The world’s largest single military operation since the 2003 invasion of Iraq began on October 16th, 2016, targeting the areas around Mosul in the Iraqi Nineveh Governorate controlled by the Islamic State of Iraq and the Levant (ISIL). This event led to displacement of over 400,000 people in the first two months and continued throughout 2016 and 2017 forcing people to flee across the border into the neighbouring Al-Hasakeh Governorate in North Eastern Syria (UNHCR, 2018).In anticipation of this influx of Iraqi refugees, the Al-Hol refugee camp was developed at the Iraqi-Syrian border as part of a preparedness plan to respond to the immediate needs of an estimated 100,000 refugees.
From October 2016, thousands of Iraqi refugees were received in Al-Hol, reaching 20,000 individuals by April 2017, and peaking to over 25,000 in October 2017. (Figure 1) By July 2018, the camp population had shrunk to 11,300 with many Iraqis returning home following the liberation of Mosul and surrounding cities (REACH, 2018). At the time of arrival of the Medical Coordinator in the camp in October 2017 there were almost 6,000 families in Al-Hol with an average of 6.2 persons per household (Suppl. Figure 3), located in about 4,000 shelters divided into six areas (“phases”). With an average of five persons per shelter (mostly tents), the average covered area per person was 3.5m2 (REACH, 2018). The largest two phases sheltered Iraqi refugees (97% of camp population) primarily from Nineveh governorate (REACH, 2017), whilst one was for Syrian IDPs (remaining 3%) primarily from Deir-Ez-Zor, Al-Hasakeh and Ar-Raqqa governorates. Camp demographics indicated a young population with 57-61% under the age of 18 years during the 12 months of data collection (Table 1 Supplementary: Age groups of Iraqi refugees Al Hol Camp March 2017-March 2018). [UNHCR, personal communication].
Iraqis fleeing the Battle for Mosul during 2016 and 2017 sought primarily safe haven in Syria, more than in Jordan and Lebanon. However, Syria was already ravaged by war since March 2011 with conflict being the country’s leading cause of death ever since (Guha-Sapir, Rodiriquez-Llanes, Hicks, Donneau, Coutts, Lillywhite, Foua, 2015), and suffering a severe public health crisis (Cousins, 2015) as Syria’s National health care system and services were already under immense pressure.
Few countries in the world today remain untouched by those forced to flee their homeland in search of protection from persecution (Begley, Garavan, Condon, Kelly, Holland & Staines, 1999). Displacement of populations can occur due to factors associated with natural or man-made disasters including conflict and war. Those displaced remaining within their home country are known as “internally displaced people” (IDPs), while people forced to flee to another country are “asylum-seekers”. Once recognised by their new country, they are granted the official state of “refugee” (UNHCR, 2007). Asylum seekers and refugees leave their country because their choice is stark: flee, or stay and risk their and their family’s life. Displaced people endure violations of human rights, repression, conflicts and brutal political persecution, all of which continue to contribute to the flight and mass migration of millions of people every year. The global numbers of people seeking refuge across borders has risen dramatically in the last decade. When the United Nations High Commission for Refugees (UNHCR) was founded in 1951, there were an estimated 1.5 million refugees worldwide. In 2018, an unprecedented 68.5 million people have been forced from home, of whom nearly 25.4 million refugees, over half under the age of 18. An estimated 10 million stateless people have been denied a nationality and access to basic rights such as education, healthcare, employment and freedom of movement. In the world today, nearly one person is forcibly displaced every two seconds as a result of conflict or persecution (UNHCR, 2018).
The need to be creative in ensuring that refugees receive adequate health coverage in conflict settings has evolved over time: UNHCR now partners with national and international non-governmental organisations (NGOs) to provide outpatient health services and a referral system to access host communities, in-patient services and specialist consultancy services. In the 1980’s, the UNICEF/WHO Alma Ata Declaration influenced international public health stating that refugee health programs should be based on the Primary Health Care model (Dick, Simmonds & Vaughan, 1983). In recent decades the burden of caring for refugees has fallen on international relief organizations, and the World Health Organization (WHO) and United Nations (UN) have partnered with several NGOs to promote healthcare for IDPs and refugees.
A body of evidence on the considerable effect of war on public health has accumulated over the past 25 years (Borton, 1996; Levy & Sidel, 1997). In a series of articles on public health and humanitarian interventions on developing the evidence base on conflict and health, it has been argued that there are practical, ethical, logistical, and security issues in the undertaking of research during conflict or political violence. While it is feasible to collect data on health services and health problems, understanding how best to upgrade health services for the host population alongside those available to refugees, and how to most humanely and efficiently provide good quality services and identify key determinants for inter-agency and inter-sectoral cooperation and coordination is key (Banatula and Zuri, 2000).
Of all disasters, the effects of armed conflicts on public health are probably of the greatest magnitude because of the initiation of mass movement and displacement of populations. Under such arduous state, people - in particular the youngest and oldest exposed to challenging environments - have a propensity to danger, injuries and exacerbation of underlying or chronic medical conditions. Although it is a common belief that high death rates are due to direct injury like gunshots, mortars, or explosions, the truth is that an overwhelming majority of morbidity and mortality caused by armed conflict is indirect and relates mainly to public health issues (Murray, King, Lopez, Tomijima, Krug (2002).
