 Good afternoon. Welcome to CSIS. And thanks for joining us on this beautiful spring Friday afternoon. I'm Steve Morrison. I'm Senior Vice President at CSIS and Director of the Global Health Policy Center here. Before I offer some reframing remarks, I wish to thank several individuals who were, who made very substantial contributions to pulling this event together. From CSIS, the single most important personality in all of this is my colleague Matt Fisher, who has been there indefinitely since the beginning. From our Ideas Lab, which produced the short video, which we will air in a few minutes, Beverly Kirk, the Senior Producer Paul Frantz, who did the graphics work, and Chris LaTondre, who did the editing. Thanks very much for your expedited work and pulling this all together on a very short schedule. We're delighted we're able to do this event jointly with the CSIS Middle East Program, and a special thanks to Rebecca Sheratzi for all her extensive support in getting the word out, and to John Alterman and Haim Malka, the leadership in that program for agreeing to move ahead with this partnership. The impetus for this event rest with my close friend and colleague Len Rubinstein, Senior Scholar at the Center for Public Health and Human Rights at the Johns Hopkins University Bloomberg School of Public Health. He's one of our speakers here today at the round table. He's been at the forefront for many years of work focused upon violent conflicts and the implications for the health sector. We've made available for you today a copy of an essay, an excellent piece of work that he kindly produced for us in early 2012, Protection of Healthcare in Armed and Civil Conflicts. In preparing for this event, we also benefited enormously from the generosity of several other individuals. Claudia Bloom from MSF Toronto, the press officer there went out of her way to share with us some footage you'll see in the video. Rick Brennan, the Director of Emergency Risk Management at WHO. In Geneva, Marcus Geiser and Mark Steinbeck from the International Committee of the Red Cross, both of whom are kindly here today with us. Very generous in sharing their insights. Marcus is the Deputy Head of the Regional Delegation here for U.S. and Canada, and Mark is the Medical Advisor, Mark Steinbeck, on the effects of weapons for the ICRC. We're here today to discuss the attacks by the systematic attacks by the government of Syria and the related actions by various armed opposition groups that are gravely damaging hospitals, clinics and other facilities, injuring and intimidating health providers and disrupting essential care for countless Syrians who remain acutely vulnerable in the need of medications, continuous care and emergency care. We're here to put a spotlight on this phenomenon, to understand the trajectory and possible scenarios that lie ahead and to think concretely about what can and cannot be done in this urgent situation. We'll hear from two individuals who have firsthand recent experience on the ground inside Syria on this particular special subject, Zahir Salul, who has come to us today kindly from Chicago. He is with the Syrian American Medical Society and Stephen Cornish from MSF, Canada. We're also joined by a senior official from the Department of State, from the Obama Administration, the Department of State Dorothy Shea, who oversees the U.S. Humanitarian response in the Bureau of Population, Refugee and Migration. She heads up the regional office responsible for that work and of course we're joined as I mentioned earlier by Len Rubinstein from Johns Hopkins. We will not today, I wish to emphasize, be debating U.S. political and security policy choices and I think it's important to emphasize that. We're going to keep our focus upon the subject that I delineated just a moment ago. So we're not going to debate whether the merits of arming rebels, establishing a no-fly zone, whether we've crossed a red line in terms of chemical weapons and what that then triggers. These are terribly important policy debates, but we're not going to treat those today and I just want to make that clear. We will hear, as we will hear, the targeted and willful systematic destruction of the health sector in Syria is truly extraordinary and it's conducted at a pace and a scale that are unprecedented and it is of course one dimension, one important vital dimension of a much larger extraordinary catastrophe that is unfolding now in Syria. As we'll hear from our speakers, the macro indicators are quite stunning. In a population of 23 million, 70,000 killed, over 6,500 in March, 1.5 million refugees. Just to remind you that this is now estimated to exceed 3 million by the end of 2013. A year ago, the refugee population was under 60,000 and this flood of refugees, as we'll hear, has now become its own vector of regional destabilization. Lebanon and Jordan each struggle to accommodate roughly half a million refugees doubling or tripling those levels is a staggering new level of human suffering. It's also an accelerating security crisis for those host countries themselves and for the region. Internally displaced populations, 4.25 million. Civilians in need of emergency humanitarian relief on a daily basis, 7 million, every three citizens still in the country of Syria. As we'll hear, this is a situation that's highly uncertain, filled with tensions and frustrations. Will there be a continued steep trajectory of violence as we've seen with the government able to continue to sustain these assaults? Will there be a precipitous collapse? Will there be some negotiated settlement? We know this is a war that defies expectations. We know that it has become a proxy conflict increasingly of a broader Shia-Sunni confrontation. We know that it's a powerful magnet attracting Islamic extremists onto the battlefield. We know that it's having profound spillover effects into Lebanon, Jordan, and elsewhere. We also know that there's clear and present danger of large-scale chemical attacks which could have profound direct health impacts on citizens. The stockpiles are not visible, they're distributed widely, could be deployed through the Shabia with a certain level of deniability. We'll hear more about that. With regard to health, there's not much that we do not know with a lot of precision, but as we'll hear from our speakers today, there are certain large realities that are coming into focus. 30,000 doctors, half of them now having departed, one-third of hospitals non-functioning, half damaged by fighting, continued hard-line government defiance of international humanitarian law, fierce opposition to cross-line relief and cross-border, increased evidence of armed opposition groups defying the neutrality and impartiality of health workers, the disruption of Syrian production of essential medicines, disruption of routine immunization programs, heightened mental disorders, resurgent outbreaks of measles and others and acute vulnerabilities, obviously of pregnant women and children. We'll talk today about what can be done in the near-term and in the long-term. In the near-term, I think we'll hear from our speakers about the appeals for high-level action, what would that take at the UN Security Council elsewhere, what kind of pragmatic steps can be taken to better protect and preserve the health infrastructure from wholesale destruction, how do you strengthen local, worthy local capacities of the many courageous folks that are struggling against these realities? How do we advance cross-line dialogues on humanitarian pauses for resumed immunizations and how do you crack the code on cross-line and cross-border operations? And, of course, how do you begin to develop active measures of protection against populations that are vulnerable to chemical attacks? In the long-term, there's a question of accountability of those responsible for these egregious acts and planning for reconstruction. So it's a broad number of issues that are coming forward. Among the best experts here today for this discussion, and I thank you all for being with us for it. We're going to open with a very brief two-minute video montage that, as I said, Beverly, Paul, and Chris kindly put together on an urgent basis. So we will watch this, then I'll invite our guests to our roundtable. Each of our guests, our roundtable speakers, will kick off with five to seven minutes of opening summary remarks. We'll have a bit of a roundtable discussion afterwards, and then we'll open the floor for your comments and questions to come back to our roundtable, folks. And we will attempt to close up by four, so thank you very much if we could view the video. The violence in Syria rages on day after day in village after village, leaving no one untouched. Not even the medical professionals trying desperately to counter the wounded and dying. The Assad regime has increasingly and systematically targeted doctors, hospitals, healthcare workers, and patients. And the armed opposition has also defied the impartiality and neutrality of medical services. Several organizations are mobilized to protect health workers and sustain services. The World Health Organization, the International Committee of the Red Cross, Syrian NGOs, Doctors Without Borders, and others. These media clips from Al Jazeera and Doctors Without Borders shed light on the issue. These doctors have come from all over the world to the border between Turkey and Syria. They're all Syrians. None of them can practice openly in their home country. So they're reduced to smuggling medical supplies in and hoping for the best. It's no easy task smuggling this quantity of equipment into a war zone. There are no more hospitals left here. They've either been bombed down by President Bashar al-Assad's army or formed into bases for rebel fighters. Instead, the injured are brought to these makeshift treatment rooms set up in people's homes and basements. But these so-called clinics are struggling to cope. There are few doctors and little medicine. MSF is working inside Syria where it has opened three hospitals. The teams also supply drugs and trained Syrians who give first aid to the wounded near the frontline. Zaha, we've asked you to open things up. You've been deeply and personally involved in this crisis in the response and mobilizing the constituency represented by the Syrian American Medical Council. Thank you for being with us. Why don't you kick things off with some opening remarks? Sure. Thank you, Steve, for inviting me. I enjoy always the visit to D.C. especially that the weather is better than Chicago for today. And I thank also for my co-speakers for being with us and I feel excited to listen to what they have to add. Just came in from Aleppo. By the way, I'm the only physician in the group so I'm going to use some medical terminology. I'm a critical care specialist practice in Chicago president of the Syrian American Medical Society. I'm also probably the only person who has direct connection to Syria. I was raised in Syria. My family is still in the city of Hamas in Syria. And I have a connection to Bashar al-Assad. He was my classmate. We graduated in the same year. But that's not a good thing. I wanted to highlight that. Anyway, came in from the city of Aleppo last week and part of the field assessment of what's happening in the medical field in Aleppo. Syrian American Medical Society like Doctors Without Borders have been doing a lot of medical relief in Syria supporting physicians, hospitals building an infrastructure for the healthcare system that is kind of underground secretive so physicians can see patients and treat them and do surgeries without being bound or shelled. So I was meeting with the director of the Aleppo Medical Council in his name is Dr. Abdulaziz. He's an attending a surgeon in the University of Aleppo who left his post about a year ago to oversee the medical care in the area that is under the control of the opposition in the city of Aleppo. So he oversees the work of 10 hospitals. And we toured with him over 5 hospitals among the 10. And what you are seeing is basically a reflection of what Steve was describing in his report. Destruction, systematic destruction of the healthcare system in Syria. Aleppo is a major city of about 5 or 6 million people before the crisis. The area that is under the control of the opposition has 3 million people 10 hospitals. It has no CT scan. It has no, it has only 10 incubators for new