Catherine M. Mullaly, MD
United Nations, 9th Report of Commission of Inquiry on Syria, February 5, 2015
Dr. Abdullah Alalwa’s soft voice is unexpectedly joyful. On an audio Skype call, from inside Syria, he laughs as he details a recent medical-resupply road trip to Tal Shehab on the Syrian-Jordanian border. He was deep inside opposition held territory and in relative safety. He remembers an innards-deep inhale of the Syrian countryside that made him smile. The cool and tranquil March air was invigorating, nature’s clemency, a reprieve, from the bloodshed and strife that awaited him back near the frontline at Inkhil in southern Syria.
Alalwa is twenty-nine years old. He is thin, just 121 pounds (or 55 kilograms) for his five-foot five-inches frame, and has a smoker’s cough. Laughter is his own medicine, a tool of psychological armor to deal with the pain of living in a war zone. When so much hurts, when so much has been lost, when so much is uncertain, what else can he do, but pretend to laugh. Make-believe is a protective masquerade – it conceals circulating sadness, unhappiness and deeper despair.
He says he looked out on the land from the passenger seat window of a white, Kia 4000 flatbed truck. The rural road headed southwest from Inkhil to Nawa and Sahm al-Jolan, shot east at Heet, and skirted the Jordanian border all the way to Tal Shehab. The tarmac pulled open in front of him, like film stretched from the truck’s, single-cab canister-like belly. Towns perforated his panoramic view. Wadi Al Harir, a seasonal waterway, crossed under a small concrete bridge less than thirty kilometers east of the Sea of Galilee. February rains returned dry earth lusciously green with life. “Dara’a is the garden of Syria,” explains Alalwa, with an undulating Arabic accent. The morning sky, pressed over Syria’s southern, Dara’a governorate, was clear of clouds and bombs. Hot weather would arrive in May. But, on that March road trip, it was springtime in Syria.
What mattered most to Alalwa was what he didn’t see. He didn’t see flying metal. There were no Russian MiG fighter jets – the namesake of aircraft designers Mikoyan and Gurevichor – and no barrel-bomb-laden helicopters tracking him from on high. The Free Syrian Army controlled the land around him, but the airspace, over all of Syria, belonged to the regime and its Commander-in-Chief, President Bashar Hafez al-Assad – a medical doctor and ophthalmologist specialized in the care of patients with poor vision. Dr. al-Assad obtained his medical degree from the University of Damascus in 1988. He went on to complete a residency in opthalmology at the Tishreen Military Hospital in Damascus before pursuing further training at the Western Eye Clinic of St. Mary’s Hospital in London from 1992-1994.
On the other hand, what Dr. Alalwa did see was a small gathering of people, perhaps on their way, he suspected, for a family picnic. Although Alalwa lives in a war zone, he internally reconciles that life goes on. He thought of his 57 year-old mother, who left their home in Inkhil for relative safety, west, near the Israeli border, and made a mental note to plan a picnic together with her soon. He imagined their time together. They would prepare food, find a quiet, green, garden-like place and share a picnic lunch together. “You know, sometime you should think about your normal life. At least you have to feel it with your family,” he says.
Areas Controlled Inside Syria
BBC March 15, 2015 http://www.bbc.com/news/world-middle-east-22798391
The war in Syria is as much an information propaganda campaign as it is a conventional battleground. Belligerents on all sides – the regime, the opposition and others – engage in disinformation drives where exaggeration is presented as reality. Truth, itself, can be a casualty in war. Searching it out, getting to truth requires getting beyond the morass of con artists and false witnesses with an agenda to push. In the world of war, the International Committee of the Red Cross – or, the ICRC – is anchored to truth. The ICRC is the moral compass of the world, founded in the humanitarian principles of neutrality, independence and impartiality. In reporting the deaths of doctors inside Syria, the messenger matters and Alalwa comes vetted through the highest levels of the ICRC. He is known as a consistent and reliable witness to the horrific and targeted attacks on doctors, hospitals and patients inside Syria.
Alalwa’s life is a doctor of pharmacy near the front line in southern Syria. He doesn’t shoot bullets and he doesn’t carry a gun. He dispenses drugs. He cares for patients. And in Syria, for Alalwa, and his physician colleagues, caring for injured patients can get them killed. “If they [the regime] catch one doctor who is helping about one injured, he will kill him,” says Alalwa. Inside Syria, doctors can be killed for the alleged crime of treating the injured. Such experiences are mapped out by the United Nations in its Human Rights Council Report of September 2013, titled: “Assault on medical care in Syria.” The Council reports:
“Anti-terrorism laws issued on 2 July 2012 effectively criminalised medical aid to the opposition. Laws 19, 20 and 21 contravene the customary international humanitarian law rule that under no circumstances shall any person be punished for carrying out medical activities compatible with medical ethics, regardless of the person benefiting therefrom.” and
“Intelligence and law enforcement agencies have forcibly disappeared medical personnel providing treatment to perceived opposition supporters. From June 2011 until early 2012, Government security services repeatedly raided Bab Sbaa National Hospital in Homs, arresting doctors and nurses. One nurse explained that “at one point there were no more doctors left in the hospital.” During 2012, Government forces conducted a wave of arrests and extra-judicial executions of medical personnel working at Aleppo’s opposition affiliated Al Zarzou Hospital. In June 2012, Air Force Intelligence arrested three medical professionals at the hospital. Their burned bodies were found three days later. In July 2012, Dr. Nur Maktabi, a senior doctor at Al Zarzou Hospital went missing. In December 2012, he was found dead. A surgical assistant at Al Zarzou Hospital disappeared in October 2012. In mid-December 2012, the hospital’s anaesthetist disappeared at a Government-controlled checkpoint on his way home from Aleppo.”
