The Syrian health tragedy Dr Adam Coutts Dr Fouad M. Fouad Brown University November 8 th 2013

Inside Syria  Nearing the third year of the conflict.  Greatest humanitarian disaster of the past two decades - largest-ever humanitarian appeal – 5.2 billion dollars.  2 million plus Syrians are now living as refugees in the neighbouring countries Lebanon, Jordan, Iraq and Turkey.  Over 115,00 killed and 600,000 seriously injured.  25% (6.25 million) of the population have become Internally Displaced (IDPs).  4,000 cross into neighbouring countries per day.  Over 9.3 million people are at elevated risk and in urgent need of food and medical assistance.

Health situation has been neglected Silent and bigger killers…  Communicable disease outbreaks  Injuries and disabilities  Chronic diseases  Mental and psychosocial disorders  Starvation and famine “Diseases don't care whether you're for Assad or against Assad, or uninterested in politics. It strikes everyone as an equal opportunity”. Anne Richard, Assistant Secretary of State for Refugees (June 2013).

Destruction of health infrastructure and supplies – system collapse  60% of medical facilities not functioning or destroyed.  Direct targeting of health workers by both sides – 180 killed.  70% of medical workforce left Syria.  Overburdened with patients - 30,000 ER/trauma cases per month nationally.  Lack of trained staff and equipment.

Siege, starvation and lack of sanitation  2.5 million people in areas under siege / inaccessible to UN.  Eastern Ghouta – Suburb of Damascus – 15,000 facing acute food shortages.  Water, sanitation and hygiene infrastructure destroyed.  Rubbish and waste remains on streets for months in opposition areas.

Source: UOSSM 2013

A regional problem - a system overwhelmed  Refugees have increased the population of Lebanon by 15% (1.3 to 1.5 million).  Cost $7.5bn in lost revenue.  Hundreds of millions of dollars required to stabilise public services.  Public health system and hospitals have reached capacity – refugees being turned away from public hospitals.  Refugees returning to Syria for treatment in government areas due to high costs in Lebanon.

Refugees June 2012 Syrian Refugees 25,400

Registered Syrian Refugees 175,000 Refugees December 2012

TODAY 805,701 Registered Syrian Refugees

December Million Registered Syrian Refugees

Photos by Rabia Shibli – Saida – South Lebanon

Health situation in Lebanon  Communicable diseases are rising - Lebanese Ministry of Health (MoH) reporting measles outbreaks increased from 9 in 2012, to 1,456 in  Threat of epidemic outbreaks in Informal Tented Settlements (ITS) due to poor sanitation and over crowding.  Discrepancies or under-reporting in health statistics. MoH recently recorded 420 cases of Leishmaniasis whereas a local NGO that operates throughout Lebanon found over 40,000 cases of skin diseases.  Health Information System of MoH and UNHCR very basic. Failing to provide accurate and timely picture.

The response – ‘less than robust’.  Syria Humanitarian Response Plan (SHARP) and Regional Response Fund (RRP).  Underfunded: donors slow to secure funds.  63% SHARP, 57% RRP currently funded.  Lack of knowledge on response capacity and quality of services already available – WHO IS DOING WHAT, WHERE AND WHAT RESOURCES DO THEY HAVE?  Leads to duplication of projects inside and outside Syria.

Threats and challenges  Massive demographic changes threaten to bring about collapse of public services.  Neglect of chronic diseases – no surveillance or treatment for cancer, CVD, Type II Diabetes, HIV among refugees will create long term burdens on all social systems.  80% of excess deaths due to health / diseases in conflicts – Darfur – 300,000 excess deaths – Lancet  Large numbers die post conflict in stabilisation phase – communicable diseases and diarrhea.

‘Less than robust’ response - Do Security Council members think the situation is ‘not that bad’? SYRIA

Possible policy responses  Long-term thinking - bridge humanitarian and development policies - need schools, health care facilities, infrastructure in host communities.  Universal Health Care, labour market reform and infastructure.  Make donor money conditional on domestic reforms taking place – Lebanon / Jordan.  INGOs demonstrate cost-effective interventions – set up field trials of existing interventions.  Compulsory health screening and treatment of refugees when registering.  Actually collect data and carry out proper surveys!

Dr Adam Coutts London School of Hygiene and Tropical Medicine Fouad M.Fouad MD, Faculty of Health Sciences American University of Beirut

ANNEX DATA AND MAPS

Current conflict situation Source: U.S. Department of State, Humanitarian Information Unit

Source: UNDSS, UMASS (October 2013) Conflict areas

Documenting the effects  Lack of reliable and robust data from inside Syria esp in areas of greatest need – opposition areas.  Reliance on informal networks of contacts built up over time – field hospitals, clinics and fellow academics / medics.  Government sources (Ministry of Health) and UN (WHO- EMRO) only cover government areas.  Two large assessments carried out in opposition areas by NGOs:  OCHA reports in April that 6.8 million people are in need  Joint Rapid Assessment of Northern Syria (J-RANS II -APRIL) million people in urgent need  OCHA to release a national assessment on November 21 st 2013.

 At least 469 health workers are currently imprisoned.  180 health workers killed by Government and opposition.  60% of hospitals / clinics destroyed or low capacity.  70% of the trained medical staff doctors and nurses have left the country.  Of 6000 physicians in Aleppo in 2011 – 30 remain.  Nationally estimated now 4,041 people per doctor, compared to 661 persons per doctor in The health workforce

Public opinion turning against refugees  Fear of sectarian conflict and civil war (52%)  Syrians are taking our job (82%)  Syrians refugees are supported financially to an unfair degree (50%)  Syrians should not be close neighbors (61% are not comfortable with the presence of Syrians living as close neighbors)  The UN should establish refugee camps for Syrians (70%)  The border with Syria should be more policed (98%) FAFO 2013 – Norwegian NGO

Italy, France, South Africa and Russia low donors

The response – ‘less than robust’  Mix of International (MSF), Syrian expat (UOSSM), Islamic Organisations (Qatari Red Crescent) and private individuals – Gulf.  Divisions between International NGOs and local NGO apparent – lack of trust especially of UN by Saudis and Islamic organisations.  Inter agency sector working groups (Health, education, WASH) in Lebanon have become ‘talking shops’ with little achieved.  INGOs / NGOs having a toxic effect and increasing community tensions due to bad planning and lack of local knowledge and networks – e.g., paying way above local market rates for services and essential goods – water and food stuffs.