Aleppo’s Healthcare System Struggles to Survive: Q&A

As pro-government forces surround the city of Aleppo, medical workers are stocking up on supplies in anticipation of an impending siege. Syria Deeply spoke to one of them, Dr. Rami Kalazi, about the health situation in opposition-held areas and the challenges of being a doctor in a besieged area.

Written by Zuhour Mahmoud Published on Read time Approx. 8 minutes

Following the recent string of missile attacks on hospitals in northern Syria by the Syrian government – aided by Russian airstrikes – it appears likely that Aleppo’s rebel-held neighborhoods will soon be under siege. Doctors and nurses working in the devastated city are girding themselves for even worse days.

The increase in violence since the Russian-backed government offensive began earlier this month has caused a dramatic deterioration in health conditions throughout the opposition-held area and surrounding neighborhoods, in some areas resulting in the outbreaks of disease, said Rami Kalazi, a neurosurgeon at al-Sakhour hospital.

Kalazi, 30, has been treating the wounded in the city since the early days of the uprising. He has stayed partly because of a strong belief in his responsibility as a doctor, partly because he is Syrian, and partly because he is stubborn.

The situation in the country has rapidly deteriorated since the Russian intervention, and those remaining in Aleppo are doubtful the upcoming cease-fire will bring any change.

Kalazi spoke with Syria Deeply about the challenges physicians face providing proper treatment for patients as they’re being shelled and facing a siege.

Syria Deeply: Only a handful of medical professionals have stayed in the city of Aleppo, with most having fled the country. What is the current state of Aleppo’s health-care system?

Rami Kalazi: Like most areas outside of government’s control, Aleppo’s health-care system is very fragile and poor, with the number of hospitals and medical facilities rapidly decreasing. In all of the liberated towns in Aleppo, there are merely 10 hospitals, only five of which have surgical capabilities. This number is too low for such a large area. Our hospital is one of the few specialized hospitals left in Aleppo.

The number of medical professionals is extremely low. For example, we only have one general surgeon and only one bone surgeon working in Aleppo. In the five surgical hospitals, there is only one doctor for each specialty. In the entire city of Aleppo we have only two gynecologists. Despite the mass migration from Aleppo, we still have 250,000 civilians living in the city. So imagine only two gynecologists amongst 250,000 people.

When it comes to medical supplies, we are very tight on the most basic necessities. While we have enough to treat emergency wounds, we don’t have the necessary materials to treat critical cases. Cancer treatments and surgical tools are unavailable. Generally speaking, this is the situation in all of the hospitals in opposition-held areas. In Aleppo we only have seven or eight ICU beds. If the respirator stops working, we don’t have anyone who would be able to fix it.

Syria Deeply: How would the situation deteriorate in Aleppo if the government is able to besiege the city? Where would medical practitioners get the necessary supplies?

Rami Kalazi: This is a very difficult question. Whenever we hear of a possibility of besiegement, we devise a plan to stock up on supplies that would last us for three to six months. But this only includes emergency medical supplies.

This is not the first time the government has attempted to besiege Aleppo. However, this time will be the worst given that many parts of the countryside are now under government control, and therefore will not be able to aid us in any way. Our biggest problem would be the lack of power sources. We don’t have electricity; we rely solely on power generators which use fuel. If you want to power a hospital for 24 hours, it uses up to 500 liters of fuel. 500 liters a day mean 15,000 liters a month. We simply cannot afford such quantities, and frankly speaking we don’t have enough storage space for it either.

Another risk imposed by the siege would be the lack of manpower. We’re already facing scarcity in medical professionals, besieging the area will only worsen the situation. After the closure of Dar al-Salam route, many doctors were unable to go back into the city because their names were flagged on the military checkpoints. We’re expecting a 30 percent decline in the number of medical professionals if the siege gets imposed.

Syria Deeply: The government and the Russian government have repeatedly denied deliberately targeting hospitals. Does the reality on the ground contradict that?

Rami Kalazi: Absolutely. There is plenty of evidence that the government and the Russian government are deliberately targeting hospitals and medical centers. First of all, medical workers have been targeted by the government since the beginning of the revolution, during the days of peaceful protests. The government used to target medical workers because they aided wounded protesters and provided documented evidence to the international community that the peaceful protesters were targeted with live bullets. Many doctors were detained and died under torture or were executed immediately. When we began setting up field hospitals and mobile clinics, the government constantly targeted it with tanks and live ammunition. The evidence that these hospitals were deliberately targeted is that they were nowhere near any military points or suspicious areas.

The government not only targeted hospitals, but even used snipers to hit ambulance vehicles transporting wounded civilians. The government used to target hospitals and mobile clinics by using heat missiles. When a target is more than 8km away from the military base, it is impossible for a bullet to hit it, so the government would fire a heat missile that would target any ambulance.

Our own hospital in Sakhour neighborhood was hit by 15 airstrikes in the past three years. Seven times the airstrikes successfully hit the hospital which resulted in shutting it down. Most of the hospitals in Aleppo have no military presence around them, but despite that, the government has targeted them time and time again, causing casualties and severe damages.

Syria Deeply: What is the daily life of a doctor working in Aleppo right now?

