Medical groups working in rebel-held areas of Syria are scrambling to boost preparedness for more chemical-weapons attacks after the deadly assault in northern Syria two weeks ago – a sign of their increased vigilance as the battlefield becomes more unpredictable.
Makeshift field hospitals and clinics were unprepared for the sarin-gas attack that struck the town of Khan Sheikhoun and killed at least 80 people on April 4. International outcry after a sarin assault in Ghouta in 2013 resulted in a U.S. and Russian brokered effort to identify and destroy Syria's chemical-weapons stockpile.
After confirmation from the Organization for the Prohibition of Chemical Weapons (OPCW), an international watchdog, health-care workers believed the deadliest chemicals had been removed from the battlefield and that the use of nerve agents represented a line that would never be crossed again.
Preparing for the possibility of more attacks using nerve agents "seemed to be a bad investment," said Dr. Houssam al-Nahhas, 29, the Syrian doctor who wrote the chemical-attack protocols for medical facilities in rebel-held areas of Syria, referring to the thinking of health-care workers in Syria at that time.
Now, as world powers squabble over the transparency of an international investigation by the OPCW into the April 4 attack, medical workers in opposition areas are taking no chances and stocking up on supplies for more such chemical attacks.
A convoy of emergency aid from the Union of Medical Care and Relief Organizations, also known by its French acronym UOSSM, purchased and distributed 10,000 ampoules of atropine – the antidote for nerve agents – to 18 hospitals last week in opposition areas of Aleppo, Hama, Latakia and Idlib. At least 70,000 ampoules of atropine, 5,000 ampoules of pralidoxime and 350 chemical suits are needed to prepare the 70 hospitals operating in northern Syria, according to the UOSSM. The convoy also delivered 100 face masks, 100 chemical suits and 224 decontamination filters.
The attack in Ghouta, which claimed between 300 and 1,300 lives, according to various estimates, was the first documented case of sarin use in the Syrian war. The United States and Russia later formulated a deal under which the regime of Syrian President Bashar al-Assad allowed international monitors to destroy its chemical-weapons stockpile. On June 23, 2014, the OPCW confirmed the last batch of such weapons – which included sarin, mustard gas and VX – were shipped out of Syria to be destroyed at sea on a U.S. vessel. Chlorine was not part of the deal.
Then came the attack on Khan Sheikhoun.
"The hospitals were equipped to deal with chlorine only," explained Dr. Hassan Dibs, who works in opposition areas of Syria. "The ability of medical workers to deal with more deadly agents declined significantly in the last three years because the UN had informed us that all the chemical weapons had been destroyed. We never thought sarin would be used again because we were confident the material had been disposed of.
"Because of this, the number of casualties from Khan Sheikhoun was so great. Doctors, nurses and paramedics were in shock," he added.
"After Ghouta, we started a serious preparedness plan for medical facilities to deal with chemical attacks like this," said Dr. al-Nahhas who was the local co-ordinator for the chemical, biological, radiological and nuclear-defence task force of the UOSSM. "After the agreement to destroy the weapons took place, we shifted our focus to choking agents, like chlorine. But obviously in Khan Sheikhoun, there was a sarin attack, which opens the door again and exposes us to these weapons."
Exposure to chlorine results in respiratory symptoms and high concentrations can cause pulmonary edema, coma and death. Nerve agents present graver symptoms because they cause overactivity in the entire body, leading to convulsions and, if the dose is high enough, immediate respiratory arrest.
Dr. Dibs said now, after Khan Sheikhoun, the focus in rebel-held areas has shifted to training medical teams on how to reduce the risks associated with nerve agents after an attack, including assisting patients around impact zones, receiving victims in care facilities while reducing the danger of secondary contamination, sterilizing emergency rooms and raising public awareness.
In Khan Sheikhoun, as in Ghouta, many fell victim to secondary contamination. Samir Youssef, 25, a construction worker, had no prior training before rushing to help the wounded who had collapsed on the street after the attack two weeks ago. "My brother told me my eyes looked bloodshot, then I felt dizzy and fell unconscious," he said. Mr. Youssef was taken to two hospitals and eventually recovered.
The training that is under way, in many ways, is a revival of the preparedness procedures Dr. al-Nahhas was attempting to promote three years ago.
Like his patients, his life had been upended by war. Unable to complete his clinical medicine degree at Aleppo University, he was forced to relocate to Istanbul. But the war had given him a new purpose. He would lead a medical team to treat casualties and, in the process, write the manual to prepare Syrian doctors working in rebel-held areas for future chemical attacks.
Hani al-Qateeni, a medic who spoke to The Globe and Mail in the immediate aftermath of the Khan Sheikhoun attack, had attended one of the training courses using Dr. al-Nahhas's manual. He knew to grab a protective mask before heading out to the scene to help the wounded.
"When we started the trainings, we were surprised. Even medical professionals didn't know the basics," he said. Before the war, medical students were taught about illnesses associated with organophosphates, which encompasses a group of nerve agents including sarin, because it was used as a pesticide in Syria, a largely agrarian economy. "But when it comes to a chemical attack with mass casualties, there was no idea about what to do."
Dr. al-Nahhas first treated patients exposed to chemical weapons in Aleppo in 2013. He recalled vividly the day an elderly man and his six grandchildren staggered into a hospital on the Syria-Turkey border, where the young doctor was making his rounds.
By then, Dr. al-Nahhas had seen their symptoms – violent cough, difficulty breathing, intense chest pain – many times and knew they had been exposed to high concentrations of chlorine gas.
Syrian military attacks using chlorine were almost routine in rebel-held areas after the Assad government officially agreed to give up its chemical-weapons stockpile following the Ghouta incident.
"Right after the attack, [the grandfather] had the good sense to wash himself with water. Then he rushed the grandchildren into the bathroom and saved the whole family," he said. "He came to the ward for advanced care, but it wasn't as serious as it could have been."
Only the man's wife, who was disabled and unable to be moved, was transferred to the intensive-care unit and later to Turkey, where she died. "I realized then how important public awareness was."
The reported use of sarin in Ghouta shocked Dr. al-Nahhas and he began preparing a response plan that he presented to a conference for medical organizations in Syria.
He is updating a manual he initially penned to help medical facilities cope with chlorine attacks. But many said that even with new training, little can be done in the event of another sarin assault without adequate stocks of medication – namely atropine and pralidoxime.
Asked if the assault on Khan Sheikhoun had better prepared him for future attacks, Mr. al-Qateeni sighed over the phone. "God willing," he said.