As an agency offering medical assistance in many conflict zones around the world, Doctors without Borders (MSF) is running mobile clinics across the Kurdistan Region and close to the frontlines helping over 300,000 refugees and internally displaced persons (IDPs).
MSF Switzerland works out of the primary health facility in Domiz refugee camp in Duhok, where it also runs the maternity ward. Its mobile clinics go from Nineveh province to Kirkuk and often operate as close to the frontlines as possible in order to reach the IDP population who have no other access to medical professionals. In their line of work, the MSF staff are witnessing terrible cases of malnutrition among those who manage to escape ISIS or survive the daily battles. They remain on the lookout and move into areas reclaimed from ISIS once they have made sure it is safe to do so.
“We have to do a balance between the safety of our teams,” says Marie Cleret, MSF’s deputy head of mission in Kurdistan. “The goal is to provide medical care to populations that have been completely deprived of medical care. So, as soon as we deem those areas that have been reclaimed from ISIS to be secure enough for us to operate there, if the assessment shows that there is a high need for medical care, we would be going.”
Here is Rudaw’s interview with Marie Cleret.
They live in very dire conditions, like unfinished buildings, tents where the air is coming in through everywhere 
Rudaw: What are the medical issues that you are seeing?
Marie Cleret: Most of the medical issues are linked to the living conditions of the refugees and IDPs. We see a lot of respiratory tract infections, especially now during the winter due to the weather. And urinary tract infections as well. They live in very dire conditions, like unfinished buildings, tents where the air is coming in through everywhere. And we also treat mental health conditions due to the living conditions and the trauma of leaving all your life behind and settling in insecure and volatile places where they have to face violence.
Sexual and reproductive health are a big need. You have a lot of women, pregnant women, who need to deliver and they don’t get adequate antenatal care nor postnatal care, delivery. It’s something that is problematic because, when you have to reach hospital to deliver and there is no hospital nearby, paying the taxi ride to go to the hospital is a financial hardship for the entire family.
And non-communicable diseases. We’re in a part of the world where the incidents of non-communicable diseases is very high. The main non-communicable diseases that we see are hypertension, diabetes and cardiovascular diseases.
What are the challenges to providing mental health services?
It needs explaining. The challenge of mental health is that you cannot just give one consultation and then stop the treatment. The main challenge is to be able to provide long term treatment to populations who are mobile, who don’t necessarily come back. Also the stigma which is linked mental health, which you have to overcome so that they will adhere to the treatment and come back for more consultations.
We have an expat mental health activity manager who is directly working with the Department of Health [of the Kurdistan Regional Government] and training their staff to some kind of capacity building in terms of mental health and a focus on the psychosocial approach. We have a good cooperation with the health authorities here. If you have time for the community to get to know the organization, what we’re doing and if you can work with patients, with them coming back for follow-up consultations, then clearly its effective. And then you can also overcome the stigma and try to overcome the simple equation that going to a mental health consultation means that you’re crazy. Seeking help and medical assistance because you’re experiencing mental heath disorders is completely normal and the treatment can actually help overcome mental health disorders.
We also treat mental health conditions due to the living conditions and the trauma of leaving all your life behind,
Is MSF providing infrastructure aid in addition to medical care?
We focus on medical care. We sometimes do NFI [non-food item] distributions but we’re leaving other actors to do it if other actors can cover so that we focus only on medical care.
We want to coordinate and make sure that we don’t duplicate assistance, which would be a pity. But we are self-funded to maintain our independence and our neutrality and our ability to work where we want to work and how we want to work, which is the main difference between MSF and the other organizations. We don’t report to the UN. In Iraq and specifically in Kurdistan, our strategy is to work where other organizations are not. So for example, in Nineveh, the strategy is to work as close possible to the front line.
As the Kurdish, Iraqi and international forces are gaining ground from ISIS, are you able to expand services?
We have to do a balance between the safety of our teams. The goal is to provide medical care to populations that have been completely deprived of medical care. So, as soon as we deem those areas that have been reclaimed from ISIS to be secure enough for us to operate there, if the assessment shows that there is a high need for medical care, we would be going. That’s what we have been doing in Nineveh. We’ve assessed Sinjar. We’re going to put another clinic in a location, which is around 10km from the frontline. But it’s according to our own assessment. It’s not according to the Kurdish authorities or the coalition forces. It’s both medical assessment and our own security assessment to ensure that our teams are safe on the ground.
In Iraq and specifically in Kurdistan, our strategy is to work where other organizations are not,
IS MSF providing the standard services that a government is expected to provide?
