Third installment of a three-part series published in the Milwaukee Journal-Sentinel by Pulitzer Center grantees Mark Johnson and Mark Hoffman.
"She's looking at me."
The doctor speaks softly, staring at the photograph he took in late March of a Syrian refugee girl in Jordan, 2, maybe 3 years old. Her dark, expressionless eyes bore into his.
And for a moment, Tarif Bakdash's thoughts drift far from his Brookfield apartment and his hectic life since the medical mission to the Zaatari refugee camp.
From Jordan, the neurologist flew to Germany, where he met with more refugees and heard stories of their perilous exodus from Syria, crossing the Aegean to Greece on flimsy, rubber boats.
From Germany, he flew home in early April. His stay was brief.
Shortly before the mission, Bakdash had resigned from his job at Children's Hospital and the Medical College of Wisconsin, yearning for a position that would allow more time to help refugees from his homeland.
So, four days after coming back, he hit the road again, journeying to interviews in six cities: Spokane, Wash.; Fort Wayne, Ind.; Springfield, Ill.; Oklahoma City, Okla.; Little Rock, Ark.; and St. Paul, Minn. Those added to five interviews he went to before the trip to Jordan.
Back in Brookfield, he has job offers and a decision to make.
Yet there he sits in his apartment, transfixed by the nameless refugee girl, whose face seems to contain the essence of Zaatari, a temporary home that feels to many refugees neither temporary, nor home.
Her brown eyes look old, he says, too old for the baby fat on her cheeks and fingers. They look like the eyes of an adult.
Bakdash makes the photo of the little girl the profile picture on his Facebook page. He makes her photo the wallpaper on his laptop.
He makes it so that her eyes stare at him all day.
Months after returning to Wisconsin, the doctors, nurses and others who accompanied Bakdash often wonder about the refugees they met in Jordan.
Neurologist Thomas Chelimsky pictures the woman with the bloodshot right eye, his last patient at the refugee camp, and his most complex. She could no longer move the eye.
She was about 40 years old, and at first he could not identify her medical condition. He asked her questions and after a few minutes, the diagnosis came to him: cavernous sinus thrombosis, a blood clot at the base of the brain caused by an infection. It is both life-threatening and rare.
Chelimsky filled out a slip for her saying she was in urgent need of an MRI scan of her brain. Then the clinic closed for the day. She became someone else's patient and he, another foreign doctor, headed home.
"She did not appear scared when I told her what I thought was going on," Chelimsky says. "She seemed quite inwardly healthy, able to handle this, like a mom who has seen much more difficult things in her life."
Jennifer Nitschke-Thomas, one of two nurses on the mission, remembers the 60-year-old woman who'd had a recent stroke and was now on her own. The woman's son was still in prison in Syria. Her daughter had been kicked out of the refugee camp.
The woman had very limited motion in her right arm and hand, making it hard to cook or perform the simple tasks of daily life.
"She had no other family to take care of her," says Nitschke-Thomas. "She just seemed devastated, without support."
Stacey Volkman, a social worker from Froedtert Hospital, remembers a little girl she knelt beside. Around the girl's head Volkman placed a string of beads.
"There looked to be so much sadness in her eyes. But the more I thought about it, I began to wonder if it was just me projecting my feelings onto her," Volkman says. "The war has been carrying on for so long, how could she know the Syria before the war, and the traumatic upheaval?"
For Bakdash, there is the nameless girl in the photograph.
And then there is Sandy Al Mekdad, an 8-year-old girl whose dilemma keeps churning through the doctor's mind. Without surgery, her tethered spinal cord will deteriorate, leaving her permanently paralyzed.
But the surgery cannot be performed at the camp, and her family cannot afford to pay an outside hospital. Jordanian hospitals do not treat refugees unless they know someone will pay.
So, 6,000 miles away, Bakdash tries to solve the problem that has stymied Sandy's father.
He contacts a neurosurgeon he met during his visit to the University of Jordan. Bakdash explains the girl's condition and asks: Can you help her?
The surgeon is willing to try.
The big picture feels overwhelming, even to Bakdash. After five years of civil war, his country is in danger of losing a generation.
