Basil Al-Reabi was riding home from school in southern Syria, in the fall of 2014, when a roadside bomb struck. The eight-year-old watched as shrapnel shredded his classmates and reduced them to a collection of body parts. As the remnants of the minibus bounced, rolled, and finally came to rest at the foot of a low embankment, three of his limbs were scythed off, his cheeks peppered with shards of blue vehicle paint.
What was perhaps most shocking, though, about the boys experiencesand the nightmare that followedwas just how routine theyve become in a country torn apart by civil war. In Basils opposition-controlled swath of the Deraa governorate, heavily-bombed and depopulated, the local field hospital had little medical equipment and even fewer drugs. Basil writhed around while staff desperately cast around for painkillers. And it fell to the lone medic in the district—a trainee oncologist—to attend to the boys brutal array of injuries. Pain. I just remember pain, Basil says.
That he survived at all, however, is testament to the exceptional resourcefulness of Syrian doctors, who, through five plus years of blood-soaked conflict, have devised a series of unique lifesaving practices. Clinic volunteers molded Basils bandages from moist printer paper to create a papier-mch-like gauze over his bleeding stumps, while splinting his broken forearm with a tree branch. As the war has continued to escalate, these improvised treatments are the only thing preventing the death toll from spiralling even further out of control. Most estimates suggest at least 400,000 Syrians have been killed since early 2011.
Were in a state of never-ending emergency within an emergency, says Hazem Rihawi, a lead NGO coordinator on the Turkish-Syrian border, who liaises between aid organizations and tries to identify where medical supplies are most needed. We dont have the resources for sophisticated surgery and treatment, so were pushing for [doctors] to use what you have.
Necessity as the Mother of Invention
Its doctors in Syrias 40 or so besieged towns and urban areas whove displayed the greatest flair for innovation. With up to a million people penned into these ghettoized slaughterhouses—largely by the forces of Syrian President Bashar Al-Assad—theyve repurposed everything at their disposal, from sewing thread for medical stitches to brooms as makeshift crutches.
I was the only heart doctor [in the area] so if I someone came to the hospital, I had to be there, and had to find a treatment, said Dr. Khaleel, a cardiologist who worked through the worst of East Ghoutas siege and who for safety reasons goes only by his first name. His home district, once part of a lush oasis outside Damascus, was ringed by government troops two years into the war, and subjected to a suffocating siege that endures to this day. I can say really that for three years, apart from an hour here or there, I didnt sleep.
Under total blockade for 13 months from late 2013until rebel fighters finally dug a number of relief tunnelsdoctors in East Ghouta sourced their own raw materials. When the supply of conventional drugs began to run low several weeks into the siege, they sought out ingredients from one of the three nearby abandoned pharmaceutical factories, and churned out their own ibuprofen and cough syrups. If the medicines dont exist [in your area], you make them. If you cant make them, you try and use something else, says Dr. Khaleel. Ghoutans also turned to the very weapons designed to kill them, setting shattered bones with splints crafted from abandoned munitions.
Then, in early 2014, as fuel reserves fell to critically low levels, Ghoutans called on their ingenuity again. With no diesel to fire the generators—or even to power the hospital lights—administrators packed organic waste into sealed spaces, and MacGyvered a sustainable biogas source. Other besieged sectors have followed their example: On a 2014 visit to Kurdish-controlled northeast Syria, I watched as a teenage boy in a blacked-out hospital in Qamashli rigged himself up to a bicycle-propelled generator. He pedaled furiously to keep the on-call specialists cell phones alive until the electricity kicked back on.
Innovations Outpaced by Slaughter
Still, for the roughly two-dozen medical professionals left to cater to an estimated 300,000 inhabitants in Aleppos besieged eastside, no manner of savvy innovations has been able to keep pace with the hostilities.
Amid heavy aerial bombardment, most of East Aleppos medical infrastructure has been knocked out of commission. That included the portable dialysis machines one Syrian-American nephrologist had cobbled together from old medical and car parts and distributed across the country. The medical possibilities now are very limited, Oussama Abo Ezz said, his voice rising but only just distinguishable on the phone above explosions in the background. Theres a huge shortage of equipment, of doctors, of medicine, electricity. And so even if were resourceful, we dont seem to have any options.
Medics across Syria say it was the Assad regimes introduction of barrel bombs, essentially metal vessels chocked full of shrapnel, that finally stretched them and their inventiveness to breaking point. In the first years of the war people came with maybe one injury, in his leg, or his back, says Dr. Khaleel. But now, with barrel bombs, everyone comes with lots of holes, cuts everywhere. Between 2010 and 2015, average Syrian life expectancy slipped from 75 to 55 years; Among the dead are at least 700 medics.
One bright spot is that hospitals are rarely short of blood—Syria has a culture of prolific donation. You could find it any time of day or night, youd go to the mosque, youd knock on your neighbors door, said Mohamad Katoub, a former doctor in East Ghouta and now an advocacy manager for the Syrian American Medical Society. But the blood bags that prevent platelets from congealing are in scarce supply. And with substitute serum and IV sacks increasingly hard to come by, much of the donated blood wont find a use.
The medical impacts of the crisis dont stop at Syrias border. Many badly maimed patients are rushed to safety as soon as their health—and frontier guards—allow. So some Jordanian hospitals have come to resemble mini-conflict zones, filled with injured civilians. In 2014, 14.6 percent of the Syrian patients at Medecins Sans Frontieres Ramtha facility in Jordan were children and 11.9 percent were adult women. By the following year, those figures had risen to 22.4 percent and 15 percent. The effect is delayed, but we always see here when things get worse, says Nagham Hussein, director of medical operations at MSFs Amman hospital. More young, more old, more women.
And while Syrian doctors unorthodox practices have surely saved lives, they also complicate follow-up care. Operations performed at lightning speed in bleak conditions with inadequate or unusual equipment can produce unconventional results. Many of the wounded arrive with no paperwork, little understanding of whats been done to them, and—particularly in the early years—a fear of divulging personal information after a lifetime in a police state. That makes it difficult to work out patients medical histories. Sometimes they mix things up too, says Ehsan El-Masry, a medical liaison officer. In Syria, they have the same word—wattar—for nerve and tendon.
And even when the new arrivals problems are clear, Syrias hellish conditions still leave their mark. Many of the patients at MSFs Amman hospital suffer from years of insufficient or bad food. Ive seen bones as thin as biscuits, says Nagham Hussein. Those whove lost legs were often amputated so high up the thigh that most prosthetics are unworkable, confining them to wheelchairs. Handicap International, an aid organization, has so far distributed more than 6000 replacement arms and legs.
Above all, though, exposure to more than five years of total war has left many Syrians with such deep psychological scars that they doubt theyll ever again live even normal-ish lives. After being discreetly smuggled over the border to Jordan days after his injury two years ago, Basil Al-Reabi has masterfully negotiated his physical limitations. He pushes himself around his Amman rehab center on his stumps, and plays a mean game of foosball with one hand. But he—like many of his young friends there—is horribly depressed. Staff need to persuade him to eat at mealtimes. And when they ask him what he wants to do in the future, he shrugs and looks around: What can I do? he says. I just want to go home.