Hospitals and Doctors under Attack in Syria: Q&A with the Chair of the Humanitarian Aid Committee for the Syrian Expatriates Organization
What follows is the conversation between Ms. French, Dr. Al Khankan, and Ms. Newland.
AF: I am Amber French, the Editor of the Source, which as you know is the Migration Policy Institute's online journal. This Q&A is intended to delve into the extremely important and timely topic of the Syrian conflict, focusing on issues relating to medical emergency and health of the hundreds of thousands of Syrian refugees and displaced population from the Syrian conflict.
I am here with Dr. Fadi Al Khankan, a pulmonologist originally from the city of Homs, Syria. Dr. Al Khankan is the Chairman of the Humanitarian Committee and a member of the Medical Committee of the Syrian Expatriates Organization (SEO). He has been an assistant professor and faculty senator at Marshall University in Huntington, West Virginia since 2003. He specializes in Pulmonary and Sleep Medicine, and is a graduate of Aleppo University [in Syria]. Dr. Al Khankan is also actively involved in a number of organizations, including the American College of Chest Physicians, the Syrian American Council, and the Syrian American Medical Society.
To my left is Kathleen Newland, MPI Co-Founder and Director of the Migrants, Migration, and Development, and Refugee Policy Programs, as well as International Rescue Committee (IRC) Overseer. She visited [Jordan and Turkey] in November with members of the IRC delegation... I would like to proceed with roughly seven or eight questions, many of them are directed to you [Dr. Al Khankan] and your experience on the ground in Syria and your activities with SEO. There are also a few questions for Kathleen for her views when she was traveling in the region and also the work of IRC. So I'll begin with Dr. Al Khankan.
When and how did the Syrian Expatriates Organization first become involved in the Syrian conflict on the ground? How has SEO's involvement evolved? Is this different from what the organization was expecting at the onset?
FAK: At the SEO, we started from the beginning of revolution. Initially, it was a Facebook movement, the same as the Syrian revolution or in Egypt or in Yemen. It was a FB movement and that [made us really organize ourselves] and to establish that organization to help to make democracy in Syria. Over the last two years, we have been working from day number one. We had applied for a nonprofit organization and we got approved. We — roughly more than 200 professionals in the United States and Canada — organized ourselves. Most of us are first generation here, so we know the Syrian people's language, we know the culture, we know what they need. Our group organized and covered most of the areas in Syria from North to South. Most of us have been activists in multiple ways and also most of us are members of other organizations... Initially we started as a movement on Facebook, then we started mainly in revolutionary support. And then we moved forward as the need of the revolution has changed from the beginning when it was a revolution of freedom to now a revolution of medical and humanitarian aid, beside freedom. So we have moved forward and became more organized, made up multiple committees. Each committee specializes in a way of supporting the Syrian people.
AF: The International Rescue Committee's report Syria: A Regional Crisis states: “Doctors described to the IRC a systematic campaign to restrict access to lifesaving health care through the strategic bombing and forced closure of hospitals and health-care facilities.” Had anyone anticipated the attacks targeting hospitals? Could you speak a little more to the ways in which doctors and other staff have responded?
FAK: The regime has been targeting the key points in each city. As we said, we divide the areas inside Syria into two zones: [one] zone under the authority of the regime and the other is freed. In those zones, the regime has been trying to target their key points, the infrastructure of each city. [They went through] whole cities, targeting gas stations, bakeries, and hospitals. They left nothing. So the infrastructure of the cities has been destroyed... For example, what we heard recently, [they send gas to] one of the gas stations. So people rush to get some diesel for heating and then they pound it to have the most casualties. So hospitals are really targeted largely. And then that moved us from using the hospitals — like in Homs, the national hospital in Homs has been bombed and it's [deserted] now — to make up secret field hospitals inside [Syria]... Just because of the need that has moved to [better organization, there are] three classes of hospitals: field hospitals, on the front line; to a little bit larger hospitals to perform a little bit more operations; to a larger hospital that is on the borders to perform more sophisticated surgeries.
AF: Kathleen, is this typical of other crises? Have we heard in other recent violent conflicts of targeted attacks on hospitals and on other important centers for [everyday] living?
