Syria, Undercover Medicine

(di Sima Barmania, per The Lancet). Fourteen months have passed since Syrian President Bashar Al Assad and his tyrannical regime began the horrific onslaught on opposition protesters and civilians. Since the violence ensued, an estimated 9000 lives have been lost and countless more injured.

The situation in Syria, described recently by international envoy Kofi Annan as “bleak” represents not only a political crisis but also a humanitarian one. Over the course of the uprising there has been information from a myriad of non-governmental organisations, including Physicians for Human Rights, Amnesty International, and Médecins Sans Frontières reporting that there have been gross breaches of medical neutrality plus the deliberate targeting of medical facilities, health workers, and their patients by government forces. However, beyond the bleakness, thousands of miles away in England, doctors from the Syrian diaspora are mobilising themselves to offer humanitarian assistance within Syria, despite the risks.

Hand in Hand for Syria is a non-political UK registered charity, which has recently been established in the aftermath of the Syrian uprising. Mohammed (a pseudonym), a native of Syria and now settled in England, is responsible for coordinating Hand in Hand’s medical response and returned from Homs last month after working in a hospital he initially set up himself. He was stirred to act by exasperation. “I got fed up of crying in front of the TV…I had to do something…hundreds of people are dying every day”, he told The Lancet.Nevertheless, due to the ever-present security issues the larger, more established charities are reluctant to operate within Syria without permission from the Syrian Government. Without this authorisation, understandably, “They [larger organisations] simply aren’t prepared to go”, says Mohammed.

While most organisations are operating on the borders, tending to burgeoning number of refugees, Hand in Hand, equipped with local knowledge, networks, and exclusive access are concentrating their efforts within Homs, Syria, where there is a distinct absence of health services.
“The hospitals are taken over by the military in Homs”, explains Mohammed, “if you get sick there is nowhere to go, so secret field hospitals are set up”.

Mohammed explains how access to Homs is made through a supply route from Lebanon across the Syrian border, but neither doctors nor medical supplies are permitted to pass across the border, so they have to be smuggled through. The perilous journey, which takes 3 days, seems precarious but fortunately he and all their doctors have returned unharmed.

Surrounding the field hospital, are ten rudimentary first aid stations manned by 40 nurses that work voluntarily and do triage; simpler injuries are dealt with there, but those that are more complex are taken to the undisclosed field hospital.

Mohammed describes the types of injury they are treating: “blast injuries, trauma from shelling, sniper wounds, and blunt trauma from collapsed buildings—all of which require urgent surgical care.” There is little reprieve for the health workers despite the supposed ceasefire.

Additionally, the doctors have treated injuries consistent with torture and they have recently found themselves questioning the exact nature of the bombs that are being used as they seem to be causing infections that are not the norm. They have thus undertaken tests to deduce whether there is an element of chemical warfare.

Aside from the acute injuries, the charity also treats chronic diseases like diabetes and asthma, for which only a limited supply of drugs exists. Syria’s pharmacies have been shut down and the only possibility of acquiring medicine is through the hospital itself; they are particularly in short supply of paediatric medicine.

Equally, the field hospital, a humble three roomed building, consisting of a waiting room, pharmacy, and a theatre, is inadequately furnished with equipment that is at best archaic, at worst simply defunct, yet staff have managed to purchase and smuggle in anaesthetics apparatus, which they are particularly proud of.

However, there is a distinct absence of health professionals in the vicinity, which caters to a population of 30 000. Before, there were 162 doctors, now there are just three that remain and do so at considerable risk to their personal safety.

However threadbare the resources, the charity is still keen to show accountability and reassure donors that the medication, food, and clothes are getting through by taking photographs and videos from inside the hospital.

Mohammed shows The Lancet some footage taken from within the field hospital—harrowing viewing, a graphic display of carnage and bloodshed. Children with gunshot wounds to the abdomen and head are visible, a father despairs in Arabic: “It’s been a whole year and nothing has happened!”

