Experiences of Syrian Refugees Living in Jordan: A Qualitative Study of the Health Effects of Displacement By Elise Presser B.S., Vassar College, 2012 M.Sc., The London School of Hygiene & Tropical Medicine, 2014 Thesis Submitted in partial fulfillment of the requirements for the degree of Master of Science in the Division of Biology and Medicine at Brown University PROVIDENCE, RHODE ISLAND March, 2019 AUTHORIZATION TO LEND AND REPRODUCE THE THESIS As the sole author of this thesis, I authorize Brown University to lend it to other institutions or individuals for the purpose of scholarly research. Date _____________ ________________________ Elise Presser, Author I further authorize Brown University to reproduce this thesis by photocopying or other means, in total or in part, at the request of other institutions or individuals for the purpose of scholarly research. Date _____________ ________________________ Elise Presser, Author ii This thesis by Stephanie Elise Presser is accepted in its present form by the Division of Biology and Medicine as satisfying the thesis requirements for the degree of Master of Science. Date ____________ _____________________________________ Jeffery Borkan, Advisor Date ____________ ____________________________________ Director, Master of Science in Population Medicine Approved by the Graduate Council Date ____________ ____________________________________ Andrew G. Campbell, Dean of the Graduate School iii Acknowledgements Foremost, I would like to extend my overwhelming gratitude to the individuals who shared their stories with me. I also thank my mentor, Dr. Jeffrey Borkan, for his assistance in developing my analysis plan and reviewing my manuscript. I would like to thank Sarah Tobin for connecting me to individuals in Jordan. I would also like to thank Dr. Michael Mello for his advice and encouragement throughout the process. I would like to thank Ayya Buayyash and Natasha Quariab for their interpretation and translation services respectively. iv Table of Contents Signature Pages ……………………………………………………………… ii Acknowledgements ……………………………………………………………… iv Table of Contents ……………………………………………………………… v Table of Figures ……………………………………………………………… v Chapters I. Abstract ………………………………………………………………1 II. Introduction ………………………………………………………………2 III. Methods ……………………………………………………………… 4 IV. Results ……………………………………………………………… 7 V. Discussion ………………………………………………………………13 VI. Conclusion ………………………………………………………………16 References ………………………………………………………………17 Appendix 1: Interview Guide ……………………………………………………… 20 Table of Figures Figure 1: Location of Amman and Za’atari Refugee Camp ……………………… 3 Figure 2: Organization of Za’atari Refugee Camp ……..………………………… 5 Table 1: Demographic information of interview participants …….…….………… 8 Table 2: Syrian refugees’ health experiences …………...………………………… 9 v Abstract Introduction: As of 2018, 68.5 million people worldwide have been forcibly displaced due to conflict, violence, persecution, or human-rights violations. Syria currently has one of the largest forcibly displaced populations in the world, many settling in Jordan. To provide effective health care, one must understand the specific needs of the give population. Displaced persons have experienced different health problems than their non-displaced counterparts. It is vital to investigate the health experiences of these populations to design health services and systems that meet their needs. Population: Subjects for this research study were Syrian adults living in Jordan who were displaced by the current conflict in Syria. Individuals interviewed for this project lived either in Za’atari Refugee Camp or in Amman. Results: Seventy-five percent of participants were living in Za’atari Refugee Camp with the remaining 25% living in the capital city of Amman. Ages ranged from 19 to 70 years old with 30% of participants under 30 years of age, 35% between 30-49, and 30% over 50 years old. Participants experienced health effects of the conflict, of the journey to Jordan, and from living as a refugee. These include direct injury, torture, sexual violence, lack of access to clean water and sanitation, lack of access to medication and health care, and high rates of mental illness. Conclusion: There is no question that conflict will affect a population’s health. However one must study specific populations and circumstances to understand exactly how health has been affected and the best way to provide quality physical and mental health care during and after the conflict. For Syrians, current care must address direct injury from conflict and displacement, infectious disease resulting from poor living conditions, and the exacerbation of chronic health issues from disruption in care. In addition, health care must address the psychological trauma that has developed from the experience of pre- and post-refugee life. 1 Introduction As of 2018, 68.5 million people worldwide have been forcibly displaced due to conflict, violence, persecution, or human-rights violations.3 Of those, 25.4 million are refugees (meaning that they have crossed an international boundary), 40 million are internally displaced, and 3.1 million are asylum-seekers.3 Syria currently has one of the largest forcibly displaced populations in the world. As of September 2018, more than 5.6 million people have fled Syria and 6.6 million people have been internally displaced by the conflict, which accounts for over half of the Syrian population.4 These