Of the 4.8 million refugees who have fled Syria, more than 2.5 million are under the age of 18. And the children who remain appear ill-prepared for the future task of rebuilding their country.
According to a United Nations report, there have been more than 4,000 attacks on schools; more than 2 million Syrian children no longer attend school.
One in four children is at risk of developing mental health disorders, the U.N. says. Girls are increasingly vulnerable to child marriages, domestic and sexual violence; boys increasingly risk "recruitment into armed groups" and "dangerous child labor, including scavenging for explosive devices."
So far, the United States has provided a haven for relatively few refugees from the Syrian civil war, although the numbers have been increasing. In the last five years, just over 7,000 Syrian refugees have entered the U.S. More than half have of them have come since January. In the early years of the war, the numbers amounted to a trickle — 23 in 2011, 41 in 2012 and 45 in 2013.
During those same three years, the U.S. admitted more than 41,000 Iraqi refugees (though in the early years of the Iraq War the numbers were much smaller).
The American response to refugees fleeing the genocides in Rwanda and Bosnia was similarly lopsided. Between 1990 and 2003, the U.S. welcomed 143,000 refugees from Bosnia, but 1,116 from Rwanda.
The difference was likely due to several factors, including America's strategic interest in Europe and lack of equivalent interest in central Africa, says Carl Bon Tempo, author of "Americans at the Gate: The United States and Refugees during the Cold War." Also the process of screening, interviewing and transporting refugees was simpler in the Balkans than it was in Rwanda.
"One of the things that happened in the post-9-11 years is that this process has begun to take a lot longer," Bon Tempo says.
Syrians face another challenge. Unlike other refugee groups, "There's not somebody in there lobbying for them," says Claudena Skran, author of "Refugees in Inter-War Europe: The Emergence of a Regime." "And there's the additional problem. They do have somebody lobbying against them."
The "against group" includes the 30 state governors, Wisconsin's Scott Walker among them, who have opposed accepting Syrian refugees.
But as Skran, a professor at Lawrence University, sees it, "refugees are the most screened group coming into the United States. They pose very little security threat. The real security risk is leaving people on their own in refugee camps. The real risk is not doing anything."
Some days Bakdash finds no good news, just a paralyzing sense of helplessness.
"They killed one of our doctors," he says one afternoon in mid-April.
Bakdash points to the photograph of a bombed-out gray car that had belonged to a doctor working at one of the underground cave hospitals inside Syria.
Hasan Al-A'raj, the health director of Hama and the only cardiologist left in the city, had been working at a hospital dug into the side of a mountain. He'd left the hospital in his car around noon to interview potential paramedics and drivers for an emergency response program, according to the Syrian American Medical Society.
Al-A'raj drove just 100 meters from the hospital before his vehicle was struck by an air-to-surface missile, killing him instantly. He left behind a wife and five children, ranging in age from 1 to 17.
"I never met him, but I can imagine just how important his work has been," Bakdash says. "Every health care provider we lose hurts hundreds if not thousands."
Two weeks later, an airstrike hits a hospital in Aleppo, killing at least 50 people and injuring 80 more.
Among the dead is a man named Muhammad Wassim Mo'az, the last pediatrician in Aleppo.
In a New York Times commentary, one of the man's colleagues describes the task of staffing a hospital in a city so heavily bombarded "that even the stones are catching fire."
"Doctors and nurses are trying our best to put on a brave face for our patients. We know that for the community we serve we represent a last hope, the final defenders of life in this city," writes Osama Abo El Ezz, Aleppo coordinator for the medical society.
"But we are also among the fallen. We have all lost medical brothers and sisters to barrel bombs and missile strikes, but we keep working through the night. We have seen neighbors and friends die in front of us. We are exhausted and there are not many of us left, but we continue our 20-hour shifts."
Such descriptions remind Bakdash that the safety he has enjoyed at American hospitals is a luxury.
In Syria, so many doctors have fled or been killed that medical residents now work as doctors. Veterinarians are treating patients in some hospitals, according to both the medical society and Physicians for Human Rights.
Each time Bakdash reads about the death of another Syrian doctor, or about the desperate conditions in the hospitals, "I always feel the urge to go," he says.
