The Syrian Refugee Crisis and its Effect on Public Services in Turkey

Impact of Syrian Refugee Crisis on Access to Health Services

Introduction

“This is the largest group of refugees, created by a single crisis, in a generation. This population needs the support of the world community, but is living in very difficult conditions and being steadily impoverished.”

DATA FOR THE SITUATION IN TURKEY AND THE WORLD

Image Courtesy of Mercy Corps

“We know that 900,000 people are registered as refugees in Turkey as a result of this 4 year conflict. However, we can see that the real figure is over 1.6 million.”

Syrian refugees’ access to health services

Legal Status

“No financial contribution will be required for the provision of basic and urgent health services and the associated medicines and treatment”.

An approach which ignores the principle of equality and is not based upon rights and freedoms is a threat to the whole of society, not only to refugees.

The legal situation regarding the utilisation of health services

Image courtesy of resettlement.be

Access to health service by refugees living in camps

Consequently, it is possible for all Syrian refugees living in the camps to access free medical treatment.

Access to health care for those outside the camps

Only 12% of Syrians have effective access to health services.

Problems experienced in health services provision

“To obtain health services, a ‘temporary residence permit’ is required. Some hospitals refuse to diagnose patients who lack this document. Because medicines are charged for, those who cannot afford them are unable to obtain them, especially those patients with chronic illnesses.”

“Patients do not know the language. There are no translators in the hospitals. Recently a Syrian was unable to explain his problem to the doctor. Because the patient could not explain the doctor was becoming irritable. Then the patient rang me and asked me to explain his problem to the doctor on the telephone. I spoke to the doctor, but the doctor refused to accept translation over the phone.”

“Because Syrians do not have Turkish Republic citizenship numbers they cannot use the online appointment system.”

“The decree allowing us to benefit from health services has only been issued recently. I took a child to the doctor for vaccination. I explained to the doctor that the decree had been issued and that vaccinations were free of charge. The doctor said that he was unaware of the decree; I told him that I had a copy with me and could show it to him. He replied that he would not accept the decree from my hands, and he needed to consult AFAD and he did not perform the vaccination.”

“The same person brings in different patients on different days and describes each of them as “my neighbour”.

“Our family is 10 people. We have been in Turkey for a year. I have a daughter who is three years old and a second will be born in 3 months time. In Syria I was shot in the foot. The bullets are still in my foot. The doctors made us come and go a lot trying to get an operation. They keep telling me to go away today and come back tomorrow. I went to the doctor with my neighbour’s daughter in order to overcome the language problem. I was so fed up that I tore up and threw away all the documents I had accumulated. What I expect from the state is to operate on me.”

“We are not experiencing a language problem in Hatay. Most of the local population know Arabic. It is always possible to find an Arabic speaker at the hospital. At the Antioch State Hospital, there is a sign in Arabic right by the entrance for a special division to the Accident and Emergency department.”

Problems encountered by health staff as a result of language difficulties

“The problems start at registration, the staff say ‘another Syrian arrived’, registration takes a long time because of communication difficulties, attempts are made to get translation support from other patients.”

“When an official translator doesn’t come, registration takes a long time. One child was going to have a heart operation and the family’s permission was required, this was obtained late because of translation difficulties, and because continuous communication was needed, the child’s stay in hospital was extended.

“They cannot go to other departments to get the results of tests, for example they do not know where the X ray department is, so sometimes they leave the hospital without picking up their results.”

“A department has been set up to deal with the language problem, and people have been appointed. However, some of those appointed do not actually know the language and this is a problem. There are problems both during diagnosis and with explaining how medicines are going to be used. We have to find someone in the hospital who knows the language or get help from other patients.”

“Language bonus should be paid for all languages other than the official language, including Kurdish. While those who know English get a language payment, health staff who know local languages are not receiving a language payment.”

“Equal and free health services must be provided in the patients’ mother tongue. It should be compulsory to provide health services in a language that the refugees can understand and there should be a 24 hour interpreting service.”

Problems with preventative health care

“Pregnancy monitoring is not being done, addresses are not recorded. Continuity of the vaccination program is important, but it is not being done.”

Women and children’s health

Infectious diseases

“One of the results of this war, the result of imperialist intervention, is migrations, the other, for us health workers, is fear of epidemics. At this stage preventative health services need to intervene. However, in Hatay, where first stage vaccinations are from time to time not even given to citizens of Turkey through lack of health staff, vaccinating unregistered Syrian refugees becomes impossible. The majority do not have a permanent address, so it is not possible to track and ensure continuity in immunisation services.”

