1. Pediatric Nephrologist facing War Chebl MOURANI ESPN Lyon Septembre 2008 Ass. Professor Hotel Dieu de France Pediatric Hemodialysis & Kidney transplant unit Beirut- Lebanon- Hotel Dieu de France

2. Overview 12 July 2006 Military conflict started between Lebanon & Israel, In 48 hours: 12 July 2006 Military conflict started between Lebanon & Israel, In 48 hours: International Airport of Beirut: out of serviceInternational Airport of Beirut: out of service Beirut Port is closed: EmbargoBeirut Port is closed: Embargo All Highways & Principal roads bombardedAll Highways & Principal roads bombarded War in South of Lebanon.War in South of Lebanon. Air Strikes: Beirut, North and East of LebanonAir Strikes: Beirut, North and East of Lebanon

5. Consequences of War Schools and Universities :closed Schools and Universities :closed All civil activities stopped. All civil activities stopped. Embargo on Fuel: Electricity shortage Embargo on Fuel: Electricity shortage Fuel distributed only for Hospitals and Doctors Fuel distributed only for Hospitals and Doctors Dangerous circulation for citizens especially for children coming to Beirut for dialysis Dangerous circulation for citizens especially for children coming to Beirut for dialysis

6. Direct Actions Decision: gather children in a secure place near dialysis centers till the end of the war Decision: gather children in a secure place near dialysis centers till the end of the war Problems to solve : Problems to solve : Housing of 30 Pediatric HD patients with their families in secure place?Housing of 30 Pediatric HD patients with their families in secure place? Ensure beds, food, water, access to sanitaries, showers, electricity, security?Ensure beds, food, water, access to sanitaries, showers, electricity, security?

7. Solutions Using public school for housing : opened after the authorization of security forces Using public school for housing : opened after the authorization of security forces Food: delivered by humanitarian associations Food: delivered by humanitarian associations Electric generator donated by City Mayor. Electric generator donated by City Mayor. Access to hospital showers for the families. Access to hospital showers for the families. Beds and covers donated by the National Committee for Disasters. Beds and covers donated by the National Committee for Disasters.

8. After 2 weeks of war New Problems: New Problems: Factory for Hemodialysis solutions bombardedFactory for Hemodialysis solutions bombarded Filters for pediatric use: shortageFilters for pediatric use: shortage Same problem for Peritoneal DialysisSame problem for Peritoneal Dialysis No possibility of delivery from outside Lebanon: maritime embargo, roads to Syria are closed.No possibility of delivery from outside Lebanon: maritime embargo, roads to Syria are closed.

9. Temporary Solutions Transfer of Pediatric patients outside Lebanon Transfer of Pediatric patients outside Lebanon Help asked from ISN Help asked from ISN Meanwhile: Meanwhile: Reducing number of HD sessionsReducing number of HD sessions High Diet restrictionHigh Diet restriction Resonium for everybody.Resonium for everybody.

10. Major Problem We can not continue Hemodialysis to children We can not continue Hemodialysis to children Parents were informed about problems in a general assembly Parents were informed about problems in a general assembly Parents: Ready to leave the country with their children. Parents: Ready to leave the country with their children. Hope: Marmara center for HD in Turkey ready to accept them. Hope: Marmara center for HD in Turkey ready to accept them.

11. Problems Diplomatic problems: no possibility to give visas for 30 families (150 persons) no similar situation before. Diplomatic problems: no possibility to give visas for 30 families (150 persons) no similar situation before. Impossible to leave Lebanon : nobody can provide guarantee to secure their lives during travelling. Impossible to leave Lebanon : nobody can provide guarantee to secure their lives during travelling. Efforts of ISN, Minister of Health, Baxter, Prime Minister, Lebanese Army Efforts of ISN, Minister of Health, Baxter, Prime Minister, Lebanese Army

12. New Hope Filters and Solution for Adults and Pediatric Patients in Turkey: Ready for shipment. Filters and Solution for Adults and Pediatric Patients in Turkey: Ready for shipment. Problems: Problems: How to bring disposable materials to Lebanon? How to bring disposable materials to Lebanon? Materials blocked in Turkey. Materials blocked in Turkey. Who will guarantee the security of the ship? Who will guarantee the security of the ship?

13. Solutions Personal contact with Ambassador of Turkey Personal contact with Ambassador of Turkey Target: save life of more than 50 children Target: save life of more than 50 children Intensive Negotiations during 48 h allowed Intensive Negotiations during 48 h allowed Turkish war Navy to embark to Lebanon through a safe naval passage Turkish war Navy to embark to Lebanon through a safe naval passage

22. Arrival of materials Engagement was respected by belligerents. Engagement was respected by belligerents. Turkish navy arrived to Lebanon with dialysis disposable. Turkish navy arrived to Lebanon with dialysis disposable. Material received in presence of CNN and local TVs, the Turkish Ambassador and Minister of health. Material received in presence of CNN and local TVs, the Turkish Ambassador and Minister of health. Filters transferred out of Beirut Port to dialysis centers in Beirut. Filters transferred out of Beirut Port to dialysis centers in Beirut.

23. Out of Beirut 20 children out of Beirut in need of material 20 children out of Beirut in need of material How to send them filters and solution in War? How to send them filters and solution in War? Red cross- Lebanese Army delivered HD materials to centers. Red cross- Lebanese Army delivered HD materials to centers. All children on HD were saved. All children on HD were saved.

26. Problems of Peritoneal Dialysis 2 children refused to leave their homes 2 children refused to leave their homes UPS was not recharging because of electricity shortage UPS was not recharging because of electricity shortage No HD available No HD available 2 infants on PD died at home 2 infants on PD died at home Impossibility to communicate with them Impossibility to communicate with them

28. Recommendations for HD We recommend after experience of July 2006 in Lebanon for hemodialysis, in situation of war: We recommend after experience of July 2006 in Lebanon for hemodialysis, in situation of war: 1.Gather children in same hospital or in a place very near to a dialysis center 2.Ensure facilities for their family to continue to live a decent life. 3.If not enough materials: reduce number of dialysis – Diet restriction + Medication + monitoring BP and Potassium. 4.Ensure electrical generator : provide fuel

29. Recommendations for PD In situation of war PD: In situation of war PD: 1.Ensure electricity for Homechoice machine. 2.UPS efficient for small period of electricity shortage. 3.Force them to come to the center in case of prolonged war 4.CAPD should be taught and material assured.

30. Role of IPNA Create a committee IPNA for catastrophic situation(disaster and war) to help pediatric nephrologists during war Create a committee IPNA for catastrophic situation(disaster and war) to help pediatric nephrologists during war Cooperate first with ISN (good experience in Turkey) Cooperate first with ISN (good experience in Turkey) International recommendations : symposium on pediatric nephrology during disaster or war International recommendations : symposium on pediatric nephrology during disaster or war