 As we've heard this morning, there are horrific things going on in Syria, huge needs. But why are we focusing on health and the health system in particular? After all, in many past wars, health has been subject to attack in Chechnya, Russian forces bombed hospitals in Kosovo, dozens and dozens of clinics were burned in Burma. Many health workers were obstructed, kidnapped, rested by the Burmese army. But Syria really is different. I've been studying this issue for more than two decades, and I've never seen anything on this scale. And when you ask why, there's a very straightforward answer why. The Independent Commission on Syria, established by the UN Human Rights Council, issued a report in February that says, that said, the pattern of attacks indicates that government forces deliberately targeted hospitals and medical units to gain military advantage by depriving anti-government armed groups and their perceived supporters, that is, civilians of medical assistance. In fact, the other day, a friend of mine who is working in Syria said that people are now afraid to go to hospitals because they're afraid they're going to be subjected to barrel bombs. So they're staying away from hospitals because they become one of the most unsafe places. And of course, this has had enormous impacts. We've heard about the destruction of the health system. But this issue has been under-reported. It gets occasional mention. And that's why we think it's important. I appreciate Steve devoting time to this issue. So we have a terrific panel to discuss the problem from a variety of perspectives. We'll start with Andrea Gittleman, who is the DC U.S. Policy Director for Physicians for Human Rights. And she'll be speaking about their documentation and mapping of these attacks. And she will be followed by Dr. Miran Brennan, who has been working in humanitarian emergencies for two decades, most with the CDC, has worked with the CDC and with the Office of Foreign Disaster Assistance in Turkey, as well as with WHO in Jordan. And then we'll go to Dr. Ron Waldman, who has been working in humanitarian crises also for many decades. And now he's a professor of global health at George Washington University. So why don't we get to it, Andrea? And we'll have time, as in other panels, for some discussion. As you see in this panel, we have some visual aids as well. Yes. Thank you, Len, for that kind introduction. I'm waiting on the—okay, I'm very sorry I won't be able to show you a lot of the interactive features of our map. But I'll just start with a few remarks about PHR, a tax on healthcare in general, and why it was we undertook this project. Just in general, as an organization, we seek to document mass atrocities. We seek to document mass atrocities, which includes the targeting of health workers during conflict. Great, okay. And in Syria, this is something that, as Len mentioned, is quite striking. We've seen attacks on hospitals and on medical professionals probably to an unprecedented degree. This is something that happens in other conflicts as well. You see attacks on health workers in Kars, Central African Republic, in South Sudan, Burma, in many different places. But it's such a striking feature of the conflict in Syria that we wanted to explore it deeply. And one of the reasons, as an organization that focuses on attacks on healthcare, the conversations around this problem usually seem to end with, well, there's violence in war, civilians are harmed, it's awful for everyone. And that's really not what we're seeing with attacks on healthcare in Syria. We're seeing hospitals and medical professionals attacked strategically. They are targeted. It's part of a purposeful campaign. It's not just a natural side effect of conflict, you know, wrong place at the wrong time. And why would government forces or other forces attack hospitals or health centers? And in general, I think there's two reasons Len touched on this a little bit, but one is that it exponentially increases the harm against the civilian population. So if someone is at a protest, for example, and is injured by riot material or, you know, their house is bombed and they're injured from that, they are then doubly harmed if they can't seek medical treatment for their injuries. Also, doctors and other medical professionals are on the front lines. They are often the first responders to people when they're hurt. And they see evidence of wrongdoing. So they can see evidence of sexual violence, for example, or of torture when someone comes out of detention. And so there's an even more sinister reason why health professionals are being targeted because they have this information. So the overall goal of this project, this is what the map looks like on our website. You can see it at phr.org. The overall goal was to visually display these attacks, looking both at attacks on health workers and on facilities. We wanted to convey the sheer magnitude, the widespread nature of these attacks and really wanted to do a few things, both that a few things come out of this project. One would just be the furtherance of improved documentation. We would also like to see the fostering of accountability mechanisms, specifically for these attacks on health care, which are war crimes and should be treated as such. And thirdly, we wanted to press for improved humanitarian access and protection for those who are delivering that access. So on this map, you can see in the legend, there are dots that signify attacks by government forces, attacks by opposition forces, by unknown perpetrators. And this is an interactive map. Oh, wait, I'm very sorry. Very interactive. Yes, okay, I won't touch anything. So you can see if