Source: Foreign Policy - by Ellen Francis (The War on Syria’s Doctors)
For five years, the Assad regime has relentlessly targeted medical workers in rebel-held territory. This is the story of their desperate fight to stay alive — and save lives.
It was April 13, just past noon, and Hasan al-Araj was behind schedule as he left an underground hospital for his next rounds. He was usually careful to check the skies above him in Hama, where he was the last surviving cardiologist in the province’s rebel-held territory, for the Russian and Syrian warplanes that regularly cruised overhead. But, in his haste, he did not use his walkie-talkie to confirm with colleagues that the skies were clear.
A missile exploded near his van as he drove away. In the wreckage, colleagues found body parts and pieces of his white medical coat.
“It was targeting,” said Ahmad al-Dbis, a pharmacist and medical aid worker who worked closely with Araj. “It’s known that that’s the location of a hospital, and it’s known that most of the people moving around there are medical staff.”
Since March 2011, at least 738 Syrian doctors, nurses, and medical aides have died in more than 360 attacks on medical facilities, according to Physicians for Human Rights (PHR). The independent human rights group holds the Syrian government and its ally, Russia, responsible for upwards of 90 percent of these attacks.
Medical aid workers accuse the Syrian government and Russia of seeking to demoralize and drive out civilians and fighters from opposition-held territory by depriving them of health care and battlefield medicine. The targeted attacks on hospitals have certainly depleted the supply of doctors in rebel areas. Earlier in April, a sniper bullet to the head killed the last doctor in the besieged town of Zabadani. Later that month, rebel-held Aleppo lost one of its last pediatricians when a regime airstrike flattened al-Quds Hospital. According to PHR, 95 percent of the medical personnel who were in Aleppo before the war have either fled, been detained, or were killed.
It is a war crime under international law to deliberately target hospitals, doctors, and nurses. In early May, after a series of airstrikes in Aleppo, the U.N. Security Council unanimously passed a resolution condemning what Secretary-General Ban Ki-moon described as “surgical strikes … hitting surgical wards.” But like so many other U.N. declarations about Syria, it had no teeth —there was no risk of punishment for violating the resolution. By the end of that month, two more hospitals were damaged as a result of air raids on rebel-held Idlib and Aleppo.
Araj, who was 46 at the time of his death, accepted the risks of his work. He sent his wife and five children to Turkey for their safety and visited his family there frequently. But he was dead set on remaining in his homeland: “Even if you give me all of Europe, I will not leave my country,” he told an assembly of doctors at a medical conference in Geneva last year, according to Dbis. “I don’t betray my country in these circumstances. And, inshallah, either I will die in Syria or we will triumph.”
Despite devastating losses, the medical system serving Syria’s rebels and the remaining civilians in opposition areas has proved resilient, like the rebellion itself. From the idealistic uprising in 2011 to the dystopian violence of 2016, Syrian health care workers have found ways to survive, adapt, and treat those wounded in horrific fighting, as well as to deliver babies and treat ordinary illnesses. Dodging arrest and torture, then missiles and snipers, they have built a clandestine health care system out of the one their government destroyed.
2011: ‘No Mercy’ for Doctors
Abu Ibrahim Bakr’s patient was not only at risk of dying — he was at risk of causing the deaths of anyone who treated him. It was June 2011, three months after the rebellion against President Bashar al-Assad’s rule erupted, in Saqba, a town near the capital of Damascus. A bullet wound in the patient’s belly marked him as a participant in the uprising. As far as the government was concerned, he was a criminal who should not be saved.
“We couldn’t move the patient around at all,” said Bakr, a general surgeon in the Damascus suburbs of Eastern Ghouta whose name is a professional alias.
In the earliest days of clandestine rebel medicine, the opposition to Assad’s rule largely consisted of nonviolent protests. The activists held no territory in the country; the only way they could treat their wounded comrades was to hijack the government’s health care system.
In Saqba, doctors sometimes smuggled injured protesters through the back door of a nearby hospital. But government forces that day had closed the roads, making the medical facility impossible to reach. A man volunteered his bedroom. Bakr unpacked one of the medical kits he and his colleagues, by then, had hidden in every town in the area. The doctors had, as he put it, “stuffed an operating room into a suitcase.” An anesthesiologist recommended dosages by cell phone.
