The Use of Empirical Medicine in the Treatment of Syrian Refugees



The Use of Empirical Medicine in the Treatment of Syrian Refugees
The Use of Empirical Medicine in the Treatment of
Syrian Refugees in Turkey
Razan Al-Nahhas
• 3 million Syrian
refugees since
2011 [2]
• ~1.6 million
refugees in Turkey
• Image shows
number of
refugees as of
August 2014
• 21 refugee camps
with over 220,000
refugees within
Turkey [4]
• Remaining
refugees living
outside of camps
within Turkish
cities and towns
• Islahiye Refugee Camp
with over 10,000 Syrian
refugees [5]
• Many camps house
25,000-40,000 refugees
• Refugee camps all
equipped with medical
• Wait times may be
several hours, many
patients told to come
back another day
Entrance to Islahiye
Refugee Camp
All physicians,
nurses, etc. working
at the clinics are
language barrier,
leading to
No on-site
pharmacies at
refugee camp
clinics; patients
must wait 2-3 days
to receive
• Clinics are very limited in resources
• All patients requiring lab work or imaging are
transported to the local state hospital, usually the
next day
• Patients presenting with acute or emergency
situations are transported by ambulance immediately
to hospital
• Over 1 million refugees not residing in
camps requiring medical care [7]
• Overwhelming amount of stress on
Turkish health care system; has spent
over $100 million dollars providing health
care for Syrian refugees [7]
• Turkish government providing
free medical care to Syrian
refugees; only available at state
• Influx of refugees has
overwhelmed hospitals
• Kilis State Hospital, built to
accommodate population of
100,000 [7]
• Since March of 2012, has treated
more than 350,000 Syrian
refugees [7]
• Sees about 2,000-3,000 patients
daily [7]
• Large percentage of patients seen are
emergency cases from across the border
• Refugee identification card is required for
non-emergent care
• Registering for refugee identification may
take anywhere from a few days to a few
• Refugees develop travel related illnesses,
may leave medications behind, or run out of
medications soon after they get to Turkey
• Turn to other options for medical care
• Syrian physicians have paired up
with international NonGovernmental Organizations
(NGOs) to develop an informal
system of medical centers
• City of Kilis is less than 10 miles
from the Syrian border
• It has experienced a continuous
influx of refugees
• There is currently a total of 6
informal medical clinics (5
multispecialty/polyclinics and 1
post-operative clinic) within Kilis
These clinics see a variety of refugees:
• those living outside of refugee camps
• those living in refugee camps
• unregistered refugees that have been
in Turkey or are just arriving
• refugees from other cities lacking such
a system, such as Gaziantep and
• Clinics see more than 500 patients daily;
2,500 total between the 5 polyclinics
• At Syrian Polyclinic 1 there are:
2 internists, 2 pediatricians, 1
ophthalmologist, 1 ENT, 1 OB/GYN, 1
psychiatrist, 2 pharmacists, 2 dentists
• Each internist at SP1
would see about 45
patients daily
• These clinics are not
formally recognized by the
Turkish government
• Clinics are limited in
resources and capacity to
• Clinics lack access to labs,
only available imaging
studies are ultrasound and
EKG machine
• Physicians must resort to
the practice of empirical
medicine; treating patients
based solely on history and
physical exam
• Conditions frequently treated empirically:
• UTI (urinalysis)
• Anemia (CBC and iron panel)
• Vaginal irritation/abnormal vaginal
discharge (pap smear and culture)
• Asthma (chest X-ray)
• Hepatitis A infection in pediatric patients
(hepatitis serum antibodies)
Cutaneous Leishmaniasis
• Practicing empirical medicine carries a higher risk of
• Physicians have had to adapt to the lack of
diagnostic tools
• In most cases, patients are discharged with
medications or instructions and their symptoms
• Patient returning with the same complaint are
instructed to go to the state hospital for further
• Certain presentations cannot be treated empirically
