Download this report in PDF formatA Special Report on:
The Medical Situation in Eastern Gouta - Damascus Suburbs
Violation Documentation Center in Syria
November - 2013
Douma Government hospital
Introduction:
In this report, VDC in Syria presents-in details- the current medical situation in each of Easter Gouta's towns and cities and the recent situation of the medical points and cadres two years and a half after the revolution, and more than a year of the severe siege witnessed in Eastern Gouta specifically, which led to a serious deterioration in all life aspects especially with regard of the medical situation.
The report depended on a methodology of visiting a number of hospitals and medical points-carried out by the members of VDC Field Monitoring Team in Eastern Gouta- to get in the actual sufferings that the towns and cities of Gouta are going through, especially regarding the medical situation, in details.
First: Targeting Medical Staffs and Objects
1-Prosecutions and Arrests against Medical Staff:
Since the outbreak of protests and the beginning of peaceful demonstrations in Eastern Gouta, the regime has used live ammunition against the demonstrators leaving a number of martyrs and wounded day after day. Due to security concerns, providing treatment for the injured has become extremely difficult especially that the regime considered such act as a crime, so doctors used their houses and private clinics-after equipping them with the medical tool available- as alternatives to the hospitals that were banned from receiving patients under penalty of arresting the wounded and the medical cadre alike. That's why treating the injured was highly classified and was carried out in secret clinics and houses.
Moreover, the regime forces-right from the beginning of the protests- have arrested dozens of doctors who have contributed to treating and providing medical care for the revolutionists.
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Doctors from Eastern Gouta under arrest until the moment: - Dr. Omar Ibrahim Sriwel was arrested in October 2012 in an ambush set by regime forces in Eastern Gouta. - Dr. Tamim Abdullah was arrested in Damascus in July 2012 -Dr. Nabil Salam was arrested in Adraa in October 2012 Dr. Ibrahim Sba'a was arrested about two months ago-
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Destruction caused by regime forces shelling of hospitals –
Douma Government Hospital
2-Targeting Hospitals and Medical Points:
In addition to the systematic arbitrary arrest against doctors and medical staffs, and before the Eastern Gouta is liberated, the regime tended to raid the hospitals and the private clinics that received the injured of the revolution persistently before, especially following Fridays' demonstrations. Among those hospitals and private clinics that have been raided to arrest the medical cadres, the injured and the wounded therein are:
-On 1-4-2011, the regime forces stormed the National Hospital, Hamdan Hospital and AlNoor Hospital to arrest the injured therein. This was the first time hospitals are being stormed in Douma, Damascus Suburbs.
-As for Hamdan Hospital, it has been stormed several other times afterwards. On 27-4-2011, the regime forces also arrested the director of the hospital. It has been raided again during the visit of the Arab Observers to Eastern Gouta.
-Fateh Hospital was also stormed on 30-6-2012 after Zamalka's first massacre.
After the liberation of many areas in Eastern Gouta i.e. after 28-10-2012, the regime distributed all the medical cadres of general hospitals on the areas under its control in order to deny the civilians their right of the necessary medical care needed not only for the revolution's victims but also for the civilians who suffer normal, chronic and serious diseases.
Afterwards, hospitals and medical points in Gouta have become a daily target of the regime forces as all Easter Gouta's hospitals-general and private-have been bombarded.
Some of these hospitals are:
Bazreh Medical Clinic in Zamalka that MIG shelled in October 2012-
-"Contagious Diseases Center" and" Maternity Care and Vaccination Center" were targeted in October 2012 by a military air raid.
-Noor Hospital in Douma was targeted by warplanes on 28-10-2012
-Hamdan Hospital in Douma was targeted by a military air raid in November 2012
-Yaman Hospital in Douma was targeted by a military air raid in November 2012
-Reehan Medical Clinic was shelled with missiles on 20-12-2012
-Douma National Hospital was targeted with a Grad missile on 13-8-2013 that led to its partial destruction.
- Fateh hospital in Kafarbatna has been bombed several times, the most recent of which was during the chemical massacre of on 21.8.2013, to prevent people from using it.
Medical point 1 in Douma was bombed seven consecutive times, the most recent of which was on 23.8.2013 just two days after the chemical massacre.