“You will not believe it,” Alalwa implores, “Come spend one day in my city and you will not believe it, really.” He moves nervously and alternates with laughs and jokes as he talks about bombs and the dead. His pale face drags down from velvet, brown eyes to a thin-haired mustache and fledgling beard. White ear buds jut out from his ears and a white, wool hat matches a white turtleneck that wraps his neck. A Kermit-the-frog green hoodie is shockingly bright, almost luminescent, and contrasts with snippets of dark hair that burst out from under his cap. Alalwa’s greatest fear is that, as a pharmacist, he will be arrested by the regime. “I prefer to die here, not to go there,” he says, referring to the regime areas. Alalwa would rather die in Inkhil than be arrested, detained, interrogated, tortured and killed by the regime. He lives in fear of those perilous and real possibilities, as do all medical professionals inside Syria.
Alalwa was born in Dara’a, Syria in May 1985. He studied pharmacy and English overseas at Gomal University, a public research university, in Dera Ismail Khan in Khyber-Pakhtunkhwa province, Pakistan, halfway between Lahore and Quetta on the west bank of the Indus River. He says he graduated with a Doctor of Pharmacy (Pharm.D.) and took his first job as a licensed pharmacist in Damascus until early 2013 when he returned home to southern Syria. On June 6th, 2013, “with two kilograms of medicine and no devices,” he says he helped establish the makeshift field hospital in Inkhil, called Shouhada Souria Hospital – “Martyrs Syria Hospital” – where he now spends his days.
Safety is an ever-changing relative experience of threat and insecurity inside Syria. In the basement of the field hospital in opposition-controlled Inkhil, Alalwa is the least unsafe he can be. There, the greatest threats to his life are the barrel bombs and jet attacks. But the regime is on the other side of the front-line, just one kilometer from his hospital in Inkhil. If fortunes flip, if borders shift, if buffers are lost, if the regime advances, the threat to Alalwa becomes focused and precise. There is no absolutely safe place for Alalwa inside Syria. At the moment, for Alalwa, daily population aerial attacks by the regime are an experienced lesser evil than specified, personalized torture imagined after arrest. But arrest could come quickly. One lost opposition battle, one wrong turn down a rural road, one unexpected advance by the regime and Alalwa can be killed or, worse, arrested and tortured before being killed. He is resigned to what could be his own gruesome death.
The Kia 4000 safely reached the front of the Union of Syrian Medical Relief Organizations (UOSSM) building in Tal Shehab, safe inside opposition-controlled southern Syria near the border with Jordan. The organization’s website says it is a coalition of international humanitarian actors founded in January 2012 in Paris to provide charitable medical relief to medical organizations inside Syria. Alalwa says he supplied the organization with electronic reports of his hospital’s work and needs and, in return, Syrian Medical Relief texted him on WhatsApp when supplies were available and ready for pickup. Alalwa paid nothing. He says he loaded the truck (to 60% capacity) with medical supplies, signed the release papers and turned north back to the field hospital at Inkhil, less than fifty kilometers away. The round trip took four hours. Alalwa says he’s made the trip many times, every one to two months. Although he is short on some medicines, he says the resupply gave enough inventory to keep his doctors working. Each clinical effort brings them closer to their own deaths.
Dara’a city was Syria’s entry portal to the Arab Spring and the ensuing war. It sits ninety kilometers south of Damascus, at the Syrian end of the Damascus-Amman highway. Inkhil is roughly halfway between Damascus and Dara’a, to the west of the main highway, and slightly closer to the Dara’a side. A 2004 census, from the Syria Central Bureau of Statistics, estimates Inkhil’s population at roughly 30,000 people. As the December 2010 Arab Spring volatility burned east from Tunis, following the self-emolation of Mohamed Bouazizi, Inkhil was one of the first towns to rise up against the al-Assad regime. Ground zero was Dara’a city where, in March 2011, fifteen boys, ages ten to fifteen, were arrested and tortured by government forces for painting antigovernment graffiti on a local school wall: “As-Shaab / Yoreed / Eskaat el nizam!” “The people / want / to topple the regime!” The government crackdown was met with popular protests and civic resistance that set the nation ablaze and has since ravaged the entire region.
