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Working in Aleppo

When Abdel Malek was brought into the emergency room in Aleppo in September 2014, his lower left leg was so badly damaged by fragments from a barrel bomb attack that the Syrian doctors thought they would have to amputate the little boy’s foot.

The doctors that remain in Aleppo are passionate and committed but did not have specialist training in vascular, orthopaedic, plastic or reconstructive surgery, understandably given how the war has halted their education and training. I took over the management of the case and was able to show them another way of treating the little boy which would also save his foot.

We took the tiny long saphenous vein from Abdel Malek’s right leg and did a bypass graft to the injured lower leg and foot. The next stage was a cross leg flap to cover the bypass graft.  Abdel Malek was kept in this position for three weeks, with his foot elevated and held in place with external fixators, to allow the flap to get its blood supply from the injured leg.

The flap was cut a month later and the legs separated. With the continuing care of the surgeons I trained, Abdel Malek’s foot healed and slowly and steadily, he started to walk again. I was overjoyed when my friends in Aleppo sent me a video on WhatsApp of Abdel Malek playing football with his friends. It demonstrated to me the power of surgery and the options it presents for reconstruction and recovery.

Moments like this were sadly very rare when I was in Syria in September – October 2014.  Indiscriminate bombing of civilian areas with grossly destructive barrel bombs – crude devices filled with TNT and shrapnel – caused the most injuries. Day after day, the emergency room and operating theatre were filled with innocent people blown to pieces by these crude devices.  Often all we could do was try to ease their pain.

Every day I worry about my Syrian friends and the people who we managed to operate on successfully and save, like little Abdel Malek.  My concern has only increased over recent months as it is clear that the Syrians and Russians are targeting hospitals.

Following a strike on one of its hospitals in Azaz, Medecins Sans Frontiers have now stopped sharing GPS coordinates showing the locations of their hospitals with the Syrian and Russian authorities.

I am at a loss as to why there is not more of an outcry. Targeting medical facilities flagrantly breaches the UN Geneva conventions.  Russia’s status as a Security Council Permanent Five member seems to insulate it from censure, which does not seem right.

As well as my concern for my Syrian friends, I worry that this targeting of healthcare workers will put off people from the UK and other more stable countries from volunteering to help in conflict zones, as I have for the past 23 years. It is one thing to go with the knowledge that you may be accidentally caught in the crossfire of a conflict; quite another to think you may actually be deliberately targeted because you are a doctor.

Why doctors? Because doctors are a source of hope for civilians. If you take out a doctor, you take out the 10,000 people they can no longer care for. If there is no healthcare system, people will despair and leave.

Publicising the plight of healthcare workers in danger is one of the objectives of the Foundation I have recently set up. We are raising the profile of humanitarian surgery in the UK and worldwide and offering scholarships for talented surgeons from conflict zones and countries where the healthcare system is under-developed to come to the UK and be trained by myself and my colleagues. We will also take the best surgical training to the front line with training courses for hostile environments.

We want people to understand the power or surgery and train as many doctors and nurses as we can so they can not only provide the best medical care to those who need it most, but also hope.

Professor David Nott
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