Running a Clinic in War
A family-run clinic fights to provide eye care in Aleppo.
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 a shortage of supplies to a lack of essential tools, that prevent my staff and me from keeping our practice functioning normally, let alone safely and efficiently.
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 it running.
ABOUT MARASHI EYE CLINIC
First, a note about the Marashi Eye Clinic. It is a family operation managed by my father, my brother, and me. 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 9 months, and backup generators provide power to our office (Figure 1). Such generators, although reliable and easily obtainable, are expensive 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.
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 a 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 (we hope) has power.
In the event that the electricity fails while I am in the OR, my microscope and phacovitrector are often 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 2).
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 sodium chloride 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 IOLs causes frequent disruptions to patients’ care. Access to OVDs and low-powered IOLs (eg, +12.00 D, +8.00 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 sterilization (Figure 3). 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 months. The city has run out of even the most basic resources, including food, several times. I am sure readers can understand why I try to stretch the blue stain I use in nearly every surgery to last for three surgeries and why I isolate doses in polycarbonate 1-mL syringes and send them for ethylene oxide sterilization 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. 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 4). Our engineer performs regular checkups on equipment, which allows us to maintain these valuable instruments. This is an important factor in preserving patients’ care in a region where access to new equipment is, for the foreseeable future, nearly nil. If our engineer cannot fix a broken piece of equipment, we say in our local parlance that it has been pronounced dead.
For laser glaucoma treatments, I usually use the Nd:YAG laser. I used to perform multipulse laser trabeculoplasty for mild to moderate cases of primary open-angle glaucoma, but I no longer have access to a micropulse laser. For patients who are unresponsive to or noncompliant with eye drop therapy, my brother performs trabeculectomy and small-incision glaucoma surgery using a Kelly Descemet membrane punch. This procedure lowers IOP by up to 15 mm Hg.
The likelihood of severe trauma is high for many of our patients, and surgical follow-up may be interrupted by real-world obstacles. This is life in 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 the laser will always be available should follow-up occur, so I prefer to use 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.
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 (Microsoft) on my laptop (Figure 5).
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 and emphasize the importance of corneal or scleral suturing.
Before the war, our physicians regularly attended professional meetings and symposiums. Visa issues and the prioritization of expenses have limited our ability to travel. We use the Internet to browse trade publications, read abstracts from society meetings, and follow the peer-reviewed ophthalmic literature. These sources detail the latest study results and frequently provide access to continuing medical education credit. Our access to such sources, however, depends on our Internet capabilities. We often use a 3G network that offers a weak signal (we generally have two bars of coverage). We used to have high-speed Internet, but it has been offline for more than 16 months.
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.
War has amplified the pandemic of poverty in our region. Nearly everyone in Aleppo has become poor. Charitable organizations have offered relief in a number of sectors, including medicine. The Marashi Eye Clinic’s free clinic for the poor, which I run, is open 2 days per week and serves approximately 1,500 patients per year (Figure 6). Patients do not pay for examinations, and we offer free bevacizumab and aflibercept injections, free laser sessions, and eye drops (excluding artificial tears). Depending on how poor they are, patients pay between nothing and $37 USD 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.
Free care is financed by the zakat system. In zakat, Muslims who can afford to do so donate 2.5% of their annual income to assist the poor. 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. 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 we are trying our best to provide the best outcomes for our patients.
Section Editor E. Randy Craven, MD
• chief of glaucoma at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
• associate professor, Johns Hopkins University, Baltimore
• (303) 748-5102; firstname.lastname@example.org
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
• www.amretina.tk; email@example.com