Meeting the health needs of Iraqi refugees in Jordan

Abstract

Over 2 million Iraqis have fled from violence in Iraq to neighbouring countries such as Jordan and Syria. But, unable to cope with the influx of refugees and their health and humanitarian needs, these countries are making entry more restrictive. Sharmila Devi reports from Amman.7-year-old Mohammad sat up in his hospital bed in Amman, Jordan, half his face concealed by thick, white bandages, as his father Salman recounted their tale. In October last year, the family was receiving condolences at a traditional mourning tent outside their Baghdad home for Salman's father, who was killed in sectarian violence because of his past job as an army officer under Saddam Hussein. As the mourners congregated, a car bomb exploded at the nearby market, prompting the panicked family to flee in all directions. Salman's experience as a policeman made him shout out warnings to people nearby but to no avail as a second bomb detonated soon afterwards.Salman had severe shrapnel injuries to both his legs and spent 15 days in hospital not knowing what had happened to his family, who were separated immediately after the attack. Eventually, he found out that five members of his family were killed. His son, Mohammad, was alive but had lost all the soft tissue on the left side of his face, including an eye and half his mouth. His left foot had been amputated. “Iraqis are not afraid of death but these children are innocent. How is anything their fault?”, asked Salman, who did not want his or his family's real names revealed, like many Iraqis who fear reprisals.Iraqi doctors could not heal and close Mohammad's gaping wound in the course of several operations that included multiple skin grafts. Eventually, Salman heard of a reconstructive surgery programme, run by Médecins Sans Frontières (MSF) at a Red Crescent hospital in the Jordanian capital Amman. MSF was forced to pull out of Iraq in 2004, because fierce violence made work impossible. But it returned to parts of Iraq last year and has treated around 300 Iraqi patients, referred by a network of some 50 doctors inside Iraq, at the Amman programme, which was set up in August, 2006.Mohammad had extensive surgery to reconstruct his nose and lips, including the transfer of a muscle in his back to rebuild his mouth in an operation done by Andre Eckhardt, a German maxillofacial surgeon based in Hanover and MSF volunteer, who works in Amman on a regular basis. “The spectrum of injuries that we are dealing with is amazing. They are not seen in the western world except in textbooks”, says Eckhardt. “It is also difficult emotionally, not during surgery but afterwards. Mohammad's story and life are always following you around.” He says that it is difficult to predict the full outcome of Mohammad's treatment. “He will never have a so-called normal life and we are trying to give him as much function as possible. He will need year-to-year surgeries until he is an adult.”MSF pays for all the Iraqi patients' transportation and accommodation costs and helps with passports and visas in liaison with the Jordanian authorities, which have confessed to being overwhelmed with the exodus of refugees from neighbouring Iraq.Conflict in Iraq since the US-led invasion in 2003, has led to the biggest Middle East refugee crisis since the creation of Israel in 1948. Up to 4·5 million Iraqis have fled their homes, with around half internally displaced, 750 000 in Jordan, and more than 1 million in Syria.Iraq's medical system has been devastated by curfews, electricity cut-offs, and threats against staff. The Iraqi Medical Association estimates that half of the 34 000 doctors registered before 2003 have fled the country and 2000 have been killed. “The humanitarian need inside Iraq and in neighbouring countries has been ignored to such an extent that both Jordan and Syria, out of desperation, have introduced visa requirements that effectively close all exit doors for Iraqis”, said Andrew Harper, who heads the Iraq Support Unit of the UN High Commissioner for Refugees (UNHCR).Few Iraqi refugees are admitted into western countries. British Home Office figures show that the UK granted asylum in only 30 of 740 rulings involving Iraqis last year. The USA says it intends to speed up resettlement of up to 1000 Iraqis per month, but critics say it is too little while at least 2000 a day are made homeless.WHO says many Iraqi refugees have chronic diseases, such as high blood pressure, cardiovascular disease, and diabetes. Doctors say some refugees arrive in Jordanian hospitals with bacteria resistant to all but very expensive antibiotics.An appeal for US$84·8 million was launched in September by a group of UN agencies—WHO, UNHCR, UNICEF, the World Food Programme, and the UN Population Fund (UNFPA). A joint statement said Iraqi amputees are in urgent need of prostheses and people with cancer and trauma are failing to receive specialised treatment. “Gaps have arisen in the national health information and disease surveillance systems, which increase the risk of vaccine preventable diseases”, said the statement. “The deteriorating purchasing power of Iraqis may also lead to rising malnutrition rates. The displaced Iraqi population also needs reproductive and child health services.”A ministerial meeting convened by WHO in August reached agreement that displaced Iraqis would receive health care on the same basis as the local population in Jordan, Syria, and Egypt. But the accord is putting severe strain on these host countries. Agreed priorities were primary health care, both preventive and curative, reproductive and child health, emergency care, and essential drugs and medical supplies, including those for chronic diseases. “Iraqis in Jordan