Moreover, all hospitals have stopped using their upper floors settling for using only their ground floors and basements due to the constant shelling by the regime forces.
3-Targeting Red Crescent Branches
The regime forces have been directly targeting all cadres of humanitarian organizations in addition to those collaborating with humanitarian and international organizations such as ICRC as many activists of the Syrian Red Crescent have been either arrested or subjected to enforced disappearance, some of whom are still imprisoned till today.
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Some Red Crescent activists in Eastern Gouta under arrest until the moment:
-The volunteer paramedic Ghyath Rafiq Biswani was arrested on 29-6-2012 while performing his humanitarian duty. His fate is still unknown. Married/ a father of three children -The volunteer paramedic Ala'a Rafiq Biswani was arrested on 29-6-2012 during a raid to his house. -The volunteer paramedic Muhammad Hasan Masri was arrested on 15-9-2012 while performing his humanitarian duty. His fate is still unknown. -The volunteer paramedic Imad Nu'man Hajeh-Douma Branch- was arrested on 2-12-2012 in Adraa while performing his humanitarian duty. His fate is still unknown. -The volunteer paramedic Mahmoud Khalil Khebeh was arrested on 2-12-2012 while performing his humanitarian duty. His fate is still unknown. -The volunteer Salim Bakbounsi was arrested in 2013 at Adraa Omalieh Branch. |
Many members of the Red Crescent have been martyred while carrying out their humanitarian duty in Eastern Gouta after being targeted by the Syrian army and security forces:
On 3-6-2012, the regime forces assassinated Dr.Adnan Wehbe in his clinic in Douma. He was the director of the Syrian Red Crescent Youth Committee, and one of the founders of the revolutionary medical activities in the city- Douma Branch.
On 1-10-2012, the volunteer activist Ahmad Ali Sa'ada (16 years) was martyred in front of his house due to his serious injuries caused by a regime forces shell that fell before his house.
A video link taken by the martyr's camera showing the moment the shell fell in front of his house:
On 21-10-2012, the volunteer Amjad Abdulhakeem Ma'dani was martyred- with the regime forces shelling- while going to the Red Crescent branch of Harasta to perform his humanitarian duty
The Paramedic Muhammad Khadra was martyred on 24-4-2012 by a sniper shot while he was inside the Red Crescent ambulance.
-The paramedic Fo'ad Bobes was martyred- during a relief mission to aid the injured in Douma city- as a result of the fall of a shell directly in front of him on 10.28.2012.
Second: The Current Medical Situation:
1 – The Medical Centers in Eastern Gouta:
After the Eastern Gouta has been liberated, the regime used all kinds of weapons against its districts committing dozens of massacres as the bombardment and air shelling increased, not to mention the severe siege that closed all entrances to the area in order to prevent any access of medical and food supplies. That situation urged the doctors and the medical staffs in the area to exert huge efforts to organize the medical actions by the least humanitarian and physical means available.
Thus the Unified Medical Office, which includes several medical offices and private
hospitals, has been established to manage the medical situation in Gouta.
It consists of 17 medical offices distributed to the towns and cities of Eastern Gouta.
According to Dr, Majed Abu Ali- the Head of Communication and Public Relations Commission of the Unified Medical Office in Eastern Gouta- these offices manage 35 medical points that are usually divided into: an emergency room, an intensive care unit, a special section for surgeries and physical therapy, in addition to a section for hemodialysis and another for incubators.
As for the mechanism of treatment in these medical offices, Dr. Majed Abu Ali describes it as follows:
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In treatment, we adopted the model of "circles" where the first circle" the narrow one" starts with treating casualties resulting from bombing and fire as a result of the war and this circle expands to include hospitalization and intensive care for those infected. Then we move to the larger circle that concerns about general diseases and health care to which we have established one medical point for each specialty such as delivering and incubators, in addition to the only one point for hemodialysis in Eastern Gouta. Added to that is a medical point for physical therapy that concerns about rehabilitating those who have lost their limbs. the greater the pressure is on Gouta, the situation is more deteriorated to the degree that we sometimes had to close down the hemodialysis and physical therapy medical points to perform surgeries for revolutionary's injured only. |
In addition to the medical points mentioned, some equipment is being used, which is still available in private hospitals as a CT scan.
