By Coleen Kivlahan, MD
Physician colleagues and their hospitals have been the targets of direct attacks during the past three years in Syria. According to UN war crimes investigators, Syrian forces have deliberately targeted hospitals, attacked field hospitals, and prevented patients from receiving medical care.
A United Nations Commission of Inquiry independent panel published its findings to draw attention to what it called “an enduring and underreported trend” in the conflict. The report cited attacks on hospitals shelled by artillery or bombed by jets or helicopters. The attacks have injured and killed both civilians and medical personnel, damaged hospitals’ infrastructure, and impeded their ability to treat patients. Most of us cannot imagine working in such circumstances.
My recent experiences in training Syrian physicians in a border community opened my eyes to levels of courage and commitment I have never seen in my 30 years of practice and international work. I came to grips with my own ignorance as I heard and saw the challenges faced by our brothers and sister physicians in Syria, and by their physician colleagues who are refugees in neighboring countries. Three of my colleagues shared their experiences about working in a field hospital, treating their fellow Syrian people. What follows are their stories.
I am a surgeon, specializing in bone and joint diseases. I work inside Syria in a field hospital with operating rooms, emergency and patient rooms, and a dedicated staff. Since the end of 2012, we have seen daily explosions of cars, barrel bombs, battles and war fronts near our hospital, and direct bombardments. Each week I leave my family behind to go to work; my wife and children live in one strange country, and I work in another strange one, my own country. I am sad when I leave them, as I do not know when I will see them again or if I will die this time in Syria. It is very difficult to reach the hospital, it takes hours crossing checkpoints.
The hurdles I face at work include the large number of patients requiring consultation and surgery each day. I have to make very rapid assessments of patients because of the overwhelming volume. I feel fatigue continuously because I am running between the OR, sick bay, and emergency rooms. We perform five to ten complicated surgical cases per day in the OR. These include the amputation of upper and lower extremities, fractures and external fixations, debridement, tendon repairs, vascular and neurological repairs, compartment syndrome, avulsion of large areas of muscle, skin and bone, and removal of bullets/shrapnel.
I have little time to eat with my colleagues, leading to isolation; I have little time for prayer, which leads to spiritual tension for me. The surgical team must operate on some cases for many hours without a break, which leads to great physical stress and anxiety within my team. The electricity often shuts down because our generator breaks or our diesel fuel runs out. This interrupts the surgical procedures and creates worry and loss of concentration for us all.
The hospital building itself has been targeted more than five times by air missiles, rockets, and barrel bombs. We hear frightening noises often and this leads to chaos inside the hospital. We feel tense and sad because we cannot perform our jobs in the best way, due to lack of concentration and fear in our hearts. We know that we are all at risk of being killed at any time. This impacts the quality of my work, and my psychological state; I feel down on myself because I cannot always deliver good care.
Another physician’s account:
My life before the revolution was a normal quiet life and quite joyful, Sometimes my mother even said to me while I was young “You will never grow up!” I always created fun wherever I went. I worked as a lawyer, played cards, and had a wonderful group of friends. Then the revolution began and things became tense. In the beginning, there were only peaceful protests, but many of us had heard about the events that occurred in the prior regime in the 1980s. When the violence increased in 2012, I could no longer go safely to work.
Some of my friends established a field hospital and needed an administrative leader. The local ambulances could not be relied upon to collect Syrian people who had been seriously injured and many of them died, therefore a field hospital was critical. My office was at the front of the hospital and I saw casualties arrive every day. I remember the first time I saw someone die; I remember that day well and did not sleep that night. I felt as if I was seeing a relative or friend dying. I frequently experienced bombardments of our hospital but especially recall the day I saw a man carrying a 7-year-old girl whose leg was amputated by a bomb. I saw that the leg was not in place and I saw the burned flesh all over her body. It was such a frightening scene.
When cars explode in front of our hospital or bombs explode nearby, we see many dead bodies, burned and mutilated people injured and dying. There are blood and screams everywhere. The psychological pressure on me has been great and I find myself becoming silent, absent-minded and angry for no reason. Sometimes during eating, I recall a patient, and I cannot finish my food. My life is constricted: I sleep, work and do it all again. I try to find ways to release my pressure but the effect is temporary and does not lessen my sadness. I am now living in an unchangeable routine. I now live without knowing the future. I do not know if I am still a normal person. All I know is that I have to be strong, because there is no way back.
And finally, from a young resident:
We are working doctors in Syria. We suffer from physical, psychological problems and difficult life conditions. I work in two field hospitals. I work all week long, 24 hours per day with one day off per week, and frequently no days off. We suffer from work pressure and lack of doctors because so many have left Syria or are detained. We have little time to sleep and our mood has changed negatively because of the current circumstances. As for me, I had to leave residency training in my second year because of the war. I now have no alternative to finish my specialization, and I do not think that these circumstances will end. Believing that I will never be able to go back to study makes me sad, tense, and angry.
We also suffer from lack of security and live in great danger because at any moment, we can have an air raid. We feel terror when we hear the aircraft’s voices (sounds). In my time at the hospital, we have been shelled many times. Now I feel that the pilot is actually targeting ME. I feel horror and fear, it is very tragic when you see one of your colleagues injured and dying. When I help them, I later collapse and feel that destiny is taking all my friends. I swear, this feeling cannot be described. In the end, I believe that we are people who got old too soon. We carry burdens and problems that exceed our capacity. The work even takes the joy out of food. It is now tasteless and once again, I say, we are too old too soon.
The Syrian crisis is not simple. But what is simple is this: Doctors, hospitals, and patients continue to be targeted throughout this conflict. These violations can happen in any country: Let’s not wait to act. What can you do to help? You can educate yourself about on-the-ground realities of Syrian physicians and other colleagues in conflict zones, you can speak out about it, and you can support international political action to protect medical neutrality by contacting your elected representatives, the White House, and the United Nations, demanding that our medical colleagues be allowed and supported to treat patients, save lives, and alleviate suffering without the fear of attacks or reprisals. Our colleagues are counting on us.
*The three narratives are translated and anonymous. All identifying details have been removed.
Coleen Kivlahan, MD, MSPH, is the senior director of the policy and regulatory group in Health Care Affairs at the AAMC. She has been a practicing physician for over 25 years and is a volunteer with Physicians for Human Rights (PHR) in the Asylum Network as a trainer and evaluator. She can be reached at firstname.lastname@example.org.