Category: Humanitarianism

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Humanitarianism Papers, Docs, and Essays

Providing Mental Health Services in Humanitarian Aid to Syria

Syria has been engaged in a devastating civil war, between multiple groups including the government regime, civilian militias, and terrorist groups for almost a decade (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). This has been devastating to the population of Syria, destroying infrastructure, historical places, schools, hospitals, and demolishing whole communities. Prior to the war, Syria’s health system was already lacking, despite improvements to life expectancy and overall health (Hendrickx, Woodward, Fuhr, et al., 2019). Mental health services were extremely limited. Only 2% of the health budget was allocated for mental health, primarily for in-patient hospital settings. Community mental health settings were exceedingly rare, as was the availability of counselors, psychiatrists, psychologists, social workers, and other mental health professionals. Additionally, the system faced problems due to “inequity, poor transparency, lack of standardized quality care, inadequate numbers of health staff, and uneven distribution of services in the regions due to an uncontrolled expansion of private services” (Hendrickx, Woodward, Fuhr, et al., 2019, p.1) for general healthcare. The government military has deliberately attacked health clinics and hospitals, including psychiatric hospitals, creating an even larger disparity in access to mental health services (Hendrickx, Woodward, Fuhr, et al., 2019). This means the majority of MHPSS services are delivered within Syria by humanitarian organizations, both national and international.

Since the onset of the Syrian Civil War in 2011, more than half of all Syrians have been forcibly displaced, split nearly evenly between internally displaced persons and international refugees (Hendrickx, Woodward, Fuhr, et al., 2019). There are also many non-displaced persons within Syria who are in need of humanitarian assistance and mental health and psychosocial support (MHPSS). It is common for Syrians to be displaced multiple times as the conflicts zones continue to shift, and more than half of those displaced are children (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Known risk factors contributing to mental illness have been experienced by Syrians as a result of the conflict, such as “exposure to traumatic events, forced displacement and ongoing stressors such as unemployment, impoverishment, social dislocation and loss of social support” (Hendrickx, Woodward, Fuhr, et al., 2019, p. 1). Human rights violations towards civilians are rampant within Syria, “including massacres, murder, execution without due process, torture, hostage-taking, enforced disappearance, rape and sexual violence, as well as recruiting and using children in hostile situations” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 12). The Universal Declaration of Human Rights and International Human Rights Law (Weissbrodt & De La Vega, 2007) have been completely disregarded within Syria since the outbreak of the conflict.

One aspect that is particularly challenging for humanitarian organizations is the disregard for their protection – and even specified targeting – by actors in the conflict (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). About 4.8 million people live in remote or difficult to access areas, and another 440,000 are trapped in active conflict zones at any one time, further complicating the ability of humanitarian organizations to deliver aid, supplies, or services.

A systemic review of the literature on the burden and access to mental health services in Syria and neighboring countries (Hendrickx, Woodward, Fuhr, et al., 2019) found large variations in rates of mental illness, such as between 16 to 80% for post traumatic stress disorder, 11 to 49% for depression, and 49 to 55% for anxiety. The most common risk factors for mental illness were being exposed to traumatic events and a history or family history of mental illness. The largest obstacles commonly reported to receiving mental health care were financial and socio-cultural. Gaps in the research were pronounced in the interventions used and the burden of mental illness primarily for those living within Syria.  Access to care and barriers were also in need of further research, as well as evaluation of psychosocial programs and interventions. Furthermore, a common problem found amongst the studies reviewed was that MHPSS interventions had not been validated with the Syrian population and had not been adapted to cultural symptoms or expressions of distress. Barriers to services were found to be “cost, language, cultural understanding, limited availability and quality of services, poor quality of services, low knowledge of mental disorder symptoms, lack of awareness of MHPSS services, and stigma and discrimination” (Hendrickx, Woodward, Fuhr, et al., 2019, p.9).

The 2018 Semi-Annual report from the Syrian Arab Red Crescent Society (SARC) shows little detail on the provisions or specifications of psychosocial support or mental health services. However, they do mention that a significant number of trainings were given on the topic of psychosocial support, numbering 15, tied for the third most numerous training category with disaster management, following first aid and community health trainings. The document also reports that psychosocial support was an included service within the thirteen community centers established in conjunction with the UNHCR in the humanitarian support project. It notes there were 22,803 beneficiaries of these psychosocial services, which also included services for children with special needs, direct support, and awareness sessions and recreational activities. In addition, SARC serves 334 shelters across Syria, which provide services to 12,000 families, and include psychosocial support activities.

The International Medical Corps is also providing psychosocial services in Syria as part of their humanitarian aid in the region. They are working on multiple projects and call for additional support in several areas. First, they seek to scale up sustainable and comprehensive MHPSS services within Syria and surrounding countries who have Syrian refugee populations. They also are training doctors and nurses in mental health and improving the training of mental health professionals within Syria to address the needs currently but also in the future. Additionally, they are “[i]nvolving affected Syrians in community outreach and in learning basic psychosocial support skills, which can strengthen community support and help establish links to formal mental health care services” (International Medical Corps, 2015). They also apply the IASC guidelines to coordinate MHPSS groups, which communicate and collaborate programs and services, advocate to donors, share resources and tools, and map current humanitarian MHPSS efforts (Hijazi & Weissbecker, 2017).

Much of the lack of support for psychological services in Syria is likely to be related to the stigma around mental illness found in many Middle Eastern societies.  While there is very little research on mental health in Syria prior to the war, we can draw assumptions from what we know of the responses of refugees towards mental health and in cultural assumptions from surrounding countries with similar cultural makeups. Syrians consist of a diversity of backgrounds and identities and are considered Arabs – though “this is a term based on the spoken language, not ethnicity” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p.10). There has been an increasing emphasis placed on tribal affiliation since the beginning of the war, which helps establish identity, community, and a structure of leadership within groups in a fragmented country. Multiple ethnic groups have been marginalized and oppressed, the largest of these being the Kurdish, which has seen a resurgence and reclaiming of cultural identity in recent years. Prior to the conflict, there were also significant amounts of refugees residing within Syria, mostly from Iraq and Palestine.

