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doi: 10.1097/01.NT.0000437150.24964.14
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Neurologists Exit Syria as Hospital System Nears Collapse

Samson, Kurt

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With more than half of Syria's hospitals either destroyed or severely damaged, many neurologists are among the estimated 15,000 doctors who have left the country in recent months seeking safe haven in other countries.

In a Sept. 13 letter published in TheLancet, a list of 55 concerned doctors from around the world, including several Nobel Prize winners and heads of international health and humanitarian organizations, warned that Syria's hospital system is on the verge of collapse and that providing health care services has become nearly impossible.

“Systematic assaults on medical professionals, facilities, and patients are breaking Syria's health-care system and making it nearly impossible for civilians to receive essential medical services,” they wrote. “The targeted attacks on medical facilities and personnel are deliberate and systematic, not an inevitable nor acceptable consequence of armed conflict. Such attacks are an unconscionable betrayal of the principle of medical neutrality.”

According to the Violations Documentation Centre in Damascus, an estimated 469 health workers are currently imprisoned, and the Council on Foreign Relations, an independent, nonpartisan information organization with members throughout the world, has said that about 15,000 doctors have been forced to flee abroad.

A recent report by the Assessment Working Group for Northern Syria, a humanitarian relief organization that is monitoring the impact of the fighting, said that in Aleppo, for instance, one of the hardest hit cities, only 36 physicians remained out of 5,000 before the conflict.

According to the letter in The Lancet, most medical assistance is currently being provided by Syrian medical personnel working under extremely dangerous conditions and critical shortages of basic medications.

Although there is no way of knowing how many neurologists remain in Syria, Neurology Today was able to reach several who were willing to share their experiences — two recently left the country and another has remained in Damascus.

The first is a US-board-certified neurologist who worked in Syria for a dozen years before leaving around four months ago. He told Neurology Today that even though he is now safely abroad, he continues to be concerned for his safety.

“It is difficult to talk about this for several reasons and I need to remain anonymous. Even if you mention where I worked I can be pinpointed very easily, and that can be very unsafe for me,” he said. “I have been in contact with colleagues who have remained in Syria, and they say suspicion of their allegiance to the Syrian regime is a constant worry, but they also fear they may be targeted for no reason by either side. While I was in Damascus, there was always fear whenever an unfamiliar person came to my door. Everyone views strangers with suspicion.”

[For purposes of anonymity, a pseudonym, Dr. Abadi, will be used.]

His fear is justified because there have been many reports of doctors being killed, imprisoned, or simply disappearing, he said, something that independent observers have also reported.

“One example is Dr. Gasan Abudahab,” he told Neurology Today. “A Syrian military neurologist for 10 or 15 years, he was assassinated on his doorstep about a year ago. I cannot understand why he was killed or who might have done it — he was simply a physician and had nothing to do with any politics, let alone the fighting.”

Another neurologist reached by Neurology Today has remained in Damascus. Also insisting on anonymity, he provided a portrait of the current situation.

“Those neurologists who have stayed behind will only work near the centers of relatively safe cities like Latakia and Tartous, and in the very close center of Damascus. A few doctors are still working in rural and hot areas where clashes happen, but most of these are general practitioners and almost all are younger physicians, he said.

In the last two-and-a half years, he said, 312 medical personnel have been killed, including 143 doctors. Another 3,000 have been arrested.

Another neurologist who asked to remain anonymous — for this story, we will refer to him with the pseudyonym, Dr. Grazi — practiced neurology at the University of Damascus Al-Assad Hospital for 11 years and another 16 years in the private sector before leaving the country with his family within the last month.

“I was practicing in Syria for the last 17 years, but came to Dubai three weeks ago seeking a neurology position here. I spent the last year traveling on a weekly basis between Damascus and Beirut, working in Damascus and visiting my wife and children in Beirut on weekend. I sent them there for safety reasons,” he told Neurology Today.

“Many doctors have left the country, and in some regions where there is fighting, there are no neurologists at all. For example in Homs, where there has been severe destruction and ongoing violence, no neurological treatment is available whatsoever. There is intense suspicion among the opposition about which doctors support the regime, but also by the regime if they suspect any doctor's allegiance.”

For the most part, he said, mainstream practice has not changed in Damascus and neurologists continue treating patients with conditions like peripheral nerve disease, Alzheimer and Parkinson's diseases. But in “hot” zones, neurological injuries caused by explosions and gunshot wounds have increased tremendously.

Even for patients fortunate to be living in areas where things are calm, obtaining necessary medications has become almost impossible, all three neurologists agreed.

“There are severe shortages of many medications, especially those for treating epilepsy, Parkinson's disease, and Alzheimer's disease, and there has been an increase in untreated stress, headaches, and epileptic seizures because most medications are no longer available due to the destruction of Syrian pharmaceutical factories, embargos, and difficulties in transporting shipments of drugs sent from other countries,” said Dr. Zahka.

“Some of these can be obtained from other countries, but they are much more expensive because of the devaluation of the Syrian pound. In the past when these could be manufactured in Syria, they were very cheap. There is a black market, but few patients can afford medications being sold on the street. I estimate that no more than 20 percent of patients have enough money to buy their medications if they can obtain them at all.”

Dr. Abadi agreed. “Embargoes do not discriminate between innocent individuals who need medicine and aggressors. Tissue plasminogen activator [tPA] for strokes? Forget it. Even if you have tPA, it is unlikely that someone who has had a stroke will be able to get through all the checkpoints within the treatment window that will allow it to be effective.”

The situation is equally bad for diagnostic equipment, he said, noting that if a CT scanner stops working, there are none available to replace it and few parts for repairs, he said.

Dr. Grazi told Neurology Today that while he has heard that the situation is improving, he has no plans to return without assurance that some stability has been achieved.

“I will not return until I am sure that it is safe, especially for my children. You can be simply walking down the street and get shot.”

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LINK UP FOR MORE INFORMATION:

•. Brundtland GH, Glinka E, zur Hausen H, d'Avila LR. on behalf of 55 signatories. Open letter: let us treat patients in Syria. Lancet. 2013; 382:1019–1020.

•. Assessment Working Group for Northern Syria. Aleppo city assessment report, March 2013: http://bit.ly/18GRk4f

Wolters Kluwer Health | Lippincott Williams & Wilkins

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