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Profile: Syrian refugee nurse

Alison Criado-Perez talks about the challenges of setting up a primary healthcare centre for refugees along the Turkey-Syria border

With no medical provisions available to unregistered Syrian refugees living along the Turkey-Syrian border in the Turkish town of Kilis, volunteer, Alison Criado-Perez and the rest of her Médecins Sans Frontières (MSF) team were in a race against time to set up health services.

Returning just last month from her mission at the Turkey-Syrian border, Alison talks to Nursing in Practice about her experiences of helping to set up a Primary Healthcare Outpatient's clinic and the emotional challenges of coming to terms with the suffering endured by the people of this country divided by war.

“When I arrived, there was absolutely no medical programme set up at all. There had been a mental health programme that had been running for a few months. I arrived at the beginning of January this year with a completely new team—there were five of us—and our remit was to try and set up primary care for Syrian refugees who might otherwise not have any access to healthcare,” Alison, who trained as a nurse in the 70s', said.

Despite a decree being passed in January this year that healthcare would be provided for any Syrian refugee, Alison said that that wasn't really the case, with Turkish authorities only providing care to registered Syrian refugees living in camps.

With refugee camps reaching full capacity, many refugees had no choice but to remain unregistered, living on their own resources or aid provided by Non-Governmental Agencies (NGOs). 

A recent report by the United Nations High Commission for Refugees (UNHCR) shows that since the uprising in Syria over two and a half years ago, the number of registered refugees has reached 750, 000. With the number of unregistered refugees thought to be around 1.3 million, an estimated two million refugees have fled the country. 

Postulating about the numbers of refugees in the camps in the area where she was based, Alison said that there were probably around 30,000-40,000 registered refugees in the camps, and about 20,000 unregistered refugees, with about 10,000 more at the transit camp on the Syrian side of the border of Kilis, waiting to cross over. Increasing exponentially at a rate of roughly 1000 a week, Alison said that there were about 30,000 unregistered refugees by the time she left, six months later in June. 

Remarking that the number of refugees had now surpassed over 1.6 million, mum-of-three Alison said, “That's one seventh of the population of the country have already left the country.”

Alison was the only medic on the team when they first arrived, and with no medical services in place at all, she and the doctor, who arrived a couple of weeks later, had to set up everything. This included preparing a medical order for all the drugs and materials that would be needed as well as thinking about the medical protocol for treating patients. They also had to identify a suitable building for a clinic, renovate it and make sure that it had all the necessary provisions required for different consulting rooms.

“We had to think of absolutely everything we'd need in a clinic and the budget for it,” Alison said.

Part of the preparations included the hiring of staff. With Turkish regulations stating that four specialists were required to open a clinic, a team of nine staff, who were all Syrian refugees living in the area, were employed. The staff included five nurses, an internal medical consultant, a gynaecologist, a general practitioner and a paediatrician.

Alison said that with rents increasing all the time due to more and more refugees arriving, the refugees most of whom had come to the border with nothing, were desperate for jobs to support their families. Many unregistered refugees lived in very poor conditions, with many families being crammed into one apartment or even garages and unfinished buildings.

“Many of them had their own stories to tell. Their houses were shelled, they fled to the border with family, with their children, just carrying suitcases full of stuff and leaving behind everything they'd got. Such a tragedy for them,” Alison said. After endless negotiations with Turkish health services and working 13-14 hours a day, the clinic was finally established after two months. Seeing up to 200 patients a day, Alison said that it was sometimes so busy that they couldn't move in the reception area. 

Towards the end of her mission, there was an influx of 4, 000 more unregistered refugees due to a double car bomb explosion in the town of Reyhanli in Turkey in a terrorist attack with the suspected involvement of the Syrian regime's intelligence agency and armed groups. 

With at least 51 people killed and 140 injured, the attack was the most serious act of terrorism to occur on Turkish soil. In the wake of the attack, Syrian refugees in the 

area no longer felt welcome, which led to their subsequent relocation to Kilis. 

Alison said that most of those treated at the clinic were children, who constituted 30% of the patients, as well as pregnant women requiring antenatal care and women needing post-delivery care. Fortunately, the local Turkish hospital had helped with the delivery of babies. Other common problems that patients were treated for included respiratory tract infections and diabetes, a growing problem in Syria with over 10% of the population affected.  

Alison said that the large number of patients requiring 

treatment for diabetes was also attributed to the fact that they had probably not been able to receive treatment with there being a shortage of drugs while the war was going on. 

There were also cases of malnutrition as well as diarrhoea towards the end of her mission among the surge of refugees who had just arrived from Rehanli, since the approach of summer meant that conditions in the park, where they were camping out, proved to be less than sanitary.  

The large proportion of women and children treated at the clinic is consistent with the profile of those given priority during evacuation procedures in times of war.

While on the physical level, it had been quite easy to settle in, Alison said that emotionally it was a very different matter. 

“Though I've been quite nonchalant about how it wasn't hard to settle in physically and we didn't have any bombings, but we felt the bombings across the border which were close enough and heavy enough that many times, our entire building would shake, and you'd hear the constant explosions. That was very hard to live with because you would be aware all the time of how many people were being damaged and how many were killed.”

Alison also talked about the stories that she heard from the psychologists in the MSF teams who also provided care for the refugees.

“When you heard the stories from psychologists of how people had been treated, and sometimes, you know, I'd lie on my bed and sob my heart out. It was so awful. So terrible the stories you'd hear of people suffering and the things that children had seen that no child should ever see…I saw some of the drawings that the children had made and one child drew a picture of a man being hung and pictures of guns pointing, and women lying flat on the floor--that was a woman being raped.”

Not being able to refer people to secondary care was also something that Alison found very challenging, with there being “no solution” for some people at times. “That was really hard. But that was something we were working on and will hopefully resolve itself,” Alison said.

Talking about how the experience has changed her, Alison said that it has given her more self-confidence about her abilities as well as made her aware again of the devastation that war is causing. 

Constantly on the move, at the time of her interview, Alison was on a walking holiday with her daughter in Greece having just returned from her MSF mission earlier in the month. Though she is taking a brief respite and looks forward to her son's wedding in August, Alison cannot wait for her next deployment.

“You spend 24 hours a day, seven days a week together. You live, work and sleep in close quarters. You do everything together. It can be tricky, but you get on really well, and when you are struggling to achieve something together, you have a wonderful feeling of comradery. It's actually hard to leave it. It's a given. 

“You live your life in a bubble, a small bubble, and it becomes your whole world. For six months it was my world, and suddenly, I had to step out of it—an aeroplane ride away, and I was in green and leafy England. And it's a very hard adjustment. It's actually harder to adjust coming back again compared to going there.”

This is Alison's eighth MSF mission, and her previous missions have included supervising clinic, primary healthcare and obstetrics, for Internally Displaced Persons living in camps in northern Uganda; participating in mobile clinics along small rivers through the rainforest in guerrilla-controlled areas of Colombia, and serving as a medical team leader on a boat evacuating the war-wounded from Misrata in Libya to Tunisia.

After taking time out to look after her family for the most part of the 80s and 90s, Alison returned to nursing in the early 2000s. She joined MSF in 2007 and hasn't looked back since. Established in 1971, MSF works in 60 countries around the world, providing both emergency medical care in response to crisis situations as well as long-term medical programmes.
Sharing what it is that motivated her to take part in this particular mission, Alison said, “It's the same thing that has always motivated me. You hear about this tremendous need. I've already learned how rewarding it is. It's the same for every mission. It's always very tiring and very demanding, but it's incredibly fulfilling and rewarding.”