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SPECIAL REPORT
KAMEDO Report No. 92
Evacuation of Swedes from Lebanon—
Observational Studies in Connection with
the War in Lebanon in Summer 2006
Per Kulling; Susannah Sigurdsson; Bertil Hamberger (expert reviewer)
Abstract
KAMEDO = Swedish Disaster Medicine Study A large-scale armed conflict between Hezbollah and Israel in July 2006 caused
Organization the evacuation of a large number of Swedish residents from Lebanon. This
These reports can be ordered from: report describes the evacuation throughout its various stages. Swedish authorities
National Board of Health and Welfare were prepared for an event of this type from the experience of the 2004 Asian
Customer Service Webstore or tsunami disaster. Lessons learned from the management and medical care dur-
National Board of Health and Welfare ing the evacuations are presented in this report.
Customer Service
SE-120 88 Stockholm Kulling P, Sigurdsson S, Hamberger B: KAMEDO Report No. 92:
Fax: +46 8 779 96 67 Evacuation of Swedes from Lebanon—Observational studies in connection
E-mail: socialstyrelsen@strd.se with the war in Lebanon in summer 2006. Prehospital Disast Med
2008;23(5):476–480.
The Swedish Disaster Medicine study organi-
zation, KAMEDO, was described in PDM
Introduction
1999;14(1):18–26, and three reports, Numbers
Relations in the Middle East have been tense for many years, including those
69–71, were published. In PDM
between Israel and groups in Lebanon. There is an almost constant risk of ter-
2000;15(3):113–118, two more reports
rorist acts or the outbreak of war in the region. A large-scale armed conflict
(72–73) were published, in PDM
between Hezbollah and Israel was triggered on 12 July 2006 and lasted for 34 days.
2001;16(1):50–52, Report No. 74 was pub-
At the time of the conflict, there were many foreign citizens in Lebanon,
lished, and in PDM 2005;20(4):258–264,
among them a large number of Swedish citizens and people residing in Sweden.
Report No. 75–76 were published. Report No.
77–80; and 82–84 were published inPDM
Background
2007;22(1). Reports 91–92 are published in
The experience from the 2004 tsunami in Southeast Asia indicated that
this issue.
Sweden needed to be more prepared to better handle events abroad that could
affect many people living in Sweden. The Ministry for Foreign Affairs, the
Information on purchase and ordering
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that can leave for a disaster area within six hours of a decision to assess the
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Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 23, No. 5
Kulling, Sigurdsson, Hamberger 477
There is disaster medicine preparedness in the county On Thursday 13 July, more and more people started to
councils. In the three municipalities with major airports, contact the Ministry for Foreign Affairs’ telephone switch-
preparedness is linked to the major airports. board and the consular unit called in the Consular
Emergency Force to respond to telephone calls. The
Events Ministry for Foreign Affairs’ Emergency Group was called
On 12 July 2006, eight Israeli soldiers were killed and two in on 14 July, and this group operated on a daily basis until
were taken prisoner by Hezbollah in conjunction with an 31 July. On Friday 14 July, the Swedish Rescue Services
attack over the Israeli-Lebanese border. This led to exten- Agency decided to send an eight-person assessment unit
sive countermeasures by the Israelis and a large-scale armed with representatives from the Swedish Rescue Services
conflict between Hezbollah and Israel. The conflict contin- Agency, the Swedish National Board of Health and
ued for 34 days. Welfare and the Swedish National Police Board to Cyprus.
The runway at the Beirut airport was bombed during The majority of evacuees were sent to Cyprus for onward
the first days, and a blockade of Lebanese airspace and ter- transportation to Sweden. The Assessment Unit also
ritorial waters was introduced. Israeli air attacks gradually judged the need for reinforcements in the area. On the
were extended, and practically all of Lebanon was attacked. same day, a crisis management staff was established at the
Large parts of the country’s infrastructure were destroyed, Swedish National Board of Health and Welfare. Personnel
rendering the evacuation of foreign citizens more difficult. participated in all meetings held by the emergency group at
the Ministry for Foreign Affairs. The medical director of
Damage the crisis management staff informed the three major city
The war destroyed many houses, especially in southern regions’ officials-on-call about the situation. A list of avail-
Lebanon. Safety in southern Lebanon and in the southern able personnel with suitable training for foreign missions
parts of Beirut was poor, and from time-to-time, virtually also was compiled.
non-existent. On commission from the Ministry for Foreign Affairs,
the Swedish Rescue Services Agency decided, to fully acti-
Disturbances in Function vate the joint response team as a complement to the
It was difficult or impossible to live a normal life and earn Ministry for Foreign Affairs personnel already in place.
a living. During the initial stages, there were 55 people from all of
Approximatley 8,400 Swedish residents were in the cooperating organizations (the Swedish Rescue
Lebanon. At times, many people gathered at the Swedish Services Agency, the Swedish National Board of Health
Embassy in Beirut, where there was a state of chaos. There and Welfare and the Swedish National Police Board), and
was a great need for evacuation from Beirut and other areas. the Joint Response Team had its base on Cyprus.