“We put him on the bed, in the bedroom, and we opened up his stomach,” the surgeon recalled.
Syria once enjoyed an advanced medical system. The average life expectancy in the country in the years before the rebellion broke out had hovered around 73, roughly on par with that in neighboring Turkey, according to World Bank data. Some of the doctors, paramedics, and nurses who have assisted the opposition were driven by their own rejection of the Assad regime; others simply felt they should provide care to all, as a fulfillment of their professional and humanitarian duty. So the practitioners formed secret networks of trusted colleagues to treat the wounded and protect patients from government reprisals.
“We noticed that many of the people who were getting injured in the streets by the security forces and the military … when they were transported to a hospital, public or private, the intelligence services would follow,” said a founding member of the Union of Free Syrian Doctors, a loose association of doctors and medical activists who banded together in late 2011 to try to fill the gap in available medical services. The doctor, a radiologist now living in West Virginia, asked that his name be withheld to protect his family still in Syria.
“Of course, every person that the intelligence services discover had treated a patient from one of the protests, his fate is to be detained, absolutely,” said the radiologist, who says he was detained and tortured himself by one of the country’s most notorious agencies, Air Force Intelligence. “He’s even classified almost in the same group as the armed rebels.”
To evade Assad’s security forces, doctors treated patients in secret, in shops and other unconventional places that would briefly be converted into emergency rooms. In desperate cases, the only way to save a patient was to sneak him or her into a government hospital. That required daring help from a network of willing doctors, nurses, and friends.
“We would communicate through a series of quick phone calls using phones linked to false names, which were bought from the black market with the IDs of dead people or fake IDs, to make it harder to trace,“ said Osama Abu Zayd, a medical equipment engineer with the Union of Free Syrian Doctors. Using the masked phones, Abu Zayd would describe the patient’s injury to a friendly hospital doctor using numeric codes for the location and type of wound.
Patients at risk of arrest were given fake names. Their doctors also worked under aliases. “Even two doctors in the same hospital, each wouldn’t know that the other is ‘revolutionary,’” Abu Zayd said.
“There are some doctors, until now, after four or five years of working with them, I still don’t know their real names,” said Mohammad Yasser Tabbaa, a co-founder of the nonprofit Syrian Expatriate Medical Association (SEMA). A Syrian expat living in Saudi Arabia, he has made more than two dozen trips to Syria since the beginning of the war to establish health care facilities there.
Friends and relatives provided referrals for new members of the network. “Between us, there is trust. We know who’s honest and who’s not,” he said.
The real danger came when someone was caught, Tabbaa added, because then the security forces would torture them until they gave up their friends’ names. “Every time, whenever anyone was caught, all his friends would go into hiding, or they would travel, or run away,” he said.
The radiologist living in West Virginia said some of the Free Syrian Union doctors had private clinics and could take in injured rebels.
“We didn’t differentiate the armed [soldier] from here or from there or whomever we found in the street — our goal was to treat people,” he said. “I don’t care, this person, what his background is.”
But even private facilities were not safe. In the early days of the revolt in 2011, security and military forces often barged into the Kafr Zita Specialty Hospital, which was owned by the cardiologist Hasan al-Araj, said his colleague Ahmad al-Dbis. When soldiers opened fire on protests in the small town, the injured would often be rushed to Araj’s private hospital in secret.
Araj and his staff performed protesters’ surgeries as quickly as they could. The demonstrators who were most wanted by the security forces were stabilized at the hospital and quietly transferred to local homes, including Araj’s house. When security forces came knocking at the hospital, Araj told them they were working on routine surgeries — like an appendix or abscess removal — and prevented them from entering the operating rooms.
“In those days, there was still a bit of respect for doctors,” Dbis said.
Over time, as the protests grew and turned more violent, government security forces became more aggressive in chasing down injured protesters and those who treated them. During the first year of conflict, an estimated 250 doctors were arrested or interrogated for treating injured protesters in Syria, according to a report published by PHR at the end of 2011.
Doctors and aid workers said Assad’s security forces examined orders for blood bags at the state-run blood banks or orders for tetanus shots, which are usually given to people with gunshot or shrapnel wounds, to track down doctors who were treating members of the opposition.
