Commission on Security and Cooperation in Europe

Testimony :: Dr. Zaher Sahloul
President - Syrian American Medical Society


Statement by Dr. Zaher Sahloul


Syrian American Medical Society

Before the Commission on Security and Cooperation in Europe

June 13, 2013


Good afternoon, Mr. Chairman and Members of this Committee. Thank you for hosting this hearing today on the humanitarian crisis facing Syrian refugees.

Since the beginning of the crisis in Syria, the Syrian American Medical Society (SAMS) has made multiple trips to Syria and its neighboring countries hosting refugees. We have sent multiple medical missions to address healthcare and psychosocial needs of Syrian refugees in Turkey and Jordan and to provide surgical and rehabilitation care to Syrian patients who were wounded in Syria due to shelling or bombing and then transported to the neighboring countries for surgical and medical care as they were denied such care inside Syria. Unfortunately many of them died or were further injured during the transportation due to unsafe and often primitive means of transportation.

We have established offices in Turkey, Jordan and now in Lebanon to address the needs of Syrian refugees and organize cross border medical relief to inside Syria, and regularly train Syrian doctors on how to deal with trauma patients they see on a daily basis within an austere environment lacking in resources.

We work in collaboration with other American, local, regional and international relief organizations and coordinate closely with local Syrian doctors.

We have sent over 100 physicians and medical personnel, both Syrian-American and non-Syrian American physicians and nurses, on medical missions under life-threatening conditions inside Syria. I have personally attended medical missions inside Syria six times over the last two years. Through our three field offices in Turkey and Jordan, and our teams of volunteer physicians, we have been one of the leading providers of medical relief aid inside of Syria, sending in millions of dollars worth of medical assistance, and have programs supporting health services for Syrian refugees in Jordan. We abide by the key humanitarian principles of neutrality, impartiality and independence and we work to serve everyone in need regardless of their ethnic, religious or political affiliation.  

Our team provides psychosocial support to Syrian refugees and oversees the surgical treatment and postoperative care to wounded Syrians transported to Amman hospital in Jordan. We also send medical supplies, medications, medical equipment and financial assistance to start field hospitals, medical points and support Syrian doctors in southern Syria. We provide similar services through our Turkey offices to Northern Syria. In the last year we spent about 5.5 million dollars in medical relief inside Syria and to Syrian refugees.

We helped to establish an underground parallel healthcare system throughout Syria to provide medical and surgical care to needy patients who are unable to seek medical and surgical care in the traditional healthcare system due to the unsafe environment and destruction of the traditional medical centers, especially in areas with ongoing hostilities.

We have established more than 16 field hospitals and 25 medical points, supported tens of traditional hospitals with medical supplies, equipment and consumables and provided medical training to more than 200 Syrian doctors in trauma care and the use of new technology to assist them in their hard, but lifesaving work.

Impact of Crisis on Neighboring Countries

    What we have seen become of Syria is heartbreaking.  Syria, a country that used to host refugees from Lebanon, Iraq and other countries in crisis, now has over 1.6 million Syrian refugees hosted in Turkey, Jordan, Lebanon, Iraq and Egypt who have fled horrific scenes of rape, torture, their homes and neighborhoods destroyed, their neighbors and children taken by violence, all too often before their eyes. There are millions of Syrians who fled the conflict and are uncounted for in the current UNHCR numbers of registered Syrian refugees. Inside Syria, nearly 6 million Syrians have been displaced from their homes, often multiple times, and their personal resources are being depleted. This amounts to nearly 30% of the Syrian population, or 1 in 3 Syrians, the equivalent of 120 million Americans. This puts an enormous strain on the economies and healthcare systems of the communities hosting IDPs and refugees. Entire neighborhoods (like Baba Amr and the old city in Homs) and cities (like Darreya and AlQusair) have been completely destroyed and depleted from their inhabitants.

    Even if the crisis ended today, millions of Syrian refugees and IDPs would be unable to return to their homes and neighborhoods due to the complete destruction, chaos and immobilization of economic life.

