MƒH When Men Drag Their Feet and Bewail Entanglement ~ SYRIA (Book Review)

Moments from History

When Men Drag Their Feet and Bewail Entanglement ~ SYRIA

WHEN I PENNED this as a Liverpool Dispatch on 27 September 2014, I was full of hope.

In the midst of Covid, I have little patience with young people who find themselves in lockdown on Campus when I consider their plight - “we can’t wash our clothes, we’ve been given no food … “ and so on, and so on, and so on.

I measure their plight against the plight of billions in decades before them, down merely the last hundred years; I recall the horrific newsreels; I read afresh with that same horror the reports I first read sixty years ago.

On this website I have, several times referred to Dr David Nott’s pioneering work in the business of being a front-line surgeon in the worst war-ravaged areas in the world for much of his life.

Dr Nott has, with his wife Eleanor, set up the David Nott Foundation, being awarded charitable status in July 2015. I have also quoted elsewhere from his book War Doctor - Surgery on the Front Line published by Picador, and the Sunday Times No. 1 Bestseller.

I will quote verbatim one passage on pages 314-321.

Dr Nott writes thus:

EXTRACT

314 - 315

The latest threat was from chemical weapons - he told me he'd recently had around twenty patients admitted following a chlorine attack. His emergency department was full, and he didn't have enough masks or oxygen cylinders to treat them all. Two patients subsequently died from the chlorine, which reacts with water and turns into hydrochloric acid, dissolving the lungs of anyone unfortunate enough to inhale it.

A week later I heard from Abu Mohammadain, who was still working in M10. He sent me a picture of a little boy he had been treating. The video showing the bloodied face of this shocked and petrified child had gone viral on social media and was on all the news channels. The little boy obviously did not understand what was going on around him. He had sustained a severe gash to his scalp and blood was pouring down his face. He sat on his own in the ambulance staring vacantly into space. No one knew where his parents were.

The next day Abu Waseem messaged me with news that the little boy’s brother had been admitted to M1. He had sustained a severe liver injury and had died on the operating table. Waseem was obviously devastated. How had things got so bad? Where was it going to end? I was becoming more and more anguished and outraged.

When President Obama had talked in 2013 about ‘crossing the red line’ after four hundred children were killed by a chemical weapons attack in Ghouta, outside Damascus, he was awaiting the outcome of a vote on military action in the British Parliament. The vote was close, but in the end 285 MPs against 272 decided not to proceed with strikes against the Syrian regime. Unfortunately the debate seemed to be more about politicking between the prime minister, David Cameron, and the leader of the opposition, Ed Miliband, rather than what was the right thing to do. It was, in some ways, a reaction to Tony Blair's support for the US invasion of Iraq a decade earlier. The aftermath of that war has left a toxic legacy: the British people just didn't want to become embroiled in someone else's war in a far away place of which they knew very little. But I have no doubt that if the West had shown strong leadership at that point, the Syrian military hierarchy would have collapsed.

Following the 2013 Ghouta attack, Assad's regime acknowledge possession of chemical weapons and agreed to be put under international supervision endorsed by UN Security Council Resolution 2118. (The deadline for the destruction of the chemical weapons stockpile was the first half of 2014, and they claimed then to have complied. However, attacks at Khan Shaykhun in April 2017 and Douma in April 2018 revealed that they had either been lying or restocking.) Meanwhile, Abu Waseem continued to text me to let me know that there were clouds of chlorine gas being dropped in barrel bombs around his hospital, and the number of attacks was increasing by the day.

At the end of August 2016 he contacted me to ask if I'd be able to help them with a patient who had a severe facial injury following a barrel-bomb attack. He was a thirty-five-year-old father of three, several of whose friends had been killed in the same attack. His mouth and the lower part of his jaw were hanging free and there was a significant risk of him developing an infection. They had done all they could, but wanted to know whether I could help them reconstruct the man's jaw. Amazingly, they had had a CT scanner built in M10, and sent me pictures of his face via WhatsApp.

316 - 317

I showed the pictures to several colleagues who were experts in faciomaxillary work. The patient had been left with only the two struts of his jawbone on either side, attached to the temporomandibular joints, the joints being the upper jaw and head.

