War’s Toll

Long before combat erupts--and decades after it ends--those who inhabit the world's conflict zones bear its burdens.

 War’s Toll


It was time to leave Syria.

The professor of Islamic history and Arabic literature had spoken publicly against his country’s regime, criticizing its human rights record and its denial of civil liberties. In the past, he had been harassed and even arrested for voicing dissent. But this time, government officials had gone a step further, issuing an ultimatum: Keep quiet, or die.

“Bashar al-Assad’s father, Hafez, was in power back then, and he ruled with an iron fist,” explains Ali Abazeed, who is in his second year of a dual MPH/MPP degree program at U-M SPH. As he describes the challenges his parents faced in Syria, Abazeed is quick to acknowledge that the current president is just as ruthless at stifling dissent and popular protest.

Abazeed’s parents fled to northeastern Algeria, a country with which they’d had no previous connection. They spent the next eight years settled in a mountainous city there, high above sea level. Years later, Abazeed’s mother would recall the cool breezes—or hawayyat, Arabic for wind—that descended into their village on hot summer days.


What words does a 13-year-old use to speak about death? To describe grief? Afghanistan was in the midst of an internal civil war when M.’s younger brother fell ill from an infectious disease. The family lived in Kabul, where medical professionals were scarce. His parents knew of a physician in a nearby village. They sent M., their oldest son, by bike—but the physician was away. By the time M. returned home, his brother had died.

His mother was also sick and died a few years later. “She used to say, ‘I am praying that you will be a doctor,’” says M., who spent last fall at U-M SPH analyzing data as a visiting scholar with CRDF Global, an independent nonprofit that promotes international scientific and technical collaboration. Following his mother’s wishes, M. went on to become a general practitioner with a specialty in infectious disease. He quickly discerned that solving his country’s biggest health problems required a public health framework. Medicine alone was not enough to serve the needs of people living through decades of war.


War has a profound effect on global public health. Violent confrontations cause death and disability, but so do war’s secondary effects, which include infectious disease, malnutrition, untreated chronic conditions, and mental health problems such as PTSD and depression. Providing just one example, in 2014, a PLOS Pathogens paper announced “a public health emergency of global concern”: an outbreak of infectious diseases throughout Syria and the surrounding countries. As a direct consequence of war, medical facilities had been attacked. One hundred and sixty doctors were killed and hundreds more jailed. Vaccine coverage in Syria dropped as low as 45 percent in some parts of the country. Polio reappeared after 15 years of eradication.

As refugees began fleeing Syria in 2011, diseases spread across the region. In 2012, Lebanon recorded just nine cases of measles. One year later, the number of cases rose to 1,760, with the vast majority occurring among Lebanese nationals. Unrest in surrounding countries “exploited deficiencies in Lebanon’s measles immunization coverage,” explain the paper’s authors.

The incidence of a disfiguring vector-borne disease called cutaneous leishmaniasis also rose, particularly in Lebanon’s Bekaa Valley, where today nearly 75,000 Syrian refugees live in informal tented settlements.

From the paper’s final section: “Without security, there can be no health.”


The 17-year-old refugee from Aleppo wore a red and white wristband with a cedar tree in the style of the Lebanese flag. Inside the tented settlement in the Bekaa Valley, where he was staying, he spoke with Ali Abazeed, who visited the camps this past summer as part of a 12-week internship at the American University of Beirut. “He wore the wristband so that maybe one day, when he encounters a Lebanese checkpoint, the guards will see the bracelet, think he’s Lebanese, and let him pass through,” explains Abazeed. In the meantime, the young man was stuck.

“I don’t think you can separate policy from health,” continues Abazeed. Take the example of infectious disease: can we identify the conditions that contributed to the current outbreaks of measles, cutaneous leishmaniasis, and other diseases among refugees? Answering the question, he believes, requires a thorough understanding of health outcomes as an outgrowth of the region’s politics, history, and economics.