    The health situation is catastrophic. Physicians have fled from the violence, unable to continue to treat patients under continuous bombardment and aerial attacks, lack of electricity and heating during the winter, and with little or no salary support. Every Syrian physician has heard stories from our colleagues about harassment, detention, torture and even death as a punishment for treating wounded inside Syria, and hospitals are regularly attacked, looted and destroyed. We have heard reports of physicians sleeping inside a hospital morgue in Syria for months at a time, with nowhere else to go. Currently we have estimated that there are at least 120 Syrian physicians among the refugees living in Jordan, but they are not able to practice medicine there or in other neighboring countries without supervision by a Jordanian physician. Despite the enormous needs, and their valuable and needed skills, Syrian refugee physicians have little they are officially able to contribute to the humanitarian response.

    Prior to the conflict, the Syrian healthcare system was advanced and specialized. Syrians were accustomed to a level of healthcare that allowed them to visit a specialist – women would go to an OB-GYN provider, for example. This simple reality has turned the typical international response to a massive refugee influx on its head. Syrians are more educated, more accustomed to specialized care, and accustomed to living in a middle income country than other refugee populations. This means that the international community has had to revisit their typical response activities and change their strategy. Syrian refugees have stretched the international community’s response system beyond its limit, and the refugee crisis shows no signs of abating.

    Looking at the escalation of Syrian refugees, by April 2013, daily refugee flows were peaking at 14,000 per day (or one refugee every 6 seconds). In March Syrian refugees crossed the 1 million mark – now not three months later, there are already 600,000 more. This is an escalation of around 200,000 new refugees each month.

    Mr. Chairman, the conflict in Syria is already spilling over into host countries, affecting their ability to provide their own citizens with services, and putting a strain on their economies and governments. By the end of 2013, UNHCR has projected that the number of Syrian refugees will reach an unprecedented 3.5 million. As you know, the UN has posted its largest appeal in history - $5.2 billion to support the response, and even that would not be enough to meet the enormous and growing needs inside and outside of Syria.

    What is needed is for countries to maintain open borders, increase humanitarian assistance and channel more direct assistance to Syrian expatriate humanitarian organizations such as SAMS that have access in hard-to-reach areas of Syria, and for major donor nations to be creative in seeking out new and non-traditional donor countries to support assistance efforts. The UN should also use cross-border assistance to reach the many underserved populations inside Syria who they cannot currently reach, which will help to stem the refugee flow outside of Syria.

But all of this is no substitute for ending the conflict. Even with more funding, the humanitarian community’s capacity to respond is limited, and the crisis is escalating at breakneck speed. What is most needed is a solution to the crisis, and it should not wait for another 93,000 Syrians to perish.


    UNHCR reported in June that Jordan is currently hosting 477,455 Syrian refugees, with about 83,000 additional people waiting to be registered. 80% of these live in urban settings rather than in camps. While the government of Jordan deserves gratitude for hosting over half a million Syrians, the sheer scale is straining Jordan’s resources as it struggles to also provide services to its own population. Nearly 10% of Jordan’s population is currently made up of Syrian refugees.

    It is much more difficult for UNHCR and international aid organizations to provide services for refugees who live outside camps and are instead living among the local community. The Jordanian government, UNHCR, and other organizations are working to provide refugees with free medical care. But there are limits to this care, leaving many cases outside the available treatment, and there is a growing difficulty, especially in Jordan, in covering more complex procedures including dialysis, invasive surgeries such as cardiac surgeries, and cancer treatments.  Many refugees in need of these services have died, since they are unable to afford treatment and are turned away from facilities.