Evacuees mainly went to Damascus, Syria and Larnaca,
Cyprus for onward transportation to Sweden. In Evacuation 16 July–16 August
Damascus, and to an even greater extent Cyprus, the con- The evacuation began on 16 July. Personnel from the
ditions were chaotic at times. Ministry for Foreign Affairs and the Swedish Rescue
Evacuation flights arrived at Sweden’s three major airports: Services Agency were flown to Aleppo in northern Syria to
(1) Arlanda airport in Sigtuna municipality; (2) Landvetter in prepare for the reception for those who would be evacuat-
Härryda municipality; and (3) Malmö airport in Svedala ed by bus. The eight personnel from the assessment unit
municipality. Many people gathered at the airports and arrived on Cyprus. One of the doctors chose to travel on to
needed assistance with onward transportation to other Beirut after a request from the Ministry for Foreign
municipalities. Many of them lacked true residence in Affairs, and arrived there the following day. On the same
Sweden since they had returned to Lebanon many years day as the assessment unit arrived on Cyprus, the other
prior and no longer had a home in Sweden. parts of the Joint Response Team also arrived and the
Swedish Rescue Services Agency established its staff on the
Responses island with support from the Cypriot Civil Defense.
Crisis Management in Sweden Personnel already in Aleppo received reinforcements of 11
The development of events in Lebanon in July 2006 caused the people from the support unit of the Swedish Rescue
evacuation of a large number Swedish residents. Along with Services Agency.
problems with the coordination and transportation of such a The Swedish National Board of Health and Welfare was
large number of people within an extremely limited time peri- placed in reinforcement status and the work with recruit-
od, the work was complicated by damage to infrastructure; air- ment of personnel continued after the Ministry for Foreign
ports and land routes within Lebanon and to Syria had been Affairs announced that this probably would be a long-term
bombed. In addition, the situation arose during the peak of the mission. The Swedish National Board of Health and
holiday season. In total, the Ministry for Foreign Affairs, in Welfare was responsible for receiving evacuees in Sweden.
cooperation with the Joint Response Team of the Swedish The Västra Götaland Region was given the task of collect-
Rescue Services Agency, and other players evacuated approxi- ing patient information to be forwarded to the correct medical
mately 8,400 people between 16 July and 16 August.The evac- care facility and to plan for possible secondary transportation.
uation was performed with the aid of 53 chartered flights, three The Region Skåne, Stockholm County Council, and
ships (that made seven journeys), and approximately 15 buses. Västra Götaland Region strengthened their disaster man-
September – October 2008 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
478 KAMEDO No. 92
agement organizations and prepared to mobilize personnel addition, the doctor could treat the medical and psycholog-
for the Joint Response Team of the Swedish Rescue ical problems that were difficult for others to assess, and
Services Agency. In close cooperation with each municipal- also could medically assess whether patients could make the
ity (Svedala, Sigtuna, and Härryda), reception at the three long and strenuous journey.
major airports also was prepared. Starting Tuesday 18 July, On 25 July, after ten days of intensive work, approxi-
work was concentrated on evacuating Swedes by ship to matley 7,500 people had been evacuated successfully, which
Cyprus, but many people traveled independently to was the majority of those who wished to receive help in get-
Damascus, Syria. ting to Sweden.
All Swedes who were evacuated to Damascus and
Cyprus continued on to Sweden using regular or chartered Syria—Initially, the only road out of Lebanon was through
flights. On Monday, 17 July, the first flight with evacuees Syria. Since the major roads from Beirut to Damascus had
landed at Arlanda airport. Starting with the second char- been bombed, the alternative was to transport evacuees by
tered aircraft, most aircraft were provided with medical person- road to Aleppo, and from there, fly to Sweden. On Sunday,
nel mainly from the Swedish National Air Medevac (SNAM). 16 July, the road to Damascus was reopened so that evacua-
The last meeting of the emergency group was held on tion work could be organized using that route instead.