natals. It has only 10 dialysis machines. It has, it's running out of saline solutions, IV solution. Oral antibiotics is not available when the time when I was there. I saw a physician who was getting IV antibiotics because he has bronchitis or pneumonia and he was not, he didn't have access to oral antibiotics. But in spite of that, in spite of the shortages of many basic medical needs and medications, the hospitals and the medical community in Aleppo were ready for a chemical attack. So in front of every hospital you have a tent that is posted, it was created locally actually and it has 3 sections. So they are expecting another chemical attack and so these tents that is created locally and Syrians are very creative by the way. I'm not saying that because I'm Syrian. But the first part would be for the patients when they come in, they will remove their clothing, the second part for washing them from the chemical weapon and the third part put a gown before they enter the emergency room. Because in the previous attacks in Aleppo people from the medical personnel who treated patients who had exposure actually some of them had symptoms and one of them had a cardiac arrest one of the nurses who treated patients. Besides the destruction that you see in the public hospitals I saw two public hospitals one of the best hospitals in Aleppo before the crisis who were completely looted and right now serve as a base for some of the military battalions one of them specialized eye hospitals in Aleppo and the other one is a children hospital in Aleppo. So the situation is really bad besides the destruction of the public healthcare system there is no garbage collection, there is a lot of displacement and crowding the poor hygiene because of lack of electricity and sometimes water, lack of diesel fuel and because of that you have a resurgence of some of the epidemics that it was not there before so you have increased numbers of hepatitis A epidemics, you have increased number of Laishmania which is a disease that is localized to the area of Aleppo caused by a parasite and it's transmitted by a sand fly which increases when you have a garbage in the area because there is no garbage collection disposal you have resurgence of other born water born diseases the Syrian American Medical Society and other NGOs have been trying to help by providing training to the physicians so they can deal with the situation by sending medical supplies across the border through Turkey and Jordan of course people who are doing that are risking their lives because in Syria if you are a physician who is caught treating patients from the other side that will risk your life and many of the physicians unfortunately have been detained, tortured and killed. I have a report of 107 physicians who have been killed in Syria so far and this is an underestimate. Some of the reports say the number is about 130. One of them is available here in the back is Dr. Ali Al-Mahameed and his number in the list is 104. He was in the city of Dar'a he's a cardiologist and early in the crisis when there were demonstrations in the city of Dar'a and security forces responded the demonstration by attacking the demonstrators so the demonstrators went to one of the local mosques and they were there under siege and some of them were injured so they started to ask for help so Dr. Ali Al-Mahameed took his car, drove his car and he went to that area and the security system blocked him from going to that area. He told them I'm a cardiologist, I just want to treat the patients so they shot him in the eye and the chest and he died in March 23rd 2011. This is one of 130 physicians who have been killed in Syria. Many of them were detained, I was just talking to one of my friends who detained for 12 days because the accusation was that he was helping the opposition by sending them serum saline serum and also treating some of the patient in his clinic so he was detained for 12 days in the prison, in one of the prisons in Damascus he told me that at one time the interrogator put a gun in his head and he told him you better admit what you have done but in spite of that because he knows that he admitted of these crimes which is treating patients who's not supposed to treat, he would spend the rest of his life in the prison he did not admit and then he was let go then he smuggled himself and his family to Lebanon then to Turkey and he's been in Turkey now for the past year or so looking for a war this is one of hundreds of physicians who had to flee Syria because they feel that if they stayed in Syria they would be targeted or harassed or prevented from doing their job which is treating patients I have a friend a physician from the city of Homs he just called me last week and he said I've been in Homs now from the beginning of the crisis he's a surgeon there are only two surgeons of his caliber in the city of Homs he's a chest surgeon he said I have to leave I said why now I mean now it's the situation that you have to stay he said I have a family with five children I'm worried about their safety and I cannot sustain my life I'm dependent on the local NGOs to pay for me because the healthcare system has been disseminated in Syria and also the economy is not working so people are not able to pay for the physician's visit so now he decided to leave and of course if he left that mean other people who are in need for his services will not be able to have surgeries the worst thing to happen for you in Syria in the city of Homs or Darra or Damascus if you have a heart attack or for a woman to have a delivery in the middle of the night because first of all it's not safe to go to the hospital and if you are lucky to go to a hospital you will not find a physician in the city of Aleppo I've seen medical students first year medical students who are working as surgeon because there's only 75 physicians in the city of Aleppo serving 3 million population I've seen an interior designer who is working in the emergency room as a medic, as a nurse because there are no nurses so the worst thing for you if you are a patient in Syria is to get sick in the middle of the night many people unfortunately are dying and of course these are not among those people who are killed many patients who are on dialysis they're not able to get dialysis because they're not able to get access to dialysis unit and they're not able to pay for it I'm going to end my briefing with the story of Dr. Ablaziz who I mentioned that he left his post and I told him why are you doing what you're doing you can still continue to work in the Aleppo University and it's safer for you to go to the other side and actually this term now you hear it more in Syria the other side because every city has the side of the opposition and the other side which is under the control of the government he said look you know if I left my post no one will take care of the hospitals in this area of the city and I know that if I quote by the government forces I will be executed right away but I believe that this is my duty because of this person because of these heroes in Syria I think we have to support the medical community in Syria there's a lot of things that can be done first of all we have to have the will political will to end the crisis because without ending the crisis the situation will continue to deteriorate right now is a disastrous already but I think we have to end the crisis and secondly we have to make sure that there is a safe transport of humanitarian assistance cross-border from Turkey and Jordan to many of the areas in cities that are in need and we're talking here about operations that the local NGOs and Syrian American Medical Society and others cannot do it on their own these are operations that requires countries and the United Nations to do it but right now it's being done by individuals and organizations so there should be an international community there are operations to cross-border humanitarian assistance so we can help these physicians supporting the physicians in Syria financially so they can stay in Syria because right now they are depleted from their savings 50% of the physicians have already left and I've mentioned some of the examples of what's happening in Syria because of the shortage of physicians these are some of the things which I believe that the international community and the US government has to push for of course ultimately no fly zone is helpful I know that this is a long shot but this is something that everyone is asking for when you go into Syria I would like to stop on this and maybe we can address some of the other issues during the Thank you, thank you Dr. Slu Steven, Cornish, MSF Thank you very much for having me here today certainly the thematic that we're covering unfortunately is becoming all too common in a number of conflict areas where our organization and others work in this lack of respect for medical facilities lack of respect for civilians and lack of respect for humanitarian assistance I won't go into great detail perhaps on the targeting on both sides that's happening given the introduction and giving the excellent presentation but certainly I think the systematization of the attacks was probably much more at the beginning of this conflict and it certainly served its purpose it created the flight of many medical personnel it destroyed large numbers of hospitals and interrupted public health care in a very significant way I think since then we've seen through the work of SAMS through the work of other organizations that the surgery capacity has been restocked if you like but in a way that's often underground in semi-clandestine that has a lot of limitations to it and which unfortunately has also been used by both sides in the conflict there's been an appropriation of medical spaces there's been a cannibalization of existing medical structures in order to supply those outposts and a lot of them have been primarily serving combatants at the expense of civilian care and so there are issues on both sides that truly need to be addressed and I think that need addressing and need our attention and certainly need our government's attention the collapse of the public health system has had a number of effects some already mentioned but certainly anyone suffering from a chronic disease has had their treatment interrupted whether it be diabetes whether it be cancer or high blood pressure we've witnessed many, many people and we call them casualties of this war we like to talk about the 70,000 dead and the hundreds of thousands injured but there are so many more that are not in the spotlight they can't be referred outside of the country because it's not considered emergency but the facilities to follow them up don't exist anymore and so what you see is a slow steady death of people that could be treated in one of our own centers we had a man arrive with two feet completely necrofeed those feet the disease might have spread to the patients that were on our burn unit and the patients that we were treating for war wounded issues and so we couldn't give him that treatment and we also couldn't send him away and you know that in a few weeks he would become an emergency patient displaced people I saw folks who had cancer their chemotherapy was interrupted and all they can do is have palliative medicines and slowly they die the interruption on the public health system is very worrying there's been a lack of vaccinations since the beginning of this conflict and when we're talking about these inhospitable conditions within which people are living with the lack of water with the lack of electricity you have in many areas numbers of families in the same apartments or in fairly difficult conditions in makeshift camps and that facilitates the comeback of measles measles had been eradicated in Syria and we're now launching measles vaccinations in many areas which we'll return to later because maybe it is one of those what can be done it might be the seeds of how to work on both sides and how to help to restore a little bit of humanitarian space part of the underground problem also makes it difficult for folks who are wounded to seek care they either don't know what a facility is or the facility is being truly kept for combatants and so is overwhelmed with the load of combatants they have and won't accept to care for civilians and so we've had a number of people who have either been evacuated in extremists on