In addition to the breaches of medical neutrality, it is also becoming more apparent that the new weapon of war for the Syrian army is rape and gender-based violence committed against both men and women.

Huda (a pseudonym) a British-Syrian pharmacist at Hand in Hand for Syria explains further: “In Syrian society a woman’s awrah (modesty) is so central, so to attack your modesty is the biggest violation and services such as the morning after pill are simply not available.”

The Office of the UN High Commissioner for Refugees (UNHCR), which is working with Syrian refugees in Jordan, Turkey, and Lebanon, has also reported cases of gender-based violence and are offering post-exposure prophylaxis to victims to protect against HIV.

UNHCR’s Laura Padoan explains: “Women are the victims of violence, especially civilians. In Muslim countries where honour is so important, victims are often too scared to report the crime to the security forces, as often they are the perpetrators.”

In fact, gender-based violence has become such a pertinent issue that the US non-governmental group Women Under Siege have produced a “crowd map” where people can document sexualised violence in Syria based on location.

Mousa al Kurdi, an outspoken Syrian obstetrician living in Britain has been vociferous in highlighting the rape of two girls aged 10 and 14 years old who are now pregnant. Al Kurdi, the chairman of the Arab Institute for Clinical Excellence, incidentally taught Bashar Al Assad (a qualified doctor) as a medical student at Damascus University decades ago.

Al Kurdi witnessed first-hand the bombardment of Baba Amr a few months earlier and is succinct in his criticism of Al Assad: “He is a monster” and calls for both “an end to the killing” and “an acceleration of the provision of aid”.

The need to expedite aid is an urgent and pressing one and a concern shared by Hand in Hand’s most recent returnee from Homs—Ahmed, an NHS anaesthetist.

Ahmed recalls a repository of case after case, “a young man in his 30s was injured by a bomb blast, a civilian, injured…one shot in the shoulder, abdomen, legs”.
“I called [the field hospital] on returning 2 days later, they said over the next 5 days, there were massive casualties and they could barely cope.”

“I feel like a traitor”, he says. “I feel more awful now, you feel like you have let them down.”

Despite the apparent sense of hopelessness, there is also a sense of ingenuity exemplified in the logistical operation of the field hospital. The hospital is a house offered by someone located on a secluded side street and relocates every few months to avoid suspicion and utilises personal networks to direct those requiring treatment to the unknown location. Even an empty transfusion bag can cause suspicion and so the “blood bank” is a close network of blood donors, which can be easily accessed.

Notwithstanding, Ahmed is fully aware of the risks: “If you are found with an empty blood bag, you are dead.” He personally knows of a dentist and a pharmacist who were killed and a further two civilians who have gone missing.

He says what hurts the most is when patients ask him “are you not speaking up for us, are you not telling people how we are suffering just to get basic treatment?” But the risks, already great, prevent him from being able to vocalise his patients’ plight.

Huda explains: “Even the medical staff in the hospital we are helping have been targeted—one doctor has had his house set alight. His family have now fled the area but he remains to continue running the field hospital.”

“It is now an offence by Syrian law for a doctor to treat a demonstrator—they call them terrorists—and the crime is arrest, detention, and torture to obtain confession of others providing medical care in this way.”

“We have recently bought an unmarked vehicle to work as an ambulance—it’s now in service in the Homs district. Even ambulance drivers are legitimate targets for this regime.”

Undoubtedly, such actions by government forces contravene international humanitarian law. A new report by Human Rights Watch (HRW) on May 2 titled They Burned My Heart documents war crimes in the Syrian town of Idlib during the peace plan negotiations. HRW “demand access to humanitarian missions” in Syria.

Although the situation in Syria is a political concern it is also a humanitarian one. “All the people that I worked with didn’t belong to any military group”, says Ahmed sorrowfully. “They are all just civilians, just everyday people.” And “I’m not a politician, I’m just a doctor.” (The Lancet)
The full interview with a Syrian volunteer is available here.