It was clear to the anguished parents that any hope to save the life of their son would be in the West, beyond the border. Thus, a 12-year-old boy appeared one morning in September 2014, draped over a donkey’s back and accompanied by his adolescent brother, who deposited him in the care of Israeli soldiers and returned to Syria. The boy lost his eyesight and suffered multiple fractures when his home in Damascus was bombed. The local surgeons had no option but to amputate his right arm below the elbow and were considering amputation of the lower limbs as well. Desperate, the family smuggled him to Israel, having heard rumors of the prospects for limb salvage there. The media tend to describe the huge numbers of casualties and refugees as masses of hundreds of thousands. Yet, individual stories such as this one vividly embody the immeasurable tragedy.1
The Syrian civil war started during the Arab Spring in 2011. After initial high hopes for a change of regimen and for democracy, the country rapidly deteriorated into a bloody conflict. Targeting civilians has emerged as a brutal form of warfare, with the intentional and systemic destruction of infrastructure for health care and education. Emergency services as well as routine medical care have collapsed.2 It is estimated that 450 000 Syrians, including >15 000 children and 10 000 women, have lost their lives. Among them are >700 physicians and health workers. More than 12 million citizens, including ∼3 million children, have been displaced, become refugees and asylum seekers, and face an insecure fate, dependent on the goodwill of countries and international agencies. Children endure the worst toll, missing years of education and often are injured and killed along with their friends, relatives, teachers, and pediatricians. They are at great risk of short- and long-term sequelae with detrimental consequences for the future of Syrian society.3
Sharing a common heritage, Syria’s neighboring countries of Lebanon, Jordan, and Turkey have been stretching their capabilities to provide humanitarian services to refugees, as have international nongovernmental organizations4 such as the International Federation of Red Cross and Red Crescent Societies, Doctors Without Borders, and Israeli Flying Aid; yet, needs are far from being met.5 Israel and Syria are not on peaceful terms and have fought 3 major wars. Despite the history of enmity, the Israeli government decided to join the humanitarian effort.
Israel is experienced in providing and leading international aid projects in worldwide disasters6 and in numerous initiatives. An example is Save a Child’s Heart, a model of regional cooperation in which thousands of children, mostly from Arab countries, had operations for congenital cardiac defects.7 Yet, establishing a sophisticated health care system designated entirely to helping a suffering neighbor and enemy nation is a novel concept. The humanitarian operation has a definite starting date of February 16, 2013, when 7 severely injured young Syrians turned for help to a military base on the Israeli border. They were promptly treated, consistent with the Medical Corps oath to treat friends and foes equally. An immediate governmental resolution was enacted for full treatment and rehabilitation, thus initiating a formal policy of compassionate aid to Syrian victims. The system comprises 3 levels of care. The first level provides emergency treatment adjacent to the border. The casualties present with severe multisystem injuries, gunshot wounds, amputations, burns, and nerve gas exposure. Some are accompanied by referral letters addressed specifically to Israeli physicians. The second level, the fully equipped field hospital, responds to the flow of casualties, requiring stabilization on arrival. The third level consists of tertiary civilian hospitals, where advanced medical care, psychosocial support, and rehabilitation are delivered.
The patients find themselves on enemy land, traumatized, malnourished, without personal belongings, and cutoff from their supportive families and environment. In the best of situations, each is attended by a family member, who generally is not able to remain for the whole hospitalization period. The entire staff (including physicians, nurses, translators, social workers, psychologists, and medical clown therapists) is recruited to provide medical as well as emotional care. Even the most experienced medical staff experience emotional turmoil, facing the severe and mutilating injuries, the tragic stories, and the suffering. The hospital personnel include Jews, Christians, Muslims, Druze, and Bedouins. Many speak Arabic, and others learn the language to achieve direct rapport. An Arabic-speaking nurse or social worker is assigned to each child, and if no family member is around, a hospitalized Syrian woman functions as a surrogate mother. Trust is built, replacing fear and anxiety.
The provision of sophisticated, multidisciplinary surgical and rehabilitation expertise enables lives to be saved and disabilities to be minimized, such as a novel limb-salvage strategy and reconstructive surgery using three-dimensional printing technology. Advanced prostheses are fitted with the aid of the International Committee of the Red Cross. Among those patients is the resilient and courageous boy brought on a donkey, who underwent numerous surgeries that saved his remaining arm and both legs.
Education, which is considered an essential child right in Israel, is provided during the prolonged hospitalization. The children participate in a comprehensive, in-hospital schooling program regulated by the Ministry of Education.
Widening the scope to address medical conditions and chronic diseases is an additional goal. One of those patients was a preschool-aged child with acute leukemia. Blood samples from all family members were smuggled into Israel. The appropriate donor, 1 of the siblings, was brought to the hospital accompanied by the mother in an extremely complicated mission. The mother exemplifies the gradual change of heart toward Israel from fear to appreciation and bonding. When her child became critically ill, she had no alternative but to turn for help in Israel, although the country is perceived as an enemy. Despite the inner change of attitude, she could not afford to publicly express her feelings of gratitude for fear of jeopardizing the safety of her family in Syria. After the bone marrow transplant and many months of the most advanced treatment, the child recovered and was able to reunite with her family in Syria.8 The departure from the deeply involved staff underscores the challenges in the management of children’s diseases under the dire political realities and epitomizes the hardship of the separation forced on both parties.
The return of rehabilitated patients to Syria poses exceptional emotional and ethical dilemmas, such as what defines the completion of treatment. On departure, the patients receive all necessary vaccinations and rehabilitation aids and are equipped with medications for a prolonged period as well as clothing and toys. Precautions are taken to protect personal safety, such as using only Arabic writing on medical documents. There is more than a sliver of hope that the relentless efforts might influence the future of the region and serve as an agent of change, ameliorating historical enmity and bridging peace.
A Talmud scripture stating “He who saves a single soul, saves the world entire” highlights the belief that each individual person is worthy and indispensable. Yet, although thousands of Syrian patients have been saved, the devastating tragedy and unmet needs are of enormous scale. Clearly the ability of the medical community to influence the political situation and refugee issues is extremely limited, and international bodies must take stronger action. Nonetheless, the community carries a moral obligation to voice the suffering and the torture and to relentlessly keep these issues high on the agenda of the free world and its leaders.
- Accepted July 31, 2017.
- Address correspondence to Anath A. Flugelman, MD, MPH, Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, 7 Michal St, Haifa, Israel 34642. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Shonkoff JP,
- Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics
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- Sasson L,
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- Berlovitz Y,
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- Copyright © 2017 by the American Academy of Pediatrics