Dr Shafi Bhuiyan with colleagues. He and his colleagues argue that COVID-19 has exposed gaps in the Canadian healthcare system.

By Shafi Bhuiyan and team of ITMDs
Toronto, Canada, Sep 3 2021 (IPS)

Access to quality healthcare is a basic human right, but for many, especially those in vulnerable communities, the right is not fully realized.

The Covid-19 pandemic exposed this systemic inequality and gaps in the Canadian healthcare system.

While surgical backlogs and delayed appointments may be prominent features of the healthcare crisis, the indirect impacts of Covid-19 must be considered. These include a halt in preventive programs, such as cancer screenings, declining health among Indigenous and aging people and for those with chronic illnesses, as well as worsening mental health among health care workers, to name just a few.

Canada already possesses a significant number of educated, qualified, and experienced Internationally Trained Medical Doctors (ITMDs) who can help fill gaps in the healthcare system. For example, Immigration Refugee Citizenship has reported that over 5,000 physicians came to Canada between 2015 and 2021, and this number does not include ITMDs who immigrated via a different method.

Many ITMDs possess much-needed cultural diversity, linguistic skills, and cross-cultural patient care talents. These can be utilized in the long-term care sector, for chronic disease prevention, and with Indigenous peoples and ethnic-racial groups, especially those residing in remote and rural areas across the country. Although 20% of the Canadian population lives in rural areas, only 8 percent of physicians work cfin these areas. Many ITMDs are well suited to provide quality healthcare for some of these communities.

Canada’s annual immigration intake plan is to welcome more than 400 000 immigrants per year in 2021-23, in keeping with the national plan for population growth. Based on data trends from Immigration, Refugee, Citizenship Canada (IRCC), this will likely include at least 900-1000 physicians each year. The need for diversity among physicians will continue to rise to provide culturally sensitive and quality care for all Canadians. ITMDs can provide culturally sensitive care and in-demand language skills to Canada’s increasingly diverse population.

Although the Truth and Reconciliation Commission of Canada (TRCC) Calls to Action were created in 2014, most healthcare calls have yet to be addressed. ITMDs can help address the long-standing shortcomings for this communities’ access to equitable healthcare and could contribute to rebuilding trust in the healthcare system.

The underutilization of immigrants’ education and qualifications has been reported to cost Canada $3 billion per year. Supporting the incorporation of internationally educated health professionals into the healthcare system would benefit Canada’s healthcare system and positively impact the economy.

Integration of internationally educated health professionals / ITMDs into the healthcare system requires a national strategy with a multi-stakeholder approach that focuses on scalable solutions. This strategy needs the engagement of governmental policymakers, regulatory bodies, employers, educational and training entities, service delivery agencies, and ITMDs themselves.

Once ITMDs have proven their expertise, they still require a bridging program to integrate their skills and expertise into the healthcare labor force. A recent survey of selected ITMDs who had participated in a career bridging program showed one-third had passed their licensing exams. These exams assess candidate’s clinical knowledge and skills to ensure they are comparable to Canadian medical graduates. Despite this achievement, another hurdle remains, to secure licensure. This is the residency program, which ranges from 3 to 5 years depending on the field of specialty.

The residency application process is complicated, but to describe it simply, medical students apply – via the Canadian Resident Matching Service, or CaRMS – for residency positions at universities across the country in one or more specialties of their choice. Not only are the total number of residency slots limited, but there are caps on the number of slots reserved for internationally trained versus Canadian medical graduates. The available slots for ITMDs are considerably smaller.

With the 2021 residency match results, data clearly illustrates the inequity i.e. a total of 2,852 Canadian medical graduates were matched. On the other hand, 410 internationally trained medical doctors were matched to residency positions. Over 90% of ITMD’s who have passed their qualifying exams cannot secure a residency due to their limited number and inequitable distribution of the residency slots.