you went to this map, you could zoom in. It works kind of like a Google map that you may be familiar with. You can zoom in into a particular area. And as you do, more dots will come up. So you'll see kind of by Damascus, there's a 31. So we couldn't really put all the dots all in one place. But as you play around with the map, you can zoom in and out. You can see more of the texture and more of the details. And then as a side note, in the legend I mentioned, you have the three different colors for the kinds of attacks on hospitals. And just in the legend, because we made it just very simple, we have government and then opposition forces. And by opposition forces, we just meant that as an umbrella to mean not government. There are, of course, many varied parts of the opposition, as we heard this morning. And then when you click on one of the yellow dots, and I'm sorry, I can't do that for you now, but when you click on it, more information will pop up and show the alleged perpetrator of the attack. Interviews from sources who may have been there. Videos, if available, or photos, links to reports in NGO documents or UN reports, a lot of that information is there. So we collected a lot of information, looking at attacks on facilities. I'll talk about that first, and then looking at attacks on health professionals. And where did we get all this information? It's pretty data heavy. We did open source searches in both English and Arabic. We had a bilingual team that spent months looking at all this information. We reviewed about 1,000 sources with each source that came in. We reviewed it with a three-person team. And then we corroborated it with field sources who were there, who had firsthand information about the attack. The kinds of reports that came in, we had official reports from the COI that Len mentioned, videos on social media, items from YouTube, people who reached out to us and just told us firsthand information. Some news reports, reports from NGOs. And then we ultimately ended up using just 200 sources. So out of that 1,000, we used about a fifth, which is, of course, a naturally conservative number. We wanted to err on the side of being conservative, so that we did not put up all the information that we gathered. We just made sure that everything could be corroborated. We usually corroborated each piece of information with three independent sources. Sometimes we only used two if they were considered very credible, like if it was from the COI report. We also had a wonderful collaboration with AAAS, the American Association for the Advancement of Science, to corroborate attacks on facilities. So we used their geospatial imaging with information we received from our field sources to verify that what happened had actually happened. So overall, we have about 150 attacks on 124 health facilities. Again, those are very conservative numbers. Overall, we found that most, the vast majority of these attacks, about 90% were committed by the government. We had to make sure, by verifying with our field sources, that these hospitals were being used as such at the time of attack. Therefore, they were IHL violations or war crimes. They were not hospitals that had been turned into military barracks or something like that before the attack. So as you see here, the greatest numbers of some of these attacks were around Aleppo, and then in the Damascus suburbs, and the greater Damascus suburbs. And in these places in general, we found that 93 times that a discriminant weapon was used to attack a hospital. So a weapon that was purposely targeting that health facility. And in 36 attacks, we found that the attacks happened in densely populated areas where a hospital was hit, but there are also civilians hit in the nearby area. But in those situations, there was no warning and no precautions made. And some of the hospitals really had nothing else around them. So the fact that they were hit with the liberate weapons shows that they were targeted because they were being hospitals. This just shows you a little graph of the information we collected month by month about the attacks on facilities. So you can see it started in 2011, it was still pretty minimal, and then it really picked up. And then once it picked up, it hasn't really leveled off since we started collecting information. So we don't expect to see a decline anytime soon. And when you click on our map, perhaps I can show you later, but if you click on the map, you can see that we then disaggregated a lot of the information that we had gathered. So we looked at different medical workers who were killed by their profession. And you can see that there's really a wide variety of professions listed here. We have dentists, students, pharmacy students, veterinarians, and the reason why we included all of those people is because with the DERFs, just the complete lack of health services, of healthcare, people with minimal training or somewhat tangential training or stepping in to fill the gap left by other medical workers. And then you can see by government, as I mentioned, Drift and Maskenholms had the greatest number of medical workers killed 78 and 77 respectively. We are still gathering more information and this map will be updated as we gather more. So this is actually, these are some graphs that were taken directly from our map. So on the map that you saw at the beginning, you can click on a red icon and icon of an individual. When you click on that, this will come up. So you can see the number of medical workers killed in each government. And then you can see this breakdown of the causes of the death, whether it was shelling and bombing or execution, torture, inability to