Syria: medicine on the front line

Interview Part 2

Malnutrition takes its toll on undernourished children ©ECHO

Interview with Dr. Ziad Alissa, co-founder and President of UOSSM France and Prof. Raphaël Pitti, Head of Training of UOSSM France by Pierre Brunet.

Pierre Brunet : Let’s come back to the Covid situation, which was discussed in the first part of this interview by Professor Pitti. What has UOSSM France been doing? I know that you started to do special Covid trainings from last June. You have set up 13 isolation centers. You provide assistance to health structures. Can you develop this emergency aid linked to Covid in Syria ?

Ziad Alissa : For Covid in Syria, there were no specialized structures. Already there is a lack of everything on the medical level. With Covid, things became a little more complicated. We tried anyway, knowing that the local authorities were not able to set up the confinement or the social distancing. So we set up isolation centers, for fragile people, people at risk. They are sent to these centers so that they can be better cared for, because we were not able to confine them properly. People can’t isolate themselves in their homes. You can’t ask someone who has Covid or who is in contact with someone to stay at home when you know that their whole family is there. How can you talk about isolation in a tent, where there are 15-20 people under the same roof, or when there are 4-5 families in each house? There are no individual rooms for people. So we have replaced containment with isolation centers, and in those centers there are areas for confirmed Covid cases, and areas for contact cases. And that’s where we treat people. It’s a reverse containment, with everything you need available: masks, gloves, equipment, oxygen, medication… With the added difficulty that it is already difficult to get the vaccines in, and that despite the arrival of vaccination, there is still a refusal of vaccine, and a logistical difficulty to vaccinate everyone. Despite all the campaigns, we have not managed to vaccinate many people. Only 3% of the people are vaccinated in the northwest of Syria, and Covid is in danger of exploding. There are many complications, many deaths. We are trying to inform people, using all the means at our disposal, about the risk of Covid, about the interest of isolation, about the interest of being vaccinated. Then we set up this first Covid training in Raqqa with Professor Raphael Pitti. It was a first in Raqqa, to train health care workers in the management of severe cases of Covid-19.

Raphaël Pitti : It is important to know that the country is completely closed, they have internet in some areas and can look for information that can be found on the internet regarding Covid.  For us too, during the first wave in the hospitals, we were confronted with a pathology that nobody knew and we did not know how to treat it either. We had to be constantly on the lookout for scientific information, through webinars, every day, trying to compare ourselves with others, to follow the recommendations issued by learned societies, etc. So in the second wave, we were much more experienced in managing this disease. We knew it better, we knew the risks it could cause and we were able to respond. Syrian health care workers, on the other hand, have not had any continuing medical education for ten years… Ten years that they have not participated in congresses, that they have not developed their training. It seemed important to us to try to review the situation with them and we organized these training sessions in the Idleb area in particular. We did it by Zoom with them, explaining the evolutionary genius of this disease, the way patients had to be treated. In the Raqqa area, we went there to meet them, to set up this training with the idea that two anti-Covid centers could open, relying on these doctors. Out of the twenty doctors we trained, we selected some in each center to take care of Covid patients. We also trained midwives: with a fellow obstetrician, Dr. Zouhair Lahna, we went to our training center in Dêrik and brought together midwives to bring them up to speed, to give them the new recommendations on complications in the first, second and third trimesters of pregnancy and resuscitation of newborns at birth. It was really important and they felt the need to say “well no, this is not how we treat anymore, this is how we proceed”. When we met with the European Commissioner for Humanitarian Aid, we told him “the war situation is a little calmer, because the regime has reoccupied 60% of the territory, except for the Idleb area and the North-East area which are still subject to violence and bombing, and it is perhaps time to rehabilitate a health service in Syria, to be able to take care of chronic pathologies, to redo preventive medicine, to launch large-scale vaccination campaigns.

Bombing, attack, mine? This child has lost both legs. ©UOSSM

We need to rehabilitate the health structures to respond beyond the emergency, because we only respond to the emergency of the day”. And today the grants are starting to decrease, and we are told “Look, you need less money, there are many more difficult situations in Yemen and so on, the economic crisis we are facing is decreasing the international grants” even though we are trying to explain that we need much more money today than in 2012, because the situation has not stopped deteriorating. To prove this, we decided to launch a public health survey in the refugee camps that have existed for ten years, in which there are children aged 4-6, children who were born in these camps, who have no health follow-up. If you go into a refugee camp in Syria, no 4-6 year old child wears glasses! And we already had dental problems linked to malnutrition, a lot of cavities in these children, because of their diet, mainly made of sugars, with very few green vegetables able to bring the trace elements they need. It will be a complete survey to take stock of their health needs and to be able, from there, according to the results, to alert the international community, to alert the WHO, to alert UNICEF about the future of these children who have been living in these camps since their birth and in a country at war for ten years. How will we rebuild tomorrow a country like Syria, with children who are already somatically and psychologically disabled? Let’s remember that the medical examinations done in schools for children aged 4-6, every year in France (compulsory examination by the directorates of maternal and child protection), note that 40% of French children have problems detected at the time of these visits. When I say 40%, I mean all kinds of problems: caries, eye problems, hearing problems, language delay, behavioral problems, somatic problems: 40% in France! What about in Syria?

