It’s a rare occurrence for a nation to act altruistically in its humanitarian engagements, and even rarer when a state does so, knowing all there is in return is potentially heightened security risks in a conflict setting. I want to use this post as a brief pause from my usual focus on chronic disease care to discuss an issue that’s been near to my heart and that I believe deserves some attention. As the humanitarian crisis in Syria escalates, U.N. Secretary General, Ban Ki-moon stated last week that current death toll estimates are more than 100,000, up from the 93,000 estimate just last month- an increasing number of Syrian victims- many of them children- find accessing lifesaving medical treatment often impossible. Refugees, by the scores, find their situation to only be a growing obstacle. As the Syrian healthcare system continues to collapse under the circumstances and the NGOs and multilaterals experience difficulty in substituting healthcare, Israel has stepped up to the plate, caring for a growing number of Syrian patients, largely pediatric patients needing emergency and intensive care. I’m very sanguine to see the growing publicity and discourse around this remarkable situation reported on in a variety of sources, ranging from BBC News to Al Arabiya and News and the New York Times. Israel is home to an outstanding healthcare system and medical workforce, whose actions have saved many young lives in this situation, and have been an exemplar display of humanitarian health care. What may surprise people — or may have been forgotten in the midst of Syria’s civil war –and only makes this story more compelling, is that Israel and Syria are still considered to be in a state of war. While Israel has repeatedly stated a policy of non-intervention in Syria’s current affairs, Israel has also ignored the decades of its tenuous relationship with Syria, in order to provide emergency relief where it can under the circumstances. While obviously heroic, this also translates to thematic lessons for the global public health community in delivery of emergency relief services and global health diplomacy.
The Current Health Care Situation in Syria:
We’ve all seen and heard the media reports of heart-wrenching stories by now: Children with bullet wounds in their backs, burn victims, and the latest: civilians affected by chemical weapons. Syrian rebel forces and the Syrian government have been fighting for over 2 years with civilian bystander lives subsequently lost. Prior to the conflict, the Syrian healthcare system was one with trained health workers, medical expertise and its own pharmaceutical industry. However, this has been severed by the violence, and drug shortage problems continue as sanctions from the international community persist. The violence-induced infrastructure breakdown has resulted in a catastrophic barrier of healthcare access. This ranges from blood banks not being able to collect emergency blood supply, unstocked pharmacies, and unpowered hospitals (electricity and water are in very short supply). With restrictions on international aid continuing — in both opposition and government-controlled areas — and with what appears to be no visible resolution or ceasefire, Syria’s health system is unlikely to see much change for the better.
Consequently, refugees are desperately seeking safety and care in Syrian’s neighboring countries. Scores of refugees have fled to Jordan, Iraq and Lebanon, where they’ve faced nearly insurmountable challenges, according to a recent CBC News report. In Jordan, the Zaatari refugee camp is under-resourced and in Northern Iraq, the Domeez refugee camp faces issues of intolerable sanitation and over-crowdedness. Syrian refugees in Lebanon have actually been asked to pay for refuge- these are, of course, people who have lost everything- to live in conditions that can be described as nothing other than deplorable. So, where is the U.N.? According to reports from the NGOs on the ground, tens of thousands of Syrians are still waiting to be registered for services. Still, with all of this, international aid is wavering.
An anonymous letter from a Doctors Without Borders worker in Syria, sent to the United Nations, just days before their June meeting to discuss the conflict, pleaded for scaled-up support: “Turn words on Syria into action,” the letter boldly stated. “After more than 2 years of raging conflict, humanitarian assistance in Syria is sub-par. The response to the Syrian crisis, which has claimed more than 100,000 lives, has been far below massive and growing needs.”
Seeking Relief at the Israeli Border: Galilee Hospitals Act
With the U.N.’s support vacillating and Syrian refugees facing insurmountable challenges in many of their neighboring countries, those who have had the wherewithal, have made their way to the fence along the Golan Heights that separates Syria from Lebanon. For Syrians, this is considered a “forbidden border,” and many approach the border with fear of repercussions from fellow countrymen, should it be discovered that they were in Israel. Due to this, the Israeli military and Magen David Adom have taken extreme measures to protect the identities of these patients and their families so that they can deliver emergency care or connect Syrians in catastrophic health conditions to the necessary care without compromising the safety upon return to Syria.
In Nahariya — in Israel’s Western Galilee region — the Western Galilee Hospital has delivered emergency relief and care to over 100 Syrian refugee patients since March, 2013. Many of these patients have been children- even infants and toddlers- affected by the conflict. Dr. Masad Barhoum is the Director General of the hospital and an Arab-Christian citizen of Israel. He gave the following description of current situation to the New York Times: “Most {patients} come here unconscious with head injuries. I’m sure there is an initial shock they hear they are in Israel.” Dr. Barhoum describes the usual patient demographic of the hospital being a mix of Arabs and Jews, but under these unique circumstances, he also told the New York Times that he is extremely proud of the level of service the hospital has been able to provide in sustaining these lives.