a securitous route in the back of taxis losing blood, some losing their lives going several hours away to seek treatment but part comes back to this initial targeting and the fact that some of them are fearful of seeking medical care in an established facility or they're being prevented from crossing either a front line or even just crossing from one territory to another so instead of going to a facility that's equipped and nearby some that our organization has worked with, some that Sam has worked with they will flee in the opposite direction often traveling two, three, four hours and then sadly quite often too late maternity was touched on very briefly but I'd like to return to that because in Syria sea sections were a very common practice and as anyone here who's had one or knows about it once you've had one or two you generally have to have a follow-up sea section on your next pregnancy and trying to find maternity care is very, very difficult there are very few places that will take women that are pregnant and generally they'll take those that are not complicated so if you have a complicated pregnancy you're at very great difficulty we had one woman who traveled for four days went to eight different structures before she found our clinic she was pregnant with twins and thankfully they're both traveling healthy babies now but very many more don't have that facility and so there is a lot that needs to be done on that side of things remaining obstacles to care there are a number not only the initial insecurity and the fact that unlike some conflicts where you have one or two front lines here you have a number of different front lines and pockets of violence that emanate from different military structures military bases and also sometimes between opposition groups themselves so it makes it very difficult to know where checkpoints are makes it very difficult to be able to arrange to have free passage for medical assistance and for humanitarian assistance basically the ground work changes almost day by day and so it's very difficult to establish a permanent security and a permanent passage there's also great suspicion in the opposition and in the government areas great suspicion of foreigners and of those seeking to help and so that also pushes the aid even farther underground and makes it even more difficult for organizations to come and help on the ground one is struck with by the absolute absence of most of the well known organizations that normally work in these areas not only inside Syria where it's very difficult but also in the surrounding refugee camps where those governments are doing the best they can with very hard level of refugees but they're treating it as a regular situation within their control and sadly they're not living up to the quality of care that's different and I think our governments need to assist the host countries to really be able to better cope with this allowing more organizations in our governments also need to back up the financial promises they've made and scale them up because the promises made were when there were 750,000 refugees we now have 1.5 million and as we heard today the prognostics are that number will double at the end of the year and we've always been several months behind the humanitarian situation we were behind last winter we were behind now this summer coming into the summer our organization is stepping in to chlorinate water in IDP camps where there are open sewers where there are overcrowding where even food and shelter is being stretched by the new arrivals and if something isn't done we'll end up with infectious disease and outbreaks this summer but the same can be said then we're already that there are going to be 1.5 million more people coming that those who are already in shelters are in very substandard shelters they sleep on the mud sometimes with just a blanket between them and the ground they need to be by now in winterised tents and those are not being bought they're not being prepositioned the camps are not being built so if we don't prepare now for next winter we're going to have a huge humanitarian disaster on our hands crossing front lines was mentioned that we share with our colleagues from the ICRC who are here they have sadly with the Red Crescent lost several of their members who are either evacuating wounded or trying to go across front lines this is something that we can't only do ourselves we certainly have to put more effort on explaining to all parties to the conflict that medical aid and passage has to be able to go across front lines and so that's something we should return to and in the opposition areas there are also with the splinter in the troops and this this real fear of the other a number of emerging risks that are becoming very difficult to tackle I'll wrap up now with the what can be done we have touched on the overwhelming need this is going to affect healthcare clearly for years to come and it will be a humanitarian situation for years to come I've said that something like a million dwellings have been destroyed so even if the war were to miraculously wrap up tomorrow there'll still be this very large population meeting humanitarian and medical assistance for time to come the cross border activity that we're able to do in northern Syria we have three hospitals supporting over 50 others sadly we're unable to work through Damascus but there we're working with networks of doctors and sending supplies it's not good enough but it's something and also bringing doctors out to train them up we're training in mass casualty training in anesthesia training small health posts just in combat first aid to be able to stop bleeding, get breathing and help people be stabilized on their transfer out and I think that's something that definitely can be increased by a number of parties at a very little expense but with the assistance that is being sent rather quietly I think it's very important that we ensure that all of those medical structures will also be serving civilian needs I visited several that didn't have space for women patients didn't have bathrooms for women patients and were designed and facilitating only those who were directly affected by the combat amongst the ranks of those who were running them and I think that's something that we need to really ensure that the assistance that's being sent is not only through the cross border that needs to be brought up but also on the Damascus side where there are limits to how far along the chain of relief systems can be followed and in some cases aid has to be passed over before it gets to its final destination and you don't know where it's going to end up and certainly there needs to be much more effort made with Damascus to allow regular cross front lines not just cross front line business and a scale up is possible I've touched on it briefly it was 1.4 I think a billion promised in January by some 30 countries or 60 countries only about a third of that has been delivered and since then the scale of the suffering and the need has gone up three fold so there's something that's wrong in this equation it's as if the political paralysis has somehow prioritized also humanitarian response and that certainly these two issues have to be linked we can't hold up the humanitarian response and the life saving needs now so there is more that we can do with the surrounding countries with the parties to the conflict and ourselves and I'll just finish on looking inward also I think our own organizations have to try harder it is difficult to risk to cross front lines it's difficult to risk to work with all parties to a conflict our own ability to continue working in Syria depends on it the conflict and to respond according to the needs that's what impartiality means so if there's a million on one side and 100,000 on the other we have to ensure that our assistance as an international community is also delivered that way and that's not always the case as we are today finally measles which is a horrible challenge might also present the beginnings of an opportunity for enclave areas there are some towns that were handed over by the government to forces that have a similar ideology or are considered friends and we've had trouble entering those areas on my last visit we were able to enter one of these areas and we saw something that goes less reported there was a big battle in Aleppo in Sheikh Mansour area this is a Kurdish area so a lot of the indiscriminate fighting in that area could be equally shared by both sides the victims fled to an area that was under Kurdish control where there was a hospital structure where they were attempting to deal with the IDPs having a very difficult time of it a organization since supported those structures the medical structures that had been set up and supported the IDPs and I think it's very important that to ensure that we're not only helping the pockets that are easiest or the pockets that we agree with all pockets and all areas of need and just to stop on measles I think we've seen elsewhere even in the most difficult times in Afghanistan under the Taliban we were able to make days of tranquility for Polio and I think it might be the starting way that we can start even in the opposition areas to work on both sides of the pocket Thank you, thank you very much Dorothy Shea Thank you Steve and thanks to CSIS for the invitation and I just want to say it's an honor to serve on this panel with the fellow panelists who have shown personal commitment to helping those in need in this crisis sometimes at great risk to themselves as we were just hearing so I'm going to coming from the State Department I am speaking from prepared to mark kind of the price of admission as a government official but hopefully in the Q&A I'll be able to speak a little more extemporaneously if you want to delve more deeply into some of these what I'd like to do is review some of the aspects of the severity of the healthcare attacks and then say a word about humanitarian agencies that the United States government and others are supporting as they heroically continue to provide assistance and then talk a little more about this funding situation that Steve just raised and conclude with some thoughts about the long term so I think it goes without saying but I'll say it that two years of conflict in Syria have taken an incredibly severe toll on the healthcare system I won't regurgitate the grim statistics that shape our work in this area but we have to be reminded every day of the tragic toll and civilian deaths of huge refugee flows which I deal with personally every day and the massive displacements inside Syria often multiple times as the fighting shifts on a daily basis hospitals clinics doctors medical staff are all being directly and violently targeted and again other panelists have talked about the statistics and their grim and their shocking I've seen reports 469 medical workers have been imprisoned I wouldn't be surprised if it's higher and then of course fearing for their safety thousands of healthcare providers have fled and who can blame them I mean I understand this crisis of conscience that this doctor that Dr. Saqlo talked about had in terms of fearing for his family's safety but I want to be clear the United States government strongly condemns these deliberate attacks patients must not be prevented from seeking care healthcare professionals must not be impeded from providing it and medical facilities and transport must not be targeted period medical care providers who remain in Syria face challenges in caring for the sick and wounded and facilities that lack fuel and electricity and equipment we've heard about that the heroic work of life-saving continues many organizations work tirelessly under extremely dangerous conditions to provide health and other basic services and I'm proud that the United States government is supporting their work so I'd like to name a few since the beginning of the conflict the Syrian Arab Red Presence volunteers have been providing medical services at great personal risk in an environment where battle lines are constantly shifting the volunteers have been working to reach communities in both government and opposition health areas and I take the point that we need to do more in opposition controlled areas and they're trying to but it is difficult 18 of them have been killed low in service the International Committee of the Red Cross