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296 www.thelancet.com/infection Vol 13 April 2013

Infectious diseases in Malian and Syrian confl ictsAs people fl ee ongoing confl icts in Syria and Mali, diff ering conditions for refugees are refl ected in distinct disease patterns. Talha Burki investigates.

For the WHO briefi ng on Syria see http://www.who.int/

hac/crises/syr/syria_presentation_13february2013.

pdf

For the 2004 article on lessons learned from previous confl ict

see Series Lancet 2004; 364: 1801–13. http://www.dx.

doi.org/10.1016/S0140-6736(04)17405-9

On March 6, 2013, the UN High Commissioner for Human Rights (UNHCR) announced that 1 million refugees had fl ed Syria since the country slipped into civil war 2 years ago. UNHCR had not expected to reach this stage until halfway through the year. A 19-year-old woman seeking haven in Lebanon was symbolically registered as the millionth refugee—her host country has seen its population swell by 10% due to the infl ux of Syrians. Large numbers have fl ed to Jordon; on March 8, a sizeable gas explosion hit the Za’atri camp that houses some 110 000 refugees. Turkey, with its patchwork of 17 refugee camps with more to follow, hosts almost 200 000 refugees. Numbers are also increasing in Egypt and Iraq; the latter already has a hefty population of internally displaced people (IDPs) of its own.

The UNHCR fi gures take into account only those refugees who have been registered, or are awaiting registration—the true number is likely to be signifi cantly higher. And not everyone fl ees across the border. Within Syria itself there are an estimated 2·5 million IDPs—“probably an underestimate”, according to Mego Terzian (MSF,

Paris, France)—and the war shows no sign of abating.

Since January 2012, Mali has faced broadly similar unrest. Until recently it was eff ectively divided into a north largely under rebel control and a south loyal to the government. But the French intervention that began earlier this year wrested control of the northern cities from Islamist forces. Refugees—some 170 000 or so—have entered Mauritania, Burkina Faso, Niger, and, in much smaller numbers, Algeria. Within the country, over 250 000 people remain displaced. But although the two confl icts might bear certain geopolitical similarities, from an infectious disease perspective, the needs of the aff ected populations are diff erent.

Firstly, the confl icts have distinct natures. The fi ghting in Syria is widespread and occurs in populous areas; hence, war-related trauma is a major source of injury among the civilian population. This is not the case in Mali, where 90% of the 16 million strong population live outside of the troubled northern areas, and the civilian population has largely escaped targeting.

But the crucial diff erence, explains Paul Spiegel (UNHCR, Geneva, Switzerland), lies in the nations respective wealth. Irrespective of its current status, Syria was a middle-income country, with middle-income problems; Mali, on the other hand, is ranked 175 in the UN’s human development index (only 14 countries rank lower). A WHO briefi ng on Syria

reports “no signs of malnutrition”. In contrast, according to UNHCR, Malians refugees face “high rates of severe and moderate malnutrition”. This is linked to malaria, which barely exists in Syria but remains Mali’s biggest killer, and episodes of diarrhoeal disease. “It is a vicious circle”, explains Chibuzo Okonta (MSF, Paris, France), “you have a case of malaria, then another morbidity, which leads to more malnutrition.” Mass displacement exacerbates matters.

Pre-emergency, the Syrians had much better access to food—3 years of inadequate rainfall had led to food insecurity in Mali—a far superior health-care infrastructure, and a richer population. All of which meant that, before the war, Syrian men and women could expect to outlive their Malian counterparts by 20 years. “The baseline health of people in Mali is far poorer than that of the Syrians”, notes Spiegel, “it makes them much more vulnerable to infectious diseases.”

Since hostilities commenced, Syrians have lost around a third of their public hospitals, and more than half have been damaged. The country had produced 90% of domestically used medicines; obviously this is no longer the case. This has clear and immediate implications for the treatment of chronic diseases such as cancer, hypertension, and diabetes (HIV treatment also faces disruption, although Syria’s prevalence is low). “Chronic diseases have become more and more prominent in situations of confl ict involving middle-income countries”, Spiegel told TLID. But as time passes, the degradation to the health-care system will have an increasingly marked eff ect on infectious disease.

