Essay: Doctors Without Borders

“Examine the challenges faced by Doctors Without Borders/Médecins Sans Frontières and the volunteer doctors involved in the Syrian refugee crisis”
Doctors Without Borders is an “international humanitarian-aid non-governmental organisation” (1). The organisation was founded in 1971 by a group of doctors and journalists in reference to the Nigerian Civil War of 6 July 1967 – 15 January 1970 as the French doctors that founded the organisation felt as though “the needs of these people outweigh respect for national borders” (1). 80% of the funding for Doctors Without Borders is through private donors and the annual budget of the organisation is approximately US$610 million (1). All of the doctors and nurses that are involved with Doctors Without Borders need to meet a certain criteria in order to be able to work for the organisation and are paid £8,988 per annum (this increases after the persons first 12 months). Just in 2015 30,000 medical professionals (mainly doctors and nurses) helped provide “medical aid in over 70 countries” (1). Since 1st October 2013 the president of Doctors Without Borders is Dr Joanne Liu and there are currently 34,146 volunteers (1).
What makes Doctors Without Borders/MSF different from any other medical aid organisation is that it does not represent any religious, political or economic group and this is done in order to be able to speak and act freely and provide immediate medical aid to those that need it the most and do not restrict any particular group from this(2).
The official page of Doctors Without Borders for Syria states that there are 70 hospitals and clinics related to MSF in northwestern, western and central Syria. Figures also show that just in 2015 there were 154,647 people who were wounded and 7,009 people died as a result of the war. 30-40% of these were victims were women and children(2).
Although MSF has been trying to run some of their biggest operations in history for Syria, one of the important issues they’ve faced throughout the 6 years of this conflict but particularly in 2015 is the fact that the severity of the violence is increasing rapidly and after the abduction and release of 5 MSF staff in May 2014 the organisation has had to shut some of their hospitals and limit their work and change the aid they provide to a non direct approach which is something they are not used to doing.
Because organisations like MSF do not take sides in any conflict, and thus are not supported by any government, they often speak and negotiate terms and come to agreement with both sides of any war and in Syria, they have spoken to the Islamic State in order to ensure that the MSF staff and the patients in hospitals will not be attacked and because the response they received was not assuring the organisation had to stop work in areas controlled by the Islamic State. MSF have stated that they have been unable to “receive permission from the government of Syria to work in areas it controls” which has resulted in “millions of people (being) out of reach of hands-on assistance from any external aid provider”(2).
A report published by Doctor’s Without Borders on the 18th February 2016 provides an overview of the “war‐wounded and war‐dead in MSF‐supported medical facilities in Syria” in 2015. The report summarises the role of MSF since the start of the conflict in 2011 as paying for the reconstruction of facilities that were damaged or destroyed, “providing medical supplies; paying a basic salary to hospital staff to enable them to focus on their medical work; providing fuel to enable the hospital generators to function”(3).
Figure 1 is able to show the amount of casualties that occurred on medical facilities and the double tap attacks that occurred just in 2015. For all of the attacks that have been carried out in 2015 there are many children, some aged under 6 and women that have been injured or killed. Moreover it has also been mentioned that when serious explosions or attacks occur many of the people that die at the site of the attacks aren’t taken to medical facilities to be registered as dead because the main focus is to get survivors the immediate medical care that they require and so therefore because of this many deaths are not reported and so the real figures of the death toll may be much higher than what is reported (3).
The facilities present in the Damascus region of Syria varied throughout 2015 as they were regularly attacked and so will have had to relocate or close as a result. Figure 2 shows the changing number of medical facilities every month for 2015, showing September 2015 to have the lowest number of MSF facilities indicating how the severity of the conflict heightened in late 2015.
A recent news report with the heading “A Second MSF Hospital Has Been Bombed in Syria in the Last 10 Days” clearly demonstrates the severity of the current circumstances for civilians in Syria but also the doctors. The hospital in Idlib, Northern Syria that had 54 staff is said to have been destroyed on the 15th February 2016 after being targeted by “four missiles following two attacks within an interval of a few minutes”. Massimiliano Rebaudengo, MSF’s Head of Mission has said
Figure 3: Picture showing the aftermath of the attacks at the hospital in Idlib, northern Syria. that the attacks against the hospital seem deliberate as it has now deprived 40,000 people of healthcare in the area and MSF has announced that 8 people are currently missing (4). This attack has resulted in the deaths of 9 staff and 16 patients (one of whom was a child) and this death toll is expected to rise once the rubble around the hospital has been cleared (5).There were 25 staff present in the hospital at the time of the attack and 5 died immediately after the attack, 3 were recovered injured from the rubbles and 2 are still missing with the remaining 15 staff whom survived (6).
