• Inside the Secret Hospitals of the Syrian Civil War

    David Nott on Traveling to Aleppo to Save Lives

    By the time I arrived, in August 2013, the healthcare system of east Aleppo had been forced into the shadows. As I had seen in other countries in crisis, many of the more senior doctors and surgeons had already left—as many as 95 percent of Aleppo’s physicians had seen which way the wind was blowing and found a route out. Those who remained were brave and committed, but there were very few of them. In the face of the regime’s targeting of healthcare workers and those seeking medical help, one of these courageous doctors had set up a network of secret hospitals to treat people injured in the war.

    To escape detection by the regime, he adopted the codename “Dr. White,” while his like-minded colleague, Noor, gave the group its name—Light of Life; noor in Arabic means light. They recruited several medical students who shared their sympathies with the uprising against Assad, and began carrying out covert medical procedures as well as giving lectures in the basic principles of emergency trauma work. Volunteers would bring wounded protesters to the safe houses, and then leave before Dr. White took over, to preserve his anonymity.
    But the care provided was limited, and the risks considerable. Noor himself was kidnapped and later killed, and three of Dr. White’s students were abducted by the security forces and murdered. The Light of Life was extinguished, and Dr. White was obliged to change his name again, and become Dr. Abdulaziz.

    By this point, some of the now-expatriate Syrian surgeons and doctors had begun to mobilize, setting up charities to try to improve the situation on the ground. My friend and colleague Mounir Hakimi’s Syria Relief was one of them. Aid and ambulances were making their way into Syria from Turkey, but the approach was scattershot. Supplies would arrive at a clinic that had just received a truckload of medicine, while other facilities were completely overlooked.

    A more coordinated response was urgently needed and so Dr. Abdulaziz set up the Aleppo City Medical Council (ACMC). The plan was to establish a formal network of clinics across the rebel-held eastern half of the city. These clinics were also assigned code names, which initially ran sequentially from M1 to M8, but later hospitals were given random numbers to disguise how many there really were. The subterfuge did not stop there—ambulances and other medical vehicles carried no sirens, insignia, or logos, and at night drove with their headlights off. Anything that looked like help for the injured was, according to the regime, aiding the rebels and so in their eyes a legitimate target.

    Our first stop on arriving in Aleppo was one of these hospitals, M10, where we were greeted by the surgeon in charge, who would become a great friend. Dr. Abu Mohammadain was in his late thirties, a urologist by training—and a very good one. The other doctors there were more junior, and needed a lot of help to deal with the number of casualties with gunshot wounds. We were taken to a small room that served as the canteen and were given a wonderful welcome meal of hummus, olives, fresh cucumber, and tomatoes, followed by some delicious tea. Dr. Mohammadain showed me the pockmarks on the walls from a recent rocket attack, and advised me to sit near the door and not the window.

    We left M10 to continue our journey to M1, the hospital where I would be based. It was a little bit farther south, and closer to the front line. As we drove through east Aleppo, I asked our driver about the mounds of rocks I could see everywhere along the route. It turned out that they had been put there deliberately to shield civilians from sniper fire from the western half of the city, which was still mostly controlled by the regime. There were also two badly damaged buses, one on top of the other, to provide further protection in an area that had been turned into a market. The market itself was full of people, with lots of fresh fruit and vegetables on display in many of the stalls. There were shops open, too, and I was amazed to see hundreds of people on the streets simply going about their everyday lives while the conflict raged around them.

    But it was plain that life for civilians in Aleppo was already appallingly difficult, whether in the rebel-controlled east of the city or in the government-controlled west. I later learned that the rebels were trying to encircle the western side of the city and close the main road up from the south. This was the primary inbound route for food and other supplies, so the regime was—equally desperately—trying to keep it open, though without much success. There was very little fresh food reaching the people of western Aleppo, and the only way to get any was to cross to the east, where supplies were more plentiful. At first, the front line was dotted with passageways allowing access to and fro, but gradually these were closed off until only one major entry-point remained, the Karaj al-Hajez crossing. At one point, around 10,000 people per day were heading from the west to the east in search of food.