is providing medical supplies, water, food ICRC is providing access to clean drinking water to at least 10 million people and I've read that the clean drinking water stocks have decreased in availability by about two thirds since the conflict began we also support the United Nations Relief and Works Agency for Palestine refugees, UNRA, which provides health, education and social services to 525,000 Palestinian refugees 235,000 of which have been displaced by the conflict UNRA reports that its health clinics have seen a significant decline in consultations so this just illustrates how inaccessible their clinics are as well, fitting that phenomenon that you all discussed 6 UNRA staff members have died and 13 are missing there are numerous other organizations, the United Nations Population Fund which has delivered ambulances, ventilators, other medical equipment other partners are also responding to gender-based violence both in Syria and neighboring countries the United Nations Children's Fund deserves our support, they've been very instrumental in trying to maintain access both the education for children affected by the conflict but also basic water, sanitation and hygiene I want to give a shout out to our colleagues from USAID who are supporting UNICEF as well because of the measles outbreak that we've seen earlier we've seen these refugees in the refugee populations as well in Lebanon, Jordan and Iraq so the US government has funded the vaccinations of here and of course a huge partner for us at the State Department the United Nations High Commissioner for Refugees, they were present in Syria long before the conflict largely supporting the Iraqi refugee population and so what they did was they sent their services to help meet the needs of displaced Syrians and of course in neighboring countries UNHCR is coordinating a full range of services for refugees including basic healthcare of course I take the point too that there's room for improvement there and I just want to note that countless NGOs, local NGOs international NGOs are also playing a vital role including those represented on this panel the governments and civil society organizations of neighboring countries have played a very important role in providing health to refugees even as the refugee influx has strained national healthcare systems and local economies we commend their generosity and respect for humanitarian principles to date mortality and malnutrition rates in the refugee camps are low the chronic disease burden is primarily consisting of diabetes cardiovascular and lung disease given the trauma that many refugees have experienced mental health and psychosocial services are also extremely important infectious diseases remain a concern TB, especially for Syrians whose treatment was interrupted by the conflict and the desert conditions in Jordan and Iraq can be pretty harsh invoking acute respiratory infections and as Dr. Saqloff says in some cases of elation a quick word on the funding front of the of the 1.6 billion dollars requested in the UN appeals donors have provided nearly 816 million so about 51% I don't think that number accounts for the 100 million that the United States announced this week though there's no lag time in the UN's tracking system and Secretary Kerry did announce an additional contribution which we can talk about more so we are grateful for the support from Congress as we make these contributions both for the UN system but also they support NGOs that are working outside the UN system doing the kind of cross-border assistance we got earlier and we do coordinate that with the opposition's assistance coordination unit looking forward I share in the view that even if a political solution were secured tomorrow the humanitarian needs would persist long into the future so we're really trying to work with humanitarian organizations now that we work with and in coordination with those who will be playing a longer term role in Syria's economic development and reconstruction and I just want to throw out one example of how this could play out in the health sector the United States has asked WHO to engage ministries of health in neighboring countries to allow Syrian health care providers who can prove their credentials to support the military and health operations so this could be win-win in the storage capacity but also allowing them to contribute to the response effort and keeping their skills sharp until such time as they can return and help rebuild the Syrian health care system this crisis is severe some have characterized it as a catastrophe understandably and so we do need to be in it for the long haul the United States government is and we remain committed to promoting access to health and other basic services in Syria in the long run thanks Dorothy Lynn Rubinstein you've been very patient well I'll try to be quick so we can get the conversation going but I do want to thank Steve and CSIS for having this event this issue of targeted attacks simply does not get enough attention and I want to briefly very briefly review four points one what's the context of these attacks in terms of what's happened in the world over the last 20 years two what do we understand of anything about what is motivating the attacks three what can we do and what is the long term prospect and how do we meet meet the needs if you look around the world in conflicts in Burma, in Colombia in Afghanistan, in Kosovo in Chechnya, in Sri Lanka the list goes on in Gaza in fact there have been specific deliberate attacks on health care services that is ambulance and hospital and doctors and nurses and patients but nothing has quite reached this scale and just if I could take two examples of what previously had been the worst in my view one was in Kosovo there was a major report in Ron Walden here today who did that report the Serb forces just burned a hundred clinics probably 25 doctors were arrested and tortured eight were put on trial providing health care to a terrorist pretty serious in Chechnya probably 30 to 40 hospitals were bombed or shelled but then you compare that to Syria and the scale is completely different when we talk about hospitals in the whole country not functioning because they were attacked you talk about 250 health workers killed and just interestingly not interestingly but important the violence documentation center there which has been keeping track of health workers who were killed reported in March that 120 doctors had been killed the last report this month 130 so that's 10 in the four to six weeks since the last report something like this that we're aware of in the past where the number of murders of health workers has been at this scale and someone mentioned that four to five hundred doctors and other health workers in prison or jailed is also to my mind unprecedented so that we have to understand that scale and that's why it's so important that we take some action why is this happening well we're not sure exactly why it's happening but we want to share one notion that comes out of some of the really excellent documentation work I mentioned the violence documentation project the independent commission UN established for Syria has done remarkably good work Human Rights Watch has done excellent documentation and what you find is very explicit statements that providing health care to an enemy is wrong and punishable and worthy of arrest, torture or murder it's not called murder it's called a legitimate response because health care has become an enemy act it's like weapons transport that's how health care is settled there's a very poignant story in one of the UN independent commission reports where there's a dialogue that a doctor reported where the Syrian soldier said why are you providing health care to the opposition why are you providing medicine to these people it's as though the norm that has been around for 150 years does not exist anymore that health care to the enemy is a hostile act and the problem actually goes deeper than Syria because we've seen this before we saw that in Kosovo we saw that in Cheshire we've seen that elsewhere but it's becoming more of an infringement of the norm in this age of anti-terrorism even under U.S. law medical care to a terrorist the violation of U.S. law so and this is happening around the world so we have some kind of norm issues that tie into the brutality of the government in Syria and that might also help explain why the opposition has also committed these kinds of acts and the impact is not just on the people it's not even a long term impact patients are terrified to go for health care and providers have been reported to refuse health care to certain people out of fear and this is harder to document but that is something we need to pay attention to so when we look at why this is happening we have to go deeper than the fact that the government pays no attention to the norms of humanitarian law so what do we do? I think what Dorothy did today is a terrific start we have to start by condemning this and it has to be condemned by government at the diplomatic level to start with and I'm really quite delighted that the U.S. government is now on record and of course we'd like to see it at higher levels we'd like to see the President and Secretary of State talk to this as well now we know condemnation may make no difference it may not change behavior but we also know that if you can recast health in the way it should be as somehow sacrosanct there are pressures that can develop and certainly not condemning is a guarantee that it will continue so condemnation sounds weak it's not like no fly zone but it's a place to start and it's important because it relates to my other point about restoration of values we've got to reaffirm those values globally and that's also why it's important to make a demand hopeless as it may seem it may seem for accountability to referral to the International Criminal Court we know all the problems of the Security Council that Russia and China are objecting and have objected probably will object to any action for the Security Council but there is value in having a campaign to make the case that silence on prosecution silence on accountability is a guarantee of no accountability and that brings us to those sitting in the room where we are who care about this issue this has to become more of a broad public issue and I'm really happy to report that in the last couple of years campaign has started the ICRC has developed it's already ever more visible healthcare engagement campaign I know MSF is about to launch its campaign and there is an NGO campaign called the safeguarding health and conflict coalition which is designed to engage UN agencies and government in a more robust response there are things that can be done to affect the short term and the long term finally on the reconstruction as Stephen pointed out and others so Mohamed pointed out the need for humanitarian action in Syria is going to go on for a long time but it's not just humanitarian action we have to start planning now for health reconstruction and there is nothing more important in terms of what's happened for future health reconstruction than the human resources because we've heard how they fled and we know those who have remained or traumatized and not only that those who have remained are going to be subject to reprisals or maybe subject to reprisals even when some kind of peace agreement came we saw this in Kosovo reprisals after the peace agreement were pervasive and if we don't think about this now for the medical community there is going to be trouble and finally for the people who have lived through this they are going to need support in terms of their own conduct what is medical ethics after you've been targeted so this is a kind of issue that all the countries including our own government in the United States need to take account of and start thinking about right now and start the conversation thank you thank you you know in listening to this one proposition that comes forward is that perhaps the situation on the ground is reaching a scale in which some of the calculations within the region and more globally may change and what I mean by that is if the staggering export of refugees into the surrounding region is going to threaten several states in terms of their stability does that give us an opportunity to re-engage in a targeted way the Russians in particular around the