It is still not known who carried out the attacks as the states that are involved in the conflict have blamed each other; Russia denied involvement, Turkey blamed the Syrian government and Syria blamed the US-led coalition (5).
This hospital’s running and medical costs had been supported by MSF since September 2015 and even its reconstruction had been done in December 2015 as it had been forced to move from its previous location due to the several attacks (6). Figure 4 demonstrates how the airstrikes destroy the hospitals into crumbles and this therefore is able to highlight just how difficult it is to reconstruct these facilities after they have been destroyed.
Michiel Hofman, the MSF Senior Humanitarian Specialist has stated in his article for the MSF that usually in other countries like “Afghanistan and Yemen there is only one military coalition in the air” and because of this the GPS details of where the MSF supported hospitals and clinics are can be shared regularly with the military to prevent an attack.
However for Syria this is not possible because there are two coalitions in the air that compete and both of these claim that they do not and will not target civilians and that their main targets are terrorists, but it is evident that it is the civilians that are heavily affected despite these claims. Moreover, another reason why the protection of hospitals in Syria is difficult is due to the fact that the Government passed an anti-terrorist law in 2012 that made any sort of humanitarian aid and medical care to the opposition illegal and so therefore these aids are often done secretly without registering with the government. And because of this very reason any hospital that has been bombed or attacked by those involved in airstrikes can be justified through the means that they were not aware that they had targeted a hospital in the first place as they were not aware of its presence.
Currently there are food drops to help civilians but Michiel Hofman states that the main reason these people are dying is due to the lack of medical care available and the severity of their war injuries, not due to food shortages. Also another point made by the senior humanitarian specialist is that when the jets drop food packages, the civilians cannot be certain that the noise they have heard is aid or a bomb and thus this method of action to aid has been shown to be highly ineffective (7).
Figure 5 is a tweet from the MSF International’s twitter page and shows pictures of aid that has been sent to Syria, stating that just in January and February 2016, “550 tons of drugs, medical material & shelters” have been sent to support the facilities in Aleppo, the largest city in Syria. This therefore shows the substantial amount of work and aid sent by organisations like Doctors Without Borders/ Médecins Sans Frontières just in Syria.
Data released by MSF shows that in 2015 there were 94 strikes on 63 MSF supported medical facilities and that 53 of the medics were wounded whilst 23 had died, demonstrating how much the attacks have escalated in the past year compared to the initial years since 2011.
MSF has been said to attempt to gain official access with the approval of the Syrian government since 2011 to work but this has still not been approved and thus meaning that the current medical and humanitarian work being carried out in Syria puts both the Doctors Without Borders at risk as an organisation but also the doctors, nurses that work with them too (8).
An article written by Dr Joanne Liu the International president of Médecins Sans Frontières/Doctors Without Borders (MSF) for the Huffington Post states that MSF estimates that there are currently “1.5 million people trapped in sieges imposed by the Syrian government-led coalition, as well as by opposition groups”. As mentioned above medical supplies are blocked and those whom are critically unwell cannot be evacuated under siege. For example in Madaya there have been 49 deaths due to starvation despite the support and medical aid given by MSF.
It is due to these difficult circumstances that has caused 6.5 million people, half of which are children to escape the conflict and travel to neighbouring countries and then Europe. Just in September 120,000 people had to migrate from their homes in Aleppo, Hama and Idlib due to the heavy bombings taking place in these areas(9). There have been numerous cases of people risking their lives to travel to Europe by small inflatable boats that are filled with migrants protected by nothing but life jackets and have often died as a result of the boats sinking.
Figure 7 clearly shows that as many migrants as possible are fitted onto one boat with the hope that they can all travel to Greece safely and then travel onto Europe. The tweet by MSF International states that just in 2016 (January, February) 56% of the arrivals in Greece are Syrian, which again indicates how the Syrian refugee crisis is possibly one of the major problems in the world currently as the vast majority of those who feel hopeless and can find no better alternative than to flee their homes are Syrians.
Dr Joanne Liu goes on to say that the conflict has escalated so much in the recent years that even escaping bombs inside of Syria is nearly impossible let alone be able to escape to neighbouring countries. The borders of Lebanon and Jordan are described as being shut for newcomers, Iraq is not an option due to the conflict that is going on their own country. The solution of the European Union for this crisis has been to hand over 3 billion euros o Turkey so they do not close off their borders but instead accept those refugees that hope to reach Europe (9).
