Air strikes dropped barrels of explosives on the city of Aleppo and its province, resulting in numerous deaths within the civilian population. MdM, which supports seven medical networks inside the country, is one of the rare international medical NGOs providing a humanitarian assistance in Syria.

For the last 15 days, a deadly offensive, led by “barrels” filled with TNT targeted residential areas or public areas such as schools, markets or hospitals. More than 500 people died in these air raids making civilians the first victims. The Syrian medical partners of MdM in Aleppo have witness how catastrophic is the situation and how the flood of injured people in several hospitals of the city is. They denounce the terrible consequences associated to the use of these weapons. Pictures of the victims or dead bodies received by MdM reveal significant mutilations, particularly on women and children who represents more than two third of the injured people.

« I will be haunted until the rest of my life by what I’ve seen over the last few days », explains Doctor F. a Syrian doctor working in one of the four hospitals supported by MdM. « It’s even worse than chemical weapons, because at least you die in only one piece…».

Most of the hospitals are overloaded by patients and are short on medical supplies. Ambulances are damaged, destroyed or without fuel anymore. According to the Syrian medical partners, the medical needs are urgent. That is why MdM has recently sent surgical equipment to achieve more than 150 interventions, medicines and 20 000 blood bags.

MdM reminds that it is imperative that all the parties involved in this conflict respect the humanitarian international right rules, which intend to save civilian population who are not directly involved in the fights. Preventing access to health care to injured populations by targeting hospitals is another crime that we are denouncing

Tents blown away, flooded buildings, snow-covered settlements, muddy swamps: harsh winter conditions have come without warning this year in the Middle East and plunged displaced Syrians and refugees into severe hardship.

Syria is the worst hit with its 6.5 million displaced people.  A lot of them live in makeshift camps or tents which are in no way appropriate for winter conditions and have no basic heating systems. MdM teams have noticed an increase in common cold, pharyngitis, laryngitis and flu in the camps of the North-Idlib region, near the Turkish border. “These infections develop because of the cold and the overcrowded camps“, explained Dr. Hamza, medical supervisor for MdM. Common illnesses are not cured because of the appropriate quantities of medicines cannot be sent. “While more and more people are getting sick, fighting in the area and bad weather conditions are preventing us to supply our healthcare centres as we should”, said Rolland Gueneau, general coordinator for MdM in Syria.

In Zaatari camp, Jordan, more than 3,000 Syrian families were housed in tents mid-October while the majority of the camp’s inhabitants now live in caravans. Last week, strong winds blew dozens of tents away and heavy rain flooded others. Zakaria, a watchman at one of MdM healthcare centres in Zaatari and inhabitant described the situation. “People who were living in these tents sought shelter in the caravans of relatives, which are now overcrowded”, he said. “We feel humiliated because, in this camp, we are particularly exposed to wind and rain. Our daily life can be disrupted simply by bad weather”, he added.

In Lebanon, winter storm Alexa and temperatures’ drop have affected hundreds of thousands of Syrian refugees who lack appropriate accommodation and are particularly vulnerable to cold. “The impact on the ground is considerable as the country’s infrastructures are not in place to cope with the situation. And unfortunately, some heating systems are only made available to the refugees at the last moment while aid distribution is complicated and slowed by the poor weather forecast. Roads are cut off at the mountain passes and vehicles can only drive through at set times during the day,” analysed Baptiste Hanquart, MdM General Coordinator in Lebanon.

Despite the obstacles and gaps that remain, the health situation is under control, in Jordan as well as in Lebanon. MdM teams are closely monitoring the healthcare centres medicines’ consumption, to prevent any shortage and anticipate needs. MdM, however, remains deeply concerned by the deteriorating health status of vulnerable populations in Syria.

In the Bekaa Valley, heavy rain and snow turn Syrian refugees’ settlements into muddy swamps – December 2013 © Sebastien Chatelier

Once a young pharmacist based in Damascus, Mareeam has been working with MdM teams in Northern Syria for more than a year now. Just like most of her Syrian colleagues, working for MdM is her way of fighting against the unprecedented crisis that is affecting her country hoping this can alleviate some of the suffering of her people. Her passion for her work as a pharmacist sadly echoes her anxiety faced with an uncertain future.