An immediate solution is developing and delivering bridging programs, including in-class training and practicum placements, to support ITMDs’ employment in work commensurate with their skills, training, and experience, such as clinical assistant, research associate, and healthcare manager. Incorporating ITMDs into the healthcare system as licensed physicians can be further achieved via Practice Ready Assessments, increased residency opportunities, and increased post-graduate public health education and training.

Developing a clear roadmap will facilitate ITMDs’ integration into the Canadian healthcare system and foster diversity and equity in health research, management, and patient care.
There is a worldwide health crisis. If we cannot save a life despite having a huge pool of foreign-trained physicians ready to serve any time, we are neglecting untapped human resources to the detriment of our health.

The inclusion of ITMDs in the health system will benefit the healthcare system, patients, and the community and have a positive impact on society by reducing wait times and ensuring a better quality of life.

ITMDs are here, ready, willing, and qualified to serve Canadians as we work together to strengthen our healthcare system. There is no better time than NOW! Let’s work together to make healthcare more available and accessible to all Canadians so that no one is left behind.

• The authors are from Asia, the Middle East, Africa, and South American countries.  
• The co-authors are Drs Bhuiyan S, Orin M, Krivova A, Fathima S, Walters J, Uzonwanne G, McGuire M, Mohammad A, Alamgir AKM, Radwan E, Tasnim N, Tazrin T, Parungao J, Saad W, Shalaby Y.

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Zimbabwe struggles to contain maternity deaths. Here in this southern African nation, the number of women dying in childbirth continues to rise. Credit: Jeffrey Moyo/ IPS

By Jeffrey Moyo
HARARE, Jan 30 2015 (IPS)

For 47-year-old Albert Mangwendere from Mutoko, a district 143 kilometres east of Harare, the Zimbabwean capital, transporting his three pregnant wives using a wheelbarrow to a local clinic has become routine, with his wives delivering babies one after the other.

But these routines have not always been a source of joy for Mangwendere.

“Over the past twenty years, I have been ferrying my pregnant wives to a local clinic using a wheelbarrow because I have no (full size) scotch cart and we have lost 12 babies in total while traveling to the clinic,” Mangwendere told IPS.

Mangwendere’s case typifies the deepening maternity crisis in this Southern African nation.An estimated 3,000 women die every year in Zimbabwe during childbirth and at least 1.23 percent of gross domestic product (GDP) is lost annually due to maternal complications – United Nations issue paper on 'Maternal Mortality in Zimbabwe', 2013

An estimated 3,000 women die every year in Zimbabwe during childbirth and at least 1.23 percent of gross domestic product (GDP) is lost annually due to maternal complications, according to Maternal Mortality in Zimbabwe, a United Nations issue paper released in 2013.

In fact, the United Nations found that maternal mortality worsened by 28 percent between 1990 and 2010. The major causes were bacterial infection, uterine rupture (scar from a previous caesarean section tearing during an attempt at birth), renal and cardiac failure, as well as hyperemesis gravidarum (condition characterised by severe nausea, vomiting and weight loss during pregnancy).

This year, the government has allocated 301 million dollars to the health sector for a country of 13.5 million, according to the local NewsDay publication, which concluded: “This is to say that the government intends to spend on average just over 22 dollars on an individual this year. Compare this with 650 dollars for South Africa, 90 dollars for Botswana, 390 dollars for Botswana and 200 dollars for Angola.”

On top of a barely adequate public transportation system, user fees for delivering pregnant women that are charged in healthcare centres are also at fault, say civil society activists.

“In 2012, the government crafted and adopted a policy that saw user fees for maternity services being scrapped,” Catherine Mukwapati, director of the Youth Dialogue Action Network, a grassroots organisation, told IPS.

“But despite this policy, some facilities still charge indirect service fees, which is scaring away many pregnant women from hospitals and clinics, leaving them in the hands of less skilled midwives.”

Zimbabwe’s local authority clinics say they have resisted scrapping maternity fees despite the official directive, claiming that they are not reimbursed as promised by the government.

