A Syrian woman escapes a fire with her child in her arms in a refugee camp in Jordan on March 8, 2013 (XINHUA)

As the world's attention shifted from the impact of the Syrian refugee crisis in the Middle East itself to its effects on Europe, those countries that continue to bear the brunt of supporting refugees have largely been left to do so without adequate funding. With the world's attention went resources, resulting in dire situations for both refugees and their hosts as they struggle to keep their economies afloat, citizens healthy and conflict at bay.

Every day the war in Syria continues provides new challenges to the humanitarian efforts to deliver aid to those who have fled their homes and crossed international borders. More than 200,000 Syrians had been killed as a result of the country's civil war that is well into its fifth year, with no signs of resolution, according to a June report called the Regional Refugee and Resilience Plan (3RP) that was released by a coalition of countries and organizations working to address the crisis.

Turkey, Lebanon and Jordan all border Syria and have taken in the majority of its refugees since the civil unrest broke out in 2012. The number of refugees in the countries that share a border with Syria is expected to reach 4.7 million by December, according to UN projections.

Like their European counterparts, these Middle Eastern countries are struggling to absorb the massive population influx, which has put an enormous strain on resources. Unlike their European colleagues, however, countries like Jordan were not self-sustaining in the first place, meaning the additional constraints are putting the entire country's welfare at risk.

Resource strains 

Jordan opened its borders to Syrians seeking asylum in the wake of the conflict. According to the UN High Commissioner for Refugees (UNHCR), the Jordanian Government has dedicated land, resources and personnel to host the 629,152 registered refugees in its care. But as theJordan Times  reported, there is a massive discrepancy between the number of registered and actual refugees, with several sources believing the real number exceeds 1.5 million, more than double the official statistic.

The conflict in Syria has exacerbated an already unstable situation in the country. As one of the most arid in the world, Jordan has limited agricultural land and a scarce water supply, according to the UN's World Food Program (WFP).

The World Bank estimates a population must have access to 1,000 cubic meters per capita to fulfill its annual needs for drinking water, sanitation, agriculture and industry. In the mid-20th century, Jordan had access to 3,600 cubic meters per person, per year. Since then, population growth, climate change and economic development have reduced the annual yield to 145 cubic meters per capita in 2008.

According to predictions made before the conflict in Syria, Jordan was anticipated to be restricted to a mere 90.5 cubic meters of water per person per year by 2020. Mercy Corps, an international aid agency working in the region, reported Jordan's annual per person water share continues to fall, and the rate of depletion has increased in recent years due to the refugee crisis.

In addition to water shortages, Jordan also lacks other natural resources, including oil, making it one of the smallest economies in the Middle East. A recent WFP report noted that over the past five years, Jordan's economic situation has deteriorated. It pointed to the region's volatile security situation as a source for this economic downturn.

The World Factbook report on Jordan compiled by the U.S. Central Intelligence Agency asserts that Jordanian King Abdullah II's fiscal reforms over the past few years have had a positive effect by reducing the budget deficit and increasing government revenues "even as an influx of over 620,000 Syrian refugees since 2011 put additional pressure on expenditures." But Jordan cannot make ends meet without significant international support.

Health at risk

Efforts to provide humanitarian aid and healthcare for Syrian refugees have encountered obstacles that are common to refugee situations, but organizations are also encountering new and unforeseen challenges. Providing basic needs such as food, water, shelter and fuel is a priority just as in other humanitarian crises, but the Syrian refugees also suffer from non-communicable diseases (NCDs) at high rates, further complicating the traditional model of refugee healthcare.

"Seventy-seven percent of all mortality is due to NCDs," Jon Gunnarsson of Médecins Sans Frontières (MSF), who works as a nurse with refugees in Jordan, said in an interview with science and development website SciDev.Net. He went on to say that NCDs represent one of the most urgent, yet underfunded, health crises facing Syrian refugees who have been displaced by the country's civil war. According to MSF, no funding is typically allotted for long-term care for NCDs, and traditionally, humanitarian medical aid has focused on emergency care and communicable diseases.