In August 2012, when her husband, a doctor in the army, decided to desert, Mareeam had no choice but to flee. As her family is from a village 15 km away from the Turkish-Syrian border, Mareeam fled there with her husband and their young daughter.

Two months after she arrived, Mareeam started working for MdM as a pharmacist and then as a pharmacy supervisor.

“MdM chose to focus its programmes in Syria on primary and reproductive health care. For me, there are huge needs in these sectors, which are not covered by other organisations. This choice makes sense for me, as a pharmacist but also as a woman and as a mother. I have a little girl and I can imagine what it is like to wake up in the middle of the night and realize that your child has a fever and to have no one to turn to, no place to go and no way to get the appropriate medicine.”

“There are countless issues in Syria right now and not all of them are linked to the bombings and violence. There are people with diabetes, people suffering from chronic diseases who cannot be cared for.”

Mareeam underlines the evolution from her work in a private pharmacy in Damascus to her role as a pharmacy supervisor for MdM.

“In Syria, before the war, patients could buy the medicines they wanted from the chemist’s. There was no control whatsoever. It was very frustrating for me, as a pharmacist, because if I refused to sell a drug deemed dangerous for a patient, I knew he would get it from the next chemist’s. The problem with this practice is that resistance to some antibiotics has got stronger and stronger. That’s why, in Syria, we have treatments that don’t exist anywhere else. In the long run, it could mean that some illnesses may become incurable.”

“In MdM, we work a lot with doctors and think thoroughly about each medicine we use in our centres. We try to raise awareness among patients. But it’s really difficult: people are used to it, it’s their way of thinking. Doctors experience a very strong pressure from patients who think they know which medicine is best for them. Through MdM, we can try to change things a bit.”

Mareeam also talks about the projects and relatives she left behind in Damascus.

“You know, three years ago, we would never have thought that all of this was going to happen. A few days before my husband decided to leave the army, we had a six-month project to buy a new house. We were talking about a new bed for our daughter. We never bought it.”

“Part of my family still lives in my village, which can be considered as safe. But their living conditions are inhumane: no electricity, no running water, and impossible communications. In the camps, it’s the same.”

Mareeam describes the instability of her exile and her fear of being pushed again on the roads of wander.

“It’s been two years I don’t really have a house and my clothes are in a suitcase. We could be forced to leave from here tomorrow.”

Day after day, the future becomes more difficult to imagine.

“I feel I’m stuck here. I have no option but to wait. My husband works in Aleppo, he leaves for two or three weeks then comes back here for a few days. When he leaves, I never know if he will be coming back, if I will see him alive again. I’ve stopped seeing the future, I see today, I see until the end of the week, no more… Syria will need ten years to recover from this war, if it ever recovers. And I don’t know if the Syrian people will be able to live together again. I don’t know if I will be able to accept the people who sided with the regime and I don’t know if these people will be able to accept me.”

A piece of chocolate and a short message: “Wishing you a better mental health”. This is how MdM teams chose to mark this year’s World Mental Health Day (10^th October) in the primary healthcare centres and schools of 33 villages of the Nablus region, Palestine.

For the third consecutive year, MdM took World Mental Health Day as an opportunity to raise awareness on the importance of mental health. “Informing communities that there is a day dedicated to mental health helps MdM to show that mental health is essential, that it is as important as physical health” said Mahmoud Isleem, Programme Manager for MdM in Nablus.

The initiative has been part of MdM’s activities aimed at improving mental healthcare in Nablus governorate. It would facilitate MdM’s work in disseminating more complex messages regarding mental health and reducing the stigma tied to mental disorders in the area.

More specifically, the distribution of chocolates on World Mental Health Day was a way to introduce MdM in 25 new villages, where MdM did not previously implement activities. As Mahmoud Isleem expressed, “the objective for us is that communities’ members now associate MdM with mental healthcare, that they know that MdM will address these issues with them in the near future”.

