The Syrian Crisis: “One death is a tragedy, one million is a statistic” Fouad M.Fouad MD Faculty of Health Sciences American University of Beirut International Conference on the Socio-Economic Dimensions of the Syrian Conflict July 4, 2013/ Crowne Plaza, Beirut, Lebanon

General overview Entering its third year (march 2011) Greatest humanitarian disaster of the past two decades, requiring the largest-ever humanitarian appeal – 5.2 billion dollars. Attacks on densely populated areas and urban centers, have caused a devastating impact on the infrastructure including health Over 200,000 refugees registered across the region with (UNHCR) in April alone

General overview In the first five months of 2013 one million Syrians have left their home country More than 1.7 million Syrians are now living as refugees in the neighbouring countries Lebanon, Jordan, Iraq and Turkey. A total of 4 million of those affected in and around Syria are children.

General overview It has now become a regional one threatening health and social welfare systems of Lebanon and Jordan. The number of registered refugees since the start of the conflict has increased the population of Jordan by 7%, and the population of Lebanon by 15%

General overview Over 10.5 million people are at elevated risk and in need of assistance in the north alone, while countrywide more than 5 million people have been displaced.

General overview The doors to Syrian refugees are starting to close Neighboring Turkey, Jordan and Iraq have essentially blocked most refugees from entering their countries. (HRW) “risk turning Syria into an open air prison for tens of thousands of Syrians unable to escape the carnage in their country”.

Syria 2010 Fast Facts

Number of people in affected: >6.8 million (OCHA) Two main sources for the number of people in affected areas: OCHA reports in April that 6.8 million people are in need (OCHA 2013/05/06) Joint Rapid Assessment of Northern Syria (J-RANS II found that 10.5 million people live in areas where access to essential goods and services is considerably compromised, leaving them at elevated risk of harm and in need of assistance. J-RANS II covered 80% of the pre-conflict population in these governorates but excluded Aleppo city. The situation on ground is highly dynamic and approaching the most precise figure is very difficult. However, these estimates indicate the "at least" number of people in need in Syria.

Sector priorities According to several assessments Health and food security were perceived as the highest priorities.(J-RANS II) Nutrition WASH Protection

Health Number of people affected: Morbidity and mortality Over 90,000 dead may be more – 130,000 according to some reports. Half a million plus injured – amputees and disabled 10.3 million people were estimated to live in sub-districts where health services are insufficient. Over 2 million people are at acute risk Direct military targeting of health care facilities and medical staff Morbidity and mortality An increased incidence of measles has been reported in Syria. Influenza-like illnesses and an increasing number of suspected Hepatitis A, unconfirmed typhoid cases The warmer weather will increase health-related risks and there are growing concerns about outbreaks of diarrhoeal-related diseases, and potentially even cholera, if basic services are not urgently restored. the routine national immunization programme has been severely disrupted by the crisis and it is reported that there was little coverage in northern Syria. Home-filtering of crude oil in several sites is causing respiratory problems and skin burns

The health workforce At least 469 health workers are currently imprisoned 70% of the trained medical staff doctors and nurses have left the country. Lacking of qualified medical expertise particularly for trauma, surgeons, anaesthesia and specialized laboratory personnel. Source: (WHO Syria situation report April 2013)

Health infrastructure and supplies 60% of the public hospitals were reportedly damaged, ranging from 0% of hospitals damaged in As Sweida, and Tartous with up to 88% damaged in Rural Damascus. (WHO/MOH 2013/04/30) Several hospitals have been looted or are used as military camps, or used for shelter by IDPs. Lack of fuel and electricity Overburdened with patients (for example, one main referral hospital receives a new emergency patient every 32 seconds). Serious allegations of abuses in public facilities have led many patients to rely exclusively on alternative health support, provided by private clinics, SARC facilities or in clandestine field hospitals. (ECHO 2013/05/24)

The referral system has broken down. There is an acute shortage of means of transportation for patients, high numbers of ambulances are damaged. Patients requiring surgical and medical interventions are no longer referred to hospitals for proper care. There are critical shortages of life-saving medicines and NCDs treatment Vaccination coverage rate dropped down to 46% for the third dose in 2012

Maternal health Inside Syria an estimated one million women of reproductive age are in need of assistance and lack access to reproductive health services An increasing number of pregnant women in conflict-affected areas are requesting an elective C-section In many affected areas, including Homs, Aleppo and Damascus, the C-section rate accounts for over 60% of all facility deliveries In addition, there are reportedly few contraceptives available. (OCHA 2013/05/22, UNFPA 2013/05/09, MSF 2013/05/06)

Mental Health and psychosocial disorders Millions of children are psychologically traumatized from witnessing / experiencing violence. Half of the 1.7 million refugees are children.

Functioning hospital

Livelihoods and food security 4 million are in need of food assistance countrywide, 480,000 in need of emergency crop and livestock support 8.9 million people live in areas where food security and livelihood opportunities are insufficient, of whom 220,000 are at acute risk. the nutritional status of children is of concern Several international reports indicates government forces intentionally targeted bakeries and civilians waiting in breadlines in air strikes (HRW)

WASH 7.4 million people live in areas where WASH services and goods are insufficient. Over 242,000 people are at acute risk. There are no country-wide estimates of the number of people affected. Damage to the water, sanitation and hygiene infrastructure is particularly severe in Rural Damascus, Idleb, Deir-ez-Zor, Homs, Aleppo, and Al-Raqqa, and per-capita availability of water supply has decreased to one third of pre-crisis levels, from 75 to 25L per person per day.