Pierre Brunet : Still on the Covid training, I feel that the main idea of these trainings is to “do the best with what we have”. That is to say that you start from the means available on the spot to “invent” protocols which are certainly based on the WHO guidelines, but which are adapted and feasible. You start from reality to produce a practicable theory instead of, as is perhaps done in the West, starting from theory to practice ?

UOSSM medical team visits IDP camp ©UOSSM

Raphaël Pitti : In a situation like Syria, with the shortage of drugs, the absence of resuscitation services, the lack of technical means, you would like us to train according to international recommendations, for countries with a high level of technology, developed? Would you like us to create a feeling of frustration, by telling them “this is what needs to be done, unfortunately for you, you can’t do it”? We are obliged to put ourselves at their level and say “what can we do, at best, in your situation, to manage these patients? Obviously, this implies that we are going to let some of them die, since there are not enough resuscitation services. If there is a sorting that is done, it is in this country. Our Syrian colleagues tell us “We used industrial oxygen”, with all that this presupposes, industrial oxygen is not pure oxygen, it can contain a certain number of elements that can alter the pulmonary alveoli and destroy them. But they did it! Did they sort it? Of course they sorted. There are people they left to die because of lack of resources, obviously. So we had to start from their daily life to find out how we could save people from this daily life.

Pierre Brunet : On training. I asked myself this question: do we train specialists, doctors, midwives, etc. at the same time, because it is urgent and because we must respond quickly to the needs, or do we say to ourselves that we will first train trainers ?

Dr. Ziad Alissa and Professor Raphael Pitti show the use of a chemical weapons protective suit. The photo was taken in 2017 at Bab Al Hawa Hospital in Syria following the chemical attacks on Khan Sheikhoun ©UOSSM

Raphaël Pitti : The important thing is to train trainers so that they can continue on their own. We wanted the training centers that we set up to be autonomous. The goal was: we trained the trainers and then the trainers, together with the directors, set up the training courses. We provided the logistical and financial support necessary for the functioning of these structures. In ten years, how could we have trained 31,000 people, travelling each time, to train how many? The Syrians, and the Syrian medical staff, during these ten years, have written a page in the history of medicine. Everything was done by the Syrians, inside Syria. We gave them the necessary help, but they were the only ones who maintained a health system despite the war situation during these ten years. We, the NGOs, have only provided them with the means. They are the real heroes of the Syrian conflict. We owe them recognition for their sacrifice. UOSSM France has counted 923 doctors who died during these ten years.

Pierre Brunet : You also emphasize what you call “community health”, i.e. proximity medical structures, primary health centers (17 created in Northern Syria), and mobile clinics. What was the need that led to the emphasis on these community health facilities ?


Ziad Alissa : We started with this idea because it was difficult for patients to go to hospitals. The hospital was becoming a dangerous zone, people were afraid to go there because the hospitals were targeted by the bombings. So with this community health system, we go where there are people, especially where there are displaced people who settle, and we set up a health center as close as possible to them. The mobile clinics also allow us to go even further, inside the IDP camps, in the most difficult to access areas. Health centers are expensive and it is difficult for us to set them up as we would like. Hence the idea of a mobile clinic, because with the same human resources, they will go to areas where there is no open center. They travel with small vans in which there is a doctor, a midwife, a nurse, with what to do a medical examination, what to treat simple diseases. If the mobile clinic detects people who have serious illnesses, who are poorly followed up, who need to go to the center, they give them an appointment at the nearest center or at the hospital. With this system, we were able to get as close as possible to the people who needed us, while reducing the risks of accessing large hospitals. People were asking themselves, “What if I go to the hospital, will I make it home alive? Not to mention the difficulties and costs of transportation. We met with Raphaël people who are dialyzed 2-3 times a week, who, instead of going 3 times to the dialysis center, will go there twice or even once a week, because they cannot afford to pay the round trip or to buy the filters.

Pierre Brunet : You tell UOSSM France that testifying is also part of our action.

Raphaël Pitti : You cannot be a doctor, be on the spot, and just take care of victims who are innocent victims, caught between belligerents, borders now closed, with a wall that separates Syria from Turkey of more than 900 kilometers. These people are in a veritable concentration camp, where death and hunger loom large. How do you expect us to go there, to see this, and to go out and resume our quiet lives? It is impossible. The action of witnessing goes hand in hand with that of care, of humanitarian aid. It is concordant, it cannot be otherwise, otherwise we become accomplices of this situation. The action of witnessing imposes itself on the humanitarian and makes him say, and in particular to the Western governments, “look at what is happening, you try to turn your head not to see what is happening, and well, we are there and we can tell you, things are not as you think they are or as you want them to be, we bring you information which is that of the field, of the voiceless”. When we asked several times to see President Hollande, as we went to see President Macron, as we went to the UN, to New York, to Geneva, etc., we went with one goal: to help them find solutions. For the humanitarian action you can count on us, but for the political action, it is up to you. Politicians often tend to want to do humanitarian work when they are asked to find political solutions to allow peace. Politicians have the impression that by giving us money, by helping us in our humanitarian action, it exonerates them from not finding a solution. Well, no, everyone has their own job. Humanitarians should do the humanitarian work and politicians should find the political solutions.

