 Good afternoon and welcome to CSIS. As of tomorrow at 5 p.m., we're closing this building and moving to 1616 Rhode Island effective next Monday. So this is the last event that the Global Health Policy Center is going to hold here in this building. I don't know if that's the same as true for the Middle East program, our co-host here, our partner here in putting this event together. I want to thank our partners in pulling this all together, Rebekah Sirazi and Matt Fisher have both been integral in organizing this and Haim Malka, director and deputy director of the Middle East program has also been very integral to this and John Alterman, thank you for agreeing to co-organize this. We did an event here back in the spring on this subject of the human humanitarian crisis in Syria. Zahir Salul was with us at that time, thank you for coming back. Zahir, again, and we thought the time was very ripe now to have another roundtable discussion. I'm going to open with a few brief remarks and then I'm going to, we're going to move into a roundtable discussion and I'll ask John Alterman to kick things off in talking about the strategic U.S. interests and we'll just move from this and we'll have our participants kick things off and we'll go a couple of rounds of discussion and then we'll open it to you all for comments and questions. Since the August 21st chemical weapon attack on the Damascus suburb of Ghouta, we've all experienced the bewildering roller coaster debate over Syria and we don't need to go into all the details and the twists and turns of that, but throughout that complex drama which brought us over the weekend to the framework agreement between the U.S. and Russia on destroying the chemical arsenal, chemical weapon arsenal, throughout this complex drama, the looming human crisis both within Syria and spilling across the region has been eclipsed. There's been woefully little reference to the human crisis in international deliberations, woefully little consideration of its exceptional scale and ferocity, its root causes and its possible future trajectory. That includes consideration of the humanitarian impact should the war widen dramatically, the long-term sustainability and effectiveness of the international response and the deep and lasting changes to the region's demography, stability and development and whether in fact the Geneva framework agreement now creates a diplomatic opening to begin to put forward these major humanitarian access and protection issues. Before our speakers begin, a few comments on the nature of this overarching human crisis. In the first two and a half years, in the two and a half years since Syria's internal war commenced in March 2011, almost one out of every three of Syria's 21.4 million citizens has paid a huge personal price in suffering and loss. There's 100,000 dead, almost 30,000 gone missing and untold number wounded. 4.25 million forcibly displaced from their homes but struggling still inside Syria. Two million who reached the profound decision to leave their country behind to flee to an uncertain, risky future in another country. A year ago, refugees numbered less than a quarter million over the course of 2013. More than 200 Syrians per month have fled to neighboring countries. That alarming pace is not slackened. By the official UN count, over 6.8 million Syrians are today in need of urgent humanitarian assistance. The true aggregate number most observers agree is far higher. UN High Commissioner for Refugees Antonio Gutierrez recently summarized the crisis in Syria as a disgraceful humanitarian calamity with suffering and displacement unparalleled in recent history. The humanitarian burden, the demand, has reached unprecedented levels. The two UN appeals in 2013 amount to 4.4 billion. Other country appeals bump that up to 5 billion. Pledges have met less than half of those total amounts. As this grim picture, as grim as this situation appears, there have been a number of courageous personalities and institutions who have struggled against this catastrophe. The neighboring countries, Jordan, Turkey, Lebanon, and Iraq have at considerable cost in a risk allowed hundreds of thousands of Syrians to enter their countries. UN agencies, OCHA under Valerie Amos, UNHCR under Antonio Gutierrez have been exceptional performers in this period, as has the International Committee of the Red Cross, Syrian Arab Red Crescent, Medecine Saint-Frenthier, Syrian American Medical Society, and many other implementers. Commendably, the US has been quick to respond generously and lead the humanitarian mobilization. From 2012 up to today, over the course of just 20 months, the US commitment has exceeded $1 billion, roughly one third of all international humanitarian commitments. Over half of that funding is directed inside Syria, the other half to the region, and an additional $250 million is going to non-lethal assistance to opposition groups. These commitments are striking and substantial, and we'll hear more from John about what this represents in terms of US national interests. And they're coming in the midst of worsening US budget constraints. They stretch our emergency budgets to their limits and potentially drain the US capacity to respond to other new high-level demands. As the crisis deepens in Syria, we need to ask ourselves how the US will begin to confront these tough budgetary trade-offs. Four other major dimensions to this. If you step back for a moment, the scale of Syria's human crisis inside Syria and the surrounding region clearly outstrips the financial and humanitarian response capacities of national governments, UN agencies, international organizations, local medical and relief societies, and international NGOs, that loose collection of humanitarian agencies is itself near the breaking point. Resources are insufficient. Operational capacities fall short. And as we've seen, the horrendously difficult humanitarian access and protection problems inside Syria are at the very core of the human crisis. To a degree seldom seen in modern war, forces on all sides to Syria's internal war routinely obstruct the delivery of humanitarian aid, violate international humanitarian law and norms, and target and kill humanitarian workers. The highest burden of this, of course, is born by responsibility as the Assad regime itself, which bears overwhelming responsibility, but it is not alone. Moreover, in this period inside Syria, there has been massive destruction of infrastructure in over a half a dozen major urban centers. And that includes health, education, transport, housing, communications, and other sectors. This also is quite remarkable. On the deliberate targeting of medical facilities, medical personnel, and humanitarian workers, I want to single out for attention some of the more recent work that has brought this forward in the international media. There was a recent letter issued this week by Lancet of 50 prominent global public health leaders calling attention to this. There's the findings of the Independent International Commission of Inquiry on Syria. There's a recent op-ed by Professor Ron Waldman, who's with us today. All very, very powerful statements. We should anticipate that this crisis is likely to worsen before it gets better. And we have to admit the need for a higher level contingency planning looking forward. As this war intensifies, driven by continued military attacks upon civilians by the Assad regime and the violent actions of an ever larger number of fragmented and divided armed opposition groups, the crisis will inexorably grow. This crisis, and we'll hear more about this from our panelists, threatens the very stability of its neighbors, particularly Lebanon and Jordan. And we need to come to terms with what that means. Over 2 million Syrians are registered refugees or awaiting registration. And many observers suspect the total number is much higher. Over 700,000 have fled to Lebanon, over 500,000 to Jordan, over 450,000 to Turkey, over 160,000 in Iraq. In Lebanon, Syrian refugees officially now comprise a sixth of the nation's population. Unofficially, they exceed 1 million and account for one in five persons on the ground. Lebanon, Jordan, and Turkey have all become increasingly vocal that this rapid, massive, unsustainable refugee influx stresses their economy's support systems and infrastructure to the breaking point. For the long term, and we'll hear more about this from our experts, this crisis is fundamentally altering the region. We have to ask what the long term changes are going to look like and what that means in terms of investments in development beyond the immediate emergency. We've talked about the need for effective contingency planning, particularly if some of the estimates, like an estimate of 2, 3.5 million refugees outside of Syria in the near term, up from 2 million. High level contingency planning will be essential if these scenarios are reached. The second is the sustainability of commitment. How do we leverage commitments from other wealthy countries who've not been at the table? How do we get Russia, China, Saudi Arabia to become a party to supporting this effort over the long term? And how do we navigate here in the US our own budget woes? Access, protection, and humanitarian capacity remain central, as we said, to this. How do we redouble international pressure and attention to improve respect for international humanitarian norms, expand cross-border access, and strengthen the coordination? And how are we going to re-stabilize