seek medical assistance, et cetera. And in general, this is just some of the causes of death of medical personnel. So you can see a lot of this, the shelling and bombing, it could have been that they were in a hospital when it was attacked. And then you can see the even more targeted acts committed against doctors who often say that they were attacked because of the work that they did, that as doctors they were treated as if they were fighters. And that by carrying medical supplies, it was similar to carrying weapons in terms of the risk of being targeted. So this is similar to what we saw before medical personnel killed by month, August and September, 2012 with the highest number of attacks. But it still hasn't leveled off. And we've been getting more and more information even since the launch of this map about four weeks ago. And now I'm very sad to report that May, 2014 has the highest number of medical personnel killed in Syria since the beginning of the conflict with 29. What this shows you is that the attacks on health workers didn't just start in one place and really intensify there. They started in a few different places and then intensified all at once. So this wasn't bad actors of a certain local group or anything like that. It was done on a country-wide scale. And here this is one hospital that was attacked pretty recently. This is one that had the only dialysis clinic in the government. And I think information like this just shows that attacks on medical workers and on hospitals, they're not just dots on a map, they're not just numbers on a graph, but these have devastating effects to large swaths of the civilian population. If you were to go to the map and click on these sites, you could see more of that information. Okay, I won't go through all of these slides, but just to talk briefly more about the medical personnel. When we launched this map a few weeks ago, we had an estimated 468 individuals killed. It's now creeping closer to 500. Again, that is a very conservative estimate, only the figures that we were able to verify. It's estimated that about 15,000 doctors have left the country since the conflict began. And this really adds up to little or no medical assistance for the people there. Very quickly on the limitations of this research, as I said, are very conservative with our numbers. There are many attacks that are likely not included here. There's selection bias, sources are biased. We have a lot of partners, a lot of sources, and we're very grateful for their work and for their partnership that they are not everywhere. And we haven't yet added the information we gleaned from May 2014. We're also starting a crowdsourcing project in Alhassica in the Northeast. We had not heard of any attacks reported from that area, and there probably are attacks there, but we're starting a crowdsourcing application. So if you go to our map, you can click on an icon and then send information if you have it. Just, I'll end with just some policy takeaways. When we look at the map, you see the graphs, the numbers, what does it really mean? I think it calls on us to do a few things. One would be not just humanitarian access, but then protection for humanitarian workers. If workers are crossing the border to deliver aid, they, as we discussed before, they could be attacked just as the Syrian doctors have been attacked there. So there needs to be negotiated protection. If that can be done on a local level, getting protection of those around, if it can be done on a national level and have an enforceable framework, something that can be done in order to make sure these individuals have the protection to carry out their important work. Accountability, again, we're talking a little bit about accountability for war crimes, crimes against humanity in Syria, attacks on health workers and doctors are war crimes, and they should be included in any sort of accountability mechanism, no matter when it happens, whether it's in Syria, in the region, internationally, no matter when it happens, it should be included. Also, we've seen the devastating nature of attacks on healthcare, and my colleagues will speak about that in more detail. We talked a bit about the resurgence of polio of measles of other diseases. Even if the conflict were to end immediately, there would be significant resources and significant time that would need to go into rebuilding the health institutions in Syria. And I would just end by saying that what we see today and what we see included in this map can not become a new normal. This cannot be how conflicts are thought, that we need to make sure that these are treated as crimes, that perpetrators are held accountable, and that in any conflict this kind of activity cannot be tolerated. I'll end there. Thank you, Andrea. Very sobering presentation. We wanna look now at what the impacts of both these attacks and the war itself is on health, and we'll start with a very textured presentation from Dr. Brennan, who has worked in the north of Syria, and take it over now. Thank you. In the interests of time, I'm gonna show very few of these slides. I would just like to remind people of the generosity of the Syrian people themselves, because in 2007 I was assigned in Damascus to UNHCR, where there were one and a half million Iraqi refugees, and it was the Syrian people that hosted those, so they have been very generous in the past. A lot of people have talked about the huge regional impact of this. Oh my God, okay, well we're not gonna look at all those. You'll be relieved to hear. Yeah, very quick. Okay, so just to give you an idea of the scale, that for CDC, this has been the second largest humanitarian emergency