The Shadow Doctors: The underground race to spread medical knowledge as the Syrian regime erases it

Ben Taub, The Shadow Doctors: The underground race to spread medical knowledge as the Syrian regime erases it. The New Yorker, 27 June 2016. “In the past five years [2011-2016], the Syrian government has assassinated, bombed, and tortured to death almost seven hundred medical personnel, according to Physicians for Human Rights, an organization that documents attacks on medical care in war zones. (Non-state actors, including ISIS, have killed twenty-seven.) Recent headlines announced the death of the last pediatrician in Aleppo, the last cardiologist in Hama. A United Nations commission concluded that “government forces deliberately target medical personnel to gain military advantage,” denying treatment to wounded fighters and civilians “as a matter of policy.””

Thousands of physicians once worked in Aleppo, formerly Syria’s most populous city, but the assault has resulted in an exodus of ninety-five per cent of them to neighboring countries and to Europe. Across Syria, millions of civilians have no access to care for chronic illnesses, and the health ministry routinely prevents U.N. convoys from delivering medicines and surgical supplies to besieged areas. In meetings, the U.N. Security Council “strongly condemns” such violations of international humanitarian law. In practice, however, four of its five permanent members support coalitions that attack hospitals in Syria, Yemen, and Sudan. The conditions in Syria have led to a growing sense among medical workers in other conflict zones that they, too, may be targeted.

Despite the onslaught, doctors and international N.G.O.s have forged an elaborate network of underground hospitals throughout Syria. They have installed cameras in intensive-care units, so that doctors abroad can monitor patients by Skype and direct technicians to administer proper treatment. In besieged areas, they have adapted hospitals to run on fuel from animal waste. [David] Nott [a British surgeon], for his part, trained almost every trauma surgeon on the opposition side of Aleppo, as part of a daring effort to spread medical knowledge as the government strives to eradicate it….

As protests erupted all over the country, government-run hospitals basically functioned as an extension of the security apparatus, targeting demonstrators who dared to seek treatment. “Some doctors manage to treat simple cases and manage to let them flee without being seen or registered,” one doctor said, in testimony collected by Médecins Sans Frontières. “But if an admission is required for the patient, then the administration of the hospital is notified, and therefore it reaches security.” Pro-regime medical staff routinely performed amputations for minor injuries, as a form of punishment. Many wounded protesters were taken from the wards by security and intelligence agents, sometimes while under anesthesia. Others didn’t make it as far as the hospital; security agents commandeered ambulances and took the patients straight to intelligence branches, where they were interrogated and often tortured and killed. M.S.F. concluded that, for Syrians who opposed the President, the health-care system was “a weapon of persecution.”

In response, some doctors established secret medical units to treat people injured in the crackdown….

In the first year of the uprising [2011], Physicians for Human Rights documented fifty-six cases of medical workers being targeted by government snipers; tortured to death in detention facilities; shot and set on fire while driving ambulances; and murdered by security agents at checkpoints, in their clinics, or at home. Several were killed while treating patients. In July, 2012, the regime enacted a new terrorism law, making it an offense to fail to report anti-government activity; according to the U.N. commission, this “effectively criminalized medical aid to the opposition.”…

In June, 2012, M.S.F. [Médecins Sans Frontières], surreptitiously opened its first Syrian field hospital, in Atmeh, a rebel-held village near the Turkish border. For a year, the organization had been asking the Assad regime for permission to operate in the country, to no avail. The hospital, code-named Alpha, was set up in six days, in a walled villa that had been donated by a local doctor. In September, 2012, David Nott travelled to Alpha with other M.S.F. staff from around the world. To make space for patients, the doctors slept on the roof, where they often heard explosions and watched jets streaking through the sky. After each attack, taxis and pickup trucks collected casualties and sped toward the villa….

[By late 2012 in Aleppo] there were eight main medical facilities, and, with only twenty physicians and a handful of surgical specialists in the opposition-held half of the city, the staff used walkie-talkies to coördinate the distribution of patients. To evade detection, the doctors established sequential code names for each hospital, M1 through M8. Most of the staff had little, if any, formal training.

Eventually, the doctors built other medical centers and gave them random names, like M20 and M30, to obscure the actual number of targets. According to Aziz, the best location for a medical facility is on a narrow street, flanked by tall buildings, so that, after an air strike, helicopters and jets have difficulty tracking the movement of wounded civilians. Ambulance workers were routinely targeted by snipers and helicopters, so many of them removed sirens and medical logos, and coated their vans with mud. At night, they drove with the headlights off.

