Before the Syrian War started in 2011, noncommunicable diseases caused 74 percent of deaths in Syria, according to World Health Organization data. Now these diseases are killing roughly the same number of people as those killed by bullets and bombs in their homeland and neighboring countries. Those afflicted by noncommunicable diseases are carrying conditions like diabetes and cardiovascular disease into settlements in Lebanon and Syria where health systems are ill-equipped to provided necessary care.
A lot of these sufferers have come from a Syrian health-care system that was already bursting at the seams, even before the onset of war. Moving into settlements in Jordan and Lebanon has meant that patients have had “treatment gaps” or their conditions have become chronic, or even life-threatening because “they have not been able to access their medication,” said Dr. Philippa Boulle, noncommunicable diseases adviser at Doctors Without Borders.
Not only are these health systems not able to cope with the overwhelming need, but also the humanitarian community faces a type of crisis with no precedent to draw on.
The level of need, combined with the underfunded international response, has meant that the humanitarian community’s focus has been on meeting the immediate needs of refugees, such as providing food, shelter, among others. As a result, the needs of noncommunicable disease sufferers are often overlooked, as “it’s not necessarily intuitive to humanitarian actors to incorporate NCD care as an integral part of the response,” Boulle said. She added that because “NCDs have never represented as much of a burden proportionately to other needs,” there are no previous humanitarian examples of how to deliver responses that adequately deliver services to sufferers.
Added to this is also the difficulty of providing services to refugees who, in Lebanon and Jordan, have primarily settled in urban settlements. In Jordan the urban population of refugees accounts for around 80 percent of refugees in Jordan, according to U.N. High Commissioner for Refugees, which “makes the situation a bit more challenging for provision of services because it’s easier when you have a camp setting to control the movement of people,” said Dr. Slim Slama, medical officer at the World Health Organization. All in all, this makes the prospect of delivering integrated and effective services more problematic.
What makes noncommunicable diseases more difficult to treat in refugee settlements, comparative to communicable diseases such as typhoid and cholera, is that patients need greater levels of care, over time. This includes initial consultation and investigation of symptoms, a decision on treatment as well as prescribing all the necessary medications to treat or ail the disease. Even then the situation can become yet more complicated for aid workers and health agencies.
“NCDs are neglected and the problem is that they are ‘creepers’ because they don’t show symptoms and shout out loudly in their initial stages,” said Boulle, adding that “it’s only once the burden has become significant and too much that people react and do something about it and at that stage it’s more acquired and has more of an effect on their lives.” Once these effects become more pronounced and chronic, diabetes sufferers, for example, can suffer further complications such as blindness, loss of limbs and so on, if not properly treated after a two- or three-week period.
With the overall humanitarian budget stretched to its limits and facing further cuts, agencies like UNHCR have had to make tough decisions between funding primary health-care facilities and emergency care. This means that the ability for refugees to access care in both countries is greatly diminished, burdening those who already have little resources or livelihood strategies to afford treatment and care. This is the case in both Jordan and particularly in Lebanon, where the private sector provides around 90 percent of health-care services.
Also cited as an issue has been the expense that sufferers pay for overall care. Unlike communicable diseases, provision of treatment and care needs to be over time, and can therefore be more costly for health-care providers and patients alike.
Treatment for noncommunicable diseases include, among other things, everything from initial consultation fees to medication costs and continued care-associated costs. Slama adds that “when you add this all together, for monthly treatment, it can become quite financially onerous on the patient, with overall care costs reaching anywhere from $30 to $50,” a great portion of a refugee’s money. A UNHCR study last year showed that around 24 percent to 36 percent of the overall refugee population in Lebanon perceived care as affordable and accessible, a very small number.
In order to improve care, “overcoming financial barriers to access, treatment and care” is seen as a primary concern, according to Ann Burton, senior public health office at UNHCR Jordan. Doctors Without Borders is currently the only humanitarian organization providing free treatment to Syrian refugees suffering from noncommunicable diseases.
Though the pressure on these services is clearly stretched and underfunded, Boulle adds that care should be “incorporated into primary care,” and not run as a parallel service to existing systems. It is clear that, over time, this approach will be more efficient and sustainable. It will ensure that no patients see treatment gaps, and that their conditions do not worsen further. If these conditions get worse there is every chance that this will, in turn, affect the ability for emergency health care to deal with a crisis that will become less silent and more of a burden of health systems.
The worrying trend is that the funding for the Syrian crisis is not meeting current demand and, in most circumstances is diminishing. Slama, who has been returning to Lebanon as an adviser over the last three years, says that “in the last two years I have seen a reduction in terms of the imbursement system for secondary care or tertiary care. The funding gaps coming from the international response are directly affecting these people.”