In a hospital for reconstructive surgery in Amman, Jordan, war-wounded patients from Iraq receive treatment for complex injuries. The project was established by Médecins Sans Frontières (MSF) in 2006 when it became clear that no such care existed for victims of the war in Iraq. It has since expanded to receive patients from Gaza, Yemen and Syria.

Since the project opened, MSF has treated approximately 4,500 patients and performed nearly 10,000 surgeries. Iraqis are the largest patient group, with 2,442 patients referred from Iraq since the start of the project.

Dr Omar Adil Alani manages patient referrals in the Iraqi capital, Baghdad. He has worked with the MSF hospital in Amman since the beginning of 2014.

"The need for reconstructive surgery in Iraq is very big due to the continuous conflict since 2003 and the financial situation our country is facing," says Dr Omar. "While they may receive initial care for their wounds, our patients do not usually have access to specialised surgical procedures. Through this project, MSF offers surgery to treat complications that appear months after the first intervention – complications that were hard to predict in the initial life-saving stage and that have a serious impact on the patient's recovery."

The hospital in Amman provides a comprehensive care package for its patients, which includes physiotherapy and psychosocial support alongside specialised surgery. Patients are also provided with accommodation and financial assistance with travel to and from the hospital as well as in-between treatments if the care plan is prolonged.

Finding the patients in need

In Baghdad, Dr Omar coordinates a team of medical liaison officers who identify and refer patients from Iraq.

"The medical liaison officers are in close contact with nine hospitals in Baghdad that deal with trauma cases," says Dr Omar. "We also reach out to other parts of Iraq through a network of medical doctors, the Directorates of Health, MSF offices and other organisations that are present in the field and that meet people in need of reconstructive surgery."

The patients referred to Amman for treatment include people with injuries caused by bombs, explosions and shells. Some have bones that are not just broken but completely shattered. Others have severe burns injuries that cover much of their body. Others have facial injuries, which can include serious damage to lower and upper jaws, making eating or even breathing difficult. Many patients have lost mobility in parts of their body; some have undergone amputatations. Most of the patients need advanced reconstructive surgery, often over many months or even years. The criteria for referrals are strict: they include only those patients whose abilities can be improved with surgery; aesthetics are considered secondary.

Mudhafar Abdulwahid Khaleefa, 43, was injured when armed men stormed the building where he worked. During the attack, he fell from the third floor and suffered multiple fractures to his leg and hip, as well as an injury to the spine. Over the following year, he had seven rounds of surgery, but the bone fractures failed to heal.

"In the end, the doctors recommended amputation above the knee," says Mudhafar. "The bone in my leg was infected and it wouldn't heal. I was starting to feel very bad emotionally. Then I was put in contact with MSF and after a medical assessment I was accepted for treatment in the hospital in Amman. Over four months they operated on my leg several times, first to treat the infection and then to progressively restore the functionality of the leg. Now I don't need a wheelchair anymore and I can walk with crutches."

Many patients who come to MSF's hospital in Amman have already undergone multiple rounds of surgery and received courses of various antibiotics. Some develop resistance to the drugs, and face having their limbs amputated in an attempt to control the infection. In Amman, these patients have the possibility of taking last-line antibiotics to save the limb.

Treating the injury is not enough

After successful surgery, patients move on to physiotherapy and other types of support. Every year,  hospital staff conduct almost 2,000 physiotherapy sessions, while 22 per cent of the patients receive mental health support. Their emotional wounds are not visible but are often deep, and can have a major impact on the patient's life and ability to recover. Most patients have had extremely distressing and traumatic experiences, and their lives have been changed forever by their injuries and the loss of loved ones.

"The psychological support I received in Amman was very important for my physical recovery," says Mudhafar.

Dr Omar describes another patient for whom the mental health support provided by the MSF team has made a huge difference. "A pregnant woman who was on a street in Baghdad when a car bomb exploded was severely burnt over most of her body and lost her baby. When she came to us she was very depressed, she had divorced her husband and wanted to commit suicide. Because of the burns on her face she had difficulties speaking and breathing. She has now had multiple surgeries in Amman and is making good progress.”

In Baghdad, Dr Omar and his team plan to expand their work so that they also have a permanent presence in Iraqi Kurdistan, increasing their ability to find patients whose lives could be changed by specialised surgery.  

"The situation here in Iraq is very difficult and many patients who need this specialised treatment don't have access to it," says Dr Omar. "I'm very happy to be in this position, because it allows me to help fellow Iraqis. To see a patient who was in a wheelchair for a long time come back from Amman walking by himself – that is an amazing feeling."