whole question of cross-border we know that there's been an inability to move anything in the Security Council in a serious fashion because of that opposition we know that Assad's intransigence on both the cross-line and cross-border and the continuing targeting is rooted in a certain amount of confidence that this is working for his advantage and so far that tragic formula has held so is this changing are we in a moment now I'd like to come to Sahir to comment on this are we coming at a moment where there could be a different kind of conversation in which the magnitude of human suffering plus the regional security threat equates into a different kind of set of pressures upon the Russians and others vis-a-vis this particular crisis that might begin to unlock some of these problems because the intransigence the deliberate systematic targeting the intransigence on the cross-line and the cross-border stuff has created this locked box in which this has been possible Sahir, can you talk? I hope so although foreign policy and I'm not expert in foreign policy is not based on humanitarian issues as everyone is aware and what drives foreign policy is national interest I'm not aware that the Russians are that concerned about the suffering in Syria one of my friends who studied in Russia reminded me with the Russians saying that killing one physician is more important than killing 100 soldiers and I think what Len has mentioned about what happened in Chechnya was happened by the same Russian government that is supporting Assad at this point but I think there is an opening right now with what's happening between regarding the conference that is being held at the end of this month hopefully we can pressure or convince the Russians to pressure the Syrian government and Assad to stop that at least on the hospitals and the healthcare system that may be an option we haven't done that before we directed our policy toward something more grand doys but maybe we can just focus on the humanitarian issues asking the Russians to help us pressuring them to stop this country and Iran that can influence the Syrian government at this point I am hopeful with this conference that will be happening at the end of this month we had the King of Jordan here last week pleading his case he sees Avalanche coming his way he's already fully in it what does this mean? the destabilizing effect of these large... so the neighbors are really concerned about the potentially destabilizing effect of these massive refugee flows and to the extent possible if it is possible to meet the humanitarian needs of those who don't have a flight risk in terms of needing to flee for their lives they wonder whether it's possible to meet some of these humanitarian needs inside Syria and that requires to the degree it's possible ramping up in a massive way the traditional humanitarian assistance reach the non-traditional which is cross-border and sort of the hybrid which is cross-line crossing conflict lines but in a sanctioned way now the way the government is operating with respect to cross-line is at a time when needs are increasing they are ramping up the bureaucratic requirements to do cross-line assistance the UN has to provide 72 hours advance notice get two signatures from two different ministers they have all kinds of bureaucratic obstacles I heard last week from the emergency director from WHO that they were prevented from including surgical supplies in a cross-line convoy that was going to Aleppo so if that's what cross-line is then we're still not going to be satisfied at the same time cross-border isn't going to be the silver bullet because you have places like Holmes and Rief Damascus that are not well positioned to take advantage of that kind of operation Steven did you have any thoughts on the question around diplomatic engagement I mean we had the Belgian statement in February right when countries sign on to a fairly strong statement you could look back on February and say it has had zero impact operationally or politically it was a well-intentioned statement and we the security council passed a resolution calling for cross-border in southern Sudan there hasn't been a single impact in southern Kortofan I mean you can look at a multitude of precedents or actions I'm raising the question whether the game is shifting in a way that you might say okay run at this particular problem in a specific way now three things the first is I think on the security council that is the place to be pushing strong for the respect of international humanitarian law and it should be on it is on so it's whoever it's that is the place to push for respect on both sides and I think it's probably unhelpful if our rhetoric is stronger on one side than the other so if we truly look at enough of the incidences that are occurring on the opposition side we've had different opposition groups raise their flags on top of medical facilities there has been also bases put very close to certain hospitals that ended up being targeted so if we come at this with a much approach I think that might be the first thing that people could agree on and actually start something and that goes to Len's point whether it then becomes fully efficient and changes everything or not it's the first step and that first step needs to be taken and I'm not sure that that step has been taking it as seriously as it could be on the neighboring countries I'm almost at a loss I published an op-ed this week on Monday the title was we are failing the Syrian people the idea that we're ramping up, that we're doing all these things there are a number of very well recognized humanitarian organizations and development organizations that cannot get registered in Turkey, cannot get registered in Lebanon that are having visa issues, registration issues these are countries we can have a discussion with those are also other countries in the region Iraq and Jordan, they're not as comfortable with folks working cross border there's also a discussion to be had and there are other ways of funding organizations to do this work and that work can be done so the first thing is if we truly burden share and truly help the surrounding countries and assistance according to me in Lebanon 50% of the refugees don't have access to healthcare in Lebanon, in the Beka valley they have to go to one central processing point to get a refugee card and that takes several weeks you've got to take your whole family by taxi where are you supposed to get this money or help then you wait four months to be registered in Jordan you have online registration and tons of different little kiosks of the UNHCR so there's a real problem also about how we're looking at responding there's less money going to Lebanon and we say because there aren't camps it's very difficult to help people and they need camps, they're never going to be ready for the winter without camps we need to put technical assistance in in order to make sure that those camps will be built but if we work strongly with those governments to really burden share, to really help on technical experience and to help them get into an emergency standpoint on this so that they allow enough humanitarian actors on the ground then we can already deal to begin with with their own issues about destabilization because of the refugee load if you don't, you risk that those borders are going to be closed and refugees won't be able to flee so if we do that first that's one and second then we encourage them on the cross-border you don't need the Russians, you don't need the Chinese you don't need anyone else to allow you or not allow you to do cross-border you only need the state that's in the country that you're in to at least either facilitate or turn a fairly good blind eye and we are able now not only our humanitarian organization trade is working like nobody's business in Syria they're exporting cotton across the border in one direction exporting olive oil soap from another there are line-ups of trucks from some borders going in and out and at the same time we watch a film that says that you can only bring these little kits maybe we've kind of done it ourselves with this clandestine word of how we're working and how we're getting across very small, very underground, very difficult but there are larger points where you can drive trucks of relief supplies in so maybe what we need to be doing is to bring trucks of relief supplies to the frontline in Aleppo and make a stand there as far as making cross-frontline assistance work can be done on both cross-border and cross-frontline but we are nowhere near meeting the overwhelming needs that are on the ground we know what they are we're hard-felt that assistance is now coming in it was 300 million I think from the Qataris 100 million from Kuwait sorry 100 million from the US it's very needed, very appreciated but we have to remember the numbers that the UN put out this 1.4 was when there were 750,000 people on the books they now have twice that many refugees plus this how many million more displaced that they want to service inside we're not meeting all of those and in some respects some of our own publicity perhaps is not terribly helpful because if we talk about bringing water to 10 million or the WFP talks about feeding 2.5 million we think they're doing that every day those shipments are handed over at a certain place and then we hope that they get places I was in Aleppo in neighborhoods with no water, no electricity folks struggling to get by with the added cost that war brings high inflation some of them are starting to displace because they can't afford just to feed their family not that they're actually under the bombs and their whole neighborhoods that have not seen any humanitarian assistance from anyone so we really need to shake ourselves up a little bit somehow so much work and very good work is being done on the political side people are trying and there are lots of obstacles but there are more solutions also more that we can do and more that we can do now and must do So here you referenced an interesting fact that you observed that hospitals in Aleppo are putting up tents, facilities with respect to chemical threats this week's Dexter Filkin's piece came out in the New Yorker which quoted a number of very authoritative folks talking about reminding us of the reality that this is a country that made over several decades, made a major investment in chemical weapons across distributed sites and has enormous capacity it's a very difficult thing to disable and we're beginning to see the suggestion that this is being used in a deliberate way very ambiguous and a continued debate around this when you ask folks who are the professionals in this area and say well what do you do in this setting it comes down to a couple of basic things it's monitors, it's gas masks it's decontamination capacities is it realistic to think that you can in a discrete way begin to be supplying some of these things to those hospitals in both opposition largely in opposition areas where this threat may be most concentrated do you have any thoughts on that? We did that last time we went to Aleppo I took with me actually gas masks I took about 120 of them and because what I discovered when we had the tour and it looks like the hospitals are stocking with supplies for another chemical weapon they are using the regular mask that we use for common cold and viral infection, they are using the same gowns that we use if patients have bacterial infection these are not effective when you have a chemical weapon attack so what we did in this last training course we trained some of the physicians who came from Aleppo on what to do when you have a chemical exposure decontamination using the anti-dote to monitoring the patients making sure that the personnel who are treating the patients are not exposed by using the proper chemical gear and I think there is a lot of this that can be done to help some hospitals in certain hot areas that people know that probably it will be targeted in the near future whether it's Aleppo area or Idlib or Hamas or Damascus and these are the areas which we had reported the previous chemical weapon exposure so protective gear for the physicians and the first responders helping them in training because this is not something that the medical community deals with on a daily basis providing them with the anti-dote with the atropine ampoules we purchased 