by AVI ASHER-SCHAPIRO
Earlier this year, a Syrian American orthopedic surgeon was shopping with his two toddlers at a Walmart in Grand Rapids, Michigan, when he heard the familiar ping of a notification from WhatsApp, the encrypted messaging service: A teenager had been shot in the leg and the bullet had passed straight through his tibia. The fractured bone punctured his skin like a spear. Although it was the surgeon’s day off, he took the call—as an expert in complex bone operations, this was his specialty.
But this was no ordinary case. His patient was over 6,000 miles away, awaiting care in a makeshift medical clinic in Madaya, a town in Syria some 28 miles from Damascus. The clinic is only a 45-minute drive from Damascus Hospital, but it might as well be on the other side of the world. Madaya, a rebel-held town controlled by the Islamist group Ahrar al-Sham, has been held under siege by Hezbollah, which is fighting on behalf of the Syrian government, since last July. Hezbollah won’t let anything in or out of the town; it was a Hezbollah fighter, locals say, who shot the teenager in the leg.
At the Madaya clinic that day, two men were on duty: a 25-year-old who had been a first-year dental student when the Syrian civil war broke out in 2011, and a veterinarian in his mid-40s. Gangrene had begun to spread down the patient’s leg, and the dental student, in a series of frantic texts, was asking the surgeon in Michigan what to do. As he walked through the parking lot of the Walmart, the surgeon picked up the phone and called the dental student, guiding him through the steps: Immediately load the patient up with antibiotics. Scrub the wound. Clear away as much dead tissues as possible without agitating the patient. Splint the leg.
“Any other call I would have ignored,” the surgeon admitted to me when we spoke in early August. But he knew that the dental student had nowhere else to turn. He is the only orthopedic surgeon in the “Madaya Medical Consultants,” a group composed of over two dozen, mostly Syrian American doctors, whose specialties include pediatrics, obstetrics, and pulmonology. They meet, digitally, in a WhatsApp chat room that supports the Madaya clinic around the clock. Most of the doctors in the group quoted in this story asked not to be identified, for fear of endangering their families in Syria. Rajaai Bourhan, a resident of Madaya, introduced me to the Madaya clinicians, whose identities I’ve also left anonymous for similar reasons.
Throughout Syria, more than 500,000 people are now under siege. The vast majority are penned in by pro-government fighters, their survival hinging on the medical know-how of the doctors, nurses, or medical students who happen to be trapped with them. In clinics like the one in Madaya, medical expertise is increasingly hard to come by, and remote medicine is often the only way patients with complex ailments can receive a semblance of care.
In Madaya, a year-long blockade enforced by a series of Hezbollah checkpoints, backed up by deadly minefields, has separated its 40,000 civilians from the rest of the country. The town hasn’t received a humanitarian-aid convoy since May, and only the most gravely injured or sick are allowed safe passage out. These evacuations require complex negotiations with rebels in other parts of Syria, in a high-stakes human trade.
This places a tremendous burden on the Madaya clinicians, the town’s two remaining full-time medical workers. Neither man has ever set foot in a medical school. The town’s most-skilled medical practitioner, a nurse with a background in anesthesiology, managed to escape last spring after receiving death threats.
But even the stifling siege can’t keep out wi-fi, which permeates the town thanks to a cluster of nearby cell-phone towers operated by Syriatel, the Syrian cellphone giant owned by Rami Makhlouf, President Bashar al-Assad’s cousin. In February 2016, a pulmonologist in Indiana who grew up outside Madaya realized he could use that wi-fi to smuggle medical advice past the blockade. During the winter of 2016, Madaya’s food stores emptied out. Dozens starved to death, and the health clinic swelled with malnourished patients. As the body count rose, the pulmonologist—a board member of the Syrian American Medical Society (SAMs), a humanitarian organization staffed by Syrian American doctors—grew increasingly desperate to boost the capacity of the town’s small clinic.
“It was the only way I could think of to help,” the pulmonologist told me recently. SAMs runs similar telemedicine programs in other parts of Syria, but Madaya is one of the only besieged areas without any trained doctors. After the anesthesiologist nurse fled, he knew the clinic would need more help than he alone could provide.
In February, the pulmonologist wrote an SOS on his Facebook page (he’s shared the posting, but asked me not to make it public since it includes names of doctors who want to remain anonymous) asking Arabic-speaking doctors to join a WhatsApp chat room that would become Madaya Medical Consultants. Within 24 hours of posting the message, over two dozen doctors joined, he recalled. Not wanting to overcrowd the group, he eventually started turning people down.
The dental student remembered the first time the doctors in the WhatsApp group helped him make a diagnosis. The day after the pulmonologist introduced him to the group, a child, whose body was body swollen and misshapen, was brought into the clinic. One of the group’s pediatricians helped identify the patient’s ailment as kwashiorkor, a disease brought on by extreme protein deficiency. First identified during a famine in West Africa in 1935, its name comes from a Ghanaian term for a child whose mother does not have enough breast milk to feed it. To treat the condition, a pediatrician in Chicago helped devise a formula using vegetable proteins that accustoms children to a high-protein diet. “We were so thankful that these doctors from so far away would volunteer their time to help us,” the dental student said.