are provided with the same medical care as Jordanians who do not have insurance”, said Nasser Judeh, a Jordanian government spokesman. “This has put an incredible burden on the Jordanian economy in terms of health, food, medicine, education, infrastructure, and resources.”The situation is particularly delicate in Jordan, which absorbed thousands of Palestinians after wars in 1948, 1967, and 1991 that sparked an exodus from the Gulf. Jordan has a population of around 6 million and the gross domestic product per head was less than $2500 last year.Jordanian authorities are extremely wary of allowing any semblance of a state within a state that could encourage domestic resentment and unrest. The kingdom is also battling against increased threats from Islamic militants, particularly since suicide bombers killed 60 people at three Amman hotels 2 years ago. Security noticeably tightened in all public areas after the bombings while authorities reportedly prevented the entry of Iraqi men aged between 17 and 35 years. Jordanian media say that every day an average of 50 000 Iraqis move between Jordan's three entry points from Iraq—the airport and two land crossings—raising security concerns.In the meantime, many Iraqi refugees say they yearn to return home. 37-year-old Nadia received severe injuries to her face and legs in a car accident caused by a sudden gun battle between militias near the Iraqi city of Najaf 3 years ago. She miscarried, her son was killed, and her husband subsequently left her. Four operations to heal her legs failed and eventually she was accepted for surgery by MSF in Amman. “I hope the next operation will work. I miss my parents and I want to go back home”, she says.Josephine Milhomme, a clinical psychologist at the Amman programme, says 30% of her Iraqi patients have severe trauma and anxiety. “In considering treatment, I have to consider what time we have before they have to return to Iraq. This can be difficult, especially in torture cases that take a long time to heal.”Iraqi doctors exiled in Jordan are also trying their best to help their countrymen. Daoud (not his real name), a doctor who has been working for the past 10 months at an Amman private hospital, tries to treat poorer Iraqis as often as possible. “Doctors are a target in Iraq and can be killed or kidnapped at any time. If you are also teaching, militias consider you a collaborator with the government and the Americans.”Daoud was able to pay a $100 000 deposit demanded by Jordan for residency papers. He is conscious that most other Iraqis cannot afford this cost. Many are living on depleted savings because they are considered illegal immigrants and unable to find even menial work. “But at least Jordan and Syria are taking us in. The USA made all these problems and will not accept us”, he says. “Most of the young people here are not working. This is a lost generation, our lost youth.” Over 2 million Iraqis have fled from violence in Iraq to neighbouring countries such as Jordan and Syria. But, unable to cope with the influx of refugees and their health and humanitarian needs, these countries are making entry more restrictive. Sharmila Devi reports from Amman. 7-year-old Mohammad sat up in his hospital bed in Amman, Jordan, half his face concealed by thick, white bandages, as his father Salman recounted their tale. In October last year, the family was receiving condolences at a traditional mourning tent outside their Baghdad home for Salman's father, who was killed in sectarian violence because of his past job as an army officer under Saddam Hussein. As the mourners congregated, a car bomb exploded at the nearby market, prompting the panicked family to flee in all directions. Salman's experience as a policeman made him shout out warnings to people nearby but to no avail as a second bomb detonated soon afterwards. Salman had severe shrapnel injuries to both his legs and spent 15 days in hospital not knowing what had happened to his family, who were separated immediately after the attack. Eventually, he found out that five members of his family were killed. His son, Mohammad, was alive but had lost all the soft tissue on the left side of his face, including an eye and half his mouth. His left foot had been amputated. “Iraqis are not afraid of death but these children are innocent. How is anything their fault?”, asked Salman, who did not want his or his family's real names revealed, like many Iraqis who fear reprisals. Iraqi doctors could not heal and close Mohammad's gaping wound in the course of several operations that included multiple skin grafts. Eventually, Salman heard of a reconstructive surgery programme, run by Médecins Sans Frontières (MSF) at a Red Crescent hospital in the Jordanian capital Amman. MSF was forced to pull out of Iraq in 2004, because fierce violence made work impossible. But it returned to parts of Iraq last year and has treated around 300 Iraqi patients, referred by a network of some 50 doctors inside Iraq, at the Amman programme, which was set up in August, 2006. Mohammad had extensive surgery to reconstruct his nose and lips, including the transfer of a muscle in his back to rebuild his mouth in an operation done by Andre Eckhardt, a German maxillofacial surgeon based in Hanover and MSF volunteer, who works in Amman on a regular basis. “The spectrum of injuries that we are dealing with is amazing. They are not seen in the western world except in textbooks”, says Eckhardt. “It is also difficult emotionally, not during surgery but afterwards. Mohammad's story and life are always following you around.” He says that it is difficult to predict the full outcome of Mohammad's treatment. “He will never have a so-called normal life and we are trying to give him as much function as possible. He will need year-to-year surgeries until he is an adult.” MSF pays for all the Iraqi patients' transportation and accommodation costs and helps with passports and visas in liaison with the Jordanian authorities, which have confessed to being overwhelmed with the exodus of refugees from neighbouring Iraq. Conflict in Iraq since the US-led invasion in 2003, has led to the biggest Middle East refugee crisis since the creation of Israel in 1948. Up to 4·5 million Iraqis have fled their homes, with around half internally displaced, 750 000 in Jordan, and more than 1 million in Syria. Iraq's medical system has been devastated by curfews, electricity cut-offs, and threats against staff. The Iraqi Medical Association estimates that half of the 34 000 doctors registered before 2003 have fled the country and 2000 have been killed. “The humanitarian need inside Iraq and in neighbouring countries has been ignored to such an extent that both Jordan and Syria, out of desperation, have introduced visa requirements that effectively close all exit doors for Iraqis”, said Andrew Harper, who heads the Iraq Support Unit of the UN High Commissioner for Refugees (UNHCR). Few Iraqi refugees are admitted into western countries. British Home Office figures show that the UK granted asylum in only 30 of 740 rulings involving Iraqis last year. The USA says it intends to speed up resettlement of up to 1000 Iraqis per month, but critics say it is too little while at least 2000 a day are made homeless. WHO says many Iraqi refugees have chronic diseases, such as high blood pressure, cardiovascular disease, and diabetes. Doctors say some refugees arrive in Jordanian hospitals with bacteria resistant to all but very expensive antibiotics. An appeal for US$84·8 million was launched in September by a group of UN agencies—WHO, UNHCR, UNICEF, the World Food Programme, and the UN Population Fund (UNFPA). A joint statement said Iraqi amputees are in urgent need of prostheses and people with cancer and trauma are failing to receive specialised treatment. “Gaps have arisen in the national health information and disease surveillance systems, which increase the risk of vaccine preventable diseases”, said the statement. “The deteriorating purchasing power of Iraqis may also lead to rising malnutrition rates. The displaced Iraqi population also needs reproductive and child health services.” A ministerial meeting convened by WHO in August reached agreement that displaced Iraqis would receive health care on the same basis as the local population in Jordan, Syria, and Egypt. But the accord is putting severe strain on these host countries. Agreed priorities were primary health care, both preventive and curative, reproductive and child health, emergency care, and essential drugs and medical supplies, including those for chronic diseases. “Iraqis in Jordan are provided with the same medical care as Jordanians who do not have insurance”, said Nasser Judeh, a Jordanian government spokesman. “This has put an incredible burden on the Jordanian economy in terms of health, food, medicine, education, infrastructure, and resources.” The situation is particularly delicate in Jordan, which absorbed thousands of Palestinians after wars in 1948, 1967, and 1991 that sparked an exodus from the Gulf. Jordan has a population of around 6 million and the gross domestic product per head was less than $2500 last year. Jordanian authorities are extremely wary of allowing any semblance of a state within a state that could encourage domestic resentment and unrest. The kingdom is also battling against increased threats from Islamic militants, particularly since suicide bombers killed 60 people at three Amman hotels 2 years ago. Security noticeably tightened in all public areas after the bombings while authorities reportedly prevented the entry of Iraqi men aged between 17 and 35 years. Jordanian media say that every day an average of 50 000 Iraqis move between Jordan's three entry points from Iraq—the airport and two land crossings—raising security concerns. In the meantime, many Iraqi refugees say they yearn to return home. 37-year-old Nadia received severe injuries to her face and legs in a car accident caused by a sudden gun battle between militias near the Iraqi city of Najaf 3 years ago. She miscarried, her son was killed, and her husband subsequently left her. Four operations to heal her legs failed and eventually she was accepted for surgery by MSF in Amman. “I hope the next operation will work. I miss my parents and I want to go back home”, she says. Josephine Milhomme, a clinical psychologist at the Amman programme, says 30% of her Iraqi patients have severe trauma and anxiety. “In considering treatment, I have to consider what time we have before they have to return to Iraq. This can be difficult, especially in torture cases that take a long time to heal.” Iraqi doctors exiled in Jordan are also trying their best to help their countrymen. Daoud (not his real name), a doctor who has been working for the past 10 months at an Amman private hospital, tries to treat poorer Iraqis as often as possible. “Doctors are a target in Iraq and can be killed or kidnapped at any time. If you are also teaching, militias consider you a collaborator with the government and the Americans.” Daoud was able to pay a $100 000 deposit demanded by Jordan for residency papers. He is conscious that most other Iraqis cannot afford this cost. Many are living on depleted savings because they are considered illegal immigrants and unable to find even menial work. “But at least Jordan and Syria are taking us in. The USA made all these problems and will not accept us”, he says. “Most of the young people here are not working. This is a lost generation, our lost youth.”