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The collapse of Syria’s dictatorship, in December 2024, allowed Dr. Bachir Tajaldin to travel to hospitals and health care facilities that had been out of reach for years. What he found horrified him.
Doctors and other providers were working amid crumbling infrastructure and outdated, broken equipment in areas that former president Bashar al-Assad’s regime had controlled. Even critical medical supplies were scarce. Medical records were missing. Salaries for medical workers were unpaid.
“There was a huge network of corruption,” Dr. Tajaldin, a country director in Turkey for the Syrian American Medical Society, a volunteer-run medical relief organization. International sanctions “didn’t affect the regime, but they did affect the infrastructure of the country. The health infrastructure is very old and very weak. It’s a disastrous situation.”
Perhaps most worrying of all was the “spotty and dangerous” skill set of medical providers in regime-controlled areas, said Dr. Amjad Rass, an internal medicine physician and chairman of the SAMS Foundation. Physicians who’d been cut off from communications and training were using protocols that had been outmoded for a decade.
A director at a Syrian children’s hospital told Dr. Rass that, during a recent visit from German physicians, a child went into cardiac arrest. The doctors on staff didn’t know how to do CPR according to protocol. “I wanted the floor to open up and swallow me,” the director recalled.
Syria’s future is still highly uncertain. New, large-scale outbreaks of politically motivated violence have killed more than 1,300 people, reigniting widespread terror. Humanitarian aid channels haven’t opened as hoped into Syria, and shutdowns in public funding have created new difficulties for nonprofits working in the war-torn country.
Increasing access to health care across Syria, especially to formerly isolated areas, must be a vital priority, SAMS volunteers said.
“Those things don’t exist in Syria”
Media reports on Syria’s health care system have primarily focused on the direct impacts of war: bombed hospitals, providers operating in darkness. But those reports focused on areas of the country that were controlled by the rebels and sometimes accessible to outsiders. Even for doctors who’d worked in the rebel-controlled northwest of Syria for years, gaining new access to regime-controlled areas was shocking.
In particular, SAMS physicians and staff described vast and widespread needs – for mental health care and psychosocial support, working dialysis equipment, cancer treatments and other specialty medications – coupled with an urgent demand to train providers in up-to-date techniques, new medical knowledge, and clinical best practices.
Doctors described such widespread fear, anger, and distrust that the situation amounted to “collective trauma,” said Dr. Iyad Alkhouri, a child psychiatrist who works with SAMS. “You…wake up one day and you don’t have any moral code or order, and society is completely collapsing,” he said.
A Sim Lab provider gives a lecture on treating shock, a life threatening medical condition, in an ICU nursing course at the Sim Lab. (Photo courtesy of SAMS)
Most urgent from a mental health perspective, he said, are the thousands of people who have been released from prisons. Many are malnourished, dealing with musculoskeletal conditions, or need treatment for tuberculosis.
“To survive an earthquake is a miracle, to survive 20 years of torture is heroism,” he said.
Dr. Alkhouri is concerned that, while Syrian psychiatrists are dedicated and well-meaning – he estimates there are about 80 of them still in Syria, where they’ve been working in appalling conditions for years to care for patients – he wants to ensure that released prisoners are treated with up-to-date approaches used with survivors of torture. Their symptoms are “a normal reaction” to living in unimaginable circumstances.
“To be told they have PTSD is so demeaning…Their main need is not medicine for nightmares. Their main need is dignity,” he said. “We have to start from zero, without insulting those professionals who worked under the regime for decades.”
Only about 10% of Syrians in need of mental health care will require a psychiatrist, Dr. Alkhouri said. The others primarily need psychologists, social workers, and other providers who focus on non-medical care, and who can provide mental health support under supervision from therapists versed in new research and techniques.
But “those things don’t exist in Syria,” he said. Instead, mental health is highly pathologized and stigmatized, seen as a medical ailment that removes people from mainstream society.
Physicians in primary care centers and emergency departments “were looking at the minimum acceptable quality of care,” Dr. Tajaldin said. Patients provided what supplies and medications they could afford, and “emergency was using whatever was available.”
“The backbone”
A simulation lab in Qah Hospital, in northwest Syria, is key to SAMS’s strategy for rebuilding Syria’s health care system.
The lab, completed in April of 2024 and supported by a Direct Relief grant of more than $708,000, precedes the regime’s fall. However, the trainings and certifications it offers – the Sim Lab has already trained more than 400 physicians and medical workers in basic and advanced cardiovascular life support, maternal and perinatal health care, and much more – have proven indispensable to doctors and other providers in newly accessible areas.
Additional, advanced trainings, such as in new surgical techniques, are also planned.
A recent SAMS training for physicians conducted in Aleppo and Latakia, two Syrian cities, taught new techniques for diagnosing and treating physical trauma, low blood oxygen, shock, kidney injury, and other emergent conditions. The training concluded with two days in the Qah Sim Lab, providing hands-on experience to help physicians prepare for a variety of life-threatening clinical scenarios.
Trainees at the SAMS Sim Lab learn to care for patients placed on ventilation. (Photo courtesy of SAMS)
“Over a decade of war has forced many academic and teaching facilities to close their doors, which has led to major disruptions to medical education programs throughout Syria. The 2023 earthquake in northwest Syria caused further strains on an already overburdened health care workforce,” explained Dan Hovey, vice president of emergency response at Direct Relief. “This medical simulation training facility will provide thousands of Syrian health care workers access to high-quality and hands-on medical training, improving the standard of care in healthcare facilities across the region.”
Many physicians and medical students in Syria lack the real-life skills they need, Dr. Rass said: “They get stumbled by someone with low blood pressure, but they can give you a whole lecture on what causes low blood pressure.”
The Sim Lab has the potential to save countless lives across Syria, but finding funding that isn’t directly focused on emergent care can be difficult. Dr. Rass said.
“I can go to any donor and say I need to support pediatric services,” he said. Convincing donors to support a high-tech training center, where the impact is longer-term and farther-ranging, is more complicated.
“You were the backbone,” he said of Direct Relief’s support.
“A new day”
Cohorts of medical providers and students from regime-controlled areas have traveled to the Sim Lab to learn lifesaving new techniques for intensive care, emergency work, and specialist treatment. “I’ve seen this on TV. I thought this would never get to Syria,” one medical student told Dr. Rass.
A trainer instructs a nurse in defibrillation techniques during a Sim Lab course. (Photo courtesy of SAMS)
Dr. Alkhouri described working with Syria’s government ministries to incorporate mental health degrees into higher education and reintegrate former political prisoners back into their families and communities. The new Ministry of Health has established a task force to address widespread health needs, like kidney disease and cancer, Dr. Rass said – and four of its nine members are SAMS physicians.
“We are assisting the health authorities to rebuild and regulate the health system,” Dr. Tajaldin explained. Assessing health care facilities’ needs, retraining providers, and finding gaps between need and available care are high priorities.
Rebuilding Syria’s once-celebrated health care system will take time, Dr. Rass said. However, SAMS has spent years working against a background of unending war and destruction. During that time, the organization hasn’t just helped meet emergent needs: It has supported oncology, surgical services, obstetrics, and a wide range of other specialty care, bolstering Syrian health care even as conflict raged on.
“SAMS cannot operate forever,” Dr. Rass said. That’s what makes the Sim Lab – and its cutting-edge training programs – so important. “Once we build the experts, that means we build the leaders of the future.”
In partnership with the Syrian American Medical Society, Direct Relief has provided $165 million in material medical aid, and $3 million in grant funding, to health care providers in Syria and organizations providing health care to Syrian refugees, since 2014.
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