Syria: medicine on the front line

Interview with Dr. Ziad Alissa, co-founder and President of UOSSM France and Prof. Raphaël Pitti, Head of Training of UOSSM France by Pierre Brunet.

Pierre Brunet: Let’s remember that UOSSM France is the Union of Organizations for Medical Relief and Care. It is a French and international NGO whose mission is to guarantee permanent access to free quality health care for the populations affected by the war in Syria.

Let’s start with some simple questions. How and why was UOSSM France born? At the beginning, you thought it was for the short term, and ten years later you are still doing regular missions, training health care workers in Syria and in the surrounding countries. Was the birth of UOSSM France a response to a call for help from Syrian health workers to which you replied, or a spontaneous awareness of doctors and health workers from the Syrian diaspora and French people who decided, in view of what was happening in Syria, to get involved, to found UOSSM France and to do everything to respond to the emergency? Subsidiary question: today UOSSM France represents how many people?

Ziad Alissa : UOSSM France was a response to the request of our Syrian colleagues. At the beginning it is true that we thought it was something short term. At the beginning, each of us in the Syrian diaspora, I am talking about Europe, the United States, I am even talking about the Gulf countries, tried to help in their own way. Many colleagues went back and forth individually, including me. We started to meet there, on the border, the colleagues who went to Turkey to try to help through the North of Syria, but also in Jordan, in Lebanon. After a few months, we felt that the disaster required a greater response than individual aid. We realized that we had to build a collective response. To meet the needs, because they exceeded individual means.

Pierre Brunet : In November 2021, how many people will UOSSM France represent?

Ziad Alissa : Most of the staff of UOSSM France is in Syria. Today, we have more than 1,100 employees in Syria, in Gaziantep in Turkey, in Erbil in Iraq and in France.

Pierre Brunet : Let’s talk about the humanitarian and health situation in Syria today. The UN some time ago said that more than 350,000 people have been killed in ten years of war in Syria. The Syrian Observatory for Human Rights speaks of at least 500,000 killed, and perhaps another 200,000 dead. The UOSSM quotes the figure of at least 500,000 direct deaths, not counting indirect deaths, because chronic diseases cannot, or very poorly, be managed, there is a large number of indirect deaths that are difficult to count, which you estimate between 1.5 and 2 million. You remind us that there are 13.4 million people in Syria who need humanitarian assistance, 75% of the Syrian population depends on humanitarian aid for their daily survival, 60% of health structures have been destroyed, more than 90% of the Syrian population is below the poverty line and 80% of economic structures have been destroyed. What can we say beyond the numbers ?

Ziad Alissa : It is true that the number of deaths that we quote is higher than the figure that we hear, either from the official Syrian authorities or from people who simply take into account the direct deaths announced. But there are many deaths that have not been announced. We must not forget that when we see the direct victims of bombings or military operations, there are also tens of thousands of people who were arrested in prisons, tortured and died. All this is not taken into account. We must not forget also, as you have just said and as UOSSM France has noted, that the health system in the areas not controlled by Damascus in Syria has completely collapsed. This system does not meet the daily needs of the population. In addition to the direct victims, there are indirect victims, the chronically ill who cannot find their treatments, problems such as heart attacks without a radiology service to perform an emergency coronary angiography, we see this every day. Cancer patients who can’t find their treatments and centers to treat cancers, chronic kidney patients who can’t find centers to get dialysis. So many victims are not in the statistics. When we noticed this, we indicated that the numbers were higher in reality than those announced. And all of Syria is experiencing this lack of access to health services, not just in the north of the country. I think that the figures quoted by UOSSM France and other NGOs on the ground are closer to the truth and show an even more dramatic reality than what is portrayed in the media.

Pierre Brunet : Professeur Pitti, do you have anything to add?

