Dr Mahmoud Hariri, one of the lead trainers, guides participants through a practical session during the Hostile Environment Surgical Training. Photo: WHO28 November 2024 – For surgeons in the operating rooms of northwest Syria, where the hum of generators replaces the sterile quiet of modern hospitals, every decision is a race against time, every procedure a battle to save lives amidst conflict.

For doctors like Dr Abdullah Al-Saleh, a general surgeon at Al-Andalus Hospital in Idlib, the stakes could not be higher. “The hardest cases are the ones where every second counts,” he says. “We deal with severe abdominal and chest injuries, where even a small delay can mean losing a life. The reality is harsh. We do what we can with what we have.”

A surge in need amid escalating hostilities

After years of conflict, the health care system in northwest Syria is hanging by a thread. Hostilities, and the associated displacement and deteriorating living conditions, have led to a sharp rise in trauma cases, overwhelming already strained hospitals. The lack of resources and specialists often forces surgeons to step into roles outside their specialty. They must master multiple skills to meet the pressing demands.

Amid this mounting pressure, the Hostile Environment Surgical Training (HEST) programme is proving to be a lifeline. Developed to empower surgeons to manage complex emergencies, it combines technical expertise with real-world application.

“If you know how to hold a knife, you can do miracles”

Participants at the HEST collaborate on a practical exercise, using anatomical models to refine critical surgical techniques for conflict and emergency settings. Photo: WHOFor Dr Mahmoud Hariri, one of the lead trainers, the training is not just about technical skills – it’s a culmination of lessons learned working in conflicts.

“There’s no room for strict specialization,” he says. “One day you’re a general surgeon, the next you’re managing vascular injuries or performing thoracic surgery. If you know how to hold a knife, you can do miracles.”

The training curriculum combines advanced techniques with innovative teaching tools tailored to conflicts. Participants work on lifelike simulators, practicing procedures like suturing a heart, stabilizing severe vascular injuries and performing tracheostomies under battlefield-like conditions. This hands-on approach ensures that surgeons are prepared to act decisively, even in the chaos of mass casualty events.

“These aren’t just theoretical skills,” says Dr Hariri. “When I performed 11 emergency heart sutures in Aleppo 13 years ago, 7 patients survived – a testament to the power of preparation.”

“Empowered to act in the moments that matter most”

Participants practice wound management techniques on a medical mannequin during the Hostile Environment Surgical Training, focusing on real-life scenarios in conflict zones. Photo: WHOFor participants, the training is more than an opportunity to learn – it’s often the difference between life and death for their patients.

Take Dr Shahira Al-Hameed, an obstetrician and gynecologist at Jisr Hospital. Recently, she faced a complex case of uterine rupture and internal bleeding. “The patient’s abdomen was filled with blood, and it was nearly impossible to identify the anatomy,” she says. “The techniques I learned here helped me stabilize her. She left the hospital alive and healthy.”

Dr Shahira joined the HEST programme to prepare for emergencies that go beyond her specialty. “As a gynaecologist, I often encounter cases where I need to manage injuries to the intestines or bladder,” she says. “This training has given me the confidence to handle such situations until a specialist arrives.”

For Dr Alaa Barhoon, a general surgeon with over a decade of experience, the training introduced faster, more effective methods that fit the realities of northwest Syria. He highlights how techniques like vascular shunting – a method to restore blood flow when vessels are severely damaged – have become essential when traditional resources are unavailable.

“Time is everything,” he says. "The new methods we’re learning can save lives in ways that older approaches cannot."

Preparing for the unpredictable

HEST also emphasizes triage systems, a critical need in hospitals faced with mass casualties. “Triage planning can make or break a hospital’s response during emergencies,” says Dr Hariri. “In many hospitals here, the lack of proper triage leads to chaos. Through this training, we’re showing how even simple systems can save lives.”

Participants gain confidence through scenario-based learning. Simulations of battlefield trauma and mass casualty events help them practice the most complex procedures under harsh conditions.

The toll of working in such conditions is heavy. Dr Al-Saleh, a father of 3, says treating injured children is particularly harrowing. “It’s impossible not to imagine my own children in their place,” he says.

Dr Shahira echoes these sentiments. “The emotional strain is immense, but seeing a mother and child survive after a complicated delivery reminds me why I chose this path.”

Ready to save lives

A trainer demonstrates advanced surgical procedures to participants during a hands-on session of the training. Photo: WHOAs the training concludes, its impact is already evident in the preparedness of its participants. “This isn’t just about surgery,” says Dr Hariri. “It’s about empowering doctors to face the worst and still deliver care.”

Beyond immediate skills, HEST focuses on long-term impact. Many participants, like Dr Ahmed Ghandour, have gone on to become trainers themselves. “I learned these techniques in 2019 and have since trained my entire surgical team in them,” says Dr Ghandour. “The ripple effect is profound – every surgeon we train can save hundreds of lives.”

