These new waves of people brought new health challenges that NGOs, U.N. agencies, and refugees themselves were not ready for -- despite years of expertise.
"When you have a population in movement you don't know where they are, what their history is and they don't want to stop," says Karl Blanchet, co founder of the Public Health and Humanitarian Crises Group
at the LSHTM. "They have to keep moving because it's now or never," he says.
After days, weeks, or months on the move people are likely to need care, for both new and chronic conditions.
35 year old Syrian refugee Abdulkarim Al Kasem left Syria in 2013, fleeing to neighboring Jordan where he has now lives. He took his wife and four children with him. "The most tiring thing was walking and holding our things on our backs," says Al Kasem.
The continuous movement presents a conveyer belt of patients at clinics located along migration routes needing treatment -- with limited supplies.
The rise of the urban refugee
In many countries, refugees no longer live in official camps, but large cities.
"There's this increasing growth of urban refugees... many of them are going to be living in very poor urban conditions," says Bayard Roberts, fellow co founder of the Public Health and Humanitarian Crises Group at LSHTM.
The hustle and bustle of the city brings greater economic opportunities. "It creates opportunities associated with living in a large city, such as employment," says Roberts.
However, access to healthcare will vary greatly and scattered populations make it harder to provide services such as vaccination drives and surveillance -- unlike a camp.
"In a camp setting, providing health care is more straightforward as facilities can be set up to meet the needs of the population, they are geographically accessible and communication is easier," says Michael Woodman, a Senior Public Health Officer with UNHCR
Woodman works on the response in Lebanon where there are no official camps and refugees live either in cities or informal settlements.
A new range of diseases
Many refugees entering Europe in the current crisis are fleeing from Syria -- a previously middle income country.
They leave behind wealthier lifestyles and bring with them a new range of diseases stemming from these lifestyles, namely chronic conditions such as diabetes, heart disease and hypertension -- known as "Non Communicable Diseases" (NCDs).
"Traditionally the focus has been on communicable (infectious) disease and maternal and child care," says Roberts. These conditions are what humanitarian agencies have most experience with -- but they now face this new era of disease.
In a 2014 survey in Lebanon by Johns Hopkins University, more than half the surveyed refugee households reported a member diagnosed with an NCD.
"People living with chronic conditions need to maintain treatment before complications set in," says Roberts.
Paying for healthcare
Refugees coming from previously middle-income countries often face the challenge of paying privately for healthcare, when it was previously free in their home country. The expense can be vast, particularly when managing chronic conditions such as diabetes, adding further cost despite no substantial income.
According to a report by UNHCR
, the average monthly spending among refugee households in Lebanon on healthcare was $66 from income averaged $265 per month. The majority surveyed didn't consider healthcare to be affordable or accessible.
"Vulnerability of refugees is increasing with 70% now living below the poverty line," says Woodman.
"Clearly conflict is going to exacerbate mental health disorders," says Roberts.
The impact of forced migration on mental health may seem obvious but care and treatment options remain scarce.
"Mental health is an increasing need as people suffer from the trauma of displacement and increasing levels of depression and anxiety from their current situation," says Woodman.
The solutions being put into place are safe spaces for people to meet and counseling to get people discussing their thoughts and experiences. "Psychosocial support, counseling, specialist consultations with psychiatrists and psychotherapy are being provided through partners," says Woodman.
A simple solution?
Blanchet has set out to tackle part of the problem by harnessing the skills of refugees themselves.
"Many of the Syrians you have in these settlements are well educated professionals, they're doctors, teachers and nurses," says Blanchet who has seen the frustration -- and boredom -- some of them face being unable to work in their new countries.
He is trialling a form of informal humanitarian assistance through a network of skilled informants providing care for refugees from within. "There were plenty of doctors and nurses who wanted to help and were devalued by the international system," says Blanchet. The trial is being conducted among settlements in the remote regions of the Bekaa Valley in Lebanon, where refugees find themselves far from hospitals and health centers
The informants provide basic primary care and conduct health assessments ready to inform Lebanese health teams when they visit. The trial is in its infancy but seeing impact. "They have saved quite a few lives," says Blanchet.
His next goal is to offer the same among refugees on the move.
"If you look at all these waves of refugees walking, amongst them you have professionals. They should be equipped to deliver the first acts of care," he says.