This is Aleppo: In A World Where Doctors Have Become Martyrs & Hospitals Battlegrounds

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Tucked in the lower floor of a building was Al-Quds hospital in Aleppo, Syria, a small 34 bed facility in the Sukkari neighborhood. Its windows and entrance were fortified with mostly sandbags for extra protection despite the many buildings around it that, in theory, protected it from being attacked.

The hospital was not a rebel-run hospital, despite it existing in a rebel-controlled neighborhood. It was a Médecins Sans Frontières (Doctors Without Borders) and International Red Cross affiliated institution with an emergency room and an 8 bed pediatrics ward. It was as fully equipped as a hospital in times of war could be.

In the rules of warfare, horrifying as such a notion’s existence is, and as dictated by multiple conventions, notably the Geneva ones, attacks on medical institutions by any side of a conflict is considered a severe violation.

A few hours ago, a fighter jet, flying at low altitude, charged a missile through Al-Quds hospital, to the background of a Syrian citizen being killed every 25 minutes over the past 48 hours.

The jet in question was commissioned by the conjoined Assad-Putin forces trying to reclaim their hegemony over Syria, despite what some anti-resistance news outlets would want you to believe, with them taking videos of the government forces attacking and portraying them as resistance fighters doing so.

The above picture is that of Dr. Muhammad Waseem Maaz. He was a man who spent most of his adult life finishing medical school, and then specializing in pediatrics, before spending his days doing the most self-less thing that any man, especially a physician could do, leave his family behind in Turkey while he helped the ailing children in Aleppo. Al-Quds was the hospital where he worked. Aleppo was the city he called home, the city that is now being ravaged by regime forces. He was the last pediatrician in Aleppo.

As regime fighter jets attacked his hospital head on, Dr. Maaz did not run for his life. He ran to the incubators to try and save as many lives as he could. His life was not one of those that made it out of that building alive, along with 27 others.

His death is not a number. Dr. Maaz’s murder is a war crime, plane and simple. The more horrifying part is that this is not a lone event. His death is one of the most worrying trends of the Syrian Civil War, and conflicts of the 21st century. It’s becoming a trend.

In Syria alone, 654 medical personnel have been killed until September 2015, according to the UN, and, in the past year alone, 7 attacks have been reported by MSF against its facilities in the country.

Syria is not the only place where attacks against hospitals and doctors occur. All sides have been attacking healthcare workers and instutions: rebels, armed groups, and governments.

A few months ago, American military led a 30 minute barrage on an MSF-led hospital which they believed to be a Taliban HQ. They killed 42 people. They justified themselves as it being an “intelligence error.” Intelligence must have come a long way not to be able to differentiate between a hospital and a terrorist haven.

MSF reports their hospitals sustaining 106 attacks in 2015, with the loss of countless lives as well as extremely valuable equipment that is, for thousands and hundreds of thousands, the only difference between life and death.

The most dangerous aspect in such attacks is that they’ve begun to be considered as normal, not as a war anomaly, setting a war precedence into them becoming not only more “mainstream” in conflict, but also more deadly and more unchecked.

The more threatened doctors are, the less they will be willing to work in those areas that require them the most. It’s already started. Over 60% of Syrian areas, for instance, have no possibility to access any

We are doctors, not martyr projects. We work at hospitals, not battle ground sites. We save lives, regardless of who those lives belong to, irrespective of green lines and battle sides. Our lives are not worthier than others, that’s for sure, but us dying because of horrifying war crimes in which we are targets means the lives of those who are equally worthy of saving are lost forever.

We are doctors, not martyrs. We promise to go to the extreme of what we can to save anyone who can be saved. Dr. Maaz was one of those doctors who did just that. The hundreds of MSF doctors who have been killed over the past years have also been doing just that. When did medicine become open season? When did the act of warfare become one that plays out in surgical theaters and in pediatric incubators?

Everyone is at fault. The Assad regime was the culprit in this case, but this is something that everyone is doing. The targeting of healthcare personnel cannot be normalized. In a world where war is everyone’s favorite pastime, certain entities should always remain off limits. These are doctors, not martyrs. They save lives without asking for theirs to be saved. Don’t make them need to.

Aleppo is dying. Aleppo is bleeding. With labels such as “humanitarian disaster” becoming way too common, one cannot but wonder: what is causing this particular disaster? It’s not an earthquake. It’s not a natural disaster. It’s missiles, and terrorist regimes, and armed factions and other men who know no morality. The murder of people just because they exist, the targeting of hospitals just because they are, the killing of doctors just because they are doing their job is not a humanitarian disaster. It’s a war crime. Call it as such.

