Our localisation and training in Ukraine
This June, we partnered with the World Health Organisation (WHO) Ukraine to deliver our training in Ukraine. We trained 69 medical professionals, including those from the frontlines and other regions, who travelled to Poltava to acquire vital trauma skills to take back to their hospitals. This course brought our global figure of doctors trained to over 2000.
No end in sight
After two years of war, Ukraine is dropping from the headlines, yet the conflict continues and conditions remain dreadful. Kateryna Barabash, Emergency Medical Services Officer at WHO said: "From a humanitarian perspective, the casualty rates are not decreasing. The need for care near the frontline remains high."
"Media attention is decreasing, affecting financial support, reducing project budgets, and diminishing humanitarian services."
Despite the lack of spotlight as other disasters intensify across the globe, we remain committed to our work in Ukraine and have now trained over 700 doctors from territories right across the country. On our latest Poltava mission, we ran two Hostile Environment Surgical Training-Anaesthesia (HEST-A) course twice and a Hostile Environment Surgical Training (HEST) course for surgeons and anaesthetists.
Localisation and sustainability
In early June, we also funded Ukrainian surgeons to come to our latest UK course to learn directly from our Co-Founder Professor Nott, and also how to take the reins and join our team as official Ukrainian trainers.
Five of these professionals trained on our course in Ukraine as members of our faculty, enhancing our sustainability and localisation efforts. They now apply their teaching skills in their work settings, training others as they operate on injured people, building capacity in Ukraine and on the frontlines.
"Our greatest achievement from this course is that localisation has actually happened. This is our first cohort of Ukrainians delivering our course near the frontline." - Nick Cartwright, Programmes Manager at the David Nott Foundation.
Missile attacks continue to devastate
Russian drone and missile attacks continue. Most recently, attacks inflicted devastation at Okhmatdyt Сhildren's Hospital in Kyiv, throwing the nation into outrage. Clearly, there remains an urgent need for surgical and anaesthetic teams that are equipped to save lives and limbs – that’s why the skills and techniques taught on our courses are essential.
Kateryna shared: "The foundation has a solid technical background in trauma surgery, offering valuable tips and tricks that match the situations they may face. Simple techniques, like tying a knot effectively, can be more impactful than revolutionary methods. Sharing practical experiences and real-life stories also make this training invaluable."
"When you have many trauma patients, it's hard to share experiences with peers. In this environment, you can do that and set up valuable learning opportunities.”
We strive to provide a safe environment for doctors to discuss patience cases and learn from real-life experiences from each other and our faculty. Creating space for this forum fosters powerful knowledge sharing of new skills and techniques.
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“Maternal health - it's a societal barometer.”
Every two minutes, a woman loses her life to preventable causes related to pregnancy and childbirth. These staggering statistics stress the need for action. In humanitarian crises, where access to healthcare is severely limited, maternal care becomes even more critical.
“800 preventable maternal mortalities are happening every day, and a woman dies every two minutes from a preventable cause. So that's women dying through pregnancy and pregnancy related conditions,” shared Dr Pippa Letchworth, our Faculty Lead for Obstetrics and Gynaecology.”
This sobering reality is what drives our passionate team to develop an obstetrics and gynaecology course aimed at addressing the most pressing challenges in maternal healthcare. In crisis settings, where resources are scarce, the course equips healthcare professionals with the skills needed to perform life-saving surgeries, particularly focusing on addressing the top global killers of women - haemorrhage, obstructed labour, sepsis, and unsafe abortion.
“75% of displaced people are women and children, and one of the five of those women will be pregnant.”
The course covers a wide spectrum of topics in maternal and neonatal healthcare in crisis. Participants begin with trauma training before transitioning into obstetrics to understand the complexities of childbirth emergencies.
Emphasis is placed on neonatal resuscitation techniques with the goal of reducing the number of stillbirths. Subsequent sessions address postpartum haemorrhage management, perineal repair, and navigating challenging deliveries like impaction and breech positions. The course also covers disruptive delivery, crucial for situations where doctors have limited access to caesarean sections.
Beyond the medical realm, our trainers advocate for a holistic approach to maternal health in their teaching. It's not just about reducing mortality rates, it's about understanding the wider implications of maternal deaths on families, communities, and societies at large. Children left motherless are at a significantly higher risk of mortality and developmental issues, perpetuating a cycle of vulnerability.
“There needs to be a call to arms to improving maternal health.”
We must advocate for women's rights, improving doctors access to education and dismantling systemic barriers that perpetuate maternal mortality.