Abazeed’s connection to Syrian politics is personal. In March of 2011, a group of schoolchildren in his parents’ hometown of Daraa spray-painted the wall of an abandoned school: The people demand the downfall of the regime, they wrote in Arabic, using the slogan chanted in Egypt, Libya, and other countries as the Arab Spring unfolded. The schoolchildren were arrested. When the town elders went to the police and requested the release of their children, they were told, “You should go back home and get to work on new children because you’re never going to see these children again.” That was the beginning of the Syrian uprising.

Three of the schoolchildren were Abazeeds.

On the Ground


“We knew we were in trouble when they airdropped disposable razors,” says U-M alumnus Tim Nellett (BA ’15), program coordinator for the university’s Peer Advisors for Veteran Education (PAVE) program. Nellett was serving in Afghanistan, his second deployment with the Marine Corps Infantry. His company had been told to pack for a ten-day mission. They were to uproot the Taliban from an area in the Helmand Valley, then return to Kandahar. But after ten days, plans changed.

Nellett and his company spent the next four and one-half months in the rural area, building fortifications, setting up checkpoints, going on patrols, and working with locals to protect the area from Taliban incursions. Occasionally this meant combat.

After that long and stressful mission, Nellett returned to Kandahar about a month before coming home. This gave him a chance to decompress. In the end, he says, he was lucky to have time to adjust to life outside an active war zone. “Some guys will be in combat, and then two days later they’re in America. It’s a lot to take in.” Even an operating toilet can be a noteworthy experience for a veteran returning from Afghanistan or Iraq. For Nellett, it was the smell: “I didn’t expect to smell America,” he says. It’s scented with pine needles.

“When you’re on deployment, your friends and family miss you,” says Nellett, “but you miss everything—the entirety of your life, because you’re so completely removed.”


Kaes Almasraf misses Iraq. “I love America,” he says, “but in Iraq, I have memories, I have friends, I have relatives, I have my work.” The former dentist and manager of a primary care clinic in Baghdad brought his family to Michigan in 2013, when he began to fear for their safety. “You feel like you become a stranger in your country,” he says, describing how decades of war have heightened religious tensions within Iraq. “In our country, the people suffer from a lot of wars, beginning in 1980 with Iran—then, then, then.” People are tired and poor he says, and the “miserable conditions can lead weak people to do things like kidnapping.” He wants his wife and daughter to be safe.

Summer 2015

Even in peacetime, a county’s landscape may remain pockmarked with evidence of war. Lebanon is much safer for its citizens than Iraq, but along its borders, the military has been demining the area since 1990. “A lot of these munitions look like toys to children,” says second-year SPH student Phoebe Harpainter, who spent last summer conducting an internship with the Land Mines Resource Center at the University of Balamand.

Having studied the public health effects of land mines for decades, her supervisor, Habbouba Aoun, has helped establish a national prosthetic and orthotic technical unit to treat those with potentially disabling injuries. More than 3,600 people have been injured or killed by land mines in Lebanon since 1975. Mine injuries now occur less than once a month—but the infrastructure Aoun and others created has found a new use. Among Syrian refugees in Lebanon, one in 30 has been injured by war. Others, particularly children, have conditions such as scoliosis and cerebral palsy that require orthotic prosthetics. These devices make it more likely that the treated children will attend school.


M. describes himself as “thankful from God”: for the opportunity to be a scholar, to conduct research that could benefit the Afghan people. Still, he acknowledges that at times, it has been difficult to concentrate on his professional work. Early during his fellowship at SPH, the Taliban took control of the northern provincial capital of Kunduz. “Hundreds of innocent people living in their houses were killed,” says the soft-spoken researcher. “Children, women, old people killed because of the war.” Afghanistan has been a conflict zone for more than 30 years.

The Afghan people are thankful for the support of the United States, M. says, but he would like to see more mutual understanding between the two nations’ peoples. He is troubled by a phrase he has heard in the U.S.: Islamic terrorism. He wants Americans to know that Islam means peace, that the majority of Afghan people do not support terrorism. Rather, they are being sacrificed in the conflict. “We are proud Muslims, but not terrorists. We condemn terrorists.”

