Ghassan Abu Sittah is a plastic and reconstructive surgeon and associate professor of surgery in London, and co-director of the Conflict Medicine Program at the Global Health Institute, American University of Beirut. Omar Dewachi and Nabil Al-Tikriti interviewed him in December 2020 about his work, his insights into the past decade of turmoil and the relationship between war, medicine and politics.

Ghassan Abu Sittah working at Al-Awdah Hospital in Jabalya refugee camp, in the Gaza Strip, May 14, 2018. Photo courtesy of Medical Aid for Palestinians.

I first met Ghassan Abu Sittah when we both joined the faculty at the American University of Beirut (AUB) in January 2011. These were inspiring times as waves of protest and hopes for social and political change sparked by the Arab uprisings spread across the region. Our connection began over a conversation about the work of the late Hanna Batatu and his insights into the historical processes that shaped power and authority in Iraq and Syria. Our friendship and partnership culminated in close to a decade of research and public health work. Together we founded and co-directed the Conflict Medicine program in the Global Health Institute at AUB. The program was our attempt to invent a new platform for social medicine practice in the region, bringing clinical, historical and sociological knowledge to bear on the understanding of the region’s protracted conflicts and their impacts on populations and communities.

During his tenure at AUB, Abu Sittah’s work radically transformed the practice of medicine and surgery. As the chair of the plastic surgery department at AUB Medical Center, he singlehandedly redefined the workload of the hospital from a focus on cosmetic surgery to one on reconstructive surgery, particularly of physical deformities in children and war injuries. His legacy has become a blueprint for a new generation of physicians that he trained and mentored. The precision of Abu Sittah’s surgical scalpel was only matched by his keen political insights and analysis that come from a deep understanding of the political predicament of the region.

– Omar Dewachi

[This interview has been edited and condensed for clarity and length.]

 

Omar: Give us some background about your career trajectory as a reconstructive surgeon and the political era you have witnessed as a medical practitioner in the Middle East.

Ghassan: Since medical school, and until I went to Beirut in 2011, my work in what we now refer to as conflict medicine—which is politically motivated and politically driven medical care—ran parallel to my official medical career. It constituted visits to Gaza during the first Intifada, Iraq after the first Gulf War, the south of Lebanon and Gaza again during its different assaults. However, when the second Intifada began in 2000, I decided that I needed to devote more time than the usual two-to-four-week missions. I took an unpaid leave from the National Health Service and went to Gaza for six months. At that point I tried to understand the context of medicine and surgery in our part of the world, particularly in conflict-related surgery. Something that struck me during my earlier shorter visits to Gaza was that all of the medical expertise during the first Intifada with gunshot wounds had almost evaporated. So, when I returned for the longer stay, I tried to understand what it is that keeps us starting all over again. I wanted to understand why we have been unable to accumulate experience and turn it into expertise.

Something that struck me during my earlier shorter visits to Gaza was that all of the medical expertise during the first Intifada with gunshot wounds had almost evaporated. So, when I returned for the longer stay, I tried to understand what it is that keeps us starting all over again.

When those six months ended, I returned to my career in the National Health Service. The next summer the London bombings happened and I was at the Royal London Hospital, which treated 200 of the victims. That was my first experience where the expertise that I had developed and the knowledge I had accumulated [in conflict medicine] were useful. This experience grew more focused after I moved to Beirut in 2011. I remember, shortly after we first met, we saw that family from Iraq where the girl had sustained facial injuries from a car bomb, her mother had lost her eye in the explosion and the father, who was an engineer, had previously lost fingers in the Iran-Iraq War. We were seeing this not in a makeshift humanitarian setting, but actually in a well-funded academic civilian center.

You and I started engaging in a quest to understand a central question: How can you build from these clinical experiences a more systematic approach to these problems? What was interesting about the work that you and I were starting to do is that the clinical was also linked to the sociological and the anthropological. Understanding the journeys that brought patients to the clinic, the kinds of injuries they had, or the kinds of injuries their relatives had and who was paying for their treatment, had clinical, but also intellectual and sociological implications. We were witnessing something that was unfolding and accelerating in the region.