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103 surgical life savers in Tripoli, Libya
We’re back from a week in the Libyan city of Tripoli after completing a first-in-our-history mission. We upskilled 103 doctors – the largest number trained on one mission – and trialled our brand-new obstetrics and gynaecology course.
Libya’s history is marked by political turmoil and civil unrest. The uprising against the rule of Gaddafi led to brutal violence against Libyan civilians and instability across the country. Today, 13 years after the ruler’s death, conflict between armed groups continues and Libya’s security remains fragile.
Outside of politics, Libya has been devastated by natural disaster. In September of 2023, heavy rain caused the collapse of two dams, leading to horrific damage and the loss of thousands of lives. Wounds inflicted by violence or natural disasters often require rapid surgical care, with a need to focus on controlling the worst of the damage first.
Surgical toolkit for any crisis
In a bid to empower Libyan doctors with skills to treat wounds caused by war or natural disaster, we partnered with the Libyan Board of Medical Specialties to deliver four surgical training courses in parallel. Over five intense days, our team of expert trainers delivered two trauma surgery courses, two anaesthesia courses and a brand-new obstetrics and gynaecology course.
According to a 2023 UN agency report, a woman dies from pregnancy or childbirth every two minutes. During conflict, women are less likely to seek maternal care and hospitals are under-staffed or under-resourced. That's why our trainers created a bespoke obstetrics and gynaecology course to help doctors better protect mothers and their babies in war and catastrophe.
During the week, we trained 103 doctors. Doctors we’d previously upskilled in Libya also joined our training faculty and led the teaching of a number of our modules for the first time. Dr Aisha Alghamji was one of them.
It really was paralysing
Dr Alghamji shared: “I remember I have a case of a 70-year-old lady. We found there was a huge bleed in her tummy. Most of her blood is – in minutes – almost drained out. It really was paralysing – what to do? She doesn’t have that much time.
"That lack of knowledge paralysed me. She is a living, human being – with dreams, hopes, a whole community. She is part of it. It keeps haunting you, that feeling. What I could do differently?"
She lost her life.
After 2018 when I attended the course with the Foundation, there is something shifted in my way of thinking. It did that thing for me, that confidence the surgeon needs to do more than their best – to run the extra mile for the patient.
I faced another case similar to it (this lady). I told immediately to me brain – ‘damage control! Damage control!’. I was able to send her home. She is alive, she is a grandmother, she is everything.”
A resilient healthcare system
Dr Moez Zeiton, Consultant Orthopaedic Surgeon and our Faculty Lead for Libya, said: “It is a privilege to have had the opportunity to lead the single most ambitious series of courses for the foundation, training over 100 doctors in a week. It was a huge effort from the foundation’s team and superb faculty to get over the line.
Candidates in Libya travelled from every part of the country with many travelling over 1000km to participate in our surgical training. Their eagerness to learn and share their own experiences was evident and they will now be equipped with the skills needed to deliver high quality care to their patients. "
This marks the beginning of continued training in Libya and a commitment to gifting doctors with extensive trauma skills to handle any challenge.
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41 Syrian doctors upskilled to screen and treat women with cervical cancer
Dr Saladin Sawan, Consultant Surgeon in Gynaecological Oncology and one of our faculty trainers, recently returned from a surgical mission in Idlib, Syria, upskilling 41 surgical residents and specialists to screen for and treat women with cervical cancer. Here, Dr Sawan shares his hopes for healthcare and future training in northwest Syria.
Syria remains engulfed in a complex humanitarian crisis. Over a decade of conflict has forced more than 12 million people to flee their homes and left displaced communities with reduced access to food, shelter and protection.
Cancer under the radar
Due to a buckling healthcare system and greater focus on other urgent needs, many are not seeking or receiving the cancer screening, diagnosis or treatments they need. Medical professionals also face challenges with transferring patients over the border to Turkey, which means cancer patient numbers in-country are growing.
Cervical cancer is preventable and curable, as long as it is detected early and managed effectively. According to the World Health Organisation (WHO), it is the 4th most common form of cancer among women worldwide.
Our faculty trainer, Dr Saladin Sawan, travelled to Idlib to upskill Syrian surgeons to offer the best possible surgical care for patients with gynaecological cancers including cervical cancer.
“During my mission, I delivered gynaecology training to a group of doctors. Every day, we practiced surgical techniques. We used chicken thighs and a cutting-edge mannequin, provided by the David Nott Foundation, to practice performing cervical smears, colposcopies to assess the cervix for cancer or pre-cancer changes, and diagnostic punch biopsy, in addition to safely performing treatments for pre-cancer cell changes, in the form of loop excision (using heat to remove cells). Each doctor had hands-on practice and then we put skills to the test in operations.”