response in our history, and we've done over 60 deployments. Now, I hope you realize that CDC doesn't actually do anything. Basically we help our operational partners on the ground to do things. So I think what this reflects is the amount of work that's been done across the region by our partners. So we've had assignments to the Office of Foreign Disaster Assistance, to WHO, UNICEF, UNHCR, and a variety of other agencies. So there is a lot of work going on in the region, we shouldn't forget that. As colleagues have mentioned before, a lot of this may be invisible because when CDC helps our partners, so when we're helping WHO, for example, we're working with the Ministry of Health. So people may not necessarily see that. So in terms of the support that's been ongoing to the region, to the host population, if you like. So WHO has been working on improving surveillance within Syria and in the surrounding countries. UNICEF and WHO have been helping to implement large-scale immunization campaigns against polio and measles inside the country. UNHCR has been paying for a lot of the secondary medical treatment that the refugees outside are requiring and then supporting the health system in that way and also supporting partners to do some primary healthcare. And again, this isn't necessarily visible. These inputs into the national health systems aren't necessarily visible. Of course, there's still a huge outstanding burden to these national systems, which the countries themselves are taking on. So just to look at some of the regional public health, the threats and the response, I think one success that in the northern part of Syria was there was no surveillance system, so with some support from OFDA and other donors, emergency surveillance was set up and it did pick up the wild polio outbreak in Syria. This was very disturbing because the last polio case in Syria had been in 1999 and then the 2014 spread has been into northern Iraq, which is in the news right now and which is going to obviously complicate the response in that country. Here you can just see where the cases are located in the north of the country, but there's also several cases in rural Damascus which are not shown down there in the south. One success story, I think, of the intervention in Syria has been the six rounds of polio campaigns which have happened in both the north and the south and have been largely successful and we know that because surveillance is ongoing and we've had one recent case in 2014. So that looks to be working, but this whole response has been a huge cost to the international community and to the countries themselves with three, four, five and six rounds of polio immunization in all the surrounding countries and now Iran has been added to that response because of the case in Iraq and because they bordered one another, obviously. Okay, we're not gonna go. So just to talk a bit about measles, Jordan, in fact, had an elimination goal for measles. It was the first country, oh, we forget that, in the region. That's giving me a headache. The first country in the region had an elimination goal so then we were hearing reports of measles cases inside Syria, measles cases among the refugees in Iraq and Lebanon, in Turkey. So, measles response activities had to be mounted in all those countries and right now, the measles response in the northern part of Syria is really only getting underway now, which reflects the difficulties of operating in that part of the country. There's been other public health threats that have emerged, cutaneous leishmaniasis, according to the agency mentor has reached epidemic proportions. Certainly in northern Syria, one reason for this is because there's now no longer vector control going on inside the country. We have reports of pertussis or whooping cough. We have reports of hepatitis, but again, one problem with the response with the northern Syria is that where do we send laboratory specimens? We can only send laboratory specimens to Damascus and outside for polio. There's nowhere to work out what the fevers of unknown origin are. We're talking hepatitis A, B, and C. Do we have cholera? So there are all those issues. So, to close, I think that we do need to make sure that the response to these public health threats or our regional, the vaccine-preventable diseases or vector-borne diseases like leishmaniasis are not going to play happily inside Syria and respect the national boundaries. So our response does have to be regional. I think that one thing we can do, which is positive, is emphasize the role of primary health care. Like many countries in the region, Syria was very medicalized with there was less emphasis on primary health care and which really depended on people showing up and coming to the clinic. So this is an opportunity to reinforce the primary health care approach inside and outside Syria. I think that the success of the polio response in the north and the south of Syria has shown that despite the multiplicity of groups, despite the targeting of health workers and facilities, it's still possible to do something. There has been, we believe, very good coverage during these polio campaigns. Now, of course, polio is easy. It's oral. People can stick it in their pockets. It has a vaccine vial monitor that tells you is it good or not. But the success of that has shown what you can do in terms of negotiations with all of these different groups and that you can reach out and conduct a population-wide public health activity in Syria. I would like to recognize that as of, to my knowledge as of now, at least three workers in that campaign have been killed. There may be more that I don't know of. And this