“The regime’s intelligence services have no mercy if they find out you’re working as a field doctor,” said Rami Kalazi, who was then completing his residency in neurology at Aleppo’s state-run Razi Hospital. “For them, this is even much worse than carrying a weapon.”
Kalazi, who worked with a group of colleagues to provide secret medical and humanitarian aid, ran a makeshift pharmacy out of the basement of the apartment building in which he lived, stocked with supplies he and colleagues took from the hospital, bought from pharmacies, or received as donations.
Eventually, the chief resident got word that the regime was after Kalazi and his wife, who also worked at the hospital. “He told us, ‘Take my advice: Pack up and leave, because you’re no longer safe,’” Kalazi recalled. He is still practicing medicine in Aleppo but in a different hospital in a rebel-held area.
F.J., a doctor working in the suburbs of Damascus during the early years of the uprising, was detained in 2012 by Assad’s security forces. He was taken to an underground room with what he estimated to be about 80 other people. There was no ventilation, no light, and no place to sit. He was tortured for seven days, he said. He and the other prisoners often found piles of dead bodies in the bathroom.
“Really, it was like hell,” he said. “Everyone was just praying to die.”
Araj, the Hama cardiologist, was arrested twice, said his wife, Najwa. The horrors of his detentions made him more vigilant about avoiding regime soldiers and checkpoints. He often told Najwa, “If a missile hits me and cuts me in two, it would be easier than spending 15 minutes in the infidel regime’s prison.”
2012: ‘Nobody Came to Teach Us’
In the summer of 2012, fighting reached Aleppo and Damascus, the country’s two most populous cities. With many activists turning into rebels and the government shifting to heavier firepower, the pressure on medical providers grew.
As the rebels began carving out territory of their own, some medics no longer needed to sneak around regime hospitals. They set up their own field hospitals and makeshift medical facilities in opposition-held areas, ushering in a new era of rebel medicine.
In and around Damascus, the doctors were rushing to adapt to the Syrian government’s shelling of entire neighborhoods. They were now less exposed to arrest — but they were exposed to bombs, and they had to re-create operating and care facilities from scratch.
“We’re in a place where there are civilians and there’s shelling,” said Mouaffak, a surgeon in Douma, who described the beginnings of the field hospitals in Eastern Ghouta. “Put two or three beds on a farm; that’s a field hospital. Put consumables that would last a while in case the area is besieged; that’s a field hospital.”
This new phase required creating new regimes of care and medical supply on the fly. Staffing at the field hospitals was inventive: No expertise, no matter how tangential to medicine, could be wasted. Doctors and other professionals were fleeing the country in droves; they had to be replaced by ad hoc trainees.
As the Free Syrian Army rebels began gaining ground against government forces in Aleppo in the summer of 2012, medical personnel at the Dar al-Shifa Hospital in the rebel-held Shaar neighborhood put out a call for volunteers. “There were a lot of massacres at the time, and there were only 10 people at that hospital in the beginning,” said Modar Shekho, who began working at the hospital as a nurse.
“This one was an engineering student, that one was a law student, another was an English student,” Shekho said. “Nobody came to teach us. There was no time.”
On his first day, he walked into the emergency room to find an orthopedic surgeon standing in a pool of blood, stitching up a patient injured by shelling.
“He said, ‘Come help me with drying the wound,’” Shekho recalled, remembering how he approached the bloodied patient and, feeling faint, went outside to collect himself.
“So I got some fresh air and then I went back to the emergency room,” he said. “I told the doctor, ‘I’ll continue with you.’… And since then, I continued. And that’s it. It became normal. My body got used to it.”
In Hama, Araj also watched his world change as Syrian army soldiers withdrew from the town of Kafr Zita around early 2013, leaving the area to the opposition.
“That’s when Dr. Hasan announced right away that his hospital would provide free surgeries for everyone,” Dbis, the pharmacist, recalled. “He announced that the hospital was for everyone, for free medical treatment, for battle injuries, and injuries from the shelling, and others.”
2013-2014: ‘Everything Vanished’
Ihsan surgical hospital was shelled for the first time in November 2013. A series of attacks ripped through the building, leaving rubble everywhere. The airstrikes blasted gaping holes in the brick walls, exposing hospitals beds with crooked IVs hanging over them to the outside world.