It really depends on where we are operating. In some places, yes, everything has been destroyed and it’s not a question of willingness from the Department of Health or Ministry of Health in Baghdad. It’s just that everything has been destroyed due to clashes or heavy fighting. And so there is nothing. But in some other places, the Department of Health is starting activities again. So you have partial activities ongoing but they can’t provide the full package yet. In some places you do have medical facilities running but the problem is that the staff that was working inside the facilities have fled, they fled the fighting, so there is no one to work there. We’re trying to cover the gaps wherever they are, as much as possible.
How does MSF ensure security for its staff?
We don’t work with security firms. We don’t have armed guards. Basically our security relies on acceptance and perception, both from the civil authorities, the military authorities but also from the community where we are working. One of our assumptions is that, if we are accepted and if the community where we are working acknowledges the value of the medical care and the work that we’re doing, they’re going to protect us in a way.
It’s a big part of our responsibilities is to ensure that community leaders where we work know us. And also that if anything happened, we’d be warned immediately. We work a lot on networking at a very high level but also at the most basic level. For example, before the team leaves one morning to set up the mobile clinic, if anything happened in the village where we’re supposed to be working, the community leader in the village would give a call to someone in our team saying it’s not safe to come today, you should not come for some time.
Where does MSF get its funding?
If Mosul happens and it takes us six months to react, then we’re losing the goal of being MSF.
In Iraq, we’re completely self-funded. It’s private donors, people like you and me, giving to MSF every month that constitutes the funding of MSF. That’s how we ensure our neutrality and independence from everyone, from the international organizations, the UN, the international donors, the authorities of the countries where we are working in, the coalition forces as well. That’s how we ensure that we’re away from any kind of influence or leverage and we can run the operations only according to our assessment of the needs on the ground.
What challenges are MSF facing in the Kurdistan region?
The extent of needs, in terms of health, are huge. Having the most appropriate response to the medical needs to be covered it can be a tricky exercise.
Another challenge is to keep the flexibility to adapt to a fast-changing context, which has been Iraq for the last couple of years. It’s changing all the time.
We’re an emergency organization so one of our main goals compared to the others is to be prepared when the emergency happens. If Mosul happens and it takes us six months to react, then we’re losing the goal of being MSF. Mosul battle is more than a hypothesis. We develop different scenarios of what could happen during and following the battle, what we would have to respond to, like massive influx of IDPs.
Basically, you work with the field teams, you work on different scenarios and the whole point is to be prepared when the emergency happens. It’s a big challenge. It’s also why we’re MSF – being ready for emergencies. And in a context like Iraq, it’s vital to be ready and to keep this flexibility of responding to the needs wherever they happen and whenever they happen.
MSF Switzerland works out of the primary health facility in Domiz refugee camp in Duhok, where it also runs the maternity ward. Its mobile clinics go from Nineveh province to Kirkuk and often operate as close to the frontlines as possible in order to reach the IDP population who have no other access to medical professionals. In their line of work, the MSF staff are witnessing terrible cases of malnutrition among those who manage to escape ISIS or survive the daily battles. They remain on the lookout and move into areas reclaimed from ISIS once they have made sure it is safe to do so.
“We have to do a balance between the safety of our teams,” says Marie Cleret, MSF’s deputy head of mission in Kurdistan. “The goal is to provide medical care to populations that have been completely deprived of medical care. So, as soon as we deem those areas that have been reclaimed from ISIS to be secure enough for us to operate there, if the assessment shows that there is a high need for medical care, we would be going.”
Here is Rudaw’s interview with Marie Cleret.
They live in very dire conditions, like unfinished buildings, tents where the air is coming in through everywhere Rudaw: What are the medical issues that you are seeing?
Marie Cleret: Most of the medical issues are linked to the living conditions of the refugees and IDPs. We see a lot of respiratory tract infections, especially now during the winter due to the weather. And urinary tract infections as well. They live in very dire conditions, like unfinished buildings, tents where the air is coming in through everywhere. And we also treat mental health conditions due to the living conditions and the trauma of leaving all your life behind and settling in insecure and volatile places where they have to face violence.
Sexual and reproductive health are a big need. You have a lot of women, pregnant women, who need to deliver and they don’t get adequate antenatal care nor postnatal care, delivery. It’s something that is problematic because, when you have to reach hospital to deliver and there is no hospital nearby, paying the taxi ride to go to the hospital is a financial hardship for the entire family.
And non-communicable diseases. We’re in a part of the world where the incidents of non-communicable diseases is very high. The main non-communicable diseases that we see are hypertension, diabetes and cardiovascular diseases.
What are the challenges to providing mental health services?
It needs explaining. The challenge of mental health is that you cannot just give one consultation and then stop the treatment. The main challenge is to be able to provide long term treatment to populations who are mobile, who don’t necessarily come back. Also the stigma which is linked mental health, which you have to overcome so that they will adhere to the treatment and come back for more consultations.
