The Plight of Syrian Refugees in Turkey: A Global Health Crisis

BY JUDE ALAWA

Imagine your hometown in chaos. Airstrikes every day. The grocery store down the street is suddenly destroyed, your friends are fleeing, and you watch a family of seven be reduced to just two. Each day, a red truck arrives in the morning, just to drag away the piles of dead bodies. You can barely walk, and you require medical assistance but can’t find any.

During January of 2016, I traveled to Turkey with a group of students from the Yale International Relations Association. In Istanbul, we met with a family of Syrian refugees who escaped from Aleppo, a city under siege for the past few years. I had the opportunity to spend some time chatting with the grandmother of the family, and she explained why they had fled: the violence, the scarce resources, and the lack of medical treatment for those who needed it. She required medical assistance to treat her failing legs, and she arrived in Turkey with the hope of finding adequate health care only to discover that the system was much more convoluted than it had appeared.

Today, Turkey bears the burden of caring for over 2.62 million refugees from Syria.¹ A large part of this responsibility entails providing some form of healthcare to non-citizens who desperately need it. Although several policies have been put forth, issues of implementation, demographics, communication, and institutional gridlock still create instability within Turkey and prevent Syrian refugees from accessing sufficient healthcare.   On January 18^th, 2013, two years after the start of the Syrian Civil War, the Turkish government issued its first policy addressing healthcare. It stated that all Syrians refugees, registered or not, in the eleven provinces along the Turkish-Syrian border would be authorized to receive the same health services as Turkish citizens but at no cost.² According to this new policy, the Turkish government had committed to provide free healthcare to a large sum of refugees. That is, they could, in theory, walk into any public hospital to see a physician and receive medical treatment.

Despite the decree, medical teams in many of the bordering regions did not uniformly apply the policy. For instance, a think tank our group met with mentioned that in the province of Hatay, teams of physicians were told that unregistered urban Syrian refugees, who comprise the majority of the refugee population, were experiencing difficulties accessing services, especially tertiary medical care. Although hospitals have been reported to be consistent in providing emergency health care to almost all refugees, follow-up visits have not been covered, largely because the visits are free for refugees, and doctors are not necessarily compensated for their work.³ About a year after the initial decree, the Turkish government introduced a new protection policy to extend health coverage to all 81 provinces in Turkey.⁴ In addition to issuing this policy, Turkey also introduced identification cards for Syrian refugees. Refugees require ID cards to access healthcare, education, and similar civil services.⁵ The purpose of introducing these ID cards was to promote the registration of refugees: if refugees knew they required ID cards to access services, they would be more inclined to register.⁶ However, in spite of the ID cards and the extension of coverage in all provinces of Turkey, the implementation of the health system remains problematic.

Most of Turkey’s troubles with refugees are derived from the assumption that the Syrian Crisis would be transient.⁷ Four years ago, when refugees first started to flee to Turkey, the Turkish government did not expect the conflict to last, and as a result they only planned for temporary accommodations. However, the persistence of the crisis and the nearly exponential influx in refugees has made the problem increasingly complicated and difficult to manage. Furthermore, it has become clear that refugees are unable to return home anytime soon, especially given the deadly circumstances in modern Syria. Every government official with whom we met in Turkey, including President Erdogan’s Chief of Staff, Ibrahim Kalin, mentioned that the likelihood of permanent residence among refugees has complicated policy issues and questions of integration, which largely include access to healthcare services.

In refugee camps, the challenge of providing health services has largely been met thus far. For instance, primary health care and vaccinations are provided to refugees and are completely funded by the Turkish government. In spite of this, however, the Turkish Medical Association has reported several inefficiencies in the system, which include a lack of access to more specialized services such as advanced procedures and medications.⁸

The healthcare situation is vastly different outside of the refugee camps (i.e., urban areas). Today, over 80% of all refugees reside in urban areas outside of the camps.⁹ Although the Turkish government has made all of its public hospitals accessible to refugees and has provided funding to staff the hospitals, urban refugees are encountering many difficulties in gaining access to hospitals and health services. These difficulties are a result of the sheer number of refugees and the lack of awareness among health workers of the governmental policies extending health coverage to all Syrian refugees with an ID card. In addition, it has been widely reported that doctors are refusing to treat chronically sick refugees who have been diagnosed with conditions such as diabetes or cancer. Because refugees with such chronic conditions require follow-ups or continuous treatment, they have encountered major shortages in treatment. In some provinces, hospital administrators have even refused to recognize the recent government decree and have demanded that refugees pay to cover their health care costs.¹⁰