March 2015 marks the fourth anniversary of the uprising and the beginning of the fifth year of ongoing hostilities inside the Syrian Arab Republic. What began as graffiti penned to walls in the streets of Dara’a by children, grew to a gradual slicing up of land and people throughout the country along ethnic, religious and ideological lines. Alawites and Shia against Sunnis, pro-government forces and Shabibha against irregular fighters and old, proxy international enemies against new, including the Islamic State of Iraq and Syria, or ISIS, and Jabhat al-Nusra, an al-Qaeda branch in Syria and Lebanon. Populations shifted and patterns of systematic and illegal torture and killing of civilians emerged.
Much has been lost from Syria’s pre-war 23 million population. The big picture numbers are staggering. More than half of the United Nations $12.9 billion 2014 global humanitarian appeal was funding support for Syria. As of December 2014, 12.2 million people, in the region, are in need of humanitarian assistance with almost 5 million people in difficult or impossible-to-reach areas inside Syria.
Precise numbers of dead are not known. The United Nations (UN) stopped counting. The UN’s last cumulative updates were 100,000 Syrian dead in July 2013 and 191,369 Syrian dead in August 2014. There are more than 3.8 million refugees, Syrians who crossed international borders into Jordan, Lebanon, Turkey and Iraq. There are almost 7.6 million Syrian internally displaced persons, or IDPs, twice the number of Syrian refugees. War forced these Syrians from their homes but they remain inside Syria. There are resident migrants, third country nationals and refugees, from other countries, inside Syria itself, including 18,000 Palestinians at al-Yarmouk, outside Damascus.
And then there are the unknown numbers of tortured, disappeared, detained and other near-dead. The most vulnerable are the more than 200,000 people besieged, Syrians trapped in their communities with no prospect for travel or access to outside aid or medical care. Government forces in Eastern Ghouta and Darayya besiege more than 180,000 people and over 25,000 are besieged by opposition forces in Nabul and Zahra. Civilians, within a stone’s throw of modern Damascus, are literally walled off from the rest of Syria with no meaningful access to water, food, sanitation, medicine or healthcare. The prescribed, fast, traumatic death for the direct conflict-affected civilians, in areas like Dara’a, is replaced with the expectant, slow, catabolic death for the besieged. The besieged are the near-dead, patients in the pipeline for the doctors remaining inside Syria.
Physicians for Human Rights (PHR) in New York City is paying attention. PHR concerns itself with stopping mass atrocities and, in doing so, documents the dead. With ongoing hostilities inside Syria, PHR is recording grave human rights violations, including not only the destruction of Syria’s healthcare system, but also the shocking rise in targeted deaths of Syria’s doctors.
Inside Syria, PHR has chronicled grave human rights violations including: denial of care to wounded civilians by government forces; invasion, attack and misuse of hospitals by government forces; attacks and delays in medical transport by security forces and the detention and torture, by government forces, of doctors for treating wounded civilians. Inside Syria, hospitals stopped being places of care and healing. They became places of medical Russian roulette, a game with chambers of disparate possible outcomes – care or torture or death – for both patients and doctors.
Doctors and hospitals in Syria moved progressively underground. A whole subterranean health network was established. Doctors have no option but to treat patients in poor conditions, such as on farms or in the basements of abandoned schools, such as at Shouhada Souria field hospital in Inkhil.
In its February 2015 report, “Syria’s Medical Community Under Assault,” PHR detailed the attacks suffered by hospitals. Accounts are updated monthly. There are now 233 documented attacks on 183 separate medical facilities inside Syria. PHR adds:
“Public hospitals have been damaged in 12 of the country’s 14 governorates. In December 2014, the World Health Organization (WHO) and the Syrian Ministry of Health reported that of the 113 public hospitals they assessed, only 45 percent were fully functioning, 34 percent were partially functioning, and 21 percent were non-functioning.”
“In Raqqa – the stronghold of IS – no obstetrics, gynecological, or pediatric services are reportedly available for the 1.6 million people living there. Medical personnel continue to flee IS-controlled areas due to restrictions on professional activities; female doctors are only allowed to treat female patients, and they must wear a niqab, even though the veil obstructs their vision and makes their work difficult or impossible.”
In a ninth floor office on West 38th Street, in New York City, Elise Baker sits in a glass-walled conference room with a colleague screening video and social media footage on a large LCD display. Baker is a Program Assistant to the investigations team, led by Director of Investigations Ms. Erin Gallagher, and helped develop an online, interactive and time-lapse crisis map of healthcare violations inside Syria. She also co-authored a sentinel March 2015 PHR report, called, “Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria.”
Since March 2011, PHR has counted the deaths of 610 medical personnel inside Syria including: 199 doctors, 120 nurses, 114 medics, 58 pharmacists and 17 ambulance workers. It says, in Syria, “In 2014, a medical worker was killed every other day on average.”