M. brought data from Afghanistan to SPH, hoping to better understand ascariasis, one of the most common worm infections in people worldwide. While at Michigan, he worked with SPH epidemiologist and Senior Associate Dean for Global Public Health Matthew Boulton to analyze the results. M.’s goal was to return to Afghanistan and improve public health, and especially to eliminate death and morbidity caused by a widespread lack of awareness of transmissible disease. This won’t be easy in a country whose people face continuing violence.

Between Worlds


“My God, this must be hell during the winter,” Ali Abazeed thought when he visited the informal tented settlements in the Bekaa Valley last summer. The settlements sit between two mountain ranges. “It’s a de facto wind tunnel.” When Abazeed and his Lebanese colleagues visited the camps to interview refugees about their health needs, the first thing the refugees would do was offer the researchers drink and food. “These are people who have almost nothing,” Abazeed remarks. Despite the hospitality, it was clear conditions had taken a toll.

Abazeed wants to devote his career to finding ways to improve the plight of refugees. His ideas include the establishment of a refugee studies center aimed at improving the existing model for accepting and welcoming refugees. He would also like to see a global effort to create infrastructure for helping them get jobs. “When you’ve been stripped of your livelihood and put into an unfamiliar territory and you’re not doing anything productive, you lose confidence that you are of some use in this world. It has an impact on your health. I think that mental health is the biggest issue in these communities. It’s a language that’s not yet spoken fluently.” 

The most common mental health problems associated with refugees include post-traumatic stress disorder (PTSD), depression, and generalized anxiety disorder. Risk factors include the number of traumas a refugee has experienced, an often prolonged asylum application process, detention, and the loss of culture and support systems. According to the Refugee Health Technical Assistance Center, which is funded by the Office of Refugee Resettlement, a branch of the U.S. Department of Health & Human Services, “different studies have shown rates of PTSD and major depression in settled refugees to range from 10–40 percent and 5–15 percent, respectively. Children and adolescents often have higher levels, with various investigations revealing rates of PTSD from 50–90 percent and major depression from 6–40 percent.” 

Abazeed reflects on the situation: “‘Refugee’ is an inherently tragic word. It means you’re not welcome at home, and you’re essentially not welcome in this other place that you’re going. And so you exist in this black hole without a home, without the familiarity of daily life. How can you not suffer from some form of psychological distress?”


“When I see pictures of these poor refugees, I can identify,” says Irene Butter, SPH professor emerita of health management and policy.

More than 70 years ago, Butter and her family, German-born Jews, were deported to Bergen-Belsen. By the time they were released, in 1945, typhus and dysentery had spread through the concentration camp, and her father, weakened by disease, died shortly after being freed. Butter herself was separated from her mother and brother, and sent to a displaced persons camp administered by the United Nations Relief and Rehabilitation Association, a precursor to today’s UN.

Butter has saved the letters she wrote to her mother from the camp. They share a common theme: “Where, when, and how are we going to be reunited?” she asks, her voice reflecting the urgency of that time. “Where are we going to live?” Butter and her mother and brother didn’t have citizenship and didn’t want to return to Germany, “even if it were possible,” Butter recalls. They had family in America, but the war was ongoing, and communication was slow.

Butter’s camp was not in war-torn Europe, but in northeastern Algeria. She remembers something very unusual—a hot wind that covered the land with sand and dust. When it’s blowing, she later recalled, “you don’t want to be outdoors.” The wind is called khamsin—Arabic for “fifty,” the number of days the wind is said to stay.

How many more days for the world’s newest wave of refugees? Where will they be settled? Will they find jobs? What effect will they have on the culture of their new countries? Butter acknowledges these are difficult questions.

Who will take responsibility? Who will find the answers?


“We were scattered to the four winds,” says Tim Nellett, describing the individuals in his military unit after they returned from deployment. After leaving the Marines, Nellett was ready to put the military behind him. But as a U-M student, he realized he missed parts of his former life, “mainly my friends and the people I served with and how close we were.” Inevitably, they returned to their various hometowns across the United States, which was quite a difference from spending every waking moment of their lives together. Says Nellett, “To have them be completely gone is a lot, is a blow.”

