Beyond Borders

Surviving war, and what comes after

I first noticed him as I looked through the broken windows at the gathering crowd. We were near the town of Baharka, north of Erbil, Kurdistan. It was afternoon, on the 10th of August 2014. He was about 12, thin and a little taller than his mates. Apart from the fact he was without shoes, he was dressed for the bright sky and 40°C heat. He was kicking a football around in the dust outside the medical clinic, hastily set up by MSF in a derelict building in the quickly thrown together camp. Occasionally, he would peer through the window then return to his game.

In the sudden crisis of that week I had been drawn away from my usual role as psychiatrist working in refugee camps with Syrians escaping their own war. Under the supervision of our senior physician, I helped out in the medical clinic. Looking around the clinic room, what you would have seen was a crowd of people – mostly women, children and elderly; huddling, sweating, around plastic tables and chairs. A makeshift partition providing some semblance of privacy. There were bottles of water for people thirsty with heat and some carpet rolled out to make the place feel more welcoming: small attempts to provide the tiniest bit of dignity and show some respect to people who had just lost their homes and livelihoods. In the previous hours, following the push by ISIS from Mosul toward Erbil, a huge exodus of humanity – some 500,000 people – had rapidly departed the eastern part of Ninewah province. The boy and his family, like the other people waiting in the clinic queue, had suddenly left villages like Qaraqosh, a town 30km east of Mosul.

The story of this family is familiar to many Iraqis. Their flight from danger had certainly not been the family’s first. Earlier that summer in the first few days of June 2014, they had fled eastward out of Mosul to escape the brutality of ISIS. At the very end of the clinic that day, after the last of more than 100 patients had been seen for their basic medical needs, the boy approached my table. He had a shy smile, hands behind his back, eyes pointed toward the ground. When I asked what we could do to help, he pointed to his calves and explained that they hurt. Hot and tired myself, but missing the extra moments I would usually have with my patients as a psychiatrist, I offered him a seat. We spent a few moments together. He explained that the night before he had fled Qaraqosh with his family. In the enormous traffic jam that night, surrounded by the fleeing city, their car could go no further. While his mother and father carried their other children, the boy carried his baby brother the extra kilometres across the border to safety in Kurdistan.

Psychiatric care
MSF’s mental health teams currently work in ‘hot spot’ provinces across Iraq and the Kurdistan region of Iraq. The teams are composed mostly of people employed locally – many being the survivors of war and displacement themselves. With the failure of public health systems in Mosul over the last two years, care for people with chronic conditions, including those with psychotic disorders, has often been unavailable for long periods. Their symptoms may have relapsed, leading to distress and placing a huge burden upon them and their families. MSF provides psychiatric care for these people with our Syrian and Iraqi psychiatrists, medical doctors and other therapists working in IDP camps each day. Stress support & psychological care There is little to be said when faced with the immediacy of situations such as those faced by Iraqis at the moment. What has been done cannot be undone. In the aftermath, however, when relative safety is reached and an uncertain future awaits, the mental health clinician’s job is to identify how much the person might have been affected by the stress of their situation, and consider approaches to support the survivor’s return to effective functioning. As well as recruiting the person’s own internal strengths and social supports, MSF uses various psychological approaches, including cognitive-behavioural and narrativetherapies. Therapeutic interventions that can help manage symptoms of trauma are also used. Working out of containers, tents and mobile clinic vehicles, our therapists and psychiatrists in 12 camps in Ninewah carry out more than 700 individual consultations each week.

More than a million displaced
As of March 2017 more than a millionpeople have been displaced from Mosul – many in the numerous IDP camps scattered across Ninewah and in Kurdish controlled territory. Thousands continue to leave Mosul each day. Each has their own story of loss and survival – like the boy and his family from Qaraqosh. The world’s responsibility is the same now as it was in 2014: To ensure safety fi rst, then water, food, shelter and medicalcare. Once acute needs are met, the mental health clinician’s role is fi rst to listen and act as witness. Observing the hurt, fear, loss and uncertainty. Using psychological interventions, clinicians can then help people understand their troubling symptoms of stress and seeing them as very normal responses to shockingly abnormal events. We also observe the resilience and strength that emerges, by necessity. We note a survivor’s courage in the face of fear, and action in the face of danger.

The Author
Dr Gregory Keane is a psychiatrist and works in the Middle East for Médecins Sans Frontières (MSF).

MSF has been in UAE since 1992 under the patronage of Sheikh Nahyan Bin Mubarak Al Nahyan, the UAE Minister of Culture, Youth, and Community Development. MSF in UAE consists of Executive, Finance, HR & Administration, Communications & Fundraising, Logistics and Desks (program manager, HR, Finance, logistics and medical referent). n Visit:

Syrian hospital supported by MSF bombed

A hospital in northern Syria supported by Médecins Sans Frontières (MSF) has been hit in an aerial attack, MSF said in a statement on 31 March.

At around 6 pm on 25 March, Latamneh hospital in northern Hama governorate was targeted by a bomb dropped by a helicopter, which hit the entrance of the building. Information collected by the hospital medical staff suggests that chemical weapons were used.

Immediately after the impact, patients and staff reported suffering severe respiratory symptoms and burning of mucous membranes – symptoms consistent with an attack using chemicals.

Two people died as a result of the attack, including Dr Darwish, the hospital’s orthopaedic surgeon. Thirteenpeople were transferred for treatment to other facilities.

“The loss of Dr Darwish leaves just two orthopaedic surgeons for a population of around 120,000,” says Massimiliano Rebaudengo, MSF’s head of mission in northern Syria.

Following the attack, the hospital went out of service for three days, after which the emergency room reopened.

Latamneh hospital is located a few kilometres from the frontline between government and opposition forces, and provides medical care for a population of around 8,000. Prior to the attacks, the hospital had an emergency room and inpatient department, and provided general and orthopaedic surgery.

“Bombing hospitals, although banned by international humanitarian law, remainscommon practice in Syria, and health services are severely affected by these repeated attacks,” says Rebaudengo.

Despite a new round of peace talks between warring parties, which began in January, increased fi ghting is taking place on several fronts. In northern Hama governorate, 40,000 people have fl ed their homes due to the fighting.

Over the past year, MSF has received reports of at least 71 attacks on at least 32 different health facilities which it runs or supports in Syria. On 22 February, an MSF-supported health facility in Idlib governorate was hit by rockets, killing six and wounding 33.

MSF directly operates four health facilities in northern Syria and provides support to more than 150 health facilities countrywide.



Date of upload: 13th May 2017

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