War zone medicine: treating friends, enemies, and staying safe.
A New York-based global health physician shares her experiences overseas.
In late February, when Russia senselessly invaded Ukraine, a handful of my medical colleagues started packing their bags almost immediately. They understood that a humanitarian crisis was all but inevitable, so they knew where they had to be.
Some flew to neighboring countries like Poland and Romania. Others went to Ukraine. Each of them was a volunteer with one of several established international medical nonprofits. But, also, each of them is a living, breathing individual, with one life to live, and one life to risk.
The thought of going to Ukraine to provide medical aid never even occurred to me. While I am not especially trained in war zone medicine, I’m an emergency physician with skills that could be useful in almost any medical situation. What I told myself is that my life is too complicated to just up and leave. I have responsibilities here at home, both at the hospitals where I work and to my family.
But is that really a good enough excuse? In the late-Madeleine Albright’s memoir Madam Secretary, she tells the story of two dissidents. Faced with danger, one says, “I would help you, but you see I cannot, because I have children.” The other says, “I would remain silent like you, but you see I cannot, because I have children.”
What drives some of my colleagues to put themselves in harm’s way?
I don’t know.
So, I decided to speak to some, both to get a sense of what these missions look like, and how they perceive their own risk. In this first installment, I spoke to a physician who volunteered to go to Iraq, and has also worked in places like Yemen and Ethiopia (her native country). In a future column, I’ll speak with volunteers who have worked in and around Ukraine, and others with expertise in this complicated area.
"They're risking their life. We should be completely proud of them."
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Dr. Tsion Firew is an emergency physician at Columbia University in New York who served near the frontline in Iraq as forces liberated Mosul from ISIS back in 2017. She was there as a volunteer with NYC Medics, a nonprofit organization that deploys medical teams when disasters (both natural and manmade) occur. While most medical nonprofit aid groups don’t send volunteers close to the fighting itself (which generally falls into the purview of the militaries and locals), Dr. Firew has been closer than most. While Tsion and I have become good friends during the pandemic (from afar), until now, we have never discussed her frontline work overseas in any detail. She tells me about working in makeshift hospitals in what sounds to have been fairly unstable and fluid situations. She speaks of three waves of patients she might expect to see after a military operation.
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“The first wave you'll see are injured soldiers, right?” (Umm, sure Tsion, I nod along.) “So, you'll stabilize them,” she continues. “And then as they go in, they'll find civilians that were immediately injured from the operation. So that would be the second wave of patients that would come via ambulance or with the medics that were embedded with the soldiers. And then the third wave would be, as they liberate the houses, go house to house and knock. And you’d find people that are not able to walk, who have been immobile for several months or years, and people with no access to food.”
Dr. Tsion Firew provides hydration to a young child while working in Iraq in 2017.
One of the “givens” in medicine, is that we take care of people regardless of who they are. That means offering the same care to your enemy as your family. While I’ve certainly taken care of patients who have done horrible things or have despicable beliefs, I can’t say I’ve ever treated an ISIS fighter.
What’s that like, I want to know?
“As difficult as it might be, you just have to give the respect. The oath that we took to take care of everyone. And we do that.” Because she was embedded with Iraqi forces who were fighting ISIS, the were sometimes tensions, she says, especially related to safety concerns.
Learning to manage that seems important. She describes how these conversations sometimes play out. “Hey, this is my patient. I'm going to give them everything that I need, that I want, to do. Whatever your own thoughts or biases might be, different than mine, right now he's my patient.” But if there’s a safety issue, she says, it gets addressed so that she can do her job. That doesn’t mean it’s easy, or that everyone is a saint.
“I think we are always challenged by those things,” she acknowledges, “but I think it's about staying true to yourself and about the integrity within this job. It is challenging. But you do it.”
What fascinates me, and so I asked directly, is whether the humanitarian act of giving medical aid to an ISIS fighter actually functions as a kind of de facto psych-ops. The idea—the pretty fantasy I’m advancing—is that maybe, just maybe, when an injured ISIS fighter receives compassionate treatment from the medical staff of his enemy, he may come to see them (and therefore all of his enemies) as more human.
Dr. Firew tells me about presumed ISIS fighters she has cared for, although many deny their associations. Through the Arabic translator, she learns that the soldiers were “quite amazed by the empathy that came out of the providers.” But that courtesy only extends so far. “We made it clear what happens inside the compound is really, um, all that we could do; providing medical care.” After that, they’re pretty much on their own, “the second they walk outside of the hospital.”
I imagine that I’d feel unsafe walking out of that hospital myself, regardless of which side I was on, or my role. Overall though, Dr. Firew tells me that she has felt safe during all of her deployments. It’s a common refrain that I’ve heard from other global health volunteers as well. Universally, these volunteers tell me that they feel safe almost all of the time.
But sometimes I wonder whether this is posturing—not for our benefit, but for their own. Many of these volunteers have treated doctors and journalists who were seriously injured as a result of putting themselves into dangerous situations. So, I know they’ve seen the genuine danger that comes with the territory. Maybe, I think, it’s easier for them to downplay the risk to themselves so that they won’t be afraid to continue this vital work, now and in the future.
Ultimately, though, I still want to get inside the mind of healthcare workers like Dr. Firew, who literally fly across the world to help relieve suffering in harrowing conditions. I ask whether I should be worried about our colleagues deploying to places like Ukraine, or simply proud of them. After repeatedly telling me that she felt safe in various situations, including in some manifestly dangerous spots, Dr. Firew acknowledges what I suspect, which is that is all comes down to location and situation, both of which can be expected to change rapidly on these missions. When she first arrives in Iraq, she finds her taxi driver playing Jay-Z on the radio and it almost feels like just another day back in New York. That is, until the car starts passing by destroyed buildings and she gets closer to the fighting.
People near the violence are at increased risk of dying, she acknowledges. So, yes, “they're risking their life. We should be completely proud of them.”
Does this mean that people like Tsion have "the right stuff?" Or are they simply downplaying the personal risks they are taking in order to help their fellow humans? Maybe, I think, there's no material difference.
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Afterword: As I mentioned, I have spoken to a handful of other physicians who have volunteered in crisis situations around the world. In an upcoming Inside Medicine, I’ll bring you their voices, including those who have been in Ukraine. The challenges they face may not be what you’d expect.
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