31 July, the same day that the final chartered aircraft left
Cyprus. Subsequently, all work was performed within the 1. Aleppo—On Sunday, 16 July, personnel were flown
ordinary operations of the Ministry for Foreign Affairs, and from the Ministry for Foreign Affairs and the
on 16 August, the evacuation work was completed. Swedish Rescue Services Agency to Aleppo. During
the first 24 hours, approximately 750 evacuees left on
Evacuation Work in Place chartered buses in addition to those who had been
The central staff of the Swedish Rescue Services Agency able to leave Lebanon by their own means. After
Joint Response Team was established on Cyprus, where the Tuesday, 18 July, there were some evacuees that con-
majority of evacuees arrived by ship before they were flown tinued to go to Aleppo, but considerably fewer than
to Sweden. Personnel from the Joint Response Team, the previously. For that reason, some of the personnel
Ministry for Foreign Affairs, and Embassy also were in were moved to Damascus, where more people arrived
Aleppo and Damascus in Syria, Mersin in Turkey and Beirut. after the road was passable once again .
Initially, the person appointed medical care coordinator 2. Damascus—During the first days of the evacuation,
by the medical personnel on Cyprus was given the mission work was performed with meager resources. Embassy
of coordinating all actions. When operations expanded, it personnel had to work hard, and a large part of their
was decided that the medical care coordinator on Cyprus time was spent drawing up manifests and helping
also would be responsible for Lebanon, while operations in people with their passports.
Turkey and Syria would be coordinated by the Swedish On Wednesday, 19 July, needed reinforcements
National Board of Health and Welfare in Stockholm. arrived from Aleppo. After 23 July, nearly all of the
Swedes had left Damascus, but evacuation work contin-
Lebanon—On Thursday, 13 July, a Ministry for Foreign ued with registration, passport controls, transportation
Affairs official who was on holiday in Lebanon during the help, etc. Fewer people needed help, and the situation
initial stages of the crisis, assumed the management of the was more manageable. After 26 July, personnel levels
Consulate-General in Beirut. Thus, work in organizing the were decreased gradually, and on Monday, 07 August,
first evacuation started at an early stage. the last medical personnel was withdrawn.
On Sunday, 16 July, bus evacuation was started. A total
of about 1,100 evacuees were bussed out of Lebanon; most Cyprus—On Sunday, 16 July, the Swedish Rescue Services
of them during the first day. Agency Assessment Unit, together with people from the
On Monday, 17 July, approximately 15 people came Ministry for Foreign Affairs, flew to Cyprus to prepare for
from Sweden as reinforcements. The doctor from the the evacuation from Lebanon. They also assessed whether
assessment unit who initially had been sent to Cyprus, but there was a need for reinforcements. Soon after, the other
after a strong request from the Ministry for Foreign Affairs parts of the Swedish Rescue Services Agency Joint
had chosen to travel on to Beirut, arrived there on Monday, Response Team arrived on Cyprus. At most, the staff had
and stayed on commission of the Swedish National Board >40 personnel at their disposal, and received support from
of Health and Welfare. the Cypriot Civil Defense, which lent to them small but
Starting Tuesday, 18 July, evacuation occurred mainly by functional premises for their work.
sea and primarily to Cyprus. Evacuation by road to Syria After Monday, 17 July, the Swedish personnel were
continued, but to a lesser degree than during the first days responsible for coordinating the reception of other
as the buses were needed for transportation from hotels to European Union citizens, since the Swedish personnel were
the harbor in Beirut. the first in place in Larnaca. The need for medical care was
Although the number of medical procedures performed small, but various medical assessments were required.
was limited, the doctor’s presence in Beirut was valuable. On the night of 19 July, a large number of evacuees
His presence had a calming effect on those fleeing the arrived on Cyprus. During the next 72 hours, the figure
country as well as the team assisting the evacuation. In climbed to about 4,000.
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 23, No. 5
Kulling, Sigurdsson, Hamberger 479
On Wednesday, 19, July air transportation from Larnaca Swedish National Board of Health and Welfare must
to Sweden began. Between 19–23 July, >20 flights were be more explicit.
made from Larnaca to Sweden, mostly to Arlanda, but also 2. It is important to establish a coordination staff to
to Landvetter and Malmö. The work in receiving the evac- work between Swedish and international authorities.
uees in the harbors, transporting them between harbors, 3. All personnel who are sent on missions abroad must
assembly points, and airports, and organizing all of the be well-prepared and trained for that type of mission.
flights continued virtually non-stop. 4. The role of medical care coordinator in particular
On Friday, 21 July, >1,000 Swedes were evacuated in 24 must be clearly described in written descriptions that
hours. The situation was particularly chaotic at the airport, must be produced for the commissions and for the
where at one point, the personnel force consisted of four to different officials.