The hospital, in a besieged district of Eastern Ghouta, had only been open five months. This was the rebel-held suburb of Damascus that had suffered the worst of the chemical gas attacks mounted by the Assad regime the previous summer. According to the hospital’s staff, it served the majority of the cases arising from the area’s population of about 500,000. The facility was now leveled. Three of the hospital’s medical staff died in the barrage.
“Everything vanished, everything,” said Abu Zayd, of the Union of Free Syrian Doctors.
Refusing to be deterred, Abu Zayd and his colleagues took what equipment remained from Ihsan to set up another hospital at a secret location in Eastern Ghouta. They tried to take precautions on safety: They reinforced the infrastructure and separated certain emergency wards in secret locations in basements, only known by hospital staff.
A few months later, it was hit in another series of airstrikes. Once again, the hospital was damaged. Once again, they had to rebuild.
Ihsan represented a new humanitarian dilemma for the Syrian opposition. Syria’s field hospitals have themselves come to pose huge health risks to the people who visit them — or even live near them. But the bombing campaigns also had the unintended consequence of helping usher in the next phase of Syria’s rebel medicine.
The Assad regime routinely uses barrel bombs, oil drums packed with high explosives that destroy indiscriminately when dropped from helicopters or planes, against rebel medical facilities. Araj’s hospital in Hama, the Kafr Zita Specialty Hospital, was hit 10 times in 2015. Three of the staff — an anesthesiologist, a desk clerk, and a lab technician — were killed last year. Two of the three floors were wiped out.
Rami Kalazi, the Aleppo neurosurgeon, says each barrel bomb attack causes “frantic panic” among civilians. He used to live next door to Sakhour Hospital, rebel-held Aleppo’s largest trauma center, before the airstrikes forced him to move. In just six months over the end of 2014 through the spring of 2015, the hospital was struck on three occasions, damaging Kalazi’s home in the process. The staff had to ship cement in from Turkey to rebuild on each occasion. The airstrikes have only continued: According to Kalazi, the hospital was hit more than 20 times in 2014 and 2015. Eight of those strikes temporarily put the hospital out of service.
“We’ve become used to being targeted,” he said.
Ambulances are also constantly under threat. Kalazi said Sakhour has lost all of its ambulances to airstrikes and now relies on ambulances from other hospitals in the district or civilian cars.
The Syrian government’s hospital bombing campaigns motivated international donors to redouble their efforts to aid Syria’s medical facilities. Syrian expat networks based in the United States, the Persian Gulf, and Turkey that previously operated on an ad hoc basis have come together as large-scale nonprofits, like SEMA and the Syrian American Medical Society (SAMS), collecting millions of dollars in private donations and state funding to keep the hospitals running. These nonprofits have received money from the United Nations, the United States, Canada, and several European countries. Money and aid have also come from individuals in the Persian Gulf and organizations like the Qatar Red Crescent. To vet recipients, aid groups rely on the guidance of local Syrian medical bureaus or on their own longtime relationships with medical staff. International organizations such as the International Committee of the Red Cross and Médecins Sans Frontières (MSF) also provide funding and supplies for medical facilities in Syria’s opposition territory.
With greater assistance from international donors, Syria’s domestic opposition started designing medical facilities able to evade, or withstand, the regime’s relentless attacks. “It became clear that we needed to set up secure hospitals, underground, in a way that the airstrikes wouldn’t affect them, whether it’s barrel bombs or missiles,” Dbis said. And that, in turn, allowed rebel doctors to move beyond short-term emergency medicine and begin providing long-term medical care.
2015: ‘The Place Will Endure’
From the inside, it could be any hospital. Men in scrubs tend to an emergency room. There are beds and sterilized equipment, and the floors are ceramic tile. But look up at the dome-shaped ceiling. The jagged rocky edges and gaping holes reveal the inside of a mountain in Hama.
Araj called it the “Central Cave” hospital. It opened in late 2015, as shells fell on his hospital aboveground. The bombardment couldn’t harm them now. The cardiologist, his colleagues, and the hospital’s patients were sheltered under 55 feet of rock and dirt. Najwa, his wife, called the buried hospital “magnificent.”
