Providing medical relief in Syria's conflict
“Keep your head down and don't say anything”, instructed my guide as we approached the Turkish border at Bab al-Hawa. We were making our way back across the border into Turkey after a long day in Atmeh refugee camp, north Syria. I was with Rola Ahmed (name changed), a British doctor of Syrian descent and her colleagues from Hand in Hand for Syria (HIH)—a UK registered charity. Within a moment the plan changed. Two ambulances screamed passed stopping short of the border gate. Two injured Free Syrian Army (FSA) fighters and a civilian were being evacuated to Turkey for urgent treatment.
Ahmed disappeared into one of the ambulances. The patient was a young woman from Aleppo—she had been shot in the head. She had a tube down her throat to help maintain her airway, and her brother—not medically trained—had been squeezing air out of a bag into her lungs for the 5-hour journey, keeping her alive. “Her eyes are open, but she's not obeying any commands”, explained Ahmed. “She's got a bullet in the brain.”
The young woman became agitated, it was important to keep her settled. Ahmed gave her pethidine, a strong painkiller. It would buy time until the Turkish paramedics arrived.
Mounir Hussein (name changed), a British-born orthopaedic surgeon and cofounder of Syria Relief, explains that a system approved by the Turkish Government exists to evacuate the severely war-wounded into Turkey through Bab al-Hawa to receive the specialist, life-saving care that Syria is now unable to provide. Health care is operating well below capacity since the start of the armed uprising, on March 15, 2011, following a bloody military crackdown on peaceful mass demonstrations in Damascus and the southern city of Deraa. There are two main reasons—an exodus of doctors who have fled because of the conflict and a lack of adequate aid and security for those who stayed. A third of public hospitals are not functioning, according to UN figures.
The north is mainly under FSA control but the risk from President Bashar al-Assad's airstrikes continues. Médecins Sans Frontières (MSF) and a few other international agencies have, however, worked here since last summer operating below the radar because of the high security risks involved. A report recently published by the International Rescue Committee (ICR) Syrian Commission on Syrian Refugees says that health-care facilities are deliberately being targeted with doctors describing “intimidation, torture and the targeted killing…in retribution for treating the wounded”. HIH says that 14 doctors were killed in November, 2012, alone. The IRC report describes 36 doctors working in Aleppo, when previously the city had 5000.
Medicine has become a weapon of war. Omar Khalili (name changed), a UK-based emergency medicine consultant working with the Syrian British Medical Society, explains how a hospital hit by an airstrike makes headline news on state television. “They call it a successful mission against terrorists.”
Attempting to address the medical shortfalls, the Union of Syrian Relief Medical Organizations (UOSSM), a coalition of Syrian medical and relief non-governmental organisations (NGOs), formed in December, 2011, in Geneva, recently opened the Bab al-Hawa hospital, near the Turkish border. UOSSM was formed in response to doctors being targeted. One objective is to manage the war-wounded inside Syria instead of transferring them to Turkey to avoid delays in treatment. At its first Annual General Meeting in London in January, UOSSM revealed that the hospital, with its 46 elective bed capacity and four operating theatres, has completed 300 operations. However, a lack of senior doctors is a concern, with one member describing it as “inexperienced people running very expensive equipment”. Most of the doctors who stayed are relatively junior. Attention is now turning to training.
Since the beginning of the conflict at least 2 million people have been displaced within Syria with more than 700 000 registered as refugees in neighbouring countries. Speaking at a recent UN donors conference in Kuwait, Antonio Guterres, UN High Commissioner for Refugees (UNHCR), said there was “no light at the end of the tunnel” with figures expected to reach 1 million by June.
The Lancet visited Atmeh in December, 2012, and the dire humanitarian picture was clear. Around 13 000 people, mainly women and children were living in exceptionally poor conditions with little evidence of outside support. One medical centre comprising of two portable cabins was providing primary health-care facilities, supported by International Medical Corps and HIH. Rola Ahmed enquired about the condition of a woman, transferred to a Turkish hospital. She had suffered 70% burns when her tent caught fire. There is no electricity in the tents and she had used a candle for light. The blaze killed her two children.
