by Zara Leima Esmati – BSc BMBS Medicine, Brighton and Sussex Medical School
The Syrian war has been declared by the United Nations as the worst humanitarian crisis of the twenty-first century. Since 2011, an estimated 5.4 million Syrian refugees have fled to seek safety in neighbouring countries Turkey, Lebanon and Jordan. Seventy-five percent of these refugees are women and children, a vast proportion women and girls of reproductive age. This huge influx of refugees has put pressure on the economies and healthcare systems of host countries. The stretch on resources and lack of adequate infrastructure to deal with such numbers has meant that even basic health needs of the refugee population at large cannot be appropriately catered for. As a result of this conflict, it is Syrian refugee women’s health which suffers disproportionately. Patriarchal values, entrenched in cultures throughout the world, amplify the difficulties female refugees endure as social dynamics shape refugee women’s health status and access to health services.
The resulting forced displacement of Syrian women and girls increases their vulnerability at every stage compared to men. Female refugees face daily threats to their safety and security as well as sexual, physical and mental abuses as they attempt to survive. They remain displaced for longer periods of time without status compared to men and face a greater array of health issues. Aspects of Syrian refugee women’s health which suffer the most include access to family planning, safe motherhood, sexual violence and disproportionate risk of STDs, including HIV. These issues are perpetuated by the horrific violence against women in such settings, which encompasses mass rape, military sexual slavery, forced prostitution, forced marriage, trafficking and the resurgence of female genital mutilation. Often women are forced to have sex for survival, food, shelter and protection, as armed conflict inevitably deprives many households of their males and increases the number of female heads of household.
The response to the refugee health crisis by Jordan and Lebanon has been, so far, largely integrative. Syrian refugees live within both host community settlements and refugee camps. In Lebanon a public-private partnership makes it difficult to enrol marginalised groups in medical insurance schemes. Uninsured Lebanese citizens and many refugees obtain care through public hospitals, which cover up to eighty-five percent of hospital care and all medication costs, but only for high-risk diseases. The refugee crisis has exacerbated this system as it has increased the patient caseload by half. Lebanon does not have a national strategy for coping with the healthcare needs of the Syrian refugee population and most refugee health requirements are tackled by the UNHCR (United Nations High Commissioner for Refugees), which covers up to seventy-five per cent of the total cost of all refugee health emergency referrals.
Jordan’s Ministry of Health provides free primary health care, but in refugee camps such as the Za’atari camp where the estimated population is 120,000, the UNHCR is once again the primary healthcare provider. In contrast, the approach in Turkey has been to reject interference from the UNHCR and other international bodies, the Turkish government making it their responsibility to set up field hospitals for refugees inside the camps. There is, therefore, significantly less data available on the delivery of healthcare to Syrian refugees in Turkey compared to Jordan and Lebanon.
Although there is some form of healthcare services in place for refugees in all three host countries, the services are very general and there is little gender specific care. Even when services are available, women often do not know how to access them. Although contraceptives are freely available to married couples in both Lebanon and Jordan the reported number of Syrian women using family planning during displacement has dipped to just 34.5%, down from 60% before the war. This has greatly increased the birth rate and number of unwanted pregnancies, with UNICEF reporting that one baby is born from a Syrian refugee woman every hour. Despite a high birth rate, these women have reported that they do not access antenatal care due to high out-of-pocket costs; increasingly, women are unable to scrape together even the extra 25% of the cost not covered by the UNHCR. The majority do not visit a gynaecologist except when they are pregnant. Only a quarter of women reported visiting a gynaecologist in the past six months and only a third felt as though reproductive health services were easily accessible.
Apart from antenatal issues, a survey carried out in refugee camps in Lebanon found that over half of women reported never once feeling safe in camps and 41% of young women have thought of ending their lives. In Lebanon, all victims of torture or survivors of sexual and gender-based violence are covered for all associated healthcare costs after the incident. However, this requires victims to come forward – Syrian refugee women often do not report incidents due to fear of shame and stigmatisation.
The first step towards improving the health of Syrian refugee women and girls is to have more centres available specifically for women. This will help to alleviate some of the judgement women may feel when seeking care, as it creates safer and more private spaces that allow women to protect their anonymity while facilitating more independent access. Centres like these, such as the Institute for Family Health in Deir Alla in Jordan, funded by the UN population fund, are slowly gaining prevalence. Beyond this, more immediate and cost-effective change will be achieved through greater provision and awareness of existing health services, as well as by addressing barriers that prevent access. As for reproductive health, education and promotion should not merely target women but also be directed towards men. Collaborative involvement in the contraceptive decision-making process will mean working with, instead of fighting against, the societal values which are in place so that they do not serve as a limitation. Overall, there needs to be a systematic change in the way that Syrian refugee women’s health is managed. Interventions for this population will succeed only if they are focused, not just on individuals, but also on broader social and economic constraints that hinder women from accessing and receiving the type of care they need.