2-Medical Cadres and Specialized Doctors:
After liberating Eastern Gouta and due to the imposed siege, the number of doctors, nurses and paramedics reduced to 10 % of that before the revolution; many of them have left to safer areas or, if they had stayed, they got either arrested or killed.
There are several medical specialties, for each of which, only one doctor is left to cover the whole area of Eastern Gouta. Some other specialties do not exist anymore in Gouta, which forces the doctors to work extra hours and to treat cases out of their specialty.
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According to Dr. Saif Eddin, the Head of Medical Point 1, the rare specialties in the medical points in Eastern Gouta are: - Vascular Surgery. - Regenerative medicine. - Thoracic Surgery. - General Surgery. - Cardiovascular Diseases. - Internal Nerves. - Jaw Surgery. Comparing to the current population in Eastern Gouta, the doctors of these specialties are few. |
Reliving and nursing cadres are undergraduate students and some paramedics of the Syrian Arab Red Crescent who have chosen to provide help on personal levels after closing the sections of the Red Crescent in Eastern Gouta, in addition to some activists who had no medical experience except for some first aid courses.
According to Dr. Saif Eddin," since May 2012, the casualties have been mostly civilians and all the medical cadres are exhausted due to the daily shelling and the acute shortness of medical staff comparing to the huge geographical area and the high population of Gouta."
Dr. Ahmad AbdulGhani who works in Al Gouta Islamic Hospital, demonstrates the issue of medical cadres:
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There are five doctors only in this hospital; we receive about 1200 to 1600 casualties monthly. We, also, make about 192 surgical operations a month. During one month, I, myself, performed 85 operations, which means that there is a huge lack in medical staff like anaesthetists and surgeons. Practically, there is one doctor for each 80,000 person as the total current population in Estern Gouta is 850,000 to 950,000.
In Orthopaedic and General Surgery sections, we are in desperate need for vascular and neurosurgery doctors to treat the casualties of shelling. Many casualties, especially, those who had neurotic bruises or medical operation, passed away due to the acute shortness of required drugs or specialised doctors. |
Third: Casualties:
1-Injuries of the Regime's fire and shelling:
During the first months of the revolution, most injuries were of gun shots; they were limited to some degree. However, when the regime started using heavy weaponry like artillery, tanks and mortars in the haphazard shelling on the Syrian cities, most injuries were caused by direct shelling or bomb's fragments which are so difficult to treat; one casualty requires many specialised doctors; sometimes, the injury includes the bones and nerves and requires a surgical operation. Due to the shortness of specialised doctors and required equipment, most of cases end up by amputating limbs.
According to Medical Point 1, in Doma, there are three amputation cases a day. Dr. Saif Eddin, a surgeon and the Head of Medical Point1, says:
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We received a seven-month-old baby girl who, along with her family, was exposed to a mortar missile while they were moving from their house; the father was killed and the mother had many broken bones and we had to amputate the baby's leg. She was still crawling and never used that leg to walk. |
The doctor continues to tell us about another case of the patient (A, R):
"We received another case- a civilian- who was at his farm in Blalieh when he was shelled; he was brought to our medical point where he was treated. However, we had to amputate his legs and arm."
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A video illustrates the relieving of a child to Al Gouta Islamic Hospital as he was injured by an air shelling. The injuries were in the chest and the belly and they had to incise the belly to operate the surgery. He was hit again by a 'Vozlika' shelling which lead to the amputation of his leg and the injury of his tibia artery:
Recovery of such patients takes longer time than usual due to the lack of special hospitalization places. patients with slight injuries need about a month to recover. Patients with broken bones need more than seven months and they might end up with a permanent handicap.
Regarding the number of surgical operations in the medical points, Dr. Majed Abu Ali says:
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According to our statistics, we have about 250 casualties every day. In Eastern Gouta there are about 1000 surgical operations a month. Such big number entails cadres of anaesthetists and doctors with different specialties, however, the remaining doctors are doing their best. |
2 -Birth Rate:
According to the 'Medical Office' in Doma, the monthly birth rate is 800 birth cases in Eastern Gouta, as the Office conducted a survey that included all delivery centers in Eastern Gouta except for house births by midwives.