The HEST training, delivered by expert trainers from the David Nott Foundation, was made possible through the support of USAID’s Bureau for Humanitarian Assistance (BHA) and implemented by the World Health Organization (WHO).

25 November 2024 – When Abbas* arrived in Lebanon in 2014 he was in his mid-20s, seeking safety and work away from the conflict in Syria.

At the Aoun al-Dadat crossing, health partners provide psychosocial support to help families – especially women and children – feel safe. Photo credit: Shafak Organization“I went alone, hoping to find a better life,” he says.

For nearly a decade Abbas managed to build a life, finding occasional work, marrying and having 4 children. By September 2024, however, the escalating violence in Lebanon left his family with no choice but to return to northwest Syria.

“We were renting a small apartment, and the financial situation was becoming unbearable,” Abbas says. “I was the only one working, and expenses kept piling up with four children. Then the shelling started. Every night, we had to evacuate to safer areas, only to return in the morning.”

After a week of constant fear, Abbas and his wife decided they had no choice but to leave. “We tried moving to a different neighborhood, but even there, the shelling continued. My children couldn’t sleep; they were terrified. That’s when we realized it was time to return to Syria.”

For many families like Abbas’s, the decision to return is not made lightly. It is often a last resort, driven by the worsening conditions in Lebanon. Northwest Syria remains unstable, offering limited resources and safety, but families are left with no other choice as they try to rebuild their lives.

A difficult journey

The journey was grueling. Families crossing into northwest Syria often have to wait for days at overcrowded border crossings, facing harsh conditions and delays. Abbas’s experience was no different. “We were stopped at checkpoints and forced to wait for hours without knowing when we could move. Traveling with 4 small children, including my 10-month-old, made everything even harder,” he shares.

Tragically, during the journey Abbas’s wife suffered a miscarriage. The emotional and physical toll has left her weakened and she is still struggling to recover.

“My wife is strong,” says Abbas, “but this loss has been very hard on her.”

After 8 exhausting days, Abbas and his family finally arrived in northwest Syria, physically and emotionally drained.

Health partners extend support to Abbas’s family

When they crossed into northwest Syria, Shafak, a humanitarian organization stationed near the Aoun al-Dadat crossing, was among the first to welcome them. “The team greeted us with kindness,” Abbas recalls. “They played with the children and helped them feel safe —something we hadn’t felt in a long time.”

Supported by UNHCR, Shafak is also coordinating the response of local organizations to support people returning. The team provided Abbas’s family with much-needed supplies, including food and nutritional support for the children, as well as psychosocial help. “They offered psychological first aid for my wife and spent time with my children to help them feel less anxious,” says Abbas.

“For many families like Abbas’s, the trauma of displacement does not end when they cross the border. Our team provides immediate care, including psychosocial support, to ensure that families—especially women and children—feel safe and supported in these difficult moments,” says a Shafak representative.

In northwest Syria, local health partners, with technical support from WHO, have scaled up services to address the needs of displaced families like Abbas’s. These include emergency care, vaccination campaigns, and mental health support at border crossings and in host communities.

Abbas now looks to rebuild

Abbas’s family now lives in a small, unfinished house in Jarablus, provided by his brother. “It’s better than living on the streets,” he says, “but it is not easy. We have no heating, and the roof leaks when it rains. The children still get scared by loud noises—they remember everything that happened in Lebanon and during the journey.”

The influx of over 8,100 Syrians fleeing Lebanon since late September has stretched the region’s already fragile health system. At border crossings like Aoun al-Dadat, medical teams provide immediate screenings and care, while ambulances are on standby for urgent referrals. Vaccination teams work to ensure children are immunized against diseases like polio and measles, particularly as many returnee children lack updated vaccinations.

Despite these efforts, the needs are vast.

“I want my kids to go to school, but I cannot afford it. My family is still distraught and in need of continued psychosocial support,” Abbas says.

Mental health support has also been critical. Families exposed to conflict and displacement often carry deep psychological scars. Health partners, like Shafak, continue to deliver psychosocial support to new arrivals, referring severe cases to healthcare centres for ongoing care.

For Abbas, the journey is far from over, but he is still hopeful. “I am grateful for the help we have received, but we will pick back up and try to rebuild our lives again. I owe it to my children and their future to keep going,” he says.

*Name changed to protect identity

KSrelief Supervisor-General Dr Abdullah Al Rabeeah with WHO Director-General Dr Tedros Adhanom Ghebreyesus during the signing of the agreement at UNGA this year.21 November 2024, Gaziantep, Türkiye – The King Salman Humanitarian Aid and Relief Centre (KSrelief) has pledged US$ 4.75 million to the World Health Organization (WHO) to support lifesaving health services in northwest Syria. This funding comes at a time when nearly 80% of the region’s population—4 million of the 5.1 million people living in northwest Syria—require health assistance amidst the ongoing challenges of prolonged conflict, funding crisis, and risk of disease outbreaks.