Both in this article and also on the MSF twitter page for Syria, the claim from both the organisation and also its International president is that the four out of five permanent members of the United Nations Security Council -France, Russian Federation, the United Kingdom, and the United States (10)- are involved in military operations and have ‘failed’ the Syrian people and have even “actively increased their suffering” (9). The appeal is for the UNSC permanent members to respect their own resolutions and also pressure their allies to implement them too. The resolutions mentioned here are in reference to the meeting the United Nations Security Council had in early December 2015 where they set a target of beginning peace talks in early January and hoped to achieve a nationwide ceasefire once the “parties concerned had taken initial steps towards a political transition” (11). Their ongoing resolution of protecting civilians, healthcare and providing humanitarian assistance has clearly failed so far and already within the first two months of 2016 there have been bombings against 16 facilities in Syria and 6 of these facilities were supported by MSF.
A statement delivered by Dr Joanne Liu in Palais des Nations, Geneva, on the 18th February 2016 explained the severity of the situation in Syria, stating that the routine attacks done on civilian infrastructure like hospitals prevent organisations like MSF from providing “lifesaving assistance” (12). Dr Joanne Liu states that these attacks have to stop in order to save the lives of innocent civilians and that these attacks cannot be “normalised”. As the international resident of Doctors Without Borders she has made it clear in several circumstances that their approach is that “the doctor of your enemy is not your enemy”, thus clarifying their neutral and totally humanitarian approach to any sort of war.
In reference to the attack to the hospital in Idbil, Northern Syria on the 15th February, Dr Joanne Liu explains that 4 missiles struck the hospital and the attack lasted 2 minutes however there was a second attack 40 minutes later when the rescuers arrived and this was done deliberately to target those that were trying to help the wounded. Moreover, some of the injured were taken to a hospital nearby and this hospital was also struck by missiles which creates the implication that it is the civilians in hospitals that are being targeted rather than the groups involved in the war.
This can then be evidenced by the fact that just over the last 13 months 101 aerial attacks have been made on purely MSF supported facilities. Again there were cases of a second attack once the rescuers and medical experts had arrived at the site and unsurprisingly people now claim to be scared to go to hospitals even if they were injured because the likelihood of them losing their life by another bomb at the hospital is not small. She indicates that it is because of this very fear that people have had to flee for their lives and escape the ground combat and air strikes.
However many of the people trying to escape the country are being prevented from doing so as there are currently 100,000 people in Azaz, Northern Syria that cannot leave and are “trapped between the Turkish border and the frontline”. The international president of MSF states that people have “a fundamental right to flee from active war” and that “bombings must stop in areas under siege” with “increased and unhindered deliveries of aid and the immediate evacuation of the wounded and sick” (12).
A 26 year old Doctor working with Médecins Sans Frontières in Syria named Ahmad Almohammad has experienced several bombing attacks whilst on duty in the hospitals supported by MSF. In the news report he explains how in Fafeen, just north of Aleppo two years ago he was working in a hospital when him and his colleagues heard a helicopter approaching and this indicated that they would be bombed very shortly. He states that “We all had to guess where the barrels from the helicopter would drop, all the staff and patients started to run, but we had no idea where to go. We could hear the noise above, we all thought the helicopter was directly over our head. It was all down to chance on whether we’d be hit. In those few seconds, it felt like my last moments.”
Having spent some time working as a doctor in Syria Ahmad Almohammad was experienced enough with bombings to know that the helicopter would drop 5 barrels and thus during the attack he and his colleagues merely waited for all five barrels to fall before looking around to see the severity of the attack and to see how many people could still be saved.
Ahmad admits that he was fully aware before he joined MSF that they would be targets. He states that “The hospitals and the health workers are the first line of targets because we are trying to keep people alive.” As with many previous examples, little was left of the hospital after the attack. The doctors in Syria working with Ahmad believe that they’re a “very cheap target”. Ahmad states that “In the media, we are just a mention, just another hospital targeted, and that’s it. Nothing else. No one is moving to protect us – we have nobody to protect the health workers. If we ever leave Syria, we are escaping from our duties to help these people, and my duties towards my people”.
