Compounding challenges for Syrian refugees in Türkiye in the wake of the earthquake
Authors: Rasha Kaloti, Jasmin Lilian Diab, Munzer Alkhalil, Diana Rayes, Aula Abbara
Journal: The Lancet Global Health (2024)

The earthquake that affected southern Türkiye and northern Syria on Feb 6, 2023, had devastating consequences, particularly impacting vulnerable communities across these areas. These vulnerable communities include 1·7 million of the 3·8 million Syrian refugees in Türkiye.1Karlsen V The earthquakes in Türkiye and Syria: a crisis within the crisis. UNHCR, April 3, 2023https://www.unhcr.org/neu/97487-the-earthquakes-in-turkiye-and-syria-a-crisis-within-the-crisis.htmlDate accessed: February 1, 2024Google Scholar With a staggering number of aftershocks (29 600) and reported deaths (54 000), the earthquake caused widespread destruction and exacerbated the already complex sociopolitical and economic context. Although Türkiye's policies toward Syrian refugees have been supportive of their rights to health care and work compared with other countries in the region, prolonged conflict in Syria leading to the refugees' extended stay in Türkiye, and a changing social, political, and economic landscape, have presented challenges for the refugees.2Mavrouli M Mavroulis S Lekkas E Tsakris A An emerging health crisis in Turkey and Syria after the earthquake disaster on 6 February 2023: risk factors, prevention and management of infectious diseases.Healthcare (Basel). 2023; 111022PubMed Google Scholar Health-care access for Syrian refugees falls under Temporary Protection regulation, a component of the 2003–13 Health Transformation Project that revolutionised the Turkish health system and established the General Health Insurance Scheme.3Kayali N Syrian refugees navigate Turkey's shifting health care terrain. MERIP, Nov 24, 2020https://merip.org/2020/11/syrian-refugees-navigate-turkeys-shifting-health-care-terrain/Date accessed: April 20, 2023Google Scholar Despite this scheme offering health-care services and medications equivalent to those provided for Turkish citizens, obstacles persist for Syrian refugees due to language barriers, differences in medical culture, and travel distances.3Kayali N Syrian refugees navigate Turkey's shifting health care terrain. MERIP, Nov 24, 2020https://merip.org/2020/11/syrian-refugees-navigate-turkeys-shifting-health-care-terrain/Date accessed: April 20, 2023Google Scholar The EU has funded Türkiye with €6 billion through the EU Facility for Refugees in Türkiye to support projects in many areas, including health care, infrastructure, humanitarian assistance, and education.4European CommissionThe EU Facility for Refugees in Turkey.https://neighbourhood-enlargement.ec.europa.eu/system/files/2023-08/frit_factsheet.pdfDate: 2023Date accessed: July 20, 2023Google Scholar For health care, 190 migrant health centres were established in Türkiye over the last few years, where Syrian refugee doctors could work as generalists, mitigating some of the language barriers faced by refugees.4European CommissionThe EU Facility for Refugees in Turkey.https://neighbourhood-enlargement.ec.europa.eu/system/files/2023-08/frit_factsheet.pdfDate: 2023Date accessed: July 20, 2023Google Scholar However, economic downturns, inflation, and rising health-care needs have hampered the programme's reach. The earthquake led to the collapse of hospitals, destruction of infrastructure, and immediate homelessness for 1·5 million people in Türkiye.5Qu Z Wang F Chen X Wang X Xhou Z Rapid report of seismic damage to hospitals in the 2023 Turkey earthquake sequences.Earthq Res Adv. 2023; 3100234Crossref Scopus (4) Google Scholar Displaced Syrians faced worsening discrimination in accessing services, given the stark and overwhelming emergency and health-care needs and the existing challenges they already faced; the social and political atmosphere worsened subsequent to the earthquake, with political actors exploiting the issue, leading to an increase in anti-Syrian sentiment.6Gebeily M Kucukgocmen A Chacar H Earthquake fans anti-Syrian sentiment in Turkey amid desperate conditions. Reuters, Feb 13, 2023https://www.reuters.com/world/middle-east/earthquake-fans-anti-syrian-sentiment-turkey-amid-desperate-conditions-2023-02-13/Date accessed: August 13, 2023Google Scholar Due to the earthquake, there were also economic impacts, shortages of housing and shelter, and job losses exacerbating the situation for Syrian refugees; these had wider impacts, such as on health-care access. Turkish authorities established Family Health Centres and Primary Health Care Units in response, deploying emergency medical teams and initiating humanitarian efforts.7Subramaniam T Haq SN Upright E et al.February 9, 2023, Turkey–Syria earthquake news. CNN, Feb 9, 2023https://edition.cnn.com/middleeast/live-news/turkey-syria-earthquake-updates-2-9-23-intl/h_2700d06892d3c9707c61820e6d21ab22Date