The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer, they told me during multiple conversations over WhatsApp and Facebook. “I’ve learned as I go,” the dental student said when we chatted over Facebook in August. “God willing, I am able to help as many people as possible.”
But there are limits to what they can do. Every day, one member of the group, a Virginia-based internist, obsessively checks the WhatsApp group for new messages: at 4 a.m. when she wakes up to breastfeed her newborn daughter, or on her lunch break at her clinic. In recent weeks, she has been trying to help the Madaya clinicians diagnose a woman who suddenly lost her vision, without warning, and is experiencing hallucinations. If a patient walked into her clinic with those symptoms, the internist said, she would immediately order an MRI. But since there’s no MRI machine in Madaya, she and three other doctors have been working to diagnose the woman “empirically,” trying out different medications the clinic happens to have and seeing if they work.
In July, as the internist recovered from the birth of her second child, she helped the Madaya clinicians perform a C-section on a woman pregnant with twins. The veterinarian, fortunately, was comfortable making the incision. But he was unprepared for all the blood the mother would lose after giving birth to two babies. So the internist explained that the woman needed a transfusion. She advised the dental student to transfer two units of blood every 30 minutes—the gap between transfusions was critical, she explained, to allow time to observe whether the mother was having an allergic reaction to the blood.
The whole exchange took place in a series of rapid-fire text messages. Though the Madaya clinicians sometimes send photos or videos of their procedures, the town’s patchy cell-phone-enabled internet service can’t reliably stream videos, and only sometimes supports phone calls. In the end, the C-section was a success; the newborns and mother are healthy and back at home. Still, no amount of hands on experience—even crash courses in surgery and complex diagnostics—can substitute for formal training. “Sometimes, talking to those two is like speaking with a first-year medical student,” the internist said. “You never know what they will know or what will be new to them.”
Doctor Silvia Dallatomasina, the medical-operations manager for Doctors Without Borders’s Syria office, explained that almost everywhere across the country “the medical staff is young or inexperienced, out of their comfort zone.” That dynamic is supercharged in Madaya. “There’s no second clinic to fall back on. You can’t bring in a doctor from a neighboring community,” explained Valerie Szybala, the executive director of the Syrian Institute, a nonprofit that helps run Siege Watch, a project monitoring Syria’s besieged communities. “For patients, there is nowhere to go. It’s that clinic, or nothing.”
At times, the group does indeed resemble a classroom. For hours every day in the chat group, doctors and the Madaya clinicians discuss the merits of different antibiotics, or analyze the urine of a patient, or try to devise a workaround for a surgery. The orthopedic surgeon in Michigan recently taught the dental student how to perform minor hand surgery without general anesthetic by suppressing a nerve in the hand to temporarily numb a wounded finger. “We became more professional, more precise,” the dental student said. “In some ways, its been an academic experience, learning things I had no way of knowing before.”
“We thank God for the group,” the veterinarian told me at the end of a full-day shift at the clinic, via a WhatsApp audio message. “Without them, we would have more questions than answers.”
For many of the doctors in the WhatsApp group, the digital thread tethering them to Madaya has become an obsession. The pulmonologist described constantly looking at his phone, even while driving in traffic, to make sure the group is answering all the questions that come up. “I can’t let it go,” he said. “My soul is attached there.” The orthopedic surgeon said he checks the chat room “multiple times every day.” Before the WhatsApp group, he had to switch off the television whenever it showed images of the Syrian civil war, overwhelmed by a feeling of helplessness. “I just shut my brain up. I didn’t want people even talking to me about it,” he said.
For the past five years, he has been in touch with his family in Aleppo, the northern province that’s become the center of the Syrian conflict in recent months. When his cousins talk about the horrors of life in a war zone, all he can say is “I’m sorry, I’m sorry,” leaving him feeling “like a jackass,” he said. Though he has no personal connection to Madaya, the WhatsApp group has given him a feeling of concrete solidarity with those suffering in Syria.
Born and raised in Damascus, the internist hasn’t been able to return to her native Syria or see her parents in five years. The WhatsApp group, she said, offers her a “portal” back into her homeland, a rare opportunity to alleviate suffering. She still has fond childhood memories of Madaya: She and her sister used to drive there from Damascus to buy rare fruits smuggled into Syria from across the Lebanese border.
Remote medicine, of course, is not enough to keep Madaya healthy. Many of the conversations in the WhatsApp group fizzle out as the doctors realize the clinic doesn’t have the right medicine or equipment—or that the Madaya clinicians can’t perform the needed procedures, like brain surgery or a lumpectomy. At that point, the doctors will promise to pray for the patient, and the chat room goes silent. When asked if these dead ends discourage him, the pulmonologist paraphrased a verse from the Koran: “If we save one life, it is as if we are saving the whole of humanity.”