November 11, 2016

Doctors in eastern Aleppo are working under extraordinarily difficult circumstances, including shortages of health staff, fuel, drugs, and medical supplies.

As they treat the wounded, their own hospitals are being hit by airstrikes. Each of the eight hospitals that were functioning before the siege has been hit, many of them multiple times, with 27 strikes on hospitals in just four months. But in almost every case, the damaged buildings were cleared of debris, patched up, and reopened within a matter of days.

The challenges of working under siege are enormous, but even under heavy bombardment, eastern Aleppo’s health workers have found ways to keep hospitals open and provide patients with medical care. 

Too Few Doctors

There are no more than 32 doctors in eastern Aleppo for an estimated population of 250,000 people. In response, doctors often work shifts at multiple hospitals and health centers, so that their specialist skills – whether in pediatrics, obstetrics, or surgery – are available to as many patients as possible.

Assistant doctors nearing the end of their training boost the numbers of hospital staff. Doctors report that when mass bombings result in large numbers of wounded patients arriving all at once, everyone in the hospital helps out, including caretakers and cleaners.

In the past three weeks, airstrikes have eased off, giving health workers the chance to recharge after an intense period during which more than 2,000 people were injured and almost 500 died, and to prepare for future periods of ground fighting, airstrikes, or indiscriminate bombardment. "Now the exhausted doctors are taking the opportunity to have a rest," says Doctors Without Borders/Médecins Sans Frontières field coordinator Patricia Garcia Peinado.

In the meantime, eastern Aleppo’s medical staff continue to provide the best medical care they can under the most difficult circumstances imaginable.

Medicines Running Low

Medicines and medical supplies are in short supply. In the months before the siege, hospital managers stockpiled supplies of drugs and other essentials, with the help of various organizations, including MSF, which has been sending regular three-monthly shipments of supplies to eastern Aleppo’s hospitals for the past two years.

Last April, a number of international organizations made an emergency delivery in case of a possible siege. "This included essential drugs, such as antibiotics and painkillers," says MSF medical coordinator Sara Ferrer Roura. "But we also sent in complex medical instruments, lifesaving equipment such as ventilators and incubators, and logistical equipment including generators to keep the electricity running during power cuts."

During a brief window in August, when the siege was broken, MSF sent in 128 tonnes of supplies, sufficient to last eastern Aleppo’s hospitals until October. "Six of the trucks had to turn back, because the bombing restarted, but 85 percent of the supplies got through," says Eduardo Yanez, MSF logistics manager. "Up to now the hospitals are still using those stocks – though they must be starting to run out."

With the extremely high numbers of wounded patients, it's likely these supplies dwindled quickly. And however carefully the hospitals ration drugs and other medical supplies, they cannot last indefinitely. There are currently no drugs to treat cancer, tuberculosis, or hepatitis, and many other drugs will reportedly run out soon.

"We are on the verge of finishing the last of our supplies and, once this happens, we will be facing an acute medical shortage, especially with medicines for chronic diseases," says Mahmoud Abu Hozaifa, manager of a pharmacy in eastern Aleppo. "But even finding painkillers is a challenge."

Hospitals urgently need to be resupplied. As soon as it is possible and security conditions allow it, MSF is ready to send in more aid. "We have already positioned in the area enough drugs to supply 12 medical facilities in eastern Aleppo – eight hospitals and four health centers," says Eduardo Yanez, whose team is on standby.

Fewer Beds in Underground Hospitals

Hospitals have been forced to move underground to protect staff and patients from airstrikes. With the higher floors of hospital buildings abandoned, and emergency rooms, operating theaters, and intensive care units shifted down into basements, there has been a significant reduction in the number of beds available for patients.

Hospital staff have dealt with this by prioritizing the most urgent cases, and setting up beds for post-operative care in nearby houses. Patients, meanwhile, are opting to spend as little time as possible in hospitals. "Women have a Caesarean section and are out within a few hours," says Sara Ferrer Roura. Many people prefer to visit local health centers, which are closer to their homes and are hit less often by airstrikes.

Fuel Shortages

Eastern Aleppo has been without electricity for months, and hospitals rely on generators to supply power for lighting and running essential equipment such as life support machines and ventilators. But generators require fuel, which is increasingly hard to get hold of in the besieged area.

In response, hospital staff are carefully rationing the fuel they use, running generators for just a few hours each day, or only when power is urgently needed. "They only run generators when they really need them for an operation, so saving fuel," says Patricia Garcia Peinado. "They are incredibly adaptable, and are learning how to work under besiegement."

Prior to the siege, MSF provided drugs, medical supplies, and equipment every three months to eight hospitals, six health centers, eight first-aid posts, a blood bank, and an ambulance service in eastern Aleppo. Since August, no deliveries of aid have been possible.

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