accessed: July 20, 2023Google Scholar However, challenges persisted for Syrian refugees, especially for particularly vulnerable groups, such as women and girls who faced shortages in reproductive health care and supplies.8Berdyklychev B Türkiye earthquakes: six months of resilient response and support. World Health Organization, Aug 1, 2023https://www.who.int/europe/news/item/01-08-2023-turkiye-earthquakes-six-months-of-resilient-response-and-supportDate accessed: June 13, 2023Google Scholar Such challenges to accessing health care in the wake of natural disasters often have a gender and intersectional element. For women and girls, the threat of gender-based violence escalated, and for older or disabled people—especially among refugees—the hurdles in accessing health care became more pronounced than before the earthquake.9CARE InternationalRapid gender analysis policy brief: Türkiye & northwest Syria earthquake response.https://www.care-international.org/resources/rapid-gender-analysis-policy-brief-turkiye-northwest-syria-earthquake-response#:~:text=Earthquakes%20are%20gender%20neutral%20%2D%20they,of%20disasters%20exacerbate%20gender%20inequalityDate: Feb 16, 2023Date accessed: May 10, 2023Google Scholar In the immediate aftermath of the earthquake, there were evident and substantial mental health and psychosocial needs for both citizens and refugees alike, including grief and secondary trauma, placing a substantial burden on first responders and caregivers. It is less clear how those needs have been met in the longer term, particularly among refugees who are affected by the already low numbers of mental health specialists in Türkiye, particularly those who speak Arabic. These shortages of mental health professionals present barriers to access to mental health support for both Turkish and Syrian populations.10Karaoğlan Kahiloğulları A Alataş E Ertuğrul F Malaj A Responding to mental health needs of Syrian refugees in Turkey: mhGAP training impact assessment.Int J Ment Health Syst. 2020; 14: 84Crossref PubMed Scopus (2) Google Scholar More than 100 countries supported emergency humanitarian efforts in Türkiye in the immediate aftermath of the earthquake;10Karaoğlan Kahiloğulları A Alataş E Ertuğrul F Malaj A Responding to mental health needs of Syrian refugees in Turkey: mhGAP training impact assessment.Int J Ment Health Syst. 2020; 14: 84Crossref PubMed Scopus (2) Google Scholar in contrast, no international aid entered northern Syria for at least 7 days after the earthquake. Northwest Syria, the area most affected by the earthquake, is essentially besieged; the Turkish border is on one side, and areas under Syrian government control on the other, with a virtually impermeable border. Despite the dire situation on both sides of the border, when the borders opened several days after the earthquake, allowing people to enter Syria, many chose to re-enter given their grave losses in Türkiye and challenges of accessing health care, shelter, and other services. Policies that support universal health coverage and equitable health-care access, and strengthen the focus on primary health-care services, can support both host and refugee populations in their recovery. The aftermath of the earthquake in Türkiye has starkly illuminated the multifaceted challenges encountered by Syrian refugees, necessitating a holistic approach that extends beyond immediate health-care needs to encompass broader socioeconomic and political determinants, which is essential for both the refugee and host populations. Improved access to health care can be achieved through focus on the improved integration of Syrian refugees and other vulnerable populations into the Turkish health-care system, fostering inclusivity and advancing universal health care for all, rather than developing a parallel health system. For this integration to occur, addressing the language and cultural barriers that Syrian refugees face through availability of translators and cultural mediators, and increasing integration of Syrian health-care professionals into the Turkish health system, continue to be paramount. Although Türkiye has policies that support the integration of Syrian health-care professionals are among the best in the Eastern Mediterranean region, obstacles persist such that some health-care professionals base themselves in Türkiye but cross into northwest Syria to work, instead of working in Türkiye. Effectively addressing these issues in the wake of the earthquake could be essential for successful investment in the right to health for all vulnerable populations in Türkiye. DR is funded by the National Institute of Mental Health, which supports her doctoral studies, including contributions to the manuscript; she is also the chair of the Syria Public Health Network. All other authors declare no competing interests. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in institutional affiliations.