WARNING: Contains distressing images
After three years under siege, mass starvation, and relentless airstrikes, the people of Madaya didn't think it could get much worse. Then their only doctor disappeared in the middle of the night.
In the besieged Syrian town, which made international headlines in January when photos of its starving residents spread around the world, the only medical care facility, slightly euphemistically called the field hospital, is now run by two dentists, an agricultural engineer and a vet. Sources told VICE News that an anaesthesiology nurse known as Doctor Khaled, who ran the clinic until mid-January, had to pay a smuggler thousands of dollars to get out of the town when he heard a hit man had been hired to kill him for talking to the media.
The tiny clinic lies in one room of a basement, moved there after staff were driven out of the main hospital by shelling. Inside there's an operating table, a stand for IV drips and some basic medication — mainly boxes of glucose solution. For the 90 patients who seek treatment there every day, mostly for malnutrition or influenza, there are few options for treatment.
"We try our best but there is little we can do," Muhammad al Shami, the agricultural engineer, told VICE News. "We can give injections and the vet can sew sutures, but beyond that it's very difficult."
There is often no other choice than to give patients suffering from severe malnutrition — who require expert medical treatment, including lab testing for protein and mineral deficiencies — some food and an IV drip. Sometimes they have neither.
"For malnourishment, just giving them food is not enough. You need to give them advanced medical care at an advanced medical center because if you feed them too quickly they can die," said a doctor from the Syrian-American Medical Society (SAMS), which works remotely with the clinic. "They don't have any of this."
A much-vaunted aid convoy that took food into the town in January following international pressure also brought some medical supplies — largely glucose solution to treat malnutrition — but these are fast running out. At least 11 people have died of starvation since then, according to SAMS.
For more complicated cases, there is very little hope. Many die if they are not allowed to leave the town to the nearest hospital, just five minutes away. The Hezbollah soldiers surrounding the town, which is encircled by coils of barbed wire and a reported 6,000 landmines, play a grotesque game of chance with patients brought to them by the clinic; some can pass through while others are sent back to their deaths.
Hezbollah — a Lebanese Shia militia group — is allied with Syrian President Bashar al Assad, and its fighters form a big part of the forces fighting for his regime. During the 2011 uprising, Madaya, which has a population of around 40,000, was one of the centers of rebel resistance against the government. In the half-decade war that has followed, Assad has used a "siege and starve" technique on rebel-held areas to force them to capitulate.
"They are being selective. With starvation cases sometimes they say yes, sometimes they say no," said the SAMS doctor, who can't be identified as members of his family are still in Syria. "They have 400 cases now that need advanced medical care right away. These patients need to get out of Madaya."
Muhammad Darwish, one of the dentists, doesn't know why they wouldn't take 12-year-old Aula Ahmad Murad, who is on the brink of death by starvation. In a video taken inside the clinic in February, she trembles as she is held upright, barely able to stand on her own. Her skin is stretched drum-tight across her face, and her tiny body is tensed in pain.
Her older sister took her to the hospital, but there is very little the staff can do.
"She is suffering from severe malnutrition," Darwish said. "It's clear she is in serious pain. Her bones are brittle due to the lack of basic vitamins and proteins in her diet. She has been living off just rice or bulgur wheat, and has been bedridden for a month.
"She needs to leave the town immediately. We've contacted all the humanitarian organizations but there's no response. We try to help her, and hope in Allah."
Until a few weeks ago, the field hospital had been run by Doctor Khaled Mohammed, who had over the course of the half-decade long Syrian civil war taught himself to perform complicated surgeries, including multiple limb amputations. Muhammad Yousif, the vet, usually assisted him.
"If a child stepped on a landmine now, there would be no one to help, unless the vet agreed to operate," said the SAMS doctor. "There is no medical care available now."
It was Doctor Khaled who took many of the pictures and videos of Madaya's emaciated citizens that first brought attention to the town's plight after three years under siege by forces allied to the Syrian regime.
Sources inside the town say that Hezbollah fighters who surround the town paid a local hit man to murder Khaled for talking to the media. But after being tipped off about the plan, he fled town that night under an assumed name — paying smugglers $7,500 to sneak him past the checkpoints.
Now that he's gone, anything approaching advanced medical care is impossible. The clinic is kept running by a WhatsApp group where they send photos and questions about patients to Syrian doctors living outside the besieged areas. Life and death hinges on their replies.
"A woman who was four months pregnant came to the clinic because she had been stabbed in the stomach," said Mohammed Shami, the agricultural engineer. "She was only 18 or 19, and she came in with her mother. We knew she had internal bleeding. We could see her intestines."
Shami sent photos of the wound to the group, who replied quickly. "They said she'd die if she didn't get help. That she needed to get out of the town. But the soldiers sent her back," hesaid Shami.
"The group said we had to get a midwife to induce a miscarriage, and that if we couldn't find one then the vet should do it."
After hours of discussion, and the intervention of UN officials, the soldiers eventually let her out. The group at the clinic doesn't know what happened to her.
"They try their best, but they don't have the experience really needed to take proper care of patients," said the SAMS doctor. "They have an operating table but they don't have anaesthesiologists, they don't have the medicine to sedate the patients or the expertise to open them up.
"We need advanced medical care for the majority of the patients inside Madaya, otherwise they will die there."
The town, which before the war was a popular summer resort for wealthy Damascans and tourists from the Gulf, is one of an estimated 18 areas under siege by both forces allied to the Syrian government and the militant Islamic State group, which have put an estimated half a million people at risk of starvation. An Amnesty report on Madaya published in January said the horrific scenes there were just the "tip of the iceberg".
There isn't likely to be any more aid coming to the town any time soon, meaning that that the people living there will continue to die of starvation and lack of basic medical care.
"We worry that they will let the convoy in one time and that's it," al Shami said. "We worry that the world will forget Madaya again and that people will continue to die in misery and starvation."
Follow Louise Callaghan on Twitter: @louiseelisabet
All photos via staff at the Madaya clinic