He lives in Kilis, Turkey with his mother and siblings and usually travels to Syria 5 days a week with MSF. His team are responsible for both providing donations that consists of drugs and medical supplies to more than 15 hospitals and clinics and they even help to provide the 100,000 people stuck behind the border with Turkey with essentials. Ahmad risks his life by crossing the border from Turkey to Syria every day and still feels like this isn’t enough due to having “three times the normal volume of patients”. “What I can provide is out of my control,” he said. “I know of an entire family killed by a rocket, and another family trapped under a damaged house for more than 20 hours. I’m used to seeing children with no arms or legs. It’s normal to lose family members here. The children are used to seeing blood, beheaded men, bodies in the street. Women have told me that they sleep fully clothed so that if they were bombed during the night, they won’t be unclothed. He states that; “When I stand in front of them, without any power to help them, I know there’s only so much I can do.”
Like the international president of the MSF Ahmad is also worried that there has been a recent escalation recently in the amount of bombings targeting civilians and hospitals compared to the past 5 years of this conflict. Ahmad’s mother is worried about him risking his life continually in order to provide aid to others and because of this he often has to lie to her and say he is safe even if thats not the case and also calls her at least twice a day so she knows he is okay.
As someone who has been on the frontline for sometime now Ahmad says that after the immediate airstrikes the next more important long term issue is the fact the people in Syria are regularly surrounded by death and because of this their mental wellbeing is significantly harmed.What people don’t realise is that the Syrian people – especially those I work with, the people in hospitals, the nurses and doctors – they’re not well, psychologically,” he said. “They do not see the danger as being danger now, because they’ve seen so many awful things, so many wounded people, so many dead people. They don’t know that they’re not well mentally.
“When they see dead people, they don’t see anything any more, because this is all they’ve known for years. Yesterday somebody came into the hospital and said 13 people died in the village next to ours, and he said it without being sad. They are numb to people dying.” Ahmad Almohammad is sick of one party blaming another party for the attacks carried out and thinks that “Whoever wants to help the Syrian government, they can do it without any permission”(13).
Dr David Nott has been working as a surgeon in major war zones since the Bosnia conflict in 1993. He has a normal day job in three different hospitals in London where he performs three different kinds of surgery and every year he takes around three months off work to go and provide medical care to those affected in conflict or war zones. He often has to work in very difficult conditions but he is regarded as being one of the country leading surgeons and has operated in countries like Iraq, Sudan, Sierra Leone and the Democratic Republic of Congo.
Dr Nott has received the Robert burns Humanitarian Award and has even successfully
Figure 10: Dr David Nott, most experienced war surgeon amputated the arm of a Congolese man with an infected shoulder over a text message from a colleague even though he had never carried out the procedure before.
Despite being used to loss due to his experience over the years in many different countries Dr Nott states that nothing quite compares to what he has witnessed in Syria as “Nearly nobody is reporting this” and “the direct attacks on healthcare and healthcare workers,” because the logic of those that attack hospitals and other healthcare is that “You take out one doctor, you take out 10,000 people he or she can no longer care for.”
He describes how in his last trip to Aleppo, Syria, in October 2014 where two doctors he knew were killed in an air to ground missile and explains how doctors are attacked because healthcare on its own is seen as a weapon and thus hospitals and ambulances are targeted on purpose in his view rather than by chance.
The pattern Dr Nott has noticed is that the “Russian jets fly very high up. Syrian jets fly lower, firing rockets and missiles. The Russian planes tend to be 10,000ft up and you don’t see it, you just see the weapon hitting the hospital.”
Due to the increased amount of attacks in the last couple of months Dr Nott says the medics are determined to set up clinics in caves outside cities and have wards underground in order to be able to escape the bombings.
Even when he isn’t able to go to Syria directly, Dr Nott has regularly given surgical advice to his colleagues in Syria however he states how there is no longer any internet in Aleppo. He has even gone to Gaziantep, Turkey in April in order to be able to “train Syrian colleagues in specialist trauma surgery”.
What frustrates Dr Nott about the general approach to the conflict in Syria is that people seem to just be fixated on fighting the threat of ISIS and have completely forgotten or ignored the humanitarian disaster that is going on because of ISIS.
“The healthcare workers I work with are not fighters, they don’t carry weapons, they’re just there to help,” he says.
“What is happening to them is totally against international humanitarian law – hospitals should be protected and they are being targeted. Targeted to ensure the destruction of the healthcare system.”
He calls for a no bombing zone to be set up in Aleppo and Idlib as these are the rebel held areas and Syria and are heavily attacked.
“It has to be achieved. Somebody has to stand up and say, ‘The humanitarian situation is so bad that this has to be achieved’. It is a systematic destruction of the healthcare system: a weapon of war which Syria and Russia are using at the moment. That has to stop.