This funding will directly support over 50 health facilities across northwest Syria, including primary health care centres, hospitals, and specialized facilities such as dialysis and tuberculosis centres. It will address critical operational gaps by covering salaries for medical and non-medical staff, procuring essential medical supplies, and enabling disease surveillance to effectively monitor and respond to outbreaks.

A long-standing partnership for health and hope

KSrelief and WHO have built a strong partnership over the years, bringing health services to the most vulnerable. “KSrelief has shown incredible commitment to supporting the people of northwest Syria through its partnership with WHO,” said Rosa Crestani, WHO Emergency Lead for the Gaziantep field office. “This collaboration is an important step toward addressing the pressing health challenges in the region. By combining our expertise and resources, we can make a meaningful impact on the health and well-being of those in need.”

The funding will also ensure the continuity of critical services such as lifesaving dialysis sessions across 20 dialysis centres, which cater to over 1,200 patients each month. “WHO will further strengthen its efforts to sustain local health systems, focusing on integrating essential healthcare services for displaced populations and host communities in Aleppo’s Azaz, Al-Bab, and Jarabulus districts,” added Ms Crestani.

Meeting urgent health needs amid escalating challenges

Years of conflict have left northwest Syria’s health system severely fragmented and under resourced. Nearly 40% of northwest Syria’s primary and secondary healthcare facilities are either partially functional or entirely non-operational. The 2023 earthquake compounded this crisis, damaging infrastructure and critical medical equipment, and leaving the health sector in dire need of support.

“In addition to the direct impact of the conflict and natural disasters, the region faces emerging health threats such as cholera, measles, and waterborne diseases, as well as escalating challenges in providing maternal and child health care,” added Ms Crestani. Today, around 2.3 million women and over 700,000 elderly people across northwest Syria continue to face limited access to essential services.

Dr Abdullah Saleh AlMoallem, the Head of KSrelief's Health and Environmental Aid Department, stated, “In light of the escalating health challenges faced by the people of northwest Syria due to the earthquake that occurred in 2023, which demands health infrastructure and critical medical equipment, the healthcare sector is in a dire situation in northern Syria. KSrelief is committed to providing vital support through our partnership with the World Health Organization.”

“Our contribution of US$ 4.75 million is a testament to our dedication to ensuring that communities receive the essential healthcare services they need. This funding will not only sustain critical health facilities but will also empower local health teams to effectively address both current and emerging health threats. We believe we can make a meaningful difference in the lives of those who have endured prolonged hardship,” Dr Saleh AlMoallem added.

The new funding from KSrelief will help WHO sustain healthcare services in northwest Syria, ensuring people can access the care they need, from basic to specialized treatments. It will also support local health teams to plan, deliver and improve services, strengthening the region’s ability to meet health needs now and in the future.

For media inquiries, please contact:

For WHO: Mrinalini Santhanam, Communications Officer, This e-mail address is being protected from spambots. You need JavaScript enabled to view it

For KSrelief: Fanar Alshehri, International Communication Specialist, This e-mail address is being protected from spambots. You need JavaScript enabled to view it

About KSrelief:

The King Salman Humanitarian Aid and Relief Centre (KSrelief) is Saudi Arabia's leading humanitarian organization, dedicated to providing aid and relief to communities affected by crises worldwide. Since its establishment in 2015, KSrelief has implemented numerous projects across various sectors, including health, education, and food security, in over 69 countries.

19 November 2024 - In the wards of Dr Muhammad Waasim Maaz Hospital, also known as Bab al Salama Surgical Hospital in Azaz, northwestern Syria, healthcare workers face a complex challenge every day: treating patients suffering from infections complicated by antimicrobial resistance (AMR). Despite limited resources, they continue to provide care to their community, encountering stories that reflect both the vulnerabilities and resilience of those they treat. 

Zeina’s journey to recovery

Zeina Saleh, along with her mother, at the Bab al Salama Surgical Hospital in Azaz, northwestern Syria. Photo credit: WHO/Mrinalini Santhanam

Six-year-old Zeina Saleh arrived at Bab al Salama Surgical Hospital with a persistent high fever, vomiting and other alarming symptoms. “Even the fever medicine didn’t help,” her mother recalls as she sits in the hospital’s isolation ward. Zeina was lethargic and unresponsive to light or sound, leaving her family deeply worried. 

Dr Anas Al-Dhaher, a pediatrician specializing in neonatology, diagnosed bacterial meningitis after conducting a thorough examination and cerebrospinal fluid analysis. “It’s a serious infection, but we initiated treatment immediately,” he explains.