PHR has documented 89 deaths of healthcare personnel by torture and an additional five deaths where tortured preceded execution. Of these 94 healthcare personnel tortured to death, 36 were doctors, 17 were nurses, 14 were medical students, 7 were pharmacists and 6 were dentists. PHR writes: “The Syrian government is responsible for 88 percent of the recorded hospital attacks and 97 percent of medical personnel killings, with 139 deaths directly attributed to torture or execution.” Belligerents on all sides are responsible for the killings, but 97 percent of the medical staff deaths are charged to the regime.
For doctors inside Syria, there are two great unknowns: First, how many doctors inside Syria have been tortured but not killed? The United Nations Commission of Inquiry on Syria details tortures including bodies hanging from ceilings and electrocution of external genitalia. And second, how many doctors are currently held in detention centers, administered by the four major Syrian intelligence arms, charged with “treating wounded people”?
Dr. Fatima works in besieged Eastern Ghouta. Her name has been changed to protect her identity. She was contacted through the Syrian American Medical Society (SAMS), the major American conduit for medical and physician aid to Syria. In February 2015, SAMS and the John Hopkins, Bloomberg School of Public Health published a joint report called, “Syrian Medical Voices from the Ground: The Ordeal of Syria’s Healthcare Professionals.” Dr. Fatima, like Dr. Alalwa, was vetted by a trusted humanitarian organization as a reliable and accurate witness to current events inside Syria.
Dr. Fatima texts and voice-mails in Arabic on Skype and WhatsApp: “Damascus regime intends to consider doctors who are willing to help innocent people are worse [than] the fighters — you can imagine the size of torture — if this regime arrest one of these doctors. I can give you rail picture because my husband one of them.” Her Facebook page from January 8th, 2015 does post a photo of a man with twenty-nine comments repeating the sentiment, “May God bless him.” She did not wish to communicate further. Confirmation of details, relating to her husband, is not possible.
One of the most atrocious stories not being told outside Syria is that doctors are being killed, tortured and detained inside Syria – because they are doctors.
Timing matters inside Syria and the people of Inkhil can set their clocks to the barrel bombs that drop from the sky. They detonate daily between 11:00 a.m. and 2:00 p.m. “We hear its voice,” says Alalwa, referring to the helicopters, “Before it reach to our city, we hear its voice. So, we go out to see if it will throw on us or not. From 10 kilometers far from us, we hear the voice.” Laughing, he adds, “It’s voice, enough to kill you!”
Through Skype, Alalwa shares multiple videos from his phone that he says he took in Inkhil. The authenticity of the footage cannot be independently confirmed. In them, the underbelly of a dove-colored helicopter propels over land and ejects two masses of metal from its cargo hold. The barrels are filled with shrapnel and explosives and detonate with timers and on impact. The color frames resurrect black-and-white, grainy video memories of the bombing Blitz of London by Nazi Germany in World War II: the roar of the Luftwaffe pilots overhead, the drop, the pause and the targeted destruction of non-military targets – civilians, churches and homes – on the ground below. Syria’s pockmarked landscape is forever transformed by an aerial bombing campaign that is longer, broader and more fatal than that experienced by Londoners. The Blitz lasted 267 days, across 16 cities with 40,000 dead. The exact numbers of dead from Syria’s barrel bombs are not known but the current campaign in Syria is 974 days and counting – more than three times as long as the Blitz.
In its sixty-four page, ninth report on the crisis, released February 2015, the United Nations Commission of Inquiry on Syria writes:
“14. The first reported use of barrel bombs was in August 2012 in Homs city. It was not, however, until mid 2013 that government forces began an intense campaign of barrel bombing of Aleppo city and governorate. Throughout 2013, 2014 and into 2015, the Government has made liberal use of barrel bombs. These makeshift explosive containers have caused thousands of civilian casualties. Barrel bombs are regularly dropped on crowded areas, such as bakery lines, transportation hubs, apartment buildings and markets. Aid distributions have also been targeted.
15. In April 2014, the Government dropped barrel bombs containing chemical agents, likely chlorine, on locations in Idlib and Hama governorates. The first attributed finding of use of chemical weapons by a warring party was noted, but did not spur greater action to end the conflict.”
Google Earth image, Inkhil, Syria – accessed April 2, 2015
“Everyday they send us three or four barrel, explosive barrel,” says Alalwa. Today, while he was at the border to replenish medical supplies, there were six drops. No one was injured – this time. When they hear the soaring voice of the visiting helicopter, he says, people look skyward and watch as the propelling dot lugs its metal tonnage undertow through the air and, then, releases. “It’s coming down,” he says, “All the people looking up and seeing the barrel coming down.” From the air, on Google earth, Inkhil looks like a bicycle wheel. There is a densely populated central hub with patchwork fields further out. Barrel bombs landing at the hub have a high probability of hitting residential homes and civic infrastructure.
Unlike Londoners in World War II, there are no underground stations to shelter the people of Inkhil. Alalwa says his nephew now looks up to the sky and can identify the helicopters that ferry the barrel bombs. “I have one nephew, he is three years of age, just three years. What he is? He is just kid. He know nothing in life. But now he can see and he tell me, ‘Look my uncle, the barrel coming toward us.’ What can you image from this child?”
