Refugee Relief International After Action Reports

Lebanon-Syria Border - September, 2012

The Refugee Relief International, Inc. Medical Team mission to the Syrian border areas had three major goals:

  1. Establish contact and develop local sources in medical, political, and military channels pertinent to relief activities for Syrian Refugees in Northern Lebanon
  2. Evaluate current state of Syrian conflict area medical capabilities, refugees and medical relief efforts
  3. Identify unmet needs and potential future projects
RRII surgeons work on a Syrian refugee wounded in the recent Syrian attacks on civilians.

Team members Mohler, Schmitzberger, and Mr. Aziz arrived 23 Sep 12. Passage through southern Beirut (Hezbollah area) was by divided surface road. There is only one major access route to the airport which gets closed down rather easily. Egress through Syria used to be the norm but is not possible anymore; only other alternative is by boat to Cyprus.

The next day team passed through Tripoli and arrived town of Berqayel. It is a Muslim area with Christian villages/townships nearby. Numerous members of the Lebanese Armed Forces (LAF) and Security Services hail from this area. These contacts proved essential to operations in the area and access to the restricted border areas.

The team immediately began a series of meetings with local surgeons, relief agency personnel dealing with Syrian refugees. We visited the main office of a local charity and a line of refugees waiting to register for aid was present. This included a middle-aged woman who had fallen that day and broken her left wrist. We suggested a closed reduction. We went to a nearby walk-in clinic that served the Syrian refugee population (100,000 in this area and growing). A hematoma block was administered and then a closed reduction was accomplished and sugar tong splint application done in cooperation with the doctor staffing the clinic. We used the materials in the clinic. That doctor would circularize the cast in 5 days and provide follow-up.

A Lebanese Red Cross post on the Syrian border, looking more like a fortress. This post routinely receives fire from across the Syrian border.

That evening we met a local who also works with IMC, an NGO hired by UNHRC to provide medical equipment, meds, and personnel for Syrian refugees. He was able to give insights into movements on the border and which regions are currently receiving patients.

The following morning the team went to the local hospital and observed several surgeries by a general surgeon. The operating rooms were clean and modern. They lacked some equipment, and only had a 2 person surgical team, but the surgeries were professional. Patient care at the hospitals is good but with a lack of attention to detail. Surgeries are done often based on the availability of funds or are withheld until funding is available. Surgical costs are very high (USD 10,000+ for major procedures) and need to be paid out of pocket by the patient or an NGO.

We were shown a complicated distal femur fracture in a 50 year old refugee, as well as x-rays of a 2 month old with a one month old humeral fracture pseudoarthrosis. The orthopedic surgeon and Dr. Mohler discussed these and advice on care was given.

The following morning we received an urgent call requesting assistance with the 2 month old. We drove north to Quobiyiat to the Notre Dame de la Paix hospital where the baby was in the operating room. We joined the surgeon just before the start of the case. It went well .The pseudoarthrosis was taken down and a 4 hole 1/3 tubular plate was placed. Radial nerve was fine.

That day we visited the Red Cross outpost at Hrar-akkar where team member Mr. Aziz had worked previously. We met the local head-officer of the district who was able to outline the involvement of the Lebanese Red Cross with refugee efforts. Currently few patients come into Lebanon through the border due to the increased Syrian military presence in these regions, as well as new landmines being deployed there. Some movement is still happening. Typically the timing of crossings is known a few hours before the patients come across the border and the Red Cross is informed where to pick them up. The Lebanese allow refugees to enter freely. These patients generally have not received any treatment whatsoever and only the most urgent cases are being smuggled across the border.

The next day we assisted at the Akkar-Rahal hospital with a distal femur fracture. The patient was a Syrian refugee and the surgery had been delayed for a few days as he needed to gather sufficient funds (11,000 USD minimum).

The following day we were able to secure permission to enter northern border areas, where we met with the local Red Cross team. Their station is located at the northernmost part of the country and this area receives sporadic rocket and mortar fire from Syria. Through informal communication networks they often receive word when a patient will be brought over from Syria and where to meet. These patients then are brought either to the only local hospital (no surgical capability), as they generally have received no care in Syria before being smuggled across the border, or are driven by ambulance directly south to a larger hospital in Halba or to Tripoli. Patient care there is acceptable though there are issues with billing and permission has to be secured before transferring a patient. Local NGOs with funds from other middle-eastern countries and the U.N. pay for treatment.

We next visited the local hospital (PHC - primary healthcare center) and met with the local attending, a general surgeon. The hospital offers very limited interventions and no surgical care. Specialists come in on a regular schedule but apparently mostly work as general practitioners and triage for further transport. A lack of funds is preventing the hospital to build and maintain an operating room though staff seems available. Currently a limited number of casualties from Syria are treated there as the border-crossing has become more difficult. Best estimates are that only 1 in 100 people injured or ill in the general area of Homs (Syria) end up receiving adequate care.

The next day we were able to meet with a Red Cross official in Tripoli. He confirmed the information we had gathered throughout the trip. He helps with the coordination of patient pick-ups in the border region and offered further contacts.   This was the last meeting prior to our Oct. 3rd departure.

There is an acute lack of treatment for injured/ill persons within Syria in the region around Homs. An estimated 1% of people needing treatment are smuggled across the border into Lebanon. Treatment is being provided and the refugee population is being cared for by local NGOs, funded by the U.N. as well as various middle-eastern states. The closing of the border through increased deployment of landmines by the Syrian regime has aggravated the medical and humanitarian situation within southern Syria. According to our sources, no NGOs are currently operating within southern Syria itself. Crossing the border is possible but even within Lebanon there is a significant threat of kidnappings, particularly in Hezbollah controlled areas.

Summary:  Medical care on the Syrian side of the border has broken down completely. Casualties from the current fighting receive little or no care from point of injury to point of contact with the Lebanese medical system. Once across the border, coordinated care is available and excellent BLS (basic life support) medevac capabilities exist through the Lebanese Red Cross. Level 1 trauma care capabilities begin about 20 km inside Lebanon on a contract basis, or through charity care. Primary care capabilities are available within 2 km of the border. In this sector, 30 refugees present for treatment per day at a primary health center, with 1-2 cases per day of major battle trauma. There is no identifiable active cross-border treatment or training teams in this sector at this time.