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Why Lebanon’s Health Sector Is Messed Up

Abdul Ra’ouf was a 4 months old baby boy and he is another Lebanese tragedy. He was refused admission to hospitals in Akkar and has passed away. I suspect Abou Faour will hold a press conference soon.

In late February, a scandal hit Hotel Dieu as the Ministry of Health, led by Abou Faour, froze its contract with that hospital over them not admitting a patient who had no other form of coverage.

Heartbreaking stories of children dying make headlines, but they don’t tell you the truth of the health sector in Lebanon. That truth is in the numbers:

Before going into what thosee numbers mean, let’s take the hypothetical scenario of a hospital with 100 beds. The beds in that hospital are divided according to coverage: those covered by insurance have the biggest chunk allocated to them (let’s say 70), while those covered by NSSF have 20 beds and those covered by the Ministry of Health have the remaining 10.

Hold that thought for a second and let’s talk about the numbers.

Half of the Lebanese population (48%) is covered by the Ministry of Health (MOH), while 23% are covered by the NSSF (daman) and only 8% are covered by private insurance. This means that about 2 million Lebanese have the MOH as their ONLY way to afford hospital care in the country.

Having half of your people covered by the ministry doesn’t seem too bad right? The truth of the matter is far less utopian.

Having half the country covered by the MOH means those 48% are entirely dependent on the MOH’s budget. The disaster is when you find out that out of all the ministries running this country, the budget allocated for the MOH to cover the needs for HALF of the country is 3%.

How The Ministry of Health’s Budget Is Divided:

16% that budget goes towards expensive drugs notably cancer treatment. Patients not covered by the NSSF have to resort to the ministry for their medication (if they can’t afford it, which is the case of  99.7% of Lebanese).

Getting the medication out of the MOH isn’t easy. Sometimes they run out of the medication and you end up having to wait until they bring it back into the country. Other times, as has happened with a friend of mine who needed a $12,000 treatment over the course of a couple of months, other people come in and take the medication that was allocated to you, sign for you and leave.

The system is rigged with wastas, bureaucracy and corruption.

80% goes to hospital care, which is where most of the people need the MOH: operations, hospital admission, etc.

So imagine ONLY having 80% of the country’s 3% budget used to essentially treat 50% of the Lebanese population. This is why the MOH has the least number of beds at the country’s major hospitals: the MOH often doesn’t pay, and when it pays, it does so extremely late.

So when you hear that a patient couldn’t find a bed at a particular hospital, it doesn’t always mean that every single bed in the hospital is full, it means that the beds for that patient’s coverage are fully occupied, and that is very easy to occur when 48% of the country gets a minimal amount of beds in the country’s major hospitals.

Does that sound harsh? Of course it does. All Lebanese are entitled to excellent care and that level of care is, sadly, rarely available outside of Beirut and its major hospitals. Why so? Because excellent care is not cheap. Those imaging equipment with fancy names you hear being thrown around on shows like House, MD and Grey’s Anatomy cost in the millions. Every time a hospital buys something to advance its level of care, they pay figures in the seven digits. Even the research that goes into advancing care is expensive.

The level of care being expensive is a big problem. The bigger problem is not having hospitals that are close to the level of those inside Beirut outside of the capital. Most of the people in the country cannot afford places like AUBMC, SGH or HDF, but they can go to public hospitals where the level of care has the potential to be excellent but is handicapped by how little funding those hospitals get.

4% of the MOH’s budget goes to help public hospitals. What you need to know is that public hospitals are not exactly under the jurisdiction of the MOH, which means that the Ministry isn’t responsible for their finances and how they run: they have a separate board of directors that is required to run them and keep them within profit margins. However, as is the case with almost all public hospitals in the country, very few (if not none) are success stories because of the lack of governmental support that goes toward them.

I rotated at one of those public hospitals not too long ago. It wasn’t an eye opening experience because I do come from a non-privileged area of the country, but it was a heartbreaking one. The hospital was in a state of near-decay. Some of the equipment didn’t work.  And all the patients were one sad story after the next.

The latest high profile example is Beirut’s Governmental Hospital which has been in the news for months now because of the lack of payment to employees. Imagine not getting your salary for months. Does it make it okay just because you’re a doctor or a nurse?

What Happens When The MOH Freezes Its Contract With A Hospital:

As a response to HDF not admitting the patient (who wasn’t a case of emergency in which case the hospital is required by law to take care of a patient), Abou Faour decided to put his ministry’s contract with the hospital on hold. I suppose he thought that was punishing the hospital enough, and you thought he was defending your rights in doing so.

What freezing that contract means is that those 10 beds in that hypothetical hospital are no longer allocated to patients covered by the MOH. Freezing a contract with a hospital affects the patients, not on the hospital.

