Sharing the pain: Improving healthcare in warzones

The desperate demand for emergency medical aid by millions of refugees displaced by conflict in the Middle East, as well as the needs of nationals in countries whose healthcare systems have been destroyed by war, calls for healthcare systems not confined by national borders.

A new report published in The Lancet calls for researchers to develop strategies to provide healthcare across borders, a concept coined "therapeutic geographies."

The report's lead author, Omar Dewachi, of the American University of Beirut in Lebanon, says: "It's a way to articulate long-term effects in the region at a larger demographic scale and at the human, individual, everyday life scale."

The paper was published yesterday as part of a series in The Lancet entitled Health in the Arab World: a view from within — a collaboration with the American University of Beirut in Lebanon and Birzeit University in the Occupied Palestinian Territories.

Although exact numbers of Iraqis travelling for medical care are not available, Dewachi found that since the American invasion of Iraq in 2003, about 5,000 Iraqis have sought healthcare at a single hospital in Beirut alone. Ali Anbori, who heads the Iraqi Society for Health Administration and Promotion, estimates that between 50,000 to 100,000 Iraqis travel each year to countries in the region like Lebanon, Jordan, Iran and Turkey, and as far as India, to receive healthcare. "The main reason many Iraqis seek healthcare abroad is that they lack confidence in the [Iraqi] health system," says Anbori.

[Being] exploited by the system compounds the effects of war.

This distrust is exacerbated by what Dewachi describes as the "militarisation of healthcare" — the dangers posed to healthcare seekers and providers during conflict and also the use of healthcare as an "instrument of violence". During times of conflict in Libya, Egypt, Bahrain, Syria and Iraq, physicians have at times participated in torture, denied care to some patients and given preferential treatment to soldiers.

The experience of Iraqis is the longest example of the impact of war on healthcare. Despite an increasing budget for Iraq's health ministry, corruption and lack of will among leaders has seen the country's health system founder. The government also encourages citizens to seek healthcare abroad by reimbursing some costs, but Anbori and Dewachi say that only people with connections receive payments for treatment in other countries.

Dewachi worries that many patients, particularly in lower and middle-income groups, are vulnerable to exploitation and overcharging when getting care abroad. This is particularly the case in Lebanon where private providers set their own prices in an overstretched system unprepared for the large influx of Syrians fleeing war in their own country.

"To save the life of a family member, everyone wants to do the best they can," Dewachi says. "[But being] exploited by the system compounds the effects of war."

Healthcare abroad is not only sought for emergencies or containing diseases like polio, but also long-term care and non-communicable diseases like cancer and diabetes. In another paper published in the series, Hanan Abdul Rahim, a public health specialist from Qatar University, says that non-emergency health issues are often not a priority in times of conflict, but they have become more prominent. She suggests healthcare in the region will improve if countries sign up to international agreements.

It could be a way of holding countries accountable, she says. "If they sign on to international commitments and they will be monitoring indicators and then they have to report on progress they make."

Dewachi, who is a public health specialist and an anthropologist, says that in addition to tackling health issues from a medical perspective, social sciences can also play a role. "My work has always tried to bring different disciplines to speak with one another in real life situations and contexts," he says. "We need to use different kinds of tools and skills and ways of thinking about health problems."

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