Our Broken Dreams in Syria

Of the 130 million babies born in the world every year, more than half a million will have congenital heart disease (CHD) requiring treatment. Only a small minority of these children will have access to surgical treatment. For others, the surgical “lottery” offered by charity medical missions is the only hope. This is an international health crisis that is largely overlooked and exacerbated by the traffic of essential medical skills from poorer countries to wealthier nations. The impact of the so called “brain drain” has left pediatric cardiac care in crisis in the developing world. If you, therefore, spend most of your adult life training and then working as a congenital heart surgeon, as I have, it is only a matter of time before you are involved in some of these missions.

At the Bristol Royal Hospital for Children in the United Kingdom, we have been involved in medical missions since 2000 and have performed hundreds of open-heart procedures in infants and children of Kenya, Trinidad and Tobago, Peru, Ecuador, and Romania. For all these missions and these countries, there are many stories to tell, but the one that is still upsetting me is the story of a lost dream in a country hit by a humanitarian tragedy: Syria. Despite a population of 20 million, there were only two heart centers for children with congenital heart disease in Syria, performing only 300-400 operations a year! It was on this basis that we decided to establish a congenital cardiac surgical program at the Al-Dir Charity Hospital in Homs, which had an established adult cardiac surgical program but no surgical service for children. Al-Behr Hospital was a charitable hospital offering treatment to those that could not afford private treatment. 

Hazaim, one of our pediatric surgeons in training from Homs, was the real engine behind this adventure, having seen how children with CHD should be treated and knowing very well the reality in his own country. Dr Mahmoud Al-Soufi, an experienced pediatric cardiologist based in Homs, was our link with the local cardiologists and an invaluable congenital heart disease specialist in the Homs region. We gathered a team that included Andrew Parry and Serban Stoica (pediatric heart surgeons), Rob Martin (consultant pediatric cardiologist), Ian Jenkins (consultant anesthesiologist), Laura and Suzie (intensivists), Beth (junior pediatric cardiologist), Martin, Martin, and Kathy (ICU nurses), William (perfusionist), and myself. We organized our first visit in April 2008.

The flight from London to Damascus was not delayed and all of us gathered at Heathrow full of excitement and enthusiasm – until I discovered that I had left my passport at home! I don’t have to tell you that this episode has been a matter of several jokes over the years regarding a surgeon’s reliability on the part of Rob and the other members of the team. I had to take another flight the day after the others. When I reached Damascus, the main road to Homs was blocked by the snow so I ended up sleeping in the middle of nowhere and causing a lot of anxiety for the team that were ready to start operating. Being Neapolitan and highly superstitious, I should have known that there was not going to be a happy ending to this story.

I finally reached Homs and the mission began. The hospital was located in an old building, but was reasonably functional. We soon met the local doctors and nurses, and were overwhelmed by their hospitality and dedication to work in quite difficult conditions. Dr. Al-Soufi immediately started to exchange views and ideas with Rob, and asked for his opinion regarding the children on whom we were going to operate. After a few hours of discussion, we had a clear plan for the week – we were going to perform ten operations. This was, of course, a drop in the ocean. Every day we had families knocking at the door, asking us to operate on their child. I have learned during these medical missions that despite the immense sadness involved, you cannot treat all; one has to remain focused and think about the ones that are going to be operated on, seeking to make the lives of those ten children worth living. And so it was. We successfully performed the first ten congenital open-heart operations in Homs, and it was an incredibly emotional week for all of us. Of course, it was hard work, especially when two teams were meeting for the first time and had to focus their efforts and start speaking “the same language.” But the daily hard work was followed by the most extraordinary hospitality and social events one could experience. We learned how to make a perfect hummus, and started our belly dancing and shisha pipe classes.

This first experience was followed by two other missions in April 2009 and December 2010. For each of these visits, Dr. Martin and Dr. Al-Soufi scanned more than 50 children and young adults in preparation for the current and the next mission. As expected, there were difficult times to face and problems to sort out, but deep inside our minds remained only the immense joy of seeing the children recovering – ready to grow up and go back to their lives. It was also a great opportunity for teaching and exchanging protocols between the local team and ourselves. We also learned a lot from having to perform complex cardiac surgery with limited intra- and post-operative resources. The intensivists were delighted to be able to undertake early extubation in patients with tetralogy of Fallot, who would have stayed much longer in intensive care in our United Kingdom unit. For all of us these missions were also a cultural journey into one of the oldest civilizations in the world, with beautiful Roman, early Christian medieval, and Islamic architecture.

In the spring of 2011, six months after our last visit, the Syrian civil war began, within the context of the Arab Spring protests. The ongoing conflict gradually moved from prominent protests to an armed rebellion, after months of military sieges claiming the lives of more than 200,000 people. The tragedy in Syria continues to affect many Syrians' access to quality health care, including the Syrian refugees in neighboring countries. About 207,000 people, most of whom are civilians, have been killed. According to UNICEF, by the end of 2014 at least 7 million Syrian children (including nearly 2 million registered child refugees) had been substantially affected.

The Siege of Homs started in May 2011 and has destroyed entire areas, including many hospital facilities. Hundreds of doctors, nurses, dentists, pharmacists, and paramedics have been killed. More than 75% of health-care professionals have been forced to leave for neighboring countries or further afield, leaving a huge gap in experience and expertise that cannot be filled.

All those smiles we experienced and joy we gave and received are now fading memories. We lost contact with many of the people we worked with. All that remains is the memory of common people working together to help other people, and the broken dream of building a congenital heart program for the children of Homs.