28-year-old Chipo Shumba pictured here holds her only child after she lost six others while giving birth over the past few years, a crisis health experts in Zimbabwe say is on the rise. Credit: Jeffrey Moyo/IPS

“Council clinics have no choice but to charge the council-subsidised 25 dollars for maternity since they haven’t received money from government,” Harare city director of health services, Stanley Mungofa, told IPS.

The actual cost of providing maternity services in council clinics has been pegged at 152 dollars, Mungofa said. At public hospitals like Parirenyatwa in Harare, the cost of a normal delivery is 150 dollars while a caesarean section costs as much as 450 dollars.

In a bid to lower the high maternity fees of public hospitals and council clinics, a group of donors pledged 435 million dollars for the nation’s health system for the period 2011-2015. The fund – the so-called Health Transition Fund – was led by the health ministry and managed by the U.N. Children’s Fund (UNICEF).

Importantly, the Health Transition Fund is helping to retain skilled workers by raising low wages. Underpaid doctors make up a large part of the country’s “brain drain” and there are now just 1.6 doctors for every 10,000 people.

Maternal fees may not apply in Zimbabwe’s countryside, where many like Mangwendere and his wives live, but other obstacles present an equally insurmountable barrier to obtaining care. Clinics and referral hospitals are often far away from people needing help, a major cause of maternity deaths there.

Finally, the tentacles of systemic corruption have reached into the health care systems. According to Transparency International, one local hospital was found to be charging mothers-to-be five dollars every time they screamed while giving birth.

A staggering 62 percent of Zimbabweans reported having paid a bribe in the previous year, the group stated in its 2013 report on global corruption.

Zimbabwe’s health sector was one of the best in sub-Saharan Africa in the 1980s, but it nearly collapsed when an economic crisis caused hyper-inflation of more than 230 million percent in 2008. Over the following years, chronic under-investment made a bad situation worse.

The increase in maternal mortality is being witnessed despite the U.N. Millennium Development Goal (MDG) for maternal health, under which countries should reduce the maternal mortality ratio by three-quarters between 1990 and 2015.

A 2012 status report on the MDGs asserted that Zimbabwe was unlikely to meet its mandate of reducing the maternal mortality ratio to 174 per 100,000 live births.

In research conducted in 2013 to address causes of maternal death, Zimbabwe’s Ministry of Health and Child Care blamed excessive bleeding after childbirth and unsafe abortion as the major causes of death, although no information was provided to back the claim.

“Statistics on maternal deaths often leave out sad realities of these similar deaths in unreachable remote areas where pregnant women and infants die daily without these cases being recorded anywhere,” said Helen Watungwa, a midwife at a council clinic in Gweru, the capital of the Midlands province, 222 kilometres outside the capital.

“But in any case, with the limited resources we have as nurses, we are doing all we can to save lives both of delivering mothers and infants,” Watungwa told IPS.

“It is truly a miracle that we continue to survive a series of pregnancies while battling to give birth often on the way to the clinic, bleeding heavily without any skilled persons to attend to us, with only our husband tottering with each one of us to the village healthcare centre using a wheelbarrow,” 28-year-old Mavis Handa, one of Mangwendere’s wives, told IPS.

Edited by Lisa Vives/Phil Harris    

Zimbabwe has criminalised gay relationships, striking fear into the hearts of many gays like these two walking side by side in the country’s capital, because they are being left out in strategies to combat HIV/AIDS. Credit: Jeffrey Moyo

By Jeffrey Moyo
HARARE, Dec 18 2014 (IPS)

Despite a mandate to eradicate HIV/AIDS under the U.N. Millennium Development Goals (MDGs), Zimbabwe has done little or nothing to reduce the rate of infection among vulnerable gays and lesbians, say activists here.

The MDGs are eight goals agreed to by all U.N. member states and all leading international development institutions to be achieved by the target date of 2015. These goals range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education.

Gays and lesbians activists here say more needs to be done because population groups such as men who have sex with men and transgender people remain at the periphery of the country’s intervention strategies.

