Growing up in a war torn country.

I was born in 1969, in a country called Lebanon. At the time, it was a beautiful and vibrant small country where people of various religions lived in harmony. In 1975, a civil war started in Lebanon which lasted 17 years.

The first year or so of the war, my parents tried to cope and live normally. I had a brother and a baby sister at the time. My memory consists of days off school because the area of our school was being shelled or because snipers were targeting that route. I also remember changing school halfway through the year, to a closer one which meant less risk of getting bombed. These are some of the ways my parents coped. There were days that we slept in the hallway in our house and watched the shelling through a distant window, as though it was fireworks. Depending on how loud it was, we began to estimate how close it was – a coping mechanism of making the situation entertaining. For us children, we coped with laughter and play in the hallway, but we were scared.

When the bombing was heavy and close, all the residents of the building went to the bomb shelter which was underground, and lived there together. Our parents played cards to make the time go by, and strategized how to get food to everyone – another coping mechanism. Politics and death tolls were common conversation; which we would imitate in an attempt to cope and understand. Children also coped by playing together and it was often soldiers and battle fields pretend play.

One of the days or weeks that we lived in our hallway, it was declared that there would be a cease fire for a few hours in the daytime, so I remember the adults deciding which father would go get bread for everyone. My father volunteered and I remember how worried I was. These strategies and collaboration of taking turns to minimize risk were coping mechanisms, and they were functional but not without psychosocial effects.

A year and a half into the war, my father decided that we had to leave the country since it was getting worse. I remember vividly how we were woken up and carried one night into a special taxi which the snipers did not target. My father placed a mattress inside the car on the back window, in case we did get shot at; as though that would have helped. Scared as can be, we were driven to a pier where we boarded a boat full of refugees like us, and we sailed off to Cyprus. How we coped during that boat ride was not so well; some got sea sick, some wet themselves and I cried.

That is my memory of living briefly in the war, the second part to my story is living as a refugee, a foreigner and then an immigrant; which I call living the war but on the outside.

My family coped by being close to friends and family. In Cyprus, we stayed with friends for over a month. After that, we flew to England and stayed with my uncle for over 6 months. There was no external support for myself or my siblings or my parents, except the welcoming support of my uncle and his wife. We all had to be patient and tolerant, and I think I personally just dealt with things day by day. We became close and protective of each other too. I did remain timid and insecure whenever I changed schools. In England, my brother cried in school every day and I just bottled it up and tried to learn English. Coping was staying out of trouble since four of us had to sleep in one room, and two families shared one bathroom.

The consequences of the war on my family include depression, eating disorders, obsessive compulsive disorders, insecurity, Tourette's syndrome and phobias; all dominantly psychosocial. The ways we coped is first by immigrating and then by being together and supporting each other. Remaining close to friends and family who understood the experience was also a great support.

The Syrian Civil War

As most of you have heard, the country neighboring Lebanon is currently at war, and the devastating impact on the children of Syria is significant. In 2013, the UN estimated that 100,000 had been killed and 2.4million had been registered as refugees in neighboring countries, of which 3/4 are women and children (CBC, 2014). Children living in Syria are living in danger of being killed, kidnapped, recruited to fight or tortured; and refugee children are living in difficult circumstances with poor access to shelter, food, health and education.

On a visit to Lebanon where almost one million Syrians are refugees, Angelina Jolie recently said "meeting these children was a heart-rending experience,… They have lost their families and their childhood has been hijacked by war. They are so young, yet they are bearing the burdens of their reality as if they are adults" (Time, 2014). Her brief statement can be seen on http://www.telegraph.co.uk/news/worldnews/middleeast/lebanon/10658101/Angelina-Jolie-thanks-Lebanon-for-assisting-Syrian-refugees.html

There are numerous organizations attempting to minimize the harm done to children inside and outside Syria; and they include the United Nations, The International Red Cross and Red Crescent, Save the Children, the International Rescue Committee and many many more.

Syrian Children in refugee camps ( UNHCR, 2013)

Their support ranges from diapers for babies, to clean water, to school supplies, to medications, medical supplies and artificial limbs, not to mention food and shelter. Some organizations are setting up centers for women and children, others are providing caravans equipped toys and educational material, others offer financial aid on a monthly basis, and the Lebanese government has accommodated the refugees with education and health services. Other countries are sending funds and support for the refugees in Lebanon, Jordan and Turkey; which hopefully benefits the children as much as possible. It is up to these host countries to regulate the support distribution.

Inside Syria, the aid is not able to reach everyone. The UN and the Red Cross/red Crescent are doing everything they can to reach needy and injured Syrians who are still in Syria, which includes many children. Their effort is simply to provide safety and medical care, and any basic needs.

Child being carried out of rubble.

From my child protection training, I am aware that one of the situations that increases the risk of child abuse and trafficking is war. Children are orphaned or homeless or parents are desperate – making them and easy targets for predators. There are thousands of Syrian orphans and these children are currently such prey, but unfortunately their own country is not protecting them. I have not found any organization that is addressing child protection from this angle, for the Syrian children.

