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Gavin: Hello, welcome to the Lancet Voice. It's May 2022, I'm Gavin Cleaver, and we're very happy to have you on board today. In this episode, I'm going to be talking to Rola Halam, who's a consultant anesthetist, humanitarian, and the founder of CanDo, a small humanitarian organisation, assisting children and frontline workers in war zones.
We're going to talk about healthcare in times of war, Syria, Ukraine, and the targeting of healthcare workers. If you'd like to chat about this episode, you can find me and my co host Jessamy over on Twitter at Gavin Cleaver and at Jessamy Bagnall. And as ever, do remember to subscribe if you haven't already.
Roller, thanks so much for joining us today.
Rola: for having me.
Gavin: You have a really amazing and incredible backstory. Tell us a little bit about coming to the UK from Syria as a refugee and then about joining the humanitarian response to the start of the Syrian war in 2011. It's such an incredible story.
How did joining this humanitarian response change your life?
Rola: So I arrived in the UK age 12 as a, as an immigrant and not speaking any English and Got very badly bullied at school, you know how mean kids are, especially when you look different and you sound different. And even though I thought I was born a doctor and that was the only thing I knew I wanted to do, my teachers told me that my GCSE grades weren't good enough to get into medical school.
And they thought I should study chemistry or biology instead, which I excelled at. I thought it was preposterous. Suggestion and one medical school, they're all free in London, saw my potential and gave me a place and so started my love affair with health and medicine. I was really on a global health trajectory.
I've always been just so deeply aware of the difference between the haves and the have nots of in global health. And and so for very many years, I was working in sub Saharan Africa and Uganda, Ethiopia and Kenya. Either teaching local health workers anesthesia or how to better manage critically sick children without the intensive care abilities that we have, in the UK and Western countries.
Life had other plans for me in 2011 the revolution started in Syria and I was living and working in the UK at the time. And I was watching it all unfold on the screens with at the beginning with excitement and awe at my country men, women, and children having finally lost their fear to stand up to a brutal dictatorship.
And then slowly but surely the unfoldment of the incredible violence and how the demands for freedom and dignity were met with bullets and bombs. My, my family were living in Damascus at the time, all of my extended family were there. We're from Barba Amal, which is where if you recall, Marie Colvin, the journalist was killed and Paul Conroy was injured and that's where my father is from.
And over 2012 members of my extended family were killed and many more made refugees. And so really I did the only thing I knew I could. I joined the humanitarian effort. I was going on medical missions to Syria when I could. I was working every evening and weekend to help build hospitals as they were being bombed and destroyed.
And as we were having to create what we called field hospitals, which were no hospital in any sense of the word. They were basements and abandoned buildings that we were having to convert into these. Rudimentary health facilities in order to try and treat patients, civilians without the target on our collective head.
And honestly, I thought it was just going to last a few weeks. And and this year, as was the 11th year anniversary of the ongoing war.
Gavin: Your experience in Syria has obviously Led you down something of a different path since and you're the founder of the CanDo, a global humanitarian community organization.
Tell us a little bit about what led to the founding of CanDo.
Rola: With all of the humanitarian work I was doing, I was working mostly with fellow Syrians, whether part of the diaspora or those who were there in country. And I made a remarkable discovery. I realized that the reason that people survive in crises is because of the work.
Of the people in crisis themselves, people were surviving because of the local doctors, nurses and aid workers who are from the heart of the affected community, that they're the people who dare to be where others won't and can't. And as I started to look at the data and why we as Syrians were struggling to get the funding that we needed in order to save the lives of our communities.
I saw that in the Syria context, for example, the data showed that. 75 percent of the humanitarian work was being carried out by Syrian organizations, right? 75%. But guess how much of the aid budget we were getting?
Gavin: It's not 75 percent is it?
Rola: It was not 75%, it was 1%. It doesn't take a genius to realize that if those who are there on the front lines and have the ability to potentially save lives and not getting the funding and the resources that they needed, that lots of lives were being lost unnecessarily.
And I witnessed this myself. In 2013, I was at one of the seven hospitals that I had helped to build and We witnessed a war crime dozens of severely burned children came flooding into our field hospital after their school was bombed with a napalm like bomb. And it's a horrific day that really is etched on my heart, mind, and soul.
