Country in Focus
The right to health for Syrian refugees
www.thelancet.com/respiratory Vol 1 August 2013
country—which is largely under rebel control—do not have access to basic services of food, water, and shelter. Health-care services in this part of the country have completely broken down. Government-controlled areas are in better shape, but there is a still a severe dearth of medical staff and extensive damage to health facilities. All of which has dire implications for public health in general, and respiratory health in particular. There have been reports of widespread pneumonia. Internally displaced Syrians gather in enclosed spaces—eg, mosques. Family homes with six to eight people might now host 20–30 individuals; in such circumstances, infectious diseases spread rapidly. “The vaccination programme seems to have collapsed, so children, particularly those under three or four, are very susceptible to any infectious disease, including pneumonia”, adds Natalie Roberts (Médicins Sans Frontières). Lack of heating compounds the problem. Clean fuels are difficult to obtain, so people resort to constructing wood fires; these rarely have proper ventilation. Inhaling the smoke is a risk factor for pneumonia and other respiratory problems. “We’re seeing people developing symptoms that are very similar to asthma—it seems to be related to the indoor smoke”, Roberts told The Lancet Respiratory Medicine. Before the war, Syria was a middleincome country. Such nations tend to face two major issues after the onset of an emergency. First, there is an increase in communicable diseases, primarily upper respiratory tract infections, accounting for roughly half the acute illnesses diagnosed in Za’atri and Domiz refugee camps in Jordon and Iraq, and diarrhoea. Second, there is an exacerbation of non-communicable diseases. 60% of men and 23% of women in Syria are smokers; with stocks of medicines
running very low, patients with COPD, lung cancer, and asthma face interruptions to their treatment. Fortunately, tuberculosis does not seem to be a major concern. Syria has a fairly low tuberculosis burden, and the screening programmes established at the Jordanian and Iraqi camps have detected only a few cases. Of increasing concern, however, is the issue of chemical weapons. In late June, UN weapons inspectors flew to Turkey, having been denied entry to Syria, to investigate whether chemical weapons have been used in the conflict. They are unlikely to be able to make any definitive judgement from over the border, but a recent report commissioned by the UN concluded that there have been four attacks in which “there are reasonable grounds to believe that chemical agents have been used as weapons”. It stopped short of blaming either side, but Britain, France, and the USA were categorical in assigning responsibility to the Assad regime, with the USA alleging that the attacks killed 100–150 Syrians. There is no question that Syria possesses chemical weapons, but there is much that remains murky: footage of unverifiable provenance, samples smuggled out of the country, and no means of preserving the
Published Online July 8, 2013 http://dx.doi.org/10.1016/ S2213-2600(13)70129-2 For the Human Rights Watch story see http://www.hrw.org/ news/2013/07/01/ iraqjordanturkey-syriansblocked-fleeing-war For more on the recent assessment for Syria see http:// reliefweb.int/report/syrian-arabrepublic/joint-rapid-needsassessment-northern-syria-iifinal-report For more about the use of chemical agents as weapons see http://www.ohchr.org/ Documents/HRBodies/ HRCouncil/CoISyria/AHRC-23-58_en.pdf
Ria Novosti/Science Photo Library
On July 1, 2013, Human Rights Watch (HRW) warned that moves to close border crossings out of Syria risked turning the country into “an open-air prison”. HRW reported that border guards in Iraq, Jordon, and Turkey were forcing back refugees, leaving “tens of thousands stranded in dangerous conditions in Syria’s conflict-ridden border regions”. It marks the latest deterioration in what the UN High Commissioner for Refugees (UNHCR) has described as the “worst humanitarian disaster since the end of the cold war”. The UNHCR has registered more than 1·7 million refugees fleeing Syria’s civil war, which began in March, 2011. The exodus has picked up pace this year, particularly over the past couple of months. Lebanon, with a population of little more than 4 million, is host to more than 600 000 Syrian refugees, scattered across 540 locations. Jordon, which denies closing its borders, has about 500 000 refugees; there are roughly the same number in Turkey, mostly accommodated in 19 camps along the border; and there are large numbers in Egypt and Iraq. By October, Syrian refugees are expected to make up a third of the Lebanon’s population. Indeed, UNHCR reckons that if current trends are maintained, more than 3 million Syrians will have sought refuge in a neighbouring country by the end of the year (providing the borders remain open). Furthermore, the UN only keeps track of registered refugees or those seeking registration. The UN estimates that 10·25 million people (half the Syrian population) will need humanitarian aid by the end of 2013. Already 6·8 million Syrians require such aid, and more than 5 million are internally displaced. The war has resulted in more than 100 000 deaths, and seems to be worsening. According to a recent assessment, 12·9 million Syrians in the north of the