AUB became a good place to try to comprehend the clinical, social and political dimensions of this phenomenon. I remember when the first Syrian wounded patient was brought to the AUB hospital in a taxi from Homs. She had suffered a blast injury to the face, which had exposed parts of her brain. It was then that we began seeing increasing numbers of Syrian patients in Lebanon, in addition to the prior Iraqi, Libyan and Yemeni cases. It was at that time when our work on the therapeutic geographies of war began to speak to the regionalization of health care and the dismantling of boundaries between health systems in the Arab world. Suddenly we were at the crossroads of all the caravans of wounded patients coming from different parts of the region.

Patients came to Beirut not just with injuries and microbes that infected their wounds, but also with their stories and knowledge of what was happening elsewhere—in Basra, Kurdistan, Syria, Deir Ezzor, Homs, Yemen. Working with our colleagues at AUB, we set up a multidisciplinary war injuries clinic and a program for pediatric war injuries to understand the injured child: to understand physiologically, clinically and biologically how they were injured and to try to see the whole picture, so that this unique experience would be captured in all of its dimensions and depth.

Omar: I remember when we gave talks about our work in conflict medicine, you often referred to war injury as akin to an “endemic” disease, in reference to the different rounds of protracted violence and militarization across the region. Could you elaborate?

Ghassan: If we create a timeline, and arbitrarily say that the region runs from Algeria to the Iraq-Iran border—bracketing out Pakistan and Afghanistan and what’s been happening there—you realize that armed conflicts have been happening almost continuously since World War I, in some shape or form. This perspective contrasts with the humanitarian discourse of emergency and temporality. During the civil war in Syria, humanitarian agencies came in with the language of emergency service and temporary conflicts. But we were witnessing patients who had, in the case of Palestine, repeated injury and re-injury within the same body of the same patient. In Iraq, injury was a social phenomenon. If you recall, we saw a lot of cases where the caregiver had been injured in one incident, and the patient had been injured in another, while the rest of the family had been affected by something else. What was unfolding in front of our eyes was in stark contrast to the discourses of the United Nations and humanitarian agencies. We knew from our patients and their stories that this was not a temporary crisis.

What was unfolding in front of our eyes was in stark contrast to the discourses of the United Nations and humanitarian agencies. We knew from our patients and their stories that this was not a temporary crisis.
We needed to reclaim and create a language in conflict-related ill health that reflected what we saw to be the reality, rather than the public relations discourse of the humanitarian agencies.

When there is violent conflict, the biosphere—the living environment that people inhabit—is fundamentally changed, it becomes what we have called an ecology of war. People become trapped in that ecology and are injured through multiple conduits. For example, we looked at the incidence of stunted growth in Syrian refugee children being treated at AUB. We found that the incidence was over 25 percent. We then did a similar study on Syrian children with cleft lip and palate and found a similarly high percentage. We did another study looking at consanguinity rates among Syrian refugees and also saw a high rate of stunted growth. All of these conduits we were investigating, these mechanisms of injury and re-injury, left us with a sense that the bullet, bomb and shrapnel were just the beginning of the road to injury and that it continues in a multitude of ways as the environment becomes more hostile. And, in the case of anti-microbial resistance, we discovered that even the building blocks of life, the DNA of these microbes, are altered during conflict.

Omar: Often when we speak about war medicine we are imagining either a humanitarian surgeon working in conflict zones or military doctors dealing with frontline injuries. But instead, civilian hospitals across the conflict zones in Syria, Iraq, Gaza and Libya have become hubs for treating conflict-related injuries, even though many doctors are not equipped for this work. How can the practice of medicine be reimagined across the region? Do civilian doctors now need to be trained in certain kinds of conflict medicine approaches?

Ghassan: The overwhelming majority of information about the management of war injuries comes from research published by the army medical corps, particularly the clinical knowledge in Western countries. Unfortunately, very little of what had been published in Russian from the Afghanistan war was translated into English or had crossed over to English-language medical journals. In the military context, surgeons, doctors and medical staff have been drilled in a specific formal pathway that led the patient straight from the medevac all the way back to Bethesda in a very systematized way.

