Running a Clinic in War
Practicing retina is challenging enough. Practicing in Aleppo is something else altogether.
This column’s first installment from the field is a sobering one. It illustrates that the real labor of international retina is less a matter of theory and more a matter of execution by determined and courageous physicians who extend care to those most removed from it. As millions of everyday citizens are ground between enormous and remote political gears, we can all take an important lesson from the heroic physicians holding their ground in Aleppo.
—Benjamin. J. Thomas, MD
The everyday challenges of maintaining and running a medical office are difficult. Since civil war began in my native country of Syria in 2011, my ophthalmology practice in Aleppo has faced unique challenges beyond those of day-to-day normal ophthalmic practice. I encounter daily obstacles—ranging from power outages to shortage of supplies to lack of essential tools—that prevent me and my staff from keeping our practice functioning normally, let alone safely and efficiently.
Dossier: Aleppo, Syria
Aleppo, Syria’s largest city, is approximately 220 miles north of the Syrian capital Damascus.
Population: 2.3 million (2005 census)
Status: Syria has been engaged in civil war since the Arab Spring protests of 2011, and the conflict has grown more complex as mulitple domestic and international military interests have entered the war. The death toll has reached nearly 250,000. Estimates are that 13.5 million people are in need of humanitarian assistance in Syria, and 4.4 million have fled the country as refugees. The Syrian civil war has resulted in the world’s largest humanitarian crisis.
Source: BBC News
War has taught me how to do a lot when you have a little. A number of changes we have made at the Marashi Eye Clinic keep the clinic running.
ABOUT MARASHI EYE CLINIC
First, a note about the Marashi Eye Clinic. The clinic is a family operation managed by me, my father, and my brother. My brother and I practically grew up in the clinic. The Marashi Eye Clinic, founded in Aleppo in 1982, is a multioffice practice with comprehensive, anterior segment, and posterior segment services. The comprehensive service is led by my father, Assad Marashi, MD. My brother Omar Marashi, MD, leads the anterior segment service, and I manage the retina service. We have three offices, one of which offers free care to poor patients. The Marashi Eye Clinic trains residents each year and hosts a number of scientific seminars.
One of the most challenging problems in my practice is power supply. Indeed, as I write these words, the main power supply has been off for 7 months, and backup generators provide power to our office (Figure 1). Such generators, although reliable and easily obtainable, are expansive to own and operate. The main generator that services my office supplies 5 amperes for 12 hours per day; this is enough, thankfully, for me to work effectively.
As you can imagine, this system is less than perfect. The clinic’s power supply shuts down during surges. At other times, the generator itself breaks. The small, gasoline-run generator on which we sometimes rely is expensive to run and not always available. I have a small uninterrupted battery supply (UPS) system used as backup to run light to a slit lamp and autorefractor, but that system, too, is unreliable and does not last long.
There are times when all generators and UPS systems fail. When this occurs, the clinic usually postpones nonurgent anterior segment cases. For urgent anterior segment cases, the clinic refers patients to another Marashi Eye Clinic branch that (hopefully) has power. In some retina cases, I use a homemade ophthalmoscope—what I call the Retina Selfie (Figure 2)—that I invented that combines a smartphone, selfie stick, and 20 D lens to capture panfundus images using the light source from the smartphone’s flash. The Retina Selfie can also be a useful tool for telemedicine, as images can easily be sent from one device to another.
I sometimes operate in facilities that have reliable generators and try their best to ensure that electricity remains steady. However, these, too, sometimes fail. In the event that the electricity fails while I am in the OR, my microscope and phacovitrector are connected to a UPS that provides approximately 30 minutes of additional power for me to finish whatever procedure I am engaged in.
Recently, we were forced to complete an operation using the flashlight app on a surgical assistant’s smartphone because my phacovitrector and microscope were not connected to the UPS system before the surgery (Figure 3).
KEEPING UP THE SUPPLIES
Managing supplies became a problem as the Syrian civil war developed. Before the war, patients had access to a wide spectrum of eye medications. Now, however, many manufacturers have stopped producing drugs in the country, and outside supplies have been cut off. If we cannot find an alternative medication, we must sometimes create our own, such as the NaCl 5% solution for corneal edema we now prepare in office.
Access to surgical supplies is hit or miss. In particular, lack of access to ophthalmic viscosurgical devices (OVDs), dyes, phacovitrector cutters, and intraocular lenses (IOLs) causes frequent disruptions to patient care. Access to OVDs and low-power IOLs (ie, +12 D, +8 D, etc.) appears to be particularly affected by supply disruptions.
