Squirming in the doctor’s chair as he braced for a shot in the forearm, the wide-eyed boy was no different from scores of other refugee children who have shuffled into Dr Tayfur Savas’s clinic in southern Turkey over the past two years, seeking treatment for a skin disease called leishmaniasis.
But his mother’s words have stayed with Savas ever since.
“These scars are a shame,” Savas recalls her telling him. “People think he's infectious. Our neighbours don't want to breathe the same air…
“She said people were refusing to sit by her son on the bus,” he said, recalling the four black, crater-like lesions which ran along the boy's forearm.
Savas said it was the first time he had heard of Syrian refugees being stigmatized in Turkey for the illnesses they carry, and a cautionary tale about the urgency of tackling communicable diseases on both sides of the border.
“Health issues can become social issues,” Savas told IRIN. “We don't want to risk worsening relations between Turks and refugees; it is a tense situation already.”
One of the most widespread communicable diseases among Syrian refugees has been cutaneous (skin-related) leishmaniasis, a vector-borne parasite that is spread from human to human by sandflies, especially in unsanitary or crowded conditions. It features large, permanently-disfiguring sores.
This summer, as the World Health Organization (WHO) warned of the near collapse of the Syrian health system, it acknowledged that hepatitis, typhoid, cholera, and leishmaniasis have increasingly spread largely unchecked inside Syria and among refugee populations.
Unlike visceral leishmaniasis, cutaneous leishmaniasis typically is not life threatening, and has not raised the same alarm bells as many other diseases. But “it is extremely stigmatizing, and is especially catastrophic for young girls, who may become unmarriageable because of the disfiguring scars it can leave on the face and body,” said Peter Hotez, dean of the National School of Tropical Medicine at the Texas-based Baylor College of Medicine. “It also looks extremely infectious, and people who don't know about the disease are likely to fear infected people when they see the lesions.”
Known as “the Aleppo Evil”, the disease's medieval nickname belies the fact that - while it has been endemic in Syria and the Middle East for centuries - it has largely been constrained to regions surrounding the northern city, Syria’s second largest. “But this is also a disease that is linked closely to human migration,” says Hotez. “Refugees are sleeping outdoors where they have no protection from sandflies, populations are moving through Aleppo that have no previous exposure to the disease, and access to health care is nonexistent. It creates a perfect storm that allows `the Aleppo Evil’ to take hold.”
An August report by the Turkish Medical Association warned that border regions were caught unprepared for leishmaniasis this summer, suggesting the country “lacked an early warning system” and needed to implement more systematic insecticide spraying and other precautionary measures in the future.
The frontline against leishmaniasis
While Turkey's health response to leishmaniasis has involved the treatment of tens of thousands of patients in state-run camps and hospitals this year, much of the burden for treating the disease inside Turkey has fallen on poorly supplied clinics, staffed by Syrian doctors and nurses, in border towns.
“Access to free health care is a guarantee for the 200,000 people inside the camps,” said a spokesperson for Ankara's Disaster and Emergency
Management Directorate (AFAD).
But outside the camps, Syrians “have been struggling to get treatment”, said Saban Alagöz, general secretary of the Gaziantep and Kilis Medical Association. “The government and doctors’ associations have just begun to respond to this problem,” he said, detailing the opening of a special leishmaniasis clinic that was established in Gaziantep this year for non-camp refugees. He estimated that Turkish doctors in the southern towns of Gaziantep and Kilis have treated just under 10,000 cases of the disease this summer.
“Leishmaniasis has not crossed over in large numbers to the Turkish population, but the problem is many Syrians still don't have access to treatment,” he said.
Many Syrians cannot afford to pay for the injections which treat leishmaniasis, and seek out clinics run by a patchwork of Syrian aid groups and activists that treat refugees for free. Turkish hospitals as a rule do not charge for emergency care for registered refugees, but often charge for medicines and non-life threatening operations.
Speaking inside the hot, crowded halls of an apartment-turned clinic in the dusty border town of Kilis, Hasan al-Mallouhi of the Syrian Expatriate Medical Association (SEMA) said the number of leishmaniasis patients at his clinic ranges from “4-10 patients a day, though the number is sometimes as high as 30”.