effort just again reflects the incredible dedication of the health workers, the community workers, the civilian population inside of Syria. And what they can do. I think I would also like to add that the last thing that we also need to do is to hold humanitarian space. This is not about, at least for the public health aspect, it's not about who controls this area, who controls that area. It's about how do we reach the population inside those areas, no matter who they're affiliated to, no matter where they are, that's the objective. And the people that we work with when we go to the governorate level, to the district and sub-district level, they understand that very well, that it's about reaching the civilian population without distinction. And I think we need to keep holding that space for themselves and for us. Thank you, Miran, and thanks for hanging in there with our challenge technology. Ron, we're gonna turn to you now for looking at the big picture of the impact of the war on health and the prospects for the future. Thanks, Len. When we put this panel together, I was asked to talk about how far the health system in Syria had deteriorated, and I think that some of the numbers are quite extraordinary. I want to point out that Syria really, it's been mentioned, was a middle-income country, but it wasn't always a middle-income country. And if we look at the trends in healthcare and some of the parameters that are measured, we see some remarkable achievements that have been made over the course of the past three decades. So it's not only a question of a decline from higher levels to lower levels, but there's been an absolute and abrupt cessation of very encouraging trends in healthcare, and this has all come to an end. I don't need to repeat the numbers that are there, but you can see that some of the gains that have been made are extraordinary. The line that says, that's from non-communicable diseases is illustrative of the fact that Syria had passed through what we call the epidemiologic transition and had most of its mortality occurring from longer-term chronic diseases as opposed to the communicable diseases, which you've just heard make up now the majority of the issues that occupy the epidemiological profile. So it's really a remarkable reversal and not only a steady decline from what had been previously a steady state. Marin made mention also of the fact that this is a pretty, it's not a primary healthcare system, actually, that existed primarily. It's more of a hospital-based, more highly sophisticated, and I would point out very highly privatized healthcare system. Government expenditure on health was really quite low at about 3% of GDP. People were used to paying for health services and the impact that the conflict has had has not only taken its toll in all of the different sectors that have been mentioned, but it affects people's ability to pay for services for themselves. And Len began by saying that we're talking about the health sector, but it's not the only sector involved and the impact has really been across the board. Nancy talked about education in the last session. We shouldn't forget that agriculture has been affected, business has been affected. So we can talk about the health sector and the humanitarian efforts being made there today, but it's important to note that even as we shine a light on health workers being killed, health workers themselves constitute a small fraction of the more than 150,000 civilian deaths that have occurred, a small fraction of the astounding figure of 500,000 injured that need care from humanitarian intervention that can be provided. So this is really a conflict that we need to remember at all times as affected those in all walks of life across the board as the fundamentally destroyed what had been a thriving and improving society prior to the outbreak of conflict. I'll have the next slide, please. Just as Nancy Lindberg mentioned that USAID is contributing to the construction of schools, she said there are a lot more schools, just as in the education sector, schools don't guarantee education. You need teachers as well. And in other sectors, you need other commodities as well. In agriculture, you need fertilizer, you need seed. It's difficult, it's impossible for farmers to produce food without those kinds of commodities and it's impossible for health staff to practice their trade without certain essential commodities. And I wanted to put a light on Syria's pharmaceutical industry which is really quite important not only for taking care of the needs of the Syrian population itself but which really was a major exporter to the region of drugs and other medical commodities. So the ramifications of its destruction are important as well. As you may see in the 30 years prior to the conflict, the booming impact of the pharmaceutical industry that grew to be able to meet more than 90% of the domestic demand for pharmaceutical products. Over $500 million sector, most of which was for domestic consumption but as I mentioned, a substantial proportion of which also provided commodities to countries of the region. Now nothing, these plants have been destroyed and where they're not destroyed and are partially functioning, these plants require raw materials in order to be able to produce their product. Those raw materials need to be imported now. We haven't talked today, at least I haven't heard it mentioned about the deterioration of Syria's economy which has been left pretty much for the imagination but the declining value of the Syrian currency means that these partially functioning pharmaceutical plants can't afford to import raw materials anymore and to sell them at the