Interview Aline Keyrouz, a 28-year-old Lebanese nurse, talks about her work for Doctors of the World/Médecins du Monde (MdM)

Ever since her childhood, Aline Keyrouz has wanted to be a nurse like her mother. Concerned for others, she wanted to heal children in Africa. Her dream became partially true when she graduated from the faculty of Nursing Sciences at Université St-Joseph, Lebanon, in 2006. She never made it to Africa, but is now committed to helping Syrian refugees and most vulnerable families in Lebanon through her work at MdM in the Emergency Response Unit[1].

Based on your previous experiences, what is different about MdM?

The humanity. I am not just a nurse healing people; I am also a human being interacting with others. At MdM, we put people at the centre. It offers me the possibility to explore other aspects of nursing including the psychological side of things. Patients I care for come along with emotional stories. You must be patient, listen to them, reassure them and not panic. Where I previously worked I didn’t have time to spend listening to patients as the focus was only on medical care.

What are the challenges you face in your work?

Remaining neutral. I live in a country where people cannot be neutral because they are raised with different political and religious views. These differences are so strong it affects all aspects of life in Lebanon. Through my work with MdM, I am learning to be more tolerant: people should be helped regardless of differences.

I am also learning to stay optimistic while working with Syrian refugees on a daily basis. I try not to be affected by the situation around me and to keep thinking positively.

What keeps you going?

“What more can we do?” This is the question that keeps me going. Each life is unique. When I know that I can make a difference in someone’s life, I get the power to carry on no matter the difficulties.

If you had to choose an experience from the field that really affected you, what would it be?

In November 2013, I went through an experience that really touched me. We were in Arsal where 20,000 Syrians sought refuge[i]. The situation was shocking and I felt powerless. Can you imagine this huge number of people coming from everywhere? Children were crying, it was chaos. What could we do? It was so frustrating, all the more so because we had limited resources. This experience made me think of the civil war in Lebanon (1975-1990) even though I didn’t live it. This must have been just how it was back then. It astonished me and I wondered how my parents survived it.

Each country has its own cultures and traditions. To an external eye, these traditions can look exotic and appealing and for some, they can be perceived as negative or incomprehensible. However, whatever one’s view on them, some traditions can make life tough on women.

Soraya[1] is a 54-year old Lebanese woman who comes from a conservative and traditional small village in South Lebanon. At 17, she married a man of similar education and, as a married woman her first obligation was to give birth to a baby boy.

Unfortunately for her, she only gave birth to girls. She was under a lot of pressure from her husband and his family to have the most-desired baby. But each time she got pregnant, the family heir never came. Soraya gave birth to eight girls. Over time, her husband, dissatisfied, became violent with her and their daughters. After the eighth girl, he decided to marry a second woman. He had to father a male child after all!

In a strange twist of faith, it was after her husband took a second wife that Soraya finally gave birth to a baby boy.

Soraya had to go through hell to have this child: pressure, violence, and – as local tradition expects women to deliver babies at home – she gave birth nine times, alone, with only the support and company of her neighbours. No doctor, no midwife, no medical follow-up. Fortunately for Soraya, she never had any complications and each delivery went well.

With nine kids to take care of, the family had to continuously struggle to make a living, even more so when the father was sent to prison. Soraya and her daughters had to stick together to run the house and pay for school fees. For some time, she considered marrying off her daughters to lessen her burden. But she realized she didn’t want her daughters to live the same life as she did and so, she refused to put them under the same traditional pressures she had to live through.

“Something I learned is that we should stop bringing children to this world like this. It is a responsibility and it is no longer accepted that we still have this lack of awareness. We are responsible of our choices regardless where we come from”.

Amel Association and Médecins du Monde both work to promote safe deliveries and access to family planning to all women in Lebanon. Unfortunately, many inequalities still exist. By collecting and sharing stories of women who couldn’t access proper health care during pregnancy and delivery, and who don’t have knowledge or access to family planning, Amel Association International and Médecins du Monde point out such inequalities and aim to raise awareness on these issues.