Due to the birth of his first child he has not been able to go back to Syria in 2015 but makes it clear that he will not stop his humanitarian work and has even set up the David Nott foundation which raises money in order to be able to fund surgeons that are heavily involved in conflict zones.
He states that, “I can’t withdraw from it. I’m probably the most experienced war surgeon in the world. I can’t stop doing it now I have a family. I wanted to have one, I wanted to have things other people had. But it would be a shame to withdraw now because there’s so much still to offer, and a new generation to teach.”(14).
An article from The Guardian released in October 2015 is able to demonstrate the increase in the intensity of the situation in Syria in recent months as even healthcare assistants working with Médecins Sans Frontières have had to migrate to Europe.
The MSF worker describes how he watched people he had known his whole entire life join ISIS and how one of the leaders in his hometown of Raqqa, Northern Syria was actually a 20 year old neighbour that he had grown up with. After joining MSF in 2014 the healthcare professional describes how difficult it became to provide aid to civilians and the wounded as ISIS was taking over the area slowly. Furthermore he describes how they had to negotiate with the leader they had been neighbours with for 20 years in order to provide aid but this clearly did not last long as the attitude of rebel groups towards humanitarian organisations such as MSF are quite hostile and got were increasingly reduced in number until eventually they had to stop working in the area altogether.
The healthcare professional knew he needed to flee Syria when they got a call from former friends of theirs that had joined ISIS, warning him about being on a list which meant that they had to leave Syria that same night and travel to Aleppo which is again the north of Syria. From there him and some of his family members crossed the border to Kilis, Turkey and stayed in Turkey for a while and worked for another health organisation but due to the strict immigration rules it was apparent that they could not stay there and build a new life and so they decided to move on to Europe for the sake of his brothers.
The MSF worker describes how he found a smuggler in the coastal city of Izmir in Turkey and paid a lot of money for him to smuggle them to Greece via a boat. They had to get on a seven metre long boat with 52 other people that included a driver who was a refugee that hadn’t actually driven a boat before and many children too. Due to the boat being overfilled with people the engine could not carry the weight and when the fuel eventually ran out people had to get out and pull it whilst swimming towards the nearest Greek island.
The planned one hour journey ended up being 7 hours long and because the boat didn’t stay on the course they had set out on initially they had no idea which island they had landed on. Once they reached the beach, feeling “exhausted from swimming and pushing the boat” there was no one in sight which is usually not the norm as refugees are expected and greeted by special healthcare workers and volunteers at the beach of Greek islands due to the high amounts of refugees fleeing Syria since the summer.They “had to climb a mountain and walk five kilometres to the nearest town”. Because they were told there was no one that could help them that day after going to the police station, they had to spend their first night in Europe sleeping on the street.
After finding out they had landed on the Greek island of Samos the next day they started to make their way through Europe and initially went to Athens and then crossed the border to Macedonia and then to Serbia and Hungary.
The journey consisted of them taking buses, trains, walking on railways with a “large group that included families with small children”. The difficult journey was often eased by the help of aid organisations like MSF and the International Red Cross. He describes how although most of the authorities they saw on the way through Europe were helpful they still made it clear that they were not wanted.
Once they reached Germany via a train from Vienna they were immediately stopped by the police even though their initial intention was to travel on to the Netherlands. He explains how once the police officers heard they were Syrian and didn’t actually have any valid travel documents they were immediately taken into custody and were locked into an empty warehouse that made the refugees feel like criminals even though they merely were the unfortunate victims of a civil war in their home country that has now been mainly taken over by ISIS.
They were then made to travel to Dortmund the next day by train and then were detained again. The only reason the MSF worker that wrote the article for The Guardian was able to escape was due to the kindness of a translator that had the same accent as him and was from the same part of Syria as him. After deciding to help them the translator gave his employee badge that allows them come in and out and it was due to this simple act of kindness that the refugee was able to freely walk out from detainment.
The family of the refugee had to split up with some living in Frankfurt whilst his father still in their hometown in Syria who he says is safe because of him being an older man. He describes his next aim as being able to get permission to stay so he can learn the language, study and maybe even have the chance of getting a job with MSF (15).
In conclusion, it is evident that Doctors Without Borders are trying relentlessly to continue with the aid they can provide to the civilians of Syria despite how dangerous doing this has become or how much they have had to limit their work due to the increased intensity of attacks to healthcare centres and doctors within Syria.