Thus, our surgeons do not discard supplies after finishing an operation. For example, I use a new phaco tip, phacoblade, and OVD each time I perform phacoemulsification. After the procedure is complete, I soak the phaco tip in distilled water, put the phaco tip and OVD syringe in a sterilization pack and send them for ethylene oxide (EO) sterilization (Figure 4). I try to avoid reusing these instruments, but I keep them in storage in case we run out of supplies.
Aleppo has been an epicenter of conflict in this war; as I write this article, the city has been under siege for more than 5 days. The city has run out of even the most basic resources, including food, several times. I’m sure readers can understand why I try to stretch the blue stain I use in nearly every surgery from a single vial to last for three surgeries, or why I isolate doses in polycarbonate 1-cc syringes and send them for EO sterialization so I can reuse them.
Since the war began, many equipment vendors have been unable to sustain maintenance services due to safety risks and difficulties raised by the economic sanctions placed on Syria. Thus, when equipment breaks, we consider it permanently broken (in our parlance, we say that broken equipment has been pronounced dead). Luckily, the Marashi Eye Clinic’s in-house engineer has managed to maintain many important pieces of equipment, such as microscopes and phacovitrectomy machines (Figure 5). Our engineer performs regular checkups on equipment, which allows us to maintain these valuable instruments. This is an important factor in preserving patient care in a region where access to new equipment is, for the foreseeable future, nearly nil.
This patient presented with bilateral corneal, scleral, and lid lacerations, as well as nonocular trauma sustained in a war-related accident. A Marashi Eye Clinic surgical trainee performed bilateral corneal and scleral suturing, which took approximately 5 hours. The patient was placed under general anesthesia so that another surgeon could manage nonocular trauma sustained by the patient.
The Marashi Eye Clinic has trained residents since its opening. The institution is also committed to continuing physician education. The war has interrupted both of these educational pursuits.
Our residency program at the Marashi Eye Clinic focuses on giving young residents the knowledge and surgical experience to successfully treat patients, and we have sought to maintain these educational efforts despite the war. Every Saturday, after our team finishes patient examinations, residents meet in my office for lectures, case presentations, and a review of the latest clinical trial results. All lectures and case presentations are displayed via PowerPoint on my laptop (Figure 6).
We slowly introduce residents to surgical procedures via our surgical training program, walking them step-by-step through surgeries such as phacoemulsification, keratoplasty, and strabismus surgery. For ocular trauma cases, which obviously do not allow advance scheduling, surgical mentors guide residents through cases, emphasizing the importance of corneal or scleral suturing.
Before the war, our physicians regularly attended professional meetings and symposiums. However, visa issues and prioritization of expenses has limited our ability to travel. We rely on web sources for updates. We use the Internet to browse trade publications (such as the one you hold in your hands), read abstracts from society meetings, and follow peer-reviewed ophthalmic literature. These sources detail the latest study results and frequently provide access to continuing medical education credit. However, our access to such sources depends on our Internet capabilities. We often use a 3G network that offers a weak signal (we generally have 2 bars of coverage); we used to have high-speed Internet, but it has been offline for more than 13 months.
PRACTICING RETINA IN ALEPPO
All retina cases from the Marashi Eye Clinic are forwarded to me after refraction testing. Because many of our patients are poor, I tend to order either fluorescein angiography or optical coherence tomography (OCT) testing at presentation. I choose the test that will cost the patient the least amount of money; I rarely order both tests.
Diabetic Eye Disease
Access to drugs has been an issue for our practice. For treatment of diabetic macular edema (DME), I use bevacizumab (Avastin, Genentech), aflibercept (Eylea, Regeneron), triamcinolone, and laser (Figure 7).
For proliferative diabetic retinopathy (PDR) of new onset, I start with anti-VEGF therapy. I perform panretinal photocoagulation (PRP) after the first injection because patients may not return for follow-up treatment due to poverty or war circumstances. In the event that a patient does return for follow-up treatment, I continue anti-VEGF therapy until neovascularization regresses and edema resolves. If a patient with PDR presents with no macular edema, I initiate PRP therapy and explain to the patient the importance of glycemic and blood pressure control, and I refer him or her to an internist for diabetes monitoring.
The average ophthalmologist in Aleppo makes approximately US$15,000 per year, chiefly because patients are charged so little. Here is a breakdown of some of the Marashi Eye Clinic’s pricing schedule.
