The Medical Sector in the North of Syria Stumbling Forward
Enab Baladi’s investigation team
Mohamed Homs – Nour Dalati – Reham al-Assaad
When she discovered her disease about a year ago, the “malignant” tumor had already spread in her breast. The woman’s discovery has signaled the beginning of her war that was not easy against cancer. This war was even worsened by a tense military reality and deterioration in the medical system, making cancer patients at the bottom of the list of priorities, said the young lady Rahaf.
Rahaf, a resident of the town of Jabal Zawiya in the southern countryside of Idlib, is suffering from breast cancer with which she has been diagnosed after pains that led to a “difficult” journey of medical tests and radiographs that confirmed her disease. However, this confirmation came at the wrong time and the wrong place.
Since Idlib did not have, until recently, specialized hospitals for early detection of tumors and with the necessary doses of chemotherapy, Rahaf was forced to travel through areas as dangerous as the disease when she had to travel to the Syrian regime controlled areas and receive treatment in its hospitals, and then return to her city.
Rahaf, 28, tried to travel to Turkey for treatment, through the clinics of Bab-al-Hawa border crossing. However, the refusal of her request and the spread of her disease left her with few options, either to give up and dispense with treatment, or to travel to the regime-controlled Damascus, Latakia, and Hama in order to conduct tests and obtain the necessary chemical doses.
Rahaf, who is a mother of two daughters, described her Damascus and Latakia treatment trip to Enab Baladi as a “heavy burden”, speaking of a security clampdown on the Syrian regime’s barriers due to the word “Idlib” written on her identity card, under the “Birthplace,” as she put it.
“Perhaps if the medical situation in Idlib had been more developed, I would have got rid of the trouble of travelling, discovered my disease earlier, and had more chance of recovery,” said Rahaf with a look of pessimism mixed with a little hope when she learned that her treatment was available in her province, specifically in the Central Hospital in Idlib city, which developed a centre for the treatment of breast tumors, last November.
The centre, which was opened under the supervision of the Idlib Health Directorate and the Syrian American Medical Society “SAMS”, may have developed the medical system in Idlib, when the Mammogram provided early detection of breast cancer, as well as providing chemotherapy for breast and lymphoma tumors, which infect tissues and lymph nodes in the body.
The assistant director of health of Idlib, Mustafa al-Eido, told Enab Baladi that the centre provides treatment services under the supervision of doctors specialized in the treatment of tumors, noting that the centre specializes in chemotherapy only, in addition to providing medical consultations for patients with malignant tumors of all kinds.
The provision of chemical treatments comes at a time when the medical sector in the north of Syria is struggling to proceed at several levels despite the limited resources and the repeated violations.
However, the problem of the lack of radiotherapy in Idlib still constitutes an obstacle to cancer patients there. Rahaf still needs to travel to the regime controlled areas for radiation tests in its hospitals, although she has got rid of the burden of receiving chemical doses in these hospitals, because they have recently started to be provided in Idlib.
The assistant director of Idlib health confirmed to Enab Baladi that the centre will provide radiation therapy and not just chemotherapy, “but in later stages.”
Cases similar to the case of Rahaf, have alerted officials to the situation of cancer patients in the opposition-controlled north of Syria. Although medical experience is still at the beginning of development and recovery after the decline, it still gives hope of a reality where more attention is given to patients with incurable diseases, including cancer patients.
Medicine in Idlib
Between emergency response and health care
As with other service sectors that have gradually grown according to need, interest, and priority in Idlib, the growth of the medical sector in the city has been natural, ranging from field medical centers to hospitals and health centers, subject to coherent administrative organization and structures.
This transition between emergency response (emergency action) and organized care is made according to the needs of the region. In the period of bombing and military targeting, the medical response is limited to addressing the damage caused by military actions on the ground, both wounded and injured.
However, when the region is in a state of appeasement, the organizations and institutions concerned are able to move forward to expand health services including quality services and secondary health services.
Idlib is currently moving towards improving medical performance in general, both at the level of the type of medical services, their number, centers, and facilities. This improvement is associated with the decline of military operations in the region to a large extent. However, the medical sector is still facing other challenges.
Human resources and support … the most important challenges
Mohamad Katoub, Advocacy Manager at the Syrian American Medical Society (SAMS) said that “Stability is one of the most important challenges of medical development, since it helps organizations to provide quality services.”