The impact of civil wars hypothesis has been tested and found to have substantial long-term effects, even after controlling for several other factors. Using data from 1991-1997, it was estimated that the additional burden of death and disability from the indirect and lingering effects of civil war was approximately equal to that incurred directly and immediately from all wars, and that the impact worked its way through specific diseases and conditions, disproportionately affecting women and children (Ghobarah, Huth, Russett (2003). The disease burden is not directly combat-related but is multifactorial and due to malnutrition, communicable diseases and exacerbation of chronic conditions. The main public health risk factors that emerge in crises are detailed by Checci, Warsame, Treacy-Wang, Polonsky, van Ommeren and Prudhon, (2017) who stress that while humanitarian public health services (water, sanitation and hygiene, nutrition and health care) seek to minimise excess health impact by reducing exposure to the risk factors, they must be available and have both high coverage and high quality.
Several of these contributing factors have been well documented: as a result of a disaster or its consequences people may suffer from specific injuries, infections (communicable diseases) destabilisation of chronic (non-communicable diseases), mental health disorders and other problems such as premature births (van Berlaer, Elsafti, Al Safadi, Souhil Saeed, Buyl, Debacker, 2017).
Forced displacement, particularly into overcrowded settlements with poor living conditions results in greater infectious disease transmission (Connolly, Gayer, Ryan, Salama, Spiegel Heymann, 2004), including upper and lower respiratory tract infections, acute watery diarrhoea, skin diseases, and fever of unknown origin in the Cox Bazzar Refugee camp in Bangladesh (MSF, 2019).
Communicable diseases, alone or in combination with malnutrition, account for most deaths in complex emergencies (Connolly, Gayer, Ryan, Salama, Spiegel, Heymann (2004). Controlling specific communicable diseases in camp settings is a challenge. The WHO supported NGO Mentor Initiative [MENTOR, 2019] has been coordinating the response to outbreaks within Syria. The number of cases of cutaneous leishmaniasis, endemic in Syria since the 18th century and formerly considered an urban problem centred around Aleppo and Idlib, have dramatically increased since the conflict, and spread within Syria and into neighbouring Iraq, Lebanon, and Jordan (Burki, 2017, Salam, Al-Shaqha, Azzi (2014): Hayani, Dandashli, Weisshaar (2015): Alasaad (2013). 41% of the consultations of Syrian refugees seeking primary medical care in neighbouring countries Jordan, Turkey and Lebanon, are for respiratory tract infections (UNHCR, 2015), reflecting the impaired living conditions both inside and outside refugee camps (Sahloul, Monla-Hassan, Sankari, Kherallah, Atassi, Badr, Abbara Sparrow, 2015).
The breakdown of healthcare systems is a reverberation of internal conflict, leading to shortage of routine daily treatment and necessary health services for the chronically ill. Non-communicable diseases (NCDs) are the leading cause of mortality worldwide with an estimated 41 million deaths in 2016, accounting for 71% of 57 million deaths annually. (WHO, 2018). In Iraq, chronic disease accounts for 43% of all deaths, 21% of which are cardiovascular (WHO, 2018).
There is limited data reported on the mental health issues of Iraqi refugees (Mateen, Carone, Al-Saedy, Nyce, Ghosn, Mutuerandu, Black, 2010) (Yanni, Naoum, Odeh, Han, Coleman, Burke (2013).
Humanitarian intervention is aimed at saving lives, alleviating suffering and maintaining human dignity of all. The Core SHPERE and minimum standards cover approaches to programming four sets of life-saving activities: water supply, sanitation and hygiene promotion; food security and nutrition; shelter, settlement and non-food items; and health action (SPHERE Project, 2011). Access to primary health care and referral hospital services for treatment of severe cases is one of the top ten interventions to reduce mortality in the acute phase of an emergency and beyond.
Healthcare workers delivering medical care to the affected people in humanitarian emergencies thus require specific knowledge about the diagnosis and treatment of the most common health conditions in refugees (Wisner & Adams, 2002) and should be capable of adapting to complex circumstances. Well trained international emergency personnel need to switch from their daily routine of attempting to save every patient, to a disaster mode of “doing the best for most”, taking into account the number of patients and the availability of time, human and medical resources (Merin, Ash, Levy, Schwaber, Kreiss, 2010).
In order to assemble a body of evidence needed to improve future humanitarian interventions, it is of the utmost importance that well organised health systems support on-going prospective collection of epidemiological data during disasters (Checci and Roberts 2005). Next to the ethical duty to publish scientific reports timely, healthcare workers need to monitor, record, and report patient’s complaints and diagnoses as a surveillance in real time, in order to be alerted immediately when notifiable or priority diseases emerge in the population.
Despite the large numbers of Iraqi refugees recognised by UNHCR, there are few published studies on their health state, mostly because host country surveillance systems do not disaggregate by nationality (Mowafi, Spiegel, 2008). Some publications have documented the health of Iraqi refugees living in camps in Jordan (Mateen, Carone, Al-Saedy, Nyce, Ghosn, Mutuerandu, Black, 2010) or resettled in European countries (van Berlaer, 2016) and have concluded that next to infectious diseases, they suffer predominantly from long neglected or untreated chronic conditions, emphasising the need for early prevention and control, and targeted health services and education.
In the light of this paucity of data on the health state of Iraqi refugees living in camps within conflict zones in Syria, to our knowledge this study is the first to report on the prevalence and healthcare seeking conditions for Iraqi refugees displaced into North Eastern Syria during the Battle for Mosul.
The aim of this study is to describe the presenting complaints, diagnoses and treatment of Iraqi war refugees in a UNHCR camp located in North Eastern Syria, and to determine the range and burden of health services utilisation in order to make recommendations on how best to improve the humanitarian response regarding the composition of the health services provided and medial team resources required to respond to these vulnerable populations.