this region, including blending development investments with emergency responses and planning over a period of the next seven to 10 years for this? And of course, the macro question, which we'll hear more from our participants, is how do we place this crisis at the center of strategic thinking about the future of Syria and the region? And how do we begin to tie and exploit whatever diplomatic breakthroughs happen if they do happen centered upon the Geneva Framework Agreement? So please join me in welcoming our guests here today. You have their bios. Zahir Salul is president of the Syrian American Medical Society. He's been indefatigable in building up that organization into a very important voice within the United States, but also an operational presence within the region and within Syria. We're joined by Rob Jenkins, director of the Office of Transition Initiatives at USAID and executive director of USAID's Syria Task Force, just back from the Stockholm meetings yesterday of the emergency directors and UN agency representatives focused upon Syria. They had met two months back in Brussels, were reconvened yesterday in Stockholm to deliberate on some of these key items that we've just mentioned. Sophie Dolonna, the executive director of Medicine Saint-François-Ferre in the US has kindly come from New York to join us today. As we all know, MSF has been a terribly important voice throughout this crisis. And my colleague, John Alterman, the Brzezinski Chair in Global Security and Geo-Strategy and director of the Middle East program at CSIS. John, if you could kick things off by talking a bit about your outlook on the significance and how you see the region and how you see the new as national interests, and then we could move to our other folks starting with Zahir. Thank you. Thank you, and thank you very much for coming. I know from the RSVP list that all of you do tremendous work, so thank you for what you do. I think what I'm gonna try to do is to link what I do and what you do, because I think there has not been enough of a link. If Syria were a contained crisis, we would think of it the way we think of the killing in the DRC. We think of it the way we think of the killing in Darfur. It's something to do, but it is something that doesn't often rise to the level of national strategic thinking. The reality is that what is happening in Syria needs to rise to the level of national strategic thinking because it is terribly important. The Syrian countryside isn't the Sudanese countryside. It's not the Congolese countryside. The problems of Syria are spilling over to a whole host of key U.S. allies and they directly threaten U.S. strategic interests. What I think is a little bit strange from the U.S. side is there hasn't been more explicit discussion of what strategic interests are in Syria because I think people are afraid that if we acknowledge that we should care, then we should have to do a lot, something we might not wanna do. But not talking about it doesn't make our interests go away and what I'm gonna try to do is to help you have the information, the ammunition to argue that we really have to care and do something about this. The underlying reality is this. The United States remains deeply tied to the Middle East and the Middle East is threatening to slip its moorings. There is no more likely cause for that prospect today than what's happening in Syria today. We are used to not thinking very much about Syria because Syria, quite frankly, has made itself into a pain in the butt for years and years and years and totally preoccupied with their weakness, they've decided that what they will do is they will obstruct. And if you want anything from the Syrians, you have to give something to the Syrians. And so we have been used to not dealing very much with them. Because every time, there was not a cooperative relationship. Whenever we wanted something, we said what will you give us? And if we really needed it, we'd give it and otherwise we'd find a workaround. We built very strong relations with all of Syria's neighbors. Now, those neighbors are under threat precisely because the problems of Syria are going across the border. There are more than two million Syrians who have fled Syria first-round in countries, as Steve mentioned. These refugees, many of them desperately poor, have put tremendous stress on US allies. Jordan, ordinarily, under the best of circumstances, Jordan strains to provide water, electricity, and adequate employment for a population of 6 million people. They now have more than a half million refugees, almost one in 10 Jordanians. Or one in 10 of the population of Jordan is a refugee. Lebanon has only 4.4 million people, and somewhere between three quarters are a million and a million refugees. These governments have a terrible time providing jobs and schools and protecting vulnerable populations in the best of times. And these are not the best of times. Many families are taking people in. The problem is when does this end? If you told me just another month, and then we're gonna resolve it, that's one thing. But people are being displaced from jobs, housing prices are going up, food prices are going up, and there is no end in sight for these countries which are strained to their capacity. The problems, I think, go well beyond the strains on infrastructure that we're used to thinking about. Gee, Jordan doesn't have enough water. What are we gonna do about Jordanian water? That's not the problem. The real problem is that these problems are going to endure for years after there is the beginning of a political settlement. It may be that a million or more Syrians will never return to their homes. While it's premature to suggest that these refugees are going to tip these countries into political and economic crisis, it's not an exaggeration to say that they make very precarious situations in these countries even more so. The collapse of any of these states would have a profound effect around the region. Jordan in particular is a bulwark of stability for Israel. It would surely make Iraq even less stable than it is today. So that's one. As you have fragile states, close allies of the United States tremendously threatened by these large refugee populations which are not going anywhere. The second piece is the radicalization piece. These radical networks that are feeding into the Syrian war and growing through the Syrian war. Estimates are there are more than a thousand Western jihadis currently fighting in Syria. That's more than a thousand people from Europe, the United States, other Western countries currently fighting in Syria. Hundreds of Algerians and Tunisians have died fighting in Syria. There are so many jihadis going into Syria that Syria is actually exporting jihadis into Iraq to go kill Shia because they have more fighters than they need. Like the Afghan war in the 1980s, Syria provides an opportunity for fighters to train, radicalize, and network. And like that war, the echoes of the Syrian conflict are likely to reverberate long after the guns in Syria fall silent. This radicalization problem, both among foreign fighters and also among refugee populations, is a problem for larger countries such as Turkey and NATO ally of the United States and also for Iraq. It may also provide a base for further strikes against Israel. I would argue that both the instability of surrounding states' problem and the radicalization problems threaten spilling over into close U.S. allies in the Gulf, which are, of course, vital to global energy supply. While the Gulf countries themselves feel justified supporting proxies in Syria so as to wage a long distance war with Iran, they would be the first to shake if a pro-Western government fell in the Levant and especially if a monarchy succumbed to popular displeasure. Similarly, as Syria learned from its own experience facilitating Jihad in the 2000s and as Saudi Arabia learned after 2001, radical networks operate in many directions. Efforts to export violence at one point often turn into processes that import violence at another. None of this is intended to downplay the scourge of chemical weapons whose earlier use in Iraq in the 1980s and in Yemen in the 1960s didn't draw the United States into war. I'm also not arguing for U.S. military intervention in Syria but what I do think is that we need a much more vigorous effort to resolve the conflict in the country which probably requires a fair dose of diplomacy and intelligence and military support. Russia has been Syria's patron but Russia is not blind to its own interests and we share a narrow set of interests with Russia which fears that radical networks are going to spread from Levant to the Caucasus. The fear that those networks will obtain chemical weapons surely played a large role in motivating Russian diplomacy last week and will motivate Russian diplomacy for the years to come. It's a common interest. It presents the United States with an opportunity to solve these fundamental problems facing the Middle East and the United States should take that opportunity. Thank you. Well, good afternoon. Thank you for inviting me again, Steve and congratulations for them moving to the new building. I'm looking forward for an event there about Syria, hopefully positive outlook on Syria. And while I'm coming here, and sorry, I don't have written remarks as Steve and John. I had a kidney stone last week so I didn't have time to prepare, but... We don't really have day jobs, you know. We work at a think tank. I have day