Locum GP Dr Hareen De Silva shares his experience of working in areas of conflict, including Syria, Ukraine, Iraq and, most recently Gaza.
I’m often asked what a GP actually does in disaster zones. When people think of places of conflict, they picture emergency medicine – and understandably so. The first time I applied for a job abroad in disaster medicine, I was rejected as the organisation said they don’t really look for GPs and only want hospital doctors.
That was in 2021. I had applied to be a medical doctor in Syria’s Al-Hawl refugee camp – the most dangerous refugee camp in the world at the time. It was also at a time where the pandemic was still raging, meaning that no hospital doctors could get time off to work abroad. So, two months later I was asked if I wanted the position. I thought ‘beggars can’t be choosers’ and took the role in a 24-hour inpatient facility within the camp.
As I couldn’t do normal acute medical work, I made my own job plan. I focussed on education – every week I would hold teaching sessions for local staff: basic pathophysiology, basic presentations, bedside teaching, quality improvement projects etc. It was all the stuff you do in GP training that you think is just a waste of time because it isn’t clinical! But it was incredibly useful for monitoring and evaluation processes. I also worked with administration and logistics which is how I eventually wound up managing teams. Since then, I have worked with different organisations leading missions in Ukraine and Iraq.
Earlier this year I spent a month in Gaza to lead a team of humanitarian healthcare workers. Of all the places in which I have worked, it was the most dangerous and by far the worst humanitarian crisis. In most places, the crisis is usually found in ‘pockets’ – in Ukraine it was on the frontlines, in Syria it was in the refugee camps. But, in Gaza there was just destruction as far as the eye could see.
One of the most difficult parts about working in this environment was trying to maintain staff wellbeing. We’re seeing devastation every day and it’s hard to keep morale up. One of the core skills of general practice is being able to assess people in a very short space of time. If you’re living and working with a team though, you get to develop relationships with them quickly and notice when someone might be a bit off. During our evening debriefs – by torchlight so we didn’t waste electricity – I would take care to notice small changes in people’s behaviour so that if it looked like somebody was struggling, I could try to support them as soon as possible, before they might deteriorate.
I look at my role as trying to fulfil Maslow’s hierarchy of needs. In Gaza, together with a logistician, I worked to ensure that our team had the essentials: accommodation, security, food, drinking water, shelter, electricity etc. In such a desperate and dangerous environment, people can’t really be happy. But, we do need to make sure that everyone is fit and able to perform in the medical role that they have. I essentially cut all the crap out so they can just go ahead and treat patients without having to worry about the logistics.
There’s no denying that this work is hard and dangerous. But it is important. We go into a place which is devastated for whatever reason – natural disaster, human made disaster, war, etc. Our role is to support the local structures and try to get them back on their feet. We’re never going to solve the issue, but it’s not about that.
For me, management is about making long-lasting changes. You can make genuine impacts on each person that you see. It’s not about treating one person and moving on to the next. We are setting up structures and teaching local staff who may not have access to certain types of education and resources – giving them skills to take forward.
For example, in Gaza an American paramedic on my team was a bedside ultrasound teacher. The Palestinian Red Crescent Society, with whom we were embedded, hosted us in their facility which allowed us to set up teaching sessions. A lot of the local clinical staff there said that they picked up a lot of things that they hadn’t come across before. Humanitarian assistance is moving more towards localisation – we are trying to decolonise the approach. We are trying to assist the local population – not impose upon it.
I couldn’t do ‘normal’ general practice all the time. In the UK I’m a locum GP, so in one week I might be working in four different practices and so can never build up relationships with the team. But, working in these humanitarian teams allows me the opportunity to engage in those collaborative operations. Sure, I could settle down and become a salaried GP – but if I do that, then I lose the flexibility of being able to deploy on missions abroad. It also means that when I come back from working abroad, I can allow myself the time off to re-adjust to normal life before picking up any more NHS work. It also makes me realise how privileged we are – and any humanitarian worker upon returning home will tell you that. Even though the NHS is in crisis, it is still far better than any other system I have worked in where I am abroad.
Part of being a general practitioner is making do with your limited support and lack of equipment. You have to manage patient care depending on what is available to you at the time; the places you can refer to; how quickly a referral might happen. Since I qualified as a GP in 2015, the state has just continued to decline. Instead of waiting three months to see a specialist, people might now be waiting up to 12 months. So while I don’t mean to equate typical general practice with working in disaster medicine, there are certain similarities: you have limited resources and you just have to go off our clinical skills, and deal with the situation and patient at hand.
Primary care is the bedrock of everything, especially in humanitarian settings. When people lose access to their chronic health management, who is better placed to address that? Not a surgeon, not an acute medical consultant, but a general practitioner. Knowing what to do if you don’t have access to a medication you would use as the first line; we know the second line and we know the third line.
GPs are trained to make do with what they have, not use guidelines as a rigid box. We think outside the box. If you’ve got the ability to manage people’s chronic health, mental health, physical health – which GPs do – then a population is much more likely to get back on their feet quicker.
Dr Hareen De Silva is a locum GP in London. He is also a trustee with Fairhealth, a UK based charity providing medical education on reducing health inequalities, and a search technician for Essex Lowland Search and Rescue Team. You can find him on X: @drhareendesilva
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