Medical care for pregnant women is one of the toughest challenges that faces doctors and medical points as there is an acute shortness of the required medicines and vitamins. Moreover, there are no regular visits to clinics due to the shortness of gynaecologists. In Douma, there are 3 female gynaecologists and two male ones; the total number is five gynaecologists, which means more difficult births and a greater need for incubators as 30% of newly-born babies need them; many babies are deprived of that due to the lack of incubators.
3 - General and Chronic Diseases:
The suffering of the medical cadres in Eastern Gouta is not limited to treating the casualties of shelling only, but also to treating the chronic and contagious diseases as all private clinics were closed long time ago, which obliged the medical points and the hospitals that are treating the injured to treat the general diseases as well.
For example, regarding the hemodialysis, Dr. Majed Abu Ali retails about the suffering of the disease's patients:
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Since the beginning of the revolution, we counted 130 patients in Eastern Gouta who need constant kidney wash. Such operations require 'imported' and very expensive medicines; each session costs 35$ and each patient needs at least 8 sessions a month. Moreover, the Kidney Wash Section require electricity which is unavailable since 28-10-2012 so the cost of the operation, the cost of electricity and small repayment for the cadre make the total cost reaches 50$ which is a huge burden for the patients and the cadre. Currently, we have about 60 patients who need a kidney wash every month (600 kidney wash sessions a month) as we handle 35 patients only, the rest had to take all the risk to go to Damascus especially those with infectious diseases like hepatitis to avoid infecting other patients. Specifying an apparatus for these patients is not a solution either as this will limit the number of patients who can benefit and this led to many death case, the last of which was the martyr of siege Fahid Sarmini. And as we are running out of the required medicines, we will be forced to close the Kidney Wash Center as we are not able to get these medicines because of the siege. |
Fourth: Under the Siege
The siege that has been imposed on the Eastern Gouta by the Syrian regime for one year caused an acute shortness of all the required medical supplies such as medicines, apparatus and even the medical disposals as any access of any medical supplies that can help casualties and patients has been prevented. Uptill now, the International Committee of the Red Cross has no access to Gouta as it is prevented by the Syrian authorities. On 29 Aug 2013, in press report 143/13, ICRC stated that there is an acute shortness of medical and needful supplies, in addition to food and water in all the besieged areas; the ones that are inaccessible for The International Committee and the Red Crescent. ICRC added that people are dying in many places in the Countryside of Damascus due to the lack of the medical supplies and cadres and that people are starving due to the lack of everyday food.
Medical supplies that are desperately required in Gouta are:
1 - Different Medicines and Painkillers:
All pharmacies in Eastern Gouta are almost empty even from the most commonly used drugs like painkillers, antibiotics, antipyretics and asthma 'sprayers' that help opening respiratory channels, in addition to every-day-use medicines, which forced the doctors to reduce the amount of painkillers while operating a surgery. Regarding this subject, Dr. Majed says:
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Due to the acute shortness of medical supplies in general and painkillers in particular, we were forced to reduce the doses of oral, muscular and vascular painkillers prescribed. For example, if a patient should take his painkiller 3 times a day, we reduce it to once a day because if we give him the needed amount, we will not be able to reduce the pain of some other patient. |
A Targeted Pharmacy
2- Surgical Tools:
Due to the daily critical and various injuries, surgeries are operated daily despite the shortness of required materials like the 'external braces' and the metallic tablets that are used in bones surgery. The doctors are forced to use such material many times although they should be used for one operation only, in addition to the acute shortness of sutures and many other materials which obliges us to use expired materials in many cases.
3- Medical Disposables:
All medical disposables like 'chest detonator', gauze, sanitizers are no longer available in Eastern Gouta, which forces doctors to invent some substitutional material when possible. For example, instead of sanitizers, doctors could construct the 'povidone' and instead of the ' colostomy bags' (bags used for extracting feces from the loin area when the patient has a defecation problem) they use usual nonmedical bags. Even the syringes that are supposed to be used once, doctors in Gouta use them more than one time after sanitizing them.
