 Thank you. Good afternoon, everybody. My name is Nancy Lindborg. I'm the president of the US Institute of Peace. And I'm delighted you're able to join us here this afternoon. Thank you for braving the rain and the wind. US Institute of Peace was founded in 1984 by Congress, dedicated to the very bold proposition that peace is very possible, that it's very practical, and that it is absolutely essential for US and international security. And nowhere is this vision more urgent than in Syria. The conflict is now entering its eighth year. We just had a weekend of events that further complicate a very complicated, long conflict with the news of the US strikes on chemical weapons. I think for anyone who's been following this conflict, the physical, the human devastation of this conflict are truly overwhelming. And the recent chemical weapons attack in Douma, which killed dozens of civilians, including women and children, is the latest example of the very terrible carnage that we've been watching through the years. Nearly half a million estimated Syrians have died in the violence. Half the population of the country has been displaced, either internally or as refugees. And we have one of the largest and most complex humanitarian catastrophes since World War II. We've seen that this conflict has transgressed so many different legal and moral norms. We've seen civilians attacked. We've seen medical workers specifically targeted and the kind of atrocities that women and children and civilians have seen that will scar people for a lifetime. And according to UNICEF, if the current pace of violence continues, this year will be the most violent since 2011. And in just the first two months of 2018, an estimated 1,000 children, so it's only April, 1,000 children have been killed or injured as a part of this war. We've seen increasing research that demonstrates the terrible effects of prolonged exposure to stress and to conflict on your brain, that these are the unseen wounds that threaten not just Syrians today, but Syrians tomorrow. And they will threaten any efforts at recovery if we don't start thinking about these efforts now. There is important work being done on this. And it is even more important that we pay attention to these unseen wounds, that we understand the impacts of violence, not just on people physically, but the emotional long-term results of living in conflict and prolonged stress. I spent three years at USAID directing humanitarian response to Syria in the early years of the conflict. And I can say it was a daily heartbreak to see what started as a peaceful demonstration in seek of a better, more responsive government, the metastasizing into the war that we've seen today. I will also note that I had an extraordinary opportunity, and I think all of us have continued to see some of those who have responded with unbelievable courage and compassion and who continue to work on these issues and to go into terrible war zones when they don't have to over and over again. Today's panel includes some of those people and some of those organizations. And it also promises to deepen our collective understanding of both the impact of the trauma and some of the ways that we can think about addressing those challenges. And we're very fortunate to have with us representatives from the State Department, from Save the Children, and from the Syrian American Medical Society. And I first encountered the Syrian American Medical Society, or SAMS, in the early days of the war when they were really calling attention to the targeting of medical personnel. And I just want to recognize David Lilly, who's here with us today, the executive director of the Syrian American Medical Society. And we thank you and all your colleagues for the extraordinary courage that they've demonstrated through this conflict. For those of you who would like to follow or to join the conversation on Twitter, please use hashtag Syria trauma. That's hashtag Syria trauma. And I'd also encourage you to check out the USIP new podcast network at usip.org slash podcast. And that will include this event and many other compelling programs into the future. So with that, I'm delighted to be able to introduce my colleague, Mona Yakubian, who's our senior advisor for Syria in the Middle East and North Africa. Here at USIP, Mona herself has long, deep background in these issues, and she will moderate the panel for you here today. Thank you again for joining us, and thank you for paying attention to this really critical issue. Mona. Thank you so much, Nancy. And let me also add my word of welcome and good afternoon to all of you. This is indeed, as Nancy has laid out, I think, very clearly, such an important topic. We had originally hoped to do this a couple months ago, and we got snowed out. And I have to say, I think it's a testament to our colleagues on the panel, including Dr. Hamza, who traveled here now, not once but twice, to take part in this panel, as to the importance of the topic at hand. I think, as we all know, we all see the very disturbing images coming from Syria. They're achingly painful to look at, in particular, of course, most recently with the chemical weapons attack on Douma earlier this month. What we don't see are those hidden wounds, the trauma that so many Syrian civilians, including children, are suffering. And that's what we do. It's a painful topic, but yet a very important one. That's what we hope to delve into today with this excellent panel. We'll be looking at the issue of trauma in the Syrian conflict, try to understand better its dimensions, but also try to learn a bit more about some of the interventions that are being designed to help begin to address this issue and also get a better grasp of some of the longer term implications at hand. So with that, I'd like to introduce our panel. And I will engage with them for a little bit in discussion. And then we will bring all of you into it. This discussion, this event, is on the record. And again, you're encouraged to tweet and join the discussion. First, let me introduce our very esteemed panel. We have, to my immediate right, Dr. Mohamed Khaled Hamza, who is currently chairman of the Syrian American Medical Society's Mental Health Committee. He also serves on its foundation board. Dr. Hamza is also a tenured professor of clinical mental health at Lamar University in Texas. In addition to his longstanding publications and presentations, he has conducted extensive research on the impact of trauma in the Syrian conflict and has a forthcoming report that will be available to all of you once it is completed. Next to Dr. Hamza, I'm pleased to welcome Amy Richmond, who is the Child Protection in Emergencies Director at Save the Children. In her current role, she oversees the Child Protection in Emergencies portfolio and team, providing strategic direction, technical oversight, and humanitarian response support. Amy is a specialist in child protection systems in conflict, and she has responded to the Syrian refugee crisis in Jordan, Lebanon, Iraq, and Turkey. And finally, last but certainly not least, it's a pleasure to welcome Katie Boumaroun, who is a Foreign Affairs Officer currently with the State Department's Near Eastern Affairs Bureau Office of Assistance Coordination. Katie's portfolio is focused on governance and education, programming in non-regime held areas in Syria. She returned recently from six weeks inside Northeastern Syria, including Raqqa City, where she had the opportunity to visit a number of State Department-supported child centers that provide remedial literacy and psychosocial support to vulnerable populations. So with that, let me open the conversation and maybe start with you, Dr. Hamza. People may not be completely familiar with your organization, SAMS, the Syrian American Medical Society, and what you do. So maybe talk a little bit just to get us started on SAMS work and how it started and where things are today. We started in 1998 as a cultural professional organization fund before 2011. And then when the revolution started in 2011, and as you've seen and was indicated earlier, peaceful demonstration happened and took place for almost a year and a half. It was SAMS start collecting its powers and started working diligently on what about to happen. We expected the worst because they are to ask for freedom in those places like Syria. But anyway, so now we are taking care of almost over 100 facilities, medical facilities. We are humanitarian, medical humanitarian aid. And we operate inside Syria and refugee camps in Jordan, in Lebanon, and in Turkey. We have a huge operation. And the CEO of SAMS, I'm happy to tell you that Mr. David Lilly is here with us to join. He joined us. And so that's simply what SAMS does. And we built hospitals, clinics, as if probably you've seen CBS 60-minute news a little bit on the cave hospitals because many of our hospitals were destroyed