jobs. I'm a critical care specialist in Chicago and I think one of the positive effects of the last three weeks' attention on Syria that the American public in general right now are paying attention to Syria. Every news outlet or media outlet in Chicago have interviewed Syrian Americans. So for the first time it looks like Americans discovered that we have Syrian Americans among ourselves and their opinion about Syria is important. So some of my patients were coming to me and they're saying, oh, we saw you on TV and we like what you're doing on Syria. Syrian American Medical Society is one of the NGOs that have been helping over the past two and a half years in delivering medical relief to Syria across the border from Turkey, Lebanon and Jordan. So we have a network of doctors, medical personnel and activists in Jordan, in Turkey, inside Syria, of course, and in Lebanon who are helping providing much needed and life-saving medical assistance to Syrian doctors and hospitals. Also, one of the observations that I was reflecting on that this is the first time that the large sector of the Syrian society look at the United States positively and the last time that many Syrians look at United States positively was 1920. When we have a commission called the Crane King Commission, Crane from Chicago, so that's my connection to him, is a businessman and that time the American government sent this commission to take the opinion of the Syrian population after the end of the Ottoman Empire in that time and there was at that time a treaty being contemplated to divide the Middle East between England and France and the commission, Crane, United States was considered a neutral country in the Middle East. So we sent this commission and actually their conclusion was very positive and they recommended to our government at that time to take seriously the aspiration of the Syrian people in the statehood. Since then, I don't think that there was much positive encounter between the Syrian politics and the American politics in the Syrian public. But right now, many Syrians look at United States as the country that can try to end the conflict in their country and they look positively at the humanitarian assistance that we are providing. We are proud as Syrian American that our nation is the large single donor in term of humanitarian assistance to the Syrian refugees and Syrians inside Syria. Turkey probably spent more money on refugees according to the estimates, $1.5 billion was spent by the Turkish government on Syrian refugees. We spent more than about $1 billion in humanitarian assistance in general. The other trends that have been happening and I'm sure that some of you or most of you are right now familiar with these scenes, very painful scenes of the children struggling to breathe and convulging before dying and that happened in August 21st. And by the way, this is not the first time that chemical weapon has been used in Syria. The first time I've seen similar scene was in December 23rd in 2012. And that was a small scale chemical weapon attack in the city of Homs, my city. And not many children at that time died. There were about 10 or 15 adults who died and we reported this chemical weapon attack to the State Department. We share with them the medical findings of the doctors over there. And since then there were at least 24 chemical weapon attack that is documented in Syria. And then of course the largest one in August 21st in Al Ghouta, East Al Ghouta and West Al Ghouta. I was speaking with some of the doctors that were treating patients in East Al Ghouta in a small city called Hamoria. And Al Ghouta, by the way, is a large area very congested in population. It's around Damascus. It has 1.5 million people and it has many cities that are medium in size and large in size. One of the cities, for example, Duma has 500,000 people. So it's not like a rural area. And this is the area where the chemical weapon fell. So this doctor from the city of Hamoria told me that his city has 10 beds. He received 750 patients that night, 750 patients. Out of them 95 died. Out of those 95 who died, 40 were children. And he was crying when he told me that for the first time in his life that he has to choose which patient he has to save or he can save. So he, of course, shows children. A couple of months ago, we had our international conference in Amman in Jordan talking about what do you do when you have limited resources and in a medical disaster like what's happening in Syria? Because the doctors in Syria are dealing with that on a daily basis. We deal with that in the United States but the different scale. For example, in the intensive care unit where I practice, sometimes they tell us that we have limited supply of this anesthesia medicine or pain medicine. So use something different. That's the extent of the limited resources we have, luckily, in this country. But over there, they don't have blood products. They don't have gauze. Sometimes they don't have CT scans. For example, the city of Aleppo, which has a population of 2 million people, one of the largest city in Syria or the second largest city, has no functioning CT scanner. So this limited resources has been a struggle and SAMS and Medicine Without Borders and other NGOs have been struggling to provide resources to the doctors so they can do their humanitarian work. Also what we've noticed that healthcare have been used as a tool to exploit the population and as a weapon. Just a couple of days ago, the United Nations Commission of Inquiry has reported their findings about targeting medical personnel and medical facilities in Syria. And this is, by the way, a confirmation of our report that we published about four months ago about the same thing. Our report called Saving Lives, Sacrificing, sacrificing, Michelle? Rescuing Lives to Save Lives, the ordeals of the Syrian medical personnel. And the United Nations Commission of Inquiry has published this findings a couple of days ago that reaffirmed the same thing, that there is a systematic abuse of the medical situation in Syria by the Syrian government and some of the also opposition fighters in order to prevent the other side from having healthcare. Some of the extremist also groups have been exploiting the healthcare situation by providing free healthcare and free clinics to the population in the area so they can win the heart and the mind. Of course, we can talk about the refugee situation. This is the worst exodus of populations since Afghanistan. So we're not talking about a million or two million, we're talking about one third of the population who are right now displaced from their neighborhoods and from their cities. The equivalent of 120 million Americans being displaced. This is biblical proportions. And sometimes these numbers, we don't take it into perspective but imagine that every person who is displaced, whether they're refugees or internally displaced, they have a painful story. They were displaced because they witnessed violence because some of their family members have been killed or injured because their neighborhood have been bombed. Some of the recent refugees, for example, to Iraq from the northeast Syria, most of them when the Iraqi Kurdistan opened the border went to Iraq because of economic reasons, not because of fear from violence. So the recent trend that many of the refugees who are going to Iraq at least are going because there's loss of economic means and their inability to sustain food and healthcare to their children and families. The most depressing, of course, the trend is that there is no end in sight. I was a little bit hopeful a few months ago when we had this panel discussion about Syria, but right now, even after this armament agreement about chemical weapon deal between United States and Russia, it doesn't look like the humanitarian crisis will end soon. Many of the Syrians I've been talking with, including my family, are very depressed because they told us that we were hoping, we were hoping that there will be an end or acceleration of the end because of this United States intervention, but right now it doesn't look like there is an end in sight. So with that, maybe I can end my remarks and then we can pick it up later on. Thank you. Rob, would you care to share with us? Thanks, Steve and John for the invite. Thank you, Sahara, for putting a face a bit on the numbers and thank you to you and you, Sophie, for the great work that both your organizations are doing. The statistics do get very daunting, and it's important to remember that that is just a mathematic way of looking at a human tragedy. Every one of those refugees, every one of those IDPs is someone's brother or sister, mother or father, someone's child. And as mentioned, with President Obama's announcement on the occasion of Eid of another $195 million, the U.S. government is the largest donor, over a billion dollars now. That includes refugees and assistance to those inside. U.S. government funding, thanks to the American taxpayer is now helping 3.5 million people inside Syria, reaching into all 14 of the governance there. We have 26 different partners and we continue to do whatever we can to get assistance inside Syria by whatever methods, means and channels that we can. Our priorities are emergency medical care, food, and much needed relief supplies. Some of the medical points and medical facilities that were involved with the response on April 21st were funded by the U.S. government. We're currently supporting 260 different