“We see a lot of patients with infectious diseases. Even when these illnesses would normally respond well to treatment with drugs, for the Syrians these are serious illnesses.”

Turkish Medical Union Central Committee, “Our prioritised proposals for averting the threat of epidemics” Press Release of 8 November 2013

“1. It is vital to start taking, without delay, measures regarding immunity in the at-risk groups in accordance with World Health Organisation guidelines, especially in the border provinces.

2. Education and training of health workers is of vital importance. During the measles outbreak, nearly 90 health workers caught measles. The sick cannot deliver services, and will infect those they attempt to serve.”

The attitude of health workers to the refugees

“There are prejudices that come from not knowing the refugees well enough. We need to break down these prejudices. Some health workers have prejudices such as, “The government are spending our money on them, they are living in luxury camps. These Arabs are dirty and carry diseases.” and also claim, “They are increasing our workload.”

“Hospital personnel reflect their own political preferences. When the patient is Kurdish, their faces turn sour. Appearance, dress and cleanliness all affect health personnel when providing services.”

“Local people are reacting to what they see as priority being given to Syrians and hold the Syrians responsible for locals not being able to find beds in hospitals. In fact, the priority given to Syrians is being given to those arriving with gunshot wounds. Other Syrians are being treated equally with locals.

At the hospital where I work 75% of patients are Syrians. Because of the large numbers of refugees, Turkish citizens have mostly moved over to private hospitals. Those Turkish citizens with green cards or without social security are particularly indignant, saying, “If we were Syrians, you would treat us.”

“Subcontract workers see the Syrians as a potential threat. They fear that tomorrow the Syrians will take their jobs from them.”

“Local people objected to health services not being given to themselves with the same ease as Syrians and stoned ambulances. The stoning happened after the Keseb attack.”

“70% of the patients in the maternity home are Syrian refugees. Turkish citizens have all fled to the private sector hospitals. Another reason for the flight to the private hospitals is the fear that the Syrians are carrying infectious diseases.”

Charges for medicines

“Because drugs are charged for, in particular the chronically ill are unable to get their medication.”

Psychosocial support for refugees

“I came with my wife, son and daughter. There bombs were falling and I use to turn up the television sound so as not hear the sound. Now we are sometimes hungry, but at least we are not frightened here. One month after we arrived here, there was a rainstorm and I hid in a corner, I could not move and I was crying. When they made a flight display over the army house I was frightened that they had come here. Every loud noise paralyses me. We are frightened, we cry. My daughter never goes out and talks to no-one. She wets the bed. We have no money and no work. Life is difficult.”

The effects of migration on Health workers

“During the first period we were receiving war wounded patients, and we did not know about treating war wounds, we also had communication problems because of language, were getting exhausted as lots of patients were arriving. Previously we had two nurses and one doctor in emergency, there weren’t any new staff. You don’t know the language and patients are arriving all the time, calling for you all the time and you can’t understand what they are saying. We weren’t able to keep up with the patients. To start with, we said that this situation would end in two or three months. Then we realised that it hadn’t ended and was continuing. We don’t get war wounded any more. We just get normal refugees who are ill.

Despite the increase in workload we didn’t get any extra staff. We were given some intern doctors as support. At nights we had an internal transfer of nurses from within the hospital. Because we have so many patients, we work two or three hours overtime. The hospital administration is not pressuring us to stay late, but we can’t just leave them. We do not get paid overtime for these extra hours. I could say that the staff have got used to this new situation. It has become to seem normal. Health care staff have started to learn a bit of Arabic.”

“Workload has increased a lot; this is why there is a reaction. In addition there is no benefit to staff in the performance evaluations, which increases the reaction.”

“The fact that diagnoses of refugees are not counted in performance assessments affects doctors negatively.”

“Treating war wounded is not easy. Seeing wounded patients all the time is a really hard situation. Part of their body is missing, this is traumatic for us, too. After Aleppo we lived through this trauma again. There is nervousness that we will see this again. Wounded children were particularly difficult for us. Colleagues with children of their own were badly affected.

“In the first period, the war wounded were carrying hand grenades on them. We were frightened that these could explode at any moment. We had no security.”

“When we were treating a patient brought into Mustafa Kemal University Medical Faculty Hospital by 112 ambulances, because explosives fell onto the floor we had to record a note and inform the security forces. It became clear that the explosive material was a hand grenade.

In this situation emergency workers responding to a 112 call and providing first aid have as little personal security as the medical teams performing medical interventions. The precaution necessary to ensure personal safety for health workers who are being forced to perform extremely difficult tasks and work for excessively long hours.