by air strikes. And that's where we at right now. We're trying to save lives, one life at a time of the Syrians and working very hard at it. So some of your research, you point the term human devastation as a way of describing and talking about the issue of trauma amongst Syrian civilians. Can you tell us a little bit more about how do you describe the issue? What are some of the key features of trauma amongst the Syrian population living in conflict? As you know, the conflict has been going on for eight years. And sometimes I just don't feel right using the word conflict because it's beyond the conflict. It's ethnic cleansing. It is a genocide that's been going on for eight years. When we started diagnosing the individuals, the patients, the beneficiaries, different places, most of the diagnoses came in as in PTSD, post-traumatic stress disorder. And of course, comorbidities joining other disorders, such as significant depression, like major depression. We reached the psychosis and behaviors, abnormal behaviors, and anxieties, panic attacks, you name it. But as we worked year after year, it was very interesting to see that really it's PTSD is kind of like creating a suit that fits all, and it's not the case. Because in any disorder that you look at, of course, just to give you a little information, we use something called the DSM-5. So consider that that's the reference for all psychiatric psychological disorders and so on. And usually when you read on any disorder as a professional trying to say, OK, is this person major depression, or little depression, sadness, or are they bipolar, or whatever. They say one or more of the following criteria should be met. Well, here it's one and more, it's everything plus more. So the frequency and the magnitude and the depth of the disorders is two-folds, three-folds of what we have seen. So the psychological injuries are very deep and very profound. So it was to the point I was like, it's not going to fit. Just saying PTSD, PTSD, it has to be a lot more. But there was nothing, again, let's call it the psychiatric manual, the DSM-5, that would really describe the severity of what we are seeing. Also, when you read about any disorder, they tell you there is a time to cope. Well, what cope? What coping? Because it's one nightmare that keeps the exposure every day and you're talking about years. And even for those that were able, they were displaced and they moved to other refugee camps and so on. It wasn't going from here and the grass is greener on the other side. They went through a different disastrous situation in a completely different environment and climate. So that added a lot more, if you want to say it, to their misery, to their agony, to their pain, to their suffering. But it was a completely different context, but the pain continued. So we kept moving from one episode of a tragedy or one episode of dilemma. And you're talking about profound. We're not talking about, well, it will be OK tomorrow. Well, it's not OK tomorrow. It's not OK even eight years after into another. So because of that, the only disorder that fits their situation, mental health situation, to describe it well, is the human devastation syndrome, which currently we've been working on it. I have an outstanding team of researchers, you name it, psychiatrists, psychologists, statisticians. And we're working hard on investigating a little more what is a human devastation syndrome. Amy, I'd like to bring you in. And maybe just begin by also for those who aren't fully familiar with Save the Children and its focus on children and protection. But specifically, maybe tell us a bit more about what Save the Children has done with respect to the Syrian conflict. Sure. Currently, Save the Children's working with Syrian children and their families in the region in Jordan, Iraq, Lebanon, and Turkey, and refugee camps and host communities. And we're also working through and with local partners in Syria, providing child protection services, including community-based psychosocial support, access to learning spaces and education, health care services and support, and food security and livelihoods, including young child and infant feeding. And can you talk a little bit more about, I know that Save the Children, I think you even have copies of it outside, but published a very powerful report entitled Invisible Wounds that looks very specifically at the issue of trauma and children. Can you talk a little bit more about the findings in that report and how you, from your organization's vantage point, how you see the issue of trauma, particularly in children, and what the implications are? Sure, thanks. So last year, we undertook this research because we were facing, as said before, an unprecedented crisis. Over 12 million Syrians displaced. And that's 65% of the country's population. And Save the Children estimates that, as we speak, every hour, 250 more children are fleeing with their families. And the psychological toll of this experiencing and witnessing violence compounded by the ongoing deprivation that displacement causes creates a situation that we call toxic stress that we've already been talking a little bit about here. And toxic stress, if left untreated, neurological evidence shows us can have devastating impact on children's healthy physical and mental development. And since Save the Children has been working with these children for over seven years now, we've been very worried about the implications of this and their development in the next generation. So we undertook a comprehensive study inside Syria, talking to children, health care, social welfare practitioners, to examine their current mental and emotional well-being. And I brought some of our key findings here today to share with you. We found that 2 thirds of the children that our partner staff work with are said to have lost a loved one, had their house bombed or shelled or suffered war-related injuries. 51% of the practitioners that we talked to said that children are turning to drugs to cope with stress, which we know can have devastating impact on their lives. 89% of those working with children said that children that they're working with behavior has become more fearful and nervous as the war goes on. 71% said that children are increasingly suffering from common symptoms of toxic stress and PTSD, which is critical because as we just discussed, our research also shows that out of functioning health facilities inside Syria, only 20% have mental health care staff that can appropriately diagnose PTSD and treat it. And in addition to that, I brought some quotes from children today to make sure that we do bring the voice of the child directly here today. They describe some of their feelings in our report. And Abud, age 12, told us, I always feel angry all the time. Rehab, age 8, from Rora Aleppo told us, I'm afraid of going to school because a plane will bomb us. Age 12 told us, I would be confused if I didn't hear or see air strikes because they happen so often. So as we see and as we know, millions of children are missing the normal aspects of a child. And if we don't scale up or commit to providing basic emotional support for these children and access to education, safe places to return to normal childhood, we risk losing a generation to these invisible wounds. And this will have, as Nancy Lindbergh had said, devastating impacts to rebuilding the country when the conflict ends. So I want us to, at some point, get into interventions. But I want to first bring Katie into the conversation and maybe have you talk a bit about the US government's civilian assistance programming in Syria. I know your portfolio focuses on, as you said, education and governance. But tell us, for those who aren't familiar, a little bit more about what the United States government is doing in that space inside Syria. Sure, so my office, the Office of Assistance Coordination, is just a small piece in the larger USG response to Syria. So in particular, my portfolio covers governance and education. So a bit on the governance stuff, we work with local provincial councils to build their legitimacy within their communities to provide essential services. So for example, in the east, in northeastern Syria, we're working with a lot of the local governance bodies to bring water back online, to provide waste management services to their communities. On the education side, and I think this is where we have kind of found the PSS, or Cycle Social Support, extremely important, is that we're trying to provide an alternative education to children in Syria. As many of you know, it's either the regime curriculum or in other areas, what we have kind of coined as the Syrian interim government, the SIG curriculum, and then in the east, I think it's more of a battle of which curriculum will be implemented. But I think with going back to your original question on what we're doing in the