In 2013, HelpAge International and Handicap International undertook a study in Jordan and Lebanon designed to provide robust evidence and data of the numbers and needs of older, disabled and injured refugees and refugees affected by chronic diseases, and to offer the opportunity to compare their needs with those of the wider refugee population.
The World Report on Disability estimates that 15.3% of the world’s population has a moderate or severe disability and that this proportion is likely to increase to 18-20% in conflict-affected populations. In comparison, of the surveyed refugees 22% are affected by an impairment and 6% by a severe impairment, and one in five of all those with an impairment have more than one impairment. Older people are disproportionately represented, with a staggering 70% with at least one impairment. Older people are also almost twice as likely as children to present with intellectual impairments.
The challenges of collecting accurate data on impairment and disability in humanitarian emergencies are starkly illustrated by the unavailability of data in Lebanon. At the time of the survey, just 1.4% of refugees registered by UNHCR in Lebanon were recorded as having a disability, with sensory impairments significantly less likely to be identified than physical impairments.
For those with impairments, adapting to a new environment in the absence of their usual family and community support structures and securing proper access to both basic and specialised services become major challenges. Survey teams reported that those with intellectual impairments and their families faced the most extreme challenges. Without a clear picture of the numbers of people affected by impairment it is of course difficult for organisations to respond effectively.
The study also analysed difficulties faced in ‘activities of daily living’ (ADL). ADL is a term used by health professionals to refer to daily self-care activities such as feeding, bathing and dressing oneself. The results show that 45% of refugees with an impairment, injury or chronic disease face difficulties in ADL, and 60% of older people face such challenges. In comparison, just 6% of the general refugee population surveyed reported difficulties. Experience shows that these refugees are less likely to access static services and consequently, mobile outreach programmes and support to family and community coping strategies form a critical part of an effective response to their needs
The Syrian conflict has been noted for its levels of conflict-related injuries. The survey found that one in 15 Syrian refugees in Jordan has been injured as a result of the war, and one in 30 refugees in Lebanon. Age and gender analysis shows that working-age men are bearing the brunt of the exposure to risk of injury, in part due to their role in the fighting, but also due to their responsibility for fetching food and water, and – for some young men – returning to Syria to check on property and assets. Many of those affected by injury are not receiving adequate care.
Beyond immediate health care, such injuries require long-term physical rehabilitation, psychological support and, for those with permanent impairments, life-long care. Of particular concern is the limited availability of physical rehabilitation support to avoid the worsening of existing injury-related health conditions and to mitigate the development of potentially permanent disability. It is critical therefore that national and international health providers work together to address the current needs of this population but also to plan for the longer-term financial and human-resource requirements needed to prepare health systems, families and communities to ensure adequate support. The care needs of those with injury pose a major challenge for humanitarian partners now, and for the long-term needs of health systems in Jordan, Lebanon and ultimately Syria. The Assad regime has made it clear that injured refugees returning from surrounding countries will be counted as part of the anti-government resistance, and hence those living with injury in neighbouring countries face an uncertain future.
Traditional health responses in humanitarian crises largely fail to address the needs of those with non-communicable, manageable chronic health conditions. Limited access to care and interruptions in treatment can result in severe complications and increasing levels of both morbidity and mortality.
Yet for many refugees the cost of accessing health services is a major barrier. In Lebanon, health service delivery is privatised and fee-paying. Although refugees can usually access health facilities, they are expected to cover the costs of treatment which may be significantly beyond their means. Some refugees in Lebanon stated that they were unable to afford the cost of transport to health centres, let alone the required contribution to their hospital bills.
In Lebanon and Jordan there is almost no health education for patients, limited capacity among health staff to properly assess patients with chronic diseases, limited services available to support early screening for chronic diseases, and no proper monitoring of conditions, laboratory tests or follow up. Finally, it is important to recognise the link between untreated chronic diseases and disability; we know that a large percentage of those with non-communicable diseases will develop impairments as the diseases progress.
As with response to the needs of those with injuries, the disease profile of the Syrian refugee population has severe consequences for health system support. HelpAge International and Handicap International are working with local and international partners including Médecins du Monde and Amel Association to improve identification and referral of those with non-communicable disease, as well as to support the national health systems to improve levels of care.
Half of the surveyed refugees affected by impairment, injury and non-communicable disease reported at least one frequent sign of psychological distress: changes in emotional state, behaviour, relationships or cognition. Again, the older population is disproportionately affected with more than 65% reporting such signs, a level three times higher than the general refugee population. Whereas younger generations may be occupied with work or the search for work, refugees with impairment and older people are often excluded from work and have more time to dwell on their plight.
Marcus Skinner email@example.com is Humanitarian Policy Manager at HelpAge International. www.helpage.org
 Based on data collected from a sample of over 3,000 refugees. See report (2014) The hidden victims of the Syrian Crisis: disabled, injured and older refugees. www.helpage.org/download/537207495fe87
See also Calvi-Parisetti P ‘Older people and displacement’, FMR 43
 World Health Organization (2011) http://whqlibdoc.who.int/hq/2011/WHO_NMH_VIP_11.01_eng.pdf?ua=1
 See also FMR 35 on Disability and displacement www.fmreview.org/disability