The Independent Doctors Association (IDA)-managed Bab al Salama Surgical Hospital’s testing lab within the main hospital. Photo credit: WHO/Mrinalini Santhanam 

Despite their swift action, there were warning signs that the infection might be complicated by antibiotic resistance. “We noticed that after starting the standard antibiotics, there wasn’t the expected rapid response in her symptoms,” Dr Anas shares. “This delay made us suspect resistance might be a factor.” 

Unfortunately, without access to culture testing at the hospital, confirming resistance was not an option. Families in Azaz often cannot afford private lab fees, leaving doctors to rely on clinical observations and standardized protocols. “Our emergency protocols always include culturing, but it is not available in our hospital. It’s only available in private labs, but it’s expensive. Also, it’s often inaccurate,” says Dr Anas. 

The medical team adjusted Zeina’s treatment to include broader-spectrum antibiotics to ensure coverage for resistant strains, guided by WHO recommendations. 

Over the next two days, Zeina’s condition improved noticeably—her fever subsided, and she began to eat and engage with her surroundings again. “She completed the full 14-day course and was discharged in good health,” Dr Anas adds. 

Left to right: Dr Husam Abob Alward, Dr Naser El Yousef and Dr Fares Al Shadidy, who work at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

Zeina’s case underscores the challenges healthcare workers face in managing infections in northwest Syria. Antimicrobial resistance complicates these situations, as doctors often must use broad-spectrum antibiotics due to the lack of diagnostic tools. This approach, while necessary, increases the risk of resistance in the long term. 

For Zeina’s mother, the experience was eye-opening. “I learned not to give antibiotics without consulting a doctor. It’s something I want other parents to know,” she says. 

In Azaz and similar communities, misuse of antibiotics is a common problem. Many people bypass doctors altogether and purchase antibiotics directly from pharmacies without prescriptions. Others start antibiotics at the first sign of illness but stop as soon as they feel better, failing to complete the full course. Such practices allow bacteria to survive and evolve, making future infections harder to treat. 

Facing complications head-on

Layal Sheikh, with her mother Azab and father Abdullah, at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

Fifteen-year-old Layal Sheikh’s story highlights the strain antimicrobial resistance places on health care systems. Layal underwent emergency surgery for a suspected abdominal tumor, but her recovery took a complicated turn. Post-surgery, she developed a severe infection. 

“The initial antibiotics didn’t work, likely due to resistance,” explains Dr Naser El Yousef, the lead surgeon who managed her case. The medical team recommended a culture test to identify the most effective antibiotics.  

While waiting for the results the team adjusted Layal’s treatment, cautiously introducing higher-generation antibiotics. This approach was paired with strict infection control measures to ensure that resistance did not worsen. “We took a careful, stepwise approach, escalating antibiotics only when absolutely necessary,” says Dr Naser. 

Over the course of several weeks Layal’s infection began to subside. Her condition stabilized and she was eventually discharged in good health, much to her family’s relief. 

For Layal’s father, the ordeal was a lesson in the importance of timely medical care. 

“We tried home remedies at first, but they didn’t help. The doctors here were thorough and supportive and I’m grateful for their efforts,” he says. 

Dr Naser reflects on the challenges healthcare workers face in managing antimicrobial resistance. “Without access to adequate resources like culture tests and referral systems, we are often navigating in the dark. It’s critical to have the right tools to provide timely and effective care,” he says. 

WHO monitors the distribution of antibiotics and advocates for responsible use while in discussion with the pharmacist at the Bab al Salama Surgical Hospital. Photo credit: WHO/Mrinalini Santhanam

WHO monitors the distribution of antibiotics and advocates for responsible use while in discussion with the pharmacist at the Bab al Salama Surgical  

WHO has been instrumental in addressing these gaps by training healthcare workers like Dr Naser and Dr Anas to effectively manage resistant infections, enhance infection control practices across healthcare facilities, and educate patients. With support from USAID’s Bureau for Humanitarian Assistance (BHA), WHO trained over 600 healthcare professionals in 2024 alone and plans to continue advocating for responsible antibiotic use, patient education, and regular testing to ensure that patients like Layal and Zeina can access quality, specialized care when needed. 

The human cost of antimicrobial resistance 

Each patient’s experience sheds light on the growing challenge of antimicrobial resistance in conflict-affected areas like northwestern Syria. Limited resources and the misuse of antibiotics complicate efforts to manage infections effectively. 

Healthcare workers like Dr Anas and Dr Naser do more than treat illnesses – they educate families and promote practices that help prevent resistance. 

“We make a point of explaining the importance of completing medication courses and seeking medical help early,” says Dr Anas. 

For patients and families, these lessons are invaluable. 

“I’ve learned to trust the doctors and follow their advice,” says Layal’s father. “It’s the best way to protect our children.”