Doctors working in makeshift field hospitals in opposition-held areas of Syria are regularly bombed, and sometimes have to let wounded patients die because they lack trained staff and medical supplies, says the head of a Syrian American medical association that operates several of the clinics.
Dr. Zaher Sahloul, president of the Syrian American Medical Society (SAMS), spoke to Syria Deeply after his organization released a report earlier this week, in conjunction with the Johns Hopkins Bloomberg School of Public Health, that lays bare the nightmarish conditions for healthcare workers and patients in areas that have come under government attack. He quoted one surgeon as saying that, if an operation was likely to take more than two hours, “we have to forget it and the patient dies.”
The joint report, based on interviews with 27 health professionals working in opposition-held areas, also quoted a doctor from Idlib in the north of the country who said that “working in a field hospital is like death”, and a doctor from Aleppo who said he could not “forget the sight of amputated limbs, severed heads and horrible cranial injuries.”
The report said that, between January and March 2014, one of the organization’s field hospitals in Aleppo averaged between 50 and 75 war-related trauma cases a day despite the fact that “only 13 surgeons and a total of about 30 doctors serve 300,000 people in Aleppo.”
The non-profit association has opened makeshift field hospitals in homes, factories and farms in Syria and surrounding countries. Since the beginning of the Syrian conflict, healthcare and access to humanitarian relief has been withheld as a tactic of war, and medical staff in opposition-controlled areas have accused the government of deliberately targeting civilian healthcare personnel and medical facilities.
According to Physicians for Human Rights, at least 610 medical personnel in Syria have been killed, and there have been at least 233 deliberate or indiscriminate attacks on 183 medical facilities since the start of the conflict.
Most Syrian health workers have fled the country, forcing those remaining to perform at levels far beyond their training. The constant threat of bombs also deters patients from seeking help, and has created impossible conditions for doctors trying to operate on patients.
Dr. Sahloul spoke to Syria Deeply about the collapse of Syria’s healthcare system and the conflict’s toll on the remaining medical professionals.
Syria Deeply: Can you describe what it’s like to run a medical facility in Syria?
Dr. Sahloul: Medical staff operate under a different set of challenges and circumstances that they would not face in non-conflict zones. They worry about the availability of medical supplies to treat patients, if the available surgical or medical team has the necessary skills to treat the patients, and the most dire concern inside Syria today: the safety of patients and medical staff under the constant threat of bombs, and where to rebuild hospitals once they have been attacked.
During my last mission to Aleppo, I went to one of the hospitals that was rebuilt by SAMS a couple years ago. It is now the largest trauma center in Syria, treating many of the victims of sniper attacks and barrel bombings in Eastern Aleppo.
The hospital was partially destroyed three times by barrel bombs and one time by missiles. Despite the ongoing strikes, the local team felt that it was necessary to rebuild the hospital because the whole neighborhood depended on it for surgical and primary care. The hospital was rebuilt four meters underground due to safety concerns. It has a big emergency room, waiting room, three operating rooms, radiology department, a lab that provides basic services like a blood bank and an ICU that we connected to medical care specialists here in the U.S. who oversee the care of patients through telemedicine. However, the fact that it is underground does not guarantee full protection from regime strikes.
Syria Deeply: What is the biggest challenge to healthcare provision in opposition-controlled areas?
Dr. Sahloul: When asked what would help them the most, almost without exception every nurse or physician said: “Stop the bombing.” It’s nearly impossible for medical staff to save lives if they know that they can be killed with their patients at any time. Unfortunately, there are many incidents where physicians, medics or ambulances drivers have been targeted and killed. Physicians for Human Rights documented the death of 610 healthcare professionals inside Syria. Because of the constant threat of death, there is a huge deficit of medical professionals from Syria. In Aleppo, an area that serves 300,000 people, there are only a few surgeons and primary-care physicians left, and absolutely no neurosurgeons or eye doctors.
In spite of the denial of the Syrian government, barrel bombings have continued day after day. When I was in Aleppo four weeks ago, we received several patients who were victims of barrel bombings. Before the crisis, Aleppo had a population of 1.8 million, but many civilians were forced to flee because of the threat of sustained barrel bombings.
Syria Deeply: What are the conditions like in besieged areas?