education realm in northeastern Syria specifically, is we're starting with PSS. We understand that most of these children, all of these children have gone through things that none of us can ever imagine, none of us kind of ever fathom. And so by putting children in a formal classroom setting, you're actually doing more damage than good. It took a while for us to kind of convince local governance bodies that Cycle Social Support was something that was the first step. But I think that we've been able to get that local buy-in. To really see children who have gone in very aggressive, as Amy had said, children are suffering. And we've had examples of children who have gone into some of our centers, which we'll talk about shortly, who have been angry, who have been aggressive. And so as the USG kind of setting up some areas where children have a safe space and able to be children once again. So I think we would all be fascinated to hear what you witnessed firsthand, having spent six weeks in Northeastern Syria, including in Raqqa city. Can you tell us a bit more about what you saw in the time that you were there? What were you doing? What did you see? How does what you saw sort of comport with what we're hearing more broadly in terms of the extent of trauma amongst children and in the population broadly speaking? So the population writ large has faced significant trauma. Doesn't matter. Children age one to two to older, elderly, they have seen more trauma in their life than any of us will imagine. But the one thing that I took away driving through Raqqa city where it's flat, where there used to be houses and buildings and shops, there's nothing. But the one thing I took away was that the Syrian people are the most resilient people that I have ever seen. It does not matter where you are. We could be driving through a neighborhood that, again, is flattened. But you have people coming back wanting to restart their lives again. Doing whatever they can to support their families. You have numerous families in a one-bedroom apartment, which building is most likely mostly destroyed. But they're coming back because they care. They want to re-establish their roots in their community. Did you hear specifics from the Syrians that you engaged with on this question of trauma? Were you able to engage with either parents, worried about their children, or hear from children directly, how the conflict is affecting them emotionally? So speaking with some of our community-based organization staff who work directly with the children on psychosocial support, they had said that what we're doing is very minimal. And the larger scheme is things, as Dr. Hamza said, it's, I think, earlier today, when we were kind of discussing before this started, it's the drop in the bucket. And what is needed to go forward is beyond, I think, what just the three of us in our organizations are doing now. But parents and teachers were very excited that activities were being kind of implemented. Children were re-engaging, learning how to be children again instead of picking up a weapon and using it or using the indoctrination that ISIS had instilled in them. So Amy, let's wait. We hear a lot this term psychosocial support. I'm wondering if you can talk a little bit about what that means. What is psychosocial support? And talk a little bit about what kinds of things, what are the specific interventions that Save the Children is implementing? Sure. The term psychosocial at the very basic level, it implies, so it's a mix of psychological and social the words. And it just implies that your psychological well-being or your internal well-being is affected by your social well-being. So if your social surroundings are not doing well, then your internal well-being will not do well. So if we can improve social conditions or connect children or grown-ups to positive factors in their lives, and we can improve or protect their internal well-being. And so psychosocial support activities or resilience building activities are meant to look at creating positive factors in children's lives. And some examples could be connecting children to trusted adults, connecting children to friends in different activities, connecting children to activities to promote joy and reduce stress at the very, very basic level. At the higher level of intervention, children need more specialized services with mental health providers. So one specific example that will exemplify resilience building psychosocial support activities that save the children is finding success within the region is our heart program, which heart stands for healing and education through the arts. And heart is save the children's approach to the expressive arts for healing. And when I say expressive arts, I'm talking about the range. So art, drawing, art, clay, modeling, traditional storytelling, and traditional drama, activities that bring joy to children's lives. And in the heart program we're implementing in school temporary learning centers, child centers, child-friendly spaces, we see that the healing begins when children are finally able to express themselves after these traumatic events, either through their artwork or to a trusted trained professional in the program. And the results that we are seeing are that children feel less isolated, more connected to peers, and making friends itself the ability to engage is a psychosocial support activity. We're also seeing children better able to engage in school. So as you can imagine, feeling stressed or scared has effect on your learning outcomes. So activities that can reduce that stress can help children be more engaged in school. And we also have many stories of children who've dropped out of school feeling afraid. A lot of children have experienced bombing and shelling in their schools or on the way to school. And we've seen children actually return back to school after going through our heart program. So that's just one example that we've seen success with in terms of psychosocial support programs in the region. Dr. Humza, can you talk a little bit about how Sam's views, what kinds of interventions they undertake with, again with respect to the issue of trauma inside Syria? Enough interventions and all of that. Well I lost my hair and can't see well anymore. The amount of work is incredible. We do have a comprehensive mental health services. See, this is falling too. Okay. The complete mental health services, we assess the situation in 2011, I mean we still assess it every year almost. And what happened is that we decided that we are going to need a psychosocial services. We are going to need psychopharmacology, medication services, and we are going to have training and so on. It was a big challenge to work on all those items and specifically when you do not have enough people. We grew from two individuals doing all the work because it was very hard in the beginning, in 2011, 2012, to convince the medical community when they are dealing with amputees and they are dealing with physical injuries to talk about the psychological injuries. So you come into someone that is trying to put an arm together or a finger to an arm or something to say, well what are we gonna do about this? And so it took a lot of work and that's how we started. So we started the psychosocial programs. We developed a number of programs for the children and those in different refugee camps and also the psychopharmacology as well. The difficulties that we faced and it is a tremendous difficulties is that the environment is not helping. Host countries have difficulties and we have a lot of difficulties. For example, medications, paying for medications, getting the medications ready, as you know. So for example, if we're gonna use a mood disorder, medication, let's say, a belify and in the United States it would be about 10 to 15 bucks. You go to some of those countries without naming the countries and the price goes about 10 to 20 times higher. Well, how are you gonna get those medications and then they do not allow you to get free medications from here to there. You have to buy from there on countries. So we face one problem after the other and you can't tell someone, well, I'll give you a little bit of a belify today and then I'll put you on chamomile next month. You can do that. You have to continue the medications and also the problem with practicing medicine. So only in specific areas like in Zatari Camp, for example, we can practice, but it doesn't matter what your credentials are and so on, you're not allowed just to go to any area and just write prescription or work with, I'm getting to the details of it. So it's a lot of difficulties that we have faced we're still facing and so on. That's in the refugee camps. Then you have inside Syria. So inside Syria it became a bigger problem in 2014, 15, 16 and now of course because of all the air strikes and the problems that's been going on. So we