all poliomyelitis cases have occurred) fell from 91% to 68% in 2012 before the outbreak.

A total of 38 type 1 Polio cases were initially confirmed (Mbaeyi et al., 2017). To inhibit

the further spreading of the disease, UN officials teamed with governments of surrounding

countries to launch an intense immunization program, lining borders and visiting refugee sites.

Teams were deployed into dangerous conflict zones to connect with children in these hard-to-

reach areas. The final case was identified in 2014, and efforts had been deemed successful in

2015 by WHO officials. Disappointingly, in June 2017, WHO reports identified a type 2,
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vaccine-derived polio virus outbreak in Deir Al Zour, and 58 cases have since been reported

(World Health Organization, 2017).

Since vaccine-derived polio is rare and only occurs in under-immunized populations, this

outbreak provides evidence to support the dire need for preventative care. Despite the violent

extremes of war, simple considerations such as a lack of preventive health care, and the ability to

wash hands can have an upstream impact leading to similar ailments causing death. When

triaging care needs, the primary focus on traumatic injuries is of obvious priority. Treatment of

preventable or curable diseases, which can be prevalent in impoverished communities lacking

adequate health care, are of similar importance but can easily be overlooked by unfamiliar public

officials.

For instance, Jordan officials recognized during an assessment of their tuberculosis (TB)

program that refugee migrants' TB status had not been evaluated, not only threatening the

diagnosed themselves but also those with whom they had been in contact. This detection

prompted emergency responses from UNHCR, Centers for Disease Control (CDC), and

International Organization for Migration (IOM). Officials once again set out to scattered

residents and migrant camps for refugee evaluation and implemented TB screening during

UNHCR intake processing (Cookson et al., 2015). Through these tactics, officials were able to

educate populations regarding TB and identify new cases as well as those who were previously

diagnosed and formerly receiving treatment (Cookson et al., 2015). From March 2012 to June

2013, 56 cases of TB among Syrian refugees, including multidrug-resistant TB (MDR-TB), were

detected (Cookson et al., 2015). Due to the challenges of health care access, families are not

seeking care until they are very sick, and, by this point, have been in contact with countless other

immunocompromised individuals.
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Violence Outside of War

The exploitation of women and children, sexual abuse, human trafficking, and forced

early marriage of young females are serious concerns. A study of Syrian refugees in a camp in

Jordan identified that 51% of females and 13% of males in the cohort were victims of forced

marriage. Syrian families explain forced and early marriages as a means to provide safety for

their child by removing them from insecure settlements. Many fear that possible sexual violence

to their daughters would ruin their honor and deem them unmarriable. Others discuss financial

concerns, hoping that their children will marry into financial security and the family will

be left with one less mouth to feed to lighten economic affliction (McAlpine, Hossain &

Zimmerman, 2016). However, forced early marriages place young women at repeated risk of

physical and sexual abuse, early pregnancy, which increases the risk of maternal mortality, and

an increased risk of contracting HIV. Other risks include post-traumatic stress disorder (PTSD),

depression, and shame (McAlpine et al., 2016).

Minimal information is available to address a means to combat such mistreatment. One

review suggested educating aid workers to distinguish human trafficking and forced early

marriages and proper tactics to arbitrate. A randomized controlled trial (RCT) is currently in

process. A program titled creating opportunities through mentorship, parental involvement, and

safe spaces (COMPASS) is being applied to two conflict-affected cohorts. This program uses

such interventions as providing education to young women and their families to help adapt and

accept new behaviors as well as provide a safe place for interaction and self-protective skill

development (Falb et al., 2016). Human exploitation through forced early marriage and
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trafficking not only is a violation of human rights, but the mental trauma can also cause

compound effects through family cycles, causing future violence. Educating these women and

their families provides a foundation for prevention, acceptance, and change.

Conclusion

The Syrian war is one of the most devastating crises of this century and has left health

systems shattered, leaving displaced Syrians without needed care, both emergent and

preventative. Although many Syrians have emigrated to bordering countries and beyond, others

have chosen to stay behind in their native land. Each group is faced with varying barriers to

receiving adequate health care. Concern for preventative care is seemingly trivial in comparison

to tortuous war crimes and brutal force, but once viewed from a perspective of providing

complete physical and mental well-being to those suffering, poor access to holistic care becomes

another form of a human rights disruption.

Humanitarian organizations, WHO and UNHCR, struggle to assist foreign health

systems, within Syria and abroad, to provide emergent and some preventative care but are

confined by militant threats and a lack of funding; these limitations force these organizations to

focus their assets on the life or death complications of war and less on health screenings and

routine vaccinations. There is a necessity to obtain enough funding to allow officials to address

deadly ailments that aren't immediate outcomes of war. Deadly and debilitating infections like

Polio and Tuberculosis are preventable if vaccinations and treatments are accessible, and equally

traumatic aftermaths of war and displacement, leading to human exploitation, can be avoidable

through support and education.

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Appendix

(UNHCR, 2017)
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(UNHCR, 2017).
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