For mental health professionals working with Syrians, there should be caution when diagnosing mental illnesses, as high rates of daily stressors may cause them to show increased symptoms for a period of time, although this is not necessarily indicative of a mental disorder (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Similar to other populations affected by war-related trauma, Syrian refugees have most commonly shown to have emotional category disorders, such as post traumatic stress, anxiety disorders, depression, and prolonged grief. Interventions which focus on non-clinical aspects such as safety, living conditions, identity, community, social roles, and building hope may have significant results in addressing mental health concerns as well (Hassan, Kirmayer, Mekki-Berrada, et al., 2015).

Syrians traditionally have used their family and friends for high levels of support and for coping with difficult situations (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). As many of these social circles have been drastically disrupted from the war, helping Syrians establish a sense of community support would be highly important. Other coping mechanisms for Syrian individuals have been reported to including praying, listening to music, watching TV, drawing, withdrawal, and smoking. Negative coping mechanisms should be watched for and sought to be decreased, while increasing positive coping mechanisms. Men may struggle to admit any “weakness” as is the cultural norm and may benefit from the use of collective activities. Women’s roles, routines, and social networks are also impacted, and they may need ways to engage in active coping and develop new routines and social networks. Many adolescents restrict themselves from sharing their emotional difficulties with their parents, because they do not want to cause them more stress or suffering in addition to the war.  Some parents report “increasingly resorting to maladaptive coping strategies, such as beating their children or being overprotective” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 17). As a result of losing caregivers or family members, family structure and the roles for individuals and between genders may have changed and cause tension within the family, and conflict with traditional norms and gender roles. Sexual violence can be exceptionally troubling to individuals, as it can result in further consequences such as being ostracized.

Domestic violence has increased since the conflict, with stress for men being the reported cause (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Use of evidence based treatment for men to reduce aggressions such as anger management and parenting classes can be used by counselors, although it should be noted these have not been adapted to the Syrian context. In providing services to victims of abuse, counselors should be mindful of the risks for stigmatization and further abuse which may occur at victims seeking counseling or being encouraged to leave their partners. Helping victims identify supportive and safe individuals in their social network can be helpful as part of treatment.

Another consideration is the increase in early marriage for girls as a result of the conflict (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). This is used as a coping mechanism which is seen as a way to provide protection and secure the future of girls at a time when many families are facing poverty, insecurity, uncertainty and the loss or absence of male family members. Early marriage can stall or end girls’ education, increase the risk of health problems and domestic violence, and cause feelings of stress and abandonment by parents for girls.

Counselors working with Syrian survivors of torture have reported that clients typically have multiple emotional and psychological symptoms, in addition to financial and legal issues (Hassan, Kirmayer, Mekki-Berrada, et al., 2015).  LGBTQI+ individuals in Syria face severe discrimination, and same-sex acts are illegal. Since the conflict, LGBTQI+ individuals are  especially vulnerable to being abused or exploited, in addition to high levels of stress and stigma. Elder Syrians are also at increased risk for psychological problems, especially those with health conditions or who have limited support networks; many have lost family members and friends due to death or displacement because of the conflict. Individuals with disabilities or chronic health conditions also show above-average levels of psychological distress. It is common for older adults and those with disabilities to be concerned about being a burden on their caretakers, feel powerless, and have fear about being separated from their families and losing access to health and social supports as a result of the conflict.

Children constitute more than 50% of displaced Syrians, and more than 75% of these are under age 12 (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). It is not uncommon for children to become separated from their families, witness acts of destruction and death, be at risk for sexual exploitation, human trafficking, physical abuse, recruited as child soldiers, and be unable to access basic services. Children have exhibited abnormally high levels of behavioral and emotional problems, with clinical levels of anxiety at around 50%. “Problems include: fears, difficulties sleeping, sadness, grieving and depression (including withdrawal from friends and family), aggression or temper tantrums (shouting, crying and throwing or breaking things), nervousness, hyperactivity and tension, speech problems or mutism, and somatic symptoms. Violent and war-related play, regression and behavioral problems are also reported among children” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 20). Most children have been forced to stop schooling as a result of the conflict. Roles for children may have also shifted, taking on adult responsibilities and concerns due to loss or injury to caregivers. Evidence from Syrian refugees shows that with positive support from families, communities, and service providers, over time emotional and behavioral problems are reduced. Interestingly, the International Medical Corps has shown high rates for children using mental health services within Syria (69%), likely due to the otherwise lack of outlets for socializing and activities (Hijazi & Weissbecker, 2017).

For international humanitarian mental health providers, it is important to understand the Syrian cultural contexts and models of illness and distress to provide improved communication and appropriate interventions with clients. It is recommended to avoid labeling and diagnostics when possible as this “can be especially alienating and stigmatizing for survivors of violence and injustince” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 22). Models of counseling should emphasize building rapport and a therapeutic alliance, and be open to exploring multiple avenues of support such as “both formal and informal medical systems, religious or community resources and strategies” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p.22).

Mental health is not discussed or understood broadly in Syrian culture, and any ideas of psychological states carry negative connotations (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Suffering is seen as just a part of life does not require psychological care unless it is debilitating. Usually, clients will report physical complaints rather than psychological ones. “Most Arabic and Syrian idioms of distress do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 22). The use of images or metaphors may be seen by international counselors as a lack of awareness, communication, or even as psychosis. However, by working with the client to understand the meaning of their expressions it can be determined what their psychological symptoms are within their cultural framework.