as they may require immediate intervention
• These patients are sent by ambulance to the state
• The clinics are also limited in the
medications available in their pharmacies
• Medication supply is provided by the parent
NGO, based on the WHO's Model List of
Essential Medicines
• Must also be approved by the Turkish
Department of Health
Examples of Unavailable Medications:*
• Metformin
• Aspirin
• Enalapril
• Metoprolol
• Insulin**
• Bactrim
• Cephtriaxone
• Augmentin
• Azithromycin
• Simvastatin (and other statins)**
• Vitamin D, B12, multivitamins
• The number of patients seen and the
medications needed are reassessed on a
monthly basis
*Since my visit, about 50 medications have
been added to the supply list
**would rely on donations
• Most patients entering Kilis State Hospital for surgery are victims of the violent conditions in Syria
• Patient often must wait several days for their turn for surgery
• The standards of discharging patients are rarely met
• Patients are discharged with no where to go
• The Malteser-International Blue Crescent Post-Operative Clinic was developed to remedy this situation
• Many of these patients
have limb amputations,
spinal cord injuries and
paralysis, 2nd and 3rd
degree burns, open
fractures of often multiple
limbs, and head and brain
• Ideally, CBCs should be
performed at least once a
• About 75% of the patients at IBC
post-op clinic have infections
• Many patients arrive from the
hospital with their wounds
already infected, as postoperative care at the hospital
is very lacking
• Like the multispecialty clinics,
the IBC post-op clinic is also
very limited in resources
• Do not have a lab or any access
to imaging
• However, they do have a
contract with a private hospital
for lab work
• Despite this, they can still only
perform blood work at most
every other day or even less
frequently, including cultures
for antibiotic sensitivity
• Patients are thus treated
empirically at first until culture
results return
• Patients dressings are changed daily
• Often times, the wound must be slightly
opened in order to be cleaned properly and
for minor debridement
• This can be very painful for the patient
• No anesthetics or sedatives available; strongest
analgesic is Tramadol, often not effective
• Despite limitations, the
informal health centers have
effectively applied empirical
medicine in the treatment of
• Have helped mitigate some of
the financial strain on the
Turkish health care system
• This system has the potential
to be a model for future health
crises and critical situations
Dr. Ahmad Alito, Syria Polyclinic 1 Director
Hiba Abood, Syria Polyclinic 1 Head Nurse
Ali Ahmad, Malteser-International Blue Crescent Post-Operative Clinic Head Nurse
Dr. Maher Azzouz, Syrian American Medical Society Mission Trip Coordinator
Dr. Ali Moradi, LECOM-Bradenton
1. Goldberg, M. (2014, August 19). Map of the Day: Syria's Ignominious Milestone - UN Dispatch.
Retrieved September 20, 2014.
2. Brumfield, B. (2014, September 23). 200,000 flee in biggest displacement of Syrian conflict, monitor
says. Retrieved September 27, 2014.
3. 2014 UNHCR country operations profile - Turkey. (2014, September 10). Retrieved September 26,
4. Siddique, H. (2014, June 19). Syrian refugees in Turkey exceed 1 million mark. Retrieved September 4,
5. Mcclelland, M. (2014, February 15). How to Build a Perfect Refugee Camp. Retrieved October 1, 2014.
6. AL ARABIYA WITH AFP. (2012, September 30). Saudi group to set up Syrian refugee camp in Turkey
within month. Retrieved October 1, 2014.
7. Chudacoff, D. (2014, September 1). Syrians build health care network in Turkey. Retrieved September 4,
8. Voice of America. (2012, April 8). Gunfire From Syria Wounds 5 in Turkey. Retrieved October 14,
9. Leishmaniasis. (2013, January 10). Center for Disease Control and Prevention. Retrieved October 14,
10. Markle, W. (2004, March 15). Cutaneous Leishmaniasis: Recognition and Treatment. American
Academy of Family Physicians. Retrieved October 14, 2014.
Thank You!