KN: I think that the Syrian crisis is unusual in the extent of the targeting of medical facilities and medical personnel also. We were told by some of [Dr. Al Khankan's] colleagues we talked to in Jordan that a colleague had recently been stopped as he was crossing the border back into Syria and was found to have medical equipment in his car. The Syrian authorities treated him exactly the same as if he had been importing weapons. They said if you were found carrying blood bags or things that are clearly palliative care, that it's just the same as if you had weapons in the eyes of the Syrian authorities. And I think that is unusual in the extremes to which the regime is going to undermine the support systems of the civilian population. As Dr. Al Khankan has said, it's not just the hospitals, but obviously in the time of war, hospitals and medical personnel are extremely critical, literally, to the survival of people. And also psychologically, I think.
I also have — and Dr. Al Khankan can correct me if I'm wrong — but I've also heard particularly in Syria that the medical profession had a special status, and that maybe it's because the dictator is himself a doctor, I don't know. Medicine is a very prestigious field. The regime had invested in medical schools and so on. And perhaps thinking that the medical profession is apolitical, that it's an area that was sort of safe to be developed within Syria because, you know, NGOs or civil society were deliberately kept down. That was obviously a miscalculation on the part of the regime because Syrian doctors have been among the most, sort of, activists and strongest supporters of the revolution.
FAK: In Syria, being a doctor was really implemented by families. Look at how many Syrian doctors are here in the United States. It's compared to other immigrants from other countries. Even Syria is much, much smaller than India or Pakistan or China, and you see a lot of doctors here. What's going on in Syria, the doctors/personnel are facing a huge burden. Even with the health-care professionals who are working for the regime... [they are not] able to help the wounded people... It's unfortunate to look at Syria now and you see a lot of shortage in doctors. All those doctors are outside Syria.
AF: ... I was surprised to hear [at the MPI event earlier today when] an audience member mentioned some of the medical students having their certificates pulled. Have you encountered this in your work?
FAK: Yes, there have been a lot of medical students, they [the authorities] pull their certificates... Unfortunately, even the medical students who fled because they are wanted, because they protest against the regime, they can't get their certificates out. They cannot get what proved they had been students there. They had been targeted by the secret services, so it's very hard. Most of them are just working in field hospitals trying to help other people.
AF: Kathleen did mention this a bit, but I did want to also have your view, Dr. Al Khankan, on the uniqueness of the Syrian conflict from a medical emergency perspective? Kathleen mentioned especially the extent to which the Syrian regime had targeted hospitals [and medical personnel]... For example, the health of refugees, not only in camps but also in urban settings. Are there any particular challenges that you face — not necessarily SEO — but that the international community should be aware of in addressing health issues for refugees in both settings?
FAK: The problem there is... Health is not a medicine [for which] you prescribe a prescription or a medical supply. Health is a whole socioeconomic status: shelters to sleep in, hot water to take a bath, clean food to eat, clean clothes, washing, electricity, gas, heat. So it's a big dilemma. Most of the work has been going on in field hospitals, taking care of the wounded. Not enough work has been done to help the chronic diseases: hypertension, diabetes, those sick people who have been really sick. They need medicine... There is also no preventive medicine. We met people who had not taken a bath for six to eight months. There is not hot water; they live in a tent. They eat... with a small fire around. I look at, for example, Atma camp, you see people living in tents in that cold weather, between the olive trees. We saw children who have no milk to drink. Women are not able to breastfeed their children because they are not eating healthy food. So the disaster is not only medical. Just trying to provide medical aid is not enough. We need huge [humanitarian resources] to help the socioeconomic status of those people.
AF: I understand. Indeed the IRC report had stated that “While camps sheltering Syrian refugees capture most of the media attention and international funding, they do not attract the majority of Syrian refugees. Many more... currently reside in urban or rural areas, not in camps.” Some of these — as you addressed — challenges to the health of refugees really comes from this idea that health is not just a medicine, but an entire cohesive package of especially very specific health needs for children and for women; so it was nice that you had spoken to this question.
But on a more positive note, have medical emergencies arising from the Syrian conflict given way to, or indicated the need for, any particular innovations or inventions in the medical or medical emergency industry?
FAK: We have worked very well in making a lot of field hospitals inside Syria. There have been a lot of volunteers who went inside Syria — organized. We have been working with a lot of programs, like the physician-sponsoring program, where we match each doctor who is working in Canada or America, we match and try to help a doctor inside Syria. We have a lot of physicians working inside Syria and we have matching between physicians outside and inside.