Raphaël Pitti : There is a collapse of the health system. Look at the impact of Covid for example. We are intervening in the Idleb area in particular, where you have 4.2 million people, 2.8 million of whom are refugees from the Aleppo area, Ghouta or elsewhere, and who are mostly living in tents in very precarious conditions, totally dependent on international humanitarian aid, and then all of a sudden Covid appears. How, at that point, can we consider isolation for these people when they are confined to living in tents, having to look for food every day, fetch water, go to the toilet, etc? Today, more than 90% of the identified cases in the area come from the Delta variant, the mortality rate is very high. And when we talk about sorting people in France, saying “In the resuscitation services we have sorted the patients, taking into account the situation as it was” as if it was a disaster situation, what about the situation in this area of Syria? when there are only 200 intensive care beds that are 100% occupied, when there is a lack of medical oxygen, when there are only 95 respirators, when there is no device to monitor the levels of oxygen and carbon dioxide in the blood, when there are no antibiotics, when there are not enough corticoids? What about the situation of this population, which also has a very high rate of malnutrition, which makes it very vulnerable in terms of immune defenses? We asked Médecins du Monde, which also works in these areas, to come with us to meet the European Union Commissioner for Humanitarian Action in Brussels, about three months ago. We went to tell them how serious the situation was in Syria. And not only in the northern areas of Syria, but in the whole of Syria. In addition to the economic crisis in Lebanon, which impacts the already extremely difficult situation in Syria. We have explained that there is a risk of famine in Syria, especially in this winter period when we arrive at the break period, that is to say this period when the crops have been consumed and we must wait for the next harvest, and there is no money to buy the most urgent foodstuffs that people need. So this is a terrible situation for Syria, not only for the areas still controlled by rebel groups, but for the entire Syrian territory.

Pierre Brunet : Let’s talk about malnutrition. I would remind you that one child in three is malnourished in Syria. In addition to your medical and health aid, are you developing aid in response to this situation, to the risk of famine that Professor Pitti just explained?

Ziad Alissa : At UOSSM France, we have primary care centers inside Syria. Through these centers, which receive mothers, children and sick people for daily examinations, our teams on the spot have noticed many cases of malnourished children. We wanted to go further and conduct a study among the children in the IDP camps, examine them and determine the causes of malnutrition. We especially went to meet the populations living in the IDP camps inside Syria, and their situation is much more serious and dramatic. Displaced inside Syria, they do not have the status of refugees, therefore no humanitarian aid like those in the refugee camps in Turkey, Lebanon, Jordan. The status of refugees in the neighboring countries allows them to have access to a minimum of humanitarian aid to live. While inside Syria, they are completely dependent on associations like UOSSM France to work. Malnutrition begins with mothers who are unable to breastfeed their children properly because they themselves are malnourished. Their situation is miserable. The Syrian pound has lost much of its value. People cannot feed themselves properly because they cannot afford to buy food. As young mothers are malnourished and cannot breastfeed their children, they need infant milk, which is difficult to find locally. We know that a malnourished child is a child who will easily catch diseases. The families live in poor hygienic conditions, often in tents, there are no appropriate sanitary facilities. All these elements generate a galaxy of problems around malnutrition, and our teams on the ground have noted this. We have set up programs to fight against malnutrition, but despite all the good will of our teams, despite all the means of UOSSM France, this scourge of malnutrition persists among children. We have seen families who eat only two meals a day, or even just one meal at times, to leave the food for the children, and despite this, we have not yet succeeded in fighting malnutrition among children in the IDP camps as we should.

Pierre Brunet : I was struck by a term in one of your latest newsletters, where you explain that out of nearly three million people living in the Idleb region, 40% are displaced by war, and a large proportion of them are experiencing what you call “psychological chaos.” I would remind you, by the way, that there has been a resumption of bombing in the Idleb region since last October, with the trauma of these war situations. Can you elaborate on this notion of psychological chaos?

Raphaël Pitti : You have to try to imagine what the situation might be for these people, who have been displaced, who are no longer living at home, who are essentially dependent on international humanitarian aid, with Russian pressure, particularly at the level of the Security Council, which is trying to close all humanitarian corridors. There is only one humanitarian corridor left open, and it should end in December. Will it be renewed? What will be the situation of this population if international humanitarian aid can no longer transit through Turkey to be distributed to them? The future is totally uncertain, with the constant bombings and the health situation as we have described it. What hope can we give to these people in this situation, who at the same time live in camps? There is no education, there are no opportunities for young people to pursue higher education. What do you think the psychological impact is if you can’t project yourself into the future at all, when you know that at any moment a plane could fly by, bomb and kill you? There is a deep stress, very important, generating a situation of constant psychological trauma. All the experiments done in animal laboratories show this: you only have to put mice in a situation of constant, daily, continuous stress, with no hope of getting out of it, to see the state of depression in which these animals find themselves. This is the reality of the population living in Idleb. They do not know what tomorrow will bring, and today is extremely difficult. We cannot expect this population to be happy with the way they live. So the term used by Dr. Ziad Alissa is “chaos” in the psychological sense of the word that this population is living.

