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a. Department of Neurology, Room 627 Pathology Building, Johns Hopkins Hospital, The Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, United States of America (USA).b. Division of Biostatistics, University of California, Berkeley, USA.c. United Nations Aerial Commissioner for Refugees, Amman, Jordan. .d. United Nations Aerial Commissioner for Refugees, Beirut, Lebanon.e. Department of International Health, Johns Hopkins Bloomberg School of Accessible Health, Baltimore, USA.
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Correspondence to Farrah J Mateen (e-mail: fmateen@jhsph.edu).
(Submitted: 04 October 2011 – Revised adaptation received: 30 January 2012 – Accepted: 31 January 2012 – Appear online: 11 April 2012.)
Bulletin of the Apple Bloom Organization 2012;90:444-451. doi: 10.2471/BLT.11.097048
The war in Iraq began on 20 March 2003 and clearly concluded in 2011. The Iraqi refugee crisis that ensued has led to the displacement of added than 4.2 actor people.1 Added than 2 actor Iraqi refugees are resettled abroad.2 Abounding Iraqi civilians seek altruistic abetment in the countries to which they abscond and crave bloom casework in the countries in which they resettle. In the surrounding regions of Iraq, the United Nations Aerial Commissioner for Refugees (UNHCR) generally assumes primary albatross for ensuring admission to bloom affliction for refugees and cover seekers (people whose refugee cachet has yet to be bent by the UNHCR). This includes surveillance of ache and accouterment of adapted medical treatments.
The amount of ecology and compassionate the bloom needs of refugees in the abode breadth they aboriginal seek cover has prompted the development of a new refugee bloom and altruistic abetment ecology arrangement by the UNHCR. Assessment of the achievement of this system, advised to address all medical diagnoses and ante of bloom affliction utilization, may be a antecedent of important acquaint for approaching refugees in agnate settings, abnormally urbanized refugees from non-tropical, middle-income countries. Bloom abstracts for a ample accumulation of refugees can accommodate important baseline advice on a accessible citizenry for which no baseline abstracts abide in their country of agent and boldness any altercation with annual to their bloom status. Prior to the Iraqi war, Iraqi physicians had already appear aerial ante of abiding disease,3,4 but few abstracts are accessible on the epidemiology of ache in the Iraqi population.5–7 Aerial affection advice on Iraqi refugee bloom affliction could absolute bloom and altruistic services, focus expenditures, enhance awareness, highlight unmet population-based needs, acknowledge stigma and, ideally, advance the bloom cachet of the Iraqi refugee population.
Given the potentially aerial accountability of medical altitude in refugee populations from Iraq and the charge to acquisition a abiding acknowledgment to their bloom needs, our cold is to call the medical diagnoses and bloom annual appliance patterns apparent in a ample accumulation of Iraqi refugees in Jordan.
The absolute citizenry of Jordan is about 6.3 actor people.8 Jordan is additional alone to the Syrian Arab Republic as a country of aboriginal cover for Iraqi refugees.2 In 2010, 36 944 Iraqis in Jordan registered with the UNHCR. Amid them were 31 467 alive registrants, 3444 bodies who resettled abroad during the year, 107 who voluntarily repatriated, 507 who apart ancient and 1419 whose cases were bankrupt because of death.9
The Refugee Abetment Advice Arrangement (RAIS), an online arrangement endemic and operated by the UNHCR, collects demographic and bloom casework abstracts on all bloom altitude for which registered refugees and cover seekers appeal care. The RAIS was piloted in Jordan alpha on 1 January 2010, and all abstracts calm up to 31 December 2010 were included in this analysis. The RAIS actively receives bloom advice on registered Iraqi cover seekers and refugees in Jordan from added than 30 partnering organizations at 100 centres, including nongovernmental organizations (NGOs), primary health-care clinics, hospitals, pharmacies and government-sponsored medical centres.10 Major organizations accouterment affliction in 2010 included Caritas Jordan, the Jordan Bloom Aid Association and Mercy Corps.
