Last October witnessed the largest number of bombings of medical facilities in a single month since the outbreak of the Syrian war, says Donna McKay, the executive director of Physicians for Human Rights (PHR).

“That is where the majority of the bombs are coming from now, from Russian airstrikes,” says McKay, adding that this is particularly true in rebel-held districts of eastern Aleppo where PHR conducted its research.

The first barrel bomb attack on a medical facility occurred on January 30, 2014 on a clinic in east Aleppo, killing a doctor and a member of the Polio Control Task Force charged with vaccinating children.

Barrel bombs pushed out of regime helicopters, and subsequently missiles and rockets fired from warplanes, have consistently been onto Aleppo medical facilities ever since.

Though Aleppo’s health care system adapted by moving many of their facilities underground, the constant threat of death from above is the primary reason for the mass exodus of medical personnel from Aleppo city, according to PHR’s report published in November. The few doctors and medical personnel who remain “are finding it impossible to survive” despite their desire to stay, McKay tells Syria Direct’s Samuel Kieke.

 Photo courtesy of Physicians for Human Rights.

“The number one call that you will hear from the physicians that you interview is: Just get them to stop the bombings so we can do our work,” says McKay. “We need to provide them with protection.”

In part two of this interview with one of two remaining neurosurgeons in Aleppo city and one of the 24 medical personnel interviewed by PHR for their report, Dr. Rami Kalazi walks us through his work day amidst air raids on and near his clinic in northeast Aleppo. [Read part 1 here.]

“Strikes are always unexpected,” Kalazi tells Syria Direct’s Ghardinia Ashour.

“We feel fear and resentment as we immediately begin to anticipate the arrival of people with serious injuries, a large number of martyrs, many permanent disabilities and lost limbs.”

Q: When you are warned of an imminent attack or air raid, what are the steps or measures that you take?

In terms of preparation in advance of a strike on the hospital… this has never happened. Strikes are always unexpected. A warning comes within 15 minutes of a strike. We feel fear and resentment as we immediately begin to anticipate the arrival of people with serious injuries, a large number of martyrs, many permanent disabilities and lost limbs.

To prepare,we ensure that the full staff is on standby and we wake up the people who are sleeping.

We inspect the ambulances and operation theater and try to secure any missing supplies. We check on the medicine supply and replenish it. We inspect the beds in intensive care and in the ward. If we have time, 15 or 20 minutes, we assess the sick people in the ward. If their condition has improved, even if they are not at 100 percent but near 100 percent, we try to move them to their houses.

We have to empty the ward to admit the new patients since we only have 15 or 20 beds. Of course, we are rarely able to prepare, because if the strike hits far away, we do not find out about it until the injured people start arriving. If the strike is nearby, we only have a short amount of time to prepare.

Q: What is your first reaction when the number of patients arriving is larger than you expected?

In the beginning, when we did not have experience in handling that number of injuries at once, we would pause for a moment, shocked. We didn’t know how to deal with the situation. Especially because in our city, medical awareness is generally low, so there were mistakes in the way that the emergency response was handled.

People were mostly being transported in civilian cars. Emergency responders were distraught, screaming and yelling as they arrived, so the emergency room turned into chaos. This was in the beginning, but then we adjusted to these situations as we gained more experience in managing them.

Even now, sometimes the number of people who arrive is greater than what we expect or what we can handle. In those situations, sometimes we feel helpless for a few minutes and we don’t know what to do because we have a large number of injured people, and the operations room and the intensive care beds cannot accommodate any more people.

The ambulances usually go to the site of the strike to transport injured people, so we do not have additional ambulances to move injured people to other hospitals. Sometimes we only have 10 minutes to take control of the situation and start transferring patients to other nearby hospitals or to the Turkish border.

Q: What keeps you going when death rains from the sky and when you’re afflicted with pain when a situation is hopeless? What keeps you in Aleppo? Is it a sense of humanitarian duty, belief, or it is just that this is your job and you must do it?

The truth of the matter is a bit complex and there are several reasons. Firstly, one of the most important reasons is faith: we believe in God and we believe that relief from suffering will come soon.