Dr Sawan trained 41 local doctors during the mission, which will improve cancer patient care while strengthening northwest Syria’s healthcare system in the long-term.
“I performed approximately 14 surgeries of different magnitude, some small procedures, some far more complex, for example radical hysterectomies for cervical cancer patients and debulking surgery for women with ovarian cancer. We used operations as teaching opportunities for local doctors – residents were assisting me and watching over my shoulder. We trained anywhere between three and seven obstetrics and gynaecology residents per day. Some doctors followed me, but I made it my goal to visit as many hospitals as I could to deliver training to those who could not travel. I was very happy.
I felt appreciated amongst a family of doctors and health professionals who looked after each other to deliver the best they could for their patients in some of the most difficult circumstances. I was certainly privileged to have had the chance to be with them.”
Eliminating cervical cancer
Due to ongoing conflict and accessibility issues, doctors in northwest Syria have limited access to training. The province also lacks a screening programme for cervical cancer prevention and early detection, leading to increased numbers of cases that require complex, radical surgery.
“WHO launched an Elimination of Cervical Cancer Elimination Initiative, which mainly targets low-income countries. The local doctors are really excited about establishing this program for women in Syria. They know the benefit, they believe in its value and importantly they feel it is only right to do since women disproportionately suffer the results of human papilloma virus infection which causes cervical cancer, unlike men. This would promote healthcare equity.”
In his training, Dr Sawan actively encouraged the local doctors not to fear making mistakes.
“Doctors become more confident and patients as a result will be safer. We strive for the doctors to test, try, play, make mistakes. The intention is that the doctors are more competent by the time they perform the operation on patients.
I am lucky to be part of the David Nott Foundation where the emphasis is also on building local expertise and sustainable care by training local health professionals in crisis areas. The donated equipment and surgical instruments meant I was able to deliver comprehensive training without compromises.”
Glimmers of peace
“Around me in Idlib, despite being in a region struck by war, there were people trying to rebuild their lives. Developing roads, restaurants opening, people moving into the city. People have started to live their lives – the dust of war settling and communities trying to get their lives back.”
Since Dr Sawan’s mission and apparent signs of a healing community, the Regime has targeted 45 cities and towns in four days, killing 52 and injuring over 240, according to an October recent report led by Assistance Coordination and Information Management Units (ACU, UMI). Despite glimmers of hope, northwest Syria remains in the thralls of conflict.
What’s next?
As unrest continues, the need for training and sharing of knowledge remains. We are committed to upskilling even more obstetric and paediatric residents in northwest Syria, but there’s much more to do.
“Outside of returning to deliver more surgical training, we also want to deliver dedicated cervical cancer screening training to residents,” shares Dr Sawan.
On-the-ground partners have also identified other, urgent areas of need.
“A local humanitarian organisation, the White Helmets, are looking to develop training for paramedics, including resuscitation and emergency obstetrics, gynaecology and neonate training. To make sure we provide the right training material for paramedics, we want to speak to them to understand exactly what their needs are in the field.”
We’ll continue to do all we can to support medical professionals in Syria.
The BMJ: Training Idlib’s obstetricians
Giving birth is one of the most vulnerable moments a woman can experience. It can be anxiety-inducing enough in a well-equipped hospital in the UK, but the women of Idlib, Syria are literally having their babies in a warzone. The threats they face are myriad, not only to themselves and their babies, but also to the physical fabric of the hospital and the medical workers who care for them. In early September the Has hospital was barrel-bombed and put out of action. Ambulance stations and a Syria Civil Defence (White Helmets) first response centre were also put out of service.
Beneath the headlines about “shapeshifting” rebel groups which have formed, fractured, and re-formed over the course of the civil war, and deals cut in regional capitals, is the suffering of the civilian population of Idlib, the last province in Syria not under regime control.
The numbers are stark; 336 maternal deaths per 100,000 births in provinces outside government control in Syria. [1] There are 9 per 100,000 in the UK. The figures for neonatal deaths are similarly distressing; 30.6 deaths per 1,000 births in Idlib compared to 3/1,000 in the UK. [2]
Violence against hospitals and medical staff affects clinical decision-making.
On 19 March 2018, the Union of Medical Care and Relief Organisations (UOSSM) reported that doctors in eastern Ghouta had, on the previous day, performed 15 caesarean sections out of a total of 30 births. The doctors said that they were being forced to do caesareans as the intense besiegement made it difficult for expecting mothers to predict when they could safely go to the hospital. The risk of complications for the mother and child are increased by the lack of incubators, medical equipment, and staff with the right training to perform follow up care.