We are working now in telemedicine. We are trying to open through the Internet — [setting up] conferences between a doctor outside [Syria] who is very well specialized here to another doctor inside for consultations, and making call schedules... to cover all the basic needs for the people inside. We have been trying to collect a lot of supplies, medical supplies... We are very organized in sending people for visiting inside Syria. We have a call, we know where to send the doctor; even sometimes we collect cases — for example, for neurologists — one of the neurologists will go there and see his own patients. Containers full of medical supplies [that] we have been trying to send [to Syria]. We [sent] one before and we are trying to send another one. But the need is so huge that not a single organization or one country can carry on. We need the whole world to stand up for Syrian people, to help in all aspects of this crisis.
KN: ...One thing that I observed in Jordan also was a great deal of sophistication in the supply chains for medical supplies and equipment. It was really impressive to see that as part of this communications revolution that Dr. Al Khankhan mentioned, you know, that he was Skyping with a fellow doctor inside Syria, and this kind of thing... If doctors are able to connect with an organization that has supplies to send, to tell them exactly what they need — “We need so many antibiotics, we need blood bags, we need forceps, whatever it is that is needed” — those packages can be assembled, electronically tagged, sent into Syria where the electronic tag is snapped with a smartphone, and the geolocation devices then sent to a dropbox so the donors can be sure that the exact supplies they sent arrived at the exact place they were intended to arrive.
This may seem trivial in a war situation, but it's very important to donors to know that their supplies are not being diverted to the Syrian army or that they are getting across the border, they're not going into the black market. So the uses of communications technology have really... and by a population, both in Syria and among Syrian expatriates, it's very sophisticated in the use of Facebook and Skype and all the tools, the dropbox that makes it possible to leave a message or to track supplies in a completely anonymous way, so that if somebody accesses the dropbox, they can't tell who the messages come from or where it's going. It just exists in cyberspace. So it's much safer and it's very reassuring to donors. We certainly hope that it will encourage them to give more.
AF: Would you have any statements?
FAK: Most of the doctors I know [in Syria], the work is not enough. We have a lot of work to do, but people inside — the doctors especially — they are working voluntarily. So, imagine a doctor who left his family, left his children, and went inside... one of the field hospitals. So you see their work; really, a lot of it, you feel like they are doing tremendous, way beyond what a human being can do, or what other doctors [can do]. I was amazed by how much innovation they had been doing, how many surgeries, what they are using.
I saw a doctor who had a flashlight, and imagine, I opened an abdomen with this flashlight in my hand, with a battery because there is no electricity. I saw a lot of non-medical personnel; for example, in one of the field hospitals I was visiting — I can't say the name where it is, north Syria — we saw the ICU run by a two-year college student, who just finished an institute of two years. And he ran it very well; he ran it really very well, as a good physician who has been trained in internal medicine, and then in critical care medicine for a total of five years after medical school training. So, I saw a lot of personnel who are very well and acceptably trained. Because of the need, people have to come up and do whatever they have to do.
AF: Kathleen, you were visiting in early November, and at that time of the year the area is beginning to prepare for the winter. I understand that winterization is a major concern which is entirely relevant to health because, as we have been discussing earlier today, [the winter has an impact] on refugees. Would you mind saying a few words about the risk of epidemics relating to the winter, especially with most of the displaced people not equipped to withstand cold weather? What are the health considerations of winter?
KN: Dr. Al Khankan would be able to speak much more technically than I about the kind of medical problems you see. But I think, just on an intuitive level, we can all understand [the difficulties of] living in a tent in the midst of winter, and it is a particularly hard and wet winter they're having in and around Syria this year. Last week, the main refugee camp in the north of Jordan was flooded, the tents were blown down, people's clothes and blankets got soaked. And those were the ones who were in an internationally run and supervised camp. The people who run camps both in Turkey and in Jordan are trying to move more to trailers than tents, to sort of small containers which are more weatherproof. But it's still very cold, and a lot of the people who fled from Syria thought this would be over in a few months. So they came out in the summer, they didn't bring warm clothes, they didn't have their basic supplies to withstand the cold.
The winterization programs — and the Syrian Expatriates Organization is involved with winterization as well — are sending in just very basic things like rubber boots because in so many of these settlements, it's wet, it's muddy. It's really easy to get sick when you're just cold and wet... In the cities, particularly big cities [like Aleppo] where there's been so much destruction of the infrastructure, people don't have firewood. They don't have diesel or kerosene to keep themselves warm. So just getting warm clothes, blankets, waterproof footwear... The winterization kits that I've seen going in are mattresses to keep people off the cold ground, tarps to keep the rain off, rubber boots, blankets, the most basic kind of supplies just to keep people going through this awful winter.
AF: When does this winter period Syria end, typically? How long does it run? When does it start? When does it end?