MdM joins Amel Association in the promotion of Dr Kamel Mohanna’s biography, recently published in French. Founder and president of Amel Association, Dr Kamel Mohanna has been one of the main initiators and developers of the partnership between Amel Association and MdM. The biography traces a life of commitment to justice, dignity and humanitarian causes. It provides a unique perspective on the upheavals that took place in the Middle East for the past sixty years.

MdM will participate in two round tables focusing on Dr Kamel Mohanna’s biography, in Beirut and Paris:

Friday 8th November 2013, 5.00 p.m. – 6.00 p.m., Salon du livre francophone de Beyrouth (room B), with

• Thierry Brigaud, MdM-France President
• Georges Corm, Former minister, Professor
• Henry Laurens, Professor and Chair of History of the Contemporary Arab World at Collège de France
• Scarlette Haddad, Journalist, L’Orient le Jour

Wednesday 13th November 2013, 6.30 p.m. – 8.30 p.m., MdM Headquarters in Paris, 62 rue Marcadet (18e), with

• Patrick Arberhard, Former MdM-France President
• Eric Chevalier, Ambassador, MdM Member
  
• Pénélope Larzillière, Sociologist, Researcher at the Institut de Recherche pour le Développement
• Thierry Brigaud, MdM-France President

In the primary healthcare centres supported by MdM in Lebanon, many Syrian refugees report psychosomatic complaints, which require specific care that cannot be provided by general practitioners. Given this situation, MdM strengthened the medical teams in the healthcare centres to include psychologists.

Noëlle Jouan is one of them. Since August 2013, she has been offering individual consultations to the patients of Kamed el-Loz healthcare centre, a village in the West Bekaa, Lebanon. This region currently hosts more than 41,000 Syrian refugees. In two months, Noëlle received 124 people, mainly Syrian women aged 14 to 30.

What are your patients suffering from?

NOELLE JOUAN: There are, of course, many cases of depression and anxiety, with all the symptoms that go with it. Nearly 15% of my patients have symptoms of post-traumatic stress disorder: for example, they systematically avoid places or people that remind them of past traumatic events.

Many women mention marital problems. In the current context, scarce resources push some parents to seek to marry off their daughters at any cost. Many of my patients are afraid that their husbands will take advantage of this opportunity. They tell me about their anxiety, their fear that their husbands could take another wife.

Degraded living conditions brought about by war and exile are sometimes seen as impossible to bear. One of my patients was a student in Syria. Her studies were her universe, there was never a question of her doing anything else. Today in Lebanon, she had to stop her studies and she now collects apples in the fields. When she remembers the notebook in which she used to write at the university, she starts to cry.

Other cases are much more serious. When I went with the mobile clinic that goes in the villages around Kamed El-Loz, I met four people with psychotic disorders in six days while I had not seen any case like this at the healthcare centre.

One case in particular struck me: a 13-year-old girl who showed no psychotic symptoms before the war in Syria. Today, she is unable to communicate, she isolates herself, and she is very aggressive. This radical change occurred when many bombs fell on her village one week. It seems that the war triggered latent issues and exile in Lebanon puts her in a precarious situation that makes her condition difficult to cure. Faced with her reactions, the girl’s parents are totally powerless. When I met the mother, she told me: ‘Take her with you, I don’t want her anymore.’I was shocked. What this child needs is precisely a feeling of security, a family who supports her. If she feels that her mother wants to get rid of her, this will not encourage her to reconnect with reality but to stay in her world.

Under normal circumstances, her family and relatives would have probably been able to provide her with the support she so desperately needs. But today, in Lebanon, her parents have nothing: they live in a tent, in a country which is not theirs, they have no work, it is hard to find food… And on top of this, they must live with the psychotic symptoms of their child. In this context, it is very difficult for them to accept her condition and to support her.

According to the World Health Organisation, ignorance and stigma are associated with mental disorders in the Middle East[1], as elsewhere in the world. Psychotherapy or psychology approaches are relatively unknown. How do you deal with this in your daily work with Syrian refugees?