Melissa Fleming, UN spokesperson for UNHCR, accepted that very little had been provided by the UN to areas outside of government control. “It has been one of our difficulties—our goal is to impartially reach all people.”
Even knowledge of the complete humanitarian situation in such areas was difficult to obtain because it was impossible to go in without permission, explained Fleming. “The UN has to respect the sovereign status of Syria.”
However cross-border negotiations have been taking place and as a result Fleming confirmed to The Lancet that the UN has some access to the Atmeh camp—some 5 months after it began to swell in numbers.
Precedence has been set by the UN following its intervention in what is today known as South Sudan. It did this through a Security Council resolution that permitted the UN to act in areas outside of central government control. However, until now this has not been done in Syria.
MSF urged equal distribution of aid in a statement ahead of the Kuwait conference. “International aid provided to Syria is not being distributed equally between government and opposition controlled areas…Donors must support cross-border humanitarian operations to reach opposition-held areas.”
Hussein of Syria Relief says that there are so many more “Atmeh's deeper within Syria…In another northern area, Sahl al Rouj, I saw children collecting rainwater to drink because they have nothing else.”
Syria Relief has raised £2·3 million since it was formed in September, 2011, mainly from the UK Syrian diaspora. Their focus, like other grassroots NGOs, has been on getting medical aid to areas with difficult access.
The recent donor conference held in Kuwait on Jan 30, resulted in an historic US$1·5 billion worth of aid pledges for the Syrian people. The bulk of the money came from the Gulf states. Saudi Arabia, Kuwait, and the United Arab Emirates each pledged $300 million. The USA pledged $155 million and the European Union $136 million.
Money will be divided between supporting Syrian refugees in neighbouring countries, through the UN's Humanitarian Assistance Response Plan, and assisting those still inside while observing sovereignty. The UN's Humanitarian Assistance Response Plan for Syria for the first 6 months of 2013 states: “All humanitarian assistance is and will continue to be delivered with full respect to the sovereignty of the Syrian Arab Republic. The Syrian Arab Red Crescent has been designated as the leading national provider of humanitarian relief.”
Speaking at the recent donor conference UN Secretary-General Ban Ki-moon said: “The United Nations will make sure that these resources are used in the most effective way possible to deliver life-saving aid to the people in need.”
How that happens remains to be seen. Mousa Al Kurdi, a prominent Syrian consultant gynaecologist and chair of the Arab Institute for Clinical Excellence, who once taught Bashar al-Assad, as a medical student, is incredulous. “How can a regime that has killed its own people be trusted to distribute aid?'
UOSSM spokesman, Tawfiq Chamaa, described meeting key figures within international NGOs, and government ministers, where support was warm and empathetic. “Symbolic amounts were coming forward but there are heavy political lines that can't be crossed, which hamper aid”, he explains. But he admitted a sense of betrayal towards the UN aid distribution plan.
UOSSM warned in November that up to 95% of the international aid sent to the SARC was “confiscated by the regime”. SARC responded saying these were “wrongful, uncertified, and politicised accusations”.
Some of the suspicion towards SARC stems from the position of its president. Abdul-Rahman Attar, one of the country's wealthiest men, with alleged business ties to Assad's cousin, Rami Makhlouf, revealed via a WikiLeaks release last year. In a statement issued in Geneva, Attar insisted SARC had provided humanitarian aid to thousands of people “regardless of their nationality, religion, or political affiliation”. Fleming, UNHCR reinforced this: “SARC works in partnership with UNHCR and without them we would be reaching thousands of fewer people.”
Hussein feels that SARC are in a difficult position. Last year, they were the only agency to get into Homs, an area under siege with an estimated population of 400 civilians. He notes that working in such places means that a degree of government control is inevitable.
Meanwhile, foreign doctors continue their work in and around Syria. 16 months ago, Ahmed was a specialist registrar working in a UK National Health Service teaching hospital, building a career. Now she has been thrust into the world of medical relief, global health policy, and coordinating aid delivery in a conflict zone. The learning curve has been steep. “We are doing the work of governments, of ministries, we are overwhelmed.”
Volume 381, Issue 9866, Pages 523 - 524, 16 February 2013