medical facilities around Syria, but you have to remember, and Zahara could help you with this, get a picture of this. Some of these are just a room in someone's apartment that might have to move immediately from one location to another as it becomes shelled. And as Steve said, I just got off a plane from Stockholm with the emergency directors of United Nations agencies met together with others from international organizations, NGOs, and the major donors of the world. And they come together about every two months to try to see what is the situation, what can we do, and what do we need to talk about and look forward. I wish we could have said, yes, we see an end in sight. It was all about contingency planning, not about planning for an end in sight, unfortunately. The first thing we did was just to grapple with the enormity of the crisis, to look at what we know, what we don't know right now. The situation in Syria is not a Syrian, humanitarian response situation as others have alluded to. It is now a regional crisis that's not just an emergency crisis. It is a regional crisis that is not going away anytime soon. UNDP's estimate is that if miraculously right now all the fighting were to stop and people could go home, it would take eight to 12 years to repatriate and resettle those people that are currently refugees and IDPs. That's if miraculously everything stopped and was okay right now, we all know that's not gonna be the case. So the timeline is already eight to 12 years out and that's just on one sector. So it was interesting that UNDP attended this along with the World Bank because we're looking at this now as the term is a comprehensive approach as what's needed. The humanitarian infrastructure, the relief infrastructure of the world is breaking under the strain of this crisis and all of the things that we're doing inside but especially outside, especially in Lebanon and Jordan, needs to be seen not in six month increments but what can be done now by the world's donors and by those two nations to help prevent the breaking apart of those societies that we're looking at. So it can't just be refugee camps. It has to be water systems, it has to be working with municipalities, it has to be long-term solutions. In this business we talk a lot about host communities and the term is now coming up that it's not host communities, it's host nations. Lebanon's a very small country. 1,400 different locations that have measurable numbers of refugees in a very small place that you can drive around in a day. To use another analogy, it's as though 50 million refugees in one year came into this country. The strain that that's putting under that country is enormous. So we talked about as donors, as the world community trying to help, what can we do to try to put into practice all the theories we've been talking about for years about working together and the relief to development continuum and the resiliency agenda. What does that actually mean now? It's no longer an academic exercise. We have to do this in real time right now working together. The World Bank just finished. They phoned in to the meeting yesterday because they were about to present the Prime Minister of Lebanon, the findings from their rapid assessment. They worked at an unprecedented rate for the World Bank. Wynn asked, I think about six weeks ago or less by the Prime Minister to carry out an assessment on the repercussions of this inflow on the economic and societal, what are the repercussions on the economy and the society. They pulled the team together within a week and a half and they completed the study and we're all gonna eagerly read it in the next few days. We're afraid there's gonna be some very, very large numbers in that about what needs to happen monetarily. So we looked at that and obviously a massive crisis requires massive funding. As Steve said, the UN appeals $4.4 billion. The largest appeal in UN history. I think it makes up more than half of what the UN's asking for for around the world, the whole world right now. And work has begun on the next appeal. These are six month increments. That one came up in June. So in two months, we're gonna have another figure for all of us to look at and as military colleagues say, admire the problem. So how do we do this? How do we, where is this money gonna come from? Because the end isn't in sight. I wish I could report that we came up with some brilliant ideas. Two months ago in Brussels, we had the same brainstorming session. How do we pull in the gulf? Pulling in the World Bank is a step, but someone has to fund the World Bank. Loans aren't gonna satisfy this problem right now for the neighboring countries. How do we pull in the IMF? How do we pull in the non-traditional donors? We're all very thankful that Kuwait gave $300 million, which is a very large amount for a gulf state to give through multilateral channels. They did that on the occasion last January of them hosting the donor conference. Ideas came up of where do we want the next donor conference to be? If that's maybe gonna to have someone write a check. But we really struggled and looked. Do we reach out to the Brazilians, to the Bricks? People talked about can we use private sector solutions in the housing sector? I'm a little bit skeptical in an emergency situation when you say you wanna turn to the private sector. I'm not sure how you're gonna get the private sector to respond to build homes that no one's gonna pay for for a very long time. But let's give it a try. Let's see what we can do. And then we talked about access. And it's hard for me to find people that wanna have dinner with me anymore because I don't shut up about access. In Syria right now, as dire as the money situation is, it's not money. It's access linked to security. How do you get what needs to be gotten to the people that need it right now? There are a lot of people, Sahar is one of them, he works with many of them, who are extremely heroic, who are risking their lives and many are losing their lives, trying to get things to where it needs to be. The ICRC, International Committee of the Red Cross, they had for six months been trying to negotiate access into Alhuta, sorry for the pronunciation, before April 21st, they had not been able, no one had been able to get the relief that we needed to get in there for six months. And after the events of April 21st, they still have not gotten inside. And ICRC complains that it's getting increasingly more difficult to get to hot spots or where there's currently fighting because the Syrian government is actively preventing them from getting there. So we talked about that and then we ended with discussion on risk. As donors, as implementers, as the United Nations, how much risk are we really willing to take in all of its forms? That's financial risk, if things get stolen in these bad places? That's how many people are going to be killed, trying to deliver the assistance? How do we make the decisions on when do we not go someplace? Knowing that people need to get the assistance but it's too dangerous to get there? There's no simple answers to that. There's no slide rule that shows you the number. But as I've spent some time now trying to educate colleagues in the United States government on, I got a question not too long ago, but surely USAID, your partners don't deliver the assistance where the war is, right? They're sort of over on the side where it's safe. And I had to say, this is not East Africa. This is not a camp in East Africa where you drive a truck up and you offload. This is people risking their lives going through lines several times a day being shot at, taking mortars to deliver assistance. It is a scary situation without a clear end in sight. And we ended the meeting noting that 10,000 people were dead since we met eight weeks prior. And then someone said, not dead, killed. A little bit different. We're gonna meet again in eight weeks. And it was for all of us to leave with the thought of how many more people will be killed and what can all of us do as donors, as implementers, as NGOs, what can we do to try to limit that number in the next eight weeks? And then plan for God knows how long after that. Thanks. Thank you very much, Rob. Sophie, thank you for being so patient. And I'd like to ask you to share your thoughts on the MSF outlook on this and your work which has been so important in this period. Thanks, Steven. And thanks for inviting me. Well, the good thing is that I don't have to repeat everything that has been said. I very much echo most of the comments, especially from Zaheir and Rob on the situation. As we see it on the ground in Syria, so clearly when I was preparing for this panel, I was thinking, okay, what could we describe today as the main challenges? Clearly the scale of the crisis and its regional nature in itself is a challenge. The fact that it's been going on for two years and that it's gonna last for long is quite unprecedented. In foreign organization like MSF, the estimated budget for this year only in Syria is about 60 million dollars, which is equivalent to our largest project in South Sudan and DRC. And it's only 60 million dollars because of the access problems that we new mentioned because of the difficulty to mobilize also finances. Otherwise, we would do much more in Syria and outside Syria. And even though we would still be a drop in a notion of needs, that's for sure. So regarding the, we have to be careful when describing this crisis from a humanitarian standpoint because the humanitarian consequences are not so different from any humanitarian crisis that we see from a medical and sanitary standpoint. So for the refugees, the needs are very clear and easy to identify. Those needs are needs for clean water, for shelter, for distribution of food, for provision of healthcare. And inside Syria, we started our response like we do in many other conflicts. That is, you start providing medical care for well-wounded and our programs were mostly focused on surgery. And gradually we had to evolve towards immunization, treatment of chronic disease, which is a clear sign of the deterioration of the health system. So although this is a challenge responding to all these needs at the same time, it's still not so different in their nature from any other humanitarian crisis we've responded to. What is unprecedented, however, is what you very eloquently described. It's certainly inside, it's the level of violence that we are witnessing and the obstacles to aid inside Syria. You talked about access. Yes, clearly access is an issue, getting access, getting authorization to work in a country. Although we're called doctors without borders, it's very rare in our history that we cross borders illegally. We always ask for an authorization. But in the case of Syria, and I think it's the first time since our early years in Afghanistan when we were crossing the border from Pakistan that we have actually made the decision as an institution to cross the border without the consent of Damascus. Because after two years of attempts to negotiate and to gain access, we were still not authorized to do so. So access is definitely an issue. And the level of violence, the systematic targeting of health facility that has started at the very, very beginning of this crisis after the first demonstration actually, there was a deliberate targeted of medical staff and health providers and health facility. This has just expanded throughout the conflict and it puts the life of our 450 staff inside Syria at risk, definitely. And it makes the work very difficult. It does limit our ability to operate, to move. When you start your operations providing surgery, it's okay to stay in the building all day long. Your anesthesiologist is here, your surgeon and the rest of the medical staff. But when you realize that there is a measles outbreak and you have to vaccinate kids and do a very basic primary healthcare, when you realize that you need to do sanitation work in a camp where there are displays coming in, then it becomes really challenging to deal with the security issue. Last week, one field hospital again, Elbab in the North was hit and nine patients were killed as well as two medical staff. And this violence is not only the fact of the government bombing health facilities. As you also mentioned, Zaheer, there are some elements in the opposition who have also adopted some criminal practices. There is no other words than this. Against the population, against journalists, against aid workers and through assassinations, through threats and killings. We lost one surgeon last week who was himself killed. So all these are critical blockages for aid and they also add to the numerous checkpoints and harassment that the population is subject to. When you talk to a refugee crossing the border into Iraq or Jordan or Lebanon, they all tell you that they had to go through numerous checkpoints, investigation, interviews and on the way, they've also exhausted all their financial resources. So when they arrive in the neighboring country, they don't even have enough money to pay for a rent or to wait until the registration by UNHCR is done. So it's a huge challenge inside syrantums of access. Outside, clearly the situation of refugees I won't repeat. I think that we are all aware of the scale of this crisis. For me, what's interesting is that six months ago we were extremely worried about the situation in Jordan. There's been, I think it's important when we talk about this type of tragedy to also recognize when there are some progress that has been made and to advocate for maintaining this effort. And what we see clearly is that in Jordan and particularly in Zaatari camp, that was a camp where we had great concerns about the risk of outbreak and the lack of international community involvement. It seems from a report I got last week that the situation is under control. The refugees in the camp get 35 letters of water per day per person, which is completely in the standards and even some Jordanian claims that they don't have as much water for their own needs. So we haven't noticed any outbreak in recent weeks. There is definitely a mobilization there. Outside of the camps is another issue. A lot of people are still waiting to be registered. And if you're not registered, you don't have access to the minimum support and relief items that you could be entitled to get. And it's also becoming very clear that the Jordanian system, a health system which claims to provide healthcare to 95% of their population is completely stretched now with the influx of refugees from Syria. So this is certainly, although Jordan seems to be under control at the moment, there is really a need to maintain and ramp up our efforts, particularly for refugees who are out of reach because they are not necessarily inside the camps. Lebanon for us is the major concern, that's for sure. We've tried to focus on healthcare, but the provision of care is extremely challenging due to the fact that the population is spread throughout the country, that the Lebanese government for a very good reason and does not wish to, does not allow any formal settlement of refugees. But the result is that there is a complete disorganization of the aid in Lebanon at the moment. And certainly the main challenge is how can we make it work better? How can we reach these people and ensure that the basic needs of this population are met at the moment? I can elaborate a bit more after, but for the moment I'm also here. Thank you very much. Thanks to all of our speakers this afternoon. Why don't we turn momentarily for one issue here about the prospects for positive change, prospects for diplomatic opening. And one of the mysteries and frustrations of the Syrian case as this crisis has burgeoned in the last 20 months, one of the frustrations I think of all of the people here has been this, the desensitization as I think Haim had labeled it. The fact that the war weariness within America and the magnitude of this crisis was not moving people to see it for the full magnitude of what it is. This was a creeping catastrophe. It hadn't really begun to register in the consciousness of Americans in a way we might expect and in other key capitals within the region and within Europe and elsewhere. What I hear you saying in various forms is that there's some change happening. So I hear you talked about how the media in Chicago was beginning to pay attention. The threat of the US returning to war was the dominant concern that seemed to crowd out many other considerations. At least for the moment with the Geneva framework, with the US Russia Geneva framework, the threat of an immediate turn to war has been withdrawn and people are perhaps able now to begin to engage and think more seriously about what this means. Rob, you mentioned about the World Bank and the fact that World Bank has jumped in on a crash basis to begin addressing these dysfunctions and threats that we've heard about in Lebanon. And John, you're talking about how this does really touch US national interests and a new debate has to begin. And you're at the front of pushing that debate, but maybe the circumstances are ones that now allow us to think about all of this in a more credible way. And Sophie, you've told us that some, there are some solutions in places like Jordan. My question to you all would be if in fact this ambitious and very uncertain Geneva framework agreement, if it's possible for this to move forward on its extraordinarily ambitious short timeframe, even if it moves forward faultingly and with enormous problems encountered politically and operationally and the like, does this create an opening, do you think? Does this create an opening to leverage higher access and protection on humanitarian operations? Does it create an opening potentially to put the humanitarian, the human crisis into the picture strategically around what the solution, does it allow the ability to get the China's and the Saudis and the Russians to make serious financial material commitments towards resolving this crisis? Those have been the missing building blocks in this entire thing. John, could you start? Yeah, if I could just sort of take your silver lining and describe the dark cloud around it, I think that the real danger of the Geneva deal is this, that the entire focus shifts from the heart-rending issues that you've heard every member on this panel describe from what Rob eloquently talked about as the eight to 12 year problem, if you resolve all the political issues and you stop working the political because you are so vested in working on the chemical weapons track, because you are looking at a small piece of the problem, you need the cooperation. For those of you who worked in the US government, you know that when there's a negotiation ongoing, everybody works to create an environment conducive to successful negotiation and the political track gets neglected and what you have in fact is an entrenchment of the refugee problem and entrenchment of the problems