Mr. Chairman, providing wounded Syrians with free surgical care and postoperative care including rehabilitation of the wounded and patients with amputations and spinal cord injuries should be a priority gap for donor countries to work to fill moving forward. Many are under the impression that all wounded Syrians are treated for free in Jordanian hospitals. Unfortunately, this is not the case most of the time. Jordanian public hospitals accept and treat surgically only a few life-threatening surgical situations and other sporadic cases. There are delays in transporting patients in need for surgical treatment. On my last visit to Jordan, I met more than 20 Syrian patients in one of the private hospitals in Amman. All of them underwent surgeries in that private hospital. The cost of surgeries is covered by SAMS and other NGOs. There are 4 private hospitals in Amman that are performing such surgeries. Over the past 20 months, more than 3000 wounded Syrians were treated in these private hospitals. The average patient cost is about $2000 with some patients costing up to $ 100,000. Total cost incurred by NGOs and individual donors is about 6 million dollars. In the last few days of my visit, there were about 15-20 new patients who require surgical procedures every day, and that is without counting other surgical non-trauma related cases, such as obstetrical cases for Syrian refugees.


By interviewing the patients, I was able to figure out the current flow of patients in Jordan. When patients are injured by bombing, shelling or in combat in Daraa or Damascus, they receive first aid and basic care in medical points or field hospitals if available. Then they are transported to Jordanian hospitals at the border that are operated by NGOs, including Al-Saudi hospital and a Moroccan hospital in Alzaatari camp, UAE hospital at the border, Abdallah Hospital at the border, Ramtha public hospital, and others. These hospitals are considered level 1 or 2 hospitals and are not equipped to perform surgeries needed to these patients (most are Orthopedic, Vascular, Urologist, Plastic and Neurosurgical). After some waiting, patients are then transferred to one of the 4-5 private hospitals in Amman for surgical treatment and postoperative care.


Mr. Chairman, we recommend that donor countries support surgical treatment of these patients indirectly by donating to the NGOs that are supporting this system right now, as well as through direct support to the Jordanian government specified for that purpose. We also recommend that they take steps to encourage the Jordanian government to include a medical team to evaluate cases at the border that require urgent care, and to work with NGOs to establish a list of criteria that is used to accept patients to different facilities to eliminate some of the confusion around where a person can find appropriate care. We also recommend that donor countries work harder to support providing medications either for free or highly subsidized for the treatment of chronic disease and antibiotics to refugees in Jordan.

Mr. Chairman, we also recommend that Jordan, Turkey and other neighboring countries grant special medical license to Syrian doctors who are residing in Jordan or Turkey that will allow them to treat, manage and operate on Syrian patients only in certain named hospitals. This could happen at little cost to the host governments, since NGOs support the treatment of patients in these facilities. Yet it would allow Syrian physicians who are refugees to contribute to the medical response and lessen the strain on the host country’s health services.

    There are other challenges to humanitarian aid delivery in Jordan that I would like to highlight that are causing more desperation among the Syrian populations in need. Currently, aid agencies deliver assistance through the Jordanian Hashemite Charity Organization (JHCO), but the process is slow and expensive. Especially given the increased hostilities and worsening humanitarian situation in Daraa, Damascus and its suburbs, and Qalamoun, it is expected that a further deterioration of the humanitarian and medical situation will lead to increased refugee outflows affecting Jordan, and an increased need to send supplies through Jordan to reach those inside Syria. Other options such as partnering with the Jordanian Red Crescent may be a complementary option to relying exclusively on JHCO for aid deliveries.

Some have placed hope around statistics noting that about 60,000 Syrian refugees have returned to Syria within the past year. Refugees have reported that they are those from the southern region of Syria, where the FSA has control, and where the main road that links this area to Damascus has been reopened. Others have shared that they returned temporarily to oversee their property, or to bring back other family members to Jordan. However these numbers can be deceiving. It has been suggested though that most of those who return to Syria ultimately come back to Jordan, adding to the already-strained system.


    Turkey is currently hosting 380,650 Syrian refugees in Turkey, with another 25,000 awaiting registration. In response to the expanding refugee population, the Turkish government began extending state health services to the Syrian refugees earlier this year.  The Disaster and Emergency Management Agency of Turkey announced that over 300 refugees voluntarily returned to Syria.  