With Israel increasing military operations, urgent humanitarian aid is unable to be deployed in Gaza. Several consignments of medical products – delivered by Doctors of the World (MdM) and reserved for health centers with zero stock – have been blocked.

Sunday, July the 20^th was one of the most deadly days since the launch of Operation Protective Edge – at least 60 Palestinians were killed, including 14 women and 17 children. The majority of the casualties so far have been civilians. The number of wounded quickly grew with the Israeli ground offensive, resulting in a massive increase in the need for emergency medicines and medical supply.

Humanitarian and medical staff still cannot be deployed. The delivery of staple goods has been brought to a standstill. With the flow of goods blocked at the Kerem Shalom border crossing for the whole Sunday, MdM’s teams were unable to supply several health centers with medical products.

Doctors of the World calls for an immediate and unconditional opening up of borders so that humanitarian aid can be delivered to Gaza.

Moreover, the Al Aqsa Der el Balah hospital – supported by MdM – was seriously damaged by shelling on Monday and the operating theatre was completely destroyed. Four people died and many more were injured.

Words and pictures by Nick Rice

Losing a home is more than a spatial separation; the emotional wrench can result in severe psychological consequences. The war in Syria has killed more than 150,000 people in three years and 40 per cent of Syria’s pre-war population of 23 million have fled their homes. For the millions leaving Syria the physical practicalities initially overshadow any mental impacts. But the effects of such traumatic and life-changing events inevitably manifest.

As the war grinds into a fourth year the number of refugees that have escaped to surrounding countries steadily approaches three million. The greatest numbers have entered Lebanon. The United Nations has registered more than a million Syrian refugees in the country, with the actual figure expected to be significantly higher. Lebanon has a population of 4.5 million, around 25 per cent of which are Syrian refugees. This represents the highest per-capita concentration of refugees recorded anywhere in recent history.

Doctors of the World has operated in Lebanon since May 2012 and, working alongside local partner organisations, provides comprehensive healthcare services to Syrian refugees and vulnerable Lebanese.

As UN staff in Lebanon register 2,500 new refugees every day, Doctors of the World is helping to confront the looming spectre of widespread psychological problems with a mental health task force. Records show a high incidence of mood and emotional disorders, alongside anxiety-related complaints. Trauma-related symptoms are typical in torture survivors whilst psychosomatic disorders and serious mental health conditions are also widespread. More than half of Lebanon’s refugees, over 520,000, are children and hyperactive/aggressive behaviour is prevalent, as is bedwetting.

Unlike in Jordan, where the formally planned Zaatari camp houses approximately 120,000 people, the conditions in Lebanon are less organised.

In the town of Al Ain we saw first hand how Doctors of the World confronts the burgeoning mental health crisis. Noëlle Jouan, 33, is a clinical psychotherapist whose thoughts on the growing mental health crisis are sobering. “The deterioration of mental health in refugees will surely increase. The separation and death of many family members weigh heavy and more help will be needed. Especially for the children… they have witnessed terrible scenes”.

As she addressed a clinic full of refugees the challenges of providing support were immediately apparent. One woman shouted, “What are you talking about ‘mental health’? We have no health, neither physical or mental, only this torture”.

In a short time several woman had broken down in tears.. Most eventually shared some of their anxieties and at the session’s end there was a sense of pressure released.

The fears confided to the mental health task force range from concerns for children and future prospects through to anxiety about sexual and physical abuse. A significant proportion of refugees are women and young girls suffering from, or at risk of, sexual and gender-based violence. It’s well-documented that during periods of war and in the aftermath of armed conflict, rates of physical and sexual abuse rise dramatically. This pervasive, under-reported and frequently unpunished crime can leave a profoundly traumatic legacy. A recent UN report highlights the difficulties faced specifically by female Syrian refugees including poverty, harrassment and extreme isolation.