But he cannot leave his aging parents, who now live just down the road from him in Brookfield.
So, he continues his weekly 6 a.m. Skype sessions, assisting the psychologist who runs the only mental health clinic still operating in northern Syria. He watches the father try to wrap his son's flailing arms in a hug. He listens to the mother who reports her daughter's medicine is reducing seizures, but also making the girl angry. From thousands of miles away, Bakdash offers advice on medications and other treatments.
On other days he talks to Milwaukee schools about his homeland's civil war and sits for radio interviews — and he feels embarrassed because it never seems like enough.
In May, Bakdash joins a group of outside doctors who use the instant messaging system Viber to assist the embattled medical personnel inside Syria.
Bakdash's cellphone becomes an hour-by-hour record of desperation. The tiny screen carries bloody photographs of the wounded along with the pleas of their Syrian caregivers. Bakdash looks at the photographs and vital signs and tries to help the medical staff when he can. Often, though, cases involve life-threatening trauma and require urgent surgical decisions that fall outside his expertise.
Instead, the messages become a way of tracking the war, keeping the horror of it front and center in his life.
"Three people died in Aleppo," he says one day, "three children."
He shares a photograph of a girl who was crushed, a large portion of her skull now a cavern. In a few places clumps of black hair can be seen matted with blood.
"The two hemispheres were entirely absent," a medical technician had messaged, describing missing portions of her brain, then adding a note of bewilderment: "Don't know what kind of weapons can do this."
Bakdash stares hard at the photo, trying to estimate the girl's age. Only by looking at a second photo is he able to guess from the size of her hands that the girl is probably a teenager.
The medical technician had sent a second message a short time later, asking: "Is there hope for her, or should we let her go?"
There was no hope, Bakdash explains.
The girl died.
One day Bakdash receives a photograph of a man's torso with the tail of a rocket jutting out.
Before doctors operate they worry whether the rocket could still detonate. As it turns out, there is no risk, says Richard Stevens, a weapons expert from the group CAT-UXO, who later examines a photo and X-ray of the patient. The rocket is missing its warhead.
It is unclear whether the Syrian medical team knew this when they began surgery. They succeeded in extracting the rocket from the man's abdomen.
The man survived.
In his public talks, the doctor grows more direct, dispensing with subtlety. He tells a high school history and psychology class that it is not enough to pray for the Syrians.
"Praying without action," he says, "is worthless."
He takes the students at Morse-Marshall High School through the numbers — the dead (470,000), those living in besieged areas (800,000), the decline in average lifespan in Syria since the war (from 76 years to 55).
Then he shows them a photograph, dead children laid out in rows. Many have been disfigured by bombs.
"Where's the head?" he demands, pointing at the image of a child who has been decapitated. "Tell me, where is the head? Where is the head?
"This is real."
He shows another photograph of a little girl with her arms raised above her head. He explains that when the girl saw the photographer's camera she thought it was a weapon. She knew to surrender.
After Bakdash finishes, three students linger behind, asking about the possibility of accompanying the doctor on his next trip to Jordan.
Late in May, Bakdash checks back with the father of Sandy Al Mekdad and with the neurosurgeon at the University of Jordan to find out what is happening with her surgery.
He learns that the neurosurgeon has been unable to reach Sandy's father. It is often very difficult to reach refugees in the Zaatari camp. Many do not have cellphones, though Sandy's father, Mahmood Al Mekdad, does.
Bakdash makes sure the father and surgeon have correct phone numbers for each other. Finally they talk, and the doctor agrees to examine Sandy.
An appointment outside the camp, however, is no simple matter.
The father must receive approval to leave the camp temporarily from a Jordanian nonprofit inside Zaatari. Then he must stand in line to receive permission from U.N. officials.
The line is long, often 300 people. But the father is determined.
He says he will line up at 2 in the morning.
With three job offers to choose from, Bakdash makes his decision.
He is going to the University of Mississippi Medical Center in Jackson, where he will teach and treat patients. The university, one of the places he visited before the trip to Zaatari, is granting him six weeks of time off; he intends to spend it on more medical missions.
Although the trip to Zaatari was brief, just four days, Bakdash sees the fruits of it long after his return.
