I have got involved in medical relief and humanitarian work since the war started in Syria. I have participated in multiple medical missions in my homeland, but also provided healthcare at the peak of the refugee crisis in different countries: Jordan, Lebanon, Turkey, and Greece. In 2011-2015 I was the President of the Syrian American Medical Society. We established quite extensive health care programs to help people inside Syria, and support the victims of war, as well as the refugees. Since 2017 I have co-founded MedGlobal which provides healthcare in low-income, middle-income countries, and disaster regions. We build our work on three pillars: emergency response, sustainable healthcare programs, and support for the resilience of healthcare systems. Now we are active in eight countries in South America and Africa, the MENA region (a group of countries situated in and around the Middle East and North Africa. — Ed.), Southeast Asia, and Ukraine.

I have been to Ukraine twice so far. MedGlobal was the first NGO that arrived in Lviv 10 days after the invasion started. Since April, we have sent five additional medical missions focusing on training for Ukrainian physicians and nurses. Also, we sent a lot of medical and surgical supplies worth $3.5 million to different hospitals on the frontline in coordination with the Ministry of Defence of Ukraine and the Ministry of Health of Ukraine. And I am gearing up for another medical mission in early October.

Russians are using the same tactics in Ukraine, they used in Syria: targeting hospitals, forcing displacement to depopulate areas, and using illegal weapons. More than 70,000 soldiers went through Syria before they came to Ukraine. What Ukrainians have experienced in Mariupol we have seen in Aleppo. Russians keep hitting the areas with missiles until everyone leaves, and then it becomes easy for them to enter empty cities, putting areas under siege. That causes malnutrition and starvation of the population in sieged areas until they are surrendering. I hope they will never use chemical weapons in Ukraine, but they may, as there are no red lines for russians. If they use nuclear weapons in Ukraine, it will be a disaster for the whole world. Their brutality is unheard of, and they do not have any norms that they abide by in the war.

The war in Syria started in 2011, so it has been going on for 11 years. Russia intervened in 2015 on the side of the Assad regime. And since then they were systematically attacking hospitals and clinics. We lost more than 1000 physicians who were victims of the war. The NGO Physicians for human rights calculated that almost 950 doctors were killed directly by the Assad regime. And some doctors were detained as they were political opponents of the regime in Syria. Russian and Assad regimes destroyed more than 580 hospitals, what caused a disruption of the healthcare services provision and displacement of the population. When there are no doctors in town, people leave.

The war affects and disrupts the healthcare system. Ukrainian hospitals will face a shortage of medical supplies and medications because they are overwhelmed with the influx of trauma patients. The direction of resources to trauma patients will affect the other parts of the healthcare system and cause a lack of medications for patients with chronic diseases: diabetes, heart disease, or COPD (Chronic obstructive pulmonary disease. — Ed.). Besides, the vaccination is at risk of disruption, and there might be gaps related to women's health.

A significant displacement of people fleeing the war leads to a shortage of healthcare providers inside the country and to the dearth of equipment to support displaced people as well as those who are in the frontline territories. According to the World Health Organization (WHO), more than half of the healthcare workers moved outside Syria during the war. In Ukraine, the numbers of people fleeing the war are also very high: around 10 million people were displaced inside the country, and more than six million became refugees. But such shortages of professionals or equipment are predictable, and they need to be addressed.

Moreover, the psycho-social impact of the war causes many problems and psychological trauma to the victims who witnessed the violence and have an uncertain future. These people require a lot of attention, as psychological trauma can manifest itself in PTSD (post-traumatic stress disorder — ed.), depression, and anxiety.

The main idea is to build resilience within the healthcare system, among the healthcare workers in Ukraine. And this can be done with training. During the war, medical professionals step beyond their usual comfort zone and do things that they were not used to doing. You may be the only internist in a town, near the frontline, but if someone requires delivery or abscess treatment you have to take care.

Healthcare workers should be trained to take care of psychological trauma related to the war. There is a short training for doctors and nurses on mental health first aid. The first few hours after an incident are critical to preventing long-term depression, anxiety, and PTSD. Also, the training for physicians on dealing with limited resources is important.

Also when there are a lot of injured people, physicians need to apply a special approach in the triage stage, deciding which patients they can and cannot help. To address this, professionals require so-called mass casualties training. MedGlobal has sent surgical teams to provide this training in several hospitals in the western part of Ukraine. A training on certain technologies that will make physicians’ life easier is important. They will not have access to CT (Computerized tomography. — ed.) scans and MRIs (Magnetic resonance imaging, — ed.) on the frontline. In this case they should know how to use the portable ultrasound: the program can be downloaded to your phone and your phone screen becomes an ultrasound screen. You can see the condition of the heart, kidneys, and lungs. We also have done trainings on portable ultrasound use in Ukraine.