Using false names, Noëlle described some of her cases. “Sawsan is a 15-year-old Bedouin girl who lives apart from her family of 13. They escaped from Syria and now live in a tent. She came to the doctor and I saw many cuts on her arms. Sawsan had been attending sessions with Noëlle for two months and revealed an awful background. “Sawsan has a lot of violence in her house because she’s a girl and there is a cultural tendency to favour boys. She suffered a lot of abuse, both physical and sexual. She told me that when she hurts herself she feels better.”

Sawsan lives away from her family and is now in fear of an honour killing at the hands of her brothers. Despite these tragic circumstances Noëlle has made significant progress in improving Sawsan’s mental health. “Sometimes I do home visits with her and the last time she’d put on a little make up; for me this was a good sign of a coping mechanism.”

Noëlle has also had success with Alya, 27, and her husband. The couple were happy in Syria but since becoming refugees in Lebanon their marriage began to fall apart. Suffering from kidney stones and unable to work, the husband vented his frustration on his wife and children. “Alya was referred to me because she attempted suicide with an overdose of medication. The problems started because they can’t work and have no money. Alya suffered a lot when she saw her children crying from hunger. The violence started because her husband had no pain relief and he’d get angry. He expressed his pain by beating his family. So I saw Alya many times to work on her suicidal thoughts.”

The consultations, provided without charge by Doctors of the World, are making a difference and the violence has now ceased. “One month ago her husband suddenly came with her to the centre. He broke down with guilt during our consultation. Now I work with them together and he behaves differently with his family. Alya told me she loved him again and could forgive him.”

These examples provide just a glimpse of this crisis. Medical teams on the ground constantly witness incidences of rape and domestic abuse. A normal number of one-to-one patients for a psychotherapist would be around 30 per week; Noëlle has more than 450 patients on her books.

While Western political and diplomatic efforts fail to make progress and the barbarity of the war shows no sign of abating, it is courageous individuals like Noëlle that remain on the frontline of this tragedy, risking their safety to ease the suffering of this embattled diaspora.

Choosing how many children one wants to have and when, to use contraceptives, and knowing more about different methods are rights of all women. These rights, promoted through family planning, have become common reality for many women in Lebanon, but not to all of them.

Zineb[1] is a 20-year-old Syrian woman from Qalamoun. Forced to flee the war, she sought safety in Lebanon where she met her husband in a grocery shop. He liked her, and the next day she found herself married. All had been settled.

Her new family, her husband’s, is from Qalamoun too. They are all demanding: Zineb must have babies and register to the UNHCR in order to benefit from aid. She eventually fell pregnant. But the pressure induced by her husband and in-laws led her to consider abortion an option. She doesn’t want her baby boy to live a life full of hardships, and she esteems him not to be a matter of business. “But I feel I have no right to do so, to take this decision. I am scared for my son”. Zineb is lost between contrary feelings…

Nidal. She will name her son Nidal, which means struggle. “…because he will have to go through a lot”, explains Zineb. She feels this is the only good thing she will give to her son: “At least he will have a strong name”.

Amel Association and Médecins du Monde both work to promote safe deliveries and access to family planning to all women in Lebanon. Unfortunately, many inequalities exist. By collecting and sharing stories of women who couldn’t access proper health care during pregnancy and delivery, and who don’t have knowledge or access to family planning, Amel Association International and Médecins du Monde point out such inequalities and aim to raise awareness on these issues.

[1] The name was changed to preserve the privacy of the interviewee.

Continued Israeli military operations are damaging the Palestinian healthcare system and restricting access to humanitarian aid. As the sanitary situation gets more critical with every passing day, Doctors of the World – Médecins du Monde (MdM) is strengthening its medical assistance to the civil population.

After ten days of Israel’s Operation Protective Edge, the toll is heavy: more than 200 Palestinians dead and 1500 injured, mainly civilians, with 18,000 more displaced. Health services have been seriously damaged by airstrikes and have had to endure frequent power cuts.

“Most of the cases received are women and children”, says Dr Hosam Abu-Elwan, an emergency physician for MdM. “Some essential drugs are starting to dry up and no one knows how long our stock will last”.