439
Planetobserver/Science Photo Library
Country in Focus
chain of custody. Still, amid the swirl of rumours, there does seem to be compelling evidence. Leeds University’s Alastair Hays points out that, assuming they have been accurately reported, the results of laboratory tests done in the UK are indicative of the lethal nerve agent sarin. “My understanding is that they have analysed either blood or urine and found a metabolite of sarin called isopropyl methyl phosphonic acid”, he said. “This metabolite is unique to sarin and could only have come from sarin”. France has documented similar findings. If a major chemical attack did occur, the consequences would be catastrophic. Sarin is colourless, odourless, and tasteless. It can quickly cause respiratory failure. “Anyone exposed to sarin complains of an initial severe constriction in the chest almost like having a tight band around it”, explains Hays. “Breathing is difficult and people gulp air. There are complications because sarin causes fluid secretion from the nose and lungs and this makes breathing even more difficult. There may be froth at the mouth as people breathe through
440
the surfactant which may have come from the lungs”. Atropine counters the effect of the nerve agent, but it is required in large quantities and has to be administered as soon as possible. “You can also administer a chemical known as an oxime which attaches to sarin and pulls it off the acetylcholinesterase”, adds Hays. But starting a large-scale treatment programme for a chemical attack in a warzone, with all the concomitant risks to the medical staff, would be virtually impossible. Those who have fled the country face different problems. Paul Spiegel (UNHCR, Geneva, Switzerland) told The Lancet Respiratory Medicine, “most refugees are [living] out[side] of [the] camp[s]; the key issue is ensuring access to health care”. Refugee camps have their own health-care services (although they frequently have to refer patients to the public system), but in Jordon more than half of Syrians live in urban communities. They access the government health care system. UN agencies and other donors help defray costs, with the most vulnerable refugees receiving free health care. All this places a tremendous strain on Jordon’s health-care services. Earlier this year, Jordon’s Minister of Health warned that “Jordan’s public health system is dangerously overstretched, and lack of funding for the health sector poses increasingly grave risks to health status and social stability”. The country is already reporting shortages in medicines to treat chronic diseases. In Lebanon, where there are no refugee camps, there is a system of copayments for those accessing health care. The UNHCR does offer assistance, but the agency concedes that “since the mostly privatised and
diffuse health care system is based on costsharing for nationals and refugees, there is insufficient knowledge on access and barriers to health care for most of the refugees living in Lebanon”. Treatment for costly chronic respiratory conditions and cancer care is particularly tricky to arrange for refugees. “The major problem is payment for the more expensive treatment and hospitalisations”, notes Spiegel. Casting a shadow over all of this is the enormous funding shortfall. Lebanon has launched an appeal for US$449 million to accommodate their refugee population; while Jordon has asked for $380 million. The humanitarian appeal for Syria itself totals $1·4 billion; and the UN’s most recent Regional Response Plan for the Syrian refugees comes to almost $3 billion (thus far, this is only 28% funded). All of which comes to $5 billion—the largest appeal in history. Even when humanitarian aid is forthcoming, there are concerns that it is simply not reaching oppositioncontrolled parts of Syria—in early May, the UN passed a resolution lambasting the “failure to ensure the safe and timely provision of humanitarian assistance to all areas affected by the fighting”. Infrastructure in the north has been almost completely destroyed. There is desultory health care, but with no electricity, heating, and continual insecurity, it is very difficult for agencies to provide any continuity of care. “Pneumonia was a big problem over last winter”, explains Roberts. There is no reason to think that the coming winter will be any different.
