Strengthening the Response to the Syrian Refugee Crisis

The headlines have been searing: men, women, and children fleeing the continuing and brutal war in Syria, but this time, seeking refuge in Europe. These individuals are among the 40 million refugees and other displaced people worldwide—the largest number since the aftermath of World War II. They include many millions of people who are displaced within Syria, and additional millions of Syrian nationals who have fled to neighboring countries. It is estimated that there are now 2 million Syrian refugees living in Turkey, 1.5 million in Lebanon, and 650,000 in Jordan.

“Half of the population has fled” from their homes, commented Professor Neil Boothby, EdD, who founded and directs PopFam’s Program on Forced Migration and Health (PFMH), which works to improve the effectiveness of humanitarian assistance. “That’s just an astounding fact to think about.”

The toll that this exodus has taken on neighboring countries has been enormous, exhausting the capacity of humanitarian actors and governments alike. “A refugee crisis typically places many kinds of strain on the host country,” Dr. Boothby maintained, from the capacity of the host country’s health system to many other social services. “And this crisis has been going on for four years. From a governance standpoint, it’s very challenging.”

Photo Credit: Peter Biro, IRC

Citing Jordan as an example, Dr. Boothby noted, “It is very, very difficult to absorb 650,000 people into your healthcare system and [integrate] children into your education system, and it’s not something that is going to be solved in the moment. It’s a long-term challenge.”

While the Syrian conflict is arguably receiving the greatest degree of press, this country is just one of many that are imploding in the Middle East, Dr. Boothby emphasized, creating additional refugee crises and an urgent need for more comprehensive and forward thinking responses in this region. To help countries successfully shoulder the staggering numbers of refugees from Syria and other regional conflicts—both to avert immediate crisis and prevent dangerous long-term consequences—Dr. Boothby’s PFMH has recently stepped up its work in this part of the world. The program has launched a new think-tank-style project which is focusing on refugee policy in the Middle East; a training and capacity-building initiative for humanitarian actors and governments in the Middle East and North Africa; and a child-focused initiative in Jordan.

Each of these new initiatives, described below, falls squarely within the PFMH’s mission: to help governments and the international development community bring systematic, evidence-based approaches to providing healthcare and other services in emergency settings, and to help countries and health systems recover from crisis.

Re-thinking the Response

Although many well-intentioned organizations have been working to address the enormous numbers of refugees and displaced people in the Middle East, most coming from Syria, this response has employed models that do not fit the current context, Dr. Boothby explained. The highly protracted nature of the conflicts in this region, the extraordinary numbers of people who have been displaced, and the more chronic nature of disease among people in this part of the world, have all challenged traditional humanitarian response, which tends to focus on providing emergency access to food and shelter and preventing the spread of infectious disease.

“Today’s long-term refugees need access to health services in contexts that go far beyond [traditional] ‘camp’ settings,” Dr. Boothby asserted. Their situations require a more holistic integration into existing governments’ health and social service infrastructures.

“In Jordan and Turkey, for example, there are formal refugee camps which are overseen by UNHCR [United Nations High Commissioner for Refugees], and this is sort of your classic plastic sheeting with separate or distinct services for refugees,” explained Dr. Boothby. However, “the larger number of displacees are really living outside of these camps in Istanbul and Amman and other cities, and…[while] the governments of each country are reaching out as humanely and as wisely as they can, [the numbers of refugees] are overwhelming their healthcare systems and other social service systems.”

Fortunately, Dr. Boothby noted, the path forward is relatively clear: “I think we know that the best way to do address [such long-term] refugee crises is to let the refugees come into the regular healthcare system [rather than] setting up parallel systems, and over time to develop the capacity to deal with the increased numbers.” Such work is not easy, however, and requires training and long-term commitment. Laying the groundwork for this reframing of refugee response—in both action and policy—is the goal of a new project which Dr. Boothby, along with his Mailman School colleague Wafaa El-Sadr, MD, MPH, have developed in collaboration with Columbia University’s Global Center.

This partnership aims to develop an evidence-based and culturally appropriate framework for promoting refugee health for the millions of individuals who suffering from long-term displacement in this region, and by doing so, to help shift policies to support such efforts. Beginning this month, the project will gather significant evidence on the needs of displaced people in this region. After this situational analysis is complete, participants will conduct collaborative research studies to test improvements to health, education, and other social services used by the native-born and refugee populations in Turkey, Jordan, and Lebanon. As is customary for the PFMH, students from Mailman will be engaged in these activities.

While the three-year project will focus on the needs of displaced people in the Middle East and Eastern Mediterranean, Dr. Boothby noted this work has the potential to transform the global policies and frameworks that are used to meet the needs of long-term refugees in many parts of the world.

New Training to Meet New Challenges

The PFMH is also launching a training and technical support program to provide practical assistance to those working to meet the needs of refugees in this region. Developed at the request of UNICEF, the project aims to help humanitarian actors and governments respond more effectively to the refugee crises they face. “This is really an effort to provide the staff of UNICEF in this region with the skills needed to improve their preparation to respond to emergencies in this particular geo-political and cultural context,” explained SM Moazzem Hossain, MD, MPH, MBA, an assistant clinical professor of population and family health and Regional Chief of the Child Survival and Development Section for UNICEF in the Middle East and North Africa (MENA) Region.