At the request of the Palestinian Ministry of Health, MdM is preparing to provide health facilities with medical supplies. Unfortunately, humanitarian aid is currently limited because of the continued bombings. Health workers are risking their lives to keep working despite clinics and ambulances being targeted by airstrikes.

Present in Gaza since 2002, MdM supports 11 health centres. Based on extensive experience in previous crises, the MdM teams have given emergency care training to locals (first aid, emergency evacuation) so communities can provide first aid.

This week’s United Nations Security Council resolution, which directly authorizes UN agencies and their implementing partners to deliver aid across Syria’s borders and conflict lines, is a welcome and unprecedented further step towards ensuring millions of people in Syria get the humanitarian assistance they desperately need. The consensus shown by the Security Council in passing this resolution is commendable; it must now lead to a massive increase in aid to those who need it.

According to the UN, the number of Syrians in need has skyrocketed to 10.8 million. Nearly half of these – some 4.7 million – are in areas that are difficult or impossible to reach; an increase of over a million people since the Security Council passed resolution 2139 in February 2014. While the responsibility to ensure the population receives assistance lies with parties to the conflict, neighbouring countries and the international community, the implementation of the resolution is a test of the Council’s credibility. For millions of women, men and children, it could be a matter of life or death.

The UN’s humanitarian agencies should seize this opportunity by working with humanitarian non-governmental organisations (NGOs) to reach the 4.7 million people in hard-to-reach areas. To support the existing work of humanitarian actors already active on the ground, we call on the UN to:

• Ensure the application of the resolution is in line with its wider intent of safe cross-border and cross-line access by the UN and NGOs to reach people in need of humanitarian aid and assistance.
• Scale up its support for NGOs that are already delivering aid across borders. In particular, we urge the UN to make sure that no restrictions are placed on NGOs in their use of the most expeditious routes – across any and all border crossings – for their aid deliveries.
• Work with all humanitarian actors to create and implement an effective system of joint planning and information-sharing to ensure that existing humanitarian operations can be expanded, not duplicated or undermined. Specifically, we ask the UN to involve international NGOs in all humanitarian fora and planning discussions in Damascus and elsewhere.
• Undertake needs assessments jointly with implementing partners, including with NGOs operating in areas where the UN has to-date been unable to reach.

This resolution must pave the way to further action. The demand for rapid, safe and unhindered humanitarian access for UN agencies and their implementing partners is just one of the provisions of the already existing resolution 2139. The Security Council must not lose sight of its previous demands; including that parties must cease the indiscriminate employment of weapons in populated areas, respect principles of medical neutrality, and demilitarize schools, hospitals and other civilian facilities. While cross-border access is essential, the Council’s demand that all parties to the conflict remove restrictions to humanitarian agencies operating across lines and in government areas must also be realized.

We have yet to see a diplomatic breakthrough transform into a humanitarian breakthrough that has a real impact on the ground for Syrians caught in this deadly conflict. The Security Council is responsible for ensuring that its words are translated into meaningful action. It is time that Council members lived up to that responsibility and pressed all parties to the conflict to respect international humanitarian law. The price of failure will be more lives lost and further untold suffering.
Signatories:

1. Alliance for Peacebuilding
2. Al-Khatim Adlan Centre for Enlightenment and Human Development (KACE) 3. Andalus Institute for Tolerance and Violence Studies
4. Arab Program for Human Rights Activists (APHRA)
5. Arab Coalition for Sudan (ACS) 6. Arab NGO Network for Development (ANND)
7. Arabic Network for Human Rights Information (ANHRI)
8. Broederlijk Delen
9. Center for Civilians in Conflict
10. Center for Victims of Torture
11. Christian Aid
12. Commonwealth Human Rights Initiative (CHRI)
13. Doctors of the World / Medecins du Monde
14. Global Centre for the Responsibility to Protect
15. Global Communities
16. Handicap International 17. Human Rights and Democracy Media Center (SHAMS) 18. Human Rights Information & Training Center (HRITC)
19. Human Rights First Society
20. Human Rights Now (HRN)
21. Human Rights Watch
22. International Rescue Committee
23. Islamic Relief
24. Norwegian Refugee Council
25. Oxfam
26. Pax Christi Flanders
27. Pax Christi International
28. Physicians for Human Rights
29. Save the Children
30. Sudan Human Rights Monitor (SHRM)
31. Union des Organisations Syriennes de Secours Medicaux (UOSSM)
32. United to End Genocide
33. World Vision
34. Zarga Organisation for Rural Development (ZORD)