Talha Khan Burki
www.thelancet.com/respiratory Vol 1 August 2013
The right to health for Syrian refugees
www.thelancet.com/respiratory Vol 1 August 2013
country—which is largely under rebel control—do not have access to basic services of food, water, and shelter. Health-care services in this part of the country have completely broken down. Government-controlled areas are in better shape, but there is a still a severe dearth of medical staff and extensive damage to health facilities. All of which has dire implications for public health in general, and respiratory health in particular. There have been reports of widespread pneumonia. Internally displaced Syrians gather in enclosed spaces—eg, mosques. Family homes with six to eight people might now host 20–30 individuals; in such circumstances, infectious diseases spread rapidly. “The vaccination programme seems to have collapsed, so children, particularly those under three or four, are very susceptible to any infectious disease, including pneumonia”, adds Natalie Roberts (Médicins Sans Frontières). Lack of heating compounds the problem. Clean fuels are difficult to obtain, so people resort to constructing wood fires; these rarely have proper ventilation. Inhaling the smoke is a risk factor for pneumonia and other respiratory problems. “We’re seeing people developing symptoms that are very similar to asthma—it seems to be related to the indoor smoke”, Roberts told The Lancet Respiratory Medicine. Before the war, Syria was a middleincome country. Such nations tend to face two major issues after the onset of an emergency. First, there is an increase in communicable diseases, primarily upper respiratory tract infections, accounting for roughly half the acute illnesses diagnosed in Za’atri and Domiz refugee camps in Jordon and Iraq, and diarrhoea. Second, there is an exacerbation of non-communicable diseases. 60% of men and 23% of women in Syria are smokers; with stocks of medicines
running very low, patients with COPD, lung cancer, and asthma face interruptions to their treatment. Fortunately, tuberculosis does not seem to be a major concern. Syria has a fairly low tuberculosis burden, and the screening programmes established at the Jordanian and Iraqi camps have detected only a few cases. Of increasing concern, however, is the issue of chemical weapons. In late June, UN weapons inspectors flew to Turkey, having been denied entry to Syria, to investigate whether chemical weapons have been used in the conflict. They are unlikely to be able to make any definitive judgement from over the border, but a recent report commissioned by the UN concluded that there have been four attacks in which “there are reasonable grounds to believe that chemical agents have been used as weapons”. It stopped short of blaming either side, but Britain, France, and the USA were categorical in assigning responsibility to the Assad regime, with the USA alleging that the attacks killed 100–150 Syrians. There is no question that Syria possesses chemical weapons, but there is much that remains murky: footage of unverifiable provenance, samples smuggled out of the country, and no means of preserving the
Published Online July 8, 2013 http://dx.doi.org/10.1016/ S2213-2600(13)70129-2 For the Human Rights Watch story see http://www.hrw.org/ news/2013/07/01/ iraqjordanturkey-syriansblocked-fleeing-war For more on the recent assessment for Syria see http:// reliefweb.int/report/syrian-arabrepublic/joint-rapid-needsassessment-northern-syria-iifinal-report For more about the use of chemical agents as weapons see http://www.ohchr.org/ Documents/HRBodies/ HRCouncil/CoISyria/AHRC-23-58_en.pdf
Ria Novosti/Science Photo Library
On July 1, 2013, Human Rights Watch (HRW) warned that moves to close border crossings out of Syria risked turning the country into “an open-air prison”. HRW reported that border guards in Iraq, Jordon, and Turkey were forcing back refugees, leaving “tens of thousands stranded in dangerous conditions in Syria’s conflict-ridden border regions”. It marks the latest deterioration in what the UN High Commissioner for Refugees (UNHCR) has described as the “worst humanitarian disaster since the end of the cold war”. The UNHCR has registered more than 1·7 million refugees fleeing Syria’s civil war, which began in March, 2011. The exodus has picked up pace this year, particularly over the past couple of months. Lebanon, with a population of little more than 4 million, is host to more than 600 000 Syrian refugees, scattered across 540 locations. Jordon, which denies closing its borders, has about 500 000 refugees; there are roughly the same number in Turkey, mostly accommodated in 19 camps along the border; and there are large numbers in Egypt and Iraq. By October, Syrian refugees are expected to make up a third of the Lebanon’s population. Indeed, UNHCR reckons that if current trends are maintained, more than 3 million Syrians will have sought refuge in a neighbouring country by the end of the year (providing the borders remain open). Furthermore, the UN only keeps track of registered refugees or those seeking registration. The UN estimates that 10·25 million people (half the Syrian population) will need humanitarian aid by the end of 2013. Already 6·8 million Syrians require such aid, and more than 5 million are internally displaced. The war has resulted in more than 100 000 deaths, and seems to be worsening. According to a recent assessment, 12·9 million Syrians in the north of the