For four months, the SEMA-run clinic was the sole medical provider to nearly 3,000 refugees who camped in makeshift tents pitched in a municipal park at the centre of the town. “These people can't even pay for real tents. So, of course, they can't go to the hospital for medicines,” said al-Mallouhi. The group said its stocks of Glucantime, the most common medicine used against leishmaniasis, had been kept afloat by donations from the international medical charity Médecins Sans Frontières.
Government authorities this month cleared out the makeshift camp and transferred its inhabitants to a new camp near the town. “But our clinic is still full every day,” al-Mallouhi said. “Now we're seeing people staying elsewhere in the town unable to afford any medical treatment, so they come to us for help.”
At a clinic run by the Union of Syrian Medical Relief Organizations (UOSSM) in the border town of Reyhanli, treating leishmaniasis has become even more difficult, as stocks have dried up and need has grown inside Syria.
Daher Zidan, the clinic's head pharmacist, said the group this year sent enough Glucantime to treat several thousand leishmaniasis patients to the group's field hospital in Bab al-Hawa, just across the border. But UOSSM says it does not have enough medicine to treat the roughly 10 patients arriving daily in Reyhanli. “We know the problem is more urgent inside Syria, so we send medicine there when we have it,” Zidan said.
Because Glucantime contains toxins, it cannot be purchased over the counter in Turkey, and Syrian doctors are not allowed to acquire the medicine by Turkish law. At a clinic perched above a car garage elsewhere in Reyhanli, Dr Fatma Salah says those restrictions led her to the unusual step of sourcing Glucantime from pharmacies inside Syria.
“Now that supply has dried up,” she said, noting that some sympathetic Turkish doctors have supplied small batches of the medicine on the side to help make up the shortage. “Still, for two months we haven't had the ability to treat the five or so people who come in for leishmaniasis every day. We're now focused on just getting painkillers, sanitary supplies, very basic things,” she said.
Refugee influx to strain medical infrastructure
The burden on already overwhelmed Syrian clinics is sure to increase as more refugees flood into Turkey. The UN estimates that as many as one million refugees may be living in Turkey by the end of the year, straining health systems, housing prices and social tensions. AFAD currently houses just over 200,000 in camps, and a spokesperson said it will have trouble assisting the additional 300,000 refugees who are already in Turkey but do not live in camps.
“We're working on getting more free treatment to people outside the camps for measles and leishmaniasis,” said Alagöz, who nonetheless acknowledged that capacity for free treatment was highly unlikely to meet demand. “Right now, we're mostly working on understanding just how big this problem is.” The government has not yet taken preventative steps, such as indoor spraying or the distribution of insecticide-treated bednets, he added.
A study by the Turkish charity Support to Life (STL) warned in August that as savings run dry and families are no longer able to independently pay for their own medical expenses, the material and medical needs of urban refugees already living in Turkey is also likely to grow exponentially.
As demand among Syrians for free health care rises, many Turks say they are unsure if hospitals should change their policy of charging for care.
“We've given enough to refugees here,” said Selma Doganer, a high school teacher in Antakya. Doganer suggested international aid organizations, not Ankara, should pay future bills. “Syrians may think our prime minister will pay for everything. But we are paying much of the bill.”
If the capacity of clinics to treat the communicable diseases of Syrians does not grow with demand, the spread of the disease might add another dimension to already strained tensions. Most of those tensions have been attributed to ethnic fault lines between Sunni refugees and large populations of Alawite and Alevi Turks who live along the border. But even without sectarian differences, foreigners are often the first to take the blame when something goes wrong.
Savas, the doctor, points to the Reyhanli bombing, when over 50 people in the border town died this May: “Reyhanli is a Sunni town, but suddenly they began to blame the refugees for everything that happened. Anger can suddenly explode in unexpected ways.”
He suggests that leishmaniasis, with its visible, infectious-looking sores, will not help the problem. “It's just another reason we need to get this under control,” he said.
Hotez, the US academic, agrees: “It's one of the most stigmatizing diseases you can have.”
Click here for more IRIN reporting on how a lack of access to water, sanitation and proper hygiene is threatening Syrians and others across the region.