came up with the telepsych. So what do we have? We have doctors on the other end inside Syria and we have our own doctors and nurses and so on here and therapists and what do we do? We train them over there on what to do and we see the patients via telepsych. It's kind of like what we do in the US when you see your psychiatrist or psychologist or therapist, but telepsych ways. And that's how we are able to see many, many patients. Of course the problem is you work, you're doing a great job and boom, air strike, you're gone, the whole clinic is gone. And then you start again. So you don't look back, you just start. Those are very difficult, what you call, moments. Can I, so Katie, I was struck by a comment you made if I understood you said having children in the classroom does more harm than good. Can you expound on that and explain what you mean and talk a little bit then about how that has shaped the way the programming looks from the State Department's vantage point inside Syria? So when you put a child in a classroom that's not necessarily ready to go back and a lot of what Amy had mentioned earlier, the aggression, the not safe environment, they don't know how to interact with one another. Children won't be able to go from running around on the streets or having no sort of formal structure to then sitting in a classroom for five, six, seven, eight hours on a day, taking notes and learning. So you have to treat a lot of the mental issues and the mental trauma before you're able to really get them learning the ABCs and the one, two, threes. So in response to that, we have set up community-based organizations in Ain Eesa, Tabqa and Raqqa with More on the Way to help children with psychosocial support activities, many of which Amy had mentioned with the art and the theater and the dancing. Going into some of our centers inside of Northeast Syria, you see drawings on one side where children who had first entered the center, we asked them or the center had asked them to really draw what their life meant. What do you see as your life right now? And some of these photos, kind of seeing it firsthand and then taking a photo of the photo and reflecting on it two months later, it's incredible. They had drawn themselves with a sword in their hands and ISIS member next to them, a coalition plane above and someone just kind of ahead lying on the floor. You have people with guns, women completely covered in black, children coming in with ISIS propaganda songs that they're singing. But through the support activities that we are providing to them, many of them are now drawing nature, they're drawing their lives in the bus, going to the center. So I think it's night and day, so a lot of work to be done. Again, a drop in the bucket of what we're doing. In addition to the centers, because we know there is a lot of children that are unable to actually get to our centers who live in more of the smaller villages, we are doing some mobile PSS, so getting a team of trained individuals out into a village to do smaller activities with children. And then now training teachers, beginning to train teachers in classrooms on child protection and norms within a classroom. So both engaging children and teachers on, okay, what are the appropriate behaviors? What is acceptable in a classroom? What is not acceptable in getting the buy-in of both the children and the teachers so that it's more of a unified approach versus one that's forced upon them? So before I open it up, I wanna kind of pivot the discussion a little bit now towards some of the longer term implications of why it is so important that this issue be addressed now. And Amy, maybe you could start, you talked about this idea of toxic stress and the ways in which it sounds as though, if not addressed, one almost reaches a point of no return or there's a, well, expound on it. I mean, is it the idea that if this trauma issue isn't addressed fairly soon and constructively that there are more permanent issues that then have to be contended with? Talk a little bit about the longer term implications. Sure. So what we are talking about with toxic stress is that there is evidence that shows if children are living with a long-term situation of toxic stress, it will impede the healthy development of their brain so they will have long-term effects both mentally and physically. And so this not only affects their future and their healthy living, but I think one of the important things I'd like to build off what we're talking about is also affects their education. And that's one of the main things that we're concerned about when we talk about there could be a lost generation as well. So we estimate there's two million children inside Syria who are not attending school. And I believe it's 43% of the Syrian refugee population outside, so that almost another million, three million children right now are still not returning to school. And our research and our report also shows around 50% of those who are attending school do not feel safe. And as we just discussed, if you don't feel safe in school, you're not learning. And so if you're feeling stressed, if you're living in a situation of toxic stress, you're not learning. And the loss of education has an enormous psychological toll on children and their families' lives. And we also have to consider if we have a full generation, we're talking about eight years here, if we have a full generation of children who have not reached their full potential in terms of education and development, what does that mean for the rebuilding of a post-war Syrian society? No, exactly. And I think you've actually teed up very well what I wanted to ask Dr. Hamza, which is exactly that question. We talked about it a little bit in some of our earlier conversations in preparing for the panel, but from your vantage point, how do you see that challenge in terms of the ways in which trauma, if unaddressed, really will impede the longer-term prospects for Syria's recovery and ultimately one would hope place it on a more stable, peaceful path? Right. Let me back up a little bit, because honestly, I don't know if everybody can see it, but let me explain it a little bit better. Let's assume that you have a very abusive father in a very abusive relationship, and then the children are watching and witnessing what's going on. So you have two layers. You have one layer where the abuse is going on and it's continuous and it's continuous. Then you have a therapist and a teacher that's trying to help the children, but that layer of abuse is still continuing. So the question here, is there any impact, any efficacy, as we say in medication? Like if you take a medication, is it really working for you? Or is it just you're popping the medicine and nothing is happening? So the question is, is there any efficacy, any impact of what the teacher and the therapist are doing when the abuse is continuing? All kinds of abuse. And let's say that it is severe abuse. And that's what's going on. So when we talk about the trauma and we talk about education, we talk about everything, we cannot really talk about it as two different contexts. They're all in the same. So we say the children are doing better. Are they really doing better? When they just got had, they just had, for example, a month ago, over 198 airstrikes, chemical attacks, organophosphate, toxicities going on. People are dying left and right because of somatic and physical problems. Phone and everything, breathing problems, and they're dying, the death is secondary to the chemical attack. And then you say, okay, only 5% has been impacted, let's say. But the others are still displaced and jumping from one another to another, one place to another. But those are all connected to families. It's like John and Michelle, they are kind of safe, but their brothers, Bobby and Jimmy, they're the ones that's being killed and tortured. Well, is there an impact on the ones? Well, the one that died died. They're gone. But what about the living ones? What about the living ones? So honestly, when we look at it, and I'm the type, I'm trying to see the bright side on the other, at the end of the tunnel. I don't know if there's one tunnel, maybe there's thousands of tunnels, is that we are dealing with symptoms of the problem. And as long as chemical attacks and ethnic cleansing and genocide happening now at this time, I mean, when we heard about the Holocaust, years ago we were like, okay, they didn't know any better. They were stupid and the world didn't do what it was supposed to do. But there were many other Holocausts happen, right? In Bosnia. And then now, and we're going like, and the world. And it's happening, it's happening. Right after the strike that happened by the US, he striked his own people again. So there was another strike against humanity. And let me say humanity, because we live, even though we say we are here and they're there, but