But what we learned from our patients is that their treatment was erratic and was always incomplete because they had to transit through different hospitals that had very limited capacity. More importantly, a lot of their complications were related to the fact that these were civilian surgeons treating complex contaminated injuries as if they were just another traffic accident. Unfortunately, despite the endemic nature of conflict in the region and the fact that we’ve been down this road numerous times in many different places, we had failed to institutionalize and retain knowledge. Thus, doctors were starting from scratch every time a conflict erupted.

Additionally, patients were being treated in the same makeshift hospitals or degraded government institutions as combatants, by whomever was left standing. Concomitant with the increase in the number of injuries, there is a migration and exodus of health professionals. As injuries increase, the number of people available to treat them decreases.

We recently conducted a retrospective study looking at patients injured in the 2006 war in Lebanon through a quality-of-life questionnaire. None of the over 70 patients that we interviewed underwent treatment in a single place. Many of them reached hospitals that were hospitals in name only, barely able to provide first aid. So, on average, each of these patients visited three or four hospitals during the course of their injury and its management. This was in a small country, imagine a place like Syria or Iraq! We are now conducting a similar study of Palestinians shot by Israeli snipers during the 2018–2019 right of return marches. It’s the same story: you get shot, you go to one hospital, then another hospital, then you’re discharged, but your reconstruction is not complete. Then you must be sent to another hospital because the whole place only has one reconstructive surgeon.

Omar: How do you understand the broader historical and political meaning of wounds in the region?

Ghassan: At the moment of injury, the weapon or the ordinance imparts on the wound and the flesh a narrative of the war, and that narrative is who killed whom, who is fighting for whom, under what project, as well as who was the enemy and who was the ally. As you and I witnessed, the patients carry that narrative with them wherever they go. So, if a patient was wounded in the Iran-Iraq war or shot by an American sniper or in the battles against the Islamic State in Iraq and Syria (ISIS), the narrative of their wounds came with them. The problem is that the narrative does not change in the lifetime of the patient. What changes is to what extent this narrative reinforces the political discourse and political project of the ruling elite at the moment.

The more we examined the narratives attached to the wounds, the more it was apparent that they are a major determinant of access to health care.
The more we examined the narratives attached to the wounds, the more it was apparent that they are a major determinant of access to health care. For example, if you remember the policeman who had thrown himself at the suicide bomber in Baghdad, his bill came to $270,000 to reconstruct his limbs, which was paid by the Iraqi government. Meanwhile, our patient who had been shot by American soldiers could not get the government to pay for his treatment in Beirut and had to borrow from his relatives.

I also saw this among Palestinian patients in Lebanon. I had a patient who was paraplegic, emaciated, in heartbreaking condition. I learned that a bullet went through him when his mom was shot by a sniper while running away from Tel al-Zaatar refugee camp during the massacre of 1976. He didn’t die, miraculously, but the bullet killed his mother. Paralyzed ever since, he grew up with stories of the massacre of Tel al-Zaatar as an important part of the rhetoric of the Palestine Liberation Organization (PLO) in the 1970s. After 1993, when the discourse of the PLO ceased to promote the return of refugees, the value of their wounds—the heroes of the 1982 Israeli invasion, the heroes of the camp war, the children of Tel al-Zaatar—the value of that narrative, no longer coincided with the narrative of the Palestinian leadership. Look at the two Palestinian intifadas—in the first Intifada, wounded Palestinians were taken to Arab countries and even flown abroad to Europe for treatment. In the second Intifada, the same thing happened. Today, however, if you’re a Palestinian in Dheisha Camp in the West Bank or in East Jerusalem shot by an Israeli sniper, the narrative of your wound does not coincide with the narrative of the Palestinian Authority leadership, and so your treatment and access to health care is completely different.

We also saw this happen with Iraqi soldiers wounded in the Iran-Iraq war (1980 to 1988). At the time, treatment provided by the Iraqi health system was outstanding. But in 2003, Iran became our friend, Saddam was gone and the wounded veteran was an embarrassment to the new ruling elite. He could not get treatment from the government for his war wounds. What one discovers is that actually, unlike what we are taught, the main determinants of viability or access to health care is the political value ascribed to the narrative of war wounds.