“No matter how much they shell, shell, shell it, nothing will happen,” Mohammad Yasser Tabbaa, the SEMA co-founder, said of Central Cave. “Maybe it will shake the place, but the place would endure.”
“This is the trend we’re trying to push for,” he added.
The financial barriers to going underground are high. “It’s not easy for all the money to go and pour into one single place,” Tabbaa said.
Central Cave cost about half a million dollars to build, underwritten by an array of aid organizations, including SEMA, the Union of Medical Care and Relief Organizations, and the Assistance Coordination Unit, the humanitarian arm of the Syrian National Coalition. The health directorate in rebel-held Hama also funneled some of the money it had received from the British government into the project, according to Dbis.
Medical workers in Hama led the initiative, bringing in local labor to tunnel into a mountain in the northern countryside, where smaller caves already existed, to make way for the hospital. After around a year of drilling and shaping rock into rooms and hallways, Central Cave now sits at the base of the mountain. It welcomes around 1,500 patients a month from Hama and Idlib, mostly for free. The hospital includes operating rooms for general and orthopedic surgery, an intensive care unit, a pharmacy, a lab, a medical ward, and X-ray facilities. SAMS, the U.S.-based aid group, still pays nearly $50,000 a month in operating costs, including the salaries for the full-time staff who live in the hospital.
All across Syria, the need to protect hospitals has become acute. Moscow’s decision to join the air campaign in 2015 has only heightened the risk: Russian warplanes brought with them stronger weapons and more destructive power. PHR has called 2015 the deadliest year yet for Syrian health care, with 122 attacks on medical facilities.
Yet the Russian escalation has failed to destroy the rebel’s infrastructure. Central Cave isn’t the only example of rebel medicine moving underground: Many hospitals have by now moved into reinforced basements, cellars, or abandoned factories. In cases where it’s impossible for medical facilities to completely move their operations, the most sensitive units, like surgical and emergency rooms, have been relocated to a subterranean level.
For some hospitals, like Eastern Ghouta’s Ihsan, the huge loss brought on by airstrikes led them to disperse their facilities. An emergency room might be almost 1,000 feet from the operating room and similarly distant from the intensive care unit.
“Our strategy was to select unknown areas, so we stayed away from governmental buildings completely,” said Abu Zayd, the representative from the Union of Free Syrian Doctors. “We settled for commercial basements, from factories, sewing shops, or other similar places.”
Patients are ferried by ambulance or sometimes travel through tunnels that connect the facilities.
“If one location is hit, not all of the departments are destroyed,” said Mouaffak, the surgeon in Douma. “If we’re in the emergency room and it’s shelled, God forbid, there are people in other departments who could still rescue us.”
Medicine in opposition areas has become increasingly sophisticated as it has evolved from its earlier state of triage and improvisation. Underground hospitals also treat civilians suffering from routine ills. Several doctors said much, if not all, the care they provide is free. The nonprofit organizations now foot the bill for their salaries, though some reported working without pay for at least the first year after the spring 2011 revolt.
“The patient is usually poor here,” Mouaffak said. “If there’s only one doctor who can do this surgery and the doctor wants the patient to pay him, it basically means the patient won’t make it.”
Doctors have also developed a methodical approach to the influx of patients that an airstrike brings. “Right away, we keep the dead on one side,” said Kalazi, the neurosurgeon in Aleppo. The most serious cases are quickly sent to the operating rooms. Sometimes patients are sent to other Aleppo hospitals and even into Turkey. Kalazi recalled working 40 hours straight in early 2014 during a day of particularly intense shelling, when Sakhour Hospital admitted around 200 patients.
Doctors report that vaccines, antiseptics, and antibiotics are often unavailable, especially in besieged areas like Eastern Ghouta that have been cut off from supply routes since 2013. In regions like Idlib and Hama, medical tools and supplies come in trucks from neighboring Turkey. Yet in Eastern Ghouta, where international aid deliveries are erratic and insufficient, underground tunnels provide an alternative lifeline. Medical supplies are smuggled in across regime lines at great financial cost and great personal risk.
If medical workers can’t get the supplies they need, they’re forced to improvise. Three doctors said small-scale factories began springing up in 2014 in the Damascus suburbs to produce materials like gauze or serum that were too difficult to import from outside areas.
