The NPHR Blog is excited to feature this post, written by Sheila Burt, as an introduction to our upcoming Northwestern Public Health Review winter issue. Burt expertly weaves together the experiences of three Chicago-based doctors who have assisted in war-torn Syria. Through her words, a painting of tragedy and hope emerges. The upcoming issue will feature pieces written about public health as it relates to the current migrant crisis in Europe and the Middle East. We look forward to sharing our work and receiving readers’ comments. – Margaret Walker (Blog Editor)
By Sheila Burt –
The smell of death – decaying corpses in charred vehicles, a bitter sulfurous odor emitting from burning buildings – permeated the air as the doctors traveled by car down Castello Road in eastern Aleppo, Syria.
It was June 2016, marking five years since the start of the country’s civil war.
At first, John Kahler, a pediatrician from Chicago who has done medical mission work throughout the world, imagined the scenes in Syria would be similar to the destruction he witnessed in Haiti after the 2010 earthquake. But as the smell of rot and decay became more pungent and children walked across mounds of rubble as if it were a part of everyday life, he realized he had entered an entirely new world of destruction almost too hard to comprehend.
“It was powers of 10 worse. I never have seen anything like the amount of destruction. In Haiti, at least you could see where you could rebuild it. There’s no rebuilding Aleppo,” Kahler recalled in a phone interview from his home in suburban Chicago. “There’s block after block of total complete destruction.”
Kahler is a pediatrician with ACCESS Community Health in Blue Island. He traveled to Syria with two other Chicago-based doctors, Sam Attar and Zaher Sahloul, with the Syrian American Medical Society (SAMS), a non-profit medical relief organization spearheading efforts to aid the country. All doctors were drawn to Syria to bear witness and stand in support of their colleagues who risk their lives everyday to treat Syrians injured in bombings and airstrikes. Medical personnel in Syria – doctors, nurses, medics – have been especially vulnerable in attacks.
To date, the conflict has displaced more than 11 million Syrians and killed an estimated 470,000 people, including scores of civilians. Since the fall of Aleppo, there is concern that the Syrian regime, backed by Russian forces, could next target Idlib, where many evacuees have been taken and health resources are limited to address the needs of the thousands injured. A cease-fire offers some cautious hope, though rebuilding the healthcare system in Syria will be an immense undertaking.
Kahler volunteered at M2, a hospital in eastern Aleppo that housed a pediatric unit. (Many hospitals in Syria are code-named to offer some protection; M stands for mashfa, which means hospital in Arabic). There, children with chronic diseases such as hepatitis, asthma, and pneumonia had exacerbated health problems due to poor hygiene and a lack of access to medicine, vaccinations, and routine check-ups. A newborn with meningitis died while he was there; other patients were dehydrated and had jaundice. Many of the patients should have been treated earlier, but parents often feared going to the hospitals in the event of an attack.
“These were a function of people who in a pre-war state, would have just come back to their doctor. It wasn’t that [the parents] didn’t know where to go; they were afraid to go,” he said. “They opted to stay home for an extra day or two to see what would happen than to go.”
Though targeted attacks on hospitals are against International Humanitarian Law, the non-profit group Physicians for Human Rights has documented 400 attacks on 276 separate facilities between March 2011 and the end of July 2016. Reports indicate that the Syrian government and backing Russian forces are responsible for the vast majority (90%) of these attacks. Many hospitals have been hit multiple times, forcing them to close or move operations underground. On top of these targeted attacks, The World Health Organization estimates that more than half of the country’s public hospitals and almost half of its public health care centers “are either closed or are only partially functioning.”
According to Elise Baker, a research coordinator at Physicians for Human Rights, a variety of attacks on health care are happening in other countries, “but what makes Syria unique is the scope and scale of these attacks.”
“(In Syria) there is this all-out war on every part of the health care system in order to prevent people living in opposition controlled areas from accessing care,” she said. “And this started at the start of the conflict, when it really still was a revolution and not yet an armed conflict.”
Baker has led a mapping project to document attacks on medical facilities and personnel through open-source research from social media posts and field source reporting. An estimated 768 medical personnel in Syria were killed between March 2011 and the end of July 2016, according to PHR.
