Healthcare Access and Health Concerns among Syrian Refugees Living in Camps or Urban Settings Overseas

Overview

Prior to the Syrian Civil War, Syria was classified as a lower-middle income nation, with a fairly stable middle class that had a relatively high socioeconomic status ². As a result, the health conditions observed in this population include chronic conditions less often associated with newly arrived refugees (e.g., hypertension, diabetes, and cancer). In addition, acute illnesses and infectious diseases reflect the challenges associated with displacement, crowding, and poor sanitation.

Primary Healthcare

Access to healthcare varies greatly depending on country of asylum and whether a refugee lives in a refugee camp or in an urban or informal settlement. UNCHR reported that the majority (72.1%) of primary healthcare visits in Zaatari camp (Jordan) were due to communicable diseases. Non-communicable diseases (21.8%), injuries (4.8%), and mental illness (1.3%) were also noted as reasons for seeking primary care. Similarly, the majority of primary healthcare visits in Iraq and Lebanon were due to communicable diseases. Notably, primary healthcare visits attributed to non-communicable diseases accounted for just 7.4% and 8.3% of all primary healthcare visits in Iraq and Lebanon, respectively ¹³.

Immunizations

Some Syrians may have received vaccinations prior to displacement, through the Syrian national immunization program; others may have received some immunizations from non-governmental organizations (NGOs) operating in refugee settlements or camps. Additionally, U.S.-bound Syrian refugees may be receiving select vaccines as part of the Vaccination Program for U.S.-bound Refugees, depending on the country of processing (see section ‘Vaccination Program for U.S.-bound Refugees’ for additional information). However, Syrian refugees generally have not completed the full ACIP-recommended vaccination schedule prior to departure for the United States.

Women’s Health Issues

Reproductive Health

A recent study assessing the health status of women presenting to six regional primary healthcare clinics in Lebanon found that 65.5% (N=452) of women between 18 and 45 years of age were not using any form of birth control. Within this group, the mean age at first pregnancy was 19 years. Additionally, 16.4% were pregnant during the current conflict. Of note, 51.6% of all women surveyed reported dysmenorrhea or severe pelvic pain, 27.4% were diagnosed with anemia, 12.2% with hypertension, and 3.1% with diabetes ²³.

Family planning services are available through the Jordanian healthcare system; however, such services are only provided to married couples ²⁴. Birth control and family planning services are available in the Zaatari Refugee Camp, where many Syrian refugees reside. However, studies indicate that only 1 in 3 women of reproductive age are aware of birth control options in the camp ²⁴. A survey of Syrian households in Jordan found that most women (82.2%) received antenatal care, with an average of 6.2 visits during pregnancy ²⁵. Furthermore, 82.2% delivered their infants in a hospital, with 51.8% of births taking place in public hospitals and 30.4% in private hospitals ²⁵.

Decisions regarding contraception and family planning are often made by the man and woman together. When offering birth control education, healthcare providers should consider providing contraception counseling to individual women and, with their consent, including male partners in these discussions ²⁶.

Female Genital Mutilation/Cutting (FGM/C)

Little published research has documented the prevalence and distribution of FGM/C in the Middle East. However, anecdotal and circumstantial evidence suggests that FGM/C exists throughout the region, including Syria and other Arab countries ²⁷. The extent to which FGM/C is practiced in Syria is unknown. FGM/C has been documented in countries where Syrian refugees are seeking asylum, including Egypt, where more than 90% of girls and women between 15 and 49 years of age are reported to have undergone FGM/C ²⁸.

FGM/C is a cultural or social custom, and is not considered a religious practice. Communities that practice FGM/C often do so with the conviction that FGM/C will ensure a girl’s proper upbringing, preserve family honor, and make a girl suitable for marriage ²⁹. FGM/C exists in numerous countries with large Muslim populations, FGM/C is carried out by followers of various religions and sects. FGM/C has been legitimized by certain radical Islamic clerics; however, there is no basis for FGM/C in the Quran or any other religious text ²⁷.