FAK: Usually it's three and a half months. Starts by November and ends by the end of February. In the winter, we are facing huge needs in Syria because Syria is a cold country and it has been snowing now in many, many cities in Syria. So what we are facing are long-term effects on the Syrian people this month. People's needs are so bad that they need everything. People live in tents. People have been using trees, olive trees, for heating... A fire just killed seven people in Atma camp in north Syria. If you look at the people inside [Syria], a lot of disease from lack of bathing and water... [Scabies, chronic diarrhea, skin lesions have all] been reported.
People lack medicine. There is no maintenance medicine, no prophylactic medicines, no chronic medicine, no money to bring medicine — pills, chronic pills, insulin. For example, a lot of medicine needs to be refrigerated, but there is no electricity. So we're looking at a huge disaster that can affect even the environment by cutting all these trees and using them. It's going to have a long-term effect, and lack of medical provision, medical supplies, hospitals, infrastructure that's destroyed — it's not going to end in a year or two. It's going to take a long time.
AF: Are there any risks of epidemics at this point?
FAK: The risk is there. What I'm afraid of [is] that [it] may have started, but there is no way of really that much organized way of discovering it early. The risk is really huge [that] this will start. This makes sense... So many people are sitting in a big prison, especially in the areas controlled by the regime. You can see these people are going have disease that's going to be epidemic between them.
AF: What types of diseases are you [referring to]?
KN: Respiratory flu, TB...
FAK: From respiratory flu, TB a lot, it's even endemic in Syria... First of all, it's very hard to discover. Also, there has been no gathering of people inside one place because the regime has been bombing so people try to spread away, and that may also make it very hard to see [an epidemic] in a big scale, but it may start in a camp around the cities or where people really see the shelling.
AF: We hear about continuing attacks on the civilian population, and medical facilities and personnel in particular. What are the obstacles to your work, whether related to resources, administration, violence, or other? How difficult is it to get medical supplies to where they are needed?
FAK: There have been a lot of obstacles, starting by the very limited resources we have, moneywise, medical supplies. Starting by the safety of the medical personnel and how to bring things inside. The problem is that no nongovernment organization ever has been able to work inside of Syria, free, without their personnel being tortured and targeted by the regime. And most of the old nongovernment organizations in Syria are 100 percent... pro-regime, like the Syrian Red Crescent. They are pro-regime, and if you work with them, it's very hard to guarantee the reach of the humanitarian aid and medical aid to the right people.
So the main obstacle is that people working inside Syria are undercover. They are well-organized, but they are using cover to work. It's very hard to deliver large-scale humanitarian or medical aid to one place without smuggling it... Syria also can be divided into zones — each one is unique by their need. For example, northern Syria, there is a way of getting in from Turkey. They just need help. In southern Syria, there are a few ways you can come in from Jordan, but in the middle also, there are whole villages, like Al Houla, beside Homs. It's very well surrounded by pro-regime cities, so it's very hard to get anything in or out. [It is devastating to our work], and that's why we started to have one of our members specialize in one area, and see what's the need in each, one by one, either medical or humanitarian. And we try to provide for that need in each area, which is different from the others.
AF (to Kathleen): Do you have any additional thoughts to share on obstacles?
KN: I was wondering, has the regime tried to block your communications — cell phones, Skype, Facebook? Has there been any sort of cyberattack on the work you're doing?
FAK: Yes. We are using mainly satellite Internet. Because Syria is close to Europe, satellite Internet has been a really successful way of communicating inside Syria. It's very hard; [there are] a lot of ways for the regime to be able to track this. Skype is very well encrypted, or VPN we're using, and the satellite Internet by using European satellites, so it's very hard for the regime to be able to track them. There have been a lot of people: activists inside lost their Facebook accounts, people have had friends inside Syria targeted, their families have been suffering because of that and targeted. But really, because of need, people really move to “What to do, what to do?” innovations. They were able to find a way of communicating outside. And basically now I freely talk to a lot of activists inside Syria over Skype, and they are using satellite Internet that cannot be traced. So we were able to do that.
KN: That's really made a huge difference, I think.
FAK: I found a lot of hospitals, especially in northern Syria, they are using diesel-based electricity generators. So there's no electricity there, but they have it in each hospital, in each house with satellite there, over Wifi covering that hospital we are freely able to talk over Skype to people here, and tell them what we saw there, for example.
KN: That's amazing.
