By Dr Natalie Roberts, Doctors Without Borders
I'm part of an MSF team based in the Aleppo region in the north of Syria. This area continues to see an enormous amount of conflict, and the health needs are massive.
Before I was in Aleppo I worked in Idlib region, where MSF runs a surgical trauma hospital with an operating theatre, an emergency department and a small in-patient department.
There are a number of expats there, including a surgeon and an anaesthetist along with about fifty Syrian staff. It's a small hospital, but it's actually very full and busy. We're currently providing support to other hospitals and health facilities in Aleppo.
Much of the healthcare infrastructure in this part of Syria has essentially collapsed, and although there are dedicated people working hard to keep facilities going, sometimes they don't have the training, the experience or the equipment to provide the medical care that people need. That's where we can help.
Not long after I arrived, I was working at an MSF hospital and a six-year-old girl was brought to us. She'd been with her family on the roof of her house, when a plane had flown over to bomb the village.
Understandably, children in Syria are now very scared of planes, so when this girl had seen the plane she ran across the roof. The family had a diesel heater because of the cold, and as the girl ran she knocked it over and splashed the burning fuel all over her legs.
She suffered serious burn injuries to her legs, and was rushed to a local health centre, but they really didn't have the equipment or even the proper pain relief to treat her.
This is a problem that we see a lot. Even when facilities are still open, often they don't have the medicines or the equipment to properly treat patients. Or if they do have the equipment, it's been damaged by bombing or by lack of maintenance. Hospitals are a target and many have been bombed.
Rebels control much of Aleppo but the fighting has battered the city
And then there's the lack of electricity, which is a huge problem. Equipment in hospitals is dependent on electricity but most places now don't have a supply so everything is run from generators, but that requires diesel which is very expensive and not always available. Vaccines and blood need to be kept in fridges, but if you don't have power, those things are useless.
At one of the emergency rooms I go to, they don't have a means of sterilising equipment. So when they get patients from a bomb blast, they'll do procedures like suturing, but they can't really sterilise the equipment so they just have to reuse. And that obviously causes problems down the line.
By the time the girl came to us, she was really traumatised and even walking into the hospital left her screaming and in tears. It took a long time for her to trust us, but eventually we were able to change her dressings and give her the beginnings of the care that she needed.
For me, that really summed up the horror of the situation in Syria. Yes, there are acute injuries from the bombings and from the violence, but there is also the psychological trauma caused by the whole situation. This poor girl has seen and experienced things that nobody - let alone a six-year-old girl - should have to experience.
When I visit different hospitals in Syria, often the casualties are children. Bombings will hit residential areas and whole families are injured or killed.
Alongside the acute injuries, children are suffering from a range of medical problems. Vaccination has essentially stopped in some areas. Whole families are living in tents or in houses with no heating or clean water, often all together in one room. Infectious diseases are starting to spread. I've seen a lot of children with basic disease like pneumonia and Hepatitis A.
There's no school. They're coping, but that doesn't mean they're behaving normally.
Rubble is cleared from in front of a hospital in Aleppo
Sometimes the children will be playing on the streets when planes fly over, and they just accept it and keep playing, even when the plane is bombing their town.
There's a man I know who has a four-year-old son, and sometimes this man helps in a local field hospital. One night he was going to help after a bombing and his four-year-old son asked him not to go, saying that if a bomb hits the house, he wanted the family to all be together so none of them would feel lonely. That's not a normal thing for a four year old to say.
You know, MSF is very good at being efficient, at knowing how to provide a good medical service with not many facilities. We're used to working in these types of conflict areas and we're one of the rare aid organisations I've seen working in the region.
The health system in Syria was very sophisticated before, and now that the infrastructure has broken down, they're struggling to optimise how they work. That's how we can help. But building that trust takes time. These people have been doing this for two years and doing an amazing job, and it does take time to build up trust. I have to tell them what I've seen and done before, and tell them what MSF does.
I remember I was visiting an emergency department at one hospital in Aleppo. It was the first time I'd been there, and we were discussing with the staff how we could help them when news came that a mortar bomb had hit a nearby market. Very quickly we started to receive casualties, brought to us in private cars, the back of pick-up trucks and on motorbikes. Ten fatalities arrived almost immediately, then four more, two who had sustained massive head injuries.
In situations like that, it's vital you triage and prioritise patients that can be helped, and it was very clear that these two patients were beyond help. But it was equally clear that there were other patients - particularly two eight-year-old girls with shrapnel wounds - who could be saved.
My role in the midst of all the panic and crisis was to point out that these girls were our priority and that we needed to focus our attention on them. Pointing that out, though, requires that the team trust me.
Fighting for Syria's largest city has been brutal
I think one of my main roles at the moment in these hospitals is to use my experience to train people and demonstrate what should be done in terms of prioritising patients during a mass casualty event. To that end, I've been delivering a training programme in different hospitals.
We teach them about triage, about managing war wounded patients, about blood transfusion, and how to do all that with reduced facilities and equipment.
It's a scary situation in Syria. This is the second period of time I've spent there, and over the last weeks I've really noticed the escalation of violence. But you do get used to it. Incidents that initially made me very frightened, I now take for granted.
The first time I was really scared was when a very large missile landed not too far away where we were staying. We could feel the windows of our house shaking. There were two of us in the house and we were both afraid.
But within a month, we were getting missiles every night - some very near - and we'd get out of bed and go to our safe room but be complaining that it was cold and our sleep was being interrupted. You even start making jokes about it, but it's just a way of coping. In reality, you never really lose the fear.
People are grateful that we're there. But we can't do everything. We can help with what we can, but the needs are huge. We set up a blood bank. We provide vaccinations. We helped with supplies for dialysis machines.
We need to set up more MSF clinics and structures. There is a need for more acute trauma surgery, but there's also a need to continue basic healthcare, treating chronic diseases and providing outpatient services. We need to continue helping with equipment and advice and support.
Take our blood bank. We've set one up in the Aleppo region in a secret location which supplies all hospitals in that area. People have been coming from 50km (30 miles) away to access it. It required a bit of work, a lot of training and equipment, but it's now up and running.
Before people were getting unsafe blood, blood that hadn't been tested and stored correctly, but now they are. Something like that is really easy to do, but it's cost effective and it saves lives.
But this is just a drop in the ocean. The suffering that people are experiencing in that country is incredible and it's frustrating and upsetting to see so many problems and know that because of security or for other reasons you can't solve it all.
But as MSF we do what we can, and it's vital we continue to help. This is a massive humanitarian emergency and the Syrian people need our help. It's as simple as that.
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