trust me, in any systems, theory you look at, we are all connected. And it might not reach us today, but it will reach one time. It's a circle, it's going on, and it's going fast. Not fast according to our times, but it's going fast according to the system theory. Meaning that all those children, what's gonna happen to them? That's a big question. Any intervention is gonna help for sure all the great work you're doing and so on. But the problem is you take care of 20 and then boom, another 100 is coming now your way. It's like you can't put enough in the pipeline, going like, okay, I'm doing great here. Yeah, but we have another 1,000 coming in. Why? Because there's another attack, another airstrike, another area has been destroyed and it's coming your way. So it's never ending beyond nightmare, okay? That is happening. So education is big, but education is not only big. For example, even in the refugee camps and so on, when we say refugee camps, you know what they are? They are refugee camps. You can't walk out. You've been there for 80 years. You live in a tent. You feel a little freezing here, you go home and you get cozy. They don't get cozy. It's a tent between you and the environment, a sheet of material. That's all. It's a tent. Well, I think this is actually a good moment to bring the audience in. So if I could. So why don't we, yes, and we have microphones, I believe. So if you just raise your hand, yes, just right up here. Thank you. And once you get the mic, please just your name and affiliation if you have one and then floor is yours. Thank you very much. First of all, just my most respect to all of the panelists up there and the amazing work that you're doing and also for USIP for hosting this extremely important issue. And personally from my work, I believe it's so under discussed. Sorry, can you give me your name? Yeah, my name is Aleksandra Thame. I work in Northern Lebanon by the border of Syria in Syrian refugee camps that I've witnessed many of the things you guys have been discussing from the children, aggressive behavior, being extremely accustomed to war planes over their heads. So for me, it's also been a very emotional experience working with these children. And so my very direct question to the three of you is the war trauma is very obvious in the children. Again, referencing things that happened to them back in Syria. But what has become very clear to me over many years with these children on the ground is that there's clearly a trauma of their ongoing conditions in the camps. As you were just discussing, Dr. Hamza, about living in this tent life where your tent is flooded in the winter and scorching hot in the summer. And I work with children that were, again, out of school for five years. There's no UN there. There's no INGOs. They've been on their own. And similar to actually what Katie was mentioning, I mean, imagining these children that are just used to being aggressive with each other, suddenly trying to put them in a space when some of them finally now are going to school is just we're not seeing a tangible impact from this that's positive on their development. So I'm just curious if any of you can expand a bit on maybe what that trauma is like of, okay, there's the war trauma from Syria and then there's the trauma of living in a refugee camp. And I really appreciate that there's been work done to expand beyond the traditional definitions of PTSD and whatever we're used to because clearly this is much more complex. It's much more deep. And as you emphasize, Dr. Hamza, it's ongoing. So thank you very much. So perhaps Dr. Hamza and Amy, and I don't know if you have thoughts on this, but on this broader question of how the conditions differ in refugee camps and what are the specifics of trauma that children and Syrians more broadly face? Yeah, let me first talk about, from a neuroscience point of view, the brain, for example, let's say that when you eat an apple or drink a Coke, the brain doesn't know that this is an apple and of course you identify it as an apple or whatever, but the process that goes through the body and so on and how the brain takes your glycogen and the sugar and so on, it processes it and so on. The trauma is the same way. So I'm using a little analogy here. So the trauma is still going on. So the brain is still traumatized. So one trauma you're hearing, you don't hear anymore the airstrikes, you don't hear the bombing, you don't hear the bombs, you don't see bodies, but now you're going through a completely different type of psychological trauma where there is a humiliation. So everything that's going on is programmed. So on one hand you are shocked, you hear the shots, you hear the war machines and so on and you are afraid and we start with PTSD. Well now we're giving you a cocktail of different disorders and different fears and different anxieties and so on and now you're living the humiliation. You're not even a second or third class citizen. You are just, excuse my language, been treated like an animal. You're an animal human in this camp. The host countries and I'll never forget one time when they asked host countries officials, okay, they said, well, why don't we just make, because a lot of individuals like professionals and architects and engineers said, we can do the same thing for almost the same cost of a 10. And the answer was from two, three different places. If you make them too comfortable, they want to stay here. So if I take that, that psychological, whatever you want to call it, concept, how would you feel if you put yourself in the shoe of that child? What kind of trauma would be it going through? Again, the low self-esteem, the humiliation, feeling you have no freedom, you can't get out, you can't be who you want to be. In addition to all of that, the abuse that is going on in the camps from sexual abuse that nobody wants to talk about it to the physical abuse to other abuses that those children are going through, it is beyond a human imagination. It is an honestly, and I'm telling you this as an expert, it is beyond what any psychiatric or medical book has written about. In part of my practice, big part of my practice, I deal with forensic cases. So I have seen it all. You name it, I've seen it, civil and criminal. This is above and tops everything we have seen. So that's the trauma you're talking about. And that's what we see inside the refugee camps. And I don't want to say just refugee camps. A lot of times they're not in refugee camps, but they are in abandoned buildings and so on. And it is amazing even when they open the door for education that many, if not most of the families say, there is no sense of sending the child to the school. Why? They put them in the afternoon and they put two, three, four grades in one class and the teacher is asleep. Okay, some of them maybe they're doing their job, but this is the truth. I went and I saw it and I was like, this is amazing. You put six and seventh and eighth and ninth grade and you're sitting down and the teacher is on the phone or whatever, they can't teach it. Anyway, that many students. So what did the family start doing? They said, you know what? We do not want to send them. Go find you a job out on the street to bring in some money. So is that a tragedy? Oh yeah, a different type of tragedy. Like I said, a cocktail of tragedies that continues. And the world is still numb to it. Amy, from Save the Children's vantage point, thank you Dr. Homestead. Do you have further points to make? I mean, I think that this idea of course, as we know, majority of Syrian refugees are not in camps but are living in and amongst host communities or in these informal, tented settlements. There are enormous issues with child labor, we know is a problem. But Amy, I don't know whether you had anything further to add on this. Sure, and thank you for bringing that point up. I believe it's five million Syrians now have left the country and it's important population to talk about and they face their own unique risks as we've talked about. ARCs, and what's important to bring up that you've been alluding to is that our experience shows that if a child experiences a traumatic event, if you can provide the basic necessities, food, water, shelter, a loving caregiver, and safety and security, the majority of children will be able to bounce back from that traumatic event. And as we discussed inside Syria, that is not happening, particularly the safety and security piece, which doesn't allow children to regain a sense of normalcy. But the children who have left with their parents or by themselves living in refugee camps, living in host urban communities and squat settlements or overcrowded apartments, children who are still on the move through past multiple borders, are also experiencing a sense of lack of physical safety. They're not accessing basic needs, food, appropriate shelter, water. Many of them have