Newsdesk

Infectious diseases in Malian and Syrian conicts

As people ee ongoing conicts in Syria and Mali, diering conditions for refugees are reected in
distinct disease patterns. Talha Burki investigates.
For the WHO brieng on Syria
see http://www.who.int/
hac/crises/syr/syria_
presentation_13february2013.
pdf

Reuters

For the 2004 article on lessons

learned from previous conict
see Series Lancet 2004;
364: 180113. http://www.dx.
doi.org/10.1016/S01406736(04)17405-9

On March 6, 2013, the UN High

Commissioner for Human Rights
(UNHCR) announced that 1 million
refugees had ed Syria since the country
slipped into civil war 2 years ago.
UNHCR had not expected to reach this
stage until halfway through the year. A
19-year-old woman seeking haven in
Lebanon was symbolically registered
as the millionth refugeeher host
country has seen its population swell
by 10% due to the inux of Syrians.
Large numbers have ed to Jordon;
on March 8, a sizeable gas explosion
hit the Zaatri camp that houses some
110 000 refugees. Turkey, with its
patchwork of 17 refugee camps with
more to follow, hosts almost 200 000
refugees. Numbers are also increasing in
Egypt and Iraq; the latter already has a
hefty population of internally displaced
people (IDPs) of its own.
The UNHCR gures take into
account only those refugees
who have been registered, or are
awaiting
registrationthe true
number is likely to be signicantly
higher. And not everyone ees
across the border. Within Syria itself
there are an estimated 25 million
IDPsprobably an underestimate,
according to Mego Terzian (MSF,

Trauma is a major problem in Syria, although epidemics may take hold

296

Paris, France)and the war shows no

sign of abating.
Since January 2012, Mali has faced
broadly similar unrest. Until recently
it was eectively divided into a north
largely under rebel control and a south
loyal to the government. But the French
intervention that began earlier this
year wrested control of the northern
cities from Islamist forces. Refugees
some 170 000 or sohave entered
Mauritania, Burkina Faso, Niger, and, in
much smaller numbers, Algeria. Within
the country, over 250 000 people
remain displaced. But although the two
conicts might bear certain geopolitical
similarities, from an infectious disease
perspective, the needs of the aected
populations are dierent.

There are ve to six families

living in a single house with no
electricity, no water and bad
quality of food. It is impossible
to have a good standard of
hygiene in such a place
Firstly, the conicts have distinct
natures. The ghting in Syria is
widespread and occurs in populous
areas; hence, war-related trauma is
a major source of injury among the
civilian population. This is not the case
in Mali, where 90% of the 16 million
strong population live outside of
the troubled northern areas, and the
civilian population has largely escaped
targeting.
But the crucial dierence, explains
Paul Spiegel (UNHCR, Geneva,
Switzerland), lies in the nations
respective wealth. Irrespective of its
current status, Syria was a middleincome country, with middle-income
problems; Mali, on the other hand,
is ranked 175 in the UNs human
development index (only 14 countries
rank lower). A WHO brieng on Syria

reports no signs of malnutrition. In

contrast, according to UNHCR, Malians
refugees face high rates of severe and
moderate malnutrition. This is linked
to malaria, which barely exists in Syria
but remains Malis biggest killer, and
episodes of diarrhoeal disease. It
is a vicious circle, explains Chibuzo
Okonta (MSF, Paris, France), you
have a case of malaria, then another
morbidity, which leads to more
malnutrition. Mass displacement
exacerbates matters.
Pre-emergency, the Syrians had
much better access to food3 years
of inadequate rainfall had led to food
insecurity in Malia far superior
health-care infrastructure, and a richer
population. All of which meant that,
before the war, Syrian men and women
could expect to outlive their Malian
counterparts by 20 years. The baseline
health of people in Mali is far poorer
than that of the Syrians, notes Spiegel,
it makes them much more vulnerable
to infectious diseases.
Since hostilities commenced, Syrians
have lost around a third of their public
hospitals, and more than half have been
damaged. The country had produced
90% of domestically used medicines;
obviously this is no longer the case. This
has clear and immediate implications
for the treatment of chronic diseases
such as cancer, hypertension, and
diabetes (HIV treatment also faces
disruption, although Syrias prevalence
is low). Chronic diseases have become
more and more prominent in situations
of conict involving middle-income
countries, Spiegel told TLID. But as time
passes, the degradation to the healthcare system will have an increasingly
marked eect on infectious disease.
MSF is only present in opposition
controlled areas, but Terzian points
out that the health-care system
is totally broken. Preventative
www.thelancet.com/infection Vol 13 April 2013