artificially supported value of the Syrian pound so that people can't sell in a way that allows them to continue making pharmaceutical products without incurring heavy losses and the population can't afford to buy these drugs anymore. So we went from meeting 6% of the country's need to meeting over 90% and at best now, it's back down to where we were 30 years ago which I think is the number that was presented before in the prior panel. Next slide please. I want to, Marin mentioned this condition. I wanted to show one slide of a disease. This is cutaneous leishmaniasis. There is an outbreak of severe proportions occurring now. We haven't mentioned the role of seasonality on the epidemiology of communicable diseases in Syria. This is the summer season there. That's why flies are thriving which are the vector for cutaneous leishmaniasis and why vector control is required. This is the high transmission season for polio. I'm not as sanguine as Marin is about having controlled adequately the situation. We have to wait to see what transpires over the next few months of the high transmission season. We have threats from other diseases such as diarrheal diseases, the hepatitis diseases that Marin mentioned, cholera as well remains a threat. This doesn't look so bad, this picture. There's a disease that if not treated early and the treatment is horrible in and of itself and only partially affected but these lesions can continue to grow, to fester and this is a disfiguring disease particularly of children when they contract it if it is not adequately cared for early in its course and now it is not. I work with an NGO that's providing services in Idlib province, MedSan Dumon, Doctors of the World and they recorded an increase in the numbers of cutaneous leishmaniasis in their primary healthcare centers over the course of the last month from 80 cases to more than 400. This is really a problem that's taken off. I have to say I signaled it at the beginning of the conflict to some of the US government authorities as something to watch as a harbinger of when a health system is deteriorating and we see that now completely out of control. The next slide please. So doctors and health professionals also need facilities from which to work. We spoke about their destruction. I just thought it would be interesting to show the numbers from WHO regarding just what's happened in 2013 over the course of the second half of the year where the number of hospitals that have been affected and rendered partially inoperative increased from 57%, not a good starting place at all to almost three quarters and those that are out of service entirely have also increased. So there aren't any of those hospitals or secondary care facilities that had been really the backbone of the health system prior to the outbreak of conflict. Next slide please. So that's all I wanted to say. Now I wanted to talk about two different issues which are much more important to me. And that is that Andrea just called for the enforcement of international law, where it exists and where there are violations, these need to be enforced everywhere. Andrea has a soft voice and said this very quietly. Many people in the humanitarian community, they're nice people. So they say, excuse me, can I please have a little bit of space in which we can provide humanitarian assistance? And they've written letters to the editors, a letter by Gro Harlan Brunblum, the former director general of the World Health Organization that I was privileged to sign, appeared last year in the Lancet. Last week, 27 CEOs of large non-governmental organizations in the United Kingdom wrote a letter to the Guardian in which they said that the efforts to expand humanitarian space in Syria have been a dismal failure. We heard earlier today about UN resolution 2139, passed and it says that we insist on cross-border delivery of humanitarian assistance, but we heard in the first presentation this morning from Damascus, hasn't changed the thing. Nothing has happened. Nothing has happened. And so to say we want to stand back, take a deep breath, reassess the situation, write some more letters, pass some more resolutions is not helping and we need to really understand that it's not helping. Do I have the solution to that? No, of course not. I'm hoping one will emerge from the audience maybe during the discussion period. The next panel will solve it. Then the next panel will provide us with the political solution or ideas for how to achieve it. But yes, the political solution is obviously the ultimate, but there has to be a humanitarian solution as well. We can't continue to just be putting on band-aids, which is what we're doing at best, and poor band-aids as well. At least if we're gonna be in the band-aid business, we ought to have the best and most effective band-aids that they can be. We're not doing that now. There isn't 2016 going to be the first of what's being called the World Humanitarian Summit. And in their opening paragraph on the World Humanitarian Summit website, you'll find that this summit is devoted to innovation and change and new techniques. But it doesn't need, we don't need new, we need them and new technologies like debit cards and other forms of cash transfers that were mentioned earlier are quite important and they help and they help to support people, but they don't solve the problem. What's really needed is a fundamental change to our ability to access people in need. We have to be concerned with the people who are affected by disaster situations like this and not so much governments. In some ways, the way the system is organized, we're seeing now is failing. We need a new kind of system and I'm