lost their loving caregiver, and love is oftentimes underestimated in terms of supporting children through traumatic events. It's extremely important. That's what our research tells us. And then children face unique threats, as some of them we've discussed, sexual assault and exploitation in refugee camps and along the fleeing routes. Many children have fled from the risk of recruitment into armed forces and armed groups and they're experiencing that alone in a refugee camp. And many children are also faced with other forms of exploitation. We talked about children in the worst forms of labor and begging on the streets. We have also seen an increase in early enforced marriage of Syrian refugees in refugee camps as a coping mechanism. All of this combined is what creates what we've just talked about, the toxic stress. So children are not able to recover as these incidences in their life continue. And it's a very important population and group of children to make sure that we include in the discussion. So thank you for bringing that question. Katie, I know your work is focused largely inside Syria, but I don't know if you had additional thoughts on refugee populations and issues that they face. So not particularly to refugees, but I think just something to note across the board and both Amy and Dr. Hamza have alluded to it is that while the focus of this conversation is primarily on children, what we also have to focus on is their parents and their communities. Because as many of us know, if our parents are arguing, we feel it as children coming down. And so that stress that they're exhibiting is then placed on us. So not only dealing with children, but dealing with the older populations as well. Other questions, please. Just raise your hand and we'll acknowledge you. Yes, here? Yes, okay. Can you raise your hand a little bit higher? Thank you. Hey, so I'm glad you mentioned the... Sorry, if you could just identify just your name and affiliation and then please ask your question. My name is Tom Fu, and I work with the Institutes for Global Engagement. And so I just have a question about the traumatic experience of adults and then how that are playing out in their lives. How that impact their behaviors. Thank you. Anyone in particular want to take that question? Let me talk about it. You know, a lot of the issues really we try not to talk about, but you know that Iosuota has been under siege for a number of years, four or five years. And we had to deal with a number of dilemmas. And again, we're doing the telepsych here. So we're talking and we're trying to see how we could help. So children as young as eight years of age, for example, leaving their area and going to the other side where the regime is available so they can get basic material or stuff like rice, food and so on. And when a child leaves, like let's say around the time, around seven at night and come back at two o'clock in the morning, you can imagine the type of favors you'll, you know, you will serve your predators with so you can bring in some food. That created a number, an immense number of abnormal behaviors at the very young age. Why? There is no father. And if there is a father paralyzed, crippled, missing, there is a mom that couldn't do or sick or ill or a caretaker. So you do not have anymore the normal structure of a family. And those that know Syria, for example, and know the Syrian structure of families and how close-knitted they are, this is totally abnormal to the, you know, to the climate, you know, to the cultural and social climate. But those are important issues that we've been dealing with. And we try and we try through Bess Mitleman, for example, one of the schools, you know, and it's been bombed just about four or five weeks ago. And we lost many staff members and so on. So you try, you know, like I said, you know, a drop in the bucket to do something, but you fix something here. It's like you fix the electricity, now it's your plumbing. You fix the plumbing and then it is something else. You could never get it right. So you deal with what you have. So that's a big problem, is that we're seeing a lot of odd behaviors, abnormal behaviors and many disorders at a very young age. Other thoughts on this particular question? Just to add and also reiterate the importance for us at looking at the mental health of adults who are raising their children because parents who are distressed, we do see an increase in violence and physical abuse in the home. They feel that parents who aren't coping it might lead to negative discipline methods. And we also see them resort to even more extreme negative coping mechanisms when they can't, when they're having a difficult time dealing, providing for the children in their house. And remember, these are families who have lost everything and the level of stress of having a household of children creates. And those negative coping mechanisms that we just discussed are sending the child to beg on the street or sending their young girl children to be married in a house. We talked to parents who really believe that's the best option for their household right now is for a young girl to be married early because she can actually access more resources in the other house and it also alleviates the burden in their household. So the issue of adults trauma and distress and toxic stress is extremely important for us in terms of looking at children's wellbeing. I know you had actually noted that in your previous intervention. One question that came to my mind as you all were talking is the issue of stigma and whether there is an issue with cultural stigma around emotional illness or mental illness or trauma. I mean, is that an issue that you have to contend with or, and I'll start maybe with you Dr. Hamza and others if you wanna chime in or is stigma not an issue that has presented itself on this? You know, amazingly, it's not anymore. They're asking for it and they're asking for services toward the beginning maybe but I think when they notice and they realize the benefit of mental health services they ask for it and they say and I need this and I need that and we have to be careful specifically with medications as well but it's, the program's doing very well specifically, you know, we have a great operation in Jordan, for example, if I use that as an example of other refugee camps. We have clinics in Ayurveda, we have clinics in El Zaftari, large clinic, mental health clinic in addition to our large clinical facility in El Zaftari, for example and also wherever we are allowed to operate. So, and if there is anything it is needing more staff, needing more funds, needing more grants so it can help us do the job. A lot of, many professionals if I say sometimes waiting in line just to jump in and to help but with the people, it is amazing, you know, if they miss one session they go back or they call or they come by and say, hey, I missed my session and I need to see if it's a psychosocial, if it's a therapy session because we have, you know, psychotherapies and so on and one thing I wanted to say we do have the best of training because simply like in the United States the mental health committee we have a number of psychiatrists and psychologists and neurologists. They are not only practitioners but they are also professors in the field and we take turns, you know, going and training the staff there. For example, just as we speak right now the psychotherapist in Lebanon and in Jordan will be trained by one of the top EMDR therapists, a psychiatrist by the name of Dr. Sultan, a Syrian British psychiatrist and he is one of the biggest name in the field of EMDR that is training our, you know, psychotherapists and so on. So they do get the best of what we have and if we cannot reach them like all the areas inside Syria we do it through telepsych. So we have an entire team dedicated just for telepsych training and then telepsych services as well. And I think with doing all of this is that the people are aware of it and they're, you know, they're needing the services and they come and I guess they benefit from our services. I would echo Dr. Hamza as I noted previously when we first started doing psychosocial activities inside Northeastern Syria there was a bit of a pushback from the local community and local governance bodies until we really kind of set forth and said, okay, this is what we're doing and showed them the advantages and the impacts of what our programming could do. So now, you know, instead of pushing us out they're welcoming us in and wanting us to establish more centers, engage more children, work with, you know, the UN and other international organizations like SAVE to kind of team up and address more children. I think it's important to note that one of the first centers that we opened up, you know, because of our capacity and because of the resources that we had available at the time we could only