By the end of 2012, Syrian government forces had attacked medical outposts at least eighty-nine times, in eight provinces. Near Damascus, they raided and burned to the ground a clinic and three hospitals, killing all the patients and staff in one of them. In Homs, they shelled a field hospital twenty times in two days. In Aleppo, military aircraft fired rockets at a children’s hospital, causing it to shut down. Ground forces spent four days shelling a mental hospital. M1 was bombed twice, M2 once, and M4, which was attacked at least four times, finally collapsed in a pile of concrete and twisted metal, crushing to death several patients and staff….

In January, 2014, ISIS kidnapped thirteen doctors from an M.S.F. field hospital in northern Syria. Eight were Syrian, and they were soon released, but the five foreigners remained hostages until the end of May. M.S.F. shut down its operations in ISIS-held areas and withdrew its foreign staff from the country….

Nott returned to M1 in September, 2014. Every hospital in the opposition-held eastern half of the city had been attacked. At M10, pieces of ceiling, glass, and concrete covered broken beds in a former ward, while a leftover bag of serum dangled near an electrical outlet. Medical staff at both facilities crammed equipment and patients into the basements and stacked sandbags around the entrances. The upper floors were deserted, serving only as shields against bombardment.

For almost a year, Syrian government helicopters had been lobbing barrels filled with shrapnel and TNT onto markets, apartment blocks, schools, and hospitals. Welded tail fins guide the barrels to land on top of an impact fuse. The methods of targeting are so rudimentary and indiscriminate that, in Aleppo, many residents have moved closer to the front lines, risking sniper fire and shelling, because the helicopters don’t drop barrels near government troops.

When a large bomb explodes, it destroys bodies in consecutive waves. The first is the blast wave, which spreads air particles at supersonic speeds. This can inflict internal damage on the organs, because, Nott said, “the air-tissue interface will bleed. So your lungs start to bleed inside. You can’t breathe. You can’t hear anything, because your eardrums are all blown out.” A fraction of a second later comes the blast wind, a negative pressure that catapults people into the air and slams them into whatever walls or objects are around. “The blast wind is so strong that in the wrong place it will actually blow off your leg,” Nott said. He showed me a photograph of a man on the operating table, whose left leg was charred mush and mostly missing below the knee. “It’ll strip everything off your leg. And that’s why people have such terrible injuries. It’s the blast wind that does that, followed by fragmentation injuries,” from bits of metal shrapnel that rip through flesh and bone, and the flame front, which burns people to death.

In the aftermath of a barrel-bomb attack, Nott said, “as you walked down the stairs to the emergency department, you just heard screams.” Barrel bombs blow up entire buildings, filling the air with concrete dust; many people who survive the initial explosion die of suffocation minutes later. Every day, patients arrived at the hospital so mangled and coated in debris that “you wouldn’t know whether you were looking at the front or the back, whether they were alive or dead,” he said. “Every time you touched somebody, the dust would go into your face and down into your lungs, and you’d be coughing and spluttering away as you were trying to assess whether this patient was alive.”…

The tiled floor of the underground emergency department at M1 was slick with blood and other fluids. Screaming men carried in headless children, as if they could somehow be saved. Hospital staffers wrapped corpses in white shrouds and stacked detached legs that still wore socks and shoes.

When barrel bombs fall on homes, they often send entire families to the ward. One day, five siblings arrived. Unable to treat any of them, Nott started filming the scene, so that he would have proof, he said, of “how terrible it was.” A baby with no feet let out a stifled cry, then died. An older brother lay silently nearby, his guts coming out. In the next room, a toddler with blood on his face shouted the name of his dying brother. Two medical workers carried in the fourth brother, who was about three years old. His pelvis was missing, and his face and chest were gray with concrete dust. He opened his eyes and looked around the room, blinking, without making a noise. There were wet, white blobs on his face, and Nott gently wiped them away. When the sister was brought into the room, he learned that a concrete block had fallen on her head, and the blobs were pieces of her brain….

The boy was dying. There was no treatment; he had lost too much blood, and his lungs had filled with concrete particles. Nott held his hand for four agonizing minutes. “All you can do is just comfort them,” he told me. I asked him what that entailed, since M1 had exhausted its supply of morphine. He began to cry, and said, “All you can hope is that they die quickly.”

A few weeks after Nott left Aleppo, he was invited to lunch at Buckingham Palace. Wild duck and vintage port were served. Janet Oldroyd Hulme, one of Britain’s most prolific growers of rhubarb, sat on his left, and the Queen sat on his right. When the Queen turned to him, he explained that he had just returned from Syria. “How was it?” she asked. “I tried to play it light, and I said it was absolutely dreadful,” he told me. The Queen pressed for details, but he couldn’t bring himself to tell her, and his bottom lip began quivering. At that point, “she summoned the corgis,” he said. For the next twenty minutes, Nott and the Queen petted the dogs and fed them biscuits under the table. As the lunch came to a close, he says, she remarked, “That’s much better than talking, isn’t it?”