The helicopters fly at seven kilometers altitude, Alalwa says. They are “special ones,” he says, able to fly out of air range of the Free Syrian Army that controls Inkhil. Gravity snaps the barrels to the ground and Inkhil’s eyes track their inevitable descent. The descriptions are a refrain in the population’s collective mind – from exposure to outcome. The voice of the helicopter, propelling white dot, metal mid-air, crash to ground, detonate, explode, mushroom plume, disperse, maim, kill and destroy. Collect the wounded. Perhaps a second attack on those who run to collect the already wounded. Ferry the injured. Bury the dead pieces. Upload images on YouTube, Skype, Facebook and WhatsApp. Repeat.
Alalwa says, “You don’t imagine. When the barrel come on the earth, you don’t know, I can’t explain for you what it can do. Families, all the families, you know, I mean, all the member of families, they can die and they can injure, from one barrel. You don’t imagine what it can do. 700 TNT come to you. What it will do? If one 700 kg of TNT. What it will do? Imagine that.” The barrel bombs create mass casualties, a disaster for doctors at Inkhil.
And there are bombing runs from jet attacks too. Those plumes are different. The plumes of the barrel bombs are brown and grey – and rise slowly, like the fizz and foam of a coca cola vanilla float. The detonations and plumes are serial and multiple: Kaboom, first visual plume, pause, pause, kaboom and a second, baby plume, that expands into the growing mother plume. In contrast, the jet attacks are rapid, linear strikes with instant plumes that flash the color of the off-white debris from the off-white concrete homes.
Both attacks deliver shrapnel and heat – high velocity projectiles and energy that explode skin and bones. In Inkhil, doctors work to salvage what remains.
Dr. Alalwa wakes up in the Shouhada Souria field hospital in Inkhil. It is 11:00 a.m. He slept six hours. His bed is on the floor behind his desk and computer. It is a brown, single mattress on top of a green and beige carpet with the long side of the mattress pushed up, parallel, against a bright pink wall. Two synthetic blankets, with brown and pink floral patterns, are pushed to one side. There is no pillow in sight. He recounts being up all night, until 05:00 a.m., filling out paper work to order medical supplies from donor agencies in Jordan. Alalwa is the field hospital pharmacist and so frames the war in terms of the binary reality of drugs in Inkhil: drugs that his doctors have and drugs that his doctors need. He has enough rocuronium, atracurium and propofol – all anesthesia drugs – for the coming weeks. He is worried, though, about coming drug shortages. He looks at the numbers again. He is running low on medical staples like morphine and drugs for children and pregnant women.
Alalwa says hospital supplies come from both Jordan and Damascus and that the road from Damascus to Inkhil is peppered with roughly ten army security stops, with two main checkpoints at Sweda and Keswa. Ferrying medicine and medical supplies around Syria is dangerous. Possession of smuggled medical goods, including simple medical bandages, is verboten and can have the courier killed, including doctors, he says. Items from the main supply stores in Damascus are scrupulously logged. He says checkpoint bribes – anywhere from US$500 to US$700 a pass – have worked up to now, with money coming from activity on the black-market.
A main distribution line from Damascus to the pharmacies in Inkhil, though, was cut off roughly two months ago. Alalwa says fifteen men transporting drug supplies were arrested at a Syrian government checkpoint for transporting medicine. These were not one-off messengers. These were regular suppliers who, Alalwa says, successfully made the medical re-supply road trip from Damascus to Inkhil every seven to ten days for three to four years. This last time, though, they didn’t make it through one of the checkpoints. Alalwa says they were arrested and their whereabouts remain unknown. Now, without resupply, the pharmacy inventories of his hospital, and that of surrounding private hospitals in the region, will suffer.
Alalwa says he left the hospital, felt the mid-day sun and took in the views of Tal Kabir and Tal Saghir – big mountain and small mountain – in the distance. He wanted to go spend an hour with his family, a five-minute drive away, before going back to the hospital. The front line – with the Free Syrian Army on one side and the Government of Syria Army on the other – is just one kilometer away. “The doctors, the nurses, all the staff, They [are] used to sleep in the hospital. Twenty-four hour, we have patients, so we should be ready. For me, I don’t live with my family, because of my work. I have to be ready,” he says.
Back at the hospital, Alalwa follows an unusual schedule: sleep from 05:00 a.m. to 11:00 a.m. at the hospital, an hour at home and then back to work at the hospital from noon to 05;00 a.m. But the daily rhythm is tied to the injured and the injured are tied to the barrel bomb alarm clocks that sound each day from 11:00 a.m. to 2:00 p.m. Medical supplies need to be ordered and the only place with internet access is at the field hospital where there is a satellite connection. Electricity comes from a generator. He says the filed hospital has no running water – it comes from a tank.
Alalwa is single with siblings still in Inkhil. “I go one hour for my family, during the day, I eat. When I wake up, I go, I eat, I see them and then come back to hospital. I stay working, up to sleep,” he reveals, “This is my life. It’s not normal life but we can consider it as normal for us. At least we are safe. It’s better than regime area. We consider it more safe. Even we have explosive barrel, barrel bomb, but it is safe for us, because if they catch us, you know we will suffer more than this. The regime army catch us, it is more difficult for us.”
