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AOAV interviews Dr Ghassan Abu-Sitta, Head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre

Dr Ghassan Abu-Sitta

Dr Ghassan Abu-Sitta is head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre, and the Co-director of the Conflict Medicine Programme at the Global Health Institute at the University. AOAV’s Executive Director, Iain Overton, interviewed Dr Abu-Sitta in Beirut, Lebanon, in February 2020 as part of the research on the lasting health impacts from the use of explosive weapons. Here, Dr Abu-Sitta discusses blast injury data and what better data collection could mean for future weapon-wounded individuals.

Iain Overton:
We’ll start from the beginning. Can you tell me your name and title?

Dr Ghassan Abu-Sitta:
My name is Dr Ghassan Abu-Sitta. I’m head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre, and I’m the Co-director of the Conflict Medicine Programme at the Global Health Institute at the University.

Iain Overton: 
For a bit of context, where have you operated?

Dr Ghassan Abu-Sitta:
I worked in Iraq during the first Gulf War, in Gaza during the first Intifada, the Second Intifada, and the 2008, 2012 and 2014 wars, and then during the Marches of Return, when the American Embassy was moved to Jerusalem. I also worked in Syria, and I worked in Mosul.

Iain Overton:
So we’re witnessing an age where civilians are disproportionately impacted by conflict, and increasingly so. Our data suggests that 90% of those killed or injured by explosive weapons in populated areas, such as towns and cities will be civilians. In your experience, do you think that the medical community and, more specifically, the wider international community, have a profound understanding of the direct and indirect effects of explosive weapons on civilians?

Dr Ghassan Abu-Sitta:
On a conceptual level, I think we’re still stuck in the frame of mind that wars are a temporal event. But what we understand is that wars actually create an ecology. And that ecology of war traps people inside it, and it injures them in ways that we don’t recognise immediately as war injuries but are as a result. For example, a child who suffers a burn in a refugee camp that’s a result of in unsafe housing, is not a war injury but it is a consequence of that ecology that the war has created. There was an article in one of the newspapers today about the epidemic of injuries, especially children with injuries, now in eastern Syria from unexploded ordinance – that is a war injury.

So, conceptually, we don’t understand that regionally. In this region and in a few regions in the world, we do not accept that war-related ill health constitutes an endemic disease; i.e. that a disease that is historically associated with a given geographic area. And the consequences of not accepting that idea is that we have not reshaped our health systems and our medical education systems to deal with war injuries as an endemic disease. I intentionally teach my students about war injuries but medical schools in Baghdad and in Gaza still don’t teach this as one of the things that their graduates will see; they spend time teaching about rare congenital abnormalities that their students won’t see.

Iain Overton: 
Do you think one of the reasons why there is this lack of evolution in terms of understanding wars as endemic is that data, or a lack of data, is an inhibitory issue?

Dr Ghassan Abu-Sitta:
So what happens is that you think this is the war to end all wars, and therefore, you don’t need to collect the data. Because there’s really no need, once you get through this current catastrophe, to learn something for the next war. And so, one of the reasons why in a lot of these communities, we don’t see this experience embedding itself within the institutions, is the lack of data; their lack of documentation. This is the point at which we start examining our experience and turning it into expertise. Without documentation, people cannot turn their medical experiences into expertise.

Iain Overton:
When a patient presented to you in some of the conflicts that you’ve been witness to, what sort of data did you collect? And what data do you think needed to be collected, that there wasn’t an onus on you to collect?

Dr Ghassan Abu-Sitta:
So currently, the medical literature, is dominated by military medicine and military medicine does not bear any resemblance to the health systems that my patients have gone through. Military medicine is a systemized first-world medicine that’s been transported into an austere environment.

My Syrian, Palestinian and Iraqi patients were treated in a rudimentary hospital and then incompletely treated and then moved to another hospital and then discharged early because they needed the beds and then they would travel to other places to get incomplete bits of their treatments. And a military patient whose data is being presented in this literature, has been from injury, airlifted and then processed through the system. And therefore the conclusions that they come to cannot be applied to a lot of the cases. And that, for me, is the main issue about what is available now in literature: it is not applicable.