really target a small number of children. The children that weren't accepted into the center I guess we could say because they didn't meet the initial requirements. I have videos of them standing outside on the fence holding the fence crying and throwing rocks inside because they were not able to participate in activities. I can say fortunately that those kids are now in centers or at least in classrooms where we have mobile centers. So really trying to engage with them and this is a serious issue that goes beyond just the three of us in our conversations. Other questions, yes. Why don't we go all the way to the back? The woman in the dark, yes. And again, please identify yourself. Hello, yes. I'm Stacey Schamber with ICANN, the International Civil Society Action Network. I wanna thank all of you for your comments today and for sharing all of your expertise. ICANN has partners in Syria, Turkey and Iraq and I've been in conversation with them about ways in which we can best support their work which sometimes includes psychosocial support but it's certainly not specialized in that. And I just wanted to hear from your perspectives about working with local partners and certainly with Sam's expertise. What from your perspective would be most needed for the local organizations on the ground there? Is there a way in which you are training others or that we can enhance the work, the coordinated work that you're already doing? Thank you. Why don't we maybe start Amy with you? Yeah, that would be great. And then we move to the rest of you. From our perspective, working with and through local partners is our preferred method. We find that it lends to sustainability and also that's our goal to be building the capacity of the region to be able to support and ongoing rebuilding efforts. And to do this one of our, so I guess the question is perspective of local partners maybe being prepared to work with children in terms of psychosocial support. A lot of times psychosocial support activities don't have to be intensive as we talked about. Sometimes just connecting children with their peers or with trusted adult or helping teachers be ready to be able to work with children who are distressed that we talked about earlier. And we are working with local partners to build their capacity in that. One of the first trainings that we offer suggests is psychological first aid for child practitioners. And psychological first aid, while it has a fancy title, it's just basically a set of tools and resources on how to talk to children who are distressed and also how to take care of your own staff's wellbeing. Cause that's critical for working in this situation. Toxic stress can also happen in adults. And if we have people working with children who are working in a state of toxic stress or burning out, we're not obviously going to be very effective for the long term. So that's our major recommendation is making sure that you have a prepared staff, working with another organization that has technical experience in that to build the capacity in that and to understand what you're doing. And just add one more important thing as I'm talking about that. Also critical, if you are going to be working with children in these areas, is to make sure that you are linked up to professional mental health services if they exist. There always has to be an option for that as well. Did you have anything to add, Katie, on this question of local partners and how that relationship works from your vantage point? So one of the things that we've been fortunate enough to have is that a lot of the staff members that work in our centers have been trained by SAVE or by the UN through UNICEF. So they have come over from, you know, further northeast Syria into Aynisa, Sabka, Baraka area. And so they kind of pick up the pieces for us. We provide them additional remote training through a trained psychosocial support expert. We tailor the trainings based on what they have told us that they're experiencing on the ground. If they've talked to a child who has had X, Y, and Z, they then talk through it and find the best way to approach it. Dealing with local partners while challenging because of the lack of potential capacity is also extremely rewarding, as Amy said, because of the long-term sustainability, something that they can continue on with years down the road. And I know, Dr. Hamza, you've spoken already at length about the training and the work that's being done with local Syrian doctors on the ground, but are there other comments that come to mind on this question? Yeah, I think all the local and the external inner groups, like your group ICANN, SAVE THE CHILDREN, your department, and so on, I think they should have a good connection of what's going on to not replicate the same work. And if you're needing expertise, then you can find it. So for example, if SAVE THE CHILDREN, they're talking about toxic stress, okay, they look at it as a major issue, which is, it is a major issue. We look at it as one component of the human devastation syndrome from a clinical perspective, right? So we're looking at things from a psychiatric and mental health because we are very comprehensive. And it's unfortunate, but eight years of agony and what's going on devastation give us a lot of skills knowing clinically what needs to be done, as well as medically. Like I said, you know, Sam's has been, within Sam's itself, mental health is one of the highest, if not the highest priority to Sam's at this point because we understand where we're at and we understand the psychological injury, both from a physical point of view and from a psychiatric point of view. Now I think, other than advocacy, other than building capacity, I think there should be building unity among all of ourselves that if there is something, like Kate, if she needs something, she can pick up the phone and say, okay, here's the situation, what do I do? Can I get some help? Because toward the end, you want all the reverse to pour in the same spot instead of each one doing its own, which is great, but there has to be unification of efforts and skills and abilities. Do we need the grants and the financial capacity and we need that? Definitely, because the cost, you would not believe how tremendous it is. Even though we try to stretch the dollar in so many directions. Other questions? Yes, gentlemen here. Thank you. My name is Hatem and I'm from Iraqi Embassy. My question about the so-called the Caliphate Cubs, we have seen many videos on tapes that ISIS have been trying to recruit children to be fighting members. And we have seen videos also children beheading innocent people. My question, are there any specific programs to help these children to bring them back to normal life? Thank you. We'd like to take that on children of ISIS. Sure, I can't speak specifically to that specific groups of children, but what I can say, obviously what you described can have a devastating impact on children and there is a need for any children experiencing those traumatic events to be in a situation where they can be accessing mental health and appropriate care. We have, through our community-based organizations, we've had a number of children who not necessarily participated in beheadings but did enroll in ISIS schools. And so hearing their stories of how they learned to count, for example, it wasn't one sheep, two sheep, three sheep, it was one grenade, two grenade, three grenade. So kind of reversing their psychology and just having them express their feelings and their thoughts. And at that point, stuff that our programming can't handle because it's at the very basic level, referring it up to another organization who has more trained therapists on hand. If I answer you, then I'm gonna make your hypothesis accurate and I disagree with your hypothesis because ISIS is political, it's not religious and we know why and how it was created. We don't need to get there. But I can tell you, as an extremist group that was created for specific purposes, to serve specific purposes, for specific entities, when a child is lost and when a child has lost at all, any predator, if you wanna call it a sexual predator, if you wanna call it a political predator, if you wanna call it a propaganda predator, is gay. So our goal is, and specifically when we dealt with, we focus on the children, is that we do not want that aggression in children. When I met with a lot of children, hundreds of children, in the beginning of this whole ethnic cleansing, genocide, every child, the boys, of course, specifically ages 10, 12, and so on, they ask them, what do you wanna do? And they say, I lost my dad, I lost most of my family, I can't wait to be strong and take arms and just go back and fight and kill those that killed my dad. Of course, who killed his dad? Everybody's fighting and killing each other. So we want to mitigate those features and characteristics of