Inkhil’s Shouhada Souria field hospital is deliberately underground. It is in the basement of what Alalwa says was a private children’s school, emptied by the war. Photos he sends show four intact upper floors of a building with the exterior walls blown away. Layered slabs of sand bags fortify approaches at ground level. It is unsafe to use above-ground space. Just days ago, he says, a barrel bomb landed just meters from the building. All hospital activities – all emergency care, all operations to save a life and all deliveries that produce new life – take place in the veritable, concrete basement sarcophagus.
Alalwa says fourteen doctors work in nine small rooms in this makeshift field hospital one kilometer from the frontline. There is a makeshift emergency room (ER), a laboratory, a hospital pharmacy, an x-ray area, two medical care areas, two sitting areas and one operating room (OR). Although the naming of rooms might suggest legitimacy to the hospital operations, there is no mistaking that this is an improvised hospital in a war zone. Alalwa and his colleagues are simply doing the best they can.
Photos of the ER show walls with peeling two-tone paint – blue on the bottom, white on the top. In the sitting areas, the walls are pink on the bottom and white on top, perhaps blue for the boys and pink for the girls, students who once played there. The baseboards, and halfway up the wall, are scuffed and broken, revealing white concrete underneath. Knotted dead-end wires poke out from the walls higher up. A bare, lit ceiling bulb casts shadows around corners and under the seats of five torn, mismatched, black, executive-style chairs lined up against a wall outside a patient-treatment area. The floor is tiled and beige with dirt-dark grout. The pink-and-white walled corridor sitting area leads to a blue-and-white walled OR. Inside, Alalwa shows expensive equipment: an anesthesia machine to put patients to sleep and a mobile X-ray, called a c-Arm, to help surgeons see broken bones during surgery.
The specialty coverage is unexpected. Alalwa says there are two anesthesiologists, one general surgeon, one urologist, two orthopedic surgeons, one obstetrician-gynecologist, one ENT surgeon, one radiologist, two general internal medicine physicians, two dentists and one pharmacist. All are male and most do not speak English. There is also one medical student – even in a war zone. He arrived to Inkhil after his studies in Damascus were disrupted three years ago. He cares for post-operative patients. Job responsibilities become fluid in war. “Now, he is doctor,” says Alalwa, “Our life make it like this, right now.”
Inside Shouhada Souria field hospital, Inkhil, Syria, March 2015.
Photo Credit: Dr. Abdullah Alalwa
In the middle of the night, Alalwa shows a photo of one man he identifies as a surgeon asleep in a framed bed next to his own mattress on the floor. There is a busted white nightstand table between them with a round black ash tray on top. A single drawer hangs open. A cell phone charger is plugged into a wall socket. A circular, silver tray, with a metal tea-pot and four used, glass tea-cups, sits off to one side on a small, brown table. The surgeon’s dark hair and forehead are buried, away from the light, in his own two acrylic, brown and pink floral patterned blankets.
The OR at Shouhada Souria field hospital is a single room crammed with two to three operating tables. At the height of a mass trauma event in Inkhil, Alalwa says two ER beds were added to the already three tables in the OR so that five patients were operated on all at once. Photos and videos are posted on the hospital’s Facebook page (https://www.facebook.com/shouhada.souria.hospital/timeline?ref=page_internal). There are photos of old men, of women and of children – blood stained, with deep wounds, and siting or lying in various states of fear, injury and consciousness. There are intravenous poles near gurneys, pink, 20 gauge, intravenous catheters taped to bloodied forearms and metal external fixator devices through broken bones. There are surgical Kelly clamps and abdominal retractors. There are mangled arms, open bellies and motionless children. Photos show people in muddied, open-toed sandals holding the bloodied hand of a patient being operated on under general anesthesia. The images cry haste. The room, the equipment, the drugs, the patients, the families and the doctors all put together, in haste, to save the near-dead.
Independent verification of Facebook photos and of photos and videos communicated directly by Skype and WhatsApp is not possible but the volume and specificity of the images tied to known attacks in Dara’a makes them convincing. I am an anesthesiologist who worked at a major teaching hospital in Boston, Massachusetts for fourteen years. I also worked as a conflict anesthesiologist with Médecins Sans Frontières (MSF) in Misrata, Libya in 2011. I grilled Alalwa. The histories and the images of the injuries, the equipment, the operative fields, the doctors and the care of the patients are all consistent with contemporary medical practice.
Alalwa estimates the hospital team performs, on average, five operations per day. It all depends on the burden of post-explosive injuries that come through the ER, where they see one hundred to one hundred twenty patients a day. If there are no bombings, the majority of ER patients are medical patients; that is, they are non-surgical. With bombings, though, attention rapidly shifts to trauma patients in need of surgical care. On one day, two months ago, Alalwa says they received 200 patients with injuries and performed 37 operations. The children and the women, all civilians, are hit. When the barrel bombs blast, the converted school basement fills with broken bodies – mangled hands, gutted thighs, penetrated torsos and exploded long bones shattered by debris. And these patients are the lucky ones. They are not yet dead.