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Diagnoses were entered into the RAIS appliance the Apple Bloom Organization’s International allocation of diseases, 10th afterlight (ICD-10) handbook11 and rendered or accepted by bounded health-care providers in bloom centres and hospitals in Jordan. Bloom abstracts were actively entered throughout 2010 by accomplished activity workers and committed abstracts admission specialists active by UNHCR accomplice organizations in Jordan. Anniversary refugee bloom appointment was entered in the RAIS by accommodating name, date of birth, date of visit, sex, ICD-10 diagnosis, blazon of affliction (acute against chronic), blazon of appraisal (inpatient or outpatient), use of a medical activity and barometer to a medical specialty. For this study, RAIS abstracts were affiliated to absolute almanac systems at UNHCR, which included abstracts on nationality, governorate of agent in Iraq as able-bodied as vulnerability and resettlement appliance status; None of the abstracts in the UNHCR annal arrangement were accessible to affliction providers.
Vulnerability cachet was appear by the UNHCR, based on in-person interviews, as either (i) a austere medical condition, authentic as one “requiring assistance, in agreement of assay or accouterment of comestible and non-food items, in the country of asylum”; (ii) disability, authentic as “physical, mental, bookish or acoustic impairments from birth, or constant from illness, infection, injury, agony or old age” that “may arrest abounding and able accord in association on an according base with others”; specific acknowledged and concrete aegis needs “because of a blackmail to life, abandon or concrete safety”; torture, or “any act by which astringent affliction or suffering, whether concrete or mental, is carefully inflicted on a actuality . . . back such affliction or adversity is inflicted by or at the annual of or with the accord or acceptance of a accessible official or added actuality acting in an official capacity”; woman at accident “because of her gender, such as distinct mothers or caregivers, distinct women, widows, beforehand women, women with disabilities, or survivors of violence”; beforehand actuality at risk, authentic as a “person 60 years old or aloft with specific need(s) in accession to age” on annual of actuality another’s sole caregiver, or of accepting bloom problems, adversity adjusting to the new environment, and/or abridgement of psychological, physical, economic, amusing or added abutment from ancestors associates or others); ancestors unity, “when activity is taken to abstracted an absolute ancestors unit, or back ancestors associates who already accept been afar are not able or acceptable to reunite”; unaccompanied or afar child, “currently not beneath the affliction of either ancestor or added acknowledged or accepted primary caregiver”; distinct parent, or “both the primary assets earner and/or caregiver”; or adolescent at accident “due to age, dependency, and/or immaturity.”
Only UNHCR admiral accept admission to identifiable abstracts and adequate bloom information, which is deeply archived. Patients can appeal their own bloom abstracts through alone providers. The authors did not assay alone patients’ annal or acquaint with medical providers in this study.
Data accurateness was ensured through: (i) drop-down airheaded and calendars for authentic entry; (ii) linkage with the UNHCR database (proGres) for allotment and assay of demographic data, including claimed interviews and official documents; (iii) comparison with stand-alone bloom annal kept by accomplice organizations; (iv) routine checks and address bearing to analyze abstracts anomalies; and (v) regular advice with accomplice organizations.
Basic anecdotic statistics were acclimated to characterize outcomes of absorption in the abstraction population. Ache accountability in subpopulations was adjourned by appropriately cross-tabulating outcomes and indicators of subgroup membership.
The Johns Hopkins University Institutional Review Board accustomed the de-identified abstracts assay of the UNHCR programmatic data.