AF: That is. I have one last question and then we can wrap up. You mentioned during the event this morning that many wounded Syrians were being treated free of charge in Turkish hospitals. Have you heard of any such incidents in other neighboring countries? What is known about the state of health-care systems in Syria's neighboring countries since the beginning of the refugee crisis? So I guess, to begin with Kathleen, do you know of the state of affairs of health care?
KN: Well the surrounding countries, and particularly Jordan and Turkey, where I have seen it more, but I think also under the Kurdish regional government in northern Iraq, and to some extent in Lebanon, although I think it's less organized in Lebanon. But Lebanon and Syria have such close interactions that a lot of people have gone to Lebanon. The authorities in those countries have opened their health-care systems, opened their schools to Syrian refugees. Now, Dr. Al Khankan mentioned in his presentation this morning that it's difficult in Turkey because of the language. You know the schools are taught in Turkish, and Syrian students are taught in Arabic, so it's more difficult.
But in Jordan, a lot of the US assistance that has gone to Jordan both during the Iraqi refugee crisis and now has been to support their school system. So that they can put on double shifts, so that they can hire additional teachers, so that they can take Syrian refugee children into the Jordanian schools. It's a tremendous lift. ... A lot of the schools just aren't able to absorb more children, so you know, in theory it's a good system, but in practice, it's under tremendous strain.
And the same is true of the medical care, the clinics. These two small towns in northern Jordan that we've been to, Mafraq, and [Ramtha], but the International Rescue Committee has set up clinics, which are open to local residents but are specifically set up to treat Syrian refugees, to relieve some of the burden on the local hospitals and clinics because they are just overwhelmed. And they are also working very closely with the local hospitals, pharmacies, and clinics, so that if they give a prescription to a refugee, he or she can take that script to a local pharmacy, and try to find one that has the medicine in stock.
... I think the neighboring countries are really trying to be helpful, but it is increasingly difficult for them. I think especially Jordan and Lebanon, because the systems are not as highly developed as they are in Turkey, they're much poorer countries. Things are pretty chaotic in Lebanon, especially along the border, so it's really very difficult. There haven't been so many refugees, but growing numbers are going to the Kurdish region of northern Iraq. And it's remote — the situation is pretty difficult there. Two of our delegation went to northern Iraq and about half the people are in camps, but it's not easy anywhere.
And one of the things that I found really very frustrating to hear is that the international community initially held back on giving financial assistance to Turkey for the refugee operations because the Turks were adhering to too high a standard. They were putting people in containers rather than in tents. They were providing levels of services that are above the minimum of what's considered to be acceptable to the international community and I thought “That's just insane.” We start punishing countries for treating refugees too well. It's really pathetic. But I think there's been some resolution of that. But I think Jordan, Lebanon, and to some extent northern Iraq are nowhere near the international standards for the basic kind of care and services that people should have access to.
AF: Do you have any additional thoughts?
FAK: What I want to say is usually medical supplies are based on the population's needs. For example, in a small city here, in Virginia, you are not going to open a big hospital in the middle of nowhere for a population of 1,000, 2,000 people. And that's what's going on in those surrounding countries where they are not prepared for this huge number, sudden increase in their populations. So they have limited supplies, or it was way beyond what everybody expected nationwide. So no such country by itself can bear or help this huge number of people in need — either humanitarian or medical. There are not that many big hospitals. And even the areas surrounding Syria are not huge cities with big hospitals, so nobody can bear, and nobody can really take this big burden. No country can do that on their own.
[Turkey has been the more successful country], more than other countries, as Kathleen said, because Turkey is a big country. The population of Istanbul is much [bigger] than all the Syrians in the world. Just Istanbul city... So they have been able to because it's a much bigger country, and they have the willingness, the intention, and the capability to work. And they have been doing a tremendous job. Still not enough, there is still a lack of hospitals and ICUs, and all the ICUs in the surrounding hospitals have been really full with wounded Syrians. Other countries are not really able to, like Jordan and Lebanon, the Turkish side of Iraq, because they are small countries, and they cannot really take all these refugees. They have a comparable number of refugees as Turkey has, so we're looking at the whole international community to intervene, to help, to really make a coalition. Use the Syrian coalition to help, to organize. There's no such one organization that's really working with other organizations to help. We need all the organizations to really intervene and help organize what should be done for the Syrian people, the same as what happened in Libya. That would be really helpful down the road.
AF: I'd like to thank you, Dr. Al Khankan and Kathleen Newland, for participating in this Q&A. I would like to invite the audience to visit the Source website for further information at www.migrationinformation.org.
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