Besides, healthcare workers need to feel that they are supported. As I have mentioned, war is destructive, but it is also an opportunity as you have many people who are ready to help. When MedGlobal announced that we are sending a medical mission to Ukraine, I was flooded by calls from trauma surgeons who have never been to Ukraine and who are not Ukrainians but who wanted to come and help. When I went to Lviv in April for the second time, the hotel was full of NGO representatives from all over the world. Why not use this opportunity to improve the healthcare system beyond what is planned?

Resilience is a buzzword in global health, especially in disaster regions. Unfortunately, natural and man-made crises and disasters become a part of our life. We are still in the midst of the COVID-19 pandemic, and now dealing with the monkeypox epidemic. A pandemic like COVID is a bit similar to war in terms of limited resources — we have to deal with an excessive number of patients that our hospitals are not used to. In my hospital in Chicago, we struggled during the peak of the COVID pandemic. Especially early in the crisis, when we did not have enough tools to deal with it. Every patient was very sick, we did not know what to do with them. We were lacking ventilators. Physicians had limited ways of protecting themselves: I had one mask for the whole week. We have never had that before in the United States. But I believe, that if you were trained to deal with war and crisis, you will be able to deal with everything.

So, resilience is the ability to adapt to a crisis. Imagine a tree. If the severe wind can break it, the tree is not resilient. If the tree can bend, and stand up after the wind — it is resilient. Physicians or nurses are resilient if they can provide healthcare to their patients facing challenges with resources under war or crisis. A resilient healthcare system adapts to crises quickly, can turn a little bit, and change its orientation and priority. If you continue to do things as before, you are not resilient.

A resilient healthcare system predicts and plans for what will happen. So the questions are: how can we train healthcare providers quickly? Can we fill the gaps by possibly providing telemedicine, using volunteers who are coming? How can we provide leadership training to people in the healthcare system, hospital administrations in different regions to make sure that they understand what they need to do? We should let doctors and nurses know that they are not left alone.

The Ministry of Health of Ukraine asked us to provide a training in chemical weapons. They were worried that russians can use these weapons in Ukraine, as they did in Syria. The Assad regime with the implicit support of russians used sarin, chlorine, and mustard gases, which caused a lot of injuries among civilians. On 21 August, we witnessed the ninth anniversary of the Ghouta Chemical Weapons Attack (Ghouta massacre. — ed.) — the largest chemical open attack in Syria, when the Assad regime used sarin to kill hundreds of people in the Damascus area. That’s why the first training we delivered in Ukraine was exactly on chemical weapons. I did it together with Dr. Riley Jones, who is a member of the MedGlobal board.

During the training we talked about classes of chemical weapons, including those russians have used previously, assassinating their political opponents. We elaborated on the detection mechanisms of different chemical agents, means of protection for the healthcare providers during chemical attacks. Also, it was important for Ukrainian physicians to learn what kind of chemical gear and antidotes hospitals should have, how to decontaminate patients who were injured with chemical weapons. We share as much as possible including the treatment protocols.

Those questions are very important, they are often ignored in the war situation. During the war, the state agencies, systems, and people are more concerned with addressing the acute impact of the disaster. And routine issues, which must continue to work, often fall from view. Now you know that Ukrainian physicians are leaving for Europe and the United States, so you need to make sure that you will have a new wave of physicians who can fill these gaps. Unfortunately, many countries that have wars and disasters lose the best of their doctors, not only for the displacement but also because some of them will become victims of the war.

In terms of medical training, I had a chance to meet with 50 medical students from Lviv University. All of them had a very optimistic view of their role in the future of Ukraine. They were very proud of Ukraine and determined to gain a victory. Also, they have high aspirations for themselves and their professional role after graduation.

Another question to answer is how do you address the disruption of medical training when you lose senior teachers in hospitals and universities because they leave? When you lead a medical college or a university, you have to be very creative. You have to use the available resources, such as online training. Hospitals are full of patients because of the trauma, and they will continue to have patients with infectious or chronic diseases. The continuity of bedside training should not be affected. Young trainees can fill the gaps that were made by the doctors who left. We have observed in Syria and Yemen that trainees step up to become full-time physicians because there is no other way to ensure medical care.

Continuing medical education for healthcare professionals and related specialists (e.g psychologists) should also be redirected and reoriented towards the war needs.