“In as far as combatting HIV/AIDS is concerned, there are no national programmes targeted for minority groups or interventions that can easily be accessible by the LGBTI (lesbian, gay, bisexual, transgender and intersex) community on prevention and care within the public healthcare system,”Samuel Matsikure, Programme Manager of Gays and Lesbians of Zimbabwe (GALZ), told IPS.“Whether the Zimbabwean government likes it or not, it has to face the reality that gays and lesbians exist and should therefore cater for their HIV/AIDS needs in emerging with strategies to combat HIV/AIDS just like it does for all other citizens, for how do we end the scourge if we ignore another group of people who will certainly spread the disease” – civil society activist Trust Mhindo

“There are knowledge gaps of healthcare workers on the needs and best methods on prevention, treatment and care for the HIV-positive LGBTI individuals,” adds Matsikure.

GALZ is a voluntary association founded in 1990 to serve the needs and interests of LGBTI persons in Zimbabwe, pushing for social tolerance of sexual minorities.

But 24 years after GALZ was founded, Zimbabwe’s Sexual Offences Act still criminalises homosexuality. According to Section 4.78 of Zimbabwe’s new constitution, persons of the same sex are prohibited from consensual sex or marrying each other.

Civil society activists say the Zimbabwean government has to accept the reality that gays and lesbians exist.

“Whether the Zimbabwean government likes it or not, it has to face the reality that gays and lesbians exist and should therefore cater for their HIV/AIDS needs in emerging with strategies to combat HIV/AIDS just like it does for all other citizens, for how do we end the scourge if we ignore another group of people who will certainly spread the disease,” Trust Mhindo, a civil society activist, told IPS.

HIV/AIDS activists here rather want the legislation on gays and lesbians changed. “We need to fight for a change of laws so that gays and lesbians are given recognition, without which fighting HIV/AIDS among LGBTI will remain futile,” Benjamin Mazhindu, Chairperson of the Zimbabwe National Network for People Living with HIV (ZNPP+), told IPS.

Globally halting the spread of HIV/AIDS by 2015 is part of the U.N. MDGs, but with members of the LGBTI sidelined in fighting the disease in Zimbabwe, the battle may be far from over.

“Most healthcare facilities in Zimbabwe are not friendly to LGBTI persons, hindering disclosures of ailments like anal STIs [sexually transmitted infections]while sexual and reproductive health information for the LGBTI community is non-existent, creating a vacuum with healthcare facilities for minorities,” GALZ director Chester Samba told IPS.

“If you today walk into any government healthcare centre, be sure not to find any information or literature on gays and lesbians in as far as HIV/AIDS is concerned,” he added.

And for many Zimbabwean gays like 23-year-old Hillary Tembo, living with HIV/AIDS amounts to a death sentence because he fears accessing medical help from government healthcare centres.

“I’m HIV-positive and ridden with STI-related sores in my anus and truly I’m afraid to show this to health workers, fearing victimisation owing to my sexuality,” Tembo told IPS.

But Zimbabwean Health Minister David Parirenyatwa told IPS: “When a person visits a healthcare centre, nothing is asked about one’s sexual orientation.”

According to Samba, although there are no reported cases of HIV-positive LGBTI people being denied antiretroviral treatment on account of their sexual orientation, “there is need for a national HIV/AIDS response to address the barriers preventing members of the LGBTI community from accessing services that address their HIV/AIDS health care needs, including access to information that is relevant to them.”

However, faced with a constitution forbidding gay relations, government here finds it an uphill task to consider a group of people that it constitutionally does not recognise in combatting HIV/AIDS.

“We can’t arm-twist our supreme law which does not condone homosexuality to fit in to the needs of a small group of people who are disobeying the law,” a top government official, speaking on the condition of anonymity, told IPS.

And for gays and lesbians in this Southern African nation, whether the U.N. MDGs matter or not, to them suffering may continue as long as they remain a forgotten lot in fighting HIV/AIDS.