refugees have primarily settled in surrounding countries; over a million are registered in Lebanon, just under 3.6 million in Turkey, and over 666,000 in Jordan.5 Expansion of the Introduction The Syrian Conflict In the midst of the Arab Spring, pro-democracy protests in Syria took place across the country starting in March, 2011. Protestors called for an end to the authoritarian regime that had not addressed longstanding political and economic hardships. To make matters worse, a four-year drought left hundreds of thousands of farming families in poverty and forced a mass migration to urban slums.6 The Syrian government, led by Bashar al-Assad, violently suppressed these demonstrations with the use of police, military, and paramilitary forces. These forces beat and fired on demonstrators and arrested protestors en mass.6 In turn, opposition militias formed and by 2012 Syria was engaged in a civil war. Armed infighting increased within both the rebel groups and the military. This infighting was exacerbated by international allies vying for control. Starting in late 2012, Turkey, Saudi Arabia, and Qatar generously funded the rebels and the United States eventually began training and equipping certain rebel groups.6 Iran and Hezbollah, on the other hand, supported the Syrian Government.6 In 2013, rebels eventually controlled much of the northern areas but were outmatched in equipment, weapons, and organization so were unable to advance farther. Islamist militants, including the Islamic State in Iraq and Syria (ISIS), began to play a large role within the conflict in 2013.6 In response, the United States launched an air strike on ISIS targets in Syria. 2 By 2015, Russia joined in the international response, saying they were targeting the Islamic state but primarily targeting anti-Assad rebel groups.6 From 2015-2016, Government forces retook control of multiple cities, including Homs and Aleppo before a ceasefire in 2017.7 The ceasefire quickly broke down with the Syrian government allegedly using chemical weapons and the US both directly intervening and continuing to back the Syrian Democratic Forces as well as newly arming Kurdish units.7 In late 2017 the Islamic State was forced to retreat and throughout 2018, the Syrian army recaptured much of the Southern territories of the country.7 In early 2019, the US announced a plan to withdraw troops from Syria.7 Widespread human rights abuses were documented throughout the conflict including the use of cluster bombs, incendiary devices, and chemical weapons.8-10 Following the use of chemical weapons, American, British, French, Israeli, and Turkish forces became more heavily involved against the government. Health Care in the Conflict Health facilities, health care workers, and aid personnel were targeted by Syrian government attacks. Hundreds of health workers were incarcerated, tortured, and/or killed.11 In addition to deliberately bombing health facilities, Syrian government forces used “double tap” attacks -- a bombing was followed shortly after by a second attack after rescue workers had arrived.12 The combination of this Figure 1. Location of Amman and Za’atari Refugee Camp2 destruction left the country with little equipment, supplies, or personnel to provide either chronic or acute medical care. Health facilities were systematically destroyed, health 3 care workers were killed, and health care training was disrupted.13 Jordan and the Crisis Jordan hosts more refugees per capita than any country but Lebanon. Approximately 8.9% of Jordan’s population is made up of refugees, the majority from the most recent Syrian crisis.14, 15 Seventeen percent of Jordanian refugees live in one of three camps, while the remaining 83% live in urban areas.14 Just under 30% of Syrian refugees live in Amman, the capital of Jordan, located in the Northern part of the country (see Figure 1).16 These refugees account for approximately 7% of the population of Amman. Over 80% of those living in urban areas such as Amman live below the poverty line.15 One of the most important aspects of any effective health system is an understanding the specific needs of a given population as well as its views of health and health care.17 Displaced persons have typically experienced different health problems than their non-displaced counterparts and likely have more limited access to health care.18-20 Such experiences change how individuals understand what it means to ‘be healthy’ and how they choose to access the limited health care options that may be available.21 Therefore, it is vital to investigate the health experiences of these populations in order to design health services and systems that meet their needs. Although there is significant study of the mental health needs of refugee populations,22-24 less research is available on the effects of displacement on refugees’ overall physical health. This study aims to give space for Syrian refugees to tell their personal stories and to contextualize these stories within the conflict and the subsequent displacement. Through this process, the study aims to understand how displacement affects physical and mental health of Syrian refugees living in Jordan. Methods Subjects and Sites Subjects for this research study were Syrian adults living in Jordan who were displaced by the current conflict in Syria. Individuals interviewed for this project lived either in Za’atari Refugee 4 Figure 2. Organization of Za’atari Refugee