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The panjandrums of global health R i c h a r d H o r t o n ’s C o m m e n t (July 13, p 112)1 suggests that recent international commitments on development cooperation have done more harm than good for health-care in Africa. I disagree. But his conclusion that our “global health panjandrums” need better feedback from beneficiaries on the ground is sound. We now have a window of opportunity to get things right.

As the international community designs successors to the Millennium Development Goals, it needs to listen to those on the receiving end of the existing international development machinery, and to draw lessons from a decade-long international drive for more eff ective aid.

The Global Partnership for Eff ective Development Co-operation allows us to do just that. Founded after the 2011 Busan High-Level Forum on Aid Effectiveness, it offers a global platform for leaders to listen to the concerns of developing countries and—crucially—to take action.

Busan saw donors and benefi ciaries reaffirming their 2005 Paris Declaration commitments on aid quality—not stepping away from them as Horton suggests. A major independent evaluation showed that the Paris principles remain highly relevant, and that Paris-style aid reforms have contributed to results in the health sector. But it also reminded us that these reforms need to be put in to perspective and viewed alongside other resources, actors, and eff orts.2

Busan was in places messy, dealing with complexities that previous international summits on development had yet to address. It was a necessary step towards a global model fi t for our times. That model must see leaders meeting their aid commitments alongside a broader set of enablers: cooperation on taxation, illicit fi nancial fl ows, climate change, and South-South partnerships, to name a few. Without

a fresh and far-reaching partnership for implementation, even the most ambitious of global goals will do little to address Africa’s health challenges.I am Coordinating Minister for the Economy and Minister of Finance of Nigeria, co-Chair of the Global Partnership for Eff ective Development Co-operation, and member of the UNAIDS–Lancet Commission. I declare that I have no confl icts of interest.

Ngozi Okonjo-Iwealacakporji@fmf.gov.ng

Federal Ministry of Finance, Abuja, Nigeria

1 Horton R. Offl ine: The panjandrums of global health. Lancet 2013; 382: 112.

2 Wood B, Betts J, Etta F, et al. The evaluation of the Paris Declaration, fi nal report. Danish Institute for International Studies, Copenhagen, 2011. http://www.oecd.org/derec/dacnetwork/48152078.pdf (accessed Aug 18, 2013).

For the Global Partnership for Eff ective Development Co-operation see http://www.eff ectivecooperation.org/

Syrian refugees in Lebanon: facts and solutions

Roughly 600 000 Syrian refugees registered by the UN High Commissioner for Refugees (UNHCR) reside in Lebanon. However, the Lebanese Government has estimated this number to be about 1·5 million—which corresponds to an increase in Lebanon’s population of more than 25%. The living conditions of Syrian refugees are tragic; many have lost their homes and family members. Although there is a solidarity between populations, Syrian refugees put pressure on the Lebanese health-care system and economy, and Lebanon hosting capacities are overstreched, thus transforming the so-called Syrian crisis into a Lebanese–Syrian crisis.

Foreign aid is far lower than what is needed to respond effectively to this humanitarian crisis. The UNHCR coordinates support with relevant ministries and non-governmental organisations such as the Amel Association. Irrespective of politics, religions, and geography, the Amel Association has so far been able to provide 110 000 services through its three mobile clinics and 24 centres

throughout Lebanon. These services are important but remain modest compared with the actual needs of the Syrian refugees.

Data collected by the Amel Association1 since January, 2013, of more than 90 000 displaced Syrian patients have shown that: 47% of patients have skin diseases (leishmaniasis, scabies, lice, and staphylococcal skin infection); 27% of patients have digestive system diseases; 19% of patients have respiratory diseases; 7% of patients, especially children, suffer from malnutrition; 2% of patients have infectious diseases (measles, jaundice, and typhoid); and 13% of patients are diagnosed with mental illness as a result of trauma and displacement.

The Lebanese Ministry of Health could not finance treatment of all displaced Syrians due to the lack of funds, but it ensured treatment of more than 600 cases of renal dialysis.

In view of this Lebanese–Syrian crisis, surely the international community needs to find a solution to the Syrian crisis; meanwhile, we need an emergency plan for the Syrian refugees.

First, to address the urgent needs of displaced Syrians, we recommend that a complete emergency plan for the economic, social, health, education, and relief domains be implemented by the Lebanese Government. This implementation should be done in cooperation with Lebanese civil society organisations and municipalities. This plan should fully integrate the Higher Relief Council, the Ministry of Public Health, and the Ministry of Social Affairs. Implementation requires fi nancial support for Lebanon from all potential donor countries and the UN.

A second emergency plan will be needed if the battle of Damascus happens, because an estimated 1 million Syrian refugees (a sixth of the Damascus population) could be expected to come to Lebanon.

Finally, a third emergency plan should be applied when a political solution puts an end to the Syrian crisis. In that

Published OnlineJuly 19, 2013http://dx.doi.org/10.1016/S0140-6736(13)61461-0

See Editorial page 743

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Roughly 500 000 Syrians live in and outside the camps in Turkey.

Basic needs such as shelter, food, health care, but also education, social activity facilities, play areas (fi gure), and employment opportunities are needed, and are provided as much as possible. According to AFAD Director General, Turkey spent US$1·5 billion for Syrian refugees.2 Health-care services are provided through primary health-care centres, 112 medical emergency stations, and tent hospitals. Thousands of seriously injured Syrians were brought to Turkey for emergency operations or intensive care. More than 1·2 million patient consultations for Syrian refugees were registered in outpatient settings.

Beyond numbers, there is also an emotional burden. Being away from home and facing uncertainty about the future affects Syrian refugees psychologically, socially, and physically. Health-care workers providing services to this vulnerable population are also aff ected. Doctors are now providing services to a large population with no medical records, who are socially and psychologically affected, and with a language barrier. Doctors face situations that are very difficult to manage. They work long hours, and manage several urgent cases. As a nurse explained to us, it is not just wounds caused by bombs or bullets that need treatment, but also spiritual wounds, fears, and pains, which need to be healed.We declare that we have no confl icts of interest.

*Pinar Döner, Adem Özkara, Rabia Kahvecidr.pinardoner@gmail.com

Public Health Center, Kilis 7900, Turkey (PD); Hitit University Faculty of Medicine, Çorum, Turkey (AO); and Ankara Numune Training and Research Hospital, Ankara,Turkey (RK)

1 UNHCR. Syria Regional Refugee Response. http://data.unhcr.org/syrianrefugees/country.php?id=224 (accessed July 17, 2013).

2 AFAD. Director General of AFAD, Dr. Fuat OKTAY informed European Union-Turkey Joint Parliamentary Committee about Syria, June 28, 2013. https://www.afad.gov.tr/EN/HaberDetay.aspx?ID=5&IcerikID=995 (accessed Aug 15, 2013).

Syrian refugees in Turkey: numbers and emotions

2 years have passed since the confl ict in Syria began; it has cost thousands of lives, and injured and displaced many. This confl ict has caused almost half a million Syrians to fl ee, seeking safety in Turkey. Besides the burden on the health-care system in Turkey, we would like to draw attention to the psychological burden on health-care professionals helping the refugees. By July 17, 2013, 201 032 Syrians were registered in 20 camps in 10 provinces in Turkey.1 More than 27 640 children live in the camps, and 4984 of them were born in Turkey.1 AFAD—the Disaster and Emergency Management Agency of the Government of Turkey—also estimates that more than 290 000 Syrians live in urban areas.

case, Syrians will need support for the reconstruction of their country.KM is President of the Amel Association. We declare that we have no confl icts of interest.

*Marwan M Refaat, Kamel Mohannarifaatmarwan@hotmail.com

Department of Internal Medicine, Cardiovascular Medicine and Cardiac Electrophysiology, American University of Beirut, Faculty of Medicine and Medical Center, 1107 2020 Beirut, Lebanon (MMR); and Faculty of Public Health, Lebanese University, Beirut, Lebanon (KM)

1 Amel Association International. http://www.amelassociation.org/ (accessed July 15, 2013).

Figure: Children’s playground in Kilis, Turkey

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For more on AFAD see https://www.afad.gov.tr/EN/Index.aspx

Ethical issues in research into confl ict and displacement

After conducting interviews to collect qualitative data on the experience of parenting in confl ict zones inside Syria and in camps and displacement zones along the border with Turkey, we would like to highlight several issues.

Ethical concerns about interviewing participants in these contexts have been raised previously,1,2 and our study protocol and ethical approval procedure also identified important concerns. Most signifi cant was the question of whether it is possible to ask recently displaced families about an aspect of psychological need without reactivating distressing accounts of trauma. Using a carefully planned, semi-structured approach, parents were able to talk about their parenting experience, were very keen to participate in discussions, and emphasised that they were used to talking about such experiences amongst themselves. They said they appreciated the approach used, and refl ected that the discussions allowed them to articulate their own strategies for coping with their situation and to share these strategies with others.

Furthermore, because of the rapidly changing nature of refugee areas especially with regard to security, it proved essential to adopt some flexibility of approach. We would therefore recommend that when considering research applications for these difficult environments, ethical review boards consider: fi rst, allowing in the phrasing of the description of procedures terms such as “as far as possible” because of the difficulties in collecting data in fi eld conditions in which rapid changes are occurring; second, identifying the primary, core components of procedures that must be left unaltered for approval to be maintained and those secondary components for which alternatives might be found that still protect the participant and researcher; third, when

See Editorial page 743