Defense In Depth
Why U.S. Security Depends on Alliances—Now More Than Ever
On a cold January night near Istanbul’s Taksim Square, a family of ten Syrian refugees sat quietly in a one-bedroom apartment. There was no furniture, and the little food the family had lay rotting in a box in a corner. Mohammed, an 18-year-old, rocked back and forth in silence on the floor. His grandmother, Fatimah, told me that he had stopped speaking after the trauma of his voyage from Aleppo: he had been shot at and had witnessed friends die. Fatimah could no longer walk. Her diabetes had robbed her of the use of her legs, she said, and her heart complications strained her breathing. The family could not afford prescription drugs or specialized medical care.
Mohammed and Fatimah are just two of the millions of refugees suffering from chronic non-communicable diseases—maladies such as diabetes, cancer, and mental illness that cannot pass from person to person but can be devastating if left untreated. As host countries have taken in the world’s displaced, they have too often failed to consistently treat these ailments. Governments must change course: non-communicable diseases increase countries’ health care costs in the long term and prevent refugees from building productive, sustainable lives in their new communities. If policymakers do not provide reliable health care to displaced people, chronic diseases could turn the global refugee crisis into an even greater burden.
THE BURDEN OF DISEASE
Chronic illnesses are not popularly associated with people fleeing war and persecution. Yet many of the countries producing today’s refugees have either long carried a heavy burden of chronic disease or have recently seen that burden increase. Over the past two decades, for instance, non-communicable diseases have affected over 90 percent of Syrians, 5.5 million of whom have fled their country since the start of the civil war in 2011. (A 2015 survey of Syrian families living outside of camps in Jordan found that half of them had at least one member with a chronic illness.) Since the U.S.-led invasion of Afghanistan in 2001, the number of annual deaths caused by non-communicable diseases in that country has grown by about 12 percent. (As of 2015, around 2.7 million Afghans were living abroad as refugees.) Displaced people from Iraq and the Balkan states similarly suffer from high rates of non-communicable diseases.
To access health care in their new countries, refugees generally need identification cards from their host governments—and getting those cards usually requires presenting documents from their home countries. The trouble is that many refugees arrive without those documents, having lost them during their migrations or having failed to take them along in the first place. As a result, some refugees wait months to receive new documents. Of the 515,000 Syrian refugees living outside of camps in Jordan in August 2016, for instance, more than 145,000 had not yet received identification cards, leaving them without access to the medical attention required to manage chronic diseases.
Even registered refugees in camps tend to lack access to reliable care. Camps rarely offer the specialist attention required to treat conditions such as breast cancer and chronic obstructive pulmonary disease. Worse, in many camps, there are not enough doctors to meet demand. At the Altinözü camp in Turkey, where around 8,000 refugees live, doctors tend to see between 50 and 80 patients per day—which can be far more than the UN Office of the High Commissioner for Refugees’ recommended limit of 50 patients per day.
As for the displaced people who move to cities in hopes of finding better work, schools, and health care, they often end up in shantytowns, where poor nutrition, smoking, and a lack of physical activity make their chronic illnesses worse. Instead of providing the continuous care that chronic ailments demand, many host countries grant urban refugees only a few visits to general practitioners.
Treatments for chronic diseases are often expensive: dialysis, used to treat kidney failure, can cost tens of thousands of dollars per year. And displaced people are often poor. Seventy percent of the Syrian refugees registered with the UNHCR in July 2016, for instance, lived below the poverty line of their host country. When refugees have to spend much of their income on treatment, they can become trapped in cycles of destitution and illness that make it harder for them to build new lives.
Poverty is not the only problem. Many refugees have a hard time navigating their host countries’ health care systems because of language barriers and a lack of knowledge about how to get help. Like most Syrian refugees in Turkey, for instance, Mohammed and his grandmother did not speak Turkish and had trouble understanding the country's referral-based system, under which patients receive basic medical attention before being referred to higher-level specialists. Refugees in such circumstances tend to prioritize other necessities, such as food, shelter, and employment, ignoring chronic conditions that do not appear to be immediate emergencies. As such conditions worsen, however, they make pursuing those other priorities harder.
Policymakers may question why they should attend to the ailments of refugees when their own citizens face similar problems. But the fact is that many refugees are not leaving their new countries anytime soon: more than half of the world’s refugees are under the age of 18, and more than half have already lived abroad for more than five years. Only when refugees are healthy can they contribute to their new communities, taking up jobs in sectors in which indigenous workers are lacking and earning enough money to become productive consumers. And when refugees avoid poverty and illness, they are less likely to fall victim to radicalization or turn to violence. Providing adequate health care for refugees is thus a practical imperative.
Policymakers should develop public health programs in the native languages of refugees to teach them about health services, risk factors for chronic ailments, and the consequences of leaving those conditions untreated. Because chronic diseases require long-term care, governments should also expand temporary health insurance plans and work to help refugees finance costly treatments and medications for chronic illnesses. Providing long-term access to the resources that would help refugees manage their chronic maladies would improve the lives of the displaced and help them contribute to the communities they might eventually call their own.