    To make things even more difficult, all the people going back and forth every day to shop, work, attend school, or simply visit relatives risked the wrath of both sides. Residents from the west might face harassment or even kidnapping for ransom when entering the rebel side, or be arrested when they tried to return home. It was worth the risk, though. In western Aleppo a loaf of bread cost 300 Syrian pounds, but only 65 in the east. These poor civilians caught between the rebels and government soldiers also faced snipers positioned in the city hall, or other nearby buildings. Dozens of people at the Karaj al-Hajez crossing were shot at by snipers every day. But people had to eat.

    Life for civilians in Aleppo was already appallingly difficult, whether in the rebel-controlled east of the city or in the government-controlled west.

    As we pulled up outside M1, about a hundred meters from the crossing, we piled out of the van with our bags and cases. I had my big gray suitcase with me, which always looked incongruous in a war zone. The first thing I noticed was the armed guards at the door, but they wore smiles as well as guns and greeted us warmly. I had expected to be shown inside and then be given a welcome tour, but the moment I arrived I was asked to help with an operation. I changed quickly and was shown into the OR, where I was greeted by a man with a beautiful command of English who looked completely at home in his environment.

    “We’ve been waiting for you!” he said jovially. This, it turned out, was the famous Dr. Abdulaziz. On the table was a man who had obviously been shot. It looked like the bullet had traversed his bowel, and he needed a small bowel resection to join it back together. It was a bit of a baptism of fire—I hardly had time to take in my surroundings before Dr. Abdulaziz told me to scrub up at the small sink nearby. I was handed a surgical gown made of green cloth rather than the usual disposable paper version that I was used to in the UK. The gloves were also different, and quite difficult to put on as they were thin and easily torn. Once I was ready, Dr. Abdulaziz handed me a pair of scissors and forceps. “The case is yours,” he said. “This is the eighth procedure I’ve done today and I need a break. But I’ll assist you.”

    And then came a sudden flashback to that disastrous test flight for Astreus a decade earlier—I was wearing the wrong glasses again. My operating glasses were in the big gray case, along with my gas mask, loupes, and other equipment. I couldn’t now take off my gown and gloves and make my excuses—a man needing an operation was on the table in front of me and there were four other surgeons in the room, including Ammar and Mounir, all waiting to watch the English doctor join up two ends of a small bowel.

    I squinted as hard as I could to try to focus on the bowel and explained that I was going to make a connection called a single-layer anastomosis. I took the 2-0 Vicryl suture and prayed to God that I would be able to see what I was stitching it to. It wasn’t the best anastomosis ever, but it was successful, although I think Dr. Abdulaziz noted my shaking hands. The anxiety about operating this quite simple procedure in front of my new colleagues was overwhelming.

    Afterward Abdulaziz introduced me to everyone, and we had a chance to talk about the plight of Aleppo and its people and what the ACMC was doing to help. He told me his parents and the rest of his family lived in west Aleppo—he had to be very careful to hide his real name, as if it became known that he was working on the east side his family would have been killed immediately.

    The doctors at M1 were all very young, mostly in their mid-twenties. There was Abu Abdullah, the general surgeon; Abu Hozaifa, the vascular surgeon; Abu Waseem, the plastic surgeon; and Abu Khalid, the orthopedic surgeon. Each of the other trauma hospitals I worked in while I was in Aleppo—M2, near the old city, and M10—had only general surgeons. The specialists would go from hospital to hospital when and if required. As a result, I shuttled between the hospitals constantly, driven around by a wonderful man called Abo Abdo, who carried a Kalashnikov on his dashboard to show he wasn’t to be messed with. However, even though many of the doctors had a title to indicate their specialty, they were still basically trainees with very little experience, and there was much work to be done to fill the gaps in their knowledge and train them up to be as effective as possible, as quickly as possible.

    In M1 the majority of injuries we saw were gunshot wounds sustained while traversing from one side of the city to the other. There were as many as seventy individual snipers dotted around east Aleppo at that time. They simply picked people off as they were crossing the street, going to work or going to the shops. Abdulaziz told me that I should expect that anyone and everyone who came in would have been shot by a sniper—from babies to the elderly, no one was immune.

    Each of the other trauma hospitals I worked in while I was in Aleppo had only general surgeons. The specialists would go from hospital to hospital when and if required.

