Our group’s flight, on a Turkish Airlines 737, landed October 7, 2019, in Erbil, Iraq—approximately four years after the Peshmerga Kurdish forces, with the help of U.S. and coalition forces, finally began to turn the tide of the war against ISIS (also known as Islamic State in Iraq and Syria). In its wake, ISIS killed, maimed, raped, and tortured the Yazidi Kurds and other minority groups in Sinjar province, occupying and creating what is arguably one of the most oppressive theocratic regimes in recent history.
Our group was there to aid the Yazidi Kurds, who number approximately 1 million people, of which hundreds of thousands reportedly have been killed by ISIS and persecuted throughout history. They are friendly, peace-loving, devout, and tolerant people.
After clearing customs, we were surprised to be traveling on a newly constructed highway, lined with the glimmering lights of hotels of downtown Erbil. The sight of multiple five-star hotels was a comfort to our anxious thoughts of the area’s conflict and danger that Americans frequently see in the media. In fact, the autonomous region of Kurdistan in northern Iraq appears more westernized than some areas of wealthier nations.
Purpose of the mission
Our protocol drivers from the Kurdish government picked us up at the Erbil airport and whisked us off to Dohuk, the most northwestern city in northern Iraq, sprawled snugly against the mountains north of the Tigris River. We came as members of the Global Surgical and Medical Support Group (GSMSG), an organization founded by Aaron Epstein, MD, a second-year general surgery resident in the department of surgery, University of Buffalo, NY, a Resident Member of the American College of Surgeons (ACS) and co-author of this article. Dr. Epstein’s previous experience in the defense and intelligence arenas motivated him to attend medical school and pursue a career in trauma and critical care surgery.
GSMSG is a 501(c)(3) not-for-profit organization that has arranged for approximately 200 U.S. health care professionals to provide care and training in Iraq/Kurdistan to Syrian Kurdish refugees, internally displaced persons (IDPs), and Iranians. GSMSG surgeons also provide care in Syria and Somalia, as well as other areas within Africa. The GSMSG team as a whole is composed of more than 1,000 U.S. health care providers, more than 200 of whom are physicians and surgeons across every specialty. The other 800 include nurses, medics, and physician assistants. Most participants in these missions are U.S. military veterans, particularly from the special operations community. GSMSG has been a magnet for the veteran community interested in humanitarian activities overseas.
Dr. Epstein created the organization in 2015 by combining his old networks in global security with his newer networks of medical professionals once he started at Georgetown Medical School, Washington, DC.
The primary objective of the organization is to provide training, as opposed to other aid organizations that usually provide itinerant care. The ultimate goal of GSMSG is to become obsolete within the population it is serving by creating long-lasting, self-sustaining solutions to humanitarian health care crises.
The GSMSG team for this mission was composed of 26 physicians and nurses, as well as one physical therapist and one occupational therapist, Barbara Ginzburg, the wife of co-author Enrique Ginzburg, MD, FACS. Among the physicians were one cardiothoracic surgeon, three obstetricians/gynecologists, five general surgeons, one dermatologist, and one anesthesiologist. The remaining team members were nurses. Most of the nurses and the anesthesiologist were retired U.S. military health care professionals. Another eight members of our GSMSG team were Special Operations veterans who also hold medical credentials.
One of our team members, Asfandiar Shukri, MD, a retired general surgeon in Bloomfield, MI, along with training local medical and surgical professionals, assisted with translation and with patient exams and workups. Dr. Shukri served in Iraq at the height of the Iran-Iraq conflict and is still active in relief missions. He was instrumental in the conviction of Saddam Hussein for the gassing of the Kurds. More specifically, he testified at the trial against Saddam Hussein in Iraq in November 2006, giving an eyewitness account of the horrific effects of weapons of mass destruction used on women, children, and the elderly during Saddam’s regime.
We arrived at the IDP camp the next morning. As we crossed through security gates, we were greeted by Yazidi Kurd children playing in the schoolyard, with the usual smiles and friendliness of all children throughout the world, even when faced with the reality of living in difficult circumstances.
We proceeded to the health care center, where we spent the rest of the morning examining patients—primarily children and their mothers. Patients presented with the usual coughs, sore throats, back and neck pain, and pediatric dermatologic issues. We also removed shrapnel from the thigh of a young boy who had been shot by ISIS. We evaluated a woman with a recurrent hydatid cyst, and we attempted to schedule surgery for her at Azadi Medical Center, the regional tertiary referral hospital in Dohuk. (The operation did not occur on this particular trip, but likely will occur on a future mission.) It became evident to us after discussions with Nezar Ismet Taib, MD, director of the Health Directorate in Dohuk, that hydatid cysts are endemic to the rural areas in northern Iraq.
In accordance with their religious beliefs, young women rarely let male physicians examine them, deferring to women surgeons and internists. One young woman would not even allow us to examine her ankle for inflammation. For this reason, the GSMSG ensures that half of the team who come on the trips are women physicians and health care professionals. On this trip, the GSMSG obstetricians and gynecologists performed the first laparoscopic total hysterectomy in the women’s hospital.
Azadi Medical Center does not provide emergency acute care surgical services. Patients needing this level of care are transferred to Dohuk Emergency Hospital, a more austere two-story complex that houses five intensive care unit beds and five emergency department (ED) triage beds for acute trauma and acutely ill individuals. The ED is divided into two separate sections by a wall, with men on one side and women on the other. Surprisingly, the Dohuk Emergency Hospital had a functioning digital X-ray room and computed tomography scan.