Hospitals And Doctors Can Also Be Greedy:

There are a lot of hospitals and doctors in the country that are greedy, and the system permits the perpetuation of that greed.

The most relevant story to that regard is of someone I knew who required a major surgery. That person’s community tried to intervene by raising the funds. Eventually a high profile charity heard of that person’s problem and donated. In doing so, they forced the hospital in question to lower their required fees by a decent amount, because that charity needed the invoices to be audited abroad.

A lot of this goes on behind closed doors. The lack of regulations means that you don’t know which part of the money is going where.

The Media Doesn’t Help:

Out of all sectors in the country, medicine and healthcare are the juiciest to be spoken about in the media, and the way the media talks about hospitals and about patients dying is ignorant.

A couple of weeks ago, Marcel Ghanem shared a story on his show about a woman who died at a hospital in Jbeil because they didn’t give her some covers from the cold. People were outraged. Were those nurses seriously watching Yasmina and not giving the woman a blanket? What an atrocity!

The truth is very different.

That patient was a cancer patient. As a result of her chemotherapy (which she was able to afford!), her immunity was immensely suppressed, rendering her unable to defend against infection. The patient presented to the ER of that hospital with what we call “neutropenic fever,” which is fever in the background of immensely suppressed immunity. Why did the patient die? Because she ended up in septic shock, a condition with extremely high mortality.

But that doesn’t sound too media-appropriate. The problem with Lebanese media isn’t that they talk about stuff that go wrong in hospitals. They should, and they should do it more. It’s that the angle they often use is useless, leads to zero changes and doesn’t highlight the real problems here: inequality, lack of funding, lack of coverage, etc.

My Own Sensational Story:

She was such an adorable 4 year old when she walked into the doctor’s clinic in Beirut, coming all the way from Tripoli. What’s your name, we asked. Farah, she answered in a barely audible singsong voice.

Farah was there for further reparative surgeries for a congenital defect she had. A tube was sticking out of her neck to allow her to breathe. The doctor offered to do the operation pro-bono, but the hospital had no beds available for her.

I saw her father weep. I have already lost two daughters, he said, by settling to hospitals in the North because I couldn’t afford Beirut. I don’t want to lose her too. And in a corner of the room, I saw my colleague tear up.

Farah is 48% of the Lebanese population.

My colleague then approached me and said: this is something you need to write about, and so I did.

 

Don’t Take Your Health Lightly


I’ve found this to be an almost natural – and quite comical – attribute to the Lebanese person (and possibly applicable everywhere too), which is: there’s nothing wrong with me unless I can’t stand on both feet anymore.

Take my mother for instance. Yesterday evening, she was shaking and trembling, suffering from acute pain in her lower back area, and she was hypothermic. I insisted we’d take her to the hospital because what was happening to her was not normal. But she vehemently refused. And soon enough, after taking a collection of over-the-counter drugs, she felt good enough to function.

My dad woke me up this morning, a scene that is oddly deja-vu, to tell me that we have to take my mother to the hospital. Why? She was having the exact same episode she had the night before. So we took my mom to the hospital and she got examined by an ER doctor who determined that she might be suffering from kidney stones. Further tests need to be done, obviously, but this is not something that over-the-counter drugs can fix.

The scene of my dad waking me up to take my mother to the hospital is deja-vu because it happened eighteen months ago when, after suffering from a mild stomach-ache which she dismissed as stomach flu, my mother couldn’t walk from pain in her lower-right abdomen the following day. Yes, you guessed it: appendicitis.

And the “funny” thing is that this doesn’t apply to my mom alone. Have you ever found yourself in the midst of those visits where people start chit-chatting about their health and prescribing drugs to each other? Well, if you haven’t  let me lay out the scenario.

Person A knocks on person B’s door. Warm Lebanese greetings ensue. Person A enters and sits down. Person B goes to prepare coffee or calls up on the maid to do so. Coffee is served. Person A and Person B start chatting about the most mundane of things. Then Person A mentions that they’ve been having this weird rash on their back. Person B knows just the thing for that! This ointment that he got prescribed by Person C who got it from Person D, etc…

It baffles me how some people can conceive and fully accept the idea that they know more about their health than a physician who went through a decade long educational process and who – in his/her most rudimentary mental form – knows at least a little more about that rash or ache.

So people, instead of seeking help from people who’s only medical knowledge is what they watch on Doctors, how about you go see a real doctor next time? Pain is the body’s way of telling  you something’s wrong. Consider it as a text message. You always reply to text messages (when you have credit). How about a text message that might be the difference between you staying alive or dying?