The current efforts to minimize the harm done to Syrian children depends on the host countries for the refugees, on the financial aid from international countries and on the NGOs involved.

References

http://www.cbc.ca/news2/interactives/syria-dashboard/

http://world.time.com/2014/02/24/angelina-jolie-visits-syrian-refugees/

http://www.telegraph.co.uk/news/worldnews/middleeast/lebanon/10658101/Angelina-Jolie-thanks-Lebanon-for-assisting-Syrian-refugees.html

http://www.unhcr.org/515adb0a9.html

Immunization in Dubai, a city in the United Arab Emirates

The impact of child immunization on survival rates is so significant for our world. Several diseases have been eradicated and millions of children have been saved, which makes this practice so influential on the entire planet. Since I had studied and worked as a pharmacist for about ten years, I have experience with vaccinations from the dispensing, storage, and efficacy perspective and so my interest in this field will always remain keen.

Though I am American, and had studied the CDC vaccination requirements, I had my two children in the United Arab Emirates, in a city called Dubai, which is where I work in a nursery as well. So I have chosen this city for a study of immunizations as a public health measure.

The United Arab Emirates is only 42 years old, and for a nation so young, the mandatory immunization policy is quite impressive. Interestingly, the nation has several governing bodies when it comes to healthcare: the Ministry of Health governs the entire country but the two big cities (AbuDhabi and Dubai) have their own health authorities.  Under the Ministry of Health's Preventive Health Services, they have an immunization program which is offered to all residents of the country (free for citizens but for a reasonable fee for non-citizens). They proudly boast that polio has been eliminated here, and they have clinics all over the country, as well as hospitals with clinics operating daily on site, which offer immunizations.

The Dubai Health Authority (DHA) has published their guidelines for vaccinations for all children (DHA, 2014). Almost 90% of the country's population is non-citizens, and they are very transient and very diverse. This means that the vaccinations of each individual can vary tremendously. In the brochure you will find that they have addressed this issue. They have schedules for children born in this country, and schedules for children or adults to catch up with immunizations, who moved to the country. I find this quite interesting and quite relevant to the nature of the population. One of the vaccines that are not given routinely in the west is the BCG vaccine, but it is given here at birth and recommended to children who move to the country later. BCG vaccine protects from tuberculosis infection, which is not prevalent in the west anymore, but still prevalent in countries that neighbor the UAE and where many of the workforce comes from. I find that this is a fabulous added public health measure, where the country's population and its influence on disease has been taken into consideration, to protect all children living in this country.

The DHA guide to immunizations also addresses many related issues, like storage of vaccinations, immunization during different conditions including pregnancy and recommendations for travelers.

So who gets vaccinated and how? The country offers free healthcare to all its citizens, which includes all immunizations, but public health serves are paid for by non-citizen residents. Most of the population has private health coverage, with some insurances covering immunization and others not. The citizens of the country are only 10% of the population, so what about the rest of the 90%? The DHA has mandated that all children get immunized in Dubai, and they enforce it by checking with schools and nurseries and pediatricians for records to prove this.  It is the responsibility of the family that works here to access the private health care serves and get the necessary immunizations. It becomes part of what people sign up for, when they decide to work here and raise their families here. At our nursery, we get inspected several times a year and the children's immunization records are inspected almost each time. In addition, recently the school my children go to has offered discounted vaccinations for anyone who needs to catch up with the UAE schedule.

The transiency of the country's population poses an additional challenge to creating an immunization policy for a few reasons: not everyone is born here, not everyone accesses the same healthcare services, children move here with various immunization history, and the various nationalities that live here can pose an added infection risk which they may be carrying.

To have an idea of the success of the immunization program, I found a report published by the AbuDhabi health authority in the neighboring city and the incidence of communicable diseases in children was impressively low.  In addition, the leading cause of deaths did not include communicable diseases.  To me, this is an indication of success although various factors play a role in the statistics.

At the nursery where I work, we ask all parents to give us a copy of their child's immunization records, and our fulltime nurse checks that they are updated based on the DHA recommendations. What I did notice in my research, which I will address immediately, is that the UAE Ministry of Health and the Dubai Health Authority has not made the Rotavirus vaccine mandatory. Even though most of the children in our care have been vaccinated for rotavirus based on their pediatrician's recommendations, I feel that this may be a worthy cause to advocate for. Through this assignment I may be initiating a study at work, of how many children are vaccinated for Rotavirus, and then accordingly, make a recommendation to all our families and hope to be supported by pediatricians or the government clinics.

Dubai Health Authority, 2014. Government of Dubai. Immunization Guidelines. Retrieved from:http://91.74.184.65/videoplayer/Immunization%20Guidelines.PDF?ich_u_r_i=e05592d03d0478b945099bc3eedc5f1a&ich_s_t_a_r_t=0&ich_e_n_d=0&ich_k_e_y=1445038914751463022401&ich_t_y_p_e=1&ich_d_i_s_k_i_d=8&ich_u_n_i_t=1

Health Authority Abudhabi, 2012. Health Statistics 2012. Retrieved from http://www.haad.ae/HAAD/LinkClick.aspx?fileticket=JY0sMXQXrOU%3d&tabid=1243

Stories of Giving Birth

The birth of my two sons.