Doctors still deliver mothers at Inkhil, where a pregnant woman can be killed trying to access the hospital. Alalwa says that there are about ten deliveries a week at Shouhada Souria field hospital – about forty a month. But the hospital is running out of supplies, including drugs like oxytocin that help stop bleeding from the uterus after delivery. So doctors send many pregnant patients, sometimes in labor, to other hospitals, in nearby Jasim or south to Jordan, for delivery.
With the growing war, most Inkhil families fled to border countries or to the Gulf, says Alalwa. He has family on the border with Israel and brothers and sisters who are safe in Kuwait, the Kingdom of Saudi Arabia and in the United Arab Emirates. It is no longer safe to stay in Inkhil and those who remain do so for a purpose – like the doctors of Inkhil who, for the acutely injured, are the difference between near-death and life.
Alalwa says that, in Inkhil, the doctors feel safe. He says he feels free to move about in Inkhil – but also notes that he works continuously and rarely leaves the hospital.
What the doctors in Inkhil fear most, says Alalwa, is shifting frontlines and arrest by the regime. He knows of doctors arrested by the Syrian Armed Forces. “After one to two years we hear they are killed,” he says. There is urgency in his voice but there is also anesthetized hope mixed with raw experience and quiet resignation. If he were arrested by the regime, Alalwa says he is certain he would be killed. “If I go there, surely I will die,” he says, “They will kill me. Sure, one hundred percent. They will consider me as terrorist. Because I am helping people, the injured people. I am helping my family. I consider all the injured people my family. That’s why they consider me as terrorist.”
The greatest risk is for doctors in regime-held areas. Physicians for Human Rights (PHR) reports 97% of the deaths of medical personnel are caused by the regime. In opposition-controlled areas, Alalwa says the Free Syrian Army does not interfere with medical care of patients and does not kill doctors for being doctors. For doctors in regime-held areas, though, the United Nations Human Rights Council and PHR write that the reality is painfully and deadly different. Those doctors are told who to treat and who not to treat, sometimes at gunpoint. Doctors in regime-held areas can be killed by regime forces for treating an injured patient suspected of being an anti-government protesters – opponents of the regime. Such care is seen as proxy support for the revolution. As a result, doctors lie about how patients were injured. In regime held areas, Alalwa says, doctors live in constant fear of surveillance, phone-tapping, arrest, disappearance, detention, interrogation, torture and death.
“I prefer to stay here and die.” says Alalwa. The safest place for Alalwa is the concrete basement of the hospital. He has no reason to travel to regime-held areas but, if the frontline shifts to the government advantage, given the choice between regime arrest and death in Inkhil, he would choose certain death in Inkhil.
In a government-controlled area of Damascus, Dr. Ayman Mahayni could not have known that he would be searched out and killed in the beginning morning hours of Monday, March 2, 2015. He could not have known that his last movements would be walking the Al-Midan Corniche in Damascus near the government-controlled area of Thuraiya. He could not have known that his final heart-beat and final breath would be met by an unknown assassin’s bullet. He could not have known that his son Mohammed, and an unidentified third person, reported to be his bodyguard, would be killed in the mêlée. When he attended medical school, when he opened his own al-Mahayni Hospital and when he worked that day, Mahayni could not have known that, on that day, his body, and that of his own son, would be buried after Dohr prayer from al-Midan’s Al Daqqak mosque in Damascus.
Dr. Mahayni could not have known his fate as one of Syria’s doctors systematically targeted and killed – for being a doctor. The Syrian Observer reported his murder and, with four years of data and reports penned by the most respected humanitarian organizations in the field, the outside world could have predicted it.
Doctors who treat protesters-turned-patients with trauma injuries are targeted by the Syrian regime and those who treat injured government security forces are labeled as spies or informants. All doctors are at risk for extrajudicial execution. Doctors are killed while walking in front of their homes and while looking after the ever growing number of trauma patients on hospital wards. No place is safe.
All of the governorates, or administrative divisions, of Syria are affected by attacks: Dar’a, As Suwaydk and Quneitra in the south; Rif Dimashq, encompassing rural Damascus, including Douma and Yarmouk, also in the south of the country; the largest governorate, Homs, at the heart of the country; Hamah; Tartus and Al Latakia at the coast and, counterclockwise to the Iraq and Turkey borders: Idlib, Halab, Ar Raqqah, Dayr Az Zawr and Al Hasakah.
The Free Syrian Army controls the area around Inkhil. From Inkhil, Alalwa says it is not more than fifteen kilometers west to Israel and not more than 35 kilometers south to Jordan. He maps out the belligerents that encircle Inkhil in binary terms – either “with us” or “not with us”. The “us” he is referring to is the Free Syrian Army, although Alalwa repeats that he is neither with the Free Syria Army nor has he picked up a gun. “Nawa with us. Jasim with us. Tal Shehab with us. Simlin with us.” Moving east, “Qayta now with army. East of Inkhil with army,” he says, with “army” referring to the Syrian armed forces. “Tybnah with army. It’s Christian,” he explains.