We have an expat mental health activity manager who is directly working with the Department of Health [of the Kurdistan Regional Government] and training their staff to some kind of capacity building in terms of mental health and a focus on the psychosocial approach. We have a good cooperation with the health authorities here. If you have time for the community to get to know the organization, what we’re doing and if you can work with patients, with them coming back for follow-up consultations, then clearly its effective. And then you can also overcome the stigma and try to overcome the simple equation that going to a mental health consultation means that you’re crazy. Seeking help and medical assistance because you’re experiencing mental heath disorders is completely normal and the treatment can actually help overcome mental health disorders.
We also treat mental health conditions due to the living conditions and the trauma of leaving all your life behind, Is MSF providing infrastructure aid in addition to medical care?
We focus on medical care. We sometimes do NFI [non-food item] distributions but we’re leaving other actors to do it if other actors can cover so that we focus only on medical care.
We want to coordinate and make sure that we don’t duplicate assistance, which would be a pity. But we are self-funded to maintain our independence and our neutrality and our ability to work where we want to work and how we want to work, which is the main difference between MSF and the other organizations. We don’t report to the UN. In Iraq and specifically in Kurdistan, our strategy is to work where other organizations are not. So for example, in Nineveh, the strategy is to work as close possible to the front line.
As the Kurdish, Iraqi and international forces are gaining ground from ISIS, are you able to expand services?
We have to do a balance between the safety of our teams. The goal is to provide medical care to populations that have been completely deprived of medical care. So, as soon as we deem those areas that have been reclaimed from ISIS to be secure enough for us to operate there, if the assessment shows that there is a high need for medical care, we would be going. That’s what we have been doing in Nineveh. We’ve assessed Sinjar. We’re going to put another clinic in a location, which is around 10km from the frontline. But it’s according to our own assessment. It’s not according to the Kurdish authorities or the coalition forces. It’s both medical assessment and our own security assessment to ensure that our teams are safe on the ground.
In Iraq and specifically in Kurdistan, our strategy is to work where other organizations are not, IS MSF providing the standard services that a government is expected to provide?
It really depends on where we are operating. In some places, yes, everything has been destroyed and it’s not a question of willingness from the Department of Health or Ministry of Health in Baghdad. It’s just that everything has been destroyed due to clashes or heavy fighting. And so there is nothing. But in some other places, the Department of Health is starting activities again. So you have partial activities ongoing but they can’t provide the full package yet. In some places you do have medical facilities running but the problem is that the staff that was working inside the facilities have fled, they fled the fighting, so there is no one to work there. We’re trying to cover the gaps wherever they are, as much as possible.
How does MSF ensure security for its staff?
We don’t work with security firms. We don’t have armed guards. Basically our security relies on acceptance and perception, both from the civil authorities, the military authorities but also from the community where we are working. One of our assumptions is that, if we are accepted and if the community where we are working acknowledges the value of the medical care and the work that we’re doing, they’re going to protect us in a way.
It’s a big part of our responsibilities is to ensure that community leaders where we work know us. And also that if anything happened, we’d be warned immediately. We work a lot on networking at a very high level but also at the most basic level. For example, before the team leaves one morning to set up the mobile clinic, if anything happened in the village where we’re supposed to be working, the community leader in the village would give a call to someone in our team saying it’s not safe to come today, you should not come for some time.
Where does MSF get its funding?
If Mosul happens and it takes us six months to react, then we’re losing the goal of being MSF. In Iraq, we’re completely self-funded. It’s private donors, people like you and me, giving to MSF every month that constitutes the funding of MSF. That’s how we ensure our neutrality and independence from everyone, from the international organizations, the UN, the international donors, the authorities of the countries where we are working in, the coalition forces as well. That’s how we ensure that we’re away from any kind of influence or leverage and we can run the operations only according to our assessment of the needs on the ground.
What challenges are MSF facing in the Kurdistan region?
The extent of needs, in terms of health, are huge. Having the most appropriate response to the medical needs to be covered it can be a tricky exercise.
Another challenge is to keep the flexibility to adapt to a fast-changing context, which has been Iraq for the last couple of years. It’s changing all the time.
We’re an emergency organization so one of our main goals compared to the others is to be prepared when the emergency happens. If Mosul happens and it takes us six months to react, then we’re losing the goal of being MSF. Mosul battle is more than a hypothesis. We develop different scenarios of what could happen during and following the battle, what we would have to respond to, like massive influx of IDPs.
Basically, you work with the field teams, you work on different scenarios and the whole point is to be prepared when the emergency happens. It’s a big challenge. It’s also why we’re MSF – being ready for emergencies. And in a context like Iraq, it’s vital to be ready and to keep this flexibility of responding to the needs wherever they happen and whenever they happen.
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