NOELLE JOUAN: When I started to work at the healthcare centre, it was hard. Syrian refugees are not used to meeting psychologists and talking to them. It is not very socially acceptable. Apart from the stigma associated with mental disorders and thus with resorting to psychology, there is, in this context, a conscious or unconscious will to ‘stay strong’. For example, the men who had been referred to me by doctors of the centre believe that mental healthcare cannot help them. Because they are men, they must be strong, and they must accept their situation and fight for their sake and for the sake of their families. More generally, I would say Syrian refugees have an unconscious collective resilience. When my patients are telling me about their problems, it is as if they could endure anything. This could be because everyone around them has the same problems: they have all lost a relative, they have all been separated from part of their family, they have all left their country, they have all given up their social position… and yet, they fight and appear strong. It is also a defence mechanism, but for me it shows a strong resilience.

At the same time, there is a deep need to talk. Precisely because everyone has problems, because the situation is difficult for everyone they cannot find anyone to talk to within their family or their community. So, little by little, more and more patients come to see me at the centre. Some women even came back several times and I now help them regularly. And everybody talks, despite their reluctance and ignorance of psychology! They talk, talk, talk, I cannot stop them. They really need to be listened to, because listening is no longer present in their daily environment.

I’m greatly satisfied to have patients coming back and to see positive developments. One of my patients told me she’s feeling a real change from our first session. She is more combative, she has a new desire to liberate herself as a woman. In one of my last home visits, I saw again a young  girl with strong suicidal tendencies. Even though she was barefoot and the physical toll of her work and the mud were not easy to hide, she had tried to hide her misery behind a tiny bit of makeup.  This makeup, for me, is a good diagnostic, a sign of hope.

Since mid-August 2013, MdM and Amel Association manage a new mobile clinic operating in the West Bekaa, around the village of Kamed-el-Loz. The clinic is part of MdM and Amel Association’s efforts to better cover the medical needs of Syrian refugees and vulnerable Lebanese living in the region.

Access to health in the Bekaa remains difficult due to the remoteness of some villages and tented settlements as well as the relatively high cost of medicines and medical consultations. The MdM/Amel mobile clinic aims to overcome these obstacles by directly providing free health care in ten isolated villages and tented settlements (Es Saouiri, Es Marsoua, Soultana Yacoub, Soultana Yacoub Tahta, Hamara, Mdakhe, El Bire, El Rafid, Khirbet Rouba, Dahr el-Ahmar).

The medical team of the mobile clinic is expected to treat 500 patients a month, therefore completing the work done at the Amel/MdM healthcare centre in Kamed-el-Loz which received 1 876 patients in July 2013.

‘Today, I already received 22 patients and dozens more are waiting. A lot of people are suffering from chronic diseases. Apart from the number of patients, it takes time to explain to each person the treatment they have to follow and the medication they have to take, as they are not necessarily familiar with them’ explains the doctor present in the mobile clinic.

More information on our programme in Lebanon…

The once prosperous nation is facing a health care crisis

By Ron Waldman, President of the Board of Directors of MdM-USA, Professor of Global Health at George Washington University President and one of the signatories of the open letter ‘Let us treat patients in Syria‘ published in the Lancet on 16 September 2013

In Syria today, the unmitigated violence is what generates attention grabbing headlines and disturbing images seen around the world. Mortar blasts, sniper fire, fighter jet sorties and, maybe even, chemical warfare are only the most spectacular of the threats to civilians throughout the country.

But amid the terror and tragic loss of human life, there is another burgeoning crisis – the total breakdown of the country’s medical system. On a recent visit to Turkey, Jordan and Lebanon, the countries that, together with Iraq, are receiving the refugees of the Syrian civil war, it became clear to me that this crisis is different from most others to which the humanitarian community has responded. Preparations for a less visible crisis need to be taken now, in advance of conflict eventually ending in the region.

It is important to keep the Syrian situation in proper perspective. Until the beginning of the war, Syria had a relatively well-developed economy, a large middle class and a high-level, functioning health care system. But with the kind of tragic irony that only war can produce, these factors have been perverted into one of the biggest humanitarian liabilities facing Syria today.

