Responding to changing health needs in protracted crises: The case of the Syrian crisis Akik C, Ghattas H, Mesmar S, Rabkin M, El Sadr W, Fouad F Presented by Fouad M. Fouad The 9 th Annual CUGH Global Health Conference New York City, NY March 18, 2018
Background and context
Push and pull factors of migration: A closer look
The Syrian conflict: Displacement in numbers Conflicts have significantly contributed to the rise in the internally and externally displaced. Syrian conflict Massive death toll & Destruction of infrastructure and social systems Mass displacement: over 6 million internally displaced and over 5 million to Jordan, Lebanon, and Turkey
During protracted humanitarian crises, if we only addressed: Evacuating people from affected areas Providing transportation, shelter, food, and water Prevention injury and infectious diseases
What would happen to: Ischemic stroke survivors taking anticoagulants? People whose diabetes is controlled by insulin? Heart attack survivors taking clot-preventing medications? People with severe lung disease receiving home oxygen therapy? People with hereditary blood disorders? Patients receiving hemodialysis for kidney failure?
NCD status in numbers GLOBALLY CVD, cancers, chronic respiratory diseases, and diabetes cause an estimated 60% of all deaths worldwide annually 80% of these deaths are in low- and middle- income countries 1 DALYs from NCDs shifted from 43% in 1990 to 54% in 2010 ² Cumulative economic losses due to NCDs in LMICs: estimated at $7 trillion, surpassing the yearly $11 billion cost of implementing effective interventions to decrease NCD burden ³ EASTERN MEDITERRANEAN REGION NCDs accounted for 57% of all deaths in 2014 4 Almost 25% of adult population (15-65 years) were hypertensive Between 20% and 40% had hypercholesterolemia Out of the 10 countries highest in diabetes prevalence, 6 countries are from the region 5 The leading cause of death in the region in 2013 was ischaemic heart disease (90.3 deaths per 100,000 people), which increased by 17.2% since 1990 6
Percent of total deaths caused by NCDs in the largest source countries of refugees in 2015
Pre-conflict NCD status in Syria Proportional mortality (% of total deaths, all ages) 2011 WHO Country Profile 2014 WHO Country Profile NCDs 77% of total deaths NCDs 46% of total deaths
Objectives Identify the NCD-related health needs of Syrian refugees in neighboring host countries Explore the systems and services available to them in Turkey, Jordan, and Lebanon Highlight gaps and best practices in NCD health service delivery in these settings
NCD status: The impact of conflict Turkey - Syrian refugees needs analysis survey 13.3 HH Adult All ages There is a HIGH BURDEN OF NCDs reported 7.6 in Lebanon and Jordan (around 50%). Turkey - Syrian Refugees in Turkey (outside camps) Turkey - Syrian Refugees in Turkey (in camps) however: Lebanon - Hidden victims of the Syrian crisis 1. Jordan Most - Hidden data victims collected of the Syrian crisis at Household 19.6 level, and report at least one member living with at least 14.6 one chronic condition; Lebanon - Health Access Utilization Survey Jordan - Health Access Utilization Survey 2. Only 5 chronic disease conditions assessed. Turkey - Evaluation of health status and health service utilization in Zeytinburnu- Istanbul Turkey - Rapid Need Assessment of Gaziantep Based Syrian Refugees Jordan* - JHAS 7.3 13 25 39.8 In Turkey, household Lebanon prevalence - LHAS ranged from 25 74 % 50.4 50.3 73.9 0 10 20 30 40 50 60 70 80 Percentage (%)
Challenges of estimating NCD prevalence in this context Prevalence is likely underreported: Because the diagnosis of some conditions requires complex diagnostics Reliance on self-reported household data as compared to clinic data Surveys often limit the list of NCDs assessed (e.g. metabolic syndrome, osteoporosis, and cancer frequently not covered) *HH : Household Asthma 18% Coronary heart diseases prevalence at 23.4% Ischemic heart diseases prevalence of 2.6% Ischemic heart diseases prevalence of 2.5%, hypercholesterolemia prevalence of 22% and neurologic disorders (including stroke) of 5% 13
Impacts The result of challenges for addressing NCDs in emergencies/protracted crises Healthcare gap for individuals with NCDs + Lack of evidence-based guidelines in emergencies = Greater NCD morbidity and mortality
think differently in terms of our response to NCDs in crises understand the context, including the gaps and complexity of NCDs in crises before proposing solutions Where do we go from here? The heart of the problem Management of NCDs is either ignored or not prioritized in emergency The protracted nature of these crises implies long-term impact that can no longer be overlooked Old solutions will not help us serve the needs of today. We must thus:
It is not that sexy to fund for NCDs and it is much more pulling at the heartstrings to fund for things for pregnant women and children. And we are guilty of [that] as well because we are responsible for prioritizing these populations and the funds required to cover those diagnostic costs... but if one thing has to be cut, it has to be NCDs. ingo key informant
Thank you
Conflict timeline Year 2011 March May 2011 July - 2013 August 2013 Septem ber - 2015 May 2015 Septem ber - 2016 December 2017 April - October Event Nationwide uprising : Security forces shoot protestors in Deraa, triggering violent unrest Opposition organizes, government retaliates: Opposition groups are formed (Free Syria Army, Jabhat al Nusra, ISIS) Government bombing of Homs and other cities. Siege of Yarmouk, a Palestinian refugee camp in Damascus, use of chemical weapons on rebel-held areas Rise of Islamists: Islamist rebels seize bases of Western-backed Free Syrian Army US and UK support for rebels suspended UN-brokered peace talks in Geneva fail Islamic State of Iraq and Syria declare "caliphate" in territory from Aleppo to eastern Iraqi province of Diyala Islamic State fought against by US, Arab countries and Kurdish force Syrian Army recaptures Yabroud, rebel stronghold near Lebanon Russian intervention: Russia carries out its first air strikes in Syria against ISIS Syrian government forces retake Homs and Aleppo, depriving rebels of major urban stronghold Russia, Iran and Turkey agree to enforce a ceasefire (government and non-islamist rebels) US intervention: Syrian air force chemical attack on rebel-held Khan Sheikhoun in Idlib
Syria: Displacement timeline Country population (2016 UN Population Division) 18,430,453 % Refugees & Asylum seekers out of the pop. 31.0% in 2016 % IDPs out of the pop. 34.3% in 2016 UNHCR - FORCIBLY DISPLACED SYRIANS 2000-2016 14000000 Asylum-seekers Refugees (incl. refugee-like situations) Internally displaced persons Grand Total 12000000 10000000 8000000 6000000 4000000 2000000 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 19