Camp.1 Health facilities are shown in salmon. Camp or in Amman. Subjects were sampled using the snowball method in June and July of 2016.25 Initial participants were identified with help from the translator and further participants were recommended by the interviewees at the end of each interview. Za’atari camp is the oldest and largest of the camps in Jordan with almost 79,000 refugees living within its borders.26 Za’atari is located along the Northern border of Jordan (see Figure 1). The camp was established in the desert, ten kilometers east of the city of Mafraq in July, 2012, through a partnership with the Jordanian government, the UN High Commission for Refugees (UNHCR), and many international aid organizations. Within a few months the camp grew from a few hundred to 15,000 residents.27 The population peaked at just over 202,000 in 2013.28 Upon the opening of a second refugee camp in 2014, Za’atari stopped accepting new refugees and the population declined to its current 79,000.28 Over this time, the camp transformed from makeshift tents with little infrastructure and poor sanitation to its present city-like conditions.27 Currently, ages in the camp range from newborns to the elderly, with almost a quarter of individuals between the ages of 18 and 59.16 An average of 80 babies are born every week.16, 26 5 Approximately 20% of the households are headed by women.26 Residents in Za’atari now live in pre-fabricated caravans. Older models measure 16x9.5 feet and consist of a single room. Newer caravans are 23x11 feet and include a small kitchen and toilet. The United Nations High Commissioner for Refugees (UNHCR) partners with four different governmental organizations and 41 humanitarian organizations that assist with safety, education, health, water and sanitation, community empowerment, and energy access.26 Primary medical care is provided in a number of clinics around the camp and secondary care is provided in two field hospitals that are also within the camp.29 For tertiary care, refugees are referred to hospitals in Mafraq, which is located outside of the camp. The camp is divided into 12 districts, each of which is further divided into blocks (see Figure 2). District 1 contains the American Medical Response’s (AMR) comprehensive medical center. District 3 contains the Eastern Mediterranean Public Health Network (EMPHNET), the AMR Mother and Child Centre, the Moroccan Field Hospital, and the Jordanian-Italian Hospital run by the Royal Medical Service. District 4 contains the Kingdom of Saudi Arabia’s (KSA) dental clinic and the Noor Houssein Shared Centre which provides women’s health, counseling, and trauma rehabilitation. District 5 contains Holy Land Institute for the Deaf, the Jordanian Health Aid Society Maternity Clinic, the International Medical Corps (IMC) Mental Health Clinic, the International Rescue Committee Primary Health Clinic, Handicap International Physical Therapy Clinic, the Qatari Red Crescent Psycho-Social Support Clinic, the KSA Hospital, and the Médecins Sans Frontières (MSF) Hospital. District 6 contains the Visual / Hearing Aids and Child Rehabilitation and the IMC Primary Health Clinic. No health care facilities exist in district 2 and districts 7-10. Just outside the Southern camp border are two AMR Comprehensive Medical Centers, the Syrian American Medical Society Foundation Clinic, and the Qatari Clinic. Data Collection This is qualitative research study utilizing semi-structured, in-depth interviews. With the use of a trained translator, subjects participated in interviews with the primary researcher that were voice recorded on a hand-held device and lasted approximately one hour in length. The interview topics loosely followed an interview guide (Appendix 1) that primarily included grand tour and 6 example questions with prompts if the interview stalled or went off course.30 However, the interviews were conversational in style, allowing the subject to lead the conversation. Interviews were continuously set up until it was determined that the data available met sufficiency of conceptual depth.31 Data Analysis Interviews were transcribed and translated into English by a native Arabic speaker. Data were analyzed using the immersion/crystallization method.32 The primary author read each interview transcript a minimum of two times while identifying emerging themes. Themes were then compared and contrasted between interviews, and transcripts were reread with identified themes in mind. Potential biases were specifically considered after the primary identification of themes and again after re-reading the transcripts. Ethical Considerations This study was approved by the Institutional Review Board of Brown University and the Jordanian Ministry of Health. A consent sheet was provided and explained before each interview and participants signed the form. Participants were free to abort the interview at any point and ask that their information be excluded from the study. No personal information, with the exception of age and gender, was recorded. Confidentiality was maintained through encryption of identifiable data, limiting access to the data to only the study team, and securely storing the data. Results Demographics A total of 20 individuals were interviewed for this project. Demographics are presented in Table 1. No participants chose to withdraw from the interview. Seventy-five percent of participants were living in Za’atari Refugee Camp with the