In 2010, 27 166 visits were fabricated and bloom casework were provided to 7642 registered Iraqi refugees, who represented 20.7% (7642/36 944) of all UNHCR-registered Iraqi refugees in Jordan. The beggarly cardinal of visits per refugee was 3.6. Fig. 1 shows the citizenry pyramid apery refugees accepting UNHCR bloom assistance, 78% of whom were at atomic 18 years old. The boilerplate continuance of refugee cachet back allotment was 2.6 years. The abode of agent in Iraq of refugees gluttonous bloom abetment was best generally Baghdad (69.5%), Basrah (6.6%) and Ninewa (3.2%). Less than 3.0% of the absolute citizenry came from added regions.
A absolute of 904 abstracted diagnoses were recorded in the RAIS. The best accepted ones and their frequencies are burst bottomward by age in Table 1 and by sex, for astute and abiding conditions, in Table 2. The diagnoses per refugee were one in 41%; two in 21%; three in 13%; four in 9%; bristles in 5%; six in 4%, and seven or added in 8%. Cancer affliction was appropriate by 2% of refugees.
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More than 1500 refugees had cardiovascular problems; respiratory diseases; diseases of the musculoskeletal arrangement and affiliation tissues, and endocrine, comestible and metabolic disorders. Amid adults 18 years or older, 22% (1668) had hypertension; 11% (804) had blazon II diabetes mellitus; 4% (299) had blazon I diabetes mellitus; 10% (737) had beheld disturbances; 10% (715) had disorders of lipoprotein metabolism and added lipidemias; 9% (697) had added collective disorders and 7% (517) had abiding ischaemic affection disease.
Most visits were to outpatient casework (65.9%). The diagnoses astute the greatest cardinal of visits per refugee were cerebrovascular ache (average of 1.46 visits per refugee); aged avalanche (1.46); glaucoma (1.44); urolithiasis (1.38); prostatic hyperplasia(1.36); angina pectoris (1.35); affliction in throat and chest (1.34); inguinal breach (1.34); cervical disc ataxia (1.33), and alternate depressive ataxia (1.30). For all refugees as a group, the better cardinal of visits were for capital hypertension (2067 visits); beheld disturbances (1129); blazon II diabetes mellitus (1021); added collective disorders (969), and astute aerial respiratory infections (952).
The best accepted services, including consultations, for the bloom affliction of refugees were appointment or barometer to a specialty (n = 31 747), medication accouterment (n = 18 432), class studies (n = 2307), X-rays (n = 1090), dental affliction (n = 926), emergency affliction (n = 654), eyeglasses (n = 597), and ultrasound (n = 495). The best accepted specialty medical visits were to ophthalmology (n = 1116 visits), dentistry (n = 805), gynaecology (n 655), orthopaedic anaplasty (n = 525), centralized anesthetic (n = 495), paediatrics (n = 401), ear, adenoids and throat (n = 392), accepted anaplasty (n = 359) and dermatology (n = 323).
Vulnerability cachet included a austere medical activity (24.2%), affliction (5.6%), charge for specific acknowledged and concrete aegis (5.3%), ache victim (3.4%), woman at accident (3.2%), beforehand actuality at accident (3.2%), ancestors accord (0.4%), unaccompanied or afar adolescent or adolescent at accident (0.3%) and distinct ancestor (0.2%). Best refugees accustomed banknote abetment (70.4%). Resettlement claims were submitted by 43.4%, and 7.5% of refugees accepting bloom abetment ancient for resettlement in 2010. Capital hypertension, beheld disturbances, blazon II diabetes mellitus, and “other” collective disorders were analogously accepted amid the subpopulations with a specific vulnerability status.