Rami Kalazi: Our work is based on 24-hour shifts. Other areas might have the capability to work on 8- or 12-hour shifts, but like I’ve mentioned, we are very low on staff so we have to work for 15-20 days at a time. Out of these 24 hours we work for a minimum of 13 consecutive hours, it’s exhausting, we get around 40-50 wounded cases a day, and in addition to that we have the regular check-ups and follow-ups.

The volume of work is huge compared to the small number of medical staff. Many of the doctors in Aleppo don’t even live there, most of them have their families living in Turkey. So they come and work for 15-20 days and then go back on “vacation” to visit their families.

Unlike normal people, we always wake up to the sound of sirens, and unlike normal people, we always go to sleep exhausted and drained.

Syria Deeply: What made you stay in Aleppo for the past five years?

Rami Kalazi: I didn’t stay in Aleppo for one particular reason. First of all, I have deep faith that this is our country, and we have to build it ourselves. Because eventually, if you are not a part of the solution to your problem, nobody will solve it for you. Then there is the responsibility I feel towards these people; they will die if we don’t help them. This is the reality. If all of us medical practitioners leave the city, people will not be able to survive. And it’s not only the wounded civilians; it’s the everyday medical problems that everyone all over the world has, like migraines, diabetes, back pain…

There is also the religious duty. I have a deep conviction that after all this suffering, if we do our part in helping people and stand our ground, we will eventually be rewarded.

In addition to all of these reasons, there’s the personal attachment to the city. Aleppo is my hometown in which I was born and raised, and spent all my childhood and adulthood. Despite the fact that I don’t work in my area in particular, as it is still under the government’s control, I still feel at home whenever I’m here. I’ve been told many times, “Okay you want to help people, you want to heal the wounded, but why stay in Aleppo? Leave Aleppo, it’s dangerous.” But I can’t.

Syria Deeply: Could you describe how you and your colleagues respond to barrel bombs and their aftermath?

Rami Kalazi: When you hear the sound of an aircraft or a falling barrel, you sense indescribable fear. It’s not something that anyone can get used to. What we got used to is how to control our reaction; how to take control of the situation. We start by preparing ourselves for the dozens, the hundreds of wounded civilians we are about to receive. We prepare ourselves psychologically for what we’re about to see, and we also check on the staff and make sure everyone is ready. We prepare the ambulances, the power generators, the operation room and then we wait…

Syria Deeply: What is the greatest struggle for you and your colleagues in Aleppo? Is it barrel bombs? Lack of equipment and medicine? Safety?

Rami Kalazi: Our main problem remains the airstrikes, all other problems are caused by airstrikes in one way or another. We simple don’t get a chance to focus on other issues because we are under constant bombardment. For example, the shortage of medical personnel is mainly due to airstrikes; to the deliberate targeting of doctors and nurses. The siege and its implications are also because of the airstrikes. There is no way an opposition group can stand a chance to defend its territory if it’s constantly bombarded from the sky.

The sheer number of airstrikes has forced the opposition to lose many areas, which has allowed the government to advance on the ground and besiege many towns and cities.

I remember back in 2013, things were much better. There were no airstrikes in this volume, and fewer barrel bombs. The civilian population in Aleppo’s liberated areas was almost 1.5 million. We had 15 operating hospitals; we had 5 times the number of doctors we have now. When the ghost of the siege came to Aleppo, all other problems started accumulating. Even the necessary equipment used to come in and out of the city, but when the supporting parties sensed the impending siege, they began to feel hesitant about providing us with extremely expensive equipment.

Syria Deeply: On Monday, Russia and the U.S. signed an agreement for a cease-fire set to take effect on Saturday. Do you think this will give the medical professionals breathing room to treat chronic cases? Are you hopeful that it will bring change on the ground?

Rami Kalazi: First of all, my colleagues and I are very skeptical about whether the cease-fire will actually take place, with the most optimistic of us giving it a 20 percent chance. This is due to the complexity of the Syrian map. It’s not only the government who’s in charge now, nor is it Russia or Iran. And the opposition factions are divided at best.

Secondly, the reason why these chronic cases don’t get proper treatment is not only because of the airstrikes; our problem is that we don’t have the necessary centers and equipment specialized in cancer treatment. We don’t have the necessary tools for critical diagnostics and surgeries.

You need to understand that the lack of equipment is also a reason why so many doctors leave. When you ask a doctor to join a hospital that is poorly equipped, they will refuse because they know that they will not have the necessary equipment to do their job and help their patients.

Another important factor to keep in mind is that the agreed cease-fire is temporary, I am expecting it to be violated by one or more parties.

Syria Deeply: What are the consequences of the steadily deteriorating health-care system and living standards in Aleppo?

Rami Kalazi: Due to the extremely poor living conditions, we are witnessing reemergence of diseases that were believed to be extinct in Syria prior to the revolution, such as leishmaniasis, which has reemerged in striking figures. Diseases like polio, measles, meningitis and tuberculosis are just examples of conditions that resurfaced in the population because of the low standards of hygiene, water pollution and the unavailability of vaccines.

Top image: Civilians walk through a street where large tarps are hung in between buildings to limit the view of government snipers in Aleppo. (Associated Press)

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