By Professor Fayez Sandouk

 

1) Introduction

Stability is usually essential for any practice and progress but war disrupts the usual routines. In addition to difficulties in safety, food, and health, life becomes very difficult and painful. What makes things more challenging is going about the daily activity for the populace, and even more, keeping up the quality of their jobs.

The crisis that my beautiful country Syria has been going through for the last seven years, created new circumstances which made practicing endoscopy, like other fields,  extremely difficult indeed. Since the break out of this unfortunate situation, my family and I along with my friends realized that it was not at all about seeking freedom. This realization was our incentive for our solidarity and strength in our stand as a part of the defense system inside Syria. We also believed that staying in our country, helping, supporting and moreover keeping things running, each in his field, during those difficult times are definitely essential elements for life to go on.

In 2013 Syria received a threat made by the President of the USA, Mr. Barak Obama to bomb our capital city Damascus setting the zero hour three and a half days after issuing his statement. This gave us a very short window of time to mobilize our resources. This threat came with a strong rumor that the so called “revolutionaries” were supposed to carry out simultaneous attacks against the Old City of Damascus and surround it from all sides. Against all odds, all Syrians, regardless of their faith, came together to work relentlessly to protect and defend our city. Two bakeries as well as two field hospitals were established, and food and medical supplies were arranged and located inside safe areas within the Old City. All was done in three and a half days! It was a wonderful feeling to know what we can accomplish when we are united and determined.

 

2) The Nation and Endoscopy in Syria before the Crisis

Syria before the War:

Before getting into details of Endoscopy problems during wars, I want to express how proud I am to be Syrian. Being the oldest continuously inhabited capital city in the world is a strong evidence of the Syrian people’s ability to communicate humanely and survive collaboratively considering what came across them all through the 7000 years they resided on this land. One more fact I want to register for history is that in February of 2011 and just two weeks before the crisis started, Syria was registered as the safest country in the world with zero debt.

Professionally; I am also proud to mention that the Syrian Gastroenterology Association was established in the year 1973, which makes it one of the first societies in the Middle East. The endoscopy Branch of the Syrian society was established in 1996 and it launched very strongly later on with a thriving teaching and communicating history. Many of the ESGE members still remember “Syrendo 2000” (1), the first international ESGE workshop that took place in Al-Asad University Hospital in Damascus in 2000. It was very successful with international transmission too. One cannot forget the support of our dearest Prof. Alberto Montori, the ESGE president at that time along with our very dear departed friend Massimo Crespi. We, in our society, used to have an annual International GI Conference along with two endoscopy workshops, one local and the other international every year. We had up to 19 conferences in 25 years and 32 endoscopy workshops between 1996 and Feb 2011 when the crisis started.

 

3) Endoscopy Difficulties during the Crisis:

A) The Shock, Safety & Security: The main issue that concerned us at the beginning was ignorance about the future. Nobody had an idea about how it was going to be, especially after seeing the rapid deterioration of other countries in the areas like Tunisia, Libya and Egypt. That is why the decision of staying in and defending was not that simple. As a real inside witness, I can clearly tell how most things got out of control in the beginning. We were in an unprecedented situation and crime rates skyrocketed. Cars were stolen everywhere; snipers controlled most of our movement; rape became daily news; murdering people for their beliefs and kidnapping people for a ransom are just examples of some of the heinous acts that prevailed. Being from a wealthy family, I had to take some measure to ensure my safety, like refreshing my memories in self-defense training, possessing a personal weapon and even getting some bodyguards.

My center: Although my endoscopy center stayed intact all the way through, yet the work almost stopped for about six months as most of the Syrian people stayed inside their homes. My patients usually come from all over the country and transportation was almost impossible between cities and even inside Damascus. The Charity Hospital I used to work in one day every week in a rural area around Damascus City was looted and then destroyed completely by what the media was calling the “Revolutionaries”! It was unheard of! What kind of a freedom seeker would willingly and knowingly destroy hospitals and other kinds of infrastructures of his own country?!

Life was so difficult. Deafening voices of war and war machines were everywhere, stealing any sense of safety and chasing away any hope for a good night sleep. Every day the voices became closer and closer. There were days when we thought that was it and death was just nearby. It took us quite a while to get used to those voices until we became experts in recognizing the different sounds of different weapons and how far away they were being used. They were scary times indeed.

As for food, the situation was not as bad, however, since our beloved country was self-dependent. Our gracious Syria, until now, has its own vital agriculture and industries like food, clothes, electricity, water, wheat, oil…etc. Yet, our problem was transportation, as roads were not safe. That is why we, in our community, helped provide food, clothes and housing as well to lots of internal immigrants. Everything we did was really very supportive to our people. It was very obvious that people were overwhelmed with a sense of doom in their air. It was really a very big challenge to help and support suppressed people at the time that our healing work almost stopped, just like all fields of work during wars.

B) Absorbing the Shock, Time for Publishing: During these trying times, we were all in shock. We were watching our Syria slipping through our fingers, and other than supporting each other, we were not sure what to do. For lack of people seeking professional help, many professionals had a lot of free time to kill.