We will continue to struggle day and night to provide quality health care that respects the human dignity of our patients, while we also struggle against the ignored problems of health workers and fight for safe working conditions, an end to violence in our working environment and a working environment that respects our human dignity, too.”

“In the first years of the war, during the first period when fighters were arriving, there was pressure put on health workers who were Alevis. Special health personnel were assigned to look after the fighters.

“The Jihadists were being allowed into the emergency wards and operating theatres in their non-sterile military clothing. This increased the risk of infection.

There was a worry that the wounded had been exposed to chemical weapons. When we communicated our worries to the provincial health directorate they replied, “We are doing chemical checks at the border”. There was threat to the health and safety of health care staff.

Some jihadists were found to have hand grenades in their pockets.

The Syrians who were coming here were Sunni Arabs. For this reason they did not want some of the nurses to touch them. For a short period, some of them were saying, “I don’t want Alevi nurses to touch me, I don’t want to be cared for by Alevis.”

“After the explosion in Reyhanli, (11 May 2013) health workers started to express their reactions. Since the explosion, armed individuals no longer come to the hospital.

Until the Reyhanli bombing health care staff were being subject to transfers and there was administrative pressure. After Reyhanli these pressure did not continue and the situation returned to normal.”

“General Practice works in this way. A population of 3–4,000 is determined and a General Practitioner provides health services for this population. But refugees are excluded from this calculation. While the number of refugees is increasing, the resulting income does not increase. In some areas the number of refugee patients has increased greatly. Despite this, no budget has been set for them. The increased work load means that the health care worker needs an additional income, but this is not forthcoming. Although our work load has increased substantially, we have been given neither extra staff, nor extra payments.

Normally, patient records are held on computer. However, we cannot enter the information on the “temporary identity cards” given to Syrian refugees into the computer system. For this reasons General Practitioners are unable to keep records. When the refugees are unregistered they cannot be treated. Sometimes patients arrive without any identity papers, not even the “temporary identity card” and for this reason record cannot be kept and patients cannot be followed up.

No supplies, lots of work, no budget. Under these conditions Family Health Centres cannot provide adequate health care.

We drew this situation to the attention of the Provincial Health Director, but the problem was not resolved.

In the Family Health Centre family planning service is at a very low level, and is not being provided properly. Refugees do not know where they can get this service. There should be a separate unit for the refugees.”

If only we had Health Centres!

“If the Health Centres had not been closed, there would not have been a limitation of numbers of health personnel by population and it would have been possible to employ more health care workers. There would not have been a limit on medical supplies. Now when a vaccination is asked for, you are cautious, because if the generator fails, the vaccines may be made useless. If the vaccines are destroyed, the General Practitioner has to pay the cost. In addition, the doctor gets warning penalty points. In the past there was no such fear and no such need for a cautious approach. The General Practitioner has to account for every dose of vaccine all the time. We are obliged to vaccinate the Syrian refugees, but we cannot account for it.

For reproductive health it would have been possible to employ staff, now legally this cannot be done. Too much work, too few people. This, in short, is what ‘Renewal in Health Care’ really means.”

“Our branch had meetings with the Provincial Health Director, the Medical Directors of hospitals, and the General Secretary of the Association of Public Hospitals. In meetings with officials we put the problems such as long working hours, lack of staff and personal safety to the agenda. After these interventions by our union some problems were partially solved.”

We must increases consciousness among health care workers, and give an open answer to the question “where did they come from”, expose pro-war policies, emphasise the humanitarian dimension.

We have once again seen the importance of preventative medicine.

Syrian refugees should have the same rights to health care as the population living in Turkey.

Equal, free, health care should be delivered in the patients’ mother tongue.

It is imperative that health care be delivered in a language in which the patients can express themselves.

There should be 24 hour uninterrupted translation support.

There should be an end to unregistered, uninsured employment. Every employee should be registered and have their social security payments credited and be receiving a living wage.

There must be an effort to overcome discriminatory ideas among our members, we have to explain that the people who are coming are the victims of war.

We must defend everywhere the idea that humane living conditions are their right, too, we must defend this right for them.

The union must not be part of the imperialist war.

Conclusion and proposals

-END-

Appendix: The views of SES about access to health services by Syrian refugees

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Public Services International is a global trade union representing 30 million working women and men who deliver vital public services in 154 countries

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Public Services International is a global trade union representing 30 million working women and men who deliver vital public services in 154 countries