“We are witnessing a paradigm change, an unchecked slide into an era in which the scale of global forced displacement as well as the response required is now clearly dwarfing anything seen before.” ~ Antonio Guterres, United Nations High Commissioner for Refugees

The global political upheaval caused by the Syrian refugee crisis could potentially mask a critical issue that has all the signs of a catastrophic public health disaster – the health of the vulnerable migrants fleeing an ongoing long-standing war that has been incredibly devastating to civilians. The conflict, which started in 2011, has resulted in more than 4.2 million Syrians escaping and relocating to neighboring countries like Lebanon, Turkey, Iraq, Egypt, and Jordan as well as Europe and Northern Africa.¹ Described as the largest humanitarian crisis of the 21^st century by the United Nations, the numbers are mind-boggling – more than 12 million are in dire need of help, including almost 6 million children, and of the registered refugees in the above countries, almost 75% are women and children, the cohorts most vulnerable to disease and death. The death toll has reached almost 200,000.²

While we continue to bicker about religion and witness an acerbic political rhetoric blindfolded by rage at terrorism, humanity and compassion have taken a backseat and rebuilding lives of the most profoundly helpless victims of war remains overshadowed by a frenzy of global power struggles.

Forced displacement due to warfare results in health disorders that are unique and remarkably harsh with long-lasting impact that can affect multiple generations. Besides the physical, mental, social, and economic outcomes, the psychological consequences are grievous and perhaps the most destructive.

Women are subjected to harassment, kidnapping, abandonment, sexual violence, complications of pregnancy and labor, and problems due to early marriage including intimate partner violence. Birth control and family planning are serious issues. Children are afflicted with deadly infections, lack of childhood immunization, malnutrition and growth retardation, physical and sexual abuse, and the manifold psychosocial consequences of separation from parents. Education goes for a toss and daily survival becomes the core objective. There is high incidence of sexually transmitted diseases, and poor access to treatment.

Indeed, disability and death due to lack of basic hygiene, food, clothing, and housing have morphed into a sinister public health problem that we have let spiral out of control in spite of years of opportunity for the rest of the world to put their act together. Add to this the violence caused by terrorism, and we have a calamity of unseen proportions in recent times, perhaps matched only by the Jewish holocaust.

The woman who gave birth on the run then walked for 11 days with her newborn, the 16-year old married off to an older man who got beaten by her in-laws and her own family for refusing sex on her wedding night, the 18-year old pregnant girl who suffered hemorrhage from excessive walking as she fled across the Lebanese border, the one who gave birth all alone in a tent – the stories are endless and cruel. Syrian ‘war brides’ are increasing – multiple wives wedded illegally to one man who may already be married, in which case the Syrian wife is degraded to the role of helper or servant. In most such cases, women get married off in exchange for a ‘bride price’ that helps her family financially for the time being. In Turkey specially, women are openly traded not just for money but for rent and other basic needs of the family. And then there are those who are in camps and rural settings – women who have coupons to buy food items tagged “For Syrians” but cannot buy sanitary pads or tampons with those coupons, mothers who watch anxiously as their children go back and forth from school, pregnant women with no access to antenatal care, wives struggling with their husbands to protect their daughters from being married for dowry – all examples of hardships that result in poor health outcomes.

Amnesty International published a report recently describing the experiences of eight Syrian families, some of them headed by single women like Yara, Nadia, and Mariam.² Healthcare hardships and safety concerns were highest on their list of problems. One of the families has a 12-year old boy with cancer, who can only get adequate treatment when they move to Europe. A gay couple recounted their struggle with the stigma of their relationship and subsequent imprisonment and torture. One of them was put in solitary confinement when he confessed that he was HIV positive. He became suicidal because he could not afford his treatment and hopes that with resettlement he will be able to get healthy. Another family has been diagnosed with elephantiasis in both father and daughter and neither has access to treatment. The father anticipates his own impending death but hopes for a cure in his child with resettlement.

Resettlement of refugees is of critical importance and without political backing we will continue to witness the downslide of the overall state of health with dangers of deadly outbreaks like cholera, polio, and measles.³ Eventually, the whole world will suffer with the intense resurgence of such diseases. A local or regional epidemic can transform into a global epidemic and eradication efforts will have to be implemented with renewed vigor. Polio is spread by contamination by sewage, cutaneous leishmaniasis by the sand fly, and cholera by poor sanitary conditions, all prevailing dangers of war-torn territories.

Polio had been eradicated in Syria for 15 years unlike other neighboring countries like Pakistan and Afghanistan but has reappeared, in part due to the reduction in childhood immunization of Syrian children by almost 50%. What was a commendable program of battling a deadly infectious disease with clinical precision by the Syrian government has been defeated by the civil war. A highly contagious virus spread by stool, polio can erupt into an outbreak from a single unvaccinated infected child. It has been estimated that for each case of diagnosed polio there are 1000 infected carriers without symptoms who can continue to spread the virus for a long time.⁴ Doctors and healthcare workers have been working selflessly to prevent an epidemic that could decimate one of the biggest public health victories of the modern world – eradication of polio in large parts of developing countries in Asia and Africa. This will negatively impact the western world soon just like the recent resurgence of other infections like measles and mumps, a direct consequence of the anti-vaccination lobbying that has led a crusade against life-saving immunizations in children.

Cholera, a highly fatal disease, spreads is a similar way through poor sanitary conditions, lack of safe drinking water, and crowded living conditions that allow the bacteria to spread brazenly. After 2010, when 450,000 citizens of Haiti suffered from cholera that erupted after the massive earthquakes, Syria and it’s neighboring countries like Iraq and Iran, are sitting ducks for a similar outbreak that will cost the world thousands of lives, billions of dollars, incredible disruption of public health programs, and long-standing healthcare safety issues that could have a domino effect globally.

Let’s not forget the past victims of war in Germany, Japan, Vietnam, and Africa and the health consequences of prolonged conflict. In my next blog I will discuss possible solutions to the healthcare crisis and how we can engage positively to create impact in our own small ways. The references below are easy-to-read resources that are trustworthy in their reporting and can increase awareness of the magnitude of the healthcare disaster that we are witnessing. After all, the world that we live in needs to be safe as well as healthy, no matter what the political consequences of war are.

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References:

(1) United Nations – http://data.unhcr.org/syrianrefugees/regional.php

(2) Amnesty International – https://www.amnesty.org/en/documents/MDE24/0004/2015/en/

(3) Sharara SL, Kanj SS. War and Infectious Diseases: Challenges of the Syrian Civil War. Heitman J, ed. PLoS Pathogens. 2014;10(11) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231133/

(4) National Geographic – http://news.nationalgeographic.com/2015/03/150305-polio-syria-iraq-islamic-state-refugees-vaccination-virus-jihad/