remaining 25% living in the capital city of Amman. Ages ranged from 19 to 70 years old with 30% of participants under 30 years of age, 35% between 30-49, and 30% over 50 years old. Many participants came from Southern Syrian 7 Table 1. Demographic information of interview participants Za’atari Amman Total Participants 15 5 20 Mean Age (years) 39.4 30.8 39.7 Range 23-70 19-59 19-70 Gender Female 7 3 10 Male 8 2 10 regions including Damascus, Dara’a, and Izra. However, a number came from more mid or northern regions including from Ghazala, Homs, Salamiyyah, Khirbat, and Allepo. The effects of displacement on health are summarized in Table 2. Health and Health Care Prior to the Conflict Participants described health care in Syria prior to the conflict as free and accessible, if “not the best.” In general, individuals were able to have their basic health needs met, including seeing providers for chronic conditions and access to medications for treatment. Participants noted that Syrians suffered from common chronic diseases like hypertension, cardiovascular disease, and diabetes. Most participants agreed, however, that more complex care was often unavailable or of poor quality. One interviewee noted that upper-middle class Syrians would travel to Jordan for more complicated medical conditions, including operations. She stated that this type of medical tourism was affordable and resulted in high quality care. Health in the Conflict Few of the individuals interviewed had taken part in the actual fighting. However, a few of the men had been injured in crossfire. One described being shot while he walked to work, resulting in spine and liver injury. Another described a head injury that continues to cause “dizziness, anger, and nervousness.” Much more common than direct conflict injury was injury due to police interrogation, primarily for males. With one exception, every individual interviewed reported that they or a male family 8 Table 2. Syrian refugees’ health experiences Health/Health care Health Effects of Health Effects Health in Za’atari Health Outside the before Conflict Conflict of the Journey Refugee Camp Camp • Basic health needs • Some direct • Lack of food • Good vaccination • Very limited health were met conflict injury - and clean water rates care access due to • High burden of bullet wounds, • Respiratory and • High burden of cost and locations chronic conditions traumatic brain eye injuries infectious disease • Lack of legal ways (hypertension, injury (TBI) from dust • Respiratory injuries to generate income cardiovascular • Torture causing • Torture from dust • Exacerbation of disease, diabetes) internal injury, • Bullet wounds • Exacerbation of chronic conditions • Care available for TBI, orthopedic • Exhaustion chronic conditions • Lack of access to acute conditions injuries • Lack of access to medications • Travel abroad for • Sexual violence medications • Mental illness complex medical • Constant • Poor quality of care • Poor, cramped needs emergency state in clinics housing conditions • Lack of transportation to camp clinics • Mental illness • Lack of opportunity member were taken into custody and tortured by the Syrian police. One interviewee stated that “there was a lot of fear. At any moment, someone could open the door and take the husband or son to jail for no reason.” She described her son’s torture which included hanging him in crucifixion and hitting him in the head and the abdomen. She described how people always got sick after the beatings. Another woman described how her only son was taken and tortured ten times. Women, on the other hand, were targeted sexually. One interviewee described how for “the female, there’s no safety.” She stated that her niece was taken by soldiers for over two weeks. Another woman described how she used to hear girls screaming throughout the night as they were being raped. Participants described the mental toll of living in constant fear as being “constantly in an emergency state.” In addition to the direct threat of injury and death, participants emphasized the demoralization of watching your home and livelihood destroyed. Many individuals noted the “sense of hopelessness” from being trapped in their homes all day, unable to go into the open. Almost all participants discussed the challenge of choosing to leave their life behind to make a 9 dangerous journey for the long-term wellbeing of themselves and their family. The Journey: Health Effects Travel from Syria to Jordan was often long and dangerous. Participants walked significant distances in the heat and dust with little food and water. Other described being crammed in a truck with 12 other people. Both groups of individuals described the dust filling their eyes and mouths even through their protective face wraps. One woman miscarried during the journey. Direct injury was also common. One interviewee reported being detained and tortured for six hours at a checkpoint before being allowed to cross. Multiple individuals discussed being shot at throughout their journey. One stated “when we were traveling, every so often there would be a projectile coming from a different area. Bullets were coming from the mountains.” Another described how they could only travel during the dark without any lights and in silence because bullets would come at them if soldiers noted any movement. To ensure that children were cooperative, she said, “they would give them medicine to sleep because they