Ask ten different surgeons their opinion and you get ten different answers. It was a difficult call, to be fair – some surgeons said that reconstruction was impossible; others suggested the only way would be to use a free flap from the leg, including one of the leg bones, and use a microscope to join up the very small arteries and veins. I had the idea of using a metal plate, fashioning it into a semicircle so it could be joined to the two remaining bones by screws, thus completing the outline of the jaw. The metal plate would then be covered by a muscle to reconstruct the floor of the mouth, and the front of the mouth would be covered by skin that would be attached to the muscle, the so-called myocutaneous flap. It would be a major undertaking at the best of times. The concept of doing it remotely, with me directing things from London, was unprecedented.

We decided to give it a try, using a muscle flap and skin from the pectoralis major muscle, which is supplied by an artery below the collarbone, and then rotate that with an appropriate patch of skin to cover the new lower jaw. Abu Waseem and his colleagues were very excited. They had a week to scour through the remaining hospitals and rubble for the correct sterile plate and screws. In the meantime I sent over as much information as I could regarding the technique.

The day before the operation we had one last Skype conversation and it was confirmed that they had two units of blood available for the procedure. As it happened, I had been asked about the situation in Aleppo by BBC Two’s Newsnight programme and told them I was about to oversee a challenging operation there via Skype. They agreed to record the procedure, and share with the world the remarkable coverage of Aleppo’s besieged doctors.

So there I was in London, looking at a large television screen. The patient was asleep on the operating table at M10 in Aleppo. We set up the Skype call and someone in the operating theatre put an iPhone on a selfie stick that was held over the table, so I could see everything that was going on during the operation. Because the surgeons had never done this procedure before, I began directing proceedings. First, they screwed the metal plate into what remained of the two struts of the jawbone, which took about two hours. Then we came to the most difficult part of the procedure. The pectoralis major muscle is the broad muscle that lies on the anterior chest wall below the nipple. Because they had never mobilised this muscle and didn't know exactly where to make the incisions, I first of all asked them to raise a deltopectoral flap, by lifting a large piece of skin below the collarbone from the chest to expose the whole of the pectoralis major muscle. This took about another hour. Meanwhile, we took lots of measurements to confirm that the muscle and skin would actually rotate underneath the metal plate into the bottom of the mouth and jaw.

We proceeded with the operation and I directed them exactly where to make the incisions. Over the next six hours they mobilised the correct amount of muscle with the correct amount of skin and by the end of the day had successfully completed the operation. It was the most extraordinary achievement.

A few days later, the report went out on Newsnight and it can still be seen on YouTube. Apart from helping the patient, it elevated the doctors’ mood – they took hope from the knowledge that people all over the world had seen what was happening.

318 - 319

Abu Waseem and his colleagues continued to let me know how the patient progressed. When the doctors at M10 removed the patient’s tracheotomy tube, he began to cry, saying, ‘God bless you all.’ I was thrilled to have been able to help both my colleagues and the patient. It was a ray of hope in the darkness of war.

In September, however, the situation deteriorated dramatically. In the last weekend of that month I had around a hundred WhatsApp messages from my Syrian colleagues. They had received 168 casualties in just a few hours, following barrel bombs and constant airstrikes through the day. Of those, around half were children, and there were many other deaths unaccounted for. It appeared that people had been queueing for food at the market when a squadron of fighters came in firing rockets. As well as rockets, government forces and the Russians were also dropping cluster bombs, and bigger devices called bunker-busting bombs, which drilled a hole on impact with the ground and then exploded several feet below the surface, thus killing people who were hiding in the basements of their houses. Hospitals were also receiving casualties who had what appeared to be ball-bearings deeply implanted in their bodies. It was horrendous. I was desperately anxious not only for my colleagues but for all the civilians and innocent children who were being slowly annihilated.

I wanted to do something as quickly as I could to encourage politicians to try to stop this disaster from getting any worse. Elly suggested that I go and see Andrew Mitchell, who was one of the most vocal MPs on humanitarian matters, and who had done good work when he was Secretary of State for International Development. Surprisingly, he agreed to meet me. We discussed the situation that was unfolding and how the civilians left in East Aleppo were being pounded every day by Syrian and Russian jets. I showed him photographs of dead and dying children that I had been sent and suggested that the British Government really needed to step in to try and stop the carnage.