aggression and revenge and so on and show them the other side. And that's one of our biggest focus. So when I say we are comprehensive, we can't just take psychosocial and say you're gonna be fine. So if you are, for example, if you have, let's say, HDS, Human Devastation Syndrome, if you have that, I can't just say, I'll give you psychosocial and you're gonna be fine. It's gonna be much more than that. There's gonna have to be psychosocial. There's gonna have to be therapy. The therapy has to be particularly and skillfully selected. Then the medication comes in and kicks in and then there's the education part. So you're talking about a comprehensive component and the way I want you to think about it, if I have a vet that has a PTSD, we can't tell them, okay, we're gonna have just little therapy and everything will be fine. No, everything will not be fine. How long is the therapy? What type of therapy do you wanna do? How many times during the week and what kind of psychosocial programs and what kind of medications? So you're targeting specific features. I mean, this is a big science and honestly, we thought we learned about the psychiatric world when we started and I was like, oh my God, we have not seen any of this before. It's not in the medical books. It's not and you're dealing with a side, a dark side that we have not seen before prior to this and now we're dealing with it. So let it be like I said, whatever the entity is, the children are prey and the children are the victims and we wanna turn them from victims to good citizens and that's our goal. I think we have time for one more question. Yes, a woman right here with the butterfly scar. Yeah. That's a good description. Hi, so I'd like to, since I'm... Oh right, my name is Jen and I work with girls and young women around the world to develop them as peacemakers and I'd like to, since I'm the last question, in with the light of hope and actually I gave a keynote at USIP on International Day of the Girl because we launched the first ever Syrian Girls and Young Women Empowerment Survey and we found three things and I called them superpowers of empowerment of Syrian young women and the first was resilience and second was hope and aspiration and the third was action and accountability. Now mind you that this was a very special population. My focus is millennials, so these were all millennial young women and it expanded 20 countries in and outside of Syria. 50% were in Syria and the 50% were outside of Syria, including United States and Western countries and they were all going to school and so going back to the action accountability, 100% of these young women, they were all getting educated and they were all learning skills and developing skills because their hope and aspiration was to go back to Syria and be able to rebuild their country. So I can't help but to think this is your army. How can we have them, they all wanna go back, they don't have an avenue or even a specific, I mean they're all studying in UK or Sweden or Dubai or wherever and Syria actually, 50% was in Damascus, how do we connect them with you and your work because I mean I feel they, we know they're gonna rebuild Syria, it's not us over here and us sitting in this room. So how can we do this connection? So I would ask you each to respond to that question and maybe in addition I would add one other small thing which is sort of what do you see as the greatest need going forward? What would you all like to see in terms of interventions going forward and why don't we start with Dr. Hamza and work our way through and I think responses need to be somewhat brief as we're coming toward the close of the event. If I tell you an airplane has two wings and a body and this is how it flies, that's not the answer, right? The answer is we connect at some level and I'm willing to share all my contact information with you but then the other party that wants to jump in and there's been in the past eight years, many parties they say I wanna, they become enthusiastic, I wanna come in and then when you start and say okay, this is what we're gonna do, the amount of work is incredible, tremendous. My life is never the same for the past eight years, I had to make a deal with my wife and kids, it's like this is my mission and David understand when our meeting starts at nine and finishes at two o'clock in the morning, once, twice a week, trying to figure out what to do and how to solve this problem. So when you tell people this is what we need to do and then suddenly out of the hundred that wants to help you get one person to stay because they want you to do the job and go like okay, here's the idea, just run with it. No, you're gonna run with me and we're gonna do it so to me, we can share contact information, all of us, we can decide on some mechanism of what needs to be done and again, we are going to hit one wall and that is who is going to fund all of this. Having just said that, just to let you know, we are at SAMS, we are taking care of all the dropouts because they're not their displaced, something happened to them in one area or another of medical students and nurses. Like we have deals with Aleppo University to graduate nurses, now we are trying to shoot for a medical school in Turkey and we are taking those students and we are putting the top notch students that fell out of their programs into medical school inside Turkey so they can come out. So we are planning 10, 20 years ahead of time. We're not gonna lose the brightest. We're not, we're focused on that. So clinically we're doing the work and I showed you only that part but I think we don't have much time to go over the other stuff but on the other hand we are doing incredible things to prepare the new generation. We've lost many health workers, of course you know that medical facilities has been targeted, medical workers been targeted and killed and so on, so what are we doing? Okay no problem, we'll regenerate and we're working with a lot of medical students. This May, the first week of May I will be the keynote speaker where we brought in a sister organization that's called SAMH, okay? And they do a lot of training for medical training and so on in education for the Syrians in Europe and Turkey and inside Syria and we're gonna have the first mental health conference and we have so many medical students and psychologist students and mental health students coming in so they can benefit and we're doing a lot of training. So now what you're talking about is awesome and Karam for example foundation is doing similar things so the thing is let's unite, let's see what it takes let's find the funds so we can go for it and find the human capital to do the job and we're open, we're open for anything, we're trying and thank you so much for your excellent question. That is great comment because while what we're talking about here really sounds weak we also found the same glimmers of hope in our research in fact I brought a quote from Aura 15 from Aleppo when she was in a focus group and we asked children what they wanted most she said I want a school and teachers to teach us and lots of students so we can be happy and get educated and read and learn. We also meet countless children who tell us when asked what do you want, how are you feeling I want to go back to school and they specifically tell us I wanna become a doctor or a nurse or a teacher to help Syria rebuild and we have to continue engaging that and I guess my answer to what we want to see is a renewed global commitment and action on education and the support needed to address the barriers to education including the critical mental health support that we're talking about today and in terms of connecting young people and youth in the region that you're talking about I mean I would love, we work in adolescent clubs and youth centers in the region but I would love to see a global youth network that is connecting and keeping them engaged because when it is time to rebuild and we see that there's hope for that it will be Syrian driven and it will be the young people that we're going to be counting on. Katie? Just to finally close I think going back to a previous comment about the Syrians regardless of you're in Syria or outside of Syria is the resiliency so the Syrians themselves regardless of when this horrible war will end will be the ones to take the lead and I think one of the first steps in addition to kind of the funding and uniting together is just ultimate peace like you can't get anything done unless you have access and access means peace. Well I want to thank the three of you for the extraordinary work you are doing on the ground inside Syria amidst and in the surrounding countries amidst enormously difficult circumstances and I want to thank you in particular as well for coming and being with us today and imparting your important insights so please join me in thanking our terrific panel.