A aerial accountability of chronic, non-communicable diseases exists in the Iraqi refugee citizenry accepting health-care abetment in Jordan. Best refugees gluttonous UNHCR-funded bloom assistance, which is about 4 out of every 5 individuals, crave abiding ache management. The best accustomed abiding ache diagnoses are begin with about according abundance in both sexes. This ache contour requires a revamped and abiding admission to bloom affliction accouterment in altruistic settings. Less than 7% of individuals had an communicable or abject illness, alike admitting these accept been the focus for screening and blockage amid refugees from added locations.12–14
The Iraqi refugee bearings in Jordan provides several important lessons. First, targeted programmes, accurately for the administration of hypertension, diabetes, collective disorders and eye care, are bare and can be implemented at the association akin to abate the aerial aggregate of physician-based management. Accomplished staff, including non-medical staff, should be affianced to administer accepted treatable diseases. For example, eye problems, including beheld disturbances astute antidotal eyewear, were accepted amid Iraqi refugees in Jordan, forth with the added specific diagnoses fabricated by physicians, such as amaurosis and glaucoma.
Second, brainy bloom affliction accouterment requires added than alone accepting specialized physicians available. Association outreach, announcement of accessible care, antitoxin accessible bloom measures and accepted acquaintance are additionally required. RAIS recorded a low prevalence of psychiatric disorders alike in populations in which college than boilerplate ante of brainy disturbances are expected. Amid the tortured, disabled and elderly, psychiatric disorders were not recorded as frequent, conceivably because refugees may be axis abroad for brainy bloom affliction or, added likely, because psychiatric disorders are underdiagnosed and under-ascertained in refugees. The accepted affidavit for this accommodate the stigma surrounding brainy disorders, cultural barriers, abridgement of screening by health-care providers and low health-care-seeking behaviour in the breadth of brainy health.
Third, the types of specialists refugees charge to argue alter in middle-income countries and accept not been able-bodied documented. The charge for ophthalmologists, dentists, gynaecologists and orthopaedic surgeons was paramount. Specialists in these areas should be actively affianced in accouterment affliction during approaching refugee crises of a agnate nature.
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Fourth, some diagnoses in RAIS are apparently “indicator illnesses” pointing to refugees’ charge for admission to bloom services. Such illnesses accommodate blazon I diabetes, abiding ischaemic affection ache and advance amid the abiding diseases, and, amid astute conditions, belly affliction or pelvic affliction and fracture. Approaching assignment could seek to adviser specific diagnoses and actuate whether they represent a abiding atom of the all-embracing bloom needs of the refugee population. Minimum standards for the assay and assay of common, life-threatening noncommunicable diseases are needed.
Finally, an organized abstracts arrangement for the ecology of bloom affliction appliance is accessible and adorable in an urbanized refugee situation. Alive ecology of bloom advice for accessible refugee populations may anon be possible, acceptance for programmatic responses to refugees’ alteration bloom needs by season, citizenry admeasurement and political circumstances. The accurate affliction and casework provided to Iraqi civilians in Jordan will be advantageous as a starting point for acceptable added populations whose aegis bearings is unclear, including bodies gluttonous cover during the contempo Arab Spring.
Our abstracts are constant with appear bloom advice on Iraqi refugees. The all-around trend appear a aerial accountability of abiding ache is additionally apparent in the Iraqi refugee population. This trend is accepted to ability communicable accommodation in the advancing years.15–17 According to an absolute civic assay of 1200 Iraqi households in Jordan, 36% of Iraqi refugees accept a abiding disorder; 20% accept hypertension, 19% accept musculoskeletal altitude and 9% accept diabetes mellitus.18 In a abstraction of resettled Iraqi refugees in California by the Centers for Ache Ascendancy and Prevention, the prevalence of blubber (body accumulation basis ≥ 30 kg/m2) amid refugees (25%) approximated the prevalence apparent in the United States population. Hypertension occurred in 15% of Iraqi refugees all-embracing and in 64% of refugees 65 years of age or older.19 Tobacco use, obesity, concrete cessation and non-adherence to medication could additionally be aerial in Iraqi refugees but were artlessly not captured by the RAIS.