With the above cultural considerations of mental health in mind for Syrians, humanitarian organizations can plan interventions and aid to address both short- and long-term assistance in a multi-layered approach. The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007) identify how MHPSS services can be coordinated and integrated throughout multiple aspects of a humanitarian operation. This includes recruiting staff and volunteers who understand the local culture, so in implementing any MHPSS service, the above information should be utilized so that all members of the team understand how to properly work with and interpret meaning from Syrian clients. This is also useful in developing a train-the-trainer model for teaching Syrian lay counselors, and while they may innately understand the local culture, it will be important for their supervisors and teams of international origin to accurately relay and understand information.

Areas of concern which present significant difficulty within Syria include the protection and human rights standards (IASC, 2007). International humanitarian organizations attempting to provide services in Syria should prepare in advance for a strategy to how they can best protect clients from human rights abuses, which are rampant in Syria currently. There may be active opposition to their aid and protections by the Syrian government, and so humanitarian actors should be well versed in International Humanitarian Law and International Human Rights Law (International Committee of the Red Cross Factsheet, 2003) and what extend their funds and resources will allow them to actively protect clients. The rebuilding of an internal network of mental health support, targeting stigma, building awareness, and strengthening the infrastructure to improve the accessibility, quality, and availability of mental health services within Syria should constitute part of long-term goal planning for humanitarian organizations (Hijazi & Weissbecker, 2017).

References

Hassan, G, Kirmayer, LJ, Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A.,Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, context and the mental health and psychosocial wellbeing of Syrians:

A review for mental health and psychosocial support staff working with Syrians affected by armed conflict. Geneva: UNHCR.

Hendrickx, M., Woodward, A., Fuhr, D.C., Sondorp, E., & Roberts, B. (2019). The burden of mental disorders and access to mental health and psychosocial support services in Syria and among Syrian refugees in neighboring countries: a systematic review. Journal of Public Health (Oxford, England). Advance online publication. https://doi.org/10.1093/pubmed/fdz097

Hijazi, Z, and Weissbecker, I. (2017). Syria crisis: Addressing regional mental health needs and gaps in the context of the Syria crisis.  International Medical Corps. Retrieved from https://internationalmedicalcorps.org/wp-content/uploads/2017/07/Syria-Crisis-Addressing-Mental-Health.pdf

Inter-Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. Retrieved from http://www.humanitarianinfo.org/iasc/content/products

International Committee of the Red Cross. (2003). Factsheet: International humanitarian law and international human rights law: Similarities and differences. 

International Medical Corps. (March 16, 2015). Ongoing war creates invisible mental health crisis for Syrian people. Retrieved from https://internationalmedicalcorps.org/press-release/ongoing-war-creates-invisible-mental-health-crisis-for-syrian-people/

Syrian Arab Red Crescent Society (SARC). (2018). Semi Annual Report 2018. Retrieved from http://sarc.sy/semi-annual-2018-report/

Weissbrodt, D. & De La Vega, C. (2007). Overview and history of international human rights. In         International Human Rights Law: An Introduction (p.14-26). Philadelphia, PA:        University of Pennsylvania Press.

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Humanitarianism Papers, Docs, and Essays

Politicization and the loss of neutrality in humanitarian aid

While neutrality and impartiality are ideals of humanitarian aid work, the reality is that in the modern era, these are increasingly difficult to maintain and uphold.

Jones (1998) discusses the relationship between psychiatrists and psychologists with their clients.  She argues that it is not of benefit to the client to remain truly neutral and detached. She uses examples such as in Nazi Germany, where psychiatrists were able to alter their frame of reference to see themselves as treating the nation, detached from the individual patient.  In this way, therapeutic treatment could condone mass extermination as part of the benefit of treating what was viewed to be the maladies of the national health and identity. She goes on to discuss how the Hippocratic Oath, and statements by the American Medical Association and the American Psychiatric Association declare that a physician or psychiatrist should have a responsibility to protect patients from harm and injustice, and advocate for clients through public action. By necessity, then, they cannot remain unattached or avoid politics. In fact, our worldview, culture, ethical codes, training, diagnosis, and treatment are bound by systems of values, which may have consequences. Bias is inevitable, and while to a degree a treating provider may suspend their own values in relation to a client, it is better to disclose and discuss with them such factors. Additionally, there should be a stronger emphasis on dealing with the cultural systems, community and environmental factors rather than on the “deficiencies” of the individual. She also imports the need of cultural context and understanding in how we diagnose and treat clients. When the larger factors are left out, it is not treating the cause of the problem or illness but rather just symptoms of it. Neutrality is an absence of responsibility, a way for the provider to keep their hands clean and removed from ethical dilemmas.

 In my work as a counselor, I can certainly understand why providers might hesitate to deeply advocate for social change for the benefit of their clients. While I think it is an honorable and critically important endeavor, it requires complex considerations of ethical dilemmas, active work for policy changes, and addressing large systemic cultural systems and values which may seem too large to tackle.  When a provider has a full caseload, this task is nearly impossible to devote the time, energy, and resources towards. With a less than full caseload, a provider may not have the income to sustain such activities on their own free time. This creates another dilemma of another societal problem within itself where the financial pay for counselors (although not so for psychiatrists) is too low to accommodate such efforts on a large scale, and/or the work/life balance is off-kilter within our society, and does not support counselors utilizing part of their time to such activities. Additionally, if one is working for an agency, the agency often frowns upon any political activity or social protests or advocacy work which is not specifically sanctioned and approved for their own benefit, and as such, the counselor could be at risk of termination.