Iain Overton:   
Where do you think the major gaps and knowledge are in terms of medical understanding of harm on civilians from explosive violence?

Dr Ghassan Abu-Sitta:   
If we want to divide the patients by age group, 90% of the clinical literature on children comes from military medicine. It’s the civilian children that were treated in the military hospitals, in Bagram and in Iraq. So we know very little, if at all, about the management of war wounds in children. Clinically, and in terms of basic science knowledge, we know even less about the way the child’s body reacts and recovers from war injuries. And this is everything from amputations to major blood loss, so we don’t even have a rapid transfusion protocol for children, to traumatic brain injury.

And we don’t understand clinically how the wounded body ages. We have some data from the VA system in the States as the Vietnam Veterans have aged and understand what happens to them, such as the rates of arthritis in amputees, or how many amputees are still ambulatory after 65. But we don’t understand this in low and middle income countries. We don’t understand the burden of care for each of these injuries over the lifetime of the patient and because the war wound evolves with the patient.

ICRC and MSF used to have a cut-off point of three months for war wounds; they didn’t treat war wounds that were older than three months. But actually, we know the all war wounds age; they age with the patient and the patient needs continuous care. I had a patient once, four years ago, who was wounded in the Iraq-Iran War in the first year, and he lost the majority of the muscles of his abdomen and had a skin graft over his bowel. So he would walk around almost like there was a straight jacket. And, this guy came to me because he had gallstones. And the surgeons can’t get to his gallbladder because he has no abdominal wall. So that injury is a continuous injury.

Iain Overton:   
Long-term outcomes from abdominal wall war wounds: the data is not even there?

Dr Ghassan Abu-Sitta:   
The only people who have that data we can’t access, as it is the Iranians. So the only long-term low to middle income, comprehensive VA system for imbursement of aid and treatment of veterans is the Iranian VA system. They have data but because of the sanctions and the politics, we can’t access Iranian data and we can’t collaborate with Iranian academics. So to give you an example, the Iranians still have the biggest data set on survivors of chemical warfare.

Iain Overton:  
So, patient data is actually very political in some regards?

Dr Ghassan Abu-Sitta: 
Absolutely. It’s political. It’s fragmented, and it’s retained by individuals. And therefore we need to be able to go to the places where we know the data sets exist in one form or another and then, using mixed methods, not just quantitative but qualitative data, interviews, interviews with providers, interviews with patients, get that data back.

Iain Overton:    
If you had to do a quick list of places where you felt there was a real possibility of doing that work, where data, however fragmented, did exist of merit, where would you say are the centres that you think physicians or clinicians should be looking at.

Dr Ghassan Abu-Sitta: 
So I would go to Gaza, I would go to Baghdad, I would go to the MSF hospitals and I would go to ICRC centres in Afghanistan. And these are the places where, at least in this region, you’re going to have data and  you are going to have to try to piece it and prize it away from institutions that like to hold on to data.

Iain Overton:   
Do you also believe there is merit in doing interviews with physicians themselves, and then see if you can find common ground amongst a number of personal experiences?

Dr Ghassan Abu-Sitta:   
So we know in clinical medicine that if you don’t have level one, level two, or level three data, if you don’t have published research, that’s either prospective or retrospective, then you go to consensus. And these are the people who have consensus. So level four evidence is there in the surgeons in Iraq, it’s there in the surgeons in Gaza, in Lebanon, in Afghanistan. And that’s where we need to find the data. You know, part of the data is consensus and opinion and experience, even if it’s not published.

Iain Overton: 
And we know that at PROTECT at Imperial and we know the International Blast Research Network at Southampton. and we know that there are other GCRF and other globally funded attempts to bring together these elements. But let us say hypothetically, in five years’ time, we have created good data out of Gaza, out of Lebanon, Sri Lanka and Ukraine. We have created a cohort of interviews of physicians from those countries as well. What do you think the outcome of improved data understanding and improved understanding of institutional memory? Where do you think that will leave us in terms of practical application when it comes to patients in conflict zones?