    As Abdulaziz filled me in I marveled at how buoyant and enthusiastic he seemed, after all that he had been through. I warmed to him immediately, and I was, in fact, already feeling very comfortable with all my new colleagues. It was still light, and after chatting for a while we decided to go for a walk outside the hospital. We went around the back of the building so I could see the effects of the airstrikes.

    I found myself looking at an apartment block that had been cut in half. One side had been demolished and lay in a pile of rubble, but the other half was still standing, exposed to the world like a giant doll’s house. You could see right into the apartments, full of beautiful wooden furniture, and in some cases ornaments and figurines were still standing on the tables and dressers. One apartment had a kitchen with wooden spoons, pots and pans, and bottles of oil and other condiments ready for use. It was the most bizarre snapshot of obviously well-to-do lives that had been torn asunder.

    Abdulaziz posed for a photograph with me and Ammar. In it, I can see that I look sad, but Abdulaziz is smiling, apparently full of hope for a better future.

    Ammar was my roommate, along with one of the junior surgeons. It turned out that Ammar had contacted Syria Relief to see if he could stay with me 24/7, acting as my interpreter, minder, surgical student, and confidant. I soon realized how lucky I was to have a man of such integrity by my side, willing to defend and support me unconditionally throughout my time in Syria. He had a terrific sense of humor, too, which also proved invaluable. Over the weeks that we spent together I came to depend upon and trust him completely. We became so close that I regarded him not just as a friend but as the brother I never had.

    Wherever I went, Ammar went, too. On the rare occasions when I was out of his sight, he still knew exactly where I was. Missions can be rather isolating and solitary experiences, so this was a novelty, but I soon came to appreciate deeply his reassuring presence.

    I was excited that first night, spent trying to sleep on a plastic mattress without sheets in my surgical scrubs, which I barely took off for the next six weeks. I already felt a strong affinity for the people I’d met, reinforced by my instinctive sympathy for the ordinary people of Aleppo and what they were going through. I had my USB drive, too, with the STAE course on it, and felt confident I’d be able to do more here than save only the lives of those casualties put in front of me.

    We didn’t have long to wait. Around five o’clock the next morning, we heard the first of many tap-tap-taps on our door—could we come down to one of the operating rooms straightaway? Ammar and I found Abu Abdullah in the middle of a procedure. He apologized for getting us up so early—“Usually,” he said jokingly, “it doesn’t start until around eleven o’clock, when the snipers get out of bed.”

    We went to scrub up in the small square room along the hallway that served all three operating rooms. The patient was a man with, as ever, a gunshot wound—a tricky one in that the bullet had traversed and almost split the right lobe of the liver in two. The patient had lost quite a lot of blood before coming in, and Abu Abdullah was trying to do the operation on his own. I told him I’d be happy to assist but he said he wanted to learn, and handed me his scissors and forceps.

    As often happens, I shuffled through my memory banks, reliving the many times I had previously operated on injured livers. The first thing to do, I told him, was to compress the liver back to its normal anatomy. Do this for as long as it takes the bleeding to stop, and for the anesthesiologist to catch up with fluids. Very often surgeons forget that there are people at the top of the table struggling to maintain the patient’s blood pressure and pulse, and continue to operate without letting the anesthesiologist know what’s happening.

    Abu Abdullah apologized for getting us up so early—“Usually,” he said jokingly, “it doesn’t start until around eleven o’clock, when the snipers get out of bed.”

    We squeezed on the liver for about half an hour, taking it in turns—me, then Ammar, then Abu Abdullah. After an hour or so, though, it was obvious that it wasn’t working. I suggested we use the omentum to try to stop the bleeding. This is a big, fatty, apron-like membrane in the gut, which can be wrapped around inflamed organs to seal them off—hence its nickname “the policeman of the abdomen.” Abdullah had never seen this done and it gave me great pleasure to show him how to move the membrane and roll it around the liver. Once attached to the liver, we closed up. Two hours later the bleeding had stopped, the patient was in recovery, and we could go back to bed.