might make a noise and then they would open fire on us again. If the child refuses, they wouldn’t let them cross until they figured something out.” One woman summed up her experience: “The death is indescribable. You leave the dead. It is as if you are dead. If you go this way, you think there’s no way you’ll arrive. You’re sure you’re going to die. That’s why I called it the journey and road of death.” Camp Living: Health effects and Health Services Once in the camps, many refugees suffered from infectious diseases. Many noted that when they arrived there was no running water. One man described how his family has “had diarrhea since the beginning, because of lack of cleanliness. There were lots of flies and so on.” Another noted that when they “first moved, it was stressful even getting to the bathroom. The bathrooms were far. [They] would need to wait an hour to use the bathroom.” He said that Za’atari eventually was upgraded to having water and electricity in each tent; however, many other camps are still severely limited. 10 Participants emphasized that conflict exacerbates existing health problems as well as creating new ones. One interviewee stated that “everything is amplified with the exhaustion.” Another stated that “all these circumstances and pressures have really taken a toll on people’s health… they’ve developed illnesses they didn’t previously have and they cannot take care of their health in the proper way they did before.” Another stated that his blood sugar used to be in the mid 100s and now is consistently 300. One man described how his family’s health had deteriorated since being in Jordan. He has hypertension and his wife has diabetes and hypertension. His father has hypertension and is partially paralyzed. His mother has Alzheimer’s and could not be kept safe from wandering off. Most interviewees reported that the quality of the camp clinics was poor. Transportation to clinics was challenging due to difficulties of providing exact locations for pick-up. He described waiting for hours for an ambulance that couldn't find his location because there were no clear landmarks for his location. He was ultimately taken to the hospital in a wheelbarrow. Once at hospitals and clinics, participants stated that wait-times were long with “no preference for those with serious diseases.” One participant stated that “even if you’re dying you need to wait in line.” Participants described waiting an average of 4-6 hours at the camp clinics. Finally, participants were unhappy with the actual medical care that they received at the camp. Many individuals interviewed stated that regardless of the complaint, patients are given painkillers. One woman believed that “90% of their medicine is just painkillers.” However, interviewees did state that there was preventative health such as vaccinations. One interviewee described how medical personnel would go around to the houses once a month to ask who had children and provide the children with vaccinations. Health Care and Health Services Outside the Camps Participants stated that receiving care outside of the camp setting is extraordinarily difficult. First of all, participants found the cost to be prohibitive. One explained that since the conflict, the exchange rate of Syrian Liras to Jordanian Dinar has crashed, leaving even formerly well-off Syrians with little ability to pay for care. Another who had gotten prior treatment in Jordan described current costs as 10-15 times more expensive than before the conflict. Many described 11 being unable to pay for medications at all. One participant noted that she previously took four pills but has since stopped because she “couldn’t afford them anymore.” Accessing health care in the community outside the camp is difficult even aside from the cost. Syrians are unable to drive with their Syrian driver’s licenses and taxis are unaffordable. Many study participants described the difficulty of navigating the Jordanian health system. One man told of going to a public hospital to get a prescription for medication. He got an appointment for a year later. He was sent to multiple doctors in different cities to get the correct paperwork. In the end he received medication for only one month. Another man described that getting a wheelchair took him four years. These challenges were even greater for non-camp dwelling participants. They get 100% of their care, rather than just tertiary services, outside of camps and described having fewer organizational resources available to help them navigate challenges. In addition, they noted that they needed to use their limited finances on shelter and food, resources provided for those living in camps, as well as medical care. One stated “I choose between food for my children and buying my medications. How can I leave my children hungry?” Mental Health Mental health was an issue for most of the individuals interviewed. Their sense of wellbeing was exacerbated by the conflict, the journey to Jordan, and life in Jordan. One woman described being sick for more than a month after arriving saying she “had an insane headache and body aches. [She] felt betrayed by [her] own people.” Now she gets migraines every few days with any disruption or anxiety. Other participants talked about feeling sad and depressed. Multiple interviewees spoke about how living in a camp with nothing to do exacerbates their anxiety and makes them feel worthless. One woman described feeling isolated. One