Ziad Alissa : We doctors who go there, as well as our teams who treat every day, can testify to violations of humanitarian law and bring back evidence of our testimony. When people talk about victims in hospitals following a bombing, and some say “No, no, we bombed soldiers, terrorists in such and such an area, in such and such a city, in such and such a neighborhood”, we see that in hospitals it is children, women, civilians who come, of all ages. We have hospital records, we have photos, we have videos, we have the doctors who treated these victims, and we can demonstrate that the victims are civilians. When we saw the use of chemical weapons, we testified. We have seen the victims of chemical weapons, we have taken samples, we have reported evidence. This is where our role as witnesses is essential.

Pierre Brunet : One last question: why this specific commitment of UOSSM France to the Rohingya refugees in Bangladesh, so far from Syria ?

Raphaël Pitti : How many Rohingyas have fled Burma? More than a million people, in the poorest country in the world, 80 million inhabitants, Bangladesh, and who received this million Rohingyas fleeing Burma, in the Cox’s Bazar camp of a million people, in a situation of immense precariousness. We were really confronted with pathologies that I never imagined seeing during my 30 years of medicine. Facial cancers, patients who had fractures that had not been reduced and who were living in impossible conditions. We saw bladder stones, young women with infected vesico-vaginal fistulas from traumatic deliveries. A population that for years had been completely abandoned to itself without any possible care. So we rented a clinic and operated for two weeks. We were two teams and we operated non-stop, and we should have stayed much longer. We thought we were providing emergency help and we were confronted with a situation of chronic pathologies that had not been treated for a very long time, and for which we would have had to stay.


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Dr. Ziad Alissa, co-fondateur et Président de l’UOSSM France

As an anaesthetist and resuscitator, Dr. Ziad Alissa has been involved since the beginning of the conflict in Syria in the implementation of medical and humanitarian aid to the health care workers in Syria by co-founding the French and international medical NGO UOSSM, the Union of Organizations for Medical Relief and Care. He has carried out some forty humanitarian missions in Syria and in the neighboring countries of Turkey, Lebanon and Jordan. Trained in war medicine by Prof. Raphaël Pitti, he coordinates the implementation of training programs for health care workers in Syria, which have enabled 31,000 health care workers to be trained since 2012.


Professor Raphaël Pitti, Head of training at UOSSM France

aphaël Pitti is an associate professor of emergency medicine, anaesthesiologist-resuscitator, and army general physician. A specialist in war medicine, he joined UOSSM France in 2012 as head of training and has enabled the training of tens of thousands of caregivers. On March 1, 2021, he carried out thirty-one humanitarian missions with Syrian caregivers in the north of the country. In June 2021, he and Dr. Ziad Alissa conducted the first training in Raqqa to fight against COVID-19.


Pierre Brunet, writer and humanitarian 

Born in 1961 in Paris to a French father and a Spanish mother, Pierre Brunet found his first vocation as a freelance journalist. In 1994, he crossed paths with humanitarian aid and volunteered in Rwanda, which had been devastated by genocide. In early 1995, he left on a humanitarian mission in Bosnia-Herzegovina, then torn by civil war. There he took on the responsibilities of program coordinator in Sarajevo, then head of mission.

Upon his return to France at the end of 1996, he joined the headquarters of the French NGO SOLIDARITES INTERNATIONAL, for which he had gone on mission. He will be in charge of communication and fundraising, while returning to the field, as in Afghanistan in 2003, and starting to write… In 2011, while remaining involved in humanitarian work, he commits himself totally to writing, and devotes an essential part of his time to his vocation as a writer.

Pierre Brunet is Vice-President of the association SOLIDARITES INTERNATIONAL. He has been in the field in the North-East of Syria, in the “jungle” of Calais in November 2015, and in Greece and Macedonia with migrants in April 2016.

Pierre Brunet’s novels are published by Calmann-Lévy:

  • January 2006: publication of his first novel “Barnum” by Calmann-Lévy, a story born from his humanitarian experience.
  • September 2008 : publication of his second novel ” JAB “, the story of a little Spanish orphan girl who grew up in Morocco and who will become a professional boxer as an adult.
  • March 2014: release of his third novel “Fenicia”, inspired by the life of his mother, a little Spanish orphan during the civil war, refugee in France, later an anarchist activist, seductress, who died in a psychiatric institute at 31 years old.
  • End of August 2017: release of his fourth novel “The Triangle of Uncertainty”, in which the author “returns” again, as in “Barnum” to Rwanda in 1994, to evoke the trauma of a French officer during Operation Turquoise.

In parallel to his work as a writer, Pierre Brunet works as a co-writer of synopses for television series or feature films, in partnership with various production companies. He also collaborates with various magazines by publishing columns or articles, notably on international news.


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