    A few hours later we resurfaced to join other members of the hospital—doctors, nurses, and ancillary staff—for breakfast. Looking around the room, I saw about 40 people eating and chatting together, like a huge family—a family in which I felt entirely at home. The women ate separately, in a room downstairs, except for one of the paramedics, Um Ibrahim. She also acted as a kind of liaison officer between the hospital and the various FSA groups in the area. A formidable woman, loud and funny, she didn’t take any nonsense from anyone and she effectively ran the hospital. She was ably assisted by her delightful 14-year-old son, Ibrahim, who helped keep everything running smoothly. She was wonderful, a mother figure to everybody in the hospital. She would come into our bedrooms to make sure we were all OK, she would be in the emergency room helping with casualties, and she would even pop up in the operating room to see how things were going.
    She came up to me during that first breakfast.

    “How many children do you have?” she asked. I said I was sorry, but unfortunately I didn’t have any.

    “Oh. How many wives do you have?” she said. I smiled and said, “None, Um Ibrahim.”

    “Whaaat!” she said, laughing and shouting at the same time. From then on, at every meal we shared, she would engineer an opportunity to say, “I am going to find you a wife before you leave Aleppo.”

    Just as Abu Abdullah had predicted, things began to get going at around midday, when the first gunshot wound arrived at the hospital. The emergency room was at ground level, as were the somewhat battered X‑ray machine and the three ORs, which were run by Mahmoud, the operating room manager. He was very experienced and was completely at ease with all the equipment that we needed. Surgeons would simply shout out his name and he would run to get the equipment they wanted. He was no pushover, though—he would stand his ground and shout back if he thought the request was ridiculous.

    The emergency room was run by a tall, good-looking young man who had been in his third year at Aleppo medical school when the revolution started. After six months in charge, he had become extremely adept at identifying which patients needed immediate treatment by examination alone. I was amazed that he managed the emergency room with just four trained nurses and ancillary staff. The ancillaries were men and women who had given up their jobs—as shopkeepers, tailors, factory workers—and were being trained to become emergency nurses.

    It was difficult for me to show my face in the emergency room, though, since it was rather more public than the operating rooms. Security was paramount, as Ammar kept reminding me. There were armed extremist groups roaming around, including members of ISIS, whose base in the Qadi Askar district was just a short distance from where we were working. It was vital that I kept a low profile—I was almost certainly the only Westerner in Aleppo at the time, and it would have been a major coup if I had been kidnapped. I was confined to the hospital grounds, leaving only to go to one of the other hospitals; I therefore spent most of my time in the operating room.

    Only once did we make a mistake, driving from M10 back to M1 with a new driver. He took a shortcut down a road we usually avoided, and we found ourselves approaching the ISIS headquarters with its black flags flying from the rooftop and black-clad armed guards at the door. Ammar was first to realize the driver’s error. It was too late to stop and reverse, as that would have attracted too much attention. Thinking quickly, he yelled at me to get down as we approached the building and as I slipped out of sight he told the driver to step on it. It was a close shave—the headquarters had become a prison and place of torture for many of Aleppo’s civilians. There were also rumors that one of the MSF surgeons working in Aleppo province had been taken there for questioning and subsequently murdered.

    There was an ever-present threat, and I had to remind myself continually not to become complacent. Abdulaziz told me that in November 2012 he had welcomed the British orthopedic surgeon Abbas Khan, who wanted to help at M1. The day after he arrived he was seen leaving the hospital with his camera. He told the security guards out front that he was going for a walk. Apparently, he wandered down a road and directly into the hands of the government forces.

    After he was reported missing his mother moved heaven and earth to try to locate him, and he was eventually found in a prison in Damascus, thanks to unofficial assistance from the Indian and Russian embassies. All attempts to get him released failed and then, thirteen months later, the UK coroner’s court deemed that he had been murdered by the Syrian regime in December 2013. The authorities denied this, claiming that he had hanged himself, but nobody believed them.

    Abbas Khan was married and had two children. I have since met his entire family, including his mother, who is still in a state of shock and disbelief that this could have happened. More recently, I gave the inaugural Abbas Khan Memorial Lecture at King’s College London, where he had been a medical student. His name, at least, lives on.


    From War Doctor: Surgery on the Front Line © 2019 David Nott, Published March 3, 2020 by Abrams Press, an imprint of ABRAMS. Excerpted with permission of the publisher.

    David Nott
    David Nott
    David Nott is a consultant surgeon, specializing in general and vascular surgery. He has also volunteered to work in disaster and war zones for over two decades. He lives in London.

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