Both my sons were born by cesarean sections. With my first son I had placenta previa which meant that I could not give birth naturally and hence we had planned the Cesarean. Starting at 16 weeks, I had been placed on restricted activity in order to avoid any contractions at all. When the day finally came at 38 weeks, the experience was quite clinical and we were just checking off on a list to begin with. I was nervous of course but so ready as well, I wanted to meet this little person so much. The doctors insisted on general anesthesia due to the risks involved and so I was taken alone into a cold operating room and prepped up like any major surgery: Gowns, large lights, betadine scrubs and IV lines. All I could think about and all I told my mother and husband was how to take care of my baby when he was delivered.

In the recovery room, after my pain was controlled, I was shown my beautiful little boy and though I was still quite lethargic, he was placed next to me for some time. In that Dubai government hospital in 2002, their practice was to wash the baby right after birth; which is something I was not keen on. I tried to breast feed after I got to my room but was not successful to begin with, so my son was given formula until I was successful a day later. My first few days were all about recovering from the cesarean and trying to breast feed; as well as learning to change diapers and burping and swaddling my little boy. My son and I went home on day 4 after surgery.

I chose to share this birth because I find that the success of my first son's birth is a perfect example of the delicate prenatal care and delivery needed for a fetus to develop successfully and then the newborn baby too. Had my placenta previa not been diagnosed, my life and his life would have been in danger if I went into natural labor. Had the medical care not been adequate, the delivery could have jeopardized both of our well-being. The successful development of my son in pregnancy and then upon cesarean delivery is due to the support I received from the medical professionals, my husband and his family, and my mother.

My second son was also born by cesarean section because according to my obstetrician, I had started contractions but my cervix had not dilated which made it risky for the baby. That experience was completely different to me for various reasons. The procedure was done under spinal anesthesia which was incredible comfortable, and I was fully awake for the delivery. My husband was in the room with me behind the big curtain and we heard our son cry after he was pulled out. It was a less stressful experience altogether. When they handed me my son, he was still in his natural state (not washed), and my husband was offered the cutting of the chord. Few minutes after I was stitched up, I was in the recovery room and my son 'crawled up' my chest and breast fed so easily. Once again, I had my husband, my mother, my in-laws and lots of family to support me; which is how my son's well being and his older brother's was ensured.

Against the odds of a high risk pregnancy and an emergency cesarean section, my two sons had a great start to their lives, with lots of love, good hygiene, breast milk, warmth and the health services needed.

Child birth in Denmark

My close friend and colleague is from Denmark, and a mother of three wonderful children. I had always heard her talk about her natural deliveries, and decided to take this assignment as an opportunity to hear about her experience. In summary, the Danish have two choices of where to deliver their babies: the government hospitals (Denmark has high quality public health care for all its citizens) or at home. It is a mid-wife that delivers the baby and doctors (anesthesiologist, obstetricians and pediatricians) are only on call. There is no pre-booked cesarean sections allowed, and they are discouraged completely unless it is medically necessary. No pain management is offered, and the birth is as natural as possible.

For all three of her children, my friend delivered naturally with a midwife, without any pain management except a little 'laughing gas'. With her first daughter in 1998 she stayed in hospital two nights as permitted for a first child, with her son in 2000 she was discharged five hours after delivery, and with her second daughter in 2001 after much pleading she was allowed two nights' stay. Breast feeding is expected of all mothers.

Maternity leave in Denmark is very impressive; my friend had 6 weeks of paid leave before the baby was due and 6 months of paid leave after delivery. Her husband had two weeks of paid leave, and she also had the option of taking an additional 6 months leave at 60% of her salary.

An interesting document that seems to be published by the healthcare system in Denmark points out more facts. During a pregnancy there are three checkups with a GP, only 2 ultrasound checks, 5-7 checkups with a midwife and only if necessary does the expectant mother see an obstetrician. Giving birth is considered an outpatient procedure, unless it is the first birth or complications are expected.

I have always been intrigued by the fact that the majority of the Danish do not own cars, and their main form of transportation is bicycles. Sure enough, when I was researching giving birth in Denmark, I found a blog that addresses this part of the culture and how pregnant women are encouraged to ride their bikes, even to get to the hospital for delivery.

I find it very interesting that such a progressive and civilized country plans the birth of its infants in such a 'back to basics' method. I find it quite contradicting to other westernized countries where the delivery itself is made as comfortable as possible, but the mother is expected back at work within 45 days or 6 weeks.  Of course with public health care, we know that costs are always minimized as much as possible, so could this be the driving force for their birthing approach or is it their 'viking' culture of endurance? Regardless, the Danish population, including their children, is considered one of the happiest in the world.

Please check out the links mentioned:

http://www.regionh.dk/NR/rdonlyres/305349A6-E2C8-40F7-870B-AAD46B27DA13/0/pregnancy_and_birth_A4_pic.pdf.

http://www.copenhagenize.com/2011/09/cycling-with-contractions-to-hospital.html