Katoub said in an interview with Enab Baladi that “the second challenge is to provide human resources that cover all kinds of services, especially as there are more than three and a half million people in the province that need different kinds of services.”
He added that “when we talk about a large population, it means that the coverage of the medical services they need is not easy to attain, such as providing vaccines, childbirth services, the treatment of chronic diseases, infectious diseases, and performing surgical operations, and we must not forget that we have a large proportion of permanent injuries that have led to physical disabilities and more.”
Meanwhile, the Dean of the Faculty of Medicine at the University of Idlib, Dr. Mohammad al-Omar, said in an interview with Enab Baladi, that some medical fields are witnessing a shortage of medical specialists in the north of Syria, such as specialists in blood and kidney diseases and neurosurgery.
The Advocacy Manager at the Syrian American Medical Society (SAMS) said that “the lack of human resources in some specialties is a major obstacle, especially in specialties such as neurosurgery. There are less than five specialists in the whole area while in cardiac surgery there are only two doctors, and they even do not have all the required and sufficient tools.”
In addition, the deputy head of health care of Idlib, Mustafa al-Eido, asserted to Enab Baladi that logistical obstacles are hindering the stability and development of the medical sector. He referred to the medical consumables provided through charity organizations, and stated that their availability depends on the amount of support and continuity.
“We have witnessed a great shortfall during dialysis sessions and hundreds of patients have been threatened with interruption. Today, we have been able to secure 16,000 sessions through Shafak organization. These sessions will serve only for six months, so we will face the same problem six months from now.”
Despite the many challenges facing the medical development in Idlib, al-Eido believed that the medical situation in the region can be considered as “an achievement”. He stressed that “it is very sophisticated compared to regime held regions, and the previous situation there.”
Organizations and Health Department… Complementary role
A number of international organizations are providing support to the medical sector in north Syria, the most prominent of which is the support US is offering through United States Agency for International Development (USAID).
Although the agency has halted the aid since last September, it has resumed its support for the Syrian American Medical Association (SAMS) and Relief International, in addition to hospitals including Maarat al-Nu’man Hospital, Maternity Hospital in Idlib and Aqrabat Hospital.
According to the report published by OFDA website, and translated by Enab Baladi, the USAID provided about 26.1 million dollars in 2018 to UNICEF so as to support water and sanitation basic programs in Syria.
Union of Medical Care and Relief Organizations (UOSSM) is also considered as one of the most prominent supporters of the medical sector in north Syria, providing primary health care centers, mobile clinics, and medical services to thousands of Syrians.
According to UOSSM annual report of 2017, the union has provided more than 24 million dollars in cash and in-kind cash to support the medical process in Syria. Support now focuses on northern Syria, mainly in opposition held areas.
Such organizations as well as others such as Shafak, Ataa and SRD provide support through funding the existing medical projects and hospitals and coordinating with Idlib Health Directorate.
Deputy Head of health care in Idlib, Mustafa al-Eido, told Enab Baladi that the Directorate has played a leading role at every stage which differed from one region to another.
He considered that organizations are a key partner of the Directorate of Health, while the Directorate represents the database addressing the entire health sector. It is the only party owning the entire data and able to lead the health sector while the aforementioned partner takes care of organization.
The Advocacy Manager of the Syrian American Medical Society (SAMS), Mohamad Katoub, referred to the importance of the role of the health directorate, for it is considered as the governance structure leading the sector, without which it will not be able to develop.
“At the moment, organizations are working to meet the needs and identify priorities along with the Directorate of Health, which sets procedures and policies,” he said.
Katoub believed that the organizations are considered as an alternative, and should not do everything “they are here to help, not to lead,” he said.
Aleppo countryside: Medical progress thanks to Turkey
As a result of the relative stability of Aleppo’s rural areas under the control of the Turkish-backed Free Army factions, the medical sector is recovering and working hard to develop the sector’s work focusing on response and health care. Turkish support provides the sector with a boost and Turkish expertise and enables a better planning for a more integrated work.
The Turkish Ministry of Health is working along with other organizations, which support the medical sector in Idlib, to improve and empower the region’s medical sector by rehabilitating and expanding hospitals in the area as well as several health centers, such as the centers of Ihtaimlat, Suran and Dabiq and al-Rai towns. A hospital at al-Bab city, which is considered as the largest and most modern in the region currently, has been opened, managed and organized by the Turkish Ministry of Health.