4-Serums:
All cities and towns in Eastern Gouta have an acute shortness of serums, which is one of the most important materials for the patient under intensive care. Doctors can't take care of the patients without this material because patients in such case are not allowed to eat or drink and the serums will substitute all the required nutrition and liquids. According to Dr. Saif Eddin, the Medical Point 1 in Doma alone requires 24 Litres during the 'usual shelling' day; during intense shelling, it requires more than 50 Litres a day. Intense Care Section only requires like 100 Litres a day.
5- Blood Bags:
Blood Bags are essential during conflicts and wars as there are a lot of casualties who need blood substitution when they have serious injuries. Still, there is an acute shortness in blood bags which, according to Dr. Majed, forced doctors to use serum bags instead by emptying them and adding anticoagulant which turn them to blood bags useful for transferring a usable blood. This is near to impossible now because serum bags are not available any more.
6-Ventilators System:
Despite their importance, oxygen ventilators (tanks and generators) are so rare and don't meet the need as there are a lot of casualties. Moreover, in Eastern Gouta, there is no center for refilling oxygen tanks, so after they're empty these tanks turn into a pile of iron. Oxygen generators, also, need electricity which, in turn, needs fuel and that's rare and so expensive.
7-Ambulances:
In addition to the small number of ambulances in Gouta, they're poorly equipped with any of the medical tools that are required for transferring casualties; due to this fact many vans and closed cars were adjusted and provided with some equipment. Still, these cars are not fully ready to operate like the normal ambulance. During intense shelling, casualties are brought to hospitals by normal cars which worsening their cases as they are carried in a haphazard manner and without fixing them, especially those with broken bones or injured spines. Even the used 'stretcher' is usually a handmade one (two wooden or iron bars with a piece of fabric).
8- Apparatus and Other Medical Materials:
Dr. Ahmad AbdulGhani told VDC in details about the unavailable apparatus and other medical materials in the Eastern Gouta:
As for Gouta Islamic Hospital, we suffer an acute shortness of essential medicines like methanol and CPR drugs. We have only one 'Shock Device' and we keep moving it from Operation Department to Emergency Department though they are far from each other. Moreover, we have only one ECG device and we have to take the patient to the location of this device and follow the chart on screen directly as we don't have paper for the device which means we have to leave some other patient to check the device. In regard to oxygen tanks, there is none, so we have use the oxygen generator which require electricity that is unavailable at the first place and the fuel is also unavailable or, if available, it is so expensive. In regard to anaesthetic drugs, there is no anaesthetic censer which is so important especially for children.
We are forced to anaesthetise children by vascular catheters and that's one of our biggest problems instead of the 'colostomy bags' we made new ones out of normal bags, still they're not practically as this causes bad smell and extra pus. For fixing broken bones, we use wood as there are no splints available. Moreover, we do not have an X-ray device and we use the 'Arc Device' to check the broken bones. This device is not accurate, especially that the patient might have bomb's fragments inside their bodies; some patients have about 20 fragments in their bodies and they might suffer a constant 'pus bleeding' and acute pain. We, also, have acute shortness of gauze, so we use towels and pieces of fabric instead.
Fifth: Responding to Emergenciess
The Chemical Massacre as an Example
The Chemical massacre on 21 Aug 2013 was a distinctive point in the medical file of besieged Gouta because of the large numbers of the injured and martyrs and the inefficiency of the hospitals and medical points that deal with such cases. This led to the death of tens of the causalities, who could have been saved if the needed medical supplies were available.
In this regard, Dr. Saif Eddin, the manager of Medical Point 1 in Douma, says:
We had received casualties of chemical and poisonous weapons use by the regime's forces for six times, the last of which was at 03: 00 am on 21 Aug 2013. At first we received four casualties with slight injuries. Then, suddenly, the number started to increase on a larger scale as they were being transferred by buses. At that day we received 600 casualties in batches, although our medical point can only accommodate 20 cases. Most of those casualties were completely unconscious and the medical cadre at the time consisted of 8 people only ‘a doctor and a number of Medicine students in addition to two nurses and two paramedics.”
Of the 600 hundred casualties, we received 98 sufferers that were in need of intensive care. Our ICU was equipped to receive only 13 patients. This made us put some of them on beds and the necessary apparatuses, while the rest were put on the ground because of the severe shortage of beds. Unfortunately, the enumeration of the martyrs in the first five minutes was 20 martyrs, which made it a historic catastrophe."