Fiona Terry, in her TED talk (2011) discusses how humanitarian action faces multiple scenarios which present “damned if we do, damned if we don’t” situations. For example, it is not uncommon for humanitarian aid supplies to fall inadvertently into the hands of terrorists. However, the war on terror has made it illegal to support terrorist organizations regardless of intentionality.  This may cause some aid organizations to limit where they deliver aid in fear of retribution for inadvertent support to terrorist groups. There is also a paradox in maintaining neutral, and treating soldiers from any side of a conflict, who then may return to the fight, thus prolonging the conflict. The standard moral stance of humanitarian organizations has been that it is better to treat and give aid, than to not, regardless of the outcome. Neutrality is meant to be a tool to provide aid to those who need it most and not be a moral judgement.  However, many organizations are now focused on providing aid as dictated by their donors, which typically falls within certain parameters and furthers the agendas of Western political goals.

Nascimento (2015) goes deeper into these paradoxes, framing it within the history of humanitarianism which originally intended to hold to the ideals of neutrality and impartiality, but due to increasingly complex geopolitical situations and conflicts, this has shifted into what is termed ‘new humanitarianism.’ On the surface, ‘new humanitarianism’ sounds to be an ultimately better strategy, focusing on “much broader and longer-term objectives, such as development or peace” (Nascimento, 2015, p. 1). However, this is complicated for humanitarian organizations working on the ground as it means an intertwining with politics and militarization. One of these problems arises from the imposition of standards which are deemed culturally “good” by the donors to the organizations and their respective governments. This places cultural and political values onto countries who may not subscribe to such notions, and requires that they make certain changes and subscribe to certain conditions in order to receive humanitarian assistance.  This can be seen as a political maneuver at the hands of the countries backing the aid, and create further animosity or backfire completely, causing the loss of aid to critically vulnerable populations who desperately need it. “New humanitarianism’ also started being questioned and challenged in its assumptions by academics and practitioners due to the fact that decisions that had humanitarian implications were increasingly being taken on the basis of political criteria and interests instead of on the victims’ needs” (Nascimento, 2015, p. 4). This also has implications on the fundamental properties of human rights, and the underlying missions of most humanitarian organizations to address these at the most basic level. Morris (1998) agrees with very similar points in his article.

With complex crises, complex and systemic responses from the international community are required to address multiple socio-political, socio-economic, environmental, and cultural factors which are, in the Western view, contributing to the emergency situation (Nascimento, 2015). However, this requires the use of multiple organizations and groups targeting different aspects of the situation, which often do not align with their goals and priorities, and may not communicate and plan effectively as a broad multi-organizational team. These failings have led to a breakdown of humanitarian aid in multiple countries. Worse than a failed humanitarian intervention, critics have proposed that “these actions emphasized the ineffectiveness and lack of professionalism characteristic of classical humanitarian organizations that fed and perpetuated conflicts and crises through their misuse of aid and poor resource distribution” (Nascimento, 2015, p. 3). There has also been an increase in the use of military deployment to provide aid themselves, or to protect and stabilize conditions for humanitarian workers, or while intervening through military force while humanitarian groups simultaneously provide aid, causing confusion in the local population in seeing humanitarianism and the use of acts of war as part of the same coin. “What has been experienced and promoted by this ‘new humanitarianism’, is essentially a misconception of the need for humanitarian aid by an international system that simultaneously denies its own roles in sustaining or addressing complex emergencies and threatens further the capacity of victims of conflict-related disasters to have access to humanitarian assistance and to the enjoyment of their human rights” (Nascimento, 2015, p. 9). Increased coordination between multiple organizations and actors, the removal of politics from conditions for humanitarian aid, and both short-term immediate assistance for basic needs and also long-term strategies to restore peace which utilize and collaborate with, rather than impose, cultural values of the country in conflict or crises, will be important considerations moving forward to provide much needed humanitarian aid.

References

Jones, L. (1998). The question of political neutrality when doing psychosocial work with survivors of political violence. International Review of Psychiatry, 10(3), 239-247.

Morris, N. (1998). Humanitarian aid and neutrality. Conference on the promotion and protections of human rights in acute crisis. London. Retrieved from https://www1.essex.ac.uk/rightsinacutecrisis/report/morris.htm#4

Nasciemnto, D. (2015). One step forward, two steps back? Humanitarian Challenges and Dilemmas in Crisis Settings. The Journal of Humanitarian Assistance. Retrieved from https://sites.tufts.edu/jha/archives/2126

TEDx Talks [username]. (2011). TEDxRC2 – Fiona Terry – The Paradox of Humanitarian Aid . YouTube. Retrieved from https://www.youtube.com/watch?v=J45cWdDEbm0&noredirect=1

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Humanitarianism Papers, Docs, and Essays

Evaluation of the Red Cross’ adherence to Core Humanitarian Standard and Humanitarian Accountability Principles

The Red Cross and Red Crescent organizations work to provide services in a variety of humanitarian situations. One area that they provide assistance is to refugees and migrants (Red Cross, 2020). They state that they provide assistance in multiple capacities, across all stages of a migrant’s journey (pre-migration, transitory, and post-migration). They provide services worldwide, including first aid, medical services, shelter, food, water, hygiene supplies, baby supplies, clothing, and “comfort” (Red Cross, 2020). It is not elaborated on what is meant by comfort. From my volunteer work with the Red Cross, I know that they provide disaster mental health services, and spiritual health services. Another important task is that of working to reconnect families who have been separated as a result of a crisis. $2.6 million has been committed to providing support in Syria and surrounding countries, and an additional $1.2 million towards refugee aid in Europe as a result of the Syrian refugee crisis. They maintain a network of information and resources across all branches to maintain coordinated efforts and consistency in their work, while utilizing local branches firsthand knowledge of situations in their areas.

The Red Cross and Red Crescent state that they apply 7 core principles to their work. These are: humanity, impartiality, neutrality, independence, voluntary service, unity and universality (Red Cross, 2020). They take care to meet many of the standards through these values of the Core Humanitarian Standard (2017). For example, the branch network can use local Red Cross chapters in providing “assistance appropriate and relevant to their needs” (Core Humanitarian Standard, 2017, p. 10), and in a timely fashion.

One area that the Red Cross and Red Crescent seems to be lacking in is the feedback from the community. I do not see any details about how “communities and people affected by crisis have access to safe and responsive mechanisms to handle complaints” (Core Humanitarian Standard, 2017, p. 14) nor that they “can expect delivery of improved assistance as organisations learn from experience and reflection” (p.16). Additionally, they do not provide any clear information on most of the Humanitarian Accountability Partnership principles (2016). Many of these principles have to do with having feedback from beneficiaries and having a “framework of accountability to their stakeholders” (HAP-I, 2016), and “meaningfully involve beneficiaries in project planning, implementation, evaluation and reporting.” There may be processes that the Red Cross and Red Crescent use to do this, but they do not make it clear on their website, and in working with them, I have never actually seen such feedback being implemented.

My recommendations for an action plan for the Red Cross and Red Crescent would be to make it a high priority to include feedback loops with the people and communities they serve. Katharina Samara Wickrama discusses this problem at large in her TED talk (2012). She notes that there is a systemic failure to be accountable to the people that humanitarian organizations claim to serve. It is important to implement consultation and informed consent, give an opportunity to provide ongoing feedback from clients, and an opportunity to be part of process that decides if that project was a success. These strategies can save money, but also equitably distributes resources based on true needs, and improves sense of ownership by beneficiaries over the services, giving them back power, control, and dignity in their lives. It also makes sure the organization is always improving and tailoring its services for the best interests of the people they are serving, and not assuming that they should impose their own values and services of what they think is needed. The Red Cross should outline a commitment to this on their website and in their trainings with volunteers and staff, and have a clear process for beneficiaries to file complaints and feedback, with a commitment to taking action on these.

References

Core Humanitarian Standard. (2017). CHS Alliance, Groupe URD and the Sphere Project.

HAP-I. (2016). Humanitarian Accountability Partnership – International.

Red Cross. (2020). “Mission and Values” and “Migration and Refugee Crisis”. Retrieved from https://www.redcross.org/about-us/our-work/international-services/migration-and-refugee-crisis.html

TEDx Talks [username]. (2012). TEDxGenevaChange – Katharina Samara Wichrama – Accountable aid. YouTube. Retrieved from https://youtu.be/ep7RWMI0YbE

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Humanitarianism Presentations and Videos

Culturally Sensitive Mental Health in International Humanitarian Crises

A presentation designed to be a potential workshop for mental health professionals who already have significant training in their field, and some awareness of working in humanitarian contexts. Maybe they have worked as a volunteer in the U.S. and are looking at volunteering abroad. This is an outline to considerations of working with both clients and staff in diverse communities in culturally sensitive ways.

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Humanitarianism

Aspects of international humanitarian law, refugee law, & human rights law relevant to mental health delivery in diverse settings

The Sphere project is a manual assembled and updated by multiple international groups and humanitarian aid organizations, with “concrete measurable benchmarks” (The Sphere Project, 2011) to outline quality, accountability, and values for humanitarian agencies, developed after mistakes from humanitarian groups during the Rwandan genocide. The Sphere has been updated to include four primary essential rights for all, and to guide the actions of humanitarians.  These are:

  1. Enhance the safety, dignity and rights of people, and avoid exposing them to harm.
  2. Ensure people’s access to assistance according to need and without discrimination.
  3. Assist people to recover from the physical and psychological effects of threatened or actual violence, coercion or deliberate deprivation.
  4. Help people claim their rights (Sphere Handbook, 2018, p.33)

In a TEDGlobal talk with António Guterres (2015), the impacts on Syrian refugees and on the communities they are fleeing to are discussed through the lens of how global policies affect human rights and suffering. The needs of Syrian refugees are exacerbated when surrounding countries taking them in, like Lebanon and Jordan, do not have the resources and also do not qualify for additional funding from sources such as the World Bank, as they are middle-income countries. These countries are then unable to provide enough support for the refugees.

As a global community, we should be supporting these countries as the front lines of defense and in supporting our collective international humanitarian commitment to refugees. Additionally, we should not be limiting how many refugees we can take in each country, as it is our duty to adjust our own society to meet the need.  Fear over security causes leaders to make harmful statements, such as Trump stating he would not allow any Muslim refugees in the US. However, statements like these actually provide fodder and support for terrorists, particularly Muslims who already reside in the US who are then ostracized and see themselves as needing to assert themselves and fight back against such statements, and so join terrorist groups. Refugees endure severe suffering, or else they would not be refugees in the first place – but then continue to be exposed to the worst conditions, unable to work, dependent on social support but often ineligible for it, health conditions and lack of medical care, and tensions with locals. 

              In the Nobel Prize acceptance speech by Medicins Sans Frontiers (MSF), also known as Doctors without Borders (Orbinski, 2000), they state “[h]umanitarian action is more than simple generosity, simple charity. It aims to build spaces of normalcy in the midst of what is profoundly abnormal. More than offering material assistance, we aim to enable individuals to regain their rights and dignity as human beings…Our action and our voice is an act of indignation, a refusal to accept an active or passive assault on the other.”

They also state “[h]umanitarianism occurs where the political has failed or is in crisis. We act not to assume political responsibility, but firstly to relieve the inhuman suffering of that failure. The act must be free of political influence, and the political must recognize its responsibility to ensure that the humanitarian can exist” (Orbinski, 2000). The responsibility for addressing the suffering of humans lies, ultimately, with political systems and countries. The needs for humanitarian organizations exist because these systems either fail to provide adequate interventions and support or are the instigators of human suffering in the first place. “Humanitarianism is not a tool to end war or to create peace. It is a citizens’ response to political failure. It is an immediate, short term act that cannot erase the long-term necessity of political responsibility” (Orbinski, 2000)

Additionally, ”[h]umanitarian action requires a framework in which to act. In conflict, this framework is international humanitarian law. It establishes rights for victims and humanitarian organizations. It fixes the responsibility of states to ensure respect of these rights, and to sanction their violations as war crimes. Today this framework is clearly dysfunctional. Access to victims of conflict is often refused. Humanitarian assistance is even used as a tool of war by belligerents. And more seriously, we are seeing the militarization of humanitarian action by the international community” (Orbinski, 2000).

The speech (Orbinski, 2000) also addresses how language shapes our view. Aside from natural disasters, humanitarian aid is not existing without the responsibility of another for a crime – and usually a crime on a massive scale, which causes significant human suffering. We tend to downplay the roles and responsibilities that actors have when we discuss the situation as a humanitarian emergency, removing it from it’s context.  At the same time, those providing humanitarian aid should refrain from politicizing or allow their preference of who to help rely on which side of a conflict one is on. The speech by MSF acknowledges that their humanitarian work exists within societal, cultural and political contexts, while at the same time working to clarify its purpose and goals outside of such, in terms of human rights and other essential rights, such as environmental ones, and to resist the urge to polarize peoples, systems, and governments as good or bad. As part of maintaining this, MSF remains an independent organization, and resists funding or oversight by any militarized group, which it views as being impossible to remain impartial.

I personally see the standards of MSF (Orbinski, 2000) as being important and applicable to using mental health care in humanitarian aid across diverse settings and peoples. Acknowledging that biases exist, and to choose to work on them in our own personal spaces with peers, mentors, and our own therapists, while aiming to approach each individual that we work with as a human being with an inherent right to dignity, worth, value, and deserving of empathy and care, regardless of their behaviors or actions. This aligns with the principles of Sphere (2018), and can be guides for how to approach care with refugees.

References

Orbinski, J. (2000). There is no such thing as military humanitarianism. Peace Magazine; Winter 2000. Retrieved from http://www.peacemagazine.org/archive/v16n1p08.htm

TEDGlobal (2015). António Guterres: Refugees have the right to be protected. Retrieved from https://www.ted.com/talks/antonio_guterres_refugees_have_the_right_to_be_protected

The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response. (2018). Retrieved from https://www.developmentbookshelf.com/doi/book/10.3362/9781908176707. DOI: 10.3362/9781908176707

The Sphere Project (2011). Introducing the Sphere Handbook 2011 . Retrieved from http://www.youtube.com/watch?v=zpXxVg-Cv8A&feature=related.

Categories
Humanitarianism

STRENGTHS PM+ for Syrian Refugees

A FAQ and introduction to a culturally-sensitive mental health program to address problems of daily living, stress, anxiety, depression and PTSD by trained peer mentors.

Categories
Humanitarianism

The Syrian White Helmets

The Syrian Civil Defense, more widely known as the Syrian White Helmets, are an organization of volunteers within Syria and in parts of Turkey. The group is made of up of “[f]ormer bakers, tailors, engineers, pharmacists, painters, carpenters, students and many more professions besides” (White Helmets, n.d., par.5). They primarily operate in opposition-held areas of Syria It was formed in 2014, but began with grassroots movements of volunteer rescue teams in 2012 (Aikins, 2014) with the escalation of the Syrian Civil War after a failed ceasefire which had been implemented by the UN (BBC, 2012). It was the beginnings of The White Helmets which drew the world’s hearts towards the conflict in Syria – the image of Omran, the five year old covered in blood and dust sitting alone in the ambulance; the video of an infant being desperately pulled from the rubble of a bombed building (Malsin, n.d.).

The group’s humanitarian framework comes from international humanitarian law from the Geneva Convention, and guided by philosophy from the Quran (The White Helmets, n.d.). Their motto, from the Quran, is “to save a life is to save all of humanity” (The White Helmets, n.d., par. 7), and they ascribe to the international humanitarian laws principles of Humanity, Solidarity, and Impartiality. They have been nominated three times for the Nobel Peace Prize and have had a Netflix documentary made about them. Their organizational structure is run by a democratically elected council and led by Raed al Saleh.

They have nearly 3000 volunteers and have rescued more than 115,000 individuals from the rubble after air raid attacks (Syria Civil Defense, n.d.). They have 221 female volunteers and openly state that they seek to include women in their work alongside male volunteers, and also in services specific to women such as maternal health clinics (The White Helmets, n.d.), as is culturally acceptable. 252 volunteers have been killed, and more than 500 injured (The White Helmets, n.d.). More than half of those killed have been in “double tap” attacks, where there is an initial attack, then a second attack after rescuers arrive to help, to specifically target them. Additionally, in 2018, about 100 White Helmet volunteers along with their families were emergency evacuated by a rescue group from Israel after becoming trapped by the Syrian military (BBC, 2018).  800 volunteers and their families had been planned for, but nearly half did not make it for the one-time rescue operation.

One of the founders of the organization, from Britain, James Le Mesurier, had created another nonprofit, called Mayday Rescue, in order to fundraise, provide equipment, and train the White Helmets in urban search and rescue (Yee, 2019).  He was found dead in Turkey in 2019 under suspicious circumstances following multiple disinformation campaigns against him by the Russian Foreign Ministry, claiming that both he and the White Helmets were actually a terrorist organization linked with al-Qaeda (Yee, 2019). Others, likely fueled by this propaganda, speculate that the White Helmets are propaganda themselves for the interests of the US and NATO (Kakade, 2016). However, the claims that the White Helmets are linked with terrorist organizations and have staged mass casualty events have been thoroughly discredited as a clear ploy by the Russian and Syrian governments (Palma, 2016, Solon, 2017).

