The 9th Annual CUGH Global Health ConferenceNew York City, NYMarch 18, 2018

Responding to changing health needs in protracted crises: The case of the Syrian crisisAkik C, Ghattas H, Mesmar S, Rabkin M, El Sadr W, Fouad F

Presented by Fouad M. Fouad

Background and context

Push and pull factors of migration: A closer look

Syrian conflict

Massive death toll &

Destruction of infrastructure and

social systems

Mass displacement: over 6 million

internally displaced and

over 5 million toJordan, Lebanon,

and Turkey

The Syrian conflict: Displacement in numbers

Conflicts have significantly contributed to the rise in the internally and externally displaced.

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 numbersGLOBALLY

• 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)

2011WHO Country Profile

NCDs 77% of total deaths NCDs 46% of total deaths

2014WHO Country Profile

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

Identify the NCD-related health needs of Syrian refugees in neighboring host countries

50.3

50.4

25

73.9

39.8

14.6

19.6

13

7.3

7.6

13.3

0 10 20 30 40 50 60 70 80

Jordan* - JHAS

Lebanon - LHAS

Turkey - Rapid Need Assessment of Gaziantep Based SyrianRefugees

Turkey - Evaluation of health status and health service utilization inZeytinburnu- Istanbul

Jordan - Health Access Utilization Survey

Lebanon - Health Access Utilization Survey

Jordan - Hidden victims of the Syrian crisis

Lebanon - Hidden victims of the Syrian crisis

Turkey - Syrian Refugees in Turkey (in camps)

Turkey - Syrian Refugees in Turkey (outside camps)

Turkey - Syrian refugees needs analysis survey

HHAd

ult

All a

ges

Percentage (%)

NCD status: The impact of conflict

There is a HIGH BURDEN OF NCDs reportedin Lebanon and Jordan (around 50%).

however:

1. Most data collected at Household level, and report at least one member living with at least

one chronic condition;

2. Only 5 chronic disease conditions assessed.

In Turkey, household prevalence ranged from 25 –74 %

13

*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%

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)

Challenges of estimating NCD prevalence in this context

The result of challenges for addressing NCDs in emergencies/protracted crises

Impacts

Healthcare gap for individuals with NCDs

+Lack of evidence-based guidelines in

emergencies=

Greater NCD morbidity and mortality

The heart of the problemManagement 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:

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?

“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 timelineYear Event2011 March –May

Nationwide uprising : Security forces shoot protestors in Deraa , triggering violent unrest

2011 July -2013 August

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 areas2013 September - 2015 May

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

2015 September - 2016 December

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)2017 April -October

US intervention: Syrian air force chemical attack on rebel-held Khan Sheikhoun in Idlib US forces intervene in Syria

Syria: Displacement timelineCountry 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

19

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

2 0 0 0 2 0 0 2 2 0 0 4 2 0 0 6 2 0 0 8 2 0 1 0 2 0 1 2 2 0 1 4 2 0 1 6

UNHCR - FORCIBLY DISPLACED SYRIANS 2000-2016Asylum-seekers Internally displaced persons

Refugees (incl. refugee-like situations) Grand Total