439
Planetobserver/Science Photo Library
Country in Focus
chain of custody. Still, amid the swirl of rumours, there does seem to be compelling evidence. Leeds University’s Alastair Hays points out that, assuming they have been accurately reported, the results of laboratory tests done in the UK are indicative of the lethal nerve agent sarin. “My understanding is that they have analysed either blood or urine and found a metabolite of sarin called isopropyl methyl phosphonic acid”, he said. “This metabolite is unique to sarin and could only have come from sarin”. France has documented similar findings. If a major chemical attack did occur, the consequences would be catastrophic. Sarin is colourless, odourless, and tasteless. It can quickly cause respiratory failure. “Anyone exposed to sarin complains of an initial severe constriction in the chest almost like having a tight band around it”, explains Hays. “Breathing is difficult and people gulp air. There are complications because sarin causes fluid secretion from the nose and lungs and this makes breathing even more difficult. There may be froth at the mouth as people breathe through
440
the surfactant which may have come from the lungs”. Atropine counters the effect of the nerve agent, but it is required in large quantities and has to be administered as soon as possible. “You can also administer a chemical known as an oxime which attaches to sarin and pulls it off the acetylcholinesterase”, adds Hays. But starting a large-scale treatment programme for a chemical attack in a warzone, with all the concomitant risks to the medical staff, would be virtually impossible. Those who have fled the country face different problems. Paul Spiegel (UNHCR, Geneva, Switzerland) told The Lancet Respiratory Medicine, “most refugees are [living] out[side] of [the] camp[s]; the key issue is ensuring access to health care”. Refugee camps have their own health-care services (although they frequently have to refer patients to the public system), but in Jordon more than half of Syrians live in urban communities. They access the government health care system. UN agencies and other donors help defray costs, with the most vulnerable refugees receiving free health care. All this places a tremendous strain on Jordon’s health-care services. Earlier this year, Jordon’s Minister of Health warned that “Jordan’s public health system is dangerously overstretched, and lack of funding for the health sector poses increasingly grave risks to health status and social stability”. The country is already reporting shortages in medicines to treat chronic diseases. In Lebanon, where there are no refugee camps, there is a system of copayments for those accessing health care. The UNHCR does offer assistance, but the agency concedes that “since the mostly privatised and
diffuse health care system is based on costsharing for nationals and refugees, there is insufficient knowledge on access and barriers to health care for most of the refugees living in Lebanon”. Treatment for costly chronic respiratory conditions and cancer care is particularly tricky to arrange for refugees. “The major problem is payment for the more expensive treatment and hospitalisations”, notes Spiegel. Casting a shadow over all of this is the enormous funding shortfall. Lebanon has launched an appeal for US$449 million to accommodate their refugee population; while Jordon has asked for $380 million. The humanitarian appeal for Syria itself totals $1·4 billion; and the UN’s most recent Regional Response Plan for the Syrian refugees comes to almost $3 billion (thus far, this is only 28% funded). All of which comes to $5 billion—the largest appeal in history. Even when humanitarian aid is forthcoming, there are concerns that it is simply not reaching oppositioncontrolled parts of Syria—in early May, the UN passed a resolution lambasting the “failure to ensure the safe and timely provision of humanitarian assistance to all areas affected by the fighting”. Infrastructure in the north has been almost completely destroyed. There is desultory health care, but with no electricity, heating, and continual insecurity, it is very difficult for agencies to provide any continuity of care. “Pneumonia was a big problem over last winter”, explains Roberts. There is no reason to think that the coming winter will be any different.
Talha Khan Burki
www.thelancet.com/respiratory Vol 1 August 2013