The collapsed healthcare system and increased spread of infectious disease as the weather is warming in Syria is already having an impact on Turkey and other neighboring countries. Infectious diseases including measles, tuberculosis, and cutaneous leishmaniasis have been prevalent diseases within Syria. With large populations exiting the country daily, these medical challenges will now be placed on neighboring countries, including Jordan and Turkey. Many are concerned that host countries’ prevention and control interventions will not likely be prepared to face a potential outbreak of measles and other diseases.

Current political tensions in Turkey have caused consequences for Syrian refugees attempting to flee from Syria. At the end of last month, Turkey closed a crossing on the border of Syria for security purposes after an attack on Reyhanli that many believe is linked to Syrian intelligence.  Some have reported that many refugees face discrimination or threats of violence within Turkey due to this situation, and tensions between segments of the Turkish population and Syrian refugees continue to grow. We believe it is important to thank Turkey and thank the Turkish people for their generous support of Syrian refugees during the crisis. Turkey has generously provided housing, food and care for Syrian refugees in 17 government-run camps in eight provinces. Another 30% of refugees in Turkey are housed in urban areas.

Mr. Chairman, we believe that Turkey needs additional support in the form of assistance to support services to refugees. More needs to be done by EU and US governments to support health services to refugees in particular, especially in order to close the gap between what is currently available for rehabilitation services for wounded and disabled Syrian refugees and the increased needs. Prosthetic limbs, support for complex treatments, and a mechanism to allow Syrian physicians to treat patients in Turkey are all gaps that need to be filled. More support is also needed for urban refugees.


Mr. Chairman, the current refugees’ situation is unsustainable to all host countries including Turkey who has a better economy and healthcare infrastructure than the other countries. There is no end in sight for the crisis and on the contrary, the UN expects the number of registered refugees to increase to a staggering 3 to 3.5 million refugees by next year as the conflict continues unabated.  Our effort should focus on ending the crisis immediately before it can cause more deaths, disability, destruction, instability and chaos in Syria and neighboring countries that will serve as fertile grounds for extremism.

Our policies should focus on addressing, among other things, the healthcare and psychosocial needs of Syrian refugees and providing them with education, job training and civic training. Civic training and education of refugees are often ignored, but they are powerful tools to counter extremism and help build a better democratic system in Syria after the crisis. Such an effort should focus on the youth and women in particular, and be sensitive to cultural and religious traditions.  We should also address the planning for a resettlement process. At this point, there is no such planning is being done, as far as we know.

Mr. Chairman, despite the tragic situation in Syria, I’m optimistic about the future, because Syria is a very unique country. It can be a model in the Middle East. Syria is not the Congo, Libya, Yemen, Somalia or Afghanistan. The most precious resource that Syria has is its human capital. Syria has an extremely diverse and talented population. Syrians, including many of our members in SAMS, are known to be natural entrepreneurs, successful, adaptive, resilient and creative. They love their homeland and they are eager to rebuild it. They aspire to what we aspire to, love our freedom and identify with our values. Syria has an educated middle class, large young population, educated women and diversified economy. Its location is very strategic as the connection between Europe and the Middle East. It has great geopolitical importance to us, as it strides close to many of our allies. I believe that at the end of the crisis, we will have a model in the Middle East that other countries can follow.

    But in order to get to this point, the current humanitarian disaster, what many are calling a genocide, has to end. Syrians and the rest of the world are looking at the US to play a more proactive role in ending the crisis. Most Syrian Americans are disappointed at our current policies and expect more proactive steps to protect the civilian population and stop destruction and mayhem. Syrian doctors are expecting the US to protect them and protect their hospitals, not only to send them first aid and medical supplies.

Increasing humanitarian assistance is critical, but it is an inadequate, unsustainable and superficial response, a bandage that will not heal the wound beneath. It will not stem the flow of millions of new refugees outside of Syria or prevent another 93,000 from dying. We urge you most of all to focus your efforts on finding a solution to the crisis.


Dr Zaher Sahloul


Syrian American Medical Society, SAMS