In addition, since Syrian refugees are concentrated in many of the provinces along the Turkish-Syrian border, overcrowding has overwhelmed the health system and thrust it into chaos. Hospital workers have complained of being overworked and exhausted due to the increased number of patients. Many doctors have requested transfers out of the area, which has led to grave concerns regarding a shortage of qualified medical personnel in the border areas. As a result, many refugees requiring medical care have not been able to see a physician. Beyond the refugees, Cengiz Candar, a famous Turkish journalist, and many other figures have mentioned that the Turkish people and staff in these areas are upset because they claim that the havoc has prevented them, as Turkish citizens, from receiving the services they pay for and to which they are entitled. For instance, one commonly cited example during meetings was Kilis, a city situated near the border. Today, Kilis is home to more than 200,000 Syrian refugees, and the number of refugees exceeds the number of actual Turkish residents. With such numbers, the central public hospital within Kilis has been unable to respond to the needs of both refugees and local patients, creating distress in the region and a point of conflict between the refugees and locals.¹¹

By far one of the most troubling obstacles preventing refugees from accessing services is the language barrier.¹² Syrians typically speak Arabic, not Turkish. The inability of Syrian refugees to communicate with locals was increasingly apparent during my visits to local markets, Syrian schools, and meetings. Not only has the language barrier complicated matters of simple communication and understanding, it has also prevented Syrian refugees from voicing their needs and rights as specified by the government. The Turkish government recognizes this problem, and the Directorate General of the Ministry of Migration mentioned that they intend to put forth programs for adults to learn Turkish and for students to gradually acquire the language throughout primary and secondary school.

As the Turkish healthcare system is definitely strained, the Turkish government has allowed international non-governmental organizations (NGOs) to provide specialized health services for Syrian refugees within Turkey. Although these efforts are not without their complications, they have added another level of temporary protection for refugees. NGOs are beginning to provide health services to non-registered and non-camp refugees but are unable to meet all of their needs. Some of the international NGOs have been able to partner with local NGOs to operate fully-functional health clinics with the help of funding from international relief organizations and support from Médecins Sans Frontières (Doctors Without Borders). For instance, the American Society of Addiction Medicine has worked closely with the International Medical Corps to build a major health center for refugees in Istanbul.¹³ A representative from the International Strategic Research Organization (USAK), a think tank based in Turkey, mentioned that a similar center will be developed in Gaziantep soon. Many of these organizations are vying for the Turkish government to ease registration restrictions for international NGOs seeking to work inside Turkey, especially for those trying to expand assistance programs to non-camp refugees in need. Similarly, public sentiment in support of these donors has encouraged the government to promote collaboration between local and international NGOs.

One of the biggest worries of the international healthcare community and the Turkish Ministry of Health is the emergence of communicable diseases. Many of the refugees moving across the border potentially act as vectors of disease, which translates into a public health threat for the Turkish population. To make matters worse, the World Health Organization announced that the incidence of polio among Syrian children has risen considerably in recent months. In response, the Turkish government has launched a campaign to vaccinate refugees in the camps and in provinces along the border. The problem, however, is that many so-called “vectors” have already arrived in urban areas, making them very hard to track down. Turkish health officials are worried that a substantial percentage of children inside and outside of the camps have yet to be vaccinated for polio, putting the people around them at a much higher risk for disease contraction.¹⁴

The most alarming news relating to health services in Turkey is a new policy on pharmacies and medical expenses, implemented by the Disaster and Emergency Management Presidency.¹⁵ According to this policy, all pharmacies within Turkey can only provide medicine to Syrians if the prescription is given by a hospital in the same district. Previously, Syrian refugees could get medicines at any pharmacy within Turkey. This new rule has not only decreased the number of pharmacies where refugees can get medicines but has also changed the attitude of pharmacies toward Syrian refugees. For example, some pharmacies are reluctant to supply medicine to Syrian refugees due to delays in receiving reimbursements from the Turkish government. In fact, over 5,000 pharmacies in Turkey have refused to provide medicine to Syrians, claiming that the government owes each pharmacy, on average, 25,000 to 40,000 Turkish liras, which translates to roughly $28,000 to $44,000 (USD). In meetings, I was told that only five pharmacies within all of Turkey still provide medications to Syrian refugees, even if they have a prescription.¹⁶ Only five.

Throughout my trip, it was evident that the public, the government, and, to a large extent, the published research support policies that encourage integration, especially with respect to health care. The system has problems, and the international community faces a great challenge ahead, but the Turkish government’s efforts are commendable. Based on a report from USAK, the Turkish government has reported that 63 Syrian doctors and 18 Syrian pharmacists have accepted positions at Temporary Protection Centers with the approval of the Ministry of Health. In conjunction with the United Nations Higher Commission on Refugees (UNHCR), the UN’s refugee agency, and the European Union, Turkey also plans to open 10 fully equipped hospitals and 12 mobile health units with the sole purpose of increasing Syrians’ access to health care services. Similarly, the UNHCR has undertaken the construction of fully staffed health facilities; five near the camps by the border and two in urban areas.¹⁷ Resolving this crisis requires a lot more effort, but hopefully, these new developments will be beneficial and effective in addressing the healthcare needs of Syrian refugees.