Like the rest of the developed world, Syria’s medical system devoted a large proportion of its resources to treating the high burden of non-communicable diseases, “diseases of the rich,” from which large swaths of its population suffer. What clearly distinguishes the Syrian refugee crisis from most others, from the health perspective, is that it is characterized not by malnourished babies, not by children suffering from vaccine-preventable diseases and not by diseases caused by poor hygiene and sanitation, but rather by patients requiring treatment for diabetes, high blood pressure, depression, cancer and other chronic conditions.

According to the U.N., one-third of Syrian hospitals have been shuttered since the conflict began and a staggering two-thirds of medical personnel have either fled or been unable to continue working. The repercussions of this breakdown on the health of the population are impossible to overestimate, and cannot be dealt with effectively until safe access for medical and public health personnel can be assured.

During my recent visit, I observed the the thousands of people with chronic conditions stranded in the region’s refugee camps. Unlike children with acute illnesses that can be treated relatively easily and inexpensively in the short term, these patients need on-going care with relatively expensive medicines or procedures. Because treatment in Syria may have been different from what is customarily done in their new host countries and because the cost of that treatment may be too much for those countries to absorb, given the large number of refugees, those who manage to survive the physical violence of the war will find themselves facing the irreversible advance of chronic illnesses without adequate medical care.

The humanitarian community has encountered similar catastrophes in the past. During the Balkan and Kosovo wars of the 1990s, the situation was the same. But, as is so often the case, problems were identified, but lessons were not learned, and the world remained unprepared for another humanitarian health crisis in a middle-class country.

What needs to be done? Decisions need to be made by host country authorities and the international community as to how to guarantee continuity of care for Syrian refugees currently suffering from chronic conditions. Decisions need to be made as to how to ensure that new cases of chronic diseases will be properly diagnosed in a timely manner and that treatment, once initiated, can be continued for a lifetime. U.N. agencies, especially the Office of the U.N. High Commissioner for Refugees and the World Health Organization, must develop and implement policies and protocols that provide medical coverage for those in Syria and in other countries at risk of suffering the same fate if their health care systems should be destroyed.

One day, the war in Syria will end. The question at that point will be what kind of society, what kind of life, will the people of Syria have? What kind of health care system will be rebuilt? Careful planning, ideally undertaken by health care professionals working on both sides of the current conflict, will be required.

That planning needs to start now. If it does not, the carnage that we are currently witnessing could, unfortunately, be only the tip of the iceberg – shorter life and high mortality could be prominent features of Syrian society for many years to come and may, in the long run, be as far-reaching and devastating as the war itself.

Original article on usnews.com available here

More information about our medical programme in Syria…

In response to rising Israeli settlers’ attacks on Palestinian villages and military activities in Nablus governorate, Médecins du Monde (MdM) started a new project in May 2013, providing psycho-social support to Palestinian communities most affected by such violence. MdM objective is to mitigate the impact of violence, especially on the mental health of Palestinians. In close collaboration with human rights organizations, MdM also aims to limit future attacks by denouncing settlers’ and military violence and requiring higher accountability of the perpetrators.

In Nablus governorate, the number of Palestinian casualties due to settlers’ attacks was four times higher in the first quarter of 2013 than it was for the same period in 2012, according to the Office for the Coordination of Humanitarian Affairs (OCHA). Interventions by the Israeli Security Forces, constant verbal and physical abuses, inhuman and degrading treatments also contribute to create a general climate of fear and intimidation.

From January 2012 to May 2013, MdM conducted the pilot phase of the project in nine villages of Nablus and Salfit governorates and uncovered the highly negative impact that such violence has on the mental health status of Palestinians. ‘We met people suffering from depression, anxiety, symptomatic stress and Post Traumatic Stress Disorders. These mental health disorders are heightened by the recurrence of violent events, the impunity of the perpetrators, the sense of injustice felt by Palestinians and their anticipation of renewed abuses’ stated Malake El Turk, MdM Field Coordinator for Nablus area.