The primary goals of the group exist within the physical and cultural space of Syria, comprised of Syrians. Their ultimate aim is to provide emergency humanitarian relief in the Syrian Civil War to anyone who is suffering, and they are known for their dangerous attempts at saving lives at any cost (James, 2014). Their actions are to act as first responders following airstrikes in Syria, providing “emergency evacuation, urban search and rescue, firefighting, community engagement, and medical response” (Asif & Asif, 2018, p. 27). Additionally, they have developed an emergency plan to prevent the spreading of COVID-19 in Syria and go door-to-door to raise awareness, while also disinfecting public areas including camps and buildings, coordinating with medical professionals in setting up quarantine facilities, and training specialized teams on how to safely evacuate COVID-infected individuals to hospitals (The White Helmets, n.d.).

An important cultural consideration of humanitarian work is the effect that outside international aid has towards the local community. The White Helmets have been much more successful than Doctors Without Borders AKA MSF, most likely due to this discrepancy of trust (Asif & Asif, 2018). An outsider can create a feeling of shame, as if one is being pitied by the international community and is hopeless to help themselves, while a culturally native individual represents strength, solidarity, trust, and resiliency. “Thus, the clinical encounter between the native population and the foreign doctor becomes a microcosm of colonial rule, one that is characterized by confrontation and distrust” (Asif & Asif, 2018, p.27). The White Helmets are also committed to the long-term rebuilding of Syria as they are Syrians themselves, and want to ensure the peace, safety, and welfare of Syrian communities in infrastructure, and social, physical, and emotional health. It is because of these culturally-relevant investments and actions that it has been recommended to increase trauma-informed psychological care training for the volunteers, as they are in a unique position to deliver such services in the immediate and long term within Syria (Lester, 2018).

While the group was founded by international backers, its approximately 3000 volunteer members are Syrians themselves (Daley, 2016). As such, they have not ever been involved in another conflict, so can only be judged on their capacity within the one context they are serving. Additionally, they appear to be culturally sensitive in that they operate within the Syrian context.  However, this does not always mean that all Syrian cultures are equally respected, although the group strives for impartiality. There have been some criticisms of their ability to do so, stating that they are opposed to the government regime, and actually are encouraging the Syrian Civil War to continue through taking sides in the conflict and continuing to accept funding from Western backers (Moore, 2019). However, evidence and support of this opinion is scarce. That being said, it is understandable that the group would be largely opposed to the governmental regime, who has been criticized heavily for their attacks on their own civilians and human rights abuses (Amnesty International, n.d.). Despite this, The White Helmets claim that they have saved lives on all sides of the conflict, including government soldiers (The White Helmets, n.d.).

Below is the information directly from the Syria Civil Defense web page on “What We Do” (n.d.)

We are a humanitarian organisation dedicated to helping communities to prepare for, respond to and rebuild after attacks in our beloved Syria.

We are best known for our search and rescue services following bombings but we provide a range of services inline with the internationally recognised activities of civil defense.

We work according to the guidelines for civil defence organisations across the world, as well as in accordance with International Humanitarian Law. As defined in Protocol I (Article 61) of the Geneva Conventions of 1949, we pledge to provide the services listed at paragraph 5:

  1. Warning the civilian population of attacks and dangers
  2. Urban Search and Rescue
  3. Evacuation of the civilian population from areas into which fighting is encroaching
  4. The provision of medical services – including first aid – at the point of injury
  5. Fire-fighting
  6. Management of emergency shelters
  7. Detection and marking of danger areas (such as areas with unexploded ordnance)
  8. Provision of emergency accommodation and supplies
  9. Emergency repair of indispensable public utilities
  10. Decontamination and similar protective measures
  11. Assistance in the preservation of objects essential for survival
  12. Emergency assistance in the restoration and maintenance of order in distressed areas
  13. Emergency disposal of the dead
  14. Management of blackout measures
  15. Complementary activities needed to carry out any of the tasks mentioned above.

As outlined in the Protocol I (Article 61) of the Geneva Conventions of 1949 we provide these services for the following purposes:

  • To protect the civilian population against the dangers arising from hostilities or other disasters
  • To speed recovery from the immediate effects of such events To provide the conditions necessary for survival of the civilian population.

While civil defence organizations are protected under the international humanitarian law applicable to all civilians and civilian objects in general, the Additional Protocol I to the Geneva Conventions, adopted in 1977, makes protection specific for civil defence.

Additionally, the White Helmets web page (n.d.) makes it clear that the organization is committed to helping rebuild physically and mentally in rebuilding communities following the end of the Civil War. One point that I found somewhat confusing is the utilization of two different web pages for the organization. It appears the White Helmets web page (n.d.) is aimed more towards generating support and fundraising, while the Syria Civil Defense website (n.d.) has more information about the organization itself and press releases.

Remember Omran, that bloodied and dusty five-year-old in the ambulance whose image wrecked our hearts all over the world? In 2017, the Syrian government media released new photos and videos of him, along with statements by the boy’s father that the family was pro-regime and that the child had been used by the rebel forces as fake propaganda (Specia & Samaan, 2017). This is just another example of how the truth around the White Helmets, and the war in Syria as a whole, is constantly being twisted and changed, making it difficult to know the truth (Haddad, 2016). Social media exacerbates this, with clearly differing messages posted to different sites, aimed at different followers, and between Arabic and English (Lynch, Freelon, & Aday, 2014). This is a common modern tactic in civil wars and human-causes acts of humanitarian crises, the post-truth age (Harsin, 2018).