MSF, known in English as Doctors Without Borders, and its partners believe as many Syrians are dying from NCDs as from the war. They have been working to increase the ability to provide care for NCDs, such as diabetes and ischemic heart disease.

According to the most recent UNHCR published data, 5.6 percent of all Syrian refugees have a documented serious medical condition, along with 8.5 percent of registered Iraqi refugees. Meanwhile, the World Factbook reports that Jordan is able to spend just 7.2 percent of its GDP on healthcare. It reveals that there are only an average of 2.5 physicians and 1.8 hospital beds per 1,000 citizens in Jordan.

Treatment needed 

Health services in Jordan nearest the Syrian border are often overwhelmed with caring for the injured and in turn ignore the sick. "There is treatment of violent injuries, but other medical problems are completely neglected," researcher Talha Burki wrote in a report published in medical journal The Lancet.

As one of the main focal points in refugee healthcare, preventing infectious diseases cannot be ignored. According to several sources, including Burki, there have been confirmed cases of measles, mumps, hepatitis A and hepatitis B among refugee populations. A documented Typhoid epidemic in Idleb, Syria has raised concerns that typhoid could spread to the refugee populations in Jordan.

Other normally treatable infections are causing more damage than necessary due to lack of access to care. For example, many refugees are no longer able to access treatment for cutaneous leishmaniasis, a skin disease, Burki reported.

UNHCR and its international partners have called for an increase in resources to provide the preventive care needed to thwart infectious disease outbreaks. Vaccination campaigns are necessary to protect the vulnerable populations, and a targeted campaign can have a considerable impact, it claims. In November 2012, Jordan led a successful measles vaccination campaign that reached 125,000 urban-dwelling refugees.

Since the crisis is likely to continue, and the living conditions and health-care system continues to deteriorate, experts have warned that rates of infectious disease may rise. Burki forecasts, "As time passes, the degradation to the healthcare system will have an increasingly marked effect on infectious disease."

Currently, only 60 percent of refugees get their healthcare needs met in urban settings. This figure includes pregnant women, who will be forced to cover their own care during pregnancy and delivery even though the majority can't afford it, according to the 3RP report. The 3RP coalition also estimates that in the refugee camps, approximately 20 percent of pre- and post-maternity care is not covered, while only 50 percent of war-wounded refugees in Jordan are receiving the nursing and convalescent care they need.

Financial requirements 

The Syrian situation is the biggest humanitarian and development crisis in recent history, with implications for global peace and security. There are dozens of organizations aiding Jordan to deliver health services to an existing and ever-growing refugee population, and increasingly, to vulnerable host country nationals, as well. The 200 partners in the 3RP believe "the international community has no choice but to continue responding to the ever-growing needs of refugees and the needs of the communities and states that host them."

The coalition reports that more than $5.8 billion has been donated to aid agencies since the first regional response plan was released in March 2012, including just over $1 billion through the end of May. But 3RP partners urge "more funds continue to be required for urgent interventions to meet immediate humanitarian needs and to strengthen the resilience of individuals, communities and institutions."

The international community has pledged $4.5 billion to the 3RP comprehensive plan, but as of this summer, only 23 percent of the funds had been delivered. This makes it incredibly difficult for organizations to provide services effectively, because they are in constant trepidation as to whether or not the funding will exist to carry out their plans.

Changing the trajectory of this complex humanitarian crisis, to assuage the burden on this vulnerable population and better the standard of care is an enormous task. This is especially true in a place like Jordan, where 3RP reports that of the 628,000 Syrian refugees, approximately 84 percent live outside refugee camps in urban and rural areas across the country in increasingly overcrowded or otherwise sub-standard accommodations. Without urgent, significant funding from the international community, getting care to those who need it will be increasingly difficult.

Kathryn Lee is a graduate student at the Johns Hopkins Bloomberg School of Public Health. Ms. Lee's article was written in a personal capacity and is independent of her affiliation with the university. Mara Lee Durrell is an editorial consultant at Beijing Review  and lived in Jordan from 2013-15

Copyedited by Jordyn Dahl

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