And one of the most devastating things for me that day was that. I, as a highly trained anesthetist and intensive care doctor, I knew exactly what these children needed, right? They needed sedation, analgesia, intubation, ventilation, extensive monitoring and then referring on to Turkey for tertiary referral care and for intensive care therapy.
But instead, I found myself. sending children, despite my best efforts, despite the efforts of my best, the best of my colleagues, choking in distress in the back of their parents cars. And children died that day because I, who could have potentially saved their lives, didn't have all of the tools and the equipment and the resources that I needed.
And it was really from that. They that can do as a an idea and then later as an organization was born with the idea of getting resources directly to the front lines to local trusted and impactful local humanitarians and health aid workers. So that we can save so many more lives.
Gavin: What is CANDU currently doing in humanitarian relief then?
Rola: We are, we've been working in Syria since 2016 and so honored to say that we have through seven of our local partners been able to deliver on 16 health projects including building the first ever crowdfunded hospital. It's a hospital that we founded through a global campaign called the People's Convoy.
And together we've impacted over a million lives now. Can Do, I founded it with the idea of supporting local health and aid workers to save children's lives in war zones. And one of the most pressing issues that has come to my attention recently has been the profound level of burnout and trauma amongst health workers.
And I think that this is not only a huge issue for my colleagues and friends and in Syria and in war affected places. But I think it's a major global health disaster actually that is about to unfold before all of our eyes. And we are collectively doing very little about it. And so one of the things that we are doing right now is co creating a bespoke trauma and recovery trauma recovery program to help provide that to frontline health and aid workers.
Because I feel like we need to, in order to save lives, we need to make sure that our own health and being is in the best shape that it can be. We can't save lives if we are deeply wounded.
Gavin: Yeah, burnout's a big problem, isn't it? Because, the world has been extra reliant on healthcare workers for the last few years during the pandemic.
So what are some of the steps you think we could take to address burnout?
Rola: Honestly, I think for a start, we need to stop thinking of it as burnout. I think there is a major difference between, what we call burnout, which actually, is It's happening in so many different professions right around the world, but what is it that separates, for example, someone who's got some of those symptoms in an office, in a tech company versus a frontline health worker?
I think actually what we're talking about is undiagnosed trauma. We're talking about people who are bearing witness every single day to injustices. To life and death who are every day having to make decisions that are extremely difficult to make because you're often in a position like I just talked about where you are having to provide frankly inadequate care to your patients.
And you know that if this was your daughter right in front of you. That this is not the care that you would want her to have and yet most of us are having to do that partly because of the under resourcing, whether at a financial level or whether at a human resource level. And I do think that we need to start thinking about it as trauma in healthcare workers rather than in burnout because that is going to radically affect.
What we do about it which is essentially that we all require trauma recovery as well as trauma informed leadership, which we can, we need to address at a, at an individual level, because at the end of the day, we hold the trauma in our bodies and therefore, we need to do that healing ourselves, but we also need to do it at that organizational level and at a policy level the moment in the UK, Boris Johnson is asking that several thousand of healthcare workers who are about to retire and not to retire.
He is saying nothing about their own health and being and the trauma that they have been through throughout these decades of service. And I believe that until we actually say one central aspect of patient care is the health and being. of the healthcare providers. We are going to constantly be in a survival mode, firefighting, treading water, trying not to drown, individually and collectively, and we are never going to come out of it until we actually do make that conscious effort at, for our own sakes, individually, but as a profession, and at a more policy level.
Gavin: Yeah, I think I think your description of it as trauma makes sense because healthcare workers have had to Shoulder so much of the burden of a kind of collective trauma over the last couple of years, haven't
Rola: they? Yeah, absolutely. And, this the, this chronic nervous system dysregulation, whether we get stuck in fight and flight, which is where I was for, I think, 10 years until last year I really fell into an abyss of what I thought was burnout.
And then as I started to learn about trauma, I realized, Oh my God, this is actually trauma, I think that I, like many health workers don't really understand it. We seem we think of trauma as PTSD only, right? If I'm not having flashbacks, if I'm not having nightmares, if I'm not having these sort of classical symptoms, then it's not that, but actually this constant activation of our system where we get sick.
stuck in, in, in in the sympathetic nervous overstimulation. And so we end up, in agitation, frustration, anger, anxiety or as I experienced for the first time last year, going into that hyper arousal straight, the, using the polyvagal theory and that dorsal ventral state where you go into disconnection, where you enter despair into.
