Letter to the editor
Wael Abdallah 1,3,4 and Malek Nassar 2,3,4
1Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Sainte Justine University Hospital, University of Montreal, Montréal, Quebec, Canada. 2Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon. 3Clinique de diagnostic prénatal, Zalka, Lebanon. 4The Lebanese Society of Perinatology, Beirut, Lebanon (Correspondence to Malek Nassar:
Keywords: war, health worker, Beirut
Citation: Abdallah W, Nassar M. In the midst of war, we choose life. East Mediterr Health J. 2025;31(2):97–98. https://doi.org/10.26719/2025.31.2.97.
Received: 17/10/2024; Accepted: 08/01/2025
Copyright: © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
A 23-year-old patient, gravida 2 para 1, with a monochorionic diamniotic pregnancy, presented at 23 weeks gestation with amniotic fluid discordance. A diagnostic ultrasound revealed stage III twin-to-twin transfusion syndrome (TTTS) according to the Quintero classification. Laser photocoagulation was scheduled and performed without complications. A follow-up ultrasound the next day showed good foetal vitality for both twins, with a normal peak systolic velocity of the middle cerebral artery in both foetuses.
Yes, we know this is not a case report. Everyday, several monochorionic diamniotic pregnancies undergo laser photocoagulation in different corners of the world. However, what makes this case unique is that it was performed in a university hospital in Beirut, in a low-income country, in the midst of war.
Following the Lebanese revolution, the COVID-19 pandemic, the worst economic crisis, and the Beirut port explosion, we have witnessed the collapse of the health sector (1). Many experts, doctors, health workers, and recent graduates have emigrated to other countries to escape the series of tragedies (1). WHO estimates that nearly 40% of doctors and 30% of nurses have left Lebanon, either permanently or temporarily (2). However, with some improvement in the country’s economic situation, the Lebanese Order of Physicians estimates that around 1000 of the approximately 3000 health care providers who left during the crisis have returned during the last year (3).
However, on 22 September 2024, Lebanon awoke to the announcement of a new war. In just one week, there were over 1000 victims, 10 000 injuries and 1 million displaced people. The country, once renowned as a tertiary referral medical hub in the Middle East, is now shifting towards a system focused primarily on basic care because during wartimes, the primary goal of the health sector is to secure essential first-level care for victims. Thus, the health sector is dominated by emergency medicine, traumatology, visceral surgery, and orthopaedics. Hospital beds are fully occupied with acute cases, leaving little focus on preventive medicine, screening and chronic disease.
Seventy-five years ago, we, as humanity, acknowledged that "everyone has the right to life" (4). Faced with this case of stage III twin-to-twin transfusion syndrome with a clear indication for fetoscopic laser coagulation and the determination of the parents who were deeply committed to the survival of their babies—going so far as to borrow money at a time when everyone is saving their resources to survive the war—we decided to proceed with this procedure to give those babies their chance at life.
With the high level of parenting stress that women typically experience during pregnancies managed with laser surgery (5), compounded by the stress of surviving in a city ravaged by war, with bombs falling and drones overhead, we proceeded with the foetal surgery to achieve nearly a 50% chance of dual survival. Despite all these challenges, we insisted on providing the highest standards of health care through a multidisciplinary approach, while continuing with medical education and training. While some people chose to use technology and laser for warfare, we chose to use laser for photocoagulation to give life.
This case highlights the resilience and dedication of healthcare professionals in the midst of overwhelming challenges. Even amid the chaos of war and collapse of the health sector, the commitment to provide life-saving interventions remains steadfast. This determination to prioritize patient care, even when resources are limited, reflects the enduring spirit of healthcare workers who strive to make a difference in the lives of their patients. Ultimately, this case serves as a testament to the power of hope and compassion, reminding us that even in the darkest times, the fight for life and dignity continues.
Funding: None.
Conflict of interest: None declared.
References
- Nemr E, Moussallem M, Nemr R, Kosremelli Asmar M. Exodus of Lebanese doctors in times of crisis: a qualitative study. Front Health Serv. 2023 Oct 30;3:1240052. doi: 10.3389/frhs.2023.1240052.
- World Health Organization. Joint statement by Dr Tedros Adhanom Ghebreyesus, WHO Director General, and Dr Ahmed Al Mandhari, Regional Director for the Eastern Mediterranean, on Lebanon. News, 19 September 2021. http://www.emro.who.int/media/news/joint-statement-by-dr-tedros-adhanom-ghebreyesus-who-director-general-and-dr-ahmed-al-mandhari-regional-director-for-the-eastern-mediterranean-on-lebanon.html.
- Baaklini S. Emigrant doctors return to Lebanon. L’Orient Today, 12 February 2024. https://today.lorientlejour.com/article/1367910/emigrant-doctors-return-to-lebanon.html.
- United Nations Department of Public Information. Universal Declaration of Human Rights - English. New York: United Nations Department of Public Information, n.d. https://www.ohchr.org/en/human-rights/universal-declaration/translations/english.
- Edwards DM, Gray PH, Soong B, Chan FY, Cincotta R. Parenting stress and psychosocial health in mothers with twin-twin transfusion syndrome managed with laser surgery: a preliminary study. Twin Res Hum Genet Off J Int Soc Twin Stud. 2007;10(2):416–21. doi: 10.1375/twin.10.2.416.