man noted that he’s “psychologically suffering. This makes [him] feel physical pain… all over. [His] nerves are in pain.” 12 Moving Forward All but one interviewee said they would return to Syria if it regained stability. Many discussed needing to rebuild the health care infrastructure from the ground up. They noted that a new healthcare system needed to address the new maladies affecting the population as a result of their dislocation and the exacerbated issues that have developed from lack of care. Most interviewees also discussed the need for a robust mental health system to help with the new psychological needs of the population. Discussion This study had tales that included common health issues that grew out of conflict, displacement, and refugee living. Understanding the specific aspects of the Syrian conflict as well as the journeys and experiences of refugees is vital when thinking about how to best address current and future health system needs. Health Experiences Direct Health Cost of Conflict and Displacement Syrians living in Jordan experienced both direct injury from the conflict as well as injury during the process of fleeing to another country. The experiences described throughout the interviews are in line with the literature from Syria and from other conflicts.33 The majority of trauma involved head, neck, chest, abdomen, or multi-body injuries.34, 35 In addition, women were particularly vulnerable to gender-specific trauma including sexual assault.36 Trauma care for these injuries is immediately necessary upon escape to a safe area.37 Refugee Health Approximately 86% of Syrian refugees report that an adult member of their household has sought medical care in Jordan.38 Many of the problems described by participants in this study were similar for those living in Za’atari and in Amman. Individuals often faced poor sanitary conditions, exposure to infectious diseases, and challenging access to quality health care.39 This reality, along with disruption in vaccination practices, has led to outbreaks and reemergence of 13 tuberculosis (TB), polio, cholera, typhoid, measles, and leishmaniasis.40, 41 Rates of both active and latent TB are high among contacts of Syrian TB patients.42 These types of outbreaks from infectious diseases not only endanger the refugees, but the surrounding populations that are exposed to illnesses. Strong surveillance and tracing are necessary to avoid further outbreaks but resources are limited. In addition to infectious disease, Syrian refugees both within and outside Za’atari discussed the exacerbation of existing chronic conditions as well as the development of new non- communicable diseases. According to literature, 50% of Syrian refugee households in Jordan have at least one individual with a chronic non-communicable disease.43 Syrian refugees have a high prevalence of hypertension, cardiovascular disease, respiratory disease, arthritis, diabetes, and cataracts.43-45 On average, 85% of refugees with a non-communicable disease have received care in Jordan, although there are high regional differences in access.46 Although studies exist looking at novel ways of addressing complex medical needs in refugees,47, 48 all too often, even the basic needs are being left unmet. Refugee Health Access The WHO articulates that even as a refugee, individuals have a right to health care. Unfortunately, this right does not translate to Syrian refugees having adequate access to quality care, a reality that is exemplified through higher rates of C-sections, anemia, and lower birth weight compared to their Jordanian counterparts.49 The UNHCR covers the full cost of primary and secondary health services for individuals in the Azaraq and Za’atari camps.26 Tertiary services are only available outside camps. Jordan has free universal health coverage for citizens and had extended this coverage to Syrian refugees until 2014. The massive increase in the health burden and population has overwhelmed the Jordanian system with widespread effects on the economic, political, and social systems. Although many aid organizations have provided pharmaceuticals, the demand continues to outweigh the supply.50 In September, 2014, the Jordanian Ministry of Health ended this coverage for Syrian refugees due to unsustainable health care costs.51 Since this change, those seeking care 14 outside of camps are responsible for paying 80% of the foreigner’s fee at government clinics,26 an amount that is prohibitively expensive for most of the refugees spoken to in this study. In general, Syrian refugees are able to access primary care for acute diseases and vaccination for children.52 Emergency care, chronic care, and obstetric and gynecology services are somewhat less accessible. Surgery and mental health services are not accessible although there is significant need.53 Participants noted various difficulties when trying to navigate the Jordanian health care system outside the camp that were in line with the literature including lack of knowledge about the system, complex referral system, high wait time, discrimination from staff, cost and availability of transportation, and simply cost of care.38, 44, 52, 54 These issues were exacerbated by the policy change requiring Syrian refugees to pay the foreigner’s fee.38, 44 Approximately 23% of refugees outside of refugee camps report a disruption to their chronic disease medications because they could not afford them.45 Older refugees