In Syria, it’s even more bizarre. If you listen to the discourse of the humanitarian sector, you can easily believe that there are no injured people living in the areas under government control. They all live in the opposition areas, and those in government areas are not worthy of humanitarian aid because that strengthens the regime. It became ludicrous, even for Médecins Sans Frontières (MSF). When Ghouta was under opposition control, the only thing you heard from the humanitarian sector was: “the wounded in Ghouta…the wounded in Ghouta.” However, once Ghouta fell to the government, there were no more wounded in Ghouta, nobody wanted to help, because the political value of the wounded in Ghouta was gone. This behavior is equally true for the other side. The Russians sent medical teams to Syria to work in government hospitals. Such polarization means that you choose your wounded based on whether their narrative suits you or not. MSF and the humanitarian sector are guilty of that, as are the allies of the Syrian government.

Nabil: You’ve worked extensively with MSF over the years. In the “field” you have also observed organizations like the International Committee of the Red Cross (ICRC), as well as other less well-known organizations, doing war surgery. From your experience, what can you say about their levels of expertise and MSF’s efforts to improve expertise through the Amman Reconstructive Surgery Hospital initiative?

Ghassan: In order to answer this question, we need to see what has been happening in medicine over the last 15 to 20 years. In North America and in the United Kingdom and Europe, there has been an increase in super specialization. Therefore, you will never find an orthopedic surgeon who is a general orthopedic surgeon. Instead, you will find an orthopedic shoulder surgeon, hip surgeon, knee surgeon or back surgeon. The general surgeons that ICRC and MSF used to recruit, who can open up a belly, do a craniotomy, deliver a child by cesarean section and put in an external fixator, are a thing of the past.

The general surgeons that ICRC and MSF used to recruit, who can open up a belly, do a craniotomy, deliver a child by cesarean section and put in an external fixator, are a thing of the past.
What is worse, most residency programs in North America now introduce laparoscopic and robotic surgery at such an early stage of medical training that a lot of the trainees don’t have experience working without that advanced technology, for example, performing a one-minute laparotomy where you have to open the belly and pack the liver and stop the bleeding wherever it’s happening. So, we are left scrambling for people who sub-specialize in trauma. This means that the ideal MSF volunteer is now either in their 60s or that they are Indian, Egyptian, Yugoslavian, for example, because they’re still being trained in a system where you have to be a generalist.

Until the Syria conflict, ICRC would not treat cases that were older than three months. It was only after they opened their war injury reconstructive surgery hospital in Tripoli, Lebanon in 2014 that they changed their mandate. This reflected two things. One, these humanitarian agencies were realizing that there is no such thing as an emergency and a temporary war; you need to stay for the long term because these are long-term conflicts. Two, the complexity of the work required different specializations.

We currently have a number of war injury reconstructive hospitals in the region: MSF supports such hospitals in Mosul, Amman, Gaza and northern Iraq. And then there’s the ICRC Tripoli hospital. These agencies used to rely on volunteers bringing their expertise with them. But now, the establishment of these institutions is, in my opinion, an admission that we need to create expertise among the volunteers while in the field. These hospitals also reveal the real nature of health needs in the region—Amman started out solely treating Iraqi patients and now treats Iraqi, Syrian and Yemeni patients simultaneously. What has been a missed opportunity is using these institutions to train regional surgeons. Imagine how many Iraqi, Syrian and Yemeni surgeons could have been trained.

The Middle East had quite robust, or at least functional, health systems that collapsed with the collapse of their nation states. The local expertise was there, but the systems have disintegrated. The majority of surgeons in Amman are Iraqi, with one or two Jordanian surgeons. The surgeons in Mosul are Iraqi, with one or two expatriates. The surgeons in Gaza are almost half Palestinian and half expatriate. So what MSF does is provide the system––the infection prevention and control, and the money, naturally––but the clinical expertise is local. They create a microcosm health system, but they now recognize that the actual expertise, or the majority of it, is locally recruited.

So what MSF does is provide the system––the infection prevention and control, and the money, naturally––but the clinical expertise is local. They create a microcosm health system, but they now recognize that the actual expertise, or the majority of it, is locally recruited.