“As homosexuality is illegal in Zimbabwe, it is difficult for prevention programmes to reach men who have sex with men (MSM) and all MSMs living with HIV/AIDS are often unable to access HIV treatment, care and support,” Samba told IPS.

Asked how many HIV-positive LGBTI persons there were in Zimbabwe, the GALZ director said that he could not give figures because “there are no mechanisms at national level to capture data based on one’s sexual orientation.”

However, in its yet-to-be published 2014 research on the impact of HIV/AIDS on LGBTI persons, GALZ says that of the 393 MSMs tested for HIV/AIDS this year, 23.5 percent were found positive while of the 179 women having sex with women (WSWs) tested for HIV/AIDS, 32.6 percent were found positive in Zimbabwe.

According to the National Aids Council in Zimbabwe (NAC),1.24 million people in the country are living with HIV/AIDS, which is approximately 15 percent of the country’s over 13 million people. LGBTI persons are part of this percentage.

Statistics from the Zimbabwe National Statistics Agency this year show that LGBTI persons in Zimbabwe contribute about four percent of the people living with HIV/AIDS.

With a membership of 6,000 gays and lesbians, GALZ says 15 percent of these are living with HIV/AIDS, with five of its members having succumbed to HIV/AIDS since January. The organisation claims that it normally loses 5 to 10 people each year. “Statistics we have so far are of GALZ-affiliated members, not representative of the national statistics,” said the GALZ director.

For many HIV-positive Zimbabwean gays like Tembo, as the world rushes towards the deadline for attainment of the U.N. MDGs, without clearly defined strategies to fight HIV/AIDS within the LGBTI community, the war against the scourge may be far from over.

“How can we triumph over HIV/AIDS when among the LGBTI community we are without strategies from government to combat the disease?” Tembo asked rhetorically.

(Edited by Lisa Vives/Phil Harris)

A young mother approaches a healthcare facility inside the Domiz refugee camp in Iraqi Kurdistan, mid-September 2014. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
DOHUK, Iraq, Sep 19 2014 (IPS)

At the largest refugee camp in Iraqi Kurdistan, young Syrian mothers and pregnant women are considered relatively lucky.

The number of registered Syrian refugees surpassed 3 million in late August, with the highest concentrations in Lebanon (over 1.1 million), Turkey (over 800,000), and Jordan (over 600,000). In all of the above, serious concerns have been expressed about the availability of healthcare services for expectant mothers.

In Lebanon, for example – which hosts the largest number of Syrian refugees, 76 percent of whom are women and children – the U.N. refugee agency (UNHCR) last year had to reduce its coverage of delivery costs for mothers to 75 percent instead of 100 percent, due to funding shortfalls.Though some in the Domiz camp live in tents on the edges of the camp with little access to basic sanitation facilities, others reside in small container-like facilities interspersed with wedding apparel shops and small groceries, and enjoy the right to public healthcare

The Domiz camp in the northern Dohuk province houses over 100,000 mostly Syrian Kurds, but is in a geographical area with a 189 percent coverage rate of humanitarian aid funding requests in 2014. The Syria Humanitarian Response Plan (SHARP) has received only 33 percent of the same.

Though some in the Domiz camp live in tents on the edges of the camp with little access to basic sanitation facilities, others reside in small container-like facilities interspersed with wedding apparel shops and small groceries, and enjoy the right to public healthcare.

This does not necessarily equate with quality healthcare, however. Halat Yousef, a young mother that IPS spoke to in Domiz, said that she had been told after a previous birth in Syria that she would need a caesarean section for any subsequent births.

On her arrival at the Dohuk public hospital, she was instead refused a bed, told to come back in a week and that she would have to give birth normally. They also told her she had hepatitis.

Fortunately, she said, her husband realised the seriousness of the situation and took her to the capital, where they immediately performed a C-section and found that she was instead negative for hepatitis. IPS met her as she was leaving healthcare facilities set up in the camp, holding her healthy 10-day-old infant.