Continued military operations are compounding a health care crisis in Gaza, with hospitals ill-prepared to meet the critical needs arising from a wide-scale emergency right now. The signatory organizations are calling for an immediate ceasefire, noting that all parties must respect international humanitarian law and abide by their obligations to protect civilians from harm. During armed conflict, the organizations noted that hospitals, health care facilities, ambulances, medical personnel and the wounded and sick are all afforded specific protection under international humanitarian law.

Over the past eight days, at least 138 civilians in Gaza have been killed and over a thousand more have been injured, including one doctor killed and 19 paramedics or medical personnel wounded. Four ambulances and six hospitals or health centers in Gaza have been damaged by Israeli airstrikes and one rehabilitation center for the disabled was destroyed. In Israel, no civilians have been killed but dozens have been injured.

Escalating violence hits particularly hard as Gaza’s health sector has been suffering from an acute shortage of fuel and supplies, with 54 percent of medical disposables and 28 percent of essential drugs at zero stock. Some hospitals are reporting that they do not have sutures, materials to treat bone injuries, or enough reactive agents to perform routine blood tests. The Ministry of Health in Gaza has just 10 days worth of the fuel reserves it needs and with power cuts caused by the chronic lack of electricity, many hospitals have long stopped providing primary and women’s health services and are now closing off wings and shutting off what machines they can. The lack of fuel also means that 25 percent of the health ministry’s ambulances have stopped running while services from mobile clinics and community health centers have also been cut or reduced.

The organizations called on the International Community to work effectively with the government of Israel, as the primary duty bearer, to ensure an immediate and sustained opening of the crossings so that patients can access the care they need and Gaza’s hospitals can restock critically low supplies. The ongoing Israeli blockade and the more recent closures of the Rafah border crossing continues to impede civilians in Gaza from accessing health care beyond the besieged coastal strip. In 2014, Israel denied approvals for 15 percent of patients referred for medical procedures in Israel and the West Bank, while the number of patients able to cross through Rafah into Egypt dropped by 95 percent.

The organizations also stressed that the International Community must support the Palestinian government in assuming its responsibility to fund and operate a coherent health care system in both Gaza and the West Bank, including East Jerusalem. In East Jerusalem, Palestinian hospitals that receive Israeli-approved patients from Gaza are facing increased demand for emergency services as tensions in Israel and the West Bank have continued over the past month. Amidst a cash flow crisis, Augusta Victoria and Makassad Hospitals fear that their life-saving services will soon be seriously compromised as they are struggling to ensure quality, low cost care to Palestinians who are sick or those injured by violent confrontations in Gaza and in the West Bank.

1. Action Aid
2. Action Against Hunger (ACF)
3. American Friends Service Committee (AFSC)
4. Al Ahli Arab Hospital, Gaza
5. CISP
6. Cooperazione Internazionale (COOPI)
7. CCFD-Terre Solidaire
8. DanChurchAid (DCA)
9. Diakonia
10. Doctors of the World – Medicins du Monde France (MdM F)
11. Doctors of the World – Médicos del Mundo Spain (MdM ES)
12. Doctors of the World – Medicins du Monde Switzerland (MdM CH)
13. Gruppo di Volontariato Civile (GVC)
14. Handicap International
15. HelpAge International
16. HEKS
17. International Learning Centers (ILC)
18. International Medical Corps (IMC)
19. KinderUSA
20. Kvinna til Kvinna
21. Medical Aid For Palestinians (MAP UK)
22. Mennonite Central Committees (MCC)
23. Mennonite Central Committees Office to the United Nations
24. Near East Council of Churches, Department of Service to Palestine
25. Refugees, Gaza
26. Norwegian Church Aid (NCA)
27. Norwegian People’s Aid (NPA)
28. Oxfam
29. Polish Humanitarian Action (PAH)
30. Première Urgence – Aide Médicale Internationale (PU-AMI)
31. PNGO
32. Solidaridad Internacional- Alianza por la Solidaridad (SI-APS)
33. Swedish Organisation for Individual Relief (SOIR)
34. Secours Islamique France (SIF)
35. Terres des Hommes Italy
36. Terres des Hommes Lausanne
37. The Carter Center
38. The Israel-Palestine NGO Working Group at the United Nations
39. The Lutheran World Federation
40. Quaker Peace & Social Witness (QPSW)
41. Vento di Terra
42. WeEffect