activities have largely dried up. We

are seeing cases of hepatitis A and
B, measles, and mumps, Terzian
said. There is treatment of violent
injuries but other medical problems
are completely neglected. Hence, for
example, patients with tuberculosis
face interruptions to their treatment,
while many patients are no longer
able to access treatment for cutaneous
leishmaniasispreviously they had
been referred to a centralised hospital
in Aleppo, which had some 3500
registered patients in 2011.
There is already a shortage of
vaccines and antibiotics, and the
security situation makes cold-chain
maintenance tricky. Damage to
vehicles and roads has massively
complicated vaccine transportation.
It all contributed to a drop in vaccine
coverage from 95% to 80% in the rst
quarter of 2012, according to WHO.
It is expected to have dropped even
further since, the agency added. Late
last year, WHO conducted vaccination
campaigns for measles reaching 13
million children and polio reaching
15 million, sizeable (if not ideal)
proportions of the countrys 25 million
children younger than 5 years.
Northern Mali has seen a comparable
breakdown in that health-care which
was available. WHO reckons almost
90% of community health centres are
no longer functioning in Kidal, Gao,
and Timbuktu. The risk of disease
outbreaks remains high, cautioned a
donor alert issued by WHO in February;
the alert requested US$29 million in
funding for Malian health services in
2013, $12 million of which is urgently
needed. Even before the crisis, the
health situation was very fragile mainly
due to lack of funding, armed
Okonta. The drug delivery system in the
north has been derailed, with serious
ramications for eorts to control
pneumonia, tetanus, and measles.
Fortunately, meningitis is unlikely to
be a problem, thanks to the vaccine roll
out.
Over in Syria, a typhoid epidemic has
taken hold in the eastern governorate
www.thelancet.com/infection Vol 13 April 2013

of Dier Ezzor, with around 1200

reported cases. Terzian talks of a village
in the north of Idlib governorate
which has seen an inux of refugees
swell its population from 3000 to
around 27 000. There are ve to six
families living in a single house with
no electricity, no water and bad quality
of food. It is impossible to have a good
standard of hygiene in such a place.
Such worries also extend to those
places where Syrian refugees have
settled. Lebanon has no refugee
camps, instead refugees are scattered
across 540 locations. Assessments
of drinking water in several of these
locations have shown high levels
of contamination; UNHCR reckons
that around a third of refugee households in the country are living with
inadequate sanitation (Lebanon has
reported a spike in diarrhoeal diseases).
Iraq and Jordan also have many
refugees living in host communities
rather than in camps.
In Syria, the UNHCR cannot operate
outside of areas outside the aegis
of the central government control.
MSF has expressed concerns that
aid is not reaching the rebel-control
-led areas. Outside the country,
agencies attempt to provided healthcare and water and sanitation for
refugees within and without camps
in Jordon, for example, a measles
vaccination campaign that began in
November 2012 reached 125 000 in
host communities (measles was an
important factor in the death toll from
the war in the Congo that started in
the late 1990s and was responsible for
some 33 million deaths; while cholera
and shigellosis killed roughly 85% of
the 50 000 Rwandan refugees who
perished within a month of reaching
Goma, Zaire in 1994).
The response to the Syrian crisis is
massively underfunded and the UN
High Commissioner, Antonio Guterres,
has warned that the international
humanitarian response capacity is
dangerously overstretched, but at
least external security is not a pressing
concern. This cannot be said of Mali. It

Reuters

Newsdesk

Malis health systems were already ravaged, before people were displaced

is almost impossible to send European

sta, for the risk of being kidnapped, to
the Mbera camp in Mauritania, Okonta
said. There are also problems with food
delivery, and water supply is less than
10 L per person per day, less than half
the minimum standard.
In a 2004 article, Spiegel and
colleagues commended the major
advances in the way the international
community responds to the health and
nutrition consequences of complex
emergencies. Lessons were learned
from the horric crises of the past and
a standard response involving, among
other things, measles vaccination,
insecticide treated bednets, vitamin A
supplementation, and oral rehydration
salts was established. But Spiegel also
noted that other interventions need
stronger health infrastructure and are
more dicult to implement during
complex emergencies.
There are perhaps a few thousand
rebel ghters remaining in northern
Mali, mainly in the mountains near
Algeria. If they can be prevented from
regaining ground, people might be
persuaded to return to their homes.
In Syria, though, there is little hope of
an end to the ghting. Latest gures
suggest 8000 people may be leaving
the country every day, placing an ever
increasing strain on its neighbours.
Things will get worse before they get
better.

Talha Burki
297