really hoping that the World Humanitarian Summit, which is being sponsored by the UN's Office for the Coordination for Humanitarian Assistance, will recognize that the way the delivery of humanitarian assistance is structured now for situations like that which prevails in Syria is inadequate and does not get the job done. I think I have another slide and then yeah, I do because we wanted also to talk a little bit about where we go from here. And I just want to mention and I brought this up at a CSIS meeting when CSIS was in the old building actually, that it's not too early to start thinking about what can and needs to happen afterwards as well. We talked because it was mentioned earlier this morning that if we were to find the solution tomorrow, it will take decades for a full and adequate recovery to occur at least in the health sector. And we have experience in rehabilitating health systems in other post-conflict settings. And I think it would be interesting and useful for people from all sides. I don't know what post-conflict Syria is going to look like politically. I think we heard just now and we do know what it's going to look like from the health sector perspective. It's going to look like the disaster it is. Planning for rehabilitation should begin now. And that planning ought to include some of these elements that we learned from past experiences in Afghanistan, in Liberia, in Democratic Republic of Congo. We've learned of some things that work and some things that don't. I've just listed some of those here, having a clear set of intervention priorities to afford so that the population knows what kind of health services it's going to have the right to receive. We need to figure out who's gonna be delivering those services because of the depletion of human resources in the health sector. We need to have a solid financial base for health sector activities and we need to have some clear means of generating additional financial support. And finally, we were talking before, Marin and myself, I have, when I work in disasters, I always like to say at the beginning that these are fundamentally data-free zones and we can't operate in public health under those circumstances. We need to begin now the plan for the development of information systems that can provide us with some direction that can be implemented down the line. Thank you, Lynn. Thank you. Well, thank you all and we'll open it for questions, but as you're formulating your questions, I wanna pose one question that follows a little bit from the last panel, but it involves a paradox. Marin, you talked about the role of WHO and the Ministry of Health in these vaccination programs and other health programs. What is the role of the Ministry of Health in a context where the government of which they're a part or destroying health facilities and attacking health personnel and yet the Ministry and the health system is supposed to respond to the crisis? We haven't talked much about this problem. I'd like to hear your thoughts on that. Not just you, Marin, but Ron too. I think that's a very tough question. I think that at least my experience has been when you get down to the lower levels of where things work, say the governorate and below and you are interfacing with the personnel there, whether they're now in opposition controlled areas or in their government controlled areas, these people were all part of the one system. And certainly the health people want what's best for the population and they are willing to do whatever it takes and to do the best they can. One of the big problems in this environment is information sharing between the health activities that are going on, let's say in opposition controlled areas and the health activities that are going on. So there's some interface taking place on a very, very local level, but it's very, very difficult in this environment to bridge that information gap to see who's being left out, who's being left in. But certainly I would say at certainly at lower levels, health is apolitical and people are working together as best they can to deliver whatever they can. Rod, do you wanna comment? I wanna second what Marin says about information. That's clearly the key to what we do in public health. And I think that this situation in Syria has really caused a problem within the humanitarian community that shouldn't be tolerated either and that is in order for a very good reason of protecting their workers and their partners, organizations that are working there have not been very forthcoming with information. It's as if, it's almost as if humanitarian workers have had to sign up for the Witness Protection Program and that's really not a very good way to get things done in the public health sphere. But in regards to your first question, Len, about what the role of the Ministry of Health, if nothing else, it's to be permissive and it's to allow for health services to be delivered to the population or for civilians to be able to access them. It hasn't been said the polio vaccination campaigns I've heard from many, many people have been quite successful of late but they were slow getting started and the officially designated first case of polio may in fact not have been the first case because of this problem with information transmission. But I do know that the delivery of polio vaccine to people living in opposition held areas was delayed by the fact that there was no entity to which polio vaccine could be delivered and it was only through a lot of behind the scenes negotiation and discussion that finally and I don't even know if I should say how this was resolved but finally public health workers and NGOs in the opposition