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Dr. Majed Abu Ali stated that 22 martyrs out of 65 ones could have been saved if the necessary equipment and drugs, yet the shortage in such medical supplies made the doctors resort to picking patients depending on their degree of responding to the assigned treatment. For example, we could not pick patients with neuro- disorders because that might have meant missing the opportunity to save another patient. So, we can say that our doctors not only are doing their jobs but also making the most difficult decisions of their lives i.e. the selection of patients among casualties. At some of our ICUs, we regretfully do not receive patients with infarcts hoping that they will get better depending only on the prescribed drugs. In short, all the above is a result of the acute shortness of the medical equipment and drugs which is caused by the prolonged siege imposed by the Syrian regime forces. |
Sixth: Backing up the Hospitals and Medical Points in Eastern Gouta
The policies of starvation and systematic siege that have been imposed on Eastern Gouta for several months pushed several people and humanitarian organizations to provide support for hospitals and medical points, however, this support-compared to the actual need- is not adequate at all as there is an acute shortness of medical supplies. Moreover, most of the 'cash' support is spent for fuel to get electricity for medical devices and for ambulances. Averagely, Eastern Gouta requires about 100,000 $ a month only to get fuel when the Syrian Army prevents the access of any kind of support like drugs or medical materials.
*List of Required Supplies in Eastern Gouta:
1- Reliving Materials: (most of which are sanitized to be used more than once) like: Syringes, 'chest detonator', povidone, gauze, sutures, splints and antibiotics.
2- Blood Bags: as we motioned above, there're not available at all and getting them requires a secret importing from the neighboring countries which is so hard due to the imposed siege.
3- Serum: one of the most essential supplies especially for intensive care patients and post-surgery patient.
4- Atropine for patients who have been exposed to chemical and poisonous materials.
5- Materials for Surgical Operations: like 'skewers' and metallic tablets for bones surgery.
6- Oxygen Tanks and Oxygen Generators.
7- Babies Incubators.
8- Various Medical Devices, especially those related to ambulances.
9- X-ray films and paper for ECG device.
Citation:
During the preparation for this report, on 13102013, all the remaining entrances to Eastern Gouta were completely closed, which led to the loss of fuel almost entirely and to a fourfold increase in prices which forecasts a medical crisis by the time the supplies run out. Moreover, on 19 Oct 2013, Free Syrian Army conquered the barrier of 'Tamico Factory' in Al Mileha which used to be a drug factory before it was turned into a military barrack by the Syrian Army. After the liberation, everything in the factory were seized ; however, it turned out that the security forces had emptied it before leaving only some specific kinds of general medicines like children medicines. As for the needed medicines such as the ones used in surgeries and for serious cases, none was obtained, not even the above mentioned ones.
Seventh: Conclusion
The current population in Gouta is more than 850,000, thousands of which are sustaining injuries and falling martyrs every day due to the haphazard attacks of the regime forces, the siege imposed for more than a year and the prevention of any medical or humanitarian aids. In addition to casualties of shelling, there are hundreds of patients with chronic and contagious diseases, and daily births that are becoming very difficult as there are no enough cadre or apparatus.
VDC, Syria condemns in the strongest words the unjust siege as a collective punishment for the people of Gouta and appeals, at the same time, to all relief and humanitarian organizations to provide immediate and urgent support for thousands of civilians, casualties and patients who are facing death due to shortness in medical cadres and apparatus. VDC, also, appeals to UN Secretary General, Mr. Ban Ki-moon to increase pressure on the Syrian Government to allow the access of humanitarian aids to all of besieged Syrian cities including Eastern Gouta as pursuant to the Presidential Statement on 2 Oct 2013.
*Violation Documentation Center in Syria pays tribute to all who contributed in the preparation of this report, especially:
- Dr. Majed Abu Ali, Head of Cooperation and Public Relation Committee in the Unified Medical Office in Eastern Gouta.
- Dr. Saif Eddin Abu Nidal, a surgeon and the Head of Medical Point 1.
- Dr. Ahmad AbdulGhani, General Surgeon in Al Gouta Islamic Hospital (field hospital).
- Muhammad Mahmoud Al Khalid, Anaesthetist in Misrata Hospital, Intensive Care Unit.
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