Baker says PHR-reported attacks are conservative due to the length of time it takes to document and verify the attack, and that the true numbers may be much higher. Many of these attacks are the result of gunfire, air and rocket strikes, or barrel bombs—explosives made from barrel-shaped containers stuffed with TNT, shrapnel, and other explosives/chemicals.
The city of Aleppo, once the largest city and cultural pride of Syria, was at the center of the conflict and subjected to repeated attacks for nearly four years. Until recently, when pro-Syrian government forces regained control, it was roughly divided into the government-held western side and the rebel-held eastern portion. Public health experts warn that assaults on medical facilities could grow worse in other parts of the country if the same tactics are used.
Attacks on Syria’s public health system also have impacted people with otherwise treatable diseases like high blood pressure, diabetes, or early-stage cancer; mental health and the psychological impact of the war, especially in children, remains untreated. Persons with disabilities are some of the most vulnerable in war, and for those who survive, the impact of the violence will be life-long.
“You have a large number of people who have disabilities, who have amputations and need artificial limbs, who need rehabilitation, who need counseling if they have psychological problems or post-traumatic stress disorder,” said Zaher Sahloul, a critical care specialist at Advocate Christ Medical Center in south suburban Chicago. “On top of that you don’t have proper clean water and sewage, and garbage collection, so that of course is a recipe for infectious diseases.”
Sahloul has visited the country 14 times, five of them in Aleppo, since the start of the conflict. He is the former president of the Syrian American Medical Society and current senior advisor. He estimates that since the conflict began life expectancy for Syrians has fallen dramatically, and more than 200,000 have died prematurely of non-infectious chronic diseases such as cardiovascular diseases, diabetes, chronic lung diseases and cancer, that otherwise could have been largely prevented.
Many of his colleagues have also reported unprecedented rates of malnutrition and babies born prematurely – issues that could have been addressed before the war but are now difficult to manage due to a fragmented public health system. Though he did not witness chemical warfare when he treated patients, his colleagues have reported cases of chlorine gas attacks used against civilians – which may not kill, but leave a lingering psychological impact.
“Imagine the fear of people when in the middle of the night, you start to smell a bleach-like (substance) and then your children start to cough and suffocate in front of your eyes,” he said. “Many people, especially children who are exposed to chemical agents, have lifelong post-traumatic stress. They have recurrent dreams and nightmares with what happened to them becoming vivid over and over and over.”
For Sam Attar, the same sense of dread and fear he felt when volunteering at Ground Zero in the aftermath of 9/11 consumes him every day while in the hospitals of Syria. Attar traveled to Syria with Kahler and Sahloul in June but stayed in the country a few weeks longer.
He volunteered at M10, the main trauma hospital in eastern Aleppo destroyed in airstrikes in October. As an orthopedic surgeon based in Chicago, he is accustomed to dealing with gaping wounds, but the situation in Aleppo continues to unnerve him. In Chicago, he works at Northwestern, a top-rated academic hospital in the U.S. Modern equipment, anesthesia, and trained staff are abundant. But in Syria, he must perform triage, deciding which patient has a better chance to live, leaving others to die.
From his office in Chicago, Attar described working in an under-staffed, barebones field hospital with limited resources.
“You’re always on edge,” he said. “When a missile lands 15 meters from the hospital, and it shakes, and you’re knocked off your feet. You’re not sure what is going to happen next. Was that a mistake? Was it done on purpose? Is there another one coming?
“Then you run to the emergency room. You’re overwhelmed and flooded with people. So many people are trying to get through the front door and there’s no place to put them. People are lying on top of each other, and there are patients on the floor, floors smeared with blood. People are coming in with their body parts, their arms and legs. You don’t know who is alive or dead. You just move on from one to the other, one patient at a time.”
His voice became shaken and soft as he recalled the patients who died in front of him: A pregnant woman who lost her unborn child from the impact of an attack and later died, leaving behind her 10-year-old son; people with such severe trauma that Attar could see their exposed brains or intestines as they waited to be treated; children who were burned so badly that they were unidentifiable.
He remembers a 5-year-old boy who was paralyzed from the chest down when shrapnel from a barrel bomb cut into his spinal cord. The boy was gasping for breath. The staff put him on life support, but he died a few days later.
