Bulletin of the World Health Organization

Syrians flee violence and disrupted health services to Jordan

Half a million Syrian refugees are sheltering in Jordan. Dale Gavlak reports on how United Nations agencies are helping the government respond to their needs, especially those of mothers and young children.

Bulletin of the World Health Organization 2013;91:394-395. doi: http://dx.doi.org/10.2471/BLT.13.020613

Syrian refugees arrive in Jordan by night in March 2013, many carrying small children
UNHCR/Jared J Kohler
Syrian refugees arrive in Jordan by night in March 2013, many carrying small children

They fled for their lives in the dead of night as their home-town, the southern Syrian city of Daraa, fell under constant shelling.

“It was so hard walking along the dirt path. There was no transport to the Jordanian border,” said “Leyla Najjar” (not her real name) of the harrowing four-hour journey before Jordanian military patrols brought her, her husband and their two daughters to safety in the country’s largest camp at Zaatari, near the Syrian border.

“What made our escape particularly difficult is that I am pregnant and had to carry and help our two young daughters the whole way,” said the 22-year-old, who did not want to give her real name for fear of reprisals against relatives she had left behind.

Najjar and her family are among the 1.4 million Syrians who have fled mainly to Iraq, Jordan, Lebanon and Turkey since 2011 to escape the violence, bombing and deteriorating conditions in which health care, food, water and energy are increasingly scarce.

“Panic is not good for pregnancy,” said Najjar, who was clad in a black headscarf. Not only that, access to medical care – especially antenatal care – has become increasingly difficult in her country as the conflict engulfing the Syrian Arab Republic over the past two years drags on.

With more than half a million displaced Syrians sheltering in neighbouring Jordan and their numbers expanding every day, the influx of refugees is putting Jordan’s health, water and energy infrastructure under enormous strain. In April, between 1500 and 3000 Syrian refugees were entering Jordan every day.

United Nations agencies, including the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF) and the United Nations Refugee Agency (UNHCR), made a public appeal on 15 April to those involved in the conflict and those with influence on the situation to stop the fighting and come to a political settlement.

In their appeal, they said that while the humanitarian needs were growing, their capacity to help was diminishing “due to security and other practical limitations within the Syrian Arab Republic, as well as funding constraints”.

“We are precariously close, perhaps within weeks, to suspending some humanitarian support,” the appeal said.

According to Muna Idris, Assistant Representative to Jordan with the United Nations Population Fund (UNFPA), “the Syrians we see in health clinics here are often seeking services that they could no longer find in their home country”.

Some pregnant Syrian women like Najjar make the journey to Jordan in spite of their condition, while others at Zaatari camp say they wanted to give birth in Jordan because of the unsafe conditions and lack of health facilities in their home country, said Dr Shible Sahbani, a UNFPA humanitarian affairs specialist.

Between 10 and 13 births were taking place every day in this camp of 120 000 residents at the end of April this year. “We estimate that there could be 1.2 million Syrian refugees in Jordan by the end of the year, including 30 000 pregnant women, many of whom will have given birth by then,” Idris said.

In April, UNFPA opened a new clinic at Zaatari camp to provide primary health care and reproductive health services, including family planning, antenatal and postnatal care, Sahbani said. UNFPA also chairs the reproductive health group, coordinating the organizations providing reproductive health care in the camp.

He said that there was a high fertility rate – an average of five children per family – among Syrian refugees, particularly those from rural areas, and that this was an opportunity to offer family planning advice and contraception.

The agency’s staff also offer refugee women the chance to learn more about their health in general and provide counselling to those who have suffered domestic violence or sexual violence, Sahbani said.

Zaatari camp has several field hospitals and clinics, including another clinic that is also supported by UNFPA and that provides primary health care level reproductive health services, such as antenatal check-ups.

While some caesarean sections are done in a Moroccan field hospital inside the camp, most women with pregnancy complications are referred to Jordanian hospitals outside Zaatari camp.

Syrian refugees bring their children to be vaccinated against measles
Syrian refugees bring their children to be vaccinated against measles

Still, the majority of Syrian refugees in Jordan live outside Zaatari camp in communities scattered throughout the country, where they may have more limited access to local health care and services.

“We have to remember the host communities where most of the refugees live. Their needs are not as visible to the international community as in Zaatari and other refugee camps,” said UNFPA’s Idris.

The United Nations says that 80 000 lives have been lost and 400 000 people have been injured since the Syrian crisis began in 2011 and the country’s health system is also suffering.

Many health professionals have left the country, according to a recent WHO report on the situation. Those who remain often face unsafe roads, snipers and military checkpoints hampering their attempts to go to work. There are critical shortages of anaesthetics and life-saving medicines, including antibiotics and drugs needed for the treatment of chronic diseases, the report says.

According to a UNHCR report released in April on the health of Syrian refugees across the region during the first three months of 2013, there is an unmet need for drugs to treat common health conditions – particularly diabetes, hypertension and cardiovascular diseases – as well as those generated by the conflict, such as mental health problems and injuries.

With international funding low, UNHCR said that providing quality health care to the refugees, particularly to those living outside the camps, was challenging not least because of the funding gap: only half of an appeal launched in January for US$ 1.5 billion by the United Nations has been received.

“We continue, with our partners, to provide medical care for refugees in the camps in Jordan and Iraq. But for those refugees who live outside the camps, often in urban settings, the situation is more difficult,” UNHCR said in a statement.

WHO’s public health expert at Zaatari, Dr Sabri Gmach, said that unlike other refugee populations he has worked with in Africa, Syrians have a tradition of seeking health services. “The need of the vulnerable population of children, the elderly, women and pregnant women is great when they arrive here because some of them have been without health services for a long time.”

Gmach said that WHO, UNICEF, UNHCR and Jordan’s health ministry completed a vaccination campaign against measles at Zaatari camp in April that succeeded in immunizing 98% of the target population of some 90 000 people – mainly new arrivals – between the ages of 6 months and 30 years.

WHO is also focusing on the refugees who live outside refugee camps, and the effect this influx is having on their Jordanian host communities, Gmach said.

In conjunction with Jordan’s health ministry, WHO and other United Nations agencies started a rapid assessment last month of governmental health facilities serving both Jordanian host communities and the Syrians living in them.

“The assessment will tell us how many and what kinds of conditions are affecting which age groups, as well as what impact that additional burden is having on the Jordanian health system, particularly in the country’s northern communities near the Syrian border,” Gmach said, adding that the situation was so fast-moving that a similar assessment done last September was “woefully out of date”.

For its part, UNFPA is supporting local nongovernmental organizations, such as the Jordanian Health Aid Society and the Aman Jordanian Association, to set up clinics and medical units in these host communities.

WHO has long supported the Jordanian government by providing training for health managers and health workers. “Now we are also helping the Ministry of Health do more effective planning so that Jordan’s health system can cope better with this stress,” said Dr Akram Eltom, WHO’s Representative in Jordan.

Next month, WHO, UNICEF and other partners will work with the health ministry on a new vaccination campaign. “Now that we have completed a successful measles vaccination campaign in Zaatari camp, we want to vaccinate the huge population of Syrians living outside camps as well as Jordanian children and adults living in those host communities. This will help protect the country against a re-emergence of measles; a potentially devastating viral illness that Jordan had not seen for several years.”