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A doctor’s life during wartime

“If they were in a European or North American context, (the patients) would have survived… So it’s frustrating, but it’s something you just have to do your best with and work in the conditions you are working in with the facilities you have.”

Dr Deirdre Foley, a medical and paediatric doctor, is speaking to the Medical Independent (MI) about her experience of being part of a Médecins Sans Frontières (MSF) mission in the small town of  Tal Ahyab, Syria. It is a town in Northern Syria, along the Turkish borders, approximately 100km north of Raqqa. Dr Foley was based there from December 2017 to June 2018.

Her main responsibilities included treating and caring for children in the paediatric wards, inpatient and outpatient departments. Dr Foley says there are many challenges for doctors when working in a war-torn country such as Syria.

“There were maybe three-to-five paediatric deaths per week and this is hard to emotionally deal with, because you would do everything [to keep them alive],” she says.

“We would give them all medication that we thought could help, but there was nowhere else to send them and there were no facilities for ventilation. So at a certain point, we just had to stop, and this is very frustrating.”

The scale of the death and suffering of children was much greater than she experienced working in Irish hospitals.

 “My experience working in Temple Street and Crumlin has meant I witnessed a few paediatric deaths, but many of these were receiving palliative care and they were semi-expected,” Dr Foley says.

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Dr Deirdre Foley

With the ongoing conflict in Syria, conditions in healthcare facilities cannot be compared to more affluent and well-off countries. According to Dr Foley, many of the healthcare facilities and services were severely damaged. Dr Foley and the rest of the MSF staff had to work in an extremely small hospital, as there were no other adequate facilities in the area.

“So we have a tiny hospital and even though the actual space wasn’t big enough and there was a bit to be desired in the structure of the hospital… we really got the best out of things, and we’re really lucky to have had the hospital to use by the medical service. There were no other hospitals in the area that could do that,” Dr Foley says.

Thalassemia

One of the chief objectives during her six months in Syria was the ‘Thalassemia Project’.

Thalassemia is an inherited blood disorder characterised by abnormal haemoglobin production. It is widespread in countries in the Middle East and can also be found in pockets of Asia. And thalassemia is also prevalent in Syria.

Treatments for this disease come typically through blood transfusions and iron chelation methods.

“These children are dependent on blood transfusions and we meet them very frequently, every two-to-three weeks. So it’s kind of a big thing in Syria. In the community, everyone knows someone who is affected by thalassemia. As a community, they really want to push and get the best services they can and these services have been decimated by the years of conflict. So what we did was, we worked on improving the safety of blood transfusions and improving the service,” Dr Foley explains.

She also believes that cases of thalassemia were aggravated as a result of the ongoing struggles in the country. Dr Foley says: “Because of the conflict in Syria, a lot of the blood transfusions received in other units outside the MSF hospitals haven’t been tested properly for hepatitis B and C. A lot of children have contracted hepatitis C from blood transfusions and are chronic carriers, and this will probably lead to liver complications.

“Also, there is a higher risk of heart failure if they are not getting enough transfusions and the frequent transfusions cause iron to build up all over their body, especially in their liver, joints, heart. This leads to cardiac failure and liver failure, and they often die in their late teens or 20s.”

One of MSF’s most recent innovations to reduce the amount of iron accumulated in the children’s bodies is by providing iron chelation medicine.

“This is the first time MSF ever did this. This [iron chelation] basically decreases the amount of iron built up in their body from the blood transfusions and vastly improves their quality-of-life and their life expectancy,” she says.

Other challenges

Another serious health challenge facing patients in these areas is pneumonia. According to Dr Foley, pneumonia is especially severe in newborns.

“Many of these babies had heart problems that they were born with as well. They had congenital heart disease. This [is caused by] a mixture of smoking indoors and cooking indoors and lack of vaccination, leading to severe pneumonia in the under-fives and the under-ones.

“We also had a lot of diarrhoea illness and viral gastroenteritis. This was just related to poor sanitation, especially in the camps for internally-displaced persons; the facilities weren’t adequate for washing and cleaning and hand-hygiene. So we saw a lot of these diarrhoea-related illnesses spread like wildfire and we would get carloads of 10 patients coming in at once from camps or villages needing treatment.”

Other diseases that arose with patients at the hospital were diabetes, due to the lack of access to specialist doctors and medication. Meningitis and sepsis in babies were also relatively common.

“I think a lot of these medical problems were because the presentation was a lot later in these children and because it was difficult for these children to get to these hospitals; it would often take them a few days to travel there. And a lot of times, roads were blocked or it was unsafe for them to travel on the roads for political reasons, so presentation was usually very late. But as well, the family structures had been broken down and one might have been separated from mothers and sisters… so you had a poor kind of education and poor recognition of a sick child in the family because of the breakdown in social structure and family support.”

Emotional situations

Throughout her time in Syria, Dr Foley has faced various tough emotional situations. Coping with patients who were very ill, or who had died, was particularly difficult, given the already challenging context she was working in.

“The main thing that I used to do when I had any patients who stuck out in my mind that were particularly complex or that had passed away or that were very unwell — I would write them down in a little diary, just the story of the patient. I think this was good for self-reflection just to get your emotions and frustrations about what you couldn’t do for the patient out, and also to see if there was anything I could have been doing a little better in these cases.”

She continued: “If you are seeing a person die in front of you, I think this [writing in a diary] really helps you release the mental burden of you carrying it around. So I felt that this helped a lot… This was very distressing and a lot of us, because we’re all working in the same environment, the ex-pat team in Tal Ahyab were very close and we would talk a lot with each other and support each other as well. So it was a very supportive environment to be in.”

Dr Foley believes her job is purposeful because she is be able to save the lives of people and witness their recovery process, regardless of the struggles she has to endure. She also believes that the teaching aspects of the job make the mission worthwhile.

“The other thing was the teaching and mentoring with the medical and nursing staff in the hospital. We saw, because the education system for the staff had been broken down for so many years, that once we started providing education sessions, we saw a really rapid and amazing improvement in staff and their work, which was fantastic to see and it feels very good that they can hopefully continue carrying on the work and continue to improve as long as education is being provided so it seems like not so much a quick-fix, but a more long-term solution,” Dr Foley says.

Although it was her first mission abroad for MSF, Dr Foley says she is eager to represent MSF on another mission if the opportunity arises.

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