“It’s always a blur when I’m there,” he said. “I remember families, moms and dads, brothers and sisters, sons and daughters. You see parents rushing to the hospital, looking for the children finding out who is alive, who has lost both legs.”
Attar, who is of Syrian descent and still has relatives in the country, also worries about the future of all Syrian children – the ones he could not tend to and the ones he treated. In his youth, Attar often wandered the streets of Syria, past open-markets and cafes. “I remember the streets being full of life with a lot of hustle and bustle,” he said. “And children running the streets playing like you’d find anywhere else in the world.”
But many of the young patients he treated this past summer know a much different Syria.
“For a lot of them, the ones that are 5, 6, or 7, this is all they’ve known since they’ve been growing up. Bombs and being hungry is what they’ve known growing up. And the ones in refugee camps, they’re growing up uneducated, feeling abandoned, stigmatized, and alienated. And that’s what worries me. When they grow up, what are they going to do? Who are they going to turn into? How are they going to perceive a world that…didn’t really take any meaningful steps to prevent them from growing up in a refugee camp?”
Yet for these doctors who have borne witness to the war, a sense of hope came from seeing the resilience of the Syrian people — the doctor, nurses, and first aid workers who risked their lives to care for their neighbors.
“It’s like the last ray of hope for a community,” Attar said. “If you have a community under siege, under bombardment, it’s the schoolteachers who choose to stay and teach children; it’s the hospitals and the people who staff the hospitals that provide some sense of hope and normalcy. It gives people a sense that life goes on and there are people who do care. There are people that are going to share the burden with you. That you’re not alone; we’re here for you and we’re in this together.”
Cover Photo: Sahloul and Kahler at the Umayyad Mosque (circa 1300)
Photos courtesy of Dr. John Kahler, Dr. Mohammed Sahloul and Dr. Sam Attar
- Syria Profile, Human Rights Watch: https://www.hrw.org/middle-east/n-africa/syria
- The Hell of Syria’s Field Hospitals, Samer Attar, New England Journal of Medicine, June 9, 2016: http://www.nejm.org/doi/full/10.1056/NEJMp1603673#t=article
- Syria: Facts and Figures, https://www.sams-usa.net/foundation/index.php/syria-crisis/facts-figures
- Physicians for Human Rights: Syria: http://physiciansforhumanrights.org/about/places/syria/
- Death Toll From War in Syria Now 470,000, Group Finds, New York Times, February 11, 2016: http://www.nytimes.com/2016/02/12/world/middleeast/death-toll-from-war-in-syria-now-470000-group-finds.html?_r=0
- Aleppo Abandoned: A Case Study on Health Care in Syria, Physicians for Human Rights: http://physiciansforhumanrights.org/library/reports/aleppo-abandoned.html
- Under Attack: Aleppo’s hospitals, The Lancet, July 19, 2014
- The War on Children in Eastern Aleppo, Doctors Without Borders, October 14, 2016: http://www.doctorswithoutborders.org/article/war-children-eastern-aleppo
- Anatomy of a Crisis: A Map of Attacks on Health Care in Syria, Physicians for Human Rights: https://s3.amazonaws.com/PHR_syria_map/web/index.html
- War is the Enemy of Health: Pulmonary, Critical Care, and Sleep Medicine in War-Torn Syria by Mohammed Z. Sahloul et al., Annals of the American Thoracic Society: http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201510-661PS#.WBY8dOErKt8
- Medical neutrality and solidarity in the Syrian armed conflict: The Journal of Global Health, Fall 2013, Volume 3, Issue 2: http://www.ghjournal.org/medical-neutrality-and-solidarity-in-the-syrian-armed-conflict/
- “We have been with Syria’s children. Their suffering must end,” by Samer Attar, John Kahler, Zaher Sahloul, Chicago Tribune, September 14, 2016: http://www.chicagotribune.com/news/opinion/commentary/ct-aleppo-syria-assad-obama-bomb-attack-perspec-0911-jm-20160909-story.html
Be on the look out for our upcoming issue:
…featured topics include:
- The Consequences of Untreated Trauma in Syrian refugee Children in Lebanon.
- A Path to Mental and Physical Health Care for Syrian Refugees in the United States.
- The Public Health Crisis in Greece
- To Learn is to Rebuild
- Early education as a path to long term health in refugee and displaced populations