Access to waste-water treatment chemicals has become increasingly difficult. Most water utilities are short of chlorine, and chlorination is not systematically carried out by public and private water truckers IDPs who have settled in public buildings and camps suffer from a shortage of available latrines. In Al Naser camp, which hosts 11,000 IDPs, there are only 4 functional latrines (one/300 person ). The global standard recommends 1 latrine for every 50 people Solid waste collection and disposal has been severely disrupted

Shelter 9.6 million people live in areas where access to shelter and NFI is insufficient. Fighting, including the use of heavy weapons, has caused widespread damage to infrastructure and houses. Around 30% of private buildings and public infrastructure in northern Syria were damaged or destroyed. These findings are confirmed by an ESCWA report in April, which outlined that an estimated 1.2 million houses have been damaged or destroyed, approximately 30% of the number of houses recorded during the 2004 census.

Information availability None / very limited As-Sweida, Dar’a, Damascus, Hama, Homs, Rural Damascus, Tartous, Quneitra, Most Aleppo, Al-Hasakeh, Ar-Raqqa, Deir-ez-Zor, Idleb, Lattakia

Information gaps: Urgent information needs on a governorate level are: Affected population in all areas not covered by the J-RANS: information on priority needs, disaggregated by affected group (IDPs, host-communities). Number of IDPs in host families, collective accommodation and unoccupied houses. Affected population figures: Sex and age disaggregated data including older age groups (60-79 and 80+). Protection: Regularly updated information on which areas are controlled by the Government or anti-Government actors or are contested. Number of people living in high intensity conflict areas. Cases and location of SGBV, number of cases of psychological trauma.

Health: Disease surveillance Livelihoods and food security: Number of people with food insecurity in all areas not covered by the J-RANS. Nutrition: Status of children under 5 years old and other vulnerable groups such as elderly in all areas. More is needed in terms of a nutrition surveillance system. Market information: More comprehensive information required on market prices, availability of products per sub-districts. Shelter: Updated and more comprehensive status of destroyed and damaged medical facilities and schools. WASH: The status of water networks per governorate (functional, partly functional, not functional). Education: Disaggregation of data between primary and secondary schools. Response: Who, What, Where of all relief agencies, in order to increase interagency, inter-sector and sub-sector coordination for relief activities

Situation in Lebanon 600,000 plus refugees – thousands unregistered. Primary and secondary health-care services are available to Syrians but they face large out-of-pocket payments. UNHCR cover 75% for secondary care. They DO NOT cover catastrophic illnesses – cancer etc requiring chemo, dialysis etc. Diseases – Leishmaniasis, measles, TB in refugee and local populations. Lebanese doctors untrained to deal with Leishmaniasis. Threat of epidemics outbreaks in informal camps due to poor sanitation and over crowding.

Situation in Lebanon Majority of refugees located in informal camps across the country.

Unofficial Government estimates : over 1 Unofficial Government estimates : over 1.2 m including more than 300,000 migrants. The refugees are hosted in over 1,200 municipalities. In May 79652 refugees were registered rising from 63000 in April the total number of refugees will reach 2 million by 2014.

Fafo Institute for Labour and Social Research poll (May 2013) Lebanese attitudes towards Syrian refugees and the crisis Fear of sectarian conflict and civil war (52%) Majority of sample do not trust Syrians Syrians are taking our jobs (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%). Refugees have reduced capacity of Lebanese government to provide public services (72%). Representative sample of 900 Lebanese citizens aged 18+

Refugees June 2012 25,400 The next 4 slides show the increase of refugees since JUNE 2012. (PLEASE RUN THE SLIDES FAST TO SHOW THE INCREASE) By June 2012, 25,400 Syrian refugees were registered in Lebanon by UNHCR. Syrian Refugees

December 2013 1 Million Registered Syrian Refugees

Problems of the response Underfunded: donors slow to secure funds. Only 35% currently funded. Compassion fatigue. Humanitarian situation in Syria and Lebanon has gone off the media and policy radar. UN initially underestimated the scale and depth of the problem despite lessons from Iraq and understanding geo-political dynamics of the region Divisions between International NGOs and local NGO apparent – lack of trust especially of UN. Lack of knowledge on response capacity inside Syria- 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 and health system collapse. 3.5 million refugees in total by end of 2013. 1.5 in Lebanon. But will be reached sooner given the escalated fighting and the world ignorance Half of Syria estimated to need urgent assistance by end of year. Cholera, measles, typhoid outbreaks due to poor sanitation and heat within Syria but also in Lebanon. Lack of vaccination coverage in Syria poses severe risks for future epidemic outbreaks particularly measles

Threats and challenges Neglect of chronic diseases – no surveillance or treatment for cancer, CVD, Type II Diabetes, HIV among refugees. Neglect of psychosocial and mental health issues. Situation of Iraqis in Syria post 2004 shows mental health needs are massive and will effect generations, labour force and health care systems.

Possible policy responses Long-term thinking - bridge humanitarian and development policies given refugees will most likely stay for another couple of years – need schools, health care facilities, sanitation infrastructure. More pressure on donors Value for money Cost-effective interventions Coordination mechanisms among different actors inside Syria and in the region; LNGOs, INGOSs, UN agencies

Possible policy responses Think now about post conflict situation (health, education, shelters) Could health be used as a benign negotiating tool given that every party has an interest?

“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.