The uprising in Syria has become so violent that it recently forced the United Nations to suspend an observer mission. During some of the worst fighting, French surgeon Jacques Bérès snuck across the border into the country and performed dozens of surgeries on the wounded.
The septuagenarian, who helped found the organization Doctors Without Borders more than 40 years ago, relied on trusted contacts to help him get in.
"The important thing is to be inside Syria, which is very difficult," he said from Paris as he prepared to head to Jordan. "When you are leaving, you are on the wrong side of the border and the regular army is looking for you."
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Although Dr. Bérès wasn't representing a recognized aid group while in Syria, the risks are also high for doctors who work in conflict areas with international organizations such as the International Rescue Committee and Doctors Without Borders, known by its French acronym MSF.
These doctors must deal with bombs exploding, armed gunmen, power outages and cultural disconnects all while trying to save lives. Here, several doctors with wartime experiences reveal how they prepare for and adapt to such conditions.
Down to a Science
Surprisingly, the doctors are able to provide tricky, high quality surgery within even while active fighting is erupting around them.
"MSF has surgery down to a fine art," Dr. Cox said.
Each of the doctor's kits contains metal boxes with nonperishable items such as scalpels or sterile dressing gowns and perishable supplies like IV fluids. All the supplies must be brought in. For Dr. Bérès, that meant making sure supplies went to a particular location.
"They are just private houses given to the revolution to be transformed into makeshift hospitals," he said. "In a war situation, if something is missing, you just forget it and you try to manage with the things you really have."
Stephen McElroy, an emergency physician based in Boston, has gone on several Doctors Without Borders missions, including one to Liberia in 2003 during that country's civil war. The MSF Belgium team that Dr. McElroy ended up being one of the few groups staying behind as the fighting closed in.
Teenagers with AK-47s roamed the streets, McElroy said. Rebels took over the hospital in Monrovia so the MSF team transformed their own living quarters into a medical center. McElroy credited the organization with having the logistics down pat and getting medical capabilities up and running at a moment's notice.
"I was able to do whatever I did only because they did 99% of the hard work," he said, describing the supplies, medications, facilities, water and sanitation set up in Liberia. "All of it in the middle of a civil war."
Tapping Local Expertise
In order to cross the Syrian border safely, Dr. Bérès spoke with humanitarian organization members and journalists who had already entered the country.
"You have to be in very faithful relationships with the people you work with," he said. "That's the main thing, to choose them carefully."
The aid organization International Rescue Committee responds to humanitarian crises around the world. Their senior health director, Dr. Emmanuel d'Harcourt, is a pediatrician by training who now supervises a team of more than 30 people to support the organization's medical program.
"We don't see a security problem as a reason not to go," he said.
Unlike organizations that set up parallel systems, the IRC has an approach that's low-tech and largely staffed by locals, d'Harcourt said. "Even in emergencies you will find systems on the ground," he said, adding that among refugees there are usually nurses and health workers whose expertise can be tapped. "You're not arriving in a vacuum, no matter how difficult the situation."
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For d'Harcourt, success means having a local staff that eventually takes over completely. He and his colleagues have trained locals who were illiterate when they met and have since become medical doctors, he said. "People will let you know what you have to do, but you have to listen to them."
Cross-cultural skills, conflict resolution experience and a calm demeanor aren't luxuries for doctors who go to dangerous locales. They're basic elements of security, Dr. d'Harcourt said. "Those things can be the difference between life and death."
Taping the Windows
Dr. Bérès has been traveling to hot spots to perform surgeries for 45 years. He's operated in dangerous places around the world that include Chechnya, Lebanon and Sudan. Doing this work means adapting to violent circumstances.
While in Homs, Syria, earlier this year, Dr. Bérès performed 89 surgeries. Nine patients didn't make it. Then in April he went to Idlib in the north and performed 45 operations. All but three survived.
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"We learn about triage in training but you really don't know what triage is when you work in a Western hospital," Dr. Cox said. "In environments like this you truly have to make decisions: 'I can help you, but I can't help you.' Mortar rounds fell near the hospital where he was working in the Congo. Dr. Cox taped the operating room windows so they wouldn't shatter. He ended up doing surgery wearing body armor.
One of his more memorable moments was after performing successful open-heart surgery on a Congolese colonel with an AK-47 injury. Suddenly rebels entered the hospital and one with a 50-caliber machine gun asked Dr. Cox to show him to the colonel.
"I said yes I can confirm he's here but he's had major open heart surgery and he can't have visitors," Dr. Cox remembered. "So this guy pulls out his gun and says, 'Doctor, if you don't take me to see him I'm going to put this gun in your mouth and I'm going to kill you.' The surgeon obliged but when they saw the patient's split chest, they realized he wouldn't be leaving soon. Later, the colonel also survived an attack as he left the hospital.
Dr. Cox said families have thanked him for trying, even when he couldn't save their loved ones. In Hangu, Pakistan, he operated in the midst of Sunni and Shia clashes, saving a 12-year-old caught in a suicide attack who was thought to be a lost cause. Other NGOs had evacuated but MSF stayed.
"The organization then got official thanks from the Sunni leaders and the Shia leaders," Dr. Cox said. "When both fighting factions come to you and they say that what you've done is good, that means a lot."