affecting the surrounding states and entrenchment of the radicalization and you put off dealing with the political issues instead of facilitating. It doesn't have to be that way, but I think there's an incentive to do it that way and I think what's incumbent on us is to keep in mind that the real prize is finding a way to deal with the political issues, that the chemical issues are a way, they need to be an entree to the political issues but they can't be a substitute for the political issues. Let me also just comment on something that Sophie said about the Zaatari camp. You know the Jordanian borders essentially been shut and I was at Zaatari just at the time just before it got shut and they were getting 3,000 people a day, it was totally out of control. That border seems to have been closed in cooperation between the Free Syrian Army and Jordanian authorities. There are a lot more people who can't get out of Syria who are trapped at that border. Even within Jordan, two thirds of Syrian refugees in Jordan are outside of camps and they are taxing all of the infrastructure, education, jobs, housing. I mean, you can't rent the hovel in some of these northern cities without paying hundreds of dollars a month. There is tremendous desperation. It's easy, I think, to look at the camps and to feel the camps are getting organized and the guys at Zaatari are doing absolutely spectacular work. I'm tremendously impressed by the people I met but they understand that they are working in a vicious context. They're a small piece of the issue and there's a broader context which ultimately the only solution to the problems are political solutions. And we can do the humanitarian issues and we can do access and everything else very important to do but we can't take our eye off the fact that unless we can find a political resolution to this, the problems are going to persist not for a year, not for two years as this says. Rob eloquently said eight to 12 or more. I mean, this is a similar human displacement to the Palestinian refugee crisis of 1948 which some of you may have heard about. That's the scale, that's the scale. And there are still many, many Palestinian refugees inside Syria who are now caught up with all this. I won't speak to the larger prospects other than as a government we have been and will remain be committed to a political solution and there is no other way to end this thing. No amount of humanitarian assistance is going to solve the problem of Syria. But if I could look for a silver lining and try to steal it back just a little bit. With other donors in the UN agencies we talked about the fact that there's been attempts at negotiations going on for a very long time on a small scale in different places to try to get humanitarian access. Sometimes it works, usually it doesn't. But as one colleague said where there's a will, there's a way. And the UN inspectors that got the access to go in to look at what happened on August 21st. In fact, that was an opening of such. There was enough attention on that issue from all sides that they actually were able to negotiate what they haven't been able to negotiate on humanitarian means. So that's a precedent. If in fact there's going to be negotiations about further inspections with the new deal that could become an opening. That if there's a regime that's put in place that has regular inspections and regular teams going out to different locations it's not too much I think to then step back once and say can we use the same sort of negotiations whatever they put in place for that to also get humanitarian access into places. It might work, it's not gonna solve the problem but it's an opening perhaps. I would think it would be awfully uncomfortable if you have chemical weapons inspectors negotiating access into sensitive areas where there's acute and raging humanitarian need if the humanitarian access and protection issues are not treated in some fashion. It's just gonna create enormous dissonance for that to be the case looking forward. Perhaps Zaheer and Sophie as operational folks. Sophie, did you wanna jump in? Yeah, I'd like to react and respond partly to your question because of course it's not for a non-government or organization like MSF to comment on what is the right political solution but we are certainly well placed to describe and comment on the humanitarian consequences of these political decisions. And what happened at the moment in Syria is that actually we are facing the humanitarian consequences of a lot of political decision and lack thereof. So for us it's clear at this moment even though we definitely welcome the shift from the discussion being purely focused on chemical weapon to a more broader diplomatic effort but it's also extremely important that humanitarian considerations be fully part of this diplomatic effort and that the demanding for those because as you said we have a window of opportunity at the moment. There is a real opportunity for discussion for making political advances. If we don't take this opportunity to address some critical humanitarian issues we're gonna lose the momentum. And there is an opportunity to ask for stopping targeting health facilities. These are very basic and fundamentals of the war law for facilitating access. There are plenty of instruments that exist in international humanitarian law to propose ideas solution that could be adapted to the Syrian context and to mobilize more resources and not just resources and not just resources from the United States. We know the effort that has been made but also trying to precisely take the opportunity and the advantage of the presence of other players around the table to have them contribute to this effort and not just the financial resources but the skills as well because we're facing a huge problem at the moment in terms of organization of aid. As I said in Lebanon, we need to do something about it. For many years there is a UN agency, UNRWA which has a lot of experience in dealing with refugees. It's hard to imagine that we don't find a better system to coordinate aid. A few things I would like to add to this and I agree with all of you, St. Sophia and Rob. This is the first time in the history of Syria, recent history that you have Palestinians who are actually fleeing Syria to Gaza. I've never imagined in my life that you will have Palestinian going back to Gaza but it's happening right now. And that will give you the gravity of the situation. Some of them came from Al-Yarmouk camp which is in the middle of Damascus. But today I was reading an interview with the head of the ICRC operation in Syria. And by the way, ICRC is doing great job with the Syrian Red Crescent also. More than 20 members of the Syrian Red Crescent have been killed because of humanitarian work and because of the security situation. And she said, and this is corroborated by doctors in Nwota and Homs that it's very difficult to get to areas in Syria, especially in the old city in Homs and Nwota for the past eight or nine months. There was some reported children who died because of malnutrition in Al-Mu'adamiya which is in West Ota. So to me it's morally repulsive that we are talking about creating safe passage for UN investigators to investigate chemical weapons that I'm sure that it will not be used again by the regime. I think the regime is smart enough to learn the lessons but we will not gonna allow safe passages for ICRC and Syrian Red Crescent and other humanitarian organization to give food and medicine to Syrians. So I think we have a window of opportunity that the international community United States can use now that the Russians are suddenly are interested in peace. Actually I wanted to believe President Putin in his op-ed that he's talking about the Pope praying for peace in Syria and so forth. So I mean I would like to believe that. So they're interested in pressuring the Syrian regime to disarm chemical weapon. Why not pressuring them now to read certain humanitarian policies that will be helpful to NGOs and to Syrians especially that the Syrian regime right now it looks like they're open to compromise. This is I think a window that we may lose in the future so we have to use it to the fullest. So I hope that we can do that with the negotiation and have a Security Council Resolution that will enforce that because without Security Council Resolution I will have doubt that the Syrian regime will respect its words. Let's open the floor for comments and questions. We have microphones in the back. We'll bring those to you. What I suggest we do is take very brief comments and questions and there's a one hand up we'll bundle together three or four and then come back to our speakers. So if you could stand up just identify yourself briefly and then offer one quick question or comment. Thank you. Nidal Garamon, I'm actually Iraqi. I did a lot of missionary trips in Iraq and Kurdistan mainly. I did not hear you saying anything. There's 200,000 refugees in Kurdistan that are well taken care of and I have the head of the KRG in here from the representative office. I went to Zaatari Camp myself with NAMA Organization, National Arab American Medical Association. And the Kurdistan is not getting any help from any side and I'm the ambassador also of health to Iraq to the World Medical Relief. So I sponsor a lot of medical containers to Iraq and Kurdistan mainly but I am going to go soon to Kurdistan to help the Syrian refugees but we are desperate and help and it's safe there. There's no threat, no