Some hospitals have medical equipment, such as CT scanners, salvaged from prewar facilities. The sandbags placed around the expensive machines suggest a constant threat of destruction.
There is still not enough anesthesia, however. “Without anesthesia, the surgery doesn’t happen,” said an anesthesiologist in Eastern Ghouta, who goes by the assumed name Abu al-Zaher. “The patient would die from the pain.”
The constant shortages have also spurred innovation. Zaher began producing a low-cost anesthetic out of ingredients he had available. He tested his formula on 50 patients receiving cesarean sections and reported the results were on par with the standard version. Basic household items, like olive jars, have been repurposed as medical instruments. Civilians and medical staff alike are trained to work outside the boundaries of what they knew.
“We held nursing workshops for the people in the towns,” Zaher said. “So now in every town, most people have some knowledge of nursing procedures.” More formalized nursing schools and academies have recently emerged: A school that opened in Idlib last year has already graduated 70 paramedics, and this June, an Eastern Ghouta health institute graduated its first cohort of 35 students.
Training also comes from overseas. In October 2012, Anas Moughrabieh, a Syrian-American doctor in Detroit, worked with SAMS to get two nurses from Syria’s Idlib province smartphones and internet-enabled cameras. Moughrabieh then became the virtual doctor to 40 patients almost 6,000 miles away.
The program has since spread to seven hospitals. A network of more than 20 volunteers in the United States and Canada now take formal shifts to provide 24/7 medical advice using apps like Viber, WhatsApp, and Skype. What the doctors see can be overwhelming.
“I asked them to stop streaming pictures,” Moughrabieh said. “I don’t want to see. I open the camera, and I see them dying, blood everywhere, patients on the floor. This is too much for me.”
2016: “What’s Wrong and What’s Coming”
The Syrian doctors and medical workers who decided to defy Assad have come a long way from bedroom surgeries. But their work teeters on a knife-edge, always at the mercy of the next air raid.
“When the planes don’t show up,” said Abu Zayd, of the Union of Free Syrian Doctors, “we wonder, ‘What’s wrong, and what’s coming?’”
Still, they stay, even as the dwindling number of doctors paints a foreboding picture. For some, it’s too late or too difficult to leave now. But in reflecting on what keeps them in Syria, most cite their religious faith, frustration with the regime’s injustices, or dedication to the medical oath they took years ago.
“The people who live here, they’re our families and our people,” said Abu Ibrahim Baker, the general surgeon in Eastern Ghouta. “How would I leave my family, my people, in this situation, under shelling?”
“I can’t tell you I didn’t think of leaving,” said Mouaffak, the surgeon in Douma, who often writes eyewitness accounts of particularly brutal days in a digital diary titled Memories of Tragedy. “But … this is my city.”
With every chapter of political, diplomatic, and military developments, Syrian doctors in the field have found ways to keep going. But no matter how deep underground these doctors go, or how much international support they garner, they are not safe.
Ahmad al-Dbis and Abdallah Darwish, two of Hasan al-Araj’s colleagues in Hama, were in Turkey for a war surgery workshop on April 13, when they learned of Araj’s death.
“‘Ahmad, we have to go to Syria right away,’” Dbis recalled Darwish saying.
“Dr. Hasan—” Darwish said, but couldn’t continue his sentence.
“I had a semi-breakdown,” Dbis recalled. “During the revolution, we became more than brothers.… Even the secrets we didn’t tell our wives, we told each other.”
Passport in hand, he rushed to his car half-dressed and crossed the border into Syria for the funeral.
“Of course, there was nothing for us to see,” Dbis said. “I mean, a lump of severed limbs in a bag — that was buried.”
Najwa and her children, who still live in Turkey, don’t have the authorization to regularly cross the border back to their home country. They couldn’t attend the funeral or visit the modest grave: a small concrete tile sitting atop a pile of soil and gravel, with patches of green sprouting around it. In black felt, the cardiologist’s gravestone reads, “The martyr Dr. Hasan Mohammad al-Araj.”
This story was produced in a investigative reporting class at Columbia Journalism School during the spring of 2016 and is part of a series on Syria’s underground medical system, which is available at http://medicineunderground.org.