five people who were dealing with 750 frustrated Swedes, 5. Guidelines, procedures, and lines of communication
along with all the others who were there at the same time. must be prepared for handling the registration of
Reinforcements included Swedish police, Ministry for injured and sick people, as well as personal data, pas-
Foreign Affairs officials, people from the church, and oth- sengers, flights, etc.
ers from the staff unit. 6. It must be possible to initiate telephone conferences
After 23 July, evacuees continued to arrive on Cyprus, with all players involved at short notice.
but not in as large numbers. In the night before Tuesday, 25 7. It is important that medical care operations are led
July, two aircraft took off with evacuees, this time from and coordinated by the Swedish National Board of
Pafos. That Tuesday evening, two aircraft left from that Health and Welfare, which must have clear and
location. After that, there were a few isolated flights to Sweden direct contacts with the medical management.
every day, and the operation gradually was scaled down. 8. The situation is facilitated if every official only
reports to one authority.
Flights to Sweden—On Monday, 17 July, the first planes 9. Clear and reliable information creates a secure and safe
with evacuees arrived at Arlanda airport. On Tuesday, 18 work situation and prevents rumors from being spread.
July, the staff of the Swedish National Board of Health and 10. Communication equipment must work, and different
Welfare heard that there were cases of illness among the systems must be available for key persons (mobile
evacuees onboard the aircraft. Therefore, the evacuation air- telephones, satellite telephones, and in certain cases,
craft were backed up with medical personnel from SNAM. VHF radio).
The Västerbotten County Council was responsible for
medical staff specially trained for aviation situations being Medical Care
present on all returning aircraft. Medical staff from SNAM 1. In order to evacuate efficiently, a reconnaissance team is
staffed 24 of the 53 aircraft chartered by the Ministry for needed in strategic places, such as at evacuation airports.
Foreign Affairs. Medical personnel were present on a fur- 2. During the first phase, it is necessary to send more
ther 10 aircraft, partly personnel from Region Skåne, and personnel than originally estimated. The need often
partly medical personnel from the Swedish Rescue Services is greater than it initially seems, and it is difficult to
Agency Joint Response Team. recover from a deficit. The objective must be that
The medical measures that arose mainly consisted of dis- there are sufficient personnel to permit them regular
tributing analgesic tablets, tranquilizers, inhalers for anti- rest and relief.
asthma medicine, intravenous drips, and analgesic injections. 3. Medical personnel must be present during all opera-
The aeromedical measures were led by command and tions abroad, even if medical problems are expected
control groups at Arlanda airport and in Umeå. to be small. Thus, other operational personnel are
relieved of medical responsibility. Having Swedish
Experience medical personnel present is a security factor for the
The Swedish authorities—primarily the Ministry for Foreign victims and emergency services personnel.
Affairs, the Swedish Rescue Services Agency, the Swedish 4. Crisis support and psychosocial support is required
National Police Board and the Swedish National Board of in all situations, and it is important to consider the
Health and Welfare—were prepared for a similar event. special requirements of children.
Among other factors, this was a result of experience from the 5. During air evacuation, personnel trained in aviation
work during the 2004 Asian tsunami disaster. Another con- medicine should be present. They can address med-
tributing factor was working with the government commis- ical needs and make medical assessments before the
sion to supervise preparedness for a situation in which Swedes evacuation flights, and assist during the flight itself.
could be affected by a disaster abroad, and the preparations It is good to use SNAM personnel even for tasks that
that were made in conjunction with this commission. are not explicitly SNAM commissions.
6. Emergency equipment must be supplemented with
Recommendations oral medication (including analgesics) as well as
Management medication for chronic illnesses.
1. The allocation of responsibility between the Ministry 7. All Swedish personnel must wear clear identification
for Foreign Affairs, the Swedish National Police badges with text in English and a Swedish national-
Board, the Swedish Rescue Services Agency, and the ity designation. The badge also must contain infor-
September – October 2008 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine
480 KAMEDO No. 92
mation regarding the authority and organization to County Councils and Municipalities
which the person belongs. 1. All county councils/regions should have an official-
on-call. It is important that the official-on-call can
Reception at Airports be reached within two hours of an alarm.
1. It is important to decide who has the organizational 2. An official-on-call must be present at the municipal
responsibility and who has the financial responsibili- level facilitates communication in the emergency
ty for receiving people at airports in operations of phase of an event.
this type in an acute situation. 3. It is important that the municipalities with major air-
2. In general, the organization for how people are ports are prepared for an event similar to the evacua-
received at airports must be improved, and personnel tion from Lebanon.
must be trained.
Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 23, No. 5