The Western Galilee Hospital is not the only hospital in Northern Israel, stepping up to the plate. The Rebecca Sieff Hospital in the Galilee town of Safed has treated at least 52 Syrian medical refugees since late spring. Many other healthcare settings in the region are seeing a growing influx of Syrian patients with no sign of tapering off.
Little is known about the operation and how, exactly, Syrian refugee patients arrive at care. Medical personnel at participating hospitals are told to wait outside for the military ambulance bringing Syrian patients in critical condition. And then, simply, the hospital calls the army to pick up the patient upon discharge. What is additionally known, and was recently confirmed by Defense Minister Moshe Ya’alon, is that the military operates a small field hospital near the Syrian border (that largely goes unadvertised) with mobile medical teams to provide basic emergency care. Lieutenant Colonel Peter Lerner, an Israeli military spokesman, has publicly stated that this is being done “purely on a humanitarian basis” and that it is intended to “facilitate immediate medical assistance on the ground, and in some cases, evacuate patients for further treatment in Israeli hospitals.” The colonel also states that “Now, efforts are under way to bring over relatives of unaccompanied children patients.”
Lessons in Public Health and Global Public Health Diplomacy
Two themes come to mind when I’ve read these heart-touching tales. One concerns the public health community and compels me to think about how population-based emergency care can be most efficaciously delivered, while the other concerns global health diplomatic actions and how this can translate to global health diplomacy.
Aside from the awe I’m in when I’ve read these articles, I’m also inclined to wonder: How can hospitals and healthcare systems get leveraged to provide services across borders when the NGOs face barriers? The Syrian Red Crescent and U.N. agencies have clearly faced barriers in delivering emergency public health services. Many readers of the Humanitarian Affairs section of FPB are actively part of the global public health community are familiar with issues of public health in conflict zones. The brave men and women working in NGO’s in these settings execute exemplar health services. But there are times our community can’t always reach patients and when they can’t access our services. In Syria, many organizations have faced up-hill battles, including agencies of the U.N. and The Syrian Red Crescent. The International Medical Corps and Medecins Sans Frontiers have managed to deliver some basic services, but access to care continues to be an issue. We often think of “access” problems that look different on a systemic level: policy discrepancies; discrimination and stigma issues; chronically mal-resourced hospitals. However, when restrictions on international aid and security threats make it nearly impossible for NGO’s to operate, it presents a dramatically definition of “access” problems. Should “state-actors” be called upon to deliver emergency services in these scenarios? Can they, perhaps, be more effective? Another hyper- emphasized theme in the public health community is ‘partnership’. It’s during times like what we see in Syria, where government partners are critical. Perhaps, it is our role in the NGO community to partner across sectors and borders to scale-up relief, bridge gaps in service, strengthen healthcare relief systems, and fulfill a common goal of sustaining human health and dignity. Ilona Kickbusch, the director of Global Health Programmes at the Institute of International Studies in Geneva, published an article in BMJ magazine, which argues that “Public health experts need to work with diplomats in order to achieve global health goals.”
Global Health Diplomacy has been, somewhat, of a recent buzz-word in the field. There are many academic theories around the use of healthcare as a tool to foster cross-border relations. Simply put, conduit that enables coordination between health and foreign policy interests. Health diplomacy is a tool on the global radar for many reasons, including national security against global pandemics and economic protection with regards to the effects of poor health on the global marketplace. However, in Israel’s case, their hospitals’ global health actions- as well as the I.D.F.’s health operations- have stated to the international community that they treat patients out of social justice incentives: the reinforcement that health is a social value and a human right. The U.N. Secretary General defines the underpinning of 21st century foreign policy as “achieving security, creating economic wealth, supporting development in low income countries, and protecting human dignity.”
That last part- concerning human dignity- also speaks to the U.N.’s Millennium Development Goals in health as a human right. In this regard, I highlight the actions of Israel’s health force and military as a perfect example of how the delivery of health services can be a diplomatic tool to incentivizing international policies, while also acting in a humanitarian fashion. This is actually not the first set of circumstances through which Israel has diplomatically delivered healthcare services: Many Palestinians have sought and received life-saving interventions in Israeli hospitals, including the brother-in-law of Hamas’s Prime Minister, who was brought to Beilinson hospital in Jerusalem, by way of the Magen David Adom, after a severe cardiac episode in 2012. According to an Al Arabiya News and the Israeli Civil Administration, 115,000 Palestinians were treated in Israel in 2011, a 13 percent increase from the year prior.
As Israel has sought to provide refugee healthcare and strengthen healthcare systems, regionally, the global public health community should watch and take note of how we might team up with public sector and hospital-sector partners, in order to optimize and improve emergency health services, encourage international health policy, and protect healthcare is a human right.
