Dr. Maher Saqqur's phone buzzes repeatedly for half an hour until he finally stops and looks down: He's getting updates on patients halfway around the world. He holds up a picture of two bandaged children, aged 6 and 7, who were rescued only hours earlier from a collapsed building in Aleppo.
In recent months, whenever the Edmonton physician's iPhone has vibrated, it's rarely been a message from his wife to get milk on the way home from his office at the University of Alberta. Most of the time it's a signal that a Russian bomb has exploded in Syria's largest city, and someone needs his help.
Dr. Saqqur is part of an international team of 20 doctors that operate a network of intensive-care units in rebel-held areas of Aleppo. Most of his Syrian patients are children. And while he's trained as a stroke neurologist, he mostly deals with neural and spinal injuries in Syria. The messages have been flying into the neurologist's phone for the past three years but the pace has picked up in recent months as the long-raging conflict has grown deadlier.
They come in at all hours of the day and night, matching the rhythm of war in Syria.
The flow of messages, some frantic, others clinical, are his only connection to the patients he is caring for in Aleppo; the texts, the diagnostic photos and the occasional video chat are all that link him to the nurses and surgeons who serve as his hands and eyes in the trauma ward.
Soft-spoken and short, he walks with frantic energy, just a flash of pastel dress shirt and tie going down a hallway. But he's not too busy to call up the photo of a CT scan he received a week earlier. It shows a baby's brain stem that has been hit by large amounts of shrapnel. "I've never seen anything like that in my career before," he says, pausing, his voice getting even quieter as he ends the sentence. It's hard for him to set aside that his youngest child is only two, not much younger than the baby in the CT scan.
Help from afar
Although he travelled to the suburbs of Aleppo earlier in the war, Dr. Saqqur has never been to the centre of the city. That isn't likely to change soon. Rebel-held areas in central Aleppo have been besieged since this summer, when Syrian Army troops advanced under Russian air support and encircled the city, trapping up to 300,000 people.
There are now hundreds of patients in the city's few remaining hospitals and medical supplies are running low. A United Nations-mediated humanitarian column in October collapsed before the wounded could be evacuated or supplies brought in.
The ICUs where Dr. Saqqur has helped patients in the past are run by international medical non-profits working with the UN, including the Syrian American Medical Society Foundation (SAMS) and the Union of Medical Care and Relief Organizations – known by its French acronym, UOSSM. Where there were 3,000 physicians in Aleppo before the war, there are now fewer than 30, according to Dr. Saqqur.
"In the last two years it became too risky for any Western physician to cross the border and go into the cities where fighting is taking place, especially since Russia came in and started targeting hospitals, ambulances and clinics," says Dr. Anas Al Kassem, a colleague of Dr. Saqqur and the chairman of UOSSM-Canada.
Dr. Al Kassem was last in Syria about four months ago, but it's recently become too dangerous to cross the border. He says tele-medicine, mostly through smartphone apps, has become the only way for most outside physicians to help.
"The technology allowing us to read the CT scan and give the hospital a report so they can act on it instantly has become a norm, every day we see images, we see patients, we discuss and send it back," he says.
It's the technology that has allowed physicians like Dr. Saqqur to help from afar. There are over 40 physicians on the message thread he's parsing on his phone during an interview with The Globe. At least 10 of them are radiologists helping read scans.
He stops in mid-sentence as he receives a report from a radiologist who'd assessed another CT scan. "They read. I'm the neurologist, I treat," he says.
Throughout the conversation, he will pause and lean over, his voice pained: "Do you understand?" he asks, after talking about the more than 300,000 casualties of the war so far. A few moments later, he'll say it again, looking at the CT scan of a child's head riddled with shrapnel. "Do you understand?"
It's a heavy burden for the 45-year-old physician to carry.
UOSSM and SAMS, the two main organizations providing outside medical aid, have become increasingly hesitant about sharing news of attacks on their medical facilities and the number of physicians they have left. A representative of UOSSM told The Globe that they fear the Russian and Syrian military have been using news releases as checklists to measure the effectiveness of their strikes.
"The past two months have been a disaster, the Russians and [the Syrian] regime have acted without restrictions," said Dr. Saqqur. Since June the local ICUs have seen 20 to 30 patients daily, he says.
The toll on the patients and staff is tragic.
"One of our physicians was killed at the door of his hospital by an air strike. His father told me something I'll never forget: It takes six months to train a fighter but it takes 12 years to train a physician. When you kill a physician, how many people are you killing?" Dr. Saqqur said.
Heroic locals with a target on their back
While many physicians would like to help, Dr. Saqqur deals with a large number of patients remotely because of his fluency in Arabic. (Born in Damascus, he's lived in Alberta since 2000.) Syria, a long-time ally of the Soviet Union and now Russia, doesn't have a lot of English speakers. Few of the remaining medical staff in Aleppo speak anything but Arabic.
Dr. Saqqur has also travelled frequently to the Turkish border, nearly every six months over the past three years, to help train nurses and surgeons. With few physicians left, he's one of a number of foreign doctors who has helped train locals to take over, administer medication and triage patients.
After three years of working with them, he has a deep bond with these men and women. They have worked together so closely for so long that even though the messages may contain minimal content, the team is in synch, mentally – it's like they can read each other's minds. And he admires their commitment.
"They come to the border for training and then go back. They could leave at any time. When they leave, they tell us that we might not see them again," Dr. Saqqur said somberly. "These people have the highest morals. I'd give each of them a Nobel prize."
He then gets a message telling him a new patient has come in: a young man hit in the head by shrapnel. There's a CT scan from a machine in a nearby facility run by the non-profit Doctors Without Borders. He relies on it almost daily. "I hope it is never bombarded," he adds with a cringe.
Dr. Saqqur says the locals feel like they have a target painted on their backs. Two of their three Aleppo ICUs have been smashed by Russian air strikes since the summer. The pace of attack has increased in the past week, with local physicians reporting that every hospital in the rebel-held part of the city has now been struck by artillery fire or Russian bombs.
"It's getting worse. These are targeted air strikes. The Russian planes came back and dropped bombs for one hour, one whole hour," he said.
The battle for Aleppo has been raging since July 2012 and killed over 300,000 people and created over 4 million refugees, according to the UN. Both the rebels and government forces have been singled out for their use of indiscriminate weapons like barrel bombs and makeshift mortars in densely populated areas.
"There are millions injured," Dr. Saqqur said. "The bottom line is the country is a big mess. Whatever we do, we cannot keep up."
Justin Giovannetti is The Globe and Mail's Alberta reporter.