terrorist. They are doing a good job at doing that. So we're gonna need help with doctors to continue this mission, supplies and to help the Kurdistan government. We thank her also. The Kurdistan leaders are doing a great job in saving many lives. Thank you. Thank you. There was a hand in the back just behind you there. Thank you. My name is Kristi Dellafield. I'm the Humanitarian Aid Liaison with the Syrian Opposition Coalition. I just wanted to get the panel's opinion on the idea of increasing the number of implementers. There are quite a few Syrian organizations inside Syria that have access but maybe the international community, INGOs and other donors are very slow to authorize and fund those organizations because they don't have the long history. Syria was not very open to the idea of registering NGOs. What do you think the international community can do to increase these organizations' capacity to work with them so that we can have 10 more Dr. Zahir's up here? Kristi, you're talking with special reference to authorization to operate within Syria itself? Okay. Do we have any other hands? Yes. Hi, my name is Rick Burzon. I'm with the National Institutes of Health. I do work in global research. Just a question about the lack of US leadership here and if maybe Bob, you could address this and because I used to work for USAID and it's a great place, but the influence that USAID may have on the State Department is mixed and the fact of the matter is that things are bad and they don't seem to be getting any better and we can talk about what we'd like to happen but I'm curious if you could speak to what your perception is on whether or not given the domestic politics that face Obama right now, if there's likely to be any US leadership on these issues which are going from bad to worse and don't look like they're getting any better. Thank you. I agree. Do we have any other folks? We have a hand over in this corner here. Take this comment and question and then we'll come back to a question. I'm from, I'm Lian Shan Jin from Shanghai Institute for International Studies. I'm here as a visiting fellow of CSRS. My question is actually about the political solution which is not so closely connected to this topic but I think that is very important. My question is that in Afghanistan we find the person like Kazai but unfortunately the situation in Afghanistan is not very optimistic. There are a lot of violence and conflicts but in Syria we have, many people are talking about intervention but the problem is that have you ever find some people like Kazai and do you think that what is the prospect of post-regime situation? Do you think that the things will be certainly much better than today? Thank you. Thank you. We'll take one more right here and then we'll come back to our speakers. Hi, my name is Agron Farade. I'm with IAPS. First I would like to thank USAID and international community as a humanitarian practitioner for all the aid that's going into Syria. Donors were really supporting our humanitarian agencies. Now I have two questions about the absorptive capacity that humanitarian actors have including MSF and access. These are two linked. Everybody wants money but can they really spend money for the right purpose? And second is I call for urgent attention to support host countries such as Jordan and Lebanon. Are we prepared to accept the results of the studies that are saying that the Jordan healthcare system has not 9% of the Jordan healthcare system is being utilized by the Syrian refugees and what we're gonna do about the numbers. So it's very easy to say the World Bank will come up with the study and percentages. Are we ready to accept that and deal with that? Thank you. Thanks. John, did you wanna lead off at all? Some of the bigger questions around opposition and what would a political solution look like and? Yeah. US leadership blockages. I think there are two issues. One is a US issue of how much is the US willing to invest in Syria. And I think quite frankly that has fluctuated and will continue to fluctuate. The president I think is increasingly focused on domestic agenda and one of the things that I think is very important is to persuade people, you and you persuade your friends and so on that there actually are American interests that's taken Syria. We need to be engaged in them because I think that message of all the messages that went out in the last two weeks I think that message has not been said clearly enough. And I think that the way they talked about this principally in terms of chemical weapons I think got us away from thinking about what is strategically important to ourself and our allies. In terms of sort of a post Assad Syria I think leaderships are forged out of conflict and there are people who manage to have supporters and there are people who can't win supporters. And that's just the only way to find out is not to have a bunch of seminars where you do interviews with people. It's to see what happens when you have a more open political process. I hope that Syria will have that opportunity. I don't think the country has been well led at all for many years. We have seen I think completely morally depraved leadership. This issue of it's morally reprehensible to keep healthcare providers out from these areas. There aren't a lot of people in the Syrian leadership who care at all about what's morally reprehensible. They're fighting a battle for survival against rebels and they want the rebels to die and their supporters to die and as large numbers as quickly as possible as a strategic objective. And we can talk about what's morally reprehensible but they think they're fighting a war and the moral stuff doesn't matter. What matters is winning. I think Syria needs a different leadership. What that leadership will look like whether you'll have a Hamid Karzai or whether you'll have a George Washington or whether you'll have a Mahjoudung. I have no idea. But the only way to find out what happens is when you have a process that people attempt to lead and some will be successful and some will not. And certainly one of the very disturbing things about the Syrian opposition is how much it has tended to fight against itself rather than unifying to fight against the regime. That's not something the United States can fix. But it certainly has been an obstacle to efforts to have a different political future in Syria. Thanks. To our friend representing the KRG and to you I had the great opportunity last week to meet with the foreign minister from the KRG who was visiting. And we had very good conversations about and congratulated that government on the response to the influx of the 46th and I guess now 51,000 refugees that came across and what a great job was done. Our office of food for peace immediately flew in by air 15 metric tons of high nutrition food for that influx and our State Department PRM, Populations Refugee and Migration Bureau is actively working there with the government of the KRG but also the implementers there on the issue. We had discussions about having more NGOs be able to get money directly from donors and then also the possibility of letting access to other Syrian populations from there and it was a very good conversation. We're gonna continue to look into that. Christy your point about, well first I wanna thank the SOC and the ACU, the Assistance Coordination Unit based in Gaziantep who's a very strong partner of USAID and the US government. We work with them very closely on coordination and have not just us but the British and others have invested a lot of time not just money but even but money and personnel to try to build the capacity of the ACU and if you look at what didn't exist I think until January, December or January it's made amazing strides and is a very, very good, solid partner. The issue about donor money going directly to local Syrian organizations, many of you might have seen the letter that came out today signed by the many, many different doctors around the world about the situation. There is a line there that talks about the international donor bureaucracy that gets in the way. We do have our bureaucracies and it is very difficult not just in Syria but anywhere in the world for a brand new organization to get a direct grant directly from the US government but there is not a single one of our partners active in Syria that doesn't partner with Syrian organizations themselves and capacity is being built by doing. It's a very, very busy time and there's not a lot of programming looking at building the capacity of NGOs for that purpose but capacity is being built and every local NGO that comes and talks to me, I say please seek out the other international partners that are there because they're actively looking to build their networks of more NGOs locally. Rick, you worked for USAID so I think you'll know what I will or will not say about politics. I will say that Secretary Kerry, if you can look at if the amount of time and energy he spends on an issue counts for leadership. He's exerting an extreme amount of leadership on this issue. He has seized with Syria as is our president. The number of meetings at the highest levels of our government on these issues is I've never seen anything like it. The sad truth is there's no easy answers and I somewhat enjoy then get frustrated by lots of people debating why are we doing acts or not doing why and then you always, well what would you do? And I go why I don't know, I can't figure it out. It's not for a lack of trying, it's not for a lack of attention. It's a very, very difficult issue as John has pointed out. Yeah, thanks. Couple of comments regarding the question about Kurdistan and we'll be happy in Sam's to help if we're invited by the local government there and send our doctors to help. We just opened recently an office in Lebanon and we'll be happy to expand and I'm sure that other organizations that are aware now with the recent influx of the Syrian refugees to Kurdistan will be also paying more attention to that and we appreciate the effort that is done by the Iraqi government and the local Kurdistani government in Iraq for what they've done. I mean they're doing great and hopefully this will continue. And I've never mentioned before but I have to mention that we really appreciate the effort that is done by the Jordanian, the Lebanese, the Turkish government, the Iraqi government, the Egyptian government, all the government that are hosting the Syrian refugees. I know that this is not easy for them, especially with their limited resources but we have to keep thanking them for what they are doing. This is not easy. By the way, the equivalent of Lebanon getting one million Syrian refugees is like we're getting 70 million Mexican refugees to the United States, 70 million. Imagine how much we will have a stretch of our means. Now regarding the issue of the absorbing capacity and access, I would agree with you that sometimes it's challenging but what we've noticed that there is a shifting priorities. So in the beginning we were focusing on field hospitals because there are many areas that the public hospitals, private hospitals were hit and destroyed and we started to support local physicians to build field hospitals and manning them with supplies and so forth. And these are, there will be a report coming in American Journal of Medicine about this phenomena which I think it's unique to the Syrian situation. Al-Bab Hospital that was bombed, I visited a few months ago. It's located in one of the cultural center in the city of Al-Bab to hide it from the Syrian regime and this is the third field hospital that was hit in Al-Bab. The one before was hidden in a private villa of previous Syrian minister was also hit and bombed and the first one was in the basement of a mosque which was also completely destroyed. So this is really something that unimaginable that you have field hospitals, makeshift hospitals that doctors are trying to save patients and then it's to keep being destroyed and bombed. I would like to mention the fact that what kills Syrians now more than even shrapnels and bombs and bullets is chronic diseases, non-communicable diseases and this is something which we all forget because first of all, Syrians have lost the economic mean to buy medications so many of them who have diabetes and heart disease are not able to buy medicine and they prefer of course to have food than medicine including some of my family members who told me, I'm not gonna stop taking the cholesterol medicine, I need food. The second thing that there is shortage of medications especially insulin, chemotherapy for cancer patients. The third thing is the security situation that patients with cancer and chronic disease are not able to travel to have chemotherapy or radiation therapy or hemodialysis. And I'll give you one example in the city of Hamas that had 49 dialysis unit before the crisis. Right now they have 12 and they have the third largest city in Syria. So many of patients who need hemodialysis either that they will die or they will become refugees because they want to have hemodialysis. So the number, the estimated number of people who died because of non-communicable diseases, NCD, is about 200,000, more than the 120,000 Syrians who were killed by bullets and shrapnels and bombing. And this is something that the NGOs and the international community should start paying attention to. Sophie. Regarding the support of delegation to Syrian NGO, this is actually what, as an organization, and it's a very unusual modus operandi for us, but this is what we started to do at the very beginning of the crisis. We supported Syrian networks and then we were invited by these same networks to run our own activity inside Syria because they were simply overwhelmed. In the meantime, we're running six hospitals and four smaller clinics inside Syria, but we also decided to continue supporting 27 other health facilities through provision of drugs and a bit of financial support. And without this support, we would have actually the facilities that were exposed to the latest chemical attack would not have been able to respond to it because we had planned the provision, the supply of atropine, which is used to treat patients exposed to neurotoxic agent. So this is, I think we all have to recognize that this is a very exceptional crisis and that there is a need for supporting whoever is in a better capacity to operate inside Syria. This being said, we're facing some dilemmas in trying to expand the support. Of course, accountability is when severe dilemma for NGOs, which are relying on the generosity of donors and who have to be accountable for the use of their resources, but in the case of Syria, it hasn't been a problem so far for us. We've been able to get very regular data, patient data information and so on. We're very comfortable with what we're doing, but the major dilemma we face is actually the transfer of risk. What does it mean to decide that you're gonna stay in your country, you're gonna send drugs because it's too dangerous for your own people, whereas the Syrians themselves, it's okay for them to take risk. And as an organization, it's a very difficult decision to make for us. This is why we've decided that a mix of both is much more acceptable than just staying away from the crisis and trying to just help those who are ready to take those risks. I think you were right to raise the Iraqi situation and the Kurdistan, but we are working in two camps at the border between Syria and Iraq at the moment in Domi's and Dohuk. And sadly enough, those camps, I think, are a victim of their own success because they are doing so well. The refugees have been, the organization is so good that we have actually, and it's certainly the first time since we've been responding to this crisis, we only had to focus on medical care. We were not asked to do much more than the rest was taken care of. So I think your point is very important because we should not forget that there is a permanent influx of people crossing into Iraq that those camps are stretched, definitely, and that they need to get attention and support in order to be able to absorb this influx and maintain their support. Now, regarding the absorption, you raised the question about our NGOs who are asking for more money, able to absorb all these funding and do a better job. I think it's a real good point and clearly in inside Syria, it's not a financial issue. It's an issue of access. If we were able to get better access, we could do much more from an operational standpoint. As an organization, we could run 10 hospitals instead of six. Of course, it would not cover all the needs, but we could definitely do more if we had more ability to operate. So inside Syria, I think the main issue is really about getting a better access and better respect for health facilities and humanitarian assistance. Outside Syria, you don't have the same security issues. So there is a greater capacity to operate, but the issue as we see it at the moment is really an issue of organization. And how can we organize this aid? How can we make it more efficient? It's really a big deal. We are constraints financially, although MSF does not seek and use government funding for the Syrian crisis. We only run our programs with private monies and institutional decision that we've made, but we also recognize that as soon as the government's funding started to operate and there was more actors on the ground, it was really for us as well. We felt less lonely and we were able to concentrate more on medical care and less on water and sanitation and shelter and so on. So clearly for us, seeing governments deploying more financial resources to this crisis has an indirect impact on our own ability to do our work. Otherwise, we have too much to cover and we just can't respond to all the needs. Thank you. We're getting to the end of our time now. This has been, I think, a really rich and interesting discussion. It shows that we are at this uncertain potential transition moment. As we've been reminded, there's a ferocious war still ongoing, catastrophic human crisis that is only partially, it's only possible to partially address right now, but we've heard also that there may be a window. There may be an opening. That could play off of the chemical weapons framework agreement possibly, that could play off of the World Bank and others getting into blended investments to stabilize the situation in Jordan and Lebanon. Perhaps a broadening of the debate around what the U.S. national interests are in this situation and measures that we've heard about. Several measures from Rob, from Zahir, from Sophie about ways of increasing capacity and access on an incremental basis to keep pushing. So I think this is obviously still highly uncertain and to be watched and we'll have to pull together again in the near to medium turn to revisit some of these issues as they evolve. But please join me in thanking these four terrific speakers. Thank you. We're adjourned.