MdM therefore chose to commit to a one-year project targeting eighteen villages of Nablus and Salfit governorates. Should a violent incident happen in one of these villages, MdM psychologists and social workers are deployed to assess the situation, in coordination with the village councils. If needed, MdM teams organize debriefing sessions gathering ten to thirty members of the community. Groups of children, adolescents, mothers and fathers are given a free space to express their feelings and counseled on ways to manage these feelings.

Through the initial assessment or the debriefing sessions, MdM teams are able to identify people suffering from serious mental health disorders and to refer them to psychiatric services.  An MdM social worker recalls a case: ‘Settlers came into the house of a family and start beating the father and mother up. Two children were sleeping when the attack occurred and woke up suddenly. The first thing they saw was settlers attacking their parents. One of the children was so shocked that he suffered amnesia. We referred him for special psychiatric care.’

MdM intervention goes even further. MdM also refers people in need of legal aid, livelihood or agricultural support to other organizations in order to encourage a comprehensive humanitarian response. As children are especially prone to conflict-related stress, MdM will organise psychosocial and recreational activities in primary schools, in partnership with the Ministry of Education and Higher Education – Directorate of Education for South Nablus.

Our team members in Nablus are available on request for interviews.

Media Contacts:

Malake El Turk, Field Coordinator Nablus / Mobile : +972 (0) 598928424 / Office: + 972 (0) 9 2335103 / fieldco.nablus.palestine@medecinsdumonde.net

Cécile Génot, Communication Coordinator Middle East – Lebanon / Mobile: + 961 70 27 93 27 / Office: + 961 (0)1 289 882 / coord.com.me@medecinsdumonde.net

Nasreddine Touaibia, Communication Officer Middle East – Jordan / Mobile: + 962 (0) 79 5928971 / Office: + 962 (0) 6568 7984 / com.officer.mdm.me@gmail.com

Notes to Editors:

MdM is an international humanitarian organisation that provides medical care to the most vulnerable populations affected by war, natural disasters, diseases, famine, poverty and exclusion with programs in 79 countries around the world. More information on MdM programmes worldwide…

Present in the Northern West Bank since 1999 and in the Gaza strip since 2002, MdM aim in Palestine is to minimise the medical and mental health impact of the daily conflict on the Palestinian population, and to bear witness to the violations of their right to health. More information on MdM programme in Palestine…

MdM ‘protection and emergency psychosocial response project’ is funded by the French Consulate – Crisis Centre and MdM. It is implemented in the villages of Southern Nablus (Bureen, Madama, Assira Alqibliya, ‘Urif, Ainabous, Awarta), South-East Nablus (Qusra, Majdal Bani Fadel, Duma, Qabalan, Jureesh, Yutma, Assawya, Alluban Asharqeyah, Jaloud, Qaryout) and villages of the Northern Salfit governorate (Kefil Hares, Marda).

As the situation steadily worsens two years into the Syrian conflict, MdM is reinforcing its local activities in a situation of extreme emergency.

Following the recent attacks on civilians in Damascus, MdM is adjusting its aid to best address glaring needs.

Syria’s terrible sanitary situation for the past two years has also caused urgent medical needs.

Before October 2012, MdM worked with Syrian refugees in bordering countries. Since then, MdM has reinforced its activities inside the country to offer direct primary healthcare to the Syrian people. Today, nine MdM primary healthcare structures are up and running inside Syria with 50 professionals providing care.     

As access to civilians worsens, MdM has developed its network of partners working directly in most conflict zones. Working hand in hand with seven Syrian associations, MdM’s financial and material aid has increased threefold over the last year.

MdM is ready for any new escalation of the conflict. Emergency medical stocks (kits for primary healthcare, surgery, caesarean and decontamination) are ready to help civilians as early as possible.

With more than 100,000 casualties, countless people injured, 1.8 million refugees and 4 million internally displaced people, the numbers keep soaring in Syria.  

MdM reminds the international community that whatever its future initiatives, only an urgent ceasefire will guarantee access to all those populations in distress.