While a ceasefire and end to the violence are urgently needed, the organizations said that the International Community must do more to find durable solutions to the conflict, including by working with the parties to end the blockade in Gaza and ensuring all parties respect their obligations under international humanitarian law.

The Syria refugee crisis is pushing Lebanon to take extreme steps, more than 20 humanitarian agencies warned today. Since 3 May 2014 there have been increasing reports of refugees experiencing difficulties in maintaining legal residence in Lebanon, and entry for Palestinian refugees from Syria seeking safety and protection in Lebanon has all but ceased.

On World Refugee Day, the Lebanon Humanitarian INGO Forum (LHIF) said that Lebanon needs greater support from international donors to provide for refugees and host communities before the situation becomes untenable. LHIF also urged all countries neighboring Syria to ensure that their borders are open to all civilians fleeing the conflict, regardless of national status.

Lebanon now hosts more refugees per capita than any other country in the world – one out of every four people living in the country is a refugee. But with over 1 million refugees already in the country and thousands more arriving every month, only a quarter of the funds needed to provide essential services for refugees and host communities in Lebanon in 2014 have so far been received.

“The Lebanese people and government have done far more than any other country to provide a safe haven for the millions fleeing conflict in Syria. This lifesaving action has to continue. By denying entry to civilians, vulnerable populations may be stuck inside Syria or forced to cross borders at unofficial points, through insecure areas affected by cross-border shelling and mines” said Niamh Murnaghan, Country Director for the Norwegian Refugee Council in Lebanon.

A lack of clarity for refugees over legal avenues for regularizing their status is leading to increased fear and inhibiting their ability to access protection and services. Many refugees who are living unofficially in Lebanon are already unable to move freely, too afraid to access legal protection or aid, and are at risk of exploitation.

Increased support for Lebanon from the international community is critical. “For many refugees, crossing a border is the only means of survival. Syria’s neighbours have an obligation to keep their borders open to refugees, but they need more help. We urgently need to see an increase in solutions offered by other states to ensure effective refugee protection including funding, resettlement and humanitarian admissions” said Médecins du Monde’s General Coordinator for Lebanon, Baptiste Hanquart.

Note to Editors:

• May 8^th: A Ministry of Interior (MoI) circular was published announcing temporary closure of Lebanese borders to PRS for security reasons (http://www.unrwa.org/prs-lebanon). Some PRS have been allowed to enter since, but the majority of these are individuals who are transiting though Lebanon or are attending specific appointments (e.g., Embassy appointments).
• June 1^st: An MoI circular was published warning Syrian refugees that if they travel to Syria after June 1^st 2014, the Government of Lebanon will no longer consider them as “displaced persons.” On June 2^nd 2014, the special ministerial committee established by the Lebanese Council of Ministers to pursue issues specific to the Syrian refugee community supported the MoI declaration and clarified that the GSO “will be notified not to consider any Syrian citizen as a displaced person if he/she is coming from a safe place in Syria.”
• There is currently a freeze on visa renewals for PRS, making it impossible for PRS who have already been in Lebanon for over a year to renew their legal status.
• The cost of renewing residency permits for Syrian refugees is $200 per person per year for everyone over the age of 15; this is a prohibitively cost for nearly all refugees.