I embarked upon a media offensive as well, appearing on the radio and television whenever I could to talk about what was happening, and the risk the doctors were facing – a risk which was brought home horribly in early October, just a few weeks after the successful Skype operation. I was sent a WhatsApp video of a bunker-busting bomb dropping directly onto the operating theatre in M10. The target was so precise that the co-ordinates of the theatre must have been known. I could only think, to my horror, that somebody must have hacked the Skype call and somehow deduced M10’s location. In the minutes after the bunker bomb fell, a further three barrel bombs and two cluster bombs were dropped on M10. At the time, the hospital's intensive care unit was full, the wards were full and the recovery unit was full. The hospital was destroyed; many patients died and the survivors were moved to surrounding hospitals, which also came under attack. But, amazingly all my surgical colleagues were still alive.

On 5 October, a UN convoy that had taken a good deal of diplomacy to organize was about to deliver medical aid and food into East Aleppo when it came under attack from the air and was wiped out. Both the Russian and Syrian air forces denied responsibility. Five days later Matthew Rycroft, the U.K.'s ambassador to the UN, delivered a damning speech to the Security Council, condemning unprecedented Russian-backed shelling in the war in Syria, saying that the country’s pretensions to peace in the country were a sham.

320 - 321

The Russian representative had vetoed a draft resolution to revive the ceasefire and end airstrikes, except those against ISIS and al-Qaeda-affiliated rebels in Syria. It was the fifth time that Russia had used its position as a permanent member of the Security Council to block UN action over Syria.

As all this was going on, Andrew Mitchell had applied to the Speaker of the House of Commons for an emergency debate under Standing Order 24. The debate went ahead on 11 October and Elly and I sat in the gallery to watch. Many good people spoke, but the chamber was not full and at the end we walked away feeling very disappointed. However, it did start the ball rolling in the sense that at least Parliament was now talking about the atrocities in Aleppo. Until then, I'd had the feeling that MPs just didn't want to know.

Over the next few days another four hundred civilians died and thousands of others were injured. Several more hospitals were put out of action. The Aleppo City Medical Council was reaching breaking point because of the volume of casualties and their dwindling resources. They finally made a formal request to the UN for the injured to be evacuated and humanitarian aid to be delivered. But because of the previous attacks on convoys, their requests fell on deaf ears.

In late October I returned to Syria, with Mounir, to Bab al-Hawa Hospital, to operate on some of the wounded who had been caught up in the heavy shelling around Aleppo. The Syrian regime claimed to have made safe corridors available to people who wanted to leave east Aleppo, but no one took them up on the offer because they didn't trust the assurances of safe passage.

For the next two weeks there was a reduction in the number of airstrikes, and although food and medical supplies were dwindling, the message out of Aleppo seemed more optimistic. I wondered whether international pressure was finally making a difference. But then the stakes were raised again. In mid-November regime leaflets rained down from the sky telling people that they had twenty-four hours to leave via the supposedly safe corridors, or they would suffer the effects of a huge offensive on east Aleppo. The following day there were nearly two hundred airstrikes and as many artillery shells, killing hundreds of civilians. The Children's Hospital was destroyed. But still people stayed – they didn't want to leave their homes, and they worried that as soon as they surrendered themselves to the care of Assad’s regime, they would be arrested, or worse.

On my return, I found myself writing in every newspaper and appearing on every television and radio channel that would have me. We had to get these people out, I argued, and via routes that they could trust, not those organised or supervised by the Syrian government. But how? It seemed an impossible task – the brutal dance of Syria and Russia in Aleppo held the city in a vice. Where could we even begin?

End of Extract

It is important to obtain full perspective.

When I wrote in 2014 - in MfH No 23 - about the Royal Air Force’s ability to hit a target with precision, I had not thought about other air forces using that same technical precision in order to destroy hospitals.

LET NO family presume that the sacrifices made in two world wars count. Human Nature is as evil today as it was in the Twentieth Century and in every century preceding.

War Doctor was published in 2019 by Picador.

The world has turned in upon itself in its preoccupation with Covid. But history time and again reminds us when our attention is deflected. When we become isolationist to wider world affairs, then there will be a reckoning, and not in our favour.

I am indeed grateful to the David Nott Foundation, and to Dr Nott himself and all the surgeons who make themselves available to practise in the world’s worst hell-holes. It takes a very special person to do so.

27 April 2021
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© Kenneth Thomas Webb 2023