However, the war alone cannot explain the high levels of maternal and neonatal morbidity. There is a serious shortage of obstetricians and midwives to care for a population of some 3 million. This can lead to non-specialists having to undertake the care of pregnant women and neonates and sometimes not making the correct decision for the patient. While not all of that population of 3 million will be having children, of course, the pressure on health services has increased as much of that population is made up of internally displaced people from areas including eastern Aleppo, eastern Ghouta and Homs. The province has become a receptacle for the vanquished as the regime has hammered those opposed to Assad’s rule. Following relentless campaigns of bombing and the use of chemical weapons, those civilians left alive boarded buses for Idlib province.
Among those on the green buses heading for Idlib in December 2016 was Farida; known as the last obstetrician in eastern Aleppo. Farida made impassioned pleas for the indiscriminate bombardment of her City to stop on several media channels in 2016. Her departure with her husband and daughter is an evident source of present pain, but there was something about those months leading up to the evacuation. “We made a difference. We were working so hard and helping so many people. Though we were under constant attack, we were part of something extraordinary and saving lives every day.”
Farida and 17 other obstetricians were in Gaziantep recently for Systematic Management and Emergency Care in Obstetrics and Midwifery (SMEC-OM), a course organised and funded by the David Nott Foundation, Hand in Hand for Aid and Development, and World Vision International. The Syrian civil war has stalled the medical education of doctors and midwives, a further major contributing factor to the poor outcomes in obstetrics and gynaecology. Postpartum haemorrhage and eclampsia/pre-eclampsia were responsible for the majority of maternal deaths in areas of Syria not under government control in 2017. [3] The SMEC-OM has been devised to save the lives of mothers and babies by training clinicians to use established algorithms and guidelines for managing conditions such as maternal collapse, post-partum haemorrhage, pre-eclampsia, sepsis, and neonate resuscitation. The Royal College of Obstetricians and Gynaecologists (RCOG) in London is supporting these efforts and the course is conducted under the auspices of its Syrian Liaison Group.
Organising this essential training is Saladin Sawan, a British-Syrian gynaecologist. Saladin is joined by a faculty of trainers from several Arab states, all of whom give up their time for free. They lecture with authority and passion for their subject, inviting debate and questions from the doctors, 90% of whom are women. The energy in the room is palpable as they question graphs and diagrams and participate in practical exercises on specialist obstetric simulator models.
What they learn is being measured by an exam comprising both a paper of multiple-choice questions and a practical assessment on a simulator. The candidates who perform most strongly in the assessment proceed to a “train the trainers” day, where they will be coached to provide help and supervision to their colleagues in Idlib. This is especially important as 35 candidates had registered to attend the training but only 18 were able to make it across the Turkish border.
Getting the best in surgical training to those who need it most is the mission of the David Nott Foundation and we were proud to be able to support this thorough, detailed training.
In the coffee area I meet Abdulaziz. Before the war, Abdulaziz was a surgeon at Aleppo University Hospital and lecturer at the University’s faculty of medicine. With a small group of others, he was instrumental in locating safe houses where emergency operations could be performed on wounded protesters in the early days of the revolution. At night he gave lectures to medical students over Skype; focusing on emergency first aid and treating gunshot wounds. [4]
It is the focused effort of Abdulaziz, Saladin, and countless other individuals and charities that has created a shadow health system in areas of Syria not under government control. As the Syrian regime and its Russian supporters bombed hospitals and medical facilities, they scrambled to set up new ones underground and in caves. As the number of doctors shrank, they strove to train and upskill those who remained.
Idlib is the final front in the Syrian civil war and it is uncertain whether the current ceasefire will hold. The diplomats and politicians negotiating Syria’s fate owe it to the obstetricians I met in Gaziantep, and the thousands of women and babies who depend on them, to come up with a solution which creates the peace, security and dignity they so greatly deserve.
Elly Nott, Co-Founder and Chief Executive, David Nott Foundation
References:
1] 2017 survey conducted by the Syrian Board of Medical Specialities (SBOMS), “article in preparation”
2] World Bank data
3] 2017 survey conducted by the Syrian Board of Medical Specialities (SBOMS), “article in preparation”
4] Ben Taub, ‘The Shadow Doctors,’ The New Yorker, June 27, 2016 Issue
Originally posted on: https://blogs.bmj.com/bmj/2018/11/09/elly-nott-training-idlibs-obstetricians/