The hospital contains 200 beds, 40 examination rooms and clinics, as well as a CT scan, two MRI, ECHO devices and four x-ray devices, according to Ahmed al-Abo, Head of the medical office of al-Bab Local Council. The hospital also includes eight operating rooms, a special section for obstetrics, and incubators as well as a dialysis unit.
In the cities of al-Rai and Mare’ in rural Aleppo, the Turkish government has constructed two hospitals with similar facilities, which will soon be opened.
These hospitals will facilitate procedures for patients who often have to move to the hospitals near the crossings and other areas in order to get the treatment they need.
Operative organizations and dual coordination
The organizations responsible for supporting the medical sector are working to provide various health services in rural Aleppo through establishing primary and secondary health care centers and referral systems, according to Dr. Uqba el-Daghim, Director of SRD organization.”
El-Daghim assured to Enab Baladi that the work of these organizations focuses on ensuring the continuity of health care centers, providing them with necessary medicines, securing vaccines and treating leishmaniasis, in addition to raising the level of the working staff by supporting the educational institutions and hosting basic and specialized training courses.
The organizations supporting the medical sector are coordinating with the Turkish Ministry of Health, which oversees the medical process, according to el-Daghim.
However, a knowledgeable source, which is familiar with medical support in the region and preferred to remain anonymous, told Enab Baladi that coordination is not limited to the Turkish side, but is done at two levels; the first is through the Aleppo Health Directorate as regard to the rural areas of southern and western Aleppo while the second level is through the Health Complex in the Turkish city of Gaziantep, led by World Health Organization (WHO), as regard to the northern countryside of Aleppo and Afrin.
Quality treatments are available… While others are not
In the countryside of Aleppo, there are specialized medical disciplines such as Orthographic, Vascular surgery and neurosurgery, according to Ahmed El-Abo, who stressed their need for future development.
“The presence of these disciplines greatly contributed into reducing the number of referrals to Turkey, which are now limited to complex cases only,” said al-Abo, the head of the medical office of al-Bab Local Council.
According to al-Abo, the area needs radiation and chemical therapy, and medical devices such as MRI and a lithotripsy device for dissociation of kidney stones.
The Head of the SRD office in Syria, Uqba el-Daghim, predicted slow progress in securing these quality services, noting that work is still ongoing to secure these services and equipment because this type is difficult to provide by donors in case of emergency .
Two medical colleges in the North
Can these universities provide qualified medical staff?
In 2015, two medical schools were established at the Free Aleppo University and Idlib University. Thousands of students, either freshmen or those who dropped out of other medical schools run by the Ministry of Higher Education in the government of al-Assad’s regime, joined the newly inaugurated colleges.
Given that the study of human medicine needs six compulsory years of studies, this means that medical student promotions have not graduated yet. However, some other students, who came to finish the rest of their designated years of studies, did actually finish and got their diplomas from the Aleppo and Idlib medicine colleges.
Medicine studies in the Free Aleppo University … Six graduates and 260 active medical students
Since its establishment three years ago, the Human Medicine School of the Free Aleppo University has been headquartered in Mare city. The dean, Dr. Othman al-Hajawi, told Enab Baladi that the college has welcomed 260 students so far.
Since then, six doctors, who came to finalize their studies, have graduated from the Aleppo’s medical school, as al-Hajawi indicated.
Al-Hajawi asserted that the students are “active in the medical field in the liberated areas and their medical contributions have a footprint in the north of Syria. The vaccination campaigns and the medical centers confirmed the efficiency of our students, and many organizations depend on them in its medical projects as physician assistants.”
He considered that the decision to found a medical school within the Free Aleppo University came in response to the lack of qualified medical staff in the region, the limited capacities of already existing medical facilities, and the lack of support from international organizations and committees, in addition to the growing number of bombing casualties who need medical care.
Medical school in Idlib: Two more years to get the diploma
600 medical students have enrolled in Idlib medical college until the academic year 2016-2017.
According to the Dean, Dr. al-Omar, Idlib’s medical school has now students in the first, second, third and fourth year, who have been accepted to the college after being submitted to an annual selection procedure. Up to now, only a small number of students, who are enrolled in the completion program, have graduated.