20,000 atropine ampoules in Turkey and we gave it to the local Aleppo Medical Council they can use it in Aleppo and also in the city of Afrin that had some of the patients we did the same in Damascus it's very cheap actually to purchase them but right now the market inside Syria there is a shortage of atropine so I think this is something else that we can do I want to come to Lynn in just a moment but can I ask you on this question around measles and outbreaks and whether there's a space now for a quiet dialogue across lines between government and opposition authorities about a tacit humanitarian cooperation in order to permit resumption of immunization campaigns or other measures depending on whether we're talking about measles or something else what do you think the realistic prospects are and how would you go about encouraging this in your view it's happening at the individual level when I witnessed in Aleppo for example that the medical council are communicating with other medical entities on the other side for example for dialysis patients so I witnessed that myself that we went to a city called Albab where you have one hospital that is under the regime and the rest of the Bab is under the opposition and we visit this straight of the art hospital that has a very functioning dialysis unit that is not functioning to the full capacity so Dr. Abdulaziz who was with me he was trying to negotiate with that administrator on why don't you take some of our patients' load and it looks like the administrator accepted that so these type of collaborations are happening we need to encourage them we need to make sure that to be aware that they are happening between the government and the opposition side I think if we can let the civic society let's say the Syrian Red Crescent be the agent of connection between these two sides I think that will happen and it's happening in Aleppo, it's happening in Idlib especially with vaccination there was some cross line humanitarian assistance lately in the city of Azaz also which is good and promising and hopefully we can push more toward that how do you get planning for the reconstruction where do you house that who leads on that how do you trigger that if you want to get planning going early in the Balkan wars it was a matter of recruiting in experts and moving them outside of the immediate war zone area and having them sit down for extended periods of time to plan how would that happen in this context and where I think it has to be Syrian driven I think one of the lessons in the Balkans is the fact that it was run by international groups had a huge impact on the development of the health system that was not very productive that it ended up without participation in Kosovo for example with the coast of our medical community it didn't work out so it's got to be Syrian driven. At the same time I think there has to be some role for the international community in committing resources in providing support WHO right now is not engaged in thinking about this because they're so consumed with the immediate humanitarian needs which is understandable but I think that process has to begin and obviously many countries including the U.S. can provide support for this effort but I think it's got to be engaging Syrians the Ministry of Health is still functioning and Zahir can speak to that too well we started an effort like this and I agree with that that Syrian organizations have to do it the problem is connecting what's happening in the diaspora Syrian diaspora with the relief effort and what's happening inside Syria there is this connection because of security reasons because the fact that government prevents these type of connections from happening six months ago I attended post-crisis recovery session for healthcare in Beirut and it was organized by UNSQA United Nations and there was a very reasonable working group and it has individuals from the outside including the Syrian Red Crescent Dr Latar was there but that was only the first the only meeting that we attended they were supposed to have a blueprint coming out of this meeting later on and I haven't heard about what happened since then we formed a coalition called Syrian International Coalition for Health to plan for the post-crisis recovery and healthcare the problem that without support whether it's financial or expertise or WHO support will stop because everyone is consumed with what's happening right now whether it's the bombing or the chemical weapon attack or the medical supply to this area catastrophes are happening on a daily basis so it's very difficult to plan ahead unless you have the resources available and the expertise also available and it's very difficult to find only Syrian expertise for post-crisis recovery we need to have the help of the international community and our government here also Thank you I would like to invite our audience to come forward with comments and questions we have microphones that we can we can bring forward please just introduce yourself briefly and offer a brief comment or question and we'll bundle together three or four opening remarks, yes please Thank you very much for informing us my name is Narmina Molazad I'm originally from Eastern Europe I'm also a medical doctor and for me it's a burden issue because I witnessed Chechnya Azerbaijan, Moldova and other regions and it's very unfortunately that Russia taking this part because as yesterday and today they're celebrating World War II victory and they know how much it was cost to win this war and now they're supporting Assad regime and also I would like to ask because doctors kind of always as a neutral part in the society is that any could be negotiation trade-off with Assad regime to prevent attacking to the medical facilities and medical doctors and nurses Thank you Other comments, questions? Yes Marcus Marcus Marcus Geiser from the International Committee of the Right Cross first of all congratulations to CSIS for having organized this excellent event yes and thanks for all excellent contributions I have just one very specific question and our colleague and friend from MSF alluded to it about the delivery of healthcare in Lebanon we from the ICRC of course to help wounded coming into Lebanon what is your reading of the excess of wounded the civilians alleged combatants sometimes from Syria for example into Lebanon can they freely move I'm not talking about the security problems on the road that they may encounter but really the problems of authorities of communities being in the wrong part of Lebanon because Lebanon of course being a very diverse society as if you could allude to that particular aspect Marcus you're talking about wounded combatants I'm talking about any wounded civilians or combatants yes entering Lebanon from Syria and navigating the territory sorry if it wasn't clear enough within Lebanon in terms of their access and like Any other questions or comments at this point right here I appreciate very much the I'm sorry I'm Jay Harman International Health Specialist with the Air Force I appreciate the comments very very much the question or one of the things that I'm looking at is the key of Russian support of Assad and what I don't know is their Russian involvement in civil society organizations NGOs that you may be able to use that as a way to pressure the Russian government not to help in this I see as long as it's a military strategy to attack healthcare workers it's going to be very difficult to change that and so that's what I'm wondering is whether there's a civil society within Russia helping with MSF or helping with other NGOs that may be a place to really push this issue thank you Do we have any other Cameron over here Cameron Hume thank you very much for doing this you mentioned sectarian issues and when you discussed refugees going into the Bukhara in particular Bukhara is essentially controlled by his Bala not the Lebanese government and recently we've seen a ramping up of the tensions between the role of his Bala and the tensions between Shia and the Sunni more widely in the region to what extent has the sectarian splits fueled the problems that you're describing and more importantly to what extent would there be a possibility to involve sectarian leaders in counteracting some of this inhumanity thank you Thank you very much would you like to start off I'd like to address the first point the first question I think that would be great if you have at least a collaboration between physicians and the side of the opposition and the other side the problem that it's very difficult and it's dangerous if you are a physician or administrator who is working in the opposition area let's say running a hospital or a clinic then that means your sentence is death if you are caught on the other side you will be killed sometimes on the spot sometimes you're going to be detained and tortured and this is reality so it's very difficult for administrator on the government area to collaborate or to communicate regularly with their colleagues probably who work together maybe for 10 years or 20 years in the same industry or same department let's say in university because of the threat on their lives that is not happening frequently unfortunately what about engaging sectarian leaders Cameron's question around you know the this is happening on a small scale especially in the some of the mixed areas that you have for example Kurdish and Arab population Turkmenica population sometimes you have areas where you have Arab population and Muslim population especially in the city of Aleppo city of Aleppo is very diverse city so you have Armenians, you have Christians of different affiliations you have Kurdish, you have Arabs you have Turkmen all of them living in the city so there is kind of kind of engagement of their leaders to help in some of the local issues and some of the local civic councils that is formed villages and the cities under the control of the opposition have leadership which is mixed also there are also some efforts to engage Alawite for example especially from Latakia and Tartus leader to make sure that they understand that they are not tied to the regime in Antakia Antakia has a reasonable Alawite population also but it is not leading anywhere. There was a recent conference for example in Cairo that is organized by the Alawite Syrian community and they said that were not tied to the regime, were not responsible of what's happening because the Syrian government or the regime has been trying from the beginning to label the conflict as a sectarian conflict and actually it's succeeding in some areas in some of the areas that I visited the bitterness toward the other side is very high and I am afraid of what happens after the end of this crisis I am afraid of the retaliation because if you are from family that lost your sons or daughters was raped by someone from the next village and you know that person then it's very difficult to predict what will happen in the next phase unless you have a very clear and well planned transitional justice system there is some effort on that front but it is not what we would like to see Yes Stephen? On that point you mentioned the inability for doctors to make these links between maybe the big divides but you also pointed out doctors that are able to make those links in some of the small areas you mentioned Albab you mentioned Aleppo and I think both for the medical personnel as well as for humanitarians that ensuring to make as many of these bridges and links and to widen those during the current phase of the conflict will only pay dividends later because people will not you can't just assist impartially once it becomes a sectarian conflict if that is in the cards and it's one of the prognostic possibilities so I mean for humanitarian purposes you should do it anyways but for doctors or for others I think bridging those gaps now will allow at least sort of a secondary level contact that can then have some trust to it have an established link and will be able to be a channel of dialogue and decency if things do spread and become much more difficult in a sectarian sense Should I go on to that? Yes The question from Marcus at the Red Cross and I'll widen the response if you don't mind to a few countries rather than only being very very specific but I think Lebanon is slightly uneven given that it has open and closed different border points so it makes it more or less difficult