Gender-Based Violence

Sexual violence is a concern for women and girls in Syria, as well as in countries of first asylum. Fear of sexual violence perpetrated by other refugees or by host country nationals may cause Syrian refugee women to stay home and only venture outside when accompanied by family members ⁹. A recent study found that 30.8% (N=452) of surveyed Syrian refugee women reported experiencing conflict-related violence, with 3.1% of surveyed women reporting non-partner sexual violence ²³.

Early and Forced Marriage

Early and forced marriage is a growing problem for young Syrian girls. Many international groups (the International Center for Research on Women, Amnesty International, the United Nations, and many others) and governments worldwide view child marriage as a human rights violation due to the child’s inability to consent to the marriage. Instances of child and forced marriages have been reported among Syrian refugees in Erbil (Iraq), Lebanon, Egypt, and Turkey ³⁰. Some Syrian refugee families believe that child marriage is the best way to protect their daughters from the threat of sexual violence in refugee camps or urban slums, and is a means to alleviate poverty ³⁰. As a result of early or forced marriage, girls are denied education, are unable to take advantage of economic opportunities, and are left at increased risk for early pregnancy and resulting maternal mortality, stillbirth, and other obstetric complications, as well as gender-based violence ^{30 31}.

Mental Health

Historically, mental illness has been stigmatized in the Syrian community. Syrians may be reluctant to acknowledge mental health issues, as such issues may be viewed as personal flaws and might bring shame upon family and friends. As a result, individuals are often reluctant to seek professional psychological or psychiatric care. However, with the recent increase in psychological trauma related to war and displacement, some Syrian refugees have become more open and accepting of mental health conditions and treatment ⁹.

The availability of mental health services for refugees overseas is limited. The quality of services is often poor, largely due to overstretched capacity and a shortage of trained mental health providers ³². However, mental health providers in the Middle East have seen an increase in the number of Syrians with severe mental health disorders. The largest psychiatric hospital in Lebanon has observed an increase in admissions of Syrians with severe psychopathology and suicidality since the conflict began ^{33 34}. Additionally, the International Medical Corps (IMC) has treated more than 6,000 Syrians, 700 (11.7%) of which had psychotic disorders, in outpatient facilities ^{34 35}.

References

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23. Reese Masterson A, et al., Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC Women’s Health, 2014. 14(1): p. 1-8.
24. Doedens W, et al., Reproductive Health Services for Syrian Refugees in Zaatri Refugee Camp and Irbid City, Jordan. 2013.
25. Doocy, S., et al., Syrian Refugee Health Access Survey in Jordan. 2014, Johns Hopkins University Bloomberg School of Public Health, World Health Organization, Jordan University for Science and Technology, United Nations High Commissioner for Refugees, Ministry of Health of the Hashemite Kingdom of Jordan.
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27. Al-Alawi, I., Middle East Conference Against Female Genital Mutilation. 2013, Stonegate Institute.
28. World Health Organization. Female genital mutilation (FGM). 2016 [cited 2016 March 7];
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29. UNICEF. Female genital mutilation/cutting. 2016 [cited 2016 March 7]; Available from: http://www.unicef.org/protection/57929_58002.html.
30. Save the Children, Too Young to Wed: The growing problem of child marriage among Syrian girls in Jordan. 2014, Save the Children Fund: London, United Kingdom.
31. USAID. Child, Early, and Forced Marriage: United States Government’s Response. 2014 [cited 2016 March 22]; Available from: https://www.usaid.gov/news-information/fact-sheets/child-early-and-forced-marriage-usg-response.
32. Weissbecker, I. and A. Leichner, Addressing Mental Health Needs among Syrian Refugees. 2015, Middle East Institute: Washington, DC.
33. Lama, S., et al., Impact of the Syrian Crisis on the Hospitalization of Syrians in a Psychiatric Setting. Community Ment Health J, 2016. 52(1): p. 84-93.
34. Hassan, G., et al., Culture, Context, and the Mental Health and Psychosocial Wellbeing of Syrians: A Review of Mental Health and Psychosocial Support staff working with Syrians Affected by Armed Conflict. 2015, United Nations High Commissioner for Refugees: Geneva.
35. Hijazi, Z. and I. Weissbecker, Syria Crisis: Addressing regional mental health needs and gaps in the context of the Syria crisis. 2015, International Medical Corps: Washington, DC.