One of the failures of MSF is their belief that capacity building should not be their priority, instead they focus on service provision. This is a mistake because even in terms of the limited timeframe of their involvement, they’re better off training and spending some of their money on increasing capacity locally. I’ll give you an example. I had pushed both MSF and ICRC, saying that if you give me $10,000, I can arrange for a Palestinian or an Iraqi surgeon, a specialist, to go to India and do a year’s fellowship in limb reconstruction or trauma reconstruction at a very, very busy trauma center and then bring them back. Their input would then be at a much higher level than someone who is coming from Johns Hopkins and has been doing robotic surgery for the last three or four years and has been sub-specializing. Yet, these humanitarian organizations flinch when you tell them that they need to do skills development work, partly because they do not view themselves as development agencies. But more critically humanitarian medicine is still held captive by the notion of the “white man’s burden” and its modern Western liberal manifestation, the humanitarian worker. MSF is unable to accept that since almost 80 percent of clinical services in the Middle East are delivered by indigenous staff it can only improve the quality of its services by investing in the training of its local staff rather than strive to recruit the right sub-specialty of doctor or nurse from the North.

Omar: Your departure from Beirut coincided with a drastic deterioration of conditions in Lebanon, including financial collapse, a popular uprising and widespread political corruption, culminating in this summer’s massive explosion in the Beirut port. Lebanon’s collapse also coincides with the COVID-19 pandemic. What are your thoughts about this last year of instability?

Ghassan: During the decade that we were there, we climatized ourselves to a certain level of functioning dysfunction in Lebanon. It’s like living with a functioning alcoholic who goes to work and does the bare minimum to stay afloat. There are electricity cuts, but you can manage your way around them with a generator. There are rubbish collection issues, but you manage by just ignoring it. Despite all of these different dysfunctionalities, there was a sense that everything around you in the region was falling apart.

The Arab state evolved in the 1950s and 1960s from one-party rule to one-ruler rule, to one-family rule. And now we live under the rule of Mafioso families. The political elites have neither the political project that the one-party states used to have, nor their vision. This is literally a network of families extending their tentacles across the whole of society, with zero interest in maintaining the semblance of a functioning state.

Unfortunately, my decision to leave was based on the experience of seeing this dynamic unfold in Iraq in the 1990s and then in other places in the Arab world and knowing what was going to happen. Since making that decision, 400 more doctors have left and yet another 200 are in the process of sorting their paperwork out. That whole regionalization story [the dismantling of boundaries between health systems in the Arab world and patients traveling across borders seeking treatment] that we witnessed has ended.

Omar: What is next for you, Ghassan?

Ghassan: I managed to put the Centre for Blast Injury Studies at Imperial College—the biomedical engineers conducing translational research—in touch with the United Nations Development Program (UNDP) in Syria. We are working on a project to locally manufacture external fixators the same way that ICRC started locally manufacturing prostheses. External fixators are used to stabilize severe fractures such as those associated with war injuries. I think we managed to get interest from UNDP in Yemen as well. The second idea I’m working on is to address this big problem that we’re facing in Gaza, Syria and Iraq, where amputees look on the Internet and see these American and German prostheses and then go to the local ICRC prosthetic center and get a fiberglass bathtub—and they’re refusing it. The researchers at Imperial College have introduced really important improvements to the quality of locally manufactured prostheses, so I’m trying to create a pipeline that links the lab with the prosthetic centers.

In terms of research, I am interested in the lifetime burden of war-related amputations. We’re applying for research grants to look at questions like how many times do they have surgeries? How many times did they change the prostheses? What is the percentage of patients with below-knee amputations in places like Gaza or Yemen who can actually wear the prostheses they were given, or are there other reasons why they can’t? In terms of clinical work, one of the reasons I went into private practice in London was to give myself the maneuverability to be able to go on missions. Once things settle down in terms of setting up the clinic and knowing exactly when I can leave, I would like to go to the hospital in Mosul and do three weeks and also maybe to go to Yemen and do some work there. London will be the base where I do research, but I will move my clinical reconstructive work to Gaza, Iraq and Yemen.

 

 

How to cite this article:

Ghassan Abu Sittah, Omar Dewachi, Nabil Al-Tikriti "The Evolution of Conflict Medicine in the Middle East – An Interview with Ghassan Abu Sittah," Middle East Report 297 (Winter 2020).
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