The Turkish people, the government officials, and Ahmet Icduygu, a Professor at Koc University, with whom I met cited Turkey’s history as the main inspiration behind maintaining an open-door policy and encouraging integration. Dating back to the times of the Ottoman Empire, World War I, World War II, and the Armenian genocide, Turkey has historically provided refuge for those fleeing civil conflict, and the Turks we met with were proud of their history of having preserved such hospitality. Despite this historical precedent, Turkey faces what could be one of the worst migrant crises of our time, with challenges of integration, implementation of services, and providing a future for multiple generations of Syrians. In spite of all of this, this inspiration demonstrates patience and benevolence. As a Syrian-American student, I am deeply saddened by the health care problems Syrians face in Turkey today. Nevertheless, I am hopeful for a resolution to the Syrian crisis and a prosperous future for all those suffering from the terror of war.

Jude Alawa is a Syrian-American from Miami, FL and a sophomore in Branford College. He hopes to study global health policy in developing regions and investigate effective measures to deliver healthcare to forcibly displaced populations. 

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The information in this article is based on correspondence with the following people:

•      Merve Ay – Alliance of International Doctors
•      Dilara Aykanat – International Lawyers
•      Serkan Cecen – Bosphorus University Student
•      Sema Genel Karaosmanoglu – Support to Life
•      Selen Ay – Head of the United Nations Higher Commission on Refugees (UNHCR) Istanbul
•      Ahmet Icduygu – Professor at Koc University
•      Cengiz Candar – Turkish Journalist
•      Selman Nacar  – Contact for Syrian Choir based in Istanbul
•      Ahmet Atan – Directorate General of the Ministry of Migration (DGMM)
•      John Bass – United States Ambassador to Turkey
•      Ibrahim Kalin  – Chief of Staff for President Erdogan of Turkey
•      Sema Ramazanoglu – Minister of Family and Social Policies of Turkey
•      Bahadir Dincer – USAK (Think Tank based in Turkey)
•      Volkan Bozkir – Minister of European Union of Turkey
•      Charles Hunter – Principal Officer at the U.S. Consulate General in Istanbul
•      Aziz Kocaoğlu – Mayor of Izmir
•      Yuksel Unal – Governor of the Esenler District

References:

1. (2016). UNHCR Syria Regional Refugee Response. Retrieved from http://data.unhcr.org/syrianrefugees/country.php?id=224
2. Dinçer, O. (2013, November). Turkey and Syrian Refugees: The Limits of Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2013/11/18 syria turkey refugees/turkey and syrian refugees the limits of hospitality november 2013.pdf
3. Kirişci, K. (2014, May). Syrian Refugees and Turkey’s Challenges: Going Beyond Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2014/05/12-turkey-syrian-refugees-kirisci/syrian-refugees-and-turkeys-challenges-may-14-2014.pdf
4. AFAD Communique, 2013/8 No. 12816.
5. (2013, October). Syrian Refugees in Turkey. Retrieved from http://www.refugeeinturkey.org/en/dosya/faq_english.pdf
6. Personal interview with Ahmet Atan, the Directorate General of the Ministry of Migration (DGMM) for Turkey
7. Personal interview with John Bass, the United States Ambassador to Turkey
8. Kirişci, K. (2014, May). Syrian Refugees and Turkey’s Challenges: Going Beyond Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2014/05/12-turkey-syrian-refugees-kirisci/syrian-refugees-and-turkeys-challenges-may-14-2014.pdf
9. Dorman, S. (2014). Urban Humanitarian Response Portal. Retrieved from http://www.urban-response.org/resource/19464
10. Dinçer, O. (2013, November). Turkey and Syrian Refugees: The Limits of Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2013/11/18 syria turkey refugees/turkey and syrian refugees the limits of hospitality november 2013.pdf
11. Personal interview with Sema Ramazanoglu, the Minister of Family and Social Policies of Turkey
12. Hammada, A. (n.d.). Crisis of Syrians in Turkey. Retrieved from http://www.syrianef.org/En/wp-content/uploads/2014/10/Crisis-of-Syrian-Refugees-in-Turkey.pdf
13. Kirişci, K. (2014, May). Syrian Refugees and Turkey’s Challenges: Going Beyond Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2014/05/12-turkey-syrian-refugees-kirisci/syrian-refugees-and-turkeys-challenges-may-14-2014.pdf
14. (2014, May). Syria Crisis Monthly humanitarian situation report.
15. (2014, May). UNHCR TURKEY – Syrian Emergency Weekly Situation Update No. 16. Retrieved from http://www.unhcr.org/turkey/uploads/root/unhcr_situation_update_26_april_-_2_may.pdf
16. Istanbul’s pharmacies refuse to give free meds to Syrian refugees. (2015, March 06). Retrieved from http://www.globalpost.com/article/6410398/2015/03/06/istanbuls-pharmacies-refuse-give-free-meds-syrian-refugees
17. Dinçer, O. (2013, November). Turkey and Syrian Refugees: The Limits of Hospitality. Retrieved from http://www.brookings.edu/~/media/research/files/reports/2013/11/18 syria turkey refugees/turkey and syrian refugees the limits of hospitality november 2013.pdf