Nellett discovered U-M’s Student Veterans of America chapter during his senior year. Though he was worried that it might be comprised of people “who are still ridiculously in love with the military,” he soon learned that it was “people like me—vets that don’t want to do anything with the military, but just want to hang out with other vets.” As Nellett’s involvement grew, he felt more connected to the university. He eventually became a peer advisor for PAVE, a newly formed peer-to-peer program providing outreach, support, and resource linkage for student veterans. Following graduation, he became the national program coordinator.

SPH alumna Marcia Valenstein, a professor of psychiatry at U-M and research scientist at VA Health Services, Ann Arbor, helped develop PAVE. She has extensive clinical experience treating veterans and is a national expert on peer-to-peer programs. Such programs, she explains, “are highly acceptable to veterans, who often believe that it takes another veteran to understand what they have experienced and to assist in the transition back to civilian life.” Nellett believes PAVE is similar to the military’s buddy system, where people work together and look out for each other. “I think that people miss doing that. That’s where we get the really fired-up vets who are engaged and want to give back.”

Nellett has mixed feelings about the public’s increased awareness of veterans living with PTSD, depression, and TBIs. Speaking about PTSD in particular, he says that on the one hand, awareness is good. “You used to not even have a word for PTSD. It was ‘shell shock,’ and people didn’t really understand it.” Now, with increased awareness, there’s more research, support, and treatment options. But Nellett and other veterans have experienced a downside. In the minds of the public, mental illness has essentially become the face of the wars in Afghanistan and Iraq. Civilians sometimes assume that all veterans must have mental health disorders, and that’s just not the case, says Nellett.

Among veterans of Operation Enduring Freedom in Afghanistan (2001–2014) and Operation Iraqi Freedom (2002–2010), 11 to 20 percent experience PTSD in a given year. This is a higher rate than among the broader American population, where seven to eight of every 100 people experience PTSD at some point in their lives. Still, there’s no doubt that PTSD has a broad reach. “It’s framed as a military problem, but it’s really not,” says Nellett. He believes it’s important to keep this in mind because it can help veterans feel less alone with their problems.



Irene Butter also gives back. She speaks at Ann Arbor schools about her experiences as a Holocaust survivor. She co-founded both the Raoul Wallenberg Medal and Lecture at U-M and Zeitouna, a group of Jewish and Palestinian women who live in Ann Arbor. Their motto: Refusing to be enemies. The group has existed for 13 years, meeting every other Wednesday to use dialogue as a process to learn from each other and to address complicated issues.

In 2013, Kaes Almasraf took a job at the Arab Community Center for Economic and Social Services (ACCESS) in Dearborn as a case worker for the Refugee Health Empowerment Program. Most of his clients come from Iraq. A long-time community partner of SPH, ACCESS helps refugees gain employment and education in health care and other fields through training, internships, and other programs.

Says Almasraf of refugees, “Each one of them when he arrives here is trying to put his feet on the ground, to be helpful to his family, to be helpful to himself, to grow.  . . . We can build—or try to build—a new life for them. Because they need it. We don’t want such newcomers to be lost here. We don’t need to hear that a refugee came here and started saying, ‘I don’t like America.’ No. If we put our hand in their hands, they will love America. We need to give them a good sign about the good country they are in right now.”

When Ali Abazeed’s parents arrived in Dearborn, Michigan, in the 1980s, they immediately felt comfortable. Ali’s father cites his appreciation for the social systems, the relationships between people, and political freedoms—for example, the freedom to pursue education or open a store. He wonders what will become of his family remaining in Syria, of the thousands of refugees who are still waiting—caught between checkpoints, living in tents. In Syria, military personnel had monitored his movements, but in this new place, nobody asked, “Where are you coming from? Where are you going?”

--Sara Talpos
Sara Talpos is a writer based in Ann Arbor.