Dr. Sahloul: Aleppo is considered semi besieged – there is only one route that connects Aleppo to the Turkish border, and this road is exposed to shelling, barrel bombing and missile attacks from fighter jets. Lately, the Syrian regime has tried to encircle Aleppo completely. If that happens, it will be a worse humanitarian crisis than it is now.
There are other areas inside Syria that are completely cut off from the outside world, like Eastern Ghouta, which is completely under siege. There is no way to smuggle or send medical supplies into the area. U.N. agencies trying to provide humanitarian assistance to Eastern Ghouta are exposed to all sorts of bureaucratic hurdles and, in many cases, are denied access to deliver medical equipment and supplies. In the rare circumstances that they are allowed to send in medical supplies, some of the supplies are taken by military troops in control of the area.
The only way to get into besieged areas like Eastern Ghouta is through tunnels, or to have people risk their lives to smuggle in medical supplies. Eastern Ghouta now has a population of 500,000, but before the crisis it had a population of two million. There are hospitals and clinics still operating in Eastern Ghouta despite a siege that has been going on for 860 days, which has left residents without any access to electricity for over two years. The only way for hospitals to function without electricity is through generators, but the price of diesel fuel inside Eastern Ghouta is now the highest in the whole world – a liter of diesel fuel costs $4, which means a gallon cost $12.
The local community is trying to come up with creative solutions to deal with the shortage of fuel. For example, SAMS partnered with the Syrian American Engineer Organization to provide sustainable energy to these hospitals. Methane is a gas that can be collected and burned as a fuel. This gas is produced by animal waste as it decays. We devised a solution where we dg holes in the ground that are filled with animal waste, then the gas can is used to operate generators.
Syria Deeply: What are the conditions of the people you are treating? How have these conditions changed over the course of the conflict?
Dr. Sahloul: In the areas under siege, besides the victims of bombings and guns, we are witnessing the spread of infectious diseases due to the lack of electricity, clean water, antibiotics and a lack of waste management. There are epidemics of typhoid fever, hepatitis A, parasites like leishmaniasis, lice and scabies and many other water-born diseases. In 2013, we had an epidemic of polio and measles because of the lack of adequate vaccinations for children under five years old.
We are also witnessing the fallout of ignoring chronic diseases – a silent killer inside Syria – such as heart disease, hypertension, cancer, diabetes and kidney disease. There is little treatment available for them, and the destruction of the pharmaceutical market and the decrease of the buying power of the Syrian pound has meant that people are no longer buying medication. In 2013, SAMS estimated that as many as 200,000 Syrians have died from chronic conditions, such as cancer, diabetes, hypertension and respiratory and heart conditions as a result of lack of access to drugs and treatment, and this number has grown since then.
Syria Deeply: How has the lack of safe facilities and medical supplies disrupted your ability to treat your patients?
Dr. Sahloul: In drastic situations, the medical community can’t save the lives of every patient that come to their hospitals. Overstretched medical staff must confront mass casualties from the combined impact of bombings and secondary attacks on rescue workers. If a local hospital has the capacity to treat 20-30 patients a day, and suddenly there are 100-200 patients coming in with injuries related to the bombings, you have a limited capacity to deal with everyone, and often the number of daily injuries leads to wrenching triage decisions.
According to our report, one field hospital in Aleppo averaged 50-75 war-related trauma cases a day between January and March 2014, yet only 13 surgeons and a total of about 30 doctors serve 300,000 people in Aleppo. One surgeon reported: “If an operation is likely to take more than two hours, we have to forget it and the patient dies.” Another respondent told us: “Once beds are filled, there is nothing to be done for others.” Choosing which patients to save is the one of the most difficult decision facing the medical staff.
Syria Deeply: What would your message be to the international community? What are your most urgent needs and concerns?
Dr. Sahloul: The international community needs to be more proactive in providing protection from the bombings, especially in terms of the targeting of hospitals, schools and clinics. There have been more attacks on hospitals and killing of physicians since the U.N. Resolution 2139, calling for the end of indiscriminate attacks against civilians, was passed last year. The international community also needs to ensure that areas under siege are addressed in an adequate way.The world has forgotten about people living under siege. U.N. reports say there are 200,000 people living under siege, but our reports found that there are more than 600,000 people completely cut off from the outside world, and most of those are women and children. Children inside Syria are dying because of lack of nutrition and access to baby milk. It’s unacceptable in the 21st century that we have civilians dying because they are forced to either surrender or starve to death.