Overall, it appears the White Helmets are a legitimate organization working diligently within a high-risk area to serve the Syrian community.  They provide an invaluable service that international organizations have struggled to do. Despite the conflict being ongoing, the organization has been successful in its mission, and seems to have the ability to continue doing so, despite the direct attacks on their lives and through the media to discredit them and attempt to eliminate their funding. That being said, Asif and Asif (2018) recommend that the White Helmets increase their indigenous independence by eliminating Western funding. While I understand this position, I think that there is always a struggle for organizations to have enough funding, so to get it from any source possible may be necessary in order to complete their mission.

I find the Syrian White Helmets to be incredibly inspiring personally and would like to see other models for indigenous humanitarian organizations given research and support around the world. I would like to see the larger international aid organizations focus their resources and funding towards supporting local, grassroots movements such as the White Helmets.  I think this is done in some capacity already, but I think there is much room for improvement.

References

Aikins, M. (2014). Whoever saves a life. Medium. Retrieved from https://medium.com/matter/whoever-saves-a-life-1aaea20b782#.kelvvhn3f

Al Asaad, S. (2018). The White Helmet myth: A soft war propaganda. Op-Ed. MEHR News Agency. Retrieved from https://en.mehrnews.com/news/132739/The-White-Helmet-myth-A-soft-war-propaganda

Amnesty International. (n.d.). Syria. Retrieved from https://www.amnestyusa.org/countries/syria/

Asif, S.M. & Asif, S. (2018). Doctors with borders: The White Helmets and radical political medicine. In: Weber AS, Verjee MA, editors. Proceedings of the 1st International Conference on Medical Humanities in the Middle East [Internet]; 2018 Nov 17-18: Doha, Qatar: Innovations in Global Health Professions Education; 2019 March. p. 27-29. https://dx.doi.org/10.20421/ighpe2019.01.09

Atlantic Council. (2017). Breaking Aleppo. Retrieved from http://www.publications.atlanticcouncil.org/breakingaleppo/

BBC. (June 12, 2012). Syria in civil war, says UN official Herve Ladsous. BBC News. Retrieved from https://www.bbc.com/news/world-middle-east-18417952

BBC. (July 22, 2018). Syria conflict: White Helmets evacuated by Israel. BBC News. Retrieved from https://www.bbc.com/news/world-middle-east-44915099

Daley, B. (October 7, 2016). Who are Syria’s White Helmets, and why are they so controversial?. The Conversation. Retrieved from https://theconversation.com/who-are-syrias-white-helmets-and-why-are-they-so-controversial-66580

Haddad, B. (2016). The debate over Syria has reached a dead end. The Nation. Retrieved from https://www.thenation.com/article/archive/the-debate-over-syria-has-reached-a-dead-end/

Harsin, J.  (2018). Post-Truth and Critical Communication Studies. Oxford Research Encyclopedia of Communication. Oxford University Press.

James, L. (2014). The most dangerous job in the world. New Internationalist. Retrieved from https://newint.org/features/web-exclusive/2014/10/10/syria-civil-defense-volunteers/

Kakade, S. (2016). White Helmets: Heroes or propaganda?. Ruggles Media. Retrieved from https://camd.northeastern.edu/rugglesmedia/2016/09/26/white-helmets-heroes-or-propaganda/

Lester, N. (2018) Introducing a Trauma-Informed Practice Framework to Provide Support in Conflict-Affected Countries. The RUSI Journal, 163(6), 28-41. DOI:10.1080/03071847.2018.1562016

Lynch, M., Freelon, D., and Aday, S. (2014). Syria’s socially mediated civil war. United States Institute of Peace. Retrieved from https://www.usip.org/publications/2014/01/syrias-socially-mediated-civil-war

Malsin, J. (n.d.). The White Helmets of Syria. Time. Retrieved from https://time.com/syria-white-helmets/

Moore, T. (2019). The White Helmets: Unneutral in the Syrian conflict. Kent State University Undergraduate Symposium on Research, Scholarship and Creative Activity. Retrieved from https://oaks.kent.edu/ugresearch/2019/white-helmets-unneutral-syrian-conflict

Palma, B. (December 15, 2016). Are the Syrian ‘White Helmets’ Rescue Organization Terrorists?. Snopes Fact Check. Retrieved from https://www.snopes.com/fact-check/syrian-rescue-organization-the-white-helmets-are-terrorists/

Solon, O. (December 18, 2017). How Syria’s White Helmets became victims of an online propaganda machine. The Guardian.  Retrieved from https://www.theguardian.com/world/2017/dec/18/syria-white-helmets-conspiracy-theories

South China Morning Post [username]. Syrian conflict: who are the White Helmets? . YouTube. Retrieved from https://www.youtube.com/watch?v=mnhkH6lYJxM&t=13s

Specia, M. and Samaan, M. (June 6, 2017). Syrian boy who became image of civil war reappears. The New York Times. Retrieved from https://www.nytimes.com/2017/06/06/world/middleeast/omran-daqneesh-syria-aleppo.html

Syria Civil Defense. (n.d.). ”Who we are” and “What we do.” Retrieved from https://www.syriacivildefence.org/en/

The Syria Campaign. (2017). Killing the truth: How Russia is fuelling a disinformation campaign to cover up war crimes in Syria. Retrieved from https://thesyriacampaign.org/wp-content/uploads/2017/12/KillingtheTruth.pdf

The White Helmets. (n.d.). Retrieved from https://www.whitehelmets.org/en/

Wright, R. (July 23, 2018). The White Helmets – Syria’s noble rescuers – have to be rescued by Israel. The New Yorker. Retrieved from https://www.newyorker.com/news/news-desk/the-white-helmets-syrias-noble-rescuers-have-to-be-rescued-by-israel

Yee, V. (November 11, 2019). James Le Mesurier, backer of Syrian White Helmets, is found dead in Turkey. The New York Times. Retrieved from https://www.nytimes.com/2019/11/11/world/middleeast/james-le-mesurier-white-helmets-dead.html