I just want to curl up and be left alone and I don't care and no one else cares and and I think we, we can as traumatized individual in a traumatized system oscillate between those two and that has negative implications, not just for our own personal health and wellbeing, but for the care that we are trying to provide to our patients.
Gavin: Yeah, I think that's very true. I wanted to talk a little bit more about humanitarian issues worldwide. And as you've touched on, there are just so many different humanitarian issues going on globally at the moment. And I think it can feel a little bit overwhelming when we think about how to deploy these limited resources.
And of course, following the pandemic, these resources are becoming ever more limited as governments look a little bit more What's your take on the current global humanitarian situation?
Rola: I think, Gavin, I want to start by saying I really reject that we have limited resources. The OECD funding for overseas development is 0.
3 percent of our global GDP. But we spend 10 times as much, 2. 5 percent on military expenditure. And so what we are short of isn't funding and resources. It is the will to prioritize peace over, over war. It is shortage of prioritizing health. Wellbeing and human rights over greed and power and making more money.
And so I believe our world is abundant. If you just look at the wealth of just US billionaires in over the pandemic, right? Their collective wealth has gone up 58%, nearly 3 trillion. Okay. The global humanitarian fund that is required right now is 46 billion. Like that, by the end of this conversation could be paid like this.
We could say there are no more humanitarian needs, the funds are all available, but we have a poor distribution and a poor prioritization. So with that in mind, what do we do with these relative limited resources? Back in 2016, the global humanitarian community came together at the World Humanitarian Summit and created these grand bargains.
And one of the main things that they said was that instead of the collective 1%, that local 1%, Humanitarian. responders get, that number should become 25 percent by 2020. We all rejoice as advocates for local humanitarian work because we know the data shows if you support local humanitarians, it is not only more effective and impactful, but it is cost efficient.
But where are we now? That number is at 3%. And so I believe that we have the decision, we have the data we're just not turning that into a reality, sadly. And I think that is where we need to be putting pressure on our governments and on the UN and on major international NGOs to uphold that because we know that will save lives and that is a great way for us to make better use of our limited resources.
Gavin: Yeah, I didn't mean to imply that the resources themselves were limited, more that the resources flowing to humanitarian organizations become. More and more limited as governments look more inward, and it's all a political choice, isn't it?
Rola: Oh, so much and I think one of the frustrations when you start to really see this work up close and personal is, the humanitarian principles of impartiality and neutrality and you just think I'm not seeing this on the ground.
This is not turning out to be how it is reflected in reality in the field and in vulnerable people's lives. And yeah, unfortunately there is a big discrepancy between our aspirations and between what we are delivering.
Gavin: You recently wrote a letter to Ukrainian frontline healthcare workers outlining some of the lessons that you took from Syria.
Tell us about a couple of those lessons, they're really interesting.
Rola: When the war started, it really took me by surprise. I had I've been for a good year on my own healing journey, and I thought I'd come a long way in it, and when it started, I found myself really going into shutdown. I, my body reacted in a very involuntary and automatic way reliving a lot of the early days of the war in Syria.
My my sister in law, Kati, is Ukrainian and as she started to tell me about how she's worried for her family over there and just how angry she was and how devastating it was for her, for them to be so close to the fighting, hearing bombs and just not able to do the one thing that we all want, which is to keep our loved ones safe.
I found it extremely triggering. And as I searched for what to do and how to help, I found myself penning a letter to my Ukrainian colleagues. Of my 11 lessons from 11 years of war. And perhaps I can read you one of those. There the letter is available on my website, drrolahalem.
com. But I'll just read you one of those. Choose to see the light. There will be some dark days. It's easy to see the horror and the worst of humanity in war. But you will also take a front row seat witnessing its very best. Every day and every moment will be a choice. Do we succumb to darkness, or do we choose the light, no matter how dim?
You are the beacons of light in the darkness of war. Others will look up to you to help them see in these dark times. So shine bright, my dears.
Gavin: Some of the approaches that we've seen in the Ukraine conflict have specifically targeted healthcare, haven't they? Do you, and of course we've seen that as a constant theme of the Syrian conflict as well.
Do you think that's becoming more of a tool of war than it used to be? Obviously, that's very worrying.