We should be used to disasters, and wars as man-made disasters. We have natural disasters that are occurring at an accelerated pace because of climate change. We have pandemics that are happening more and more often. In medical schools, we should teach how to deal with limited resources. How to plan, prepare, adapt, and reallocate. How to preserve resources in war, disaster, and peace situation. Medical ethics will create a lot of tension and conflicts between physicians and nurses dealing with crises and wars. I remember one vivid example. One of my colleagues was an anaesthesiologist in a small town near Damascus. On the night of the sarin gas attack, a hospital, that has 20 beds and two ventilators, was overflowed with 700 suffocating and gasping for air patients. Unfortunately, he and his team could not manage all of them. By the morning he had 140 dead patients. Such situations can happen, so students have to drill a “rehearsal” in the emergency room. They have to decide how they will triage injured patients when it happens in reality. It should become the second nature to them, otherwise, going to create psychological trauma. So, this should be a part of the medical curriculum.

Also, coping with disinformation is something that we should be trained on as physicians in medical school. I think the Ukrainian government is doing a great job in terms of fighting the disinformation campaign. We have seen the impact of disinformation on COVID vaccination, I still have patients who tell me that COVID is not real. I still have patients who are not vaccinated in the United States as they believe that the vaccine is planting a microchip in their arms so that the government can control them (laughing. — ed.). We did not have such disinformation in the past. Now it's available, and we have to be able to fight it as doctors and nurses.

Foremost, is critical thinking. This is something that we emphasize in the United States. Not only absorbing and memorizing a large sum of information but the ability to use resources on your own. The ability to have patterns of patients, to think on your feet, and adapt to the situation. I think these capacities are more important than just having a lot of information. How do you deal with different situations? How do you apply the knowledge that you have to certain patients? How do you use resources? Also, the ability to use new technology. During my time in training, we used to go to libraries to read books. Nowadays, everything is available on your mobile. Nowadays, it's easy for students to check out information on their phones using Google. The ethics of medicine, ethics of situations, and mental health issues should also be part of the training and curriculum.

Everyone who goes to war will have some impact on their mental health. Humans are fragile creatures. So, we need to understand what mental health means and why healthcare providers get psychological trauma in war. Medical professionals can be afraid to become victims of violence. Their families can be affected too. Moreover, they are dealing with minimal resources, lack of equipment, and subspecialists’ support. All these facts harm mental health.

So, how do you deal with burnout syndrome? You need to understand that this happened. As physicians, we usually do not reflect on our mental health. So, you have to know that this may hit you similarly to other patients, and you have to be self-reflective and mindful about these issues. Certain things should be done on an individual level and the healthcare system level. Otherwise, medical professionals will have more mistakes and medical errors. Some physicians may commit suicide. Some health care workers may drink more alcohol and use drugs.

So, to prevent burnout syndrome you should do regular exercise, practice mindfulness, or pray, meditate, have good nutrition, good social network, and friends that support you outside the work. When you leave the hospital, your work should not come with you home. Also, mandatory breaks at work are important. And the healthcare system should plan that by providing opportunities for physicians and nurses.

Ukrainian physicians and nurses are ready to learn. Like a sponge, they are absorbing all the information. I remember one training I have provided in the Ukrainian hospital. We were in the middle of the training on chemical weapons, when the sirens sounded. Everyone went to the bomb shelter in the basement of the hospital and stayed there for 30 minutes as the sirens were on. Then we were supposed to come back and continue the training. I expected them to be gone. But everyone came back. It means that medical professionals are taking the training seriously, they want to learn.

My colleagues also said that the Ukrainian trauma surgeons are well-trained. They are better than doctors in other regions of the world which we have trained. Look, I have mentioned the portable ultrasound device. Usually, it takes two days to provide a training. But Ukrainian doctors could absorb all the information during half a day, and were already prepared to provide care for their trauma patients using this device. In general, we had a very good impression of the healthcare system in Ukraine.

During my first visit to Ukraine in March, it was very cold. But the hospitality of the people in Ukraine and the determination I have seen, the beauty of the city, the cuisine make me come back again and again. My colleagues have the same experience. Dr Judah Slavkovsky — a trauma surgeon in Peoria, Illinois — came the first time and afterwards he did four more missions, because he liked the people, and the experience. He felt that his contributions were meaningful. And I am sure he and others will continue to come after the war ends. So this crisis is also an opportunity. I believe we can make things better if people in healthcare system are resilient. I have seen this resilience in the healthcare professionals in Ukraine.