to for that to be an evacuation route especially on a civilian side because Lebanon has a private health care system so you have to pay for the care once you get there a bridge too far probably for many on the civilian side certainly as far as receiving large numbers for the combatant side I think they've done a fairly good job as in most conflict areas of setting up rear-based referral in a number of surrounding countries and have a lot of means at their disposition and a lot of assistance On the Turkish border and on other borders it's also very uneven in Turkey it's a public system so very good care if you can get there but very uneven as to what a referral is what an emergency is and who gets to go across as he doesn't so from some borders you're in an ambulance and you're on your way and others it's quite a struggle but they are doing a much better job of extending emergency referral care to civilians Dorothy if the countries in the region the neighboring countries are already excessively burdened and afraid and they're seeing this changing their own internal dynamics they see as Cameron suggested a sort of fueling exacerbation of sectarian tensions and they see another a second wave a second deluge coming in their direction how would you predict they're going to behave in terms of trying to mitigate or preempt either effectively or completely counter-productively in this next phase because we're at this moment where the word is out that this is coming the next deluge is coming and Israeli actions last weekend were in some ways motivated by this very same prospect with a heavy security dimension to it of the bombings but how do you see this breaking out within the regional behavior well first of all it's critical that the governments and the people of the neighboring countries understand and have confidence in in a comfort zone that they are not in this alone they need the support of the international community and they need to know it's not going to just be there today but it's going to be there 6-8 months from now it'll be there in a potential worst case scenario that people have described for example if there's a battle for Damascus and you have half a million people moving in a 24 hour period or if there is a large-scale chemical weapon event that would also there are various scenarios that people have talked about and so we have encouraged our partners to engage in very robust contingency planning for their own right but also with those neighboring governments so that they're prepared and that gives them the confidence they need to see that the funding is on the line as well by the way I should mention that new appeals are expected to come out for both inside Syria and the regional response either at the end of this month or early next month so that's number one to know that they're not alone but we also need to think about are there some creative solutions that we haven't yet put on the table and I have participated in some discussions with partners and there are no easy answers here but some of the neighboring governments have wanted to explore would it be possible to do an evacuation even if it's of a symbolic number of the total number of several hundred thousand refugees to a third country this was done in Kosovo for example it's a little bit more difficult to do for countries like us in a post 9-11 world but we need to put creative options on the table can I take the floor to address a couple of things that were said by others too I want to let you know Steve that we have been hounding UNHCR and they have been responding to ramp up their registration efforts and as of last Friday when I attended with them in Geneva they have gotten down to 30-day waiting periods in everywhere but south Lebanon where it's still 60 days but that's better than the four months we were at I mean they have put on the ground virtual registration factories and so they have more work to do but we're seeing some progress I also want to address and I identify very much with what you were saying about the needs basis for humanitarian assistance and how we need to adhere to that strictly my concern is that sometimes that argument can be flipped on its head and there can be almost a facile assumption that just because a civilian is in a government controlled city or village they are less deserving than a civilian in an opposition controlled I'm not saying that you were suggesting that but I want to get out there for the wider group that we in working with our partners are constantly asking them to make sure they're adhering to the needs basis neutrality impartiality and that extends whether to government controlled or opposition controlled areas and we are hungry and they are even more hungry for information about gaps so to the extent that those of you who are on the ground or who have people on the ground and those of you out there too who have information about these communities and we know they're out there but up until now let us feed that information into the machine and try to address it thank you one small point I'm saying it'll help out your point and it's often not seen certainly we're not trying to start a facile argument at all because that's not the point and those who are working in Damascus have a whole number of added difficulties in being able to work there to keep their visas to keep everything going and that's why for one is still dealing with a million Iraqi refugees from a previous conflict so it's certainly not going to be easy for them to just roll out the punches and start doing things in a more cavalier way we're at an advantage that we can do that and that's how together the humanitarian system ends up balancing itself out but we fully respect the work of UNICEF UNHCR and the very important work the difficulty is that they're sort of cloistered on their side and we're a little bit cloistered on our side and we're able both of us to pass through and to end up bringing assistance where it's needed most when it's needed most this is the difficulty that I think does need explaining Len you raised the question around the ICC on the criminal court getting active now how could that be triggered to a higher level accountability as a way of putting people on notice well I think the first thing to do is to raise it as an issue that you've got to put it out there before there could be any action there has to be some discussion and consideration that this is important governments think this is important and they will push it forward whether it could be included in a Security Council resolution on Syria a place about disarmament or other things that are being discussed right now with the Russians I don't know but that's the first thing is to put it on the table and that's how sometimes think of Darfur no one thought there could be a Security Council referral for the ICC in Darfur but it happened and the only way it's going to happen is if you push it just on two other little points they're not little at all they've been adequately discussed I think there are reports that in Lebanon sectarian a sectarian basis for providing health care for people coming from Syria is becoming an issue and it could become a much bigger issue and we ignore it at our apparel and the second about the refugee flow I think it was alluded to here but I think it's worth underlining that the stability issue that you raised is very much tied to the level of the sectarian commitment by the donor community and they really go hand in hand Thank you We're going to go to our audience for another round Ron and then Mark others do we have others who are interested Ron Thanks Ron Waldman, George Washington University on Doctors of the World USA I wanted to come back to an issue that has been raised already but maybe I would really like to spend a little bit more time for the panelists to spend a little bit more time discussing it and that is that we've been involved in too many situations where there's a conflict and an emergency response that goes on for a certain period of time and then it ends and then the next day the planning for the stabilization the return, the reconstruction and the rehabilitation begins so we have this notion of you know, relief to development transitions that are the rage now in our circles I really would like to hear some more if there are any ideas about when the planning should begin whether or not the US government and others are making concrete investments and planning for reconstruction afterwards because if not unnecessary preventable mortality is going to continue far longer than it should and I'm very aware organizations like SAM should be very, very active and in fact perhaps in the lead it would really be a shame if one day after the emergency needs are met to the extent that they possibly can be and some sort of piece returns to the region if for months and months and even years after that excess preventable morbidity and mortality continues to occur because there hasn't been adequate upfront planning to develop any of the six elements that WHO calls fundamental to health systems and this is something I think that can be taking place outside of the conflict theater now it's not necessary for the same people to even be involved it would be great if the same organizations were involved but starting now to develop concrete plans including concrete budgeting, concrete plans for human resources, concrete plans for pharmaceutical resupply, concrete plans for even governance and leadership that might take place in the medical and public health communities over and above what if a political solution is found seems to me that this is an ideal opportunity in some ways as sad as it is to say for us to do something right in this situation thank you. Thanks, Ron. Mark. Thanks very much. It's on. Okay, Mark Steinbeck with the International Committee of the Red Cross Dr. Seher, you mentioned atropin of course for a physician we know about atropin if anyone here is not a physician you watch the movie The Rock you know that when you're exposed to a chemical agent you self-inject atropin intracardiac and I was thinking ten years ago I found myself in Baghdad and one of the things which sanctions had done was basically bleed out surgical tubing and atropin because these were dual use and we were supplying huge amounts of atropin and surgical tubing are you implying with your comment that perhaps the government has been stockpiling atropin or it's just being used up or there's just not enough getting into the country it depends on maybe after this Hold for one second. Are there other comments or questions just now? Okay, why don't we come to Seher Okay, well you know a couple of comments regarding the question about atropin it depends on the area so definitely you have areas where you have a huge shortage like the mascus and the reef the mascus and we purchased recently 20,000 ampoules from the pharmacies there but at higher price than the rest of the market in Syria and we stocked it in a warehouse in East Ghouta because many people in Daraya and these areas are expecting a chemical weapon attack in that area it is available in Turkey in Lebanon and Jordan it is available in some of the pharmacies in Aleppo so you can purchase it from the local market it's expensive and you need to you know we provide them with the price so they can purchase it and also the issue of transportation because even after we purchased the amount in the ampoules in the mascus it took some time to transport them from the mascus to East Ghouta it took few weeks because of the blockade in these areas in terms of the first comment was the first comment about Waldman's question around planning for the reconstruction I mean I agree completely with you you know looking at previous conflicts many times healthcare indicators deteriorate right after the end of the conflict and mortality rate actually increases because of the disintegration of the healthcare system and public healthcare in some of the area and you have a window of two to three years where you really either you make it or you start to come up or you don't make it some countries like Haiti for example did not make it there was no adequate planning there was no maybe infrastructure in the civic societies that can sustain or build on the planning although there was a lot of goodwill from the international community in the case of Haiti in Syria we're not seeing