"Anyone who has truly suffered knows this: suffering is neither glamorous nor edifying. It can be redemptive, but must never be romanticized."

Traveling to a place in conflict or a third-world country to provide medical care is often more heartbreaking than it is heartwarming. In the face of stacked odds and overwhelming sickness, it is easy to feel helpless and overwhelmed. Working with the Syrian refugees, I felt myself traverse through an emotional pendulum in the course of the day. 

Join me on a typical day.

My first patient of the day is a beautiful little girl with silky dark hair and long eyelashes, who gazes up at me and reaches for my blonde hair as her parents tell me about her long and complicated medical history, including her congenital heart defect, and her scoliosis. Together, we pull up her shirt and I listen to her heart, to the rasping holosystolic murmur. I run my hands over her spine, matching the murmur of her heart to my own words under my breath.

Her family lets me know that she was once seen by a cardiothoracic surgeon - when they had access to care - and that once upon a time she was supposed to have surgery. But life changes quickly in the face of war. The surgery never happened, and she hasn't seen a doctor since.

I call for the medical student running our clinic and scribble down a list of things on a piece of paper. He ushers the family off to the side of the room. We have a certain amount of funds allocated to emergency surgical procedures. This patient would not be able to obtain care without this. Over the next week, our team will work to schedule and pay for her surgery at a local hospital.

I have no time to wonder "what if" because my next patient is already through the door. He's a happy bright-eyed child and he laughs as I tickle his protuberant belly during my exam. Medical school textbook pictures flash in my head and my heart sinks. Does he have frontal bossing?

I try to keep the smile on my face as he reaches out for a sticker and I see his wrists. 

I don't need to lift his shirt to know that if I do, I'll feel the knobbiness at his costochondral junctions that forms what we call the rachitic rosary. I don't need to have him stand up to see the bowing in his legs. I rack my brain to try to remember how much Calcium and Vitamin D I have with me, and then extrapolate that to the number of patients I'll be seeing. I don't have to do the math to know it's not enough - it's not even close. I feel sick. I feel helpless. But I smile. His parents and I talk about the foods that they have available and I try to help them come up with anything they can to supplement his diet. He giggles and waves as his parents carry him out the door and it's almost as though I can feel my heart shattering as I wave back.

Patients flood in and out of my room all day. I see countless children with rickets, in varying stages.

This disease is virtually nonexistent in the United States - I feel angry that I'm seeing it here and in such vast numbers. In between patients, I call our trip leader into my room and pleadingly push a stack of money into his hands. I need him to go to a store - any store ("IS there even a store?!" my mind screams) and buy as much formula as he can. I need it for the infants - these mothers are breastfeeding exclusively because it's the only thing they have to feed their babies. In the US, breastfeeding mothers are either told to supplement themselves, or supplement their babies with Vitamin D, because the amount in the breastmilk isn't sufficient. Here, that's not an option. This combined with severe malnutrition and starvation presents an uphill battle - I realize I'm looking at an entire population of Vitamin D-deficient people. This requires intervention on a far greater scale than myself in order to make a difference. In the absence of liquid drops, we crush vitamin tablets and dissolve them for the infants and young children. I talk to the mothers about Vitamin D for themselves. I'm reminded of the saying "How do you eat an elephant? One bite at a time".

One of the clinic workers tries to bring me food, but I don't stop to eat. How can I eat in front of these people who are so desperately hungry that their bodies are breaking down in every possible way? I break up the snacks into pieces and distribute them to the children who look the hungriest, making sure my door is closed when they eat it, so I don't cause fights over food. I nibble on some crackers, but it almost makes me feel guilty. I drink water instead. Halfway through the day, my stomach rumbles and I realize I've been drinking non-purified water. I make a mental note to take some antibiotics myself later on tonight.

Later in the afternoon, a family brings in an infant, only two weeks old. She's not eating, she's had diarrhea for four days, and she seems floppy and isn't really waking up. As soon as I see her, I feel a pit in my stomach. I examine her and instantly, I know. She needs a hospital. She has probably needed a hospital from the time she was born. I run through the list of supplies I need and I know that out of everything I want, I have one, maybe two things. I rummage through the pharmacy, thinking "what would I do if I was in my hospital back home?" and try to make do with what I have. When the family leaves, they hug me and thank me profusely. "For what?" I think. Her chance of survival is slim. I don't know if I've altered that trajectory at all.

The sun rises higher in the sky and the heat beats down on the roof of the building. The fan goes out in my room, then the electricity goes out altogether. I'm dripping in sweat and there's no water left. I feel dizzy, but when I look outside, the line of parents with children stretches around the corner. If I stop to rest, children won't get seen. I rest my head between my knees for a minute and then greet the family of a playful child with a cleft palate.

I rack my brain, bringing up long-stored-away embryology knowledge from medical school. Bilateral cleft lip with palate involvement. I don't know if I've ever seen this in the States.

He's been eating well despite his deformity and from my exam, he is otherwise healthy. I talk with my team and he is scheduled for a surgical repair. He's lucky that he'll get a repair soon - he's still young enough that any speech or language problems may be minimal. I'm hopeful for him.

I see twins next. They're both in Pavlik harnesses for treatment of developmental hip dysplasia.

I do careful exams of both, checking for easy dislocation of the hip. This feels like foreign territory to me. I wish I had an ultrasound machine or an x-ray. Without follow-up, its hard to know what their prognosis will be or if they will need surgical intervention. I wish I could call my pediatric Orthopedic friends back in the States. I make a mental note to discuss this with them when I get home. For now, these little ones are stable. I tell their families to take advantage of any free clinic they can, so at least they will get exams once in a while.

Before I know it, the line has dwindled, the building has quieted, and it's my last patient of the day. A young girl, maybe 10 or 11 years old, shuffles in with an older woman, her eyes to the ground. The older woman explains that the girl doesn't have any family left so she took her in. She grabs the girl by the hand and pulls her out of the chair, lifting her shirt.

"She was escaping the bombs with her family, but got caught in the fire. Her family didn't make it out."

I gently run my hands over the scars on her body, but all I can think about is the scars that she's carrying inside. She turns around to face me and I put my hands on her cheeks. She makes eye contact for the first time. We are both quiet. I don't know what to say, so I pull her close and she rests her head on my shoulder.

As they leave my room to see our psychiatrist, I ask my translator for a moment alone. My back against the door, I slide to the ground with my head in my hands and blink back tears. This devastation is beyond anything I could have imagined.

Some of the families that bring their children to see me know on some level that there is nothing I can do. But they come to share their stories and their lives. I promised them that if nothing else, I would bear witness. The horrors they have suffered will not go unknown. Their lives mean something. I hear what they're saying and I will pass it on.

At the end of the clinic day, we pack up our rooms. In the midst of all the supplies, there is a bag of balloons. Across the room, someone discovers a box of face paint. The children gather.

Even in darkness, there is color. Even in tragedy, there is hope. The road to recovery is long for Syria and it's hard to see an end in sight. It's hard to feel optimistic in the face of so much adversity. But I have never met a more resilient population in my life and if they can smile, so can I - above all, there will be happiness.

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