Beyond Borders

The needs right now and in the future

Dr Khalid Elsheikh, Deputy Programme Manager for Iraq, Syria, Jordan and Turkey, and Dounia Dekhili, Programme Manager for Iraq, Syria, Jordan and Turkey, are both members of MSFís operational cell based in United Arab Emirates, and itís from there that they manage some of MSFís activities in Syria. In early April, they agreed to discuss the way MSF works in Syria after six years of war, the challenges faced, the changes and the constants.

Question: When were you last in Syria and what was your objective there?

Dr Khalid Elsheikh: I was last there in 2014. I was conducting an explo (exploratory trip to evaluate the medical needs) along with two colleagues Ė a surgeon and a nurse. The needs were vast, particularly among internally displaced people, but it was impossible to act on them. Every day and every night we were shelled, it seemed to be targeted. The area where we stayed, along with the hospital where we conducted evaluations, had never come under attack before, and suddenly there was a period of intense bombardment in a localised area. We even moved our accommodation to a new area, and once again we came under fire from missiles. It became clear that our presence put the local population in danger, and we made the decision to withdraw. I felt lucky after that Ė it really was just a matter of luck that we werenít hit.

Question: Youíve been to different projects in Syria a number of times, including projects in Aleppo and Idlib. Have you ever witnessed one of the mass casualty events we see so often in the media?

Dr Khalid Elsheikh: Iím a General Practitioner by training and my role in Syria was as an Emergency Coordinator rather than as a medical responder. However, I did witness some mass casualty events, and during these I took responsibility for triage. During these events, there were huge influxes of people, and it was incredibly crowded. People are desperate in these times Ė being responsible for triage can mean telling people that their loved ones canít be treated Ė desperate families would bring someone who had already diedand insist on their receiving treatment. When there are so many others who need urgent attention, we have to continue. But itís very difficult trying to explain why someone canít be taken to the operating theatre when their loved ones insist.

Question: What are the primary medical concerns in Syria right now?

Dr Khalid Elsheikh: The victims of war are highlighted in the media Ė we are confronted with horrifying images of people killed and injured in bombings Ė but these are the direct victims. We hear very little about the indirect victims. Currently, there are huge numbers of people with chronic diseases without medication; there are people who are sick, but wonít seek help as they fear hospitals may be targeted by military attacks. Most of the health facilities now functioning were created in a state of emergency. As large facilities are so frequently targeted, medical staff tend to work in converted shops, houses or farms. Often we have to work in poor conditions, with a lack of supplies. The most vulnerable demographic right now is women and children, and the lack of routine vaccination (against preventable diseases like measles, rubella, tetanus or pneumonia) is a serious concern. MSF seems to be the only organisation providing routine vaccinations right now.

Question: What are the long-term implications for healthcare in Syria?

Dr Khalid Elsheikh: We save the lives we can, but the fact is that people need more than saving. They need physiotherapy to help them walk again, they need reconstructive surgery to help them regain mobility and perform everyday tasks. So many people will now suffer from disabilities. This new generation growing up will be particularly vulnerable to disease, because they simply didnít receive the routine vaccinations they needed. In medical circles, people discuss the eradication of things like Polio Ė but thatís just not realistic when so many young people will go without the protection they need. Aside from the physical issues, an enormous people will now have to live with post-traumatic stress disorder. They will have to learn to live, to work and to interact with others, after witnessing stunning brutality and widespread carnage. These things canít be underestimated.

Question: How does the situation in Syria compare to working in other armed conflicts?

Dounia Dekhili: Whatís different here is that we have been forced to stay away from such a catastrophe, with zero ability to negotiate humanitarian space, for such a long period of time. The last time I was there was in May 2013, visiting two of our medical facilities in Atma and Qabasin soon after they were opened. Our project in Qabasin closed in October 2014. We had already evacuated the expatriate team following staff kidnappings by the so-called ĎIslamic Stateí (IS) earlier in the year. The kidnappings actually occurred far from Qabasin, but there were so many armed groups operating at the time, that it became difficult to tell who was who, and who it was possible to negotiate with. Initially it was possible to negotiate with certain groups, and they gave us space to work, even IS. But this diminished rapidly, and we were never able to negotiate with the government in Damascus. Crossing the border with Turkey became very complicated in the summer of 2013. We withdrew expatriate staff from Atma on February 2014. Since the evacuation of expatriate staff, we have relied on working with our Syrian colleagues through remote management.

Question: How effective is this remote management of medical facilities?

Dounia Dekhili: Our Syrian colleagues are sustaining the projects remarkably well under the circumstances. To qualify that statement, itís important to understand that the majority of medical staff now working inside Syria were not trained to work in a war zone, but they have had to learn as they work. This is not ideal, and medical staff at MSF are usually expected to have a good level of experience before they even begin their training for emergency situations. There is a big difference between medical work in a secure, well-staffed and well-equipped environment, and frontline medical work. So, the fact that the staff inside Syria continue to save lives, with remote training, guidance and assessment, is amazing. However, this approach comes with problems. Without being there in person, itís very difficult to assess the level of danger our staff experience. This is extremely frustrating.

Question: Did you ever witness the trauma we hear so much about in the media?

Dounia Dekhili: I remember when the hospital in Atma first opened Ė we could hear the shelling. At that time the frontline was about 15km away. When we heard the shelling, the teams would prepare for mass casualties. Sometimes military helicopters would fly over, and the fear in our patients was palpable. In fact, any time a plane or a helicopter flew over, people would become nervous. When the situation posed a more imminent threat, we would gather our staff and patients into a small, slightly more secure room. The first patient I saw, and one that I wonít forget, was a 12-year-old boy, wounded by shrapnel. Itís always a shock to see civilian casualties in war, but some stay with you. The further away the frontline moved from the hospital, the more internally displaced people would come to the hospital for assistance, and the more burns patients we received, as a result of living conditions in displacement camps. Apart from that, Syria used to have a good health system, so people used to receiving healthcare suddenly didnít know where to turn. Earlier on in the conflict, we had plans to open more paediatric facilities, and centres for mothers and children. But the opportunity for this diminished.

Question: How do the staff cope with the constant threat of warfare, arenít they scared?

Dounia Dekhili: Unfortunately, people become used to it Ė it becomes normal for them. But then you have events like the recent chemical attacks (04.04.2017) and understandably, staff become worried. We put staff psychologists in place so that our colleagues have someone to turn to, but obviously working remotely means we can only offer a phone line. Itís not ideal, but people do use it. When more parties became involved in the war, notably when the Russian intervention began, the bombing intensified. People were certainly scared after that. A lot has changed in this war, but the one constant has been the total disregard for civilian protection. Not just from the warring countries, but those who refuse to give refuge.

Question: What do you think hasnít been said, that is worth saying?

Dounia Dekhili: We see a lot of images and reports on military action, a lot of discussions on the war itself, but very few reports on the mass displacement and human costs that go beyond numbers. There isnít a human face to this war.


MSF regional branch office in UAE
MSF has been in the UAE since 1992, under the patronage of His Excellency Sheikh Nahyan Bin Mubarak Al Nahyan and is a member of International Humanitarian City (IHC). MSFís work in the UAE includes support for medical humanitarian assistance and operations in Iraq, Syria, Jordan, Turkey, Yemen and Lebanon. In addition, MSF UAE is the primary logistical hub providing medical assistance to people based in Afghanistan, which remains one of MSFís largest operational programmes, with 2,303 full-time staff and 366,000 outpatient consultations held in 2015.



Date of upload: 13th May 2017

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