Hence, I started thinking of publishing something. A few days later, a wonderful opportunity opened up through my very dear friend from Shiraz, Iran Prof. Kamran Lankarani. He was responsible for a big GI Publication project named “Gastroenterology Research and Practice”. I was assigned an article review with the title: Pre-cancerous Lesions in Colo-Rectal Cancer (2). It took me about 9 months of hard work along with the Cancer Research Center and the Nuclear Energy Center in Syria to achieve. This article has been cited more than 133 times so far. I believe this article to be a victory during this war dedicated to my country, colleagues, Syrian patients and myself too.

Moreover, I became a faculty member in a Virtual University (3) located in USA, which is related to a big organization Called Imamia Medical International (IMI) (4). It is mainly a non-profit organization recognized by the United Nations. It gives health education and support for poor countries all over the world, especially during natural disasters like earthquakes and floods. In this newly established university, I contributed about 70 Endoscopy Lectures in the field of Endoscopy in the teaching program.

Due to being caught in some difficult events, I sometimes start a project, but I do not have the chance to see it through. My very dear friend Prof. Jean Francois Rey gave me the honor of sharing a publication project with him about the Advanced Diagnostic Endoscopy Course (ADEC). I was happy that he thought of me within those very tough days. Initially I started working on this project, but, unfortunately, had to quit later on due to a crisis we faced at that time with people who lost their houses in the war. Thank you Jean Francois!

C) Endoscopy Practice Difficulties: Endoscopy Practice became much more difficult. We faced numerous challenges trying to obtain accessories, repair instruments and machines, keep up with new expensive technology, maintain proper disinfection, deal with the immigration of endoscopy assistants and endoscopists and train novice professionals. All of these became very costly indeed as the Syrian currency lost more than 10 folds of its value. In other words, it became one of our main concerns to maintain safety and tranquility in order for us to be able to practice serious medicine in our area during those tough days.

Being under sanctions made it almost impossible for us to transfer money. Therefore, most accessories and instruments companies fell in a noticeable shortage of supplies. I have a wide experience that I have accumulated while helping many countries that used to be in similar conditions in the Middle East, Asia and Africa. I have a wide network of friends all over the world who are rich and successful in their careers and believe, like me, in “Humanity Talk”. We all know how to get the out dated endoscopic accessories in donations, get them into the countries in need, scientifically re-sterilize and then re-use them. That occurred during the bad days of Iraq, Pakistan and many other African countries. Here, I want to thank Dr. Ajay Kumar from New Delhi, India who presented a few years ago a lecture in Lahore, Pakistan entitled: “Reprocessing of Endoscopic Accessories”. It was such an informative lecture that helped us overcome many difficulties. Our local companies also gave generous support by donating lots of materials with many free repairs. Another problem one should mention here was the cost of performing of the procedures tripled at the time that the value of the Syrian pound dropped down ten folds.

The other serious problem was the lack of maintenance due to sanctions. It still pains me deeply to think about how a big company like Olympus was not allowed for four years to sell me a Battery for my Olympus CE even though I had been a valued customer of them prior to the war in Syria. I was compelled to resort to the black market to purchase a battery which turned out to be fake.

A number of sophisticated procedures are not being done any more as the repair is very expensive, like double balloon endoscopy. Other procedures stopped because they became very expensive that our patients cannot afford the cost, like “Spy Glass cholangioscopy”, and “Stretta” enodscopic treatment of GERD. However; I am still doing those procedures in Iraq.

With our insistence, collaboration and sincerity we were able to obtain most of the needed supplies, upgrade our machines with expensive new technology while keeping up safety and quality for the sake of our patients. Falling back on family wealth as well as donations, I managed to keep things running.

D) Endoscopy Training Difficulties: Some of our readers may remember my previous article that was published in the World Endoscopy Organization (WEO) Newsletter “no.12” with the title “A Personal view in Endoscopy Education” (1) in which I mentioned the details of my Endoscopy Training programs. I also mentioned about the wide training network all over the world starting from my own center in Damascus. Like all other issues, endoscopy training has also been badly affected. I will describe on endoscopy training in four directions: My center, my international network, in Iraq and lastly in Gaza Strip, Palestine.

My center: Currently, in my center and because of the difficult circumstances, I am training local Syrian doctors only. There are two levels: those who are in the last 6 months of their 5 years GI specialty. They usually come to my center for training on advanced endoscopy procedures since my center is a main referral center. The other local group are those who are planning to travel abroad to work in other countries and they need condensed hands on practice and tricks before starting their own career. Other trainees from Arabic and especially Gulf countries were not able to come to Syria as they used to do before the war.

My International Network: Until now, I am still the Chairman of the Young Clinicians Program for GI doctors under 40 of age, in Africo-Middle East Association of Gastro-Enterology (YCP in AMAGE) which is a branch of World Gastroentrerology Organization (WGO). Although not as before, I am still using the network of this program trying to get training positions for young doctors. Last year, I succeeded in getting EUS training for two young Iraqi colleagues in Iran. Thanks for my very dear friends Prof. Reza Malekzadeh and Dr, Rasoul Sotoudehmanesh!