Dr Ghassan Abu-Sitta:
So, it will improve clinical services, through the experience and the knowledge available, for patients. It will help transfer experience from individuals, who eventually will either emigrate or retire, to institutions. It will help the argument that medical education needs to change in response to these wars the same way as it changed in response to the Industrial Revolution. A lot of this knowledge that we now, for some arbitrary reason, think of as postgraduate knowledge belongs further upstream before people disappear, before you get the graduates coming out and being in Iraq and in Syria; the people who manage the emergency rooms are the first and second year graduate. So if you’ve been injured in a blast injury in Iraq, you’re going to see a guy who’s not been through the wars, you’re going to see a fresh face graduate. Unless we move this knowledge and accept that this is part of the disease load of the region, we are going to continue giving people sub optimal clarity.

Iain Overton:   
So what we currently have this fragmented data, incomplete data, patients own profiles disappearing over time because they may move and become refugees. We have individual memories not being proficiently captured, and then translated into institutional memory. And finally, we have as well as other things, but we also have a challenges of some of the data being quite military, and therefore that is a very different system from the civilian system that effects most people. All of those, though, if you approach it with a more holistic understanding, actually can translate into something which can be a real practical benefit to physicians going forward.

Dr Ghassan Abu-Sitta:
Absolutely. And, what we understand from Central America is that even when the political side of the conflict finishes, the destruction of the economic, social fabric of society leads to prolonged interpersonal conflict with identical weaponry. So as many people now are killed in El Salvador, Guatemala, from AK47s and M16s, that used to be killed during the Civil War in these countries. Now it’s not called Civil War, it’s called gang warfare, but at the same, at the end of the day, it’s causing massive migration, it’s causing the refugees, and it is clinically manifesting itself in an identical way. These people are weapons wounded and that’s why a lot of the medical literature is changing. So now ICRC talks about weapons wounding rather than war injury, because in a lot of circumstances, it’s the same injury with the same weapons, but it’s not war.

Iain Overton:
So there is a bit of a contradiction; we’re living in an age where data is omnipresent, and there’s so much data out there and yet simultaneously, we’re not necessarily intrinsically learning from that data, particularly in conflict zones. But are you optimistic?

Dr Ghassan Abu-Sitta: 
Two things are happening in the last five years that I think that are changing. One, funders are now responding to this idea that actually our knowledge is insufficient currently to really impact outcome in these situations and there needs to be directed research funding to answer these questions. And, two, that the argument for humanitarian organisations, publishing data is being won. So if you look at the data, the number of publications coming out of MSF, clinical publication is going up. The number of publications coming out of the ICRC is going up. They’re still completely out of proportion to the data that they have but at least they’re starting to. ICRC sits on a mountain of data because ICRC documents everything; research was always a secondary, even tertiary, part of its mission.

Iain Overton:
So, in your prestigious and long career you must have witnessed the face of war changing to some degree, but ultimately the tragedy of war, a constant, but you are seeing approaches towards data slowly changing and do you think that there are steps being taken that will ultimately mean a better understanding of the burden of care and the best response by physicians to that burden.

Dr Ghassan Abu-Sitta:
So there’s two things that are that are happening particularly in the UK; that the funders are responding and that within the medical establishment indeed UK, there’s an understanding that this kind of experience and expertise is translatable. I mean, I remember in the early 90s, my bosses used to tell me not to put this stuff on my CV because it showed a lack of commitment to a surgical career. Now, it’s considered a plus. And actually, it’s considered that it improves your skills in the NHS if you have done this kind of work before.

Iain Overton: 
So, you think that we’re stepping in the right direction, and that the next few years, may create data sets or create understanding that actually will be profoundly helpful for future conflicts?

Dr Ghassan Abu-Sitta:   
Absolutely. I think once we have the data, and we follow the trends, and we identify the loci where the data is stuck, we’ll be able to understand more about what these patients need.

Iain Overton: 
Thank you, Dr. I hope what you say will come to pass.