Secondly, the group that has remained here is well read and educated. They know that every war comes to an end, and that if we can help to shape this end ourselves, it will be ajust end. What has happened in Syria ishorrible, but during the first and second world wars, the same thing that is happening in Syria happened there, perhaps even worse. Despite that, they were able to stand back up on their feet thanks to the people who stayed in the country and didn’t leave. For these two reasons we remain here.

The third principle is the humanitarian call. We know that only a very small number of us has stayed here and that if we leave, there will be no doctors left in the liberated areas. Then the hospitals will be empty. Hospitals and medical centers are what keep a city or any area alive. If medical services stop, the people will either die or leave. We are certain that if we leave, the peoplewill perish.The humanitarian call makes us stay.

But no matter how much someone learns about war, he doesn’t know as much as someone who lives the dangerous reality. This is especially true in Aleppo, which is considered one of the most dangerous cities in the world. This is particularly true in our hospital, which is the most-targeted hospital and has been bombed more than 35 times either by barrel bombs or by warplanes, and it has been directly hit eight times. It is impossible for anyone to completely adapt to this situation. But we are psychologically prepared.

So yes, we are here and we know that many of our colleagues have either been tortured to death, are still detained, or were killed by bombardment. We know that our fate is one of those three. Or maybe God will grant us our lives so we can stay and build our country.

In the liberated areas in general, but particularly in the cities (especially Aleppo), it is very difficult to work. But the people who have stayed are here because of their conviction. Despite the difficult financial and living conditions,the constant danger, and the intensity of the work,they remain optimistic and positive: Ready, sympathetic and dedicated. Sometimes they feel stressed from working 24 hours a day, but this does not mean that are ready to give up or are anxious to leave their work.

Q: With the destruction of medical facilities, has the spread of certain illnesses become a bigger risk? What kills more people: bombings or these widespread diseases? What illnesses have spread recently? 

I can’t respond in detail because I am not a a family doctor or anutritionist… but generally speaking, we have seen many statistics and the leading cause of death by far is bombardment. Leishmaniasis [a parasitic disease, spread by sandflies, that can cause skin ulcers and damage internal organs] and hepatitis A were prevalent in Aleppo before, but of course the incidence of these diseases has increased dramatically since the crisis began.

Firstly and most importantly, we cannot safely and properly dispose of waste; secondly, the decrease in health awareness in society coupled with a lack of medical facilities; and thirdly, the lack of medical staff.

The main reason some diseases that had previously disappeared such as polio, measles, and supposedly cholera are now spreading is due to a lack of vaccinations and the spread of waste, as I mentioned before.

Cholera [a bacterial infection of the small intestine that causes severe diarrhea often leading to dehydration] is expected to spread. The virus can spread merely through direct contact with someone who is infected. Thus, it could become an epidemic.

Q: Do you ever feel like you are getting accustomed to seeing such atrocities? Do you ever have to try and suppress your gut reaction when you first are confronted with someone who has been severely injured in an airstrike in order to continue your work?

Yes, with the nature of our profession, we have the ability to control ourselves and manage situations more so than the general population. Yet, no matter how many serious injuries we see, we can’t become so accustomed that we cease to feel anything.

Sympathy will always be there and we will always be affected by serious cases that we see. Whenever we see a serious injury, or even a non-serious one, we are affected and are disturbed. This feeling will always remain ingrained inside of us even though we try not to show this to the patient, so as to avoid breaking his spirit.

However we don’t become hysterical or distracted to the extent that we are unable to do our job.

We have experienced massacres in which many children get killed or critically injured. We might have stopped for a second and been very upset to the point that we may have cried when we see children in front of us with such injuries. Adults affect us, but truly children’s suffering affects us more.

I remember one time during a massacre, seven or eight dying children who had suffocated under rubble had arrived one after the other to the emergency room over a period of just five minutes. All we could do was try to resuscitate them—in such cases there is a 99 percent chance that these efforts won’t help because oxygen has been cut off to the brain for a long period of time.

I want to just say that if there is a possibility to cover the deficit we have, particularly for chronic illnesses such as kidney failure, heart disease and cancer… If only we were able to provide them with medical facilities and the necessary medicine… Now, after four years of war, these patients with chronic illnesses have started to constitute the second-largest reason for fatalities, second only to war fatalities. In this regard, we are in urgent need of help.