are particularly vulnerable as they also often have physical limitations and food insecurity.55 Mental Health Mental health challenges intertwine and complicate the physical illness facing refugees. Individuals interviewed often connected their physical symptoms with their mental pain, particularly for stress and depression, and many studies have shown that poor mental health leads to worse outcomes for physical health problems.56 One of the major stressors linked with depression, highlighted in many of the interviews for this study, is the subjective fall in social status that refugees experience.23 In addition, conditions like post-partum depression are higher in Syrian refugees than their Jordanian counterparts.57 Children are particularly vulnerable and may experience toxic stress which can affect them throughout their lives.24 Unsurprisingly, the development of post-traumatic stress syndrome, depression, and anxiety are all related to the number of traumatic events experienced by an individual.58 Approximately one third of refugees develop post-traumatic stress disorder.59, 60 The development of the disorder is 15 related to how centrally individuals place the trauma in their personal story. Individuals able to situate their trauma apart from their sense of self have lower rates of PTSD. In Syrian refugees, young adults were more likely to separate their personal story from the trauma and therefore had lower rates of psychiatric conditions.59 Conclusion This type of analysis of the physical and mental health of populations that experience conflict and dislocation is necessary in order to create a health system that fits the new needs of the population. There is no question that conflict will affect a population’s health. However one must study specific populations and circumstances to understand exactly how health has been affected and the best way to provide quality physical and mental health care during and after the conflict.17, 21 Although interviews were continued until sufficient conceptual depth was met, this study is limited by its small sample size, the sampling methodology, and limitation of sampling to one site. To fully understand the health needs of the Syrian population, a significantly larger study is needed that includes a wide array of camp and non-camp settings in multiple countries and includes internally displaced people. However, this study, in combination with existing literature, does provide insight into potential current and future health care needs of Syrian refugees. For Syrians, current care must address direct injury from conflict and displacement, infectious disease resulting from poor living conditions, and the exacerbation of chronic health issues from disruption in care. In addition, health care must address the psychological trauma that has developed from the experience of pre- and post-refugee life. All of these needs must also be addressed when looking to rebuild the Syrian health care system. Syrians in this sample want to return to their country. They recognize, however, that they have new needs that must be addressed. 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Posttraumatic Stress Disorder and Psychiatric Co-morbidity among Syrian Refugees of Different Ages: the Role of Trauma Centrality. Psychiatr Q. 2018; 89:909-21. 60. Chung MC, Shakra M, AlQarni N, AlMazrouei M, Al Mazrouei S, Al Hashimi S. Posttraumatic Stress Among Syrian Refugees: Trauma Exposure Characteristics, Trauma Centrality, and Emotional Suppression. Psychiatry. 2018; 81:54-70. 19 Appendix 1 Interview Guide Background • Where were you born/where do you consider home? • What is your home like geographically? • Who is in your immediate and extended family? • Who lived in your home before you left Syria? • How did you spend your time? • What was healthcare like in Syria? • Did you have any health problems while you were living in Syria? What sort of treatments did you get to help with those problems? Displacement • What made you decide to leave Syria? • What happened between the time you decided to leave and when you ended up here? • Did you experience any new health problems during that time? Were you able to do anything about them? Jordan • What has life been like here? Do you have your family here with you? What is going well? What has been difficult? • What are your living arrangements like here? • How do you spend your time? • Have you had any new or recurring problems with your health since you’ve been here? Who do you go to if you have a medical issue? Are you more or less likely to seek medical help than you were when you lived in Syria? • What have your interactions with the health system here been like? Have you been able to get care for ongoing problems? Have you been able to get care for new problems? Have you had any care that is to keep you well (vaccinations etc.)? How long do you have to wait to see a health care worker if you need to? Other • Do you feel like this experience has impacted your level of stress? • Are there ongoing issues that add to your stress? • Do you think any of these physical problems you’ve experienced could be related to the stress you have had in your life recently? • Do you think this experience has changed the way you think about health? • What does it mean to you to be healthy? • If things settle down in Syria, would you ever consider returning? • What would you like to see in a healthcare system in the future? 20