Alalwa says he is not afraid of the “Free Army”. “They respect us,” he says, adding, “Why I should be afraid? All my way with Free Army.”
When the indiscriminate bombs hit the ground, Alalwa says hundreds of patients and family members pour into Inkhil’s small field hospital. He remembers two days in particular. One was the day he saw sixteen injured people brought to the hospital at the same time inside one car.
The other was on May 15, 2014. On that day, bombs destroyed the first field hospital in the neighboring city of Jasmin. Alalwa says the explosion shredded the body of his friend and colleague, 28 year old Dr. Waled Shbat, an orthopedic surgeon. “We could not recognize him,” says Alalwa. Shbat was from Namar city and worked in Jasmin’s first field hospital, in a school’s basement. “He just was right now going from operation room. He finish one surgery for child then went to relaxes on his bed,” says Alalwa. Shbat died. Alalwa says more than fifteen people were injured. A nurse survived the attack but suffered a traumatic head injury. Alalwa transported him to the Jordanian border for ongoing care.
Jasmin, which, as of March 2015 was opposition-controlled, had hospitals before the war. Alalwa says there was never a hospital in Inkhil before the fighting began. In Jasmin, there were two hospitals: one public and one private. The private hospital was named after the current Syrian Prime Minister, Dr. Wael Nader al-Halq. Al-Halq, a Sunni muslim, is an obstetrician-gynecologist who obtained his medical degree from the University of Damascus in 1987, one year before Dr. Bashar al-Assad. President Bashar Al Assad appointed al-Halq Prime Minister of Syria in 2012, when his predecessor fled to Jordan.
Jasmin’s government hospital is no longer there. It was bombed by rebels Alalwa identifies as Japhat Al Nosra – allegedly linked to Al Qaida. When the government hospital was destroyed, Jasim doctors created their first field hospital in the school basement, just as in Inkhil. When that was bombed by regime forces, and killed Shbat, doctors moved to hastily re-establish the field hospital in the basement of the private Al-Halq Hospital. Syrian Prime Minister Al-Halq’s eponymous hospital is now in territory controlled by the opposition Free Syrian Army.
The numbers of patients goes up and the supply of doctors goes down.
Inside Syria, patient numbers have escalated – for both trauma and normal medical care for conditions like hypertension, kidney failure and diabetes. The WHO now estimates over 1,000,000 people inside Syria who are in need of operative and non-operative healthcare. For perspective, Massachusetts General Hospital in Boston has a 900-bed capacity. In order to care for the current patient backload inside Syria, with both acute and chronic injuries, overnight, the country would need to build over one thousand MGH- equivalents to clear the load.
Dr. Naser Hamood is the medical coordinator for the Syrian American Medical Society (SAMS) office in Amman, Jordan. He says that there is a critical shortage of anesthesiologists and obstetricians in Syria. He says that, given the attacks on hospitals, the risks to pregnant women, in particular, are considerable. They can be attacked traveling to the hospital in labor or while in hospital for delivery that can take hours. Time is risk. This has created something very unexpected. Hamood says that inside Syria, c-section rate have increased in certain places; a typical c-section takes about an hour to perform, but the blood loss is much higher than normal deliveries. Nevertheless, in some places, it is safer for a pregnant patient “to make a c-section than to make a normal delivery,” he says.
But c-sections and trauma surgery require doctors. They require surgeons and anesthesiologist who don’t leave. Doctors continue to live and work inside Syria, in hospitals, that are targeted for destruction with intentional, aerial bombings by the regime. Airspace over Syria is tightly controlled by the government, led by President Bashar al-Assad. A doctor is systematically blowing up and killing the very profession he swore to uphold.
At graduation, doctors take an oath to “never do harm to anyone.” But what happens when they themselves are harmed? Who protects the doctors?
There are rules to war. That collective legal framework is called International Humanitarian Law (IHL). The classic rules of war were negotiated and codified at the First (1899) and Second (1907) Peace Conferences at The Hague, Netherlands. These international treaties established terms for conduct of war between nations. Rules of engagement – the military ethical principles of distinction and proportionality – emerged. Distinction means that parties to a conflict distinguish between civilians and combatants. Direct targeting of civilians, for death or injury – daily images from Syria – violates this military ethical principle of distinction. Where a military objective is gained with incidental, not targeted, injury and death to civilians, the gain in military advantage has to far outweigh the civilian cost – this is the principle of proportionality. The theater of war is not a simulated wild west shoot out. Civilians, including doctors, cannot be directly targeted. As a matter of international law, military commanders must minimize harm.
Further legal texts ultimately agreed to in the post-World War II United Nations world, guaranteeing further protections, became known as the Geneva Conventions (1949). There are four Geneva Conventions and each one details the protections afforded to particular groups, covering the treatment of the wounded on land, and at sea, