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
LECOM-Bradenton
OMSII
• 3 million Syrian
refugees since
2011 [2]
• ~1.6 million
refugees in Turkey
[2]
• Image shows
number of
registered
refugees as of
August 2014
[1]
• 21 refugee camps
with over 220,000
refugees within
Turkey [4]
• Remaining
refugees living
outside of camps
within Turkish
cities and towns
[3]
• Islahiye Refugee Camp
with over 10,000 Syrian
refugees [5]
• Many camps house
25,000-40,000 refugees
[5]
• Refugee camps all
equipped with medical
clinics
• 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
Turkish
•
Significant
language barrier,
leading to
ineffective
communication
•
No on-site
pharmacies at
refugee camp
clinics; patients
must wait 2-3 days
to receive
medications
• 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]
[6]
• Turkish government providing
free medical care to Syrian
refugees; only available at state
hospitals
• 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
weeks
• 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
[8]
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
Istanbul
• 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
perform
• 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
misdiagnosis
• Physicians have had to adapt to the lack of
diagnostic tools
• In most cases, patients are discharged with
medications or instructions and their symptoms
resolve
• Patient returning with the same complaint are
instructed to go to the state hospital for further
evaluation
• Certain presentations cannot be treated empirically
as they may require immediate intervention
• These patients are sent by ambulance to the state
hospitals
• 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
injuries
• Ideally, CBCs should be
performed at least once a
day
• 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
Conclusion
• Despite limitations, the
informal health centers have
effectively applied empirical
medicine in the treatment of
patients
• 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
Acknowledgements:
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
References:
1. Goldberg, M. (2014, August 19). Map of the Day: Syria's Ignominious Milestone - UN Dispatch.
Retrieved September 20, 2014. http://www.undispatch.com/map-day-syrias-ignominious-milestone/
2. Brumfield, B. (2014, September 23). 200,000 flee in biggest displacement of Syrian conflict, monitor
says. Retrieved September 27, 2014. http://edition.cnn.com/2014/09/22/world/meast/syria-civil-war/
3. 2014 UNHCR country operations profile - Turkey. (2014, September 10). Retrieved September 26,
2014.http://www.unhcr.org/pages/49e48e0fa7f.html
4. Siddique, H. (2014, June 19). Syrian refugees in Turkey exceed 1 million mark. Retrieved September 4,
2014. http://syrianmonitor.blogspot.co.uk/2014/06/syrian-refugees-in-turkey-exceed-1.html#more
5. Mcclelland, M. (2014, February 15). How to Build a Perfect Refugee Camp. Retrieved October 1, 2014.
http://www.nytimes.com/2014/02/16/magazine/how-to-build-a-perfect-refugee-camp.html?_r=1
6. AL ARABIYA WITH AFP. (2012, September 30). Saudi group to set up Syrian refugee camp in Turkey
within month. Retrieved October 1, 2014. http://english.alarabiya.net/articles/2012/09/30/240977.html
7. Chudacoff, D. (2014, September 1). Syrians build health care network in Turkey. Retrieved September 4,
2014. http://www.aljazeera.com/news/middleeast/2014/08/syrians-build-health-care-network-turkey2014822114122103742.html).
8. Voice of America. (2012, April 8). Gunfire From Syria Wounds 5 in Turkey. Retrieved October 14,
2014. http://www.voanews.com/content/turkey-gunfire-from-syria-wounds-three146653835/180360.html
9. Leishmaniasis. (2013, January 10). Center for Disease Control and Prevention. Retrieved October 14,
2014. http://www.cdc.gov/parasites/leishmaniasis/diagnosis.html
10. Markle, W. (2004, March 15). Cutaneous Leishmaniasis: Recognition and Treatment. American
Academy of Family Physicians. Retrieved October 14, 2014.
http://www.aafp.org/afp/2004/0315/p1455.htm
Thank You!