the goodwill and we're not seeing the adequate consistent communication between stakeholders or players from the outside and the inside in order to plan you need to know who will be implementing the plan next and the problem that no one knows right now in Syria who will be in the driver's seat after the end of the crisis is it a technocrat government is it the regime is it a combination of the regime and the opposition so that's why you have these hurdles besides there is no international will to help the Syrian organizations to do this planning you have potentially a neutral organization you could have a world bank or any number of organizations provide the hosting function for a group of expert Syrians that are representative of a certain spectrum that would collect facts and begin thinking about this I mean it sounds like that's already processes already begun there's a problem first of all Ron you're completely right that this has to be thought about now when we talk about this so-called relief development continuum and wars in recent years much of the discussion has been in countries with very poor infrastructure to begin with South Sudan, Liberia DRC Afghanistan and that is in a way the model we're starting from scratch Syria had a functioning health system and it wouldn't take a starting from scratch approach to get the health system back up the bad example or the example of how not to proceed is Iraq where we don't want to have a whole discussion but it was done extremely poorly with a very centralized system with kind of show hospitals not really consideration or consultative process in Syria you did have a system you have people who were working in the system who know the system you have a lot of human capital that could go into planning if there were support internationally and then to me the huge issue I mentioned before is the human resources issue because so many people have fled and how are you going to rebuild that capacity and how are people going to be able to live in an environment when they've been traumatized but these can be addressed as well if planning started now Dorsey you wanted to say something I would just note that indeed these planning efforts are ongoing it sounds like there may be several and maybe they need to be coordinated I know the Syrian opposition's assistance coordination unit is looking at this longer term horizon of reconstruction for example there have been discussions among donors it was the EU commissioner for development and humanitarian assistance Kristalina Georgieva who recently made the rounds in Washington and talked about a broader political initiative that would bring in the World Bank and the international financial institutions that would bring in development actors and would bring in private sector actors I mean really looking at this on a grand scale on how to get to that reconstruction phase In talking to the UN last week the and the question was raised okay there's an interagency inter-UN committee looking at reconstruction is health on the agenda the answer was no the answer was it's focused upon revitalizing the economy dealing with security and dealing with governance that health was perhaps nominally cited so Stephen I'll get to you in just one moment I wanted to first ask what do you think the prospects are for getting those the 50% of your medical your doctor base that have stopped practicing and most of them have exited what's the prospects in your view of coming back there's great variation in these situations in the degree to which people migrate back home and obviously this becomes speculative and much of it is contingent on the security and how to what degree schools and other schools in economy and basic security is restored in order to get people back to agree to come home but what's your own sense of what the prospects are I think this is a great question I just want to highlight the issue that Syria is not like other countries like the Congo for example Syria has very successful healthcare system to start with we had 30,000 physicians so the ratio of physicians to population is about 1 to 1,000 or 1 to 900 which is very reasonable the healthcare indicators in Syria which is mostly was middle class very reasonable in terms of child mortality and all of these things and the Syrian universities are known to produce good doctors Bashar al-Assad is not one of them by the way so but there's a lot of excitement by the way in spite of the desperation and the disastrous situation in Syria among the Syrian expatriate and the diaspora community to go back and build and I know that there is a large percentage of physicians and other professionals will be excited to go back and build when safety is not an issue within the healthcare community for a physician who fled Syria in the last two years and started working let's say in the Gulf States or in Europe it's very difficult for them to go back so definitely maybe there will be 20%, 25% of physicians who will not go back at all because they found a life they have established job and they're going to take some time to build what has been destroyed in Syria but many of them are excited many of the rest who left Syria are excited to go back either because they're not working right now in Turkey and Iraq and Lebanon and Jordan they don't have license to work and the government are not allowing them to work or because they want to go back and be part of this building generation and many organizations and many of my colleagues who have been outside of Syria for 30 years and 40 years and 20 years also are planning to go back when the crisis ends so there is a lot of hope but it needs the support of the international community and a platform for them to coordinate their work. Thank you. Steven you had some thoughts and then I want to come back and close with asking each of you for just one final thought about what you want us to take away as the sort of top line priority looking forward. Steven you had some thoughts on some of the questions Ray? Just a small seed perhaps of hope to this reconstruction side and that is that Aleppo having been the pharmaceutical capital of the country and the industrial zone having not been attacked during this war it's been kept unscathed so there could be a common point of interest between business between medicine and between whatever government is in place after that would have a number of reasons for trying to jump start itself and I think there's a lot of capital there that was not destroyed and that would probably be able to be put back online not seamlessly but certainly without the type of complete rebuilding that one would have seen in Iraq a point of hope perhaps. Thank you. Lynn do you want to help us end this today with a closing thought? Well I'll close like how I open. Thank you Steve for having this event and my closing thought is we have to move from tragedy to moral outrage nothing is going to change unless there is a demand for change and I think the entire international community must raise its collective voice and that means citizens as well as governments that's how the only way this could possibly change. Thank you Stephen. Just two things one also to thank CSIS for putting on this debate it's a very important debate that is larger than Syria and I think that's very important to raise the issues of healthcare under attack in so many different conflicts around the world and unless we start to rebuild and not just with the rhetoric but actually with the real fundamentals of humanitarian law and respect for medical personnel for civilians, for humanitarians we are really putting ourselves at risk in the long term. I think in looking at Syria itself I can't stress enough how much that moral outrage that you spoke about is required we together are all doing our best but our best is not enough at this stage and we clearly must do a lot more in order to at least meet the very basic life-saving needs of Syrians over the next number of months and then of course get on to this very important reconstruction and the after but in the short term we really have to have a concerted effort with the host countries they need real support they need technical support they may not be asking for all the types of support that they need but clearly they are in many cases almost turning into humanitarian situations themselves and if we don't help them realize that before it's too late we might have an even bigger crisis on our hands Thank you, Dorothy I'm going to invoke the heads of the four UN humanitarian agencies who did an editorial jointly in the New York Times a couple weeks ago that I think it was titled enough they're really calling for a political solution to this war because there is no humanitarian solution and we are going to do our best as the United States and the government and the partners that we fund but we are constantly playing catch up and it's incredibly frustrating because we want to do better and in part I think we can do better by taking advantage of the local resources that the host governments have they're also highly educated populations so again we don't need to go in there with all of the outside experts but we need to do a better job of taking advantage of local expertise in responding to the refugee crisis Thank you You get the benediction That's tough, very tough but I just want to mention that in my multiple visits and I'm sure that Steve would share that with me to Syria, what I've seen that the population in light of the stress, in light of the bombing and the shelling and the suffering but they are overcoming many of the hurdles that we are talking about and they are doing that because of their perseverance they are doing that with minimal support from the international community because of the creativity that the Syrian people has and because they believe in Syria as a model to the rest of the Middle East I believe because Syria has the ingredients for success as a country it has diversity, it has educated population, it has a human capital it has relatively functioning system in terms of civic society to start before the crisis and it continued and it got empowered now because of the crisis so we need to focus on these ingredients of success the civic society, the local NGO organization and also the educated class doctors in Syria had always leading role and if we can focus on physicians and empower them make sure that they have what it takes to overcome this crisis I think that would be very helpful some of you maybe have seen the clip in Grey's Anatomy which is a famous soap here about some of the American physicians who wanted to train their Syrian colleague on what to do in this situation when you have a austere environment so you don't have that many things they want to train them so they can send them back to Syria so there was this clip where you have a couple of surgeons from United States training Syrian doctors so they told them imagine that you are in a situation where you don't have this part of surgical sets you don't have these medications and you don't have this type of equipment then the Syrian physician told them well the situation actually is much harder than what you're describing so remove this remove this and remove that and then turn off the light and that's what's happening in Syria in some of the field hospitals that Steve has described people are doing surgeries in caves in some of the field hospitals I've visited they have no electricity they have no ventilators they have no anesthesia general anesthesia for patients they have blood products and they are doing surgeries on patients and the patients are surviving and I think if we if we look at the success stories in Syria and try to maybe make Syrians hopeful of the day after and focus on the day after I think hopefully we can end this crisis that's what we are lacking right now because there's not many people are talking about what happens after the end of the crisis thank you well I'm so impressed with the commitment and contributions that you're all making here Sy, Stephen, thank you so much for coming the distance to be with us and the work that your organizations are doing Dorothy, thank you so much the administration is doing a great deal and it's great that you could come and be with us and lend thank you again for bringing this all forward and pulling it together so it would be possible please join me in thanking our panelists