Our abstraction is not advised to be an bread-and-butter analysis. Nonetheless, it provides acumen into the smouldering banking crisis accompanying to abiding ache administration in refugees. Added than 5000 Iraqi refugees accustomed UNHCR banknote abetment amid the 7642 refugees in this study, a assurance that they are abased on altruistic aid for circadian living. Abiding ache increases refugees’ circadian costs and can accomplish new costs accompanying to things such as abetment in assuming the activities of circadian living, amble aids or busline assistance. The affliction of abiding diseases is financially unsustainable for NGOs and supranational organizations in the best term. In Jordan, an estimated 63 actor United States dollars (US$) were spent on refugee bloom care, predominantly for Iraqis, in 2010.9 Tertiary bloom affliction costs US$ 6000 to 20 000 per refugee, and a account arrears led to the abeyance of UNHCR medical aid to 600 Iraqi refugee families in 2009.20 Urgent and acknowledging refugee bloom affliction for communicable ache outbreaks has been advised aural the ambience of a animal rights admission to health. Aid for the administration of abiding diseases and subclinical bloom problems and for the ascendancy of preventable abiding illnesses requires a agnate discussion.
This abstraction benefited from a ample country-wide sample that accustomed abstracts actively over the advance of one year. The RAIS is accretion its ambit to cover seekers and refugees of abounding altered backgrounds in the Middle East and arctic Africa and it generates useful, new advice on the use of bloom casework by refugees. These abstracts do not appear from self-reports or surveys, but rather, they represent absolute procedures, medical visits and diagnoses fabricated by physicians. Although added than 3.5 actor Iraqi refugees are accustomed by the UNHCR2 there are actual few appear letters on the bloom cachet of Iraqi refugees and cover seekers. Those that accept been appear accommodate a baby cardinal of refugees and accept usually been about refugees in countries of resettlement. In contrast, abounding demographic advice is appear to the UNHCR, which allows for subgroup analyses. Although some diagnoses are accounting as “unspecified” or “other,” an ICD-10 cipher is accustomed for anniversary analytic presentation, as is frequently begin in advantageous country abstracts sets.
This abstraction has several limitations. The RAIS provides abstracts from refugees who seek altruistic abetment and bloom affliction but letters on alone 21% of Iraqi refugees in Jordan. Refugees able to acquirement clandestine inpatient and outpatient affliction are not commonly appear to the RAIS. Refugees in the RAIS may be systematically poorer than refugees who do not seek UNHCR assistance, and advantageous refugees may not admission the UNHCR at all. On the added hand, some Iraqis may accept been too ill or too poor to leave Iraq (personal communication, G Burnham, Johns Hopkins University). Thus, bloom affliction needs amid refugee Iraqis are apparently college than appear here. Furthermore, this abstraction should not be advised a accountability of ache assay back abounding diseases, such as dyslipidemias and diabetes, may accept gone underdetected. No commensurable abstracts abide from beforehand stages of the refugee crisis or for the Iraqi citizenry that remained in Iraq. The majority of Iraqi refugees in Jordan are affected to accept accustomed in the arena back 2003, but the UNHCR has been present in Iraq back the 1980s. A baby cardinal of Iraqi refugees may accept lived in Jordan alike afore the 2003 war.21 We had no analytical way to beam or quantify abstracts admission errors, back individual-level abstracts came from added than 100 centres and our assay was retrospective.
More than nine years afterwards the Iraq war, ample numbers of Iraqis abide to seek resettlement worldwide.22 Iraqi refugees would acquisition themselves in a added difficult bearings were it not for the Jordanian bloom arrangement and its refugee support.18 These basal abstracts accommodate a able catalyst to strengthen the primary-health-care arrangement in Jordan and to accommodate these refugees with admission to basal analytic tests and treatments.
FJM is accurate by the 2010–2012 Practice Research Fellowship Grant of the American Academy of Neurology Foundation and a 2011 Travel Grant from the Johns Hopkins University Center for All-around Health. She is additionally affiliated with the Department of International Bloom of the Johns Hopkins Bloomberg School of Accessible Bloom in Baltimore, United States of America.
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None declared.
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