MSF is only present in opposition controlled areas, but Terzian points out that “the health-care system is totally broken”. Preventative

“‘There are fi ve to six families living in a single house with no electricity, no water and bad quality of food. It is impossible to have a good standard of hygiene in such a place’”

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Trauma is a major problem in Syria, although epidemics may take hold

Newsdesk

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activities have largely dried up. “We are seeing cases of hepatitis A and B, measles, and mumps”, Terzian said. “There is treatment of violent injuries but other medical problems are completely neglected.” Hence, for example, patients with tuberculosis face interruptions to their treatment, while many patients are no longer able to access treatment for cutaneous leishmaniasis—previously they had been referred to a centralised hospital in Aleppo, which had some 3500 registered patients in 2011.

There is already a shortage of vaccines and antibiotics, and the security situation makes cold-chain main tenance tricky. Damage to vehicles and roads has massively complicated vaccine transportation. It all contributed to a drop in vaccine coverage from 95% to 80% in the fi rst quarter of 2012, according to WHO. “It is expected to have dropped even further since”, the agency added. Late last year, WHO conducted vaccination campaigns for measles reaching 1·3 million children and polio reaching 1·5 million, sizeable (if not ideal) proportions of the country’s 2·5 million children younger than 5 years.

Northern Mali has seen a comparable breakdown in that health-care which was available. WHO reckons almost 90% of community health centres are no longer functioning in Kidal, Gao, and Timbuktu. “The risk of disease outbreaks remains high”, cautioned a donor alert issued by WHO in February; the alert requested US$29 million in funding for Malian health services in 2013, $12 million of which is urgently needed. “Even before the crisis, the health situation was very fragile mainly due to lack of funding”, affi rmed Okonta. The drug delivery system in the north has been derailed, with serious ramifi cations for eff orts to control pneumonia, tetanus, and measles. Fortunately, meningitis is unlikely to be a problem, thanks to the vaccine roll out.

Over in Syria, a typhoid epidemic has taken hold in the eastern governorate

of Dier Ezzor, with around 1200 reported cases. Terzian talks of a village in the north of Idlib governorate which has seen an infl ux of refugees swell its population from 3000 to around 27 000. “There are fi ve to six families living in a single house with no electricity, no water and bad quality of food. It is impossible to have a good standard of hygiene in such a place.”

Such worries also extend to those places where Syrian refugees have settled. Lebanon has no refugee camps, instead refugees are scattered across 540 locations. Assessments of drinking water in several of these locations have shown high levels of contamination; UNHCR reckons that around a third of refugee house-holds in the country are living with inadequate sanitation (Lebanon has reported a spike in diarrhoeal diseases). Iraq and Jordan also have many refugees living in host communities rather than in camps.

In Syria, the UNHCR cannot operate outside of areas outside the aegis of the central government control. MSF has expressed concerns that aid is not reaching the rebel-control -led areas. Outside the country, agencies attempt to provided health-care and water and sanitation for refugees within and without camps—in Jordon, for example, a measles vaccination campaign that began in November 2012 reached 125 000 in host communities (measles was an important factor in the death toll from the war in the Congo that started in the late 1990s and was responsible for some 3·3 million deaths; while cholera and shigellosis killed roughly 85% of the 50 000 Rwandan refugees who perished within a month of reaching Goma, Zaire in 1994).

The response to the Syrian crisis is massively underfunded and the UN High Commissioner, Antonio Guterres, has warned that “the international humanitarian response capacity is dangerously overstretched”, but at least external security is not a pressing concern. This cannot be said of Mali. “It

is almost impossible to send European staff , for the risk of being kidnapped, to the Mbera camp in Mauritania”, Okonta said. There are also problems with food delivery, and water supply is less than 10 L per person per day, less than half the minimum standard.

In a 2004 article, Spiegel and colleagues commended the “major advances in the way the international community responds to the health and nutrition consequences of complex emergencies”. Lessons were learned from the horrifi c crises of the past and a standard response involving, among other things, measles vaccination, insecticide treated bednets, vitamin A supplementation, and oral rehydration salts was established. But Spiegel also noted that “other interventions need stronger health infrastructure and are more diffi cult to implement during complex emergencies”.

There are perhaps a few thousand rebel fi ghters remaining in northern Mali, mainly in the mountains near Algeria. If they can be prevented from regaining ground, people might be persuaded to return to their homes. In Syria, though, there is little hope of an end to the fi ghting. Latest fi gures suggest 8000 people may be leaving the country every day, placing an ever increasing strain on its neighbours. Things will get worse before they get better.

Talha Burki

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Mali’s health systems were already ravaged, before people were displaced