David Epstein, MD, an interventional radiologist in south Florida, and Dr. Aaron Epstein’s father, has participated in multiple missions. Dr. David Epstein is the only interventional radiologist training health care professionals in Kurdistan to perform angiographic embolization techniques.
Establishing a self-sustaining surgical care system
After the second day at the IDP camp, we went to Azadi Medical Center and spent the rest of the mission operating alongside the Kurdish surgeons. The public health system provides free medication and surgical services each day until 1:00 pm. Approximately five operating rooms (ORs) were in use that day. Patients were undergoing pediatric and adult urologic procedures, general surgery operations—including laparoscopic cholecystectomy and hernia repair—as well as otolaryngology procedures. Paramedian hernias are common in multiparous women, and umbilical hernias are repaired with only mesh and sutured down circumferentially after primary closing of the fascial defect.
The surgeons claim minimal recurrence and migration, as well as low infection rates. Turnover time is minimal because documentation and all the regulatory processes of ORs in the U.S. are absent. The operations at Azadi Medical Center are performed mainly by the most senior fellows under the supervision of their attendings, who are commonly scrubbed during complex cases in the morning. All private cases are performed in the afternoon, and all cases at the public emergency hospital are staffed by senior residents. Laparoscopic equipment for all cases is available for use, but single-case throwaway equipment, such as clip appliers, are unavailable because of cost constraints.
Focusing on long-term needs
Although GSMSG teams do clear backlogs in cases both for primary and surgical care, the organization’s main focus is capacity building and establishing training programs for local medical professionals. Too often, groups with good intentions enter an area to provide care, only to leave local populations with little to no follow-up opportunity, or leave behind material donations that cannot be locally replenished or are so technologically advanced that the local health care community is unable to use them.
We also recognize that a lot more goes into reducing morbidity and mortality rates among populations in conflict areas than providing surgical care. For that reason, the GSMSG focuses on providing care and training at the nursing and prehospital medic levels.
To date, in Iraq alone the GSMSG has trained more than 2,000 local health care professionals in prehospital care, trained more than 200 individuals in nursing care, and conducted training sessions for more than 500 local physicians and surgeons. The GSMSG has tended to thousands of primary care patients and completed hundreds of major operations across nearly all major subspecialties, ranging from coronary artery bypass graft, to Ilizarov procedures, to total abdominal hysterectomies. We also maintain follow-up and the ability for local physicians to contact our surgeons stateside for consultation as needed. Fulfillment of this responsibility is usually routed through Dr. Aaron Epstein to the most appropriate provider on the GSMSG roster, and the conversations take place via Skype, FaceTime, or other video-conferencing technology.
It should be noted that expanded participation by chief residents and fellows in GSMSG will provide greater access for underserved populations in need of surgical care.
Expanded participation by U.S. chief residents and fellows on future GSMSG missions would prove beneficial for both the trainees and the local population. For the U.S. trainees, participation in a mission would be a great opportunity to refine techniques such as open procedures, which are rarely done in the U.S., and often only in response to an adverse event caused by medical or operative errors. However, all surgeons should be able to do an open procedure, as it is the ultimate fallback when laparoscopic or robotic equipment fails. Technological advances have the surgical community looking so far forward that we sometimes forget to take the occasional look back, to remember our fundamental roots. After all, the most basic surgical intervention only requires sharp steel, bright lights, and brain power—and maybe some suture.
The GSMSG provides a unique opportunity for senior U.S. surgical trainees and fellows to join senior attending-level surgeons overseas in order to experience austere surgical settings and to perform fundamental surgical interventions that are rarely part of training in the U.S. Not only would such an opportunity benefit U.S. trainees, but it would benefit individuals interested in pursuing careers in rural practice or in austere settings. The opportunity to operate under the supervision of leading surgeons from top-tier institutions is rarely available to most U.S. surgical residents.
Obviously, such operative experience is only done to the extent that these procedures provide the maximum benefit to the patient population. It should be noted that expanded participation by chief residents and fellows in GSMSG will provide greater access for underserved populations in need of surgical care. It is clear that this program and others like it create a win-win for both patients and providers. Basic procedures, such as those for acute cholecystitis, appendicitis, or herniated bowel, are lifesaving for the patient, but also give the trainee the chance to refine fundamental skill sets.
Participation in GSMSG is a unique experience that motivated, compassionate, adventurous surgeons will appreciate. GSMSG covers the cost of transportation, room, and board once the senior physician arrives in Erbil. One gets a sense of giving back when participating in the GSMSG mission to Iraq. The experience promotes an appreciation for the geopolitical region of the Middle East and its historical and religious importance. The GSMSG team experience truly is life-changing.
It is important to note that while pockets of ISIS activity have been reported in the most rural areas around the Syrian border, security was never an issue while we were deployed in Dohuk or in Erbil. It was an honor and a privilege to serve the Yazidi people during this mission.
One of our local Kurdish/Iraqi partners in the region once told Dr. Aaron Epstein, “For decades, all we have ever known in the region has been the might of the American military. But with GSMSG and your teams, we have truly seen the might of the American heart.” What we who work in medicine have learned is that the human touch and the human presence go a long way toward healing individuals. Often our presence alone provides the needed healing for patients we see in the field. To know that someone is willing to sacrifice time and income to show patients that we care does wonders for those in need.
If you are interested in joining the GSMSG team, visit the Global Surgical and Medical Support Group website.