While there are many dedicated humanitarian responders working to address refugee crises in this part of the world, Dr. Hossain explained, many lack knowledge about the specific needs of refugees in this region, creating an urgent need for culturally appropriate and country-specific training that can address health, nutrition, and Water, Sanitation, and Hygiene (WASH) needs. “Most [existing] training modules are based upon conflicts that have taken place in Africa and Asia but in the last ten years the conflicts which have erupted in this region have been different and more complex than conflicts which have taken place in the past in other regions,” Dr. Hossain noted. In addition, most existing emergency response trainings focus on one particular topic—e.g. health, nutrition, or WASH—which makes it difficult for the limited personnel in small UNICEF country or field program offices to accrue the comprehensive training they need.

To build the capacity of UNICEF personnel to address all of these issues within this regional context, Dr. Hossain has been developing a comprehensive new training program with colleagues at UNICEF MENARO and assistance from Shatha El Nakib, MPH ‘15, an Egyptian-born Mailman graduate who now works as a public health program officer for PopFam based in Jordan. This eight-day training program will be implemented in December in Jordan for UNICEF health, nutrition, and WASH officials from the MENA region. Dr. Hossain expects the course to subsequently be made available online for additional UNICEF personnel and partners, and eventually, for wide-ranging stakeholders in the region and PMFH students.

This training, Dr. Hossain stressed, is envisioned as the first step in a far more wide-reaching capacity building initiative in the region that will also address significant gaps in data collection, which are preventing countries from accurately assessing and responding to the needs of refugees. The need for such data is especially acute given the differences in the burden of disease that humanitarian actors are encountering as they work to serve people impacted by conflict in this region, explained Ms. El Nakib.

“Non-communicable diseases are among the leading causes of morbidity and mortality among refugees in this region,” she said, adding, “This is not what humanitarian responders are used to in Africa, countries where they might have been prepared to respond to malaria or measles but not to diabetes and cardiovascular disease. These chronic conditions can be very expensive to treat and can require a whole new level of care.”

While countries dealing with refugees in this region tend to be middle-income countries, Ms. El Nakib explained, they don’t have healthcare infrastructures to handle the large numbers of refugees they are receiving or to adequately address their high rates of chronic illness. In 1993, Ms. El Nakib noted, 70 percent of the world’s refugees were from low-income countries, while in 2010, 70 percent were from middle-income countries. “Bridging the gap between [temporary] humanitarian action and sustainable development is our biggest challenge,” Ms. El nakib affirmed. The long-term goal of this new programming, Dr. Hossain added, is to strengthen the capacity of increasingly fragile health systems in the countries that have been so hard hit by refugee crises in this region.

Implications for Children

Some of the most catastrophic consequences of the protracted Syrian war and its concomitant refugee crisis involve children, Dr. Boothby explained. Accordingly, the PFMH is also launching a new program that will focus on the young and vulnerable. “Children that end up in Turkey and Jordan as neighboring countries face a number of challenges,” he said. “One, is that they have been there a long time, in some cases for a couple of years, and two, is the fact that only one out of four of these children is in any formal education or school.”

Not only are children missing out on their education, Dr. Boothby noted, but many are taking on jobs to help their families survive and are being exploited in the process. “When I was last in Jordan, I found boys working in battery factories that were being exposed to chemicals, and one child had chemicals splashed in his eye and was blind,” Dr. Boothby recounted. “Increasingly, girls are ending up as domestics, and that is a very challenging situation for a teenage girl. So, there are many protection problems that are faced by refugee children from Syria.”

These protection problems pose long-term threats to the health and wellbeing of these children and to the security of the region. “The absence of children from school and exposure to toxic stress in childhood are major predictors of chronic disease and other kinds of chronic problems in adulthood,” Dr. Boothby said. “We know that 85 percent of our intellectual capacity is developed in the first years of life,” Dr. Boothby explained, yet many children in Jordan—both those born into poverty and those coming to the country as refugees—are not receiving the essential cognitive, nutritional, and social support that they need for optimal development.

Accordingly, “the queen of Jordan has started the Jordan River Foundation,” Dr. Boothby explained. This institution, he said, “is interested in engaging us in questions around how we invest in children’s body and brain health in the context of massive displacement where the systems are being overwhelmed and what key investments can be made to avoid a lost generation.”

As one of the first steps in such efforts, the PFMH will work with Jordanian stakeholders to convene a “Childhood Summit,” with the goal of securing widespread commitment and action to improve developmental outcomes for all children growing up in Jordan. It is an important step, Dr. Boothby says, and an urgent one. “We need to start getting our heads around the huge numbers of children [in this region] who are brutalized, uneducated, and exposed to extreme ideologies,” he contended, adding that the future wellbeing of these children will be essential to any meaningful recovery from the current crisis. “If we don’t invest wisely in children,” Dr. Boothby cautioned, “recovery will not be possible.”