Al-Omar has confirmed to Enab Baladi that the students who have received their diplomas are now working in the medical sector. However, he noted that Idlib medical school will start providing graduate doctors for medical facilities and clinics in two years.
For post-graduation majors, al-Omar said that the efforts are under way to establish a residency and specialization system in hospitals located in areas controlled by the opposition factions.
Since last August, the college of medicine at Idlib University has been recognized by World Federation for Medical Education (WFME) which is the largest international body specialized in teaching medicine around the world.
Bombing and kidnapping: Violations have stalled the medical sector in the north
In last June, a number of doctors and pharmacists in Idlib announced the suspension of emergency and non-emergency work for three days in protest against violations committed against the medical sector in the province.
These protests came as an expression of disdain against repeated assaults against medical personnel in Idlib, and the abduction of many doctors by unknown groups which demanded a huge ransom of 50.000 dollars, in exchange for releasing the abductees.
The phenomenon of kidnapping medical personnel has noticeably grown in Idlib at a time when aerial bombardment operations have decreased, and medical projects in the province have begun to recover. Such improvement has collided again with security tension on the ground.
Medical sector devastated by bombing
During 2018, hospitals in Syria have witnessed a record number of bombardments, according to a UN report released last May.
The UN said that during the first months of 2018, 92 air strikes have targeted health facilities in Syria, compared to 112 similar attacks in 2017.
The number of victims who have fallen due to these bombings was estimated at 89 dead and 135 wounded, throughout Syria in 2018, according to the UN statement.
Idlib had a large share of this statistic. During the following year, there were frequent attacks on medical facilities, which caused the Kernabal Surgical Hospital (formerly Orient Hospital), the National Hospital in Maarat al-Numan, the Sarja Hospital in Ariha city, and the health centre in Tel Mardikh to be shut down.
The health Director in the Idlib Free zone, Dr. Monther Khalil, said during a press conference about the military escalation against medical facilities in the north of Syria, last May, that targeting medical facilities in the north is executed systematically using warplanes and artillery shelling.
Khalil stated that 50 percent of the medical work in the area is suspended, and 25 percent of Idlib’s medical capacity is not available for the time being, pointing out that the medical facilities in the province serve about 3.3 million locals as well as displaced persons.
In addition to international and local concerns, international organizations have been calling for four years now to stop targeting hospitals in Syria.
In September last year, vital facilities in Idlib were subjected to heavy shelling, raising the fears of Doctors Without Borders (MSF) which warned, in a statement, of losing the entire health care system in the region after shutting down a number of hospitals either because of the bombing, or out of fear.
On the other hand, relative stability, which was achieved in the areas controlled by the Turkish-backed Free Syrian Army in Aleppo, has contributed to decreasing the rate of bombardments targeting medical facilities, compared with the situation in Idlib.
Security tension raises concerns among medical staff
Last summer, several doctors and medical workers have been kidnapped in areas under the control of opposition factions in Idlib and Aleppo. Such alarming incidents have called for re-initiating precaution measures for fears of grave damages affecting the medical sector.
Although the kidnappings did not result in casualties in general, the victims suffered significant financial losses. Thus, these abductions caused considerable concerns among health professionals.
On 9 June, unknown individuals have kidnapped Dr. Mahmoud Mutlaq in the Idlib-Ariha road. Dr. Mutlaq is one of the most qualified doctors in the city of Idlib and has more than 20 years of medical experience in genealogical surgery.
He was released in June 15 for a sum of 120,000 dollars, equivalent to 50 million Syrian pounds. Thus, activists from Idlib recently reported that Dr. Mahmoud Mutlaq has sold his farm in Idlib and departed to Damascus after being subjected to abduction and torture.
Hay’at Tahrir al-Sham has been accused of carrying on the kidnapping operation, which was followed by the abduction of Dr. Mazen Dukhan for hours. Thus, the organization has announced responsibility for taking Dr. Dukhan against his will under the pretext that it was a “security operation”.
As a result, the syndicate of physicians and pharmacists in the region issued a statement, last June, to protest against the increasing violations committed against the medical staff in Idlib, as well as chaos and the absence of adequate insecurity measures, in addition to the employment of “systematic policies” to push medical workers to leave the area.