Until recently, many mothers would also simply give birth in their tents. On August 4, Médicins San Frontiéres (MSF) opened a maternity unit in the camp that offers ante-natal check-ups, birthing services headed by MSF-trained midwives and post-natal vaccinations provided by staff who are also refugees.

Information on breastfeeding and family planning advice is also provided, according to MSF’s medical team leader in the camp, Dr Adrian Guadarrama.

MSF estimates that 2,100 infants are born in the camp every year, and others to refugees living outside of it.

The United Nations Population Fund (UNFPA) has long been providing safe delivery kits to healthcare providers. It also works to prevent unwanted pregnancies and provides contraceptives to those requesting them, thereby ensuring that pregnancies are planned, wanted and safer.

The clean delivery kits contain a bar of soap, a clear plastic sheet for the woman to lie on, a razor blade for cutting the umbilical cord, a sterilised umbilical cord tie, a cloth (to keep the mother and baby warm) and latex gloves.

UNFPA humanitarian coordinator Wael Hatahet told IPS that so far the programmes in Iraqi Kurdistan for Syrian refugees had received enough funding to cover the necessary services, and this was why ‘’the situation is no longer an emergency one for Syrians here’’.

Hatahet said that he gives a good deal of credit to the Kurdistan Regional Government (KRG), which – despite having seen a major cut in public funds from the central government as part of a prolonged tug-of-war between the two – continues to support Syrian refugees coming primarily from the fellow Kurdish regions across the border.

Many residents expressed dissatisfaction to IPS about what they considered ‘’privileged treatment’’ given to Syrian refugees while the massive influx of internally displaced persons (IDPs) that have arrived in the region over the past few months – after the Islamic State (IS) extremist group took over vast swathes of Iraqi territory in June – are seen to be suffering a great deal more.

Even Hatahet, who is of Syrian origins himself, noted that he had seen ‘’Iraqi IDPs wearing the same set of clothes for the past 15 days’’.

‘’We obviously try to support with garments and dignity kits,’’ he said, ‘’but it’s really, really sad.’’

However, he also noted that ‘’almost all the IDP operations are supported by the Saudi Fund [for Development]’’ totalling some 500 million dollars and announced in summer, ‘’which was strictly for IDPs and not refugees.’’

Hatahet expressed concerns that a broader shift in focus to Iraqi IDPs might result in a loss of the gains made in this geographical area of the Syrian refugee crisis, urging the international community to remember that ‘’we have 100,000 refugees scattered within the host community’’ and not just in the camps.

The Turkish office of UNFPA told IPS that, in its area of operations, ‘’it is estimated that about 1.3 million Syrian refugees have entered Turkey, of which only one-fifth of them are staying in camps due to limited space. 75 percent of the refugees are women and children under 18 years old.’’

It pointed out that ‘’women and girls of reproductive age under conditions of war and displacement are especially vulnerable to gender-based violence, including sexual violence, early and forced marriage, high-risk pregnancies, unsafe abortions, risky deliveries, lack of family planning services and commodities and sexually transmitted diseases.’’

(Edited by Phil Harris)

At a time when HIV rates have stabilised or declined elsewhere, the epidemic is still advancing in the Arab world, exacerbated by factors such as political unrest, conflict, poverty and lack of awareness due to social taboos.

According to UNAIDS (the Joint United Nations Programme on HIV/AIDS), an estimated 270,000 people were living with human immunodeficiency virus (HIV) in the countries of the Middle East and North Africa (MENA) region in 2012.

“It is true that the Arab region has a low prevalence of infection, however it has the fastest growing epidemic in the world,“ warns Dr Khadija Moalla, an independent consultant on human rights/gender/civil society/HIV-AIDS.With the exception of Somalia and Djibouti, the [HIV] epidemic is generally concentrated in vulnerable populations at higher risk, such as men-who-have-sex-with-men, female and male sex workers, and injecting drugs users

The United Nations estimates that there were 31,000 new cases and 16,500 new deaths in 2012 alone. “Infections grew by 74 percent between 2001 and 2012 while AIDS-related deaths almost tripled,” says Dr Matta Matta, an infection specialist based at the Bellevue Hospital in Lebanon.