Rola: It is extremely worrying. I think we are normalizing the hideously abnormal back in 2014 when I was advocating for the protection of healthcare in Syria I said, Our hospitals and our healthcare workers are protected by the Geneva Conventions for our collective well being and for our collective protection.
And if we allow them to break for one, they will break for all. And in future wars, we will see the targeting of healthcare becoming more of a reality. And that's. Devastatingly, what we're seeing in Ukraine have been over a hundred documented attacks on healthcare workers and healthcare facilities during this time.
In Syria, for context, physicians for human rights have documented about 600 attacks killing over 900 colleagues and friends of my healthcare, fellow healthcare workers. And we are collectively turning a blind eye to it. It, our governments are, the United Nations are it's not enough to be publishing reports and saying we condemn this requires action for us to actually uphold these international humanitarian laws that we have written, otherwise they just become useless pieces of paper.
And unfortunately, dictators and regimes around the world. Know that there aren't many people who are going to stand up and say I'm sorry. This is not okay
Gavin: Does your organization have to operate in a different way bearing in mind the potential for targeting of health care workers?
Rola: One of the most shocking, heartbreaking things and conversations that I regularly have with my fellow health workers is, where can we build this hospital so it will be the least likely to be bombed?
We should not be asking that question. When the last children's hospital in Aleppo was bombed in 2016, and I launched the People's Convoy campaign together with 38 organizations, that was the first question that our local partners, IDA, were asking. And we were being asked, it's like, how do we build this hospital so it doesn't get bombed?
And to the extent that actually a lot of people were worried to support You know, the rebuild of a hospital and the provision of healthcare for the worry that if we're going to build it, maybe it'll just get bombed again, and so it dramatically affects, how we provide these services, but also more to the point, we've lost according to data, but I believe it's much more than that over 50 percent of our healthcare work.
And, there are some incredible beings, like Nurse Malachi, who has been injured ten times in the line of duty. She's had her skull broken, her vertebrae broken, she's been severely damaged, and every single time she recovers and she went back to Aleppo to continue to save lives as the head of a pediatric hospital as the head of the nursing of the pediatric hospital.
But, those people are far and few between. And most people will go, screw this. I'm out of here. I'm going to take my family to safety because there's no future for us here. And so it has dramatic effects on the number of healthcare workers, the health, the quality of the health that we're able to deliver.
And now just over 50 percent of our hospitals are functional, which is woefully inadequate for the healthcare needs of a population. We've got 14. 6 million people just in Syria alone in need of healthcare. So it has dramatic effects.
Gavin: What are some of the things that can be done to keep healthcare workers safe?
Rola: I think there needs to be a renewal of our collective intent of our international humanitarian laws and the Geneva Conventions. I would like to see governments and the UN taking initiative on saying if we have actually agreed that these are the norms that we need to uphold those. And I think it needs to start with that.
But I really do also believe that. The safety aspect is part of this greater urgent and important need to centralize and prioritize the health and the well being of healthcare workers of which safety is an aspect of. And so whether that safety, because you're in a war zone or whether that's safety because of COVID or any other, illnesses and diseases that impact the safety of healthcare workers around the world.
I really believe that it's about centralizing that for the With the purpose of saving more lives so for me it really starts there and and that's where I think we need to be working.
Gavin: How do you think the next few years look? Hopefully we can end on a slightly upbeat note.
Are there any kind of reasons to be optimistic in the coming years?
Rola: Oh my god, yes. Yeah. Look, I always say that in Syria I witnessed the worst of humanity, but I really also witnessed its very best. There is a reason that I still get out of bed feeling inspired to do the work that I do, and that is because of the millions.
of incredible health workers, aid workers, frontliners, people who are every day facing injustice, life and death, and are continue to be willing to stand up to speak out and lead for change. We don't make sexy headlines like a bombing or a shooting, but every time there is catastrophe or disaster.
Invisibly, these frontliners are running to the aid and rescue and risking their lives to save others. And that, that is enough reason to be hopeful for me for very many years to come.
Gavin: That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamyn Eye on Twitter, on our handles, at Gavin Cleaver, and at Jessamyn Bagonall. You can subscribe to The Lancet Voice, if you're not already, wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts, tied to each of the Lancet's specialty journals, where we look in depth at one new article per month.
Thanks so much for listening, and we'll see you again next time.