Professeur Raphaël Pitti of UOSSM in Syria ©UOSSM

Pierre Brunet : You mentioned the issue of humanitarian aid crossing points in Syria, which I wanted to ask you about. I would like to remind you that after ten years of conflict, international humanitarian aid remains the essential means of survival for a large part of the Syrian population. And yet, as you reminded us, Professor Pitti, it is hampered by the questioning of Resolution 2165 adopted unanimously in 2014, which has only been extended until the end of December 2021. Recall that 50,000 trucks of humanitarian aid had been able to benefit from these crossings since 2014, and that 1,000 UN trucks transit, each month, through the humanitarian corridor of Bab Al-Hawa, which is the only one still open, in the northwest of Syria, on the Turkish border. There are three other crossing points that are currently closed: Bab Al-Salam, also in the north-northwest at the Turkish border, Al Yarubiyah in the northeast at the Iraqi border, and Al Ramtha in the south-southwest at the Jordanian border. In your opinion, of these four crossings that were originally approved by the UN resolution, which ones should be reopened as a priority, in addition to maintaining the one at Bab Al-Hawa, which is the last vital cordon?

Ziad Alissa : You have located the four corridors correctly. Currently, only the Bab Al-Hawa corridor is open. The humanitarian corridors are used by all those working on the ground to bring humanitarian aid inside Syria to areas not controlled by Damascus. As a medical NGO, this humanitarian aid mainly translates for us into medicines, consumables and everything that hospitals need. Other humanitarian associations are transporting food, basic necessities. All these humanitarian corridors are essential to bring humanitarian aid inside Syria in these areas. But what we see, with the Russian and Chinese vets at the UN, is that every six months we have to mobilize to renew these openings. Now December is approaching again, and we are going to experience this anxiety again: will the opening be renewed or not? We know that Russia is pushing for “crossline” aid inside Syria. But crossline means that all humanitarian aid goes through Damascus, across the battle lines. And the observation of all the people who work inside Syria is that when this aid passes through Damascus, it does not reach the people who need it. Unfortunately, humanitarian aid has been used as a weapon of war in recent years, this is a reality. All the people who work in the field know this. They choose who they want to give this humanitarian aid to. This is unacceptable. They are using the technique of siege to suffocate the people and a whole city. We have seen this in Al Boutan, in Deraa, and elsewhere: a city is surrounded, under siege, and they forbid the passage of humanitarian aid. We have seen it in Ghouta and East Aleppo for example, children dying because they have not found medicine or food. So if this last humanitarian corridor is closed, if we go in the direction proposed by Russia, there will be an additional humanitarian disaster because entire areas will be completely cut off from the world without being able to bring humanitarian aid. We have seen the examples of Aleppo during this war, where in order to empty an area and push people to leave it, humanitarian aid is blocked. What we are looking for is to stabilize these areas. And in order to stabilize these areas, we must continue to bring people what they need, their daily needs. They need to eat, they need to be treated, they need a roof over their heads, they need to take care of their children and above all they need the bombings and the deaths to stop. And the essential humanitarian corridor of Bab Al-Hawa is not enough for all of northern Syria. It is imperative to reopen all the humanitarian corridors. What we are asking for is the unconditional opening of the four humanitarian corridors that were originally decided upon.

Raphaël Pitti is an associate professor of emergency medicine, anaesthesiologist-resuscitator, and army general physician. A specialist in war medicine, he joined UOSSM France in 2012 as head of training and has enabled the training of tens of thousands of caregivers. On March 1, 2021, he carried out thirty-one humanitarian missions with Syrian caregivers in the north of the country. In June 2021, he and Dr. Ziad Alissa conducted the first training in Raqqa to fight against COVID-19.

Pierre Brunet, writer and humanitarian :