However, both Moalla and Matta explain that figures can be often misleading in the region, due to under-reporting and the absence of consistent and accurate surveys.

With the exception of Somalia and Djibouti, the epidemic is generally concentrated in vulnerable populations at higher risk, such as men-who-have-sex-with-men, female and male sex workers, and injecting drugs users.

In Libya, for example, 90 percent of those in the latter category also live with HIV, notes Matta. Furthermore, adds Moalla, most Arab countries do not have programmes allowing for exchange of syringes.

The legal framework criminalising such activities in most Arab countries means that it is difficult to reach out to specific groups.  With the exception of Tunisia, which recognises legalised sex work, female sex workers who work clandestinely in other countries are not safeguarded by law and thus cannot force their clients to use protection, which allows for the spread of disease.

Lack of awareness, the absence of voluntary testing and of sexual education, social taboos, as well as poverty, are among the factors driving HIV in the region. “Arab governments and societies deny the epidemic and the absence of voluntary testing means that for every infected person we have ten others that we do not know about,” stresses Moalla.

People living with HIV or those at risk face discrimination and stigma.  “More than half of the people living with HIV in Egypt have been denied treatment in healthcare facilities,” explains Matta.

This bleak scenario is compounded by the security challenges prevailing in the region which not only make it difficult to deliver prevention and other programmes, but also restrict access to services by those on treatment and cause displacement and loss of follow-up according to the UNAIDS report.

The war in Iraq that began in 2003, for example, led to the destruction of most of the country’s programmes and facilities under the National AIDS Programme and, according to Moalla, the national aids centre in Libya was recently burnt down.

In addition, in some countries, conflict has significantly increased the vulnerability of women. By 2012, for example, only eight percent of the estimated number of pregnant women living with HIV in the MENA region received appropriate treatment to prevent mother-to-child transmission according to the UNAIDS report.

Meanwhile, only a few governments have worked on effective programmes to fight the epidemic, although there are signs of the emergence of NGOs tackling the problem with people living with HIV and providing them with support.

“North African countries and Lebanon have generally done better than others, while Gulf countries are doing the least,” says Moalla, adding that less than one in five people living with HIV are receiving the medicines they need in the Arab region.

While some efforts have been made with the UNDP HIV Regional Programme pioneering legal reform in several countries, as well as drafting an Arab convention on protection of the rights of people living with HIV in partnership with the League of Arab States, these are not enough.

“The Arab world attitude taking the high moral ground on the issue of HIV is no barrier for the epidemic,” says Matta. “The region’s governments need to address a growing problem that is only worsened by the general upheaval.”

(Edited by Phil Harris)

Syrian mother and child near Ma'arat Al-Numan, rebel-held Syria, in autumn 2013. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
BEIRUT, Jul 19 2014 (IPS)

Gaunt, haggard Syrian children begging and selling gum have become a fixture in streets of the Lebanese capital; having fled the ongoing conflict, they continue to be stalked by its effects.

Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

By the end of January, almost 40,000 Syrian children had been born as refugees, while the total number of minors who had fled abroad quadrupled to over 1.2 million between March 2013 and March 2014.Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

Lack of proper healthcare, food and clean water has resulted in countless loss of life during the Syrian conflict, now well into its fourth year. These deaths are left out of the daily tallies of ‘war casualties’, even as stunted bodies and emaciated faces peer out of photos from areas under siege.

The case of the Yarmouk Palestinian camp on the outskirts of Damascus momentarily grabbed the international community’s attention earlier this year, when Amnesty International released a report detailing the deaths of nearly 200 people under a government siege. Many other areas have experienced and continue to suffer the same fate, out of the public spotlight.