Following news reports on the journey to Zaatari, a nonprofit group contacts Bakdash. Salvatorian Mission Warehouse in New Holstein arranges to send a large container with 10,000 pounds of medical products, clothing, food and hygiene supplies to a refugee camp in Turkey.
"If this goes OK, then we will try for other refugee camps," says David Holton, the warehouse director.
A local public radio station interviews Bakdash, and afterward one of the listeners sends clothing for him to donate. People email the doctor, interested in doing mission work to help the refugees.
In June, a Madison group called Open Doors to Refugees invites Bakdash to speak at a benefit that raises $1,600. He presents his slide show, warning the small crowd of 60, "Some of these photos are going to be tough."
He shows them the rows of dead children.
"We lose people night and day," he says. "We have bullets in the heads of kids. We have bullets in their backs, shrapnel in their eyes. You name it...
"These are kids. They're being killed. You don't bring these kids here, most of them will probably end up like this.
"Do we have a responsibility? Oh, you bet we do."
He shows them the photo of the little refugee girl from his Facebook page, "a picture that keeps haunting me," he tells them.
"Look at her eyes. She is looking at you."
At 2 in the morning, his alarm sounds. The doctor wakes, flicks on the light and shuffles into the living room in his pajamas to call Syria.
It is the holy month of Ramadan, and, to accommodate his schedule of eating before each 18-hour fast, Bakdash must wake much earlier for his weekly Skype sessions with the mental health clinic.
On this morning in late June, there are technical problems and he cannot use Skype to see the patients. Unwilling to give up, he calls by cellphone, chatting with the psychologist who runs the clinic, while children wail in the background.
It is hard enough to practice medicine from 6,000 miles away, with only a few minutes to view and speak with each patient on Skype. By phone, the task is more difficult still. Bakdash picks up bits and pieces:
A boy, a year and a half old with seizures and developmental delays. Bakdash changes the child's medications, getting rid of one that can cause liver damage in very young children.
A 5-year-old boy, who suffers from drop attacks, seizures in which he crashes to the ground. One such fall resulted in a skull fracture. Bakdash advises the psychologist to increase one medication.
A 15-year-old girl who has been experiencing abnormal facial movements when she is upset. She is to be married soon. Bakdash believes the problem's origin may be psychological rather than physical. It would help if he could see her. Instead, he must ask the parents to record her when she has an episode and bring the footage when they return.
After the patients depart, the 39-year-old psychologist, Musab al-Jaweesh, confides in Bakdash. The clinic is struggling financially. The Canadian nonprofit agency that was supporting its work is unable to do so any longer. Although the Syrian American Medical Society has agreed to step in, the process of transferring funds is not so simple and the money has yet to arrive.
In the meantime, Jaweesh has kept the clinic going with his own money. The electricity cuts off so often that he needs to buy a generator. Keeping medications on hand is sufficiently risky that he pays two bodyguards to protect the clinic.
Bakdash listens sympathetically, suggesting that the psychologist may have to close the clinic until money arrives.
"I can't," Jaweesh says. "I can't close it."
Bakdash's departure is set. In the third week of July he will leave for Mississippi, taking with him his parents, though both would rather be returning to Syria.
His mother and father came to America in 2012 when conditions in their country were growing worse. They expected to stay only a few months. It has now been four years and they miss their homeland terribly.
"We have roots," his father, Fouad Bakdash, explains.
His mother, Nawal Bakdash, says simply, "I want to die in Syria."
She has no illusions about the country she would find on her return. Just thinking about Syria reminds her of her college years when she majored in English literature and developed a fondness for the poet T.S. Eliot.
"I studied 'The Wasteland,'" she says. "Now my country is the wasteland."
Six thousand miles away in Jordan, Mahmood Al Mekdad, waits in line and receives U.N. permission to leave Zaatari. Then he takes his daughter to see the surgeon in Amman.
Bakdash calls to find out what happened.
After examining Sandy, the doctor at the University of Jordan agreed that she needs surgery. She will still require an approval from a Jordanian medical relief agency.
Almost three months after meeting the girl, Bakdash has found a doctor willing to perform the operation.
The surgeon says he will charge no fee.
For one child, one of millions of refugees, there is hope.