This program includes many centers and a number of helpful friends who offered me positions for YCP training. With great honor, I can mention here my very dear “Lieber” Prof. Lucas Greiner from Wuppertal, Germany who became a real brother “als Bruder fur mich” to the degree that I learned German so I can communicate with him in his native language. We used to do workshops and build up continuous bridges among countries in-need. Big scholars in endoscopy in Europe, like my friends Prof. Guido Costamagna from Rome, Prof. Horst Neauhaus from Dusseldorf, Germany, and the Late Michel Cremer from Belgium were part of this program. It also included centers in Egypt like Teodore Bilharz of Cairo with Prof. Ibrahim Mostafa and Al-Mansoura GI center with Prof. Gamal El-Ebeidi. All of those centers used to offer us free teaching and accommodation while I or the trainee arranged flight tickets fares.

Work in Iraq: The third training context of mine is to do cases in other countries. I used to do almost regular cases in Lebanon, Pakistan, Iraq and many other countries. This became very difficult for me during our new circumstances. Yet, I was very happy that I managed to continue this activity in Iraq where I have a fifteen year old project. It was one of my international supportive teaching programs for countries that used to suffer from unfair “Sanctions” or countries that used to be in wars and did not have a chance for quality professional practice. In spite of this long war in Iraq, I have gained a wide network of friends, patients and relationships. I established a big referral endoscopy center in Al-Kafeel Hospital in Karbalaa (5,6), Iraq, which is a private sector related to what is called “Al-Atabah Al-Abbassya”. This hospital is considered the 5.th state of art hospital in the Middle East. I usually work in my own center in Damascus for 2-3 weeks and go to Karbalaa for 10-14 days. Most of the patients I see there are my own and not the hospital’s. Almost 500 patients wait for my visit. Working from 8.00 AM till about 9.00 or 10.00 PM, I see about 15 patients in my Gi clinic and do about 15 different procedures a day, 50% of them are standard like upper and lower endoscopy, and the other half are usually referred to me for some kind of difficulties. Our center in Karbalaa is specialized in advanced endoscopy like pancreatic endoscopy, Klatskin’s, Fundal varices Cyanoacrylate injections, Stretta the endoscopic treatment for GERD, piecemeal and ESD polypectomies etc.

Moving between Damascus and Karbalaa in Iraq is another story indeed. In the beginning, when Damascus airport was closed, it was very difficult for me to drive 3 hours by car across the borders of Lebanon, get into Beirut airport, fly for ninety minutes to Al-Najaf city in Iraq, and then take a taxi for about 2 hours to reach the city of Karbalaa. Although exhausting, it was very exciting and overwhelmed me with satisfaction. I was very happy because I considered this 9 to 10 hour trip between driving and flying another challenge and victory to myself and to my Syria during its crisis. I was able to link the closed artificial, political borders between the sisters “Syria, Lebanon and Iraq”. What helped me to pass this challenge is the looks of gratitude on my patients’ faces across all those borders. That very difficult way of travel became history when Damascus airport reopened after a couple of years. Since then, it takes me an hour and 10 minutes flying from Damascus to Al-Najaf and two hours driving to Karbalaa. Contrary to what the world outside thinks, Syria and Iraq are much safer now. A big number of check points is distributed generously everywhere in order to ensure safety and security.

Gaza Strip: Lastly; I feel very proud to talk about Gaza Strip in Palestine. Ten years ago, they did not have an advanced endoscopy GI center. They used to lose bleeding or acute cholangitis patients while waiting to have the chance to get out of the strip to the “West Bank” for emergency endoscopic treatment. Three months starting from March 2011, which was just at the beginning of the crisis in Syria, I had the honor of receiving a very smart Palestinian gastroenterologist Dr. Khalid Matar in my center asking for training in ERCP. He obtained his GI specialty in Qatar, then Palestine. He also trained in Egypt and Thailand. He was seeking even the small tricks of advanced ERCP intervention. I loved this young man like my own son. He is an intelligent man filled with enthusiasm to help his suppressed community. While he was having his training with me, I helped him design the advanced endoscopy unit in the “European Hospital” inside Gaza Strip. I had the opportunity to plan the space to be one of the best in the area. I also helped him get many free aids. He has been working in this center since then. Fortunately, we are in touch continuously and I still give him consultations and discuss and plan for difficult cases. Thank you Khalid!

At the end, I do hope that this article will inspire my colleagues not to give up on their divine right to have a decent life, and to come together in a stand against injustice and to move on in life thinking about the less fortunate and how we can contribute to their wellbeing.

 

References:

  1. WEO/OMED E-Newsletter Issue 12, 2010: Professor Fayez Sandouk: A personal view in Endoscopy Education
  2. Pre-cancerous lesion in Colorectal cancer: Hindawi Publishing Corporation
  3. Gastroenterology Research and Practice. Volume 2013, Article ID 457901, 11 pages 
  4. Imamia Medics International – E-Learning
  5. Imamia Medics International – IMI’s Global Headquarters & Intentional Community
  6. A world without barriers – Hospital Treatment
  7. Al-Kafeel Super Specialty Hospital Karbala