A Palestinian-Syrian originally from Yarmouk who has escaped abroad told IPS that some of her family are still in Hajar Al-Aswad, an area near Damascus with a population of roughly 600,000 prior to the conflict. She said that those trapped in the area were suffering ‘’as badly if not worse than in Yarmouk’’ and had been subjected to equally brutal starvation tactics. The area has, however, failed to garner similar attention.

The city of Homs, one of the first to rise up against President Bashar Al-Assad’s regime, was also kept under regime siege for three years until May of this year, when Syrian troops and foreign Hezbollah fighters took control.

With the Syria conflict well into its fourth year, the U.N. Security Council decided for the first time on July 14 to authorize cross-border aid without the Assad government’s approval via four border crossings in neighbouring states. The resolution established a monitoring mechanism for a 180-day period for loading aid convoys in Turkey, Iraq and Jordan.

The first supplies will include water sanitation tablets and hygiene kits, essential to preventing the water-borne diseases responsible for diarrhoea – which, in turn, produces severe states of malnutrition.

Miram Azar, from UNICEF’s Beirut office, told IPS that  ‘’prior to the Syria crisis, malnutrition was not common in Lebanon or Syria, so UNICEF and other actors have had to educate public health providers on the detection, monitoring and treatment’’ even before beginning to deal with the issue itself.

However, it was already on the rise: ‘’malnutrition was a challenge to Syria even before the conflict’’, said a UNICEF report released this year. ‘’The number of stunted children – those too short for their age and whose brain may not properly develop – rose from 23 to 29 per cent between 2009 and 2011.’’

Malnutrition experienced in the first 1,000 days of a child’s life (from pregnancy to two years old) results in lifelong consequences, including greater susceptibility to illness, obesity, reduced cognitive abilities and lower development potential of the nation they live in.

Azar noted that ‘’malnutrition is a concern due to the deteriorating food security faced by refugees before they left Syria’’ as well as ‘’the increase in food prices during winter.’’

The Syrian economy has been crippled by the conflict and crop production has fallen drastically. Violence has destroyed farms, razed fields and displaced farmers.

The price of basic foodstuffs has become prohibitive in many areas. On a visit to rebel-held areas in the northern Idlib province autumn of 2013, residents told IPS that the cost of staples such as rice and bread had risen by more than ten times their cost prior to the conflict, and in other areas inflation was worse.

Jihad Yazigi , an expert on the Syrian economy, argued in a European Council on Foreign Affairs (ECFR) policy brief published earlier this year that the war economy, which ‘’both feeds directly off the violence and incentivises continued fighting’’, was becoming ever more entrenched.

Meanwhile, political prisoners who have been released as a result of amnesties tell stories of severe water and food deprivation within jails. Many were detained on the basis of peaceful activities, including exercising their right to freedom of expression and providing humanitarian aid, on the basis of a counterterrorism law adopted by the government in July 2012.

There are no accurate figures available for Syria’s prison population. However, the monitoring group, Violations Documentation Centre, reports that 40,853 people detained since the start of the uprising in March 2011 remain in jail.

Maher Esber, a former political prisoner who was in one of Syria’s most notorious jails between 2006 and 2011 and is now an activist living in the Lebanese capital, told IPS that it was normal for taps to be turned on for only 10 minutes per day for drinking and hygiene purposes in the detention facilities.

Much of the country’s water supply has also been damaged or destroyed over the past years, with knock-on effects on infectious diseases and malnutrition. A major pumping station in Aleppo was damaged on May 10, leaving roughly half what was previously Syria’s most populated city without running water. Relentless regime barrel bombing has made it impossible to fix the mains, and experts have warned of a potential humanitarian catastrophe for those still inside the city.

The U.N. decision earlier this month was made subsequent to refusal by the Syrian regime to comply with a February resolution demanding rapid, safe, and unhindered access, and the Syrian regime had warned that it considered non-authorised aid deliveries into rebel-held areas as an attack.