The likelihood of encountering severe trauma is high for many of our patients, and surgical follow-up may be interrupted by real-world obstacles. This is the life of a city in war circumstances. The high chance of recurring trauma and the everyday hurdles to attending follow-up visits factor into surgical decision-making for emergency patients.
I use laser photocoagulation for repair of all tears and holes, whether high risk or not, because follow-up is not likely to occur and the patient may be exposed to severe trauma at any moment, thus aggravating the condition. Also, given frequent power losses, there is no guarantee that laser will always be available should follow-up occur, so I prefer to administer it when possible.
I perform vitrectomy for rhegmatogenous and tractional retinal detachments and nonclearing vitreous hemorrhages. I always use silicone oil as a tamponade, and I leave it in for 3 to 6 months because our patients are prone to severe trauma at any moment.
War has amplified the pandemic of poverty in our region. Nearly everyone in Aleppo has become poor due to the war. Charitable organizations have offered relief in a number of sectors, medicine being one of them. The Marashi Eye Clinic’s free clinic for the poor, which I run, is open 2 days per week and serves approximately 1500 patients per year (Figure 8). Patients do not pay for examinations, and we offer free bevacizumab and aflibercept injections, free laser sessions, and eyedrops (excluding artificial tears). Depending on how poor they are, patients pay between nothing and US$37 for cataract surgery per case; IOLs, OVDs, and blades are paid for by third parties.
Financing such a clinic presents its own problems. We are unable to offer free vitrectomies. The Marashi Eye Clinic free clinic for the poor does not own its own equipment for such procedures, so I must perform them at third-party hospitals.
From the BMC Archive
Devastating Situations: Severe Ocular Gunshot Injuries From the Egyptian Revolution
By Omar A. Barrada, MD, Mahmoud M. Soliman, MD, and Ayman M. Khattab, MD
Retina Today Volume 10, Issue 1
Find online at: bit.ly/egypt316
FINANCING FREE MEDICAL RETINA
Free medical retina is financed by the zakat system. In zakat, Muslims who can afford to do so donate 2.5% of annual income to assist the poor. Because our free clinic accepts poor patients referred to us by other organizations, and because treating retinal diseases is expensive, we rely on zakat to defray a large portion of our costs.
Our clinic has gained the trust of many patients who donate to the zakat system. Some of our patients who can afford the 2.5% donation offer money directly to the free medical retina program to purchase anti-VEGF agents and rental time for laser and OCT devices. All intravitreal injections are performed in the hospital’s OR, and the patient is required to pay only for hospital admission fees, which are usually less than US$3; if a patient is unable to afford these costs, we dip into our zakat fund to defray the costs. Patients also pay for postinjection eyedrops, although I sometimes provide them. We provide the repeated injections required as long as the zakat funds allow it. Thankfully, we have seen a significant improvement in a number of our patients since initiating this program in February 2016.
WHY DO I STAY IN ALEPPO?
Every time I ask myself why I remain in Aleppo, I find the answer when I enter the clinic—the clinic I grew up in, that serves the people of my city.
Aleppo is my home. This city, even in its current condition, is the best city in the world. My practice is where I feel comfortable, despite the daily challenges it presents. Aleppo is not a hotel that allows customers to change accommodations when services are not perfect. I am not waiting for Syria to give me something; rather, I am asking myself if I am doing enough for Syria.
Running a clinic during a war has taught me lessons in survival and adaptation. Our services are far from perfect, but at least we are trying our best to provide the best outcomes for our patients. n
Section Editor Benjamin J. Thomas, MD
• vitreoretinal surgeon, Florida Retina Institute, Jacksonville, Fla.
• financial interest: none
Ameen Marashi, MD
• partner and chief of retina service, Marashi Eye Clinic, Aleppo, Syria; assistant, Muthusamy Virtual University for Postgraduate Ophthalmologists; author, Retina Assistant Module, an online educational resource listed by the International Council of Ophthalmology that helps retina specialists triage retinal disease by offering automated management recommendations
• financial interest: co-owner, Marashi Eye Clinic
• www.amretina.tk; firstname.lastname@example.org
The Marashi Eye Clinic accepts donations to fund their free opthaclinic. If you are interested in donating, please contact either of us so we can forward you instructions on how to wire money through secure channels.
Benjamin J. Thomas, MD
Section Editor, Global Retina
Editor-in-Chief, New Retina MD