health held areas were able to obtain adequate quantities of polio vaccine in the late fall of 2013 several months after the cases had been officially announced. So I think that the Ministry of Health needs to be more health oriented and less politically oriented, I can put it that way. Okay, why don't we open it? Hello. Hello. I'm Dr. Adana Wells. I'm an expert in the Russian language internet. This question is for Andrea. Are there positive links between the bombings of these hospitals and the Syrian leadership? Why don't we take a couple others? We're gonna just, we only have time for one round back there and then we'll take the questions and then we'll wrap it up. My name is Ruth Abaya. I'm a pediatric emergency medicine physician at the Children's Hospital of Philadelphia. I'm here today with the AAP. My question is in the setting of this dedicated bombing of healthcare facilities, the question that naturally emerges is shouldn't we be providing care in other settings that we're not advertising as healthcare facilities, particularly for children where you can provide preventative medicine without a whole lot of resources. You don't need a lot of sophisticated equipment other than some basic infrastructure such as refrigeration. So is that something that's being explored and is that a particular or potential inroad? Another question? Sorry, sorry, thank you, yeah. The question is, is mental health obviously in a conflict situation, the needs are enormous, capacity is declined. What can you say about what the need is, what the capacity is, what we could do if we had the ability to? Okay, so we have a question about the responsibility of leadership for the attacks on hospitals. Should health facilities go underground, as it were? Is that your question? Right? Alternative facilities, and then the question about mental health. So, Angie, you wanna go first? Sure, I'd be happy to. Thank you for your question. We've found out that about 90% of the attacks were committed by government forces. And this is. I understand the government forces that they're positively now. Yes, so that is a very good question when we come to accountability mechanisms. And yes, we can connect this to leadership based on the information. If you were to go to the map and click on a certain attack, you can find information there and sometimes within a UN report about the alleged perpetrators, about commanders. And you can see, even if you just kind of pan out, let your eyes go fuzzy, the fact that this is happening all over, so is that there's some kind of systematic nature to these attacks happening. So there's that, just kind of soft inference that we can make. And then if you click on the individual attack, you can find more information about who was involved, whether it was commanded. And so this isn't something that is just happening at a low level. We can see that there are orders, we can see it was systematic. And that, of course, would come into play in any sort of accountability mechanism. So thanks for your question. And then just for the care and other settings, we'll run a series of underground field clinics. Not all of the field clinics were included in our map for a number of reasons, but also we don't want to talk about the clinics. We don't want to paint a target on them either. But a lot of this is going underground and it's not new. I mean, even shortly after the conflict, a lot of healthcare was taking place in basements and hallways and places that don't really have the normal capacity to cater to that kind of need. So just on that, yes, people, if you like, have voted with their feet. So schools, somebody's front room, the basement, whatever, are now being turned into ad hoc clinics. But remember, this was a population with very sophisticated diagnosis and illnesses. And furthermore, people know they have those illnesses. So if I have leukemia, I know. If I have talosemia, I know. If I need dialysis, I know. These are not things that can be really provided in somebody's basement. So that's the issue. As for mental health, partners are trying to, it's a huge issue. Partners are kind of trying to begin to address it in the refugee population. But it's an extremely difficult intervention to do at scale. So I would say no way are those needs being met. Alan, probably, I'd be 10 million people or more in Syria have been affected. Psychologically, and probably have some symptoms of PTSD, I wouldn't be surprised. Right now, what's being seen in the hospitals is trauma, physical trauma, and people are involved in life-saving activities. There's no space for mental health right now. It's interesting when I went very quickly through what ought to come afterwards. But in Afghanistan, when a basic package of health services for health sector rehabilitation was put together, initially there was no mental health as part of that because of the problem that Miran says. The interventions aren't as clear and it's difficult to find the resources to be able to take them to scale. But a few years into the recovery, into the health system recovery, it was added in and services are being delivered. But that's why I'm saying shouldn't wait that long. This is the time to begin to develop clear-cut, uniform protocols to be able to train people, professionals and paraprofessionals in their implementation and to begin to grapple with a problem that's going to only become increasingly apparent as the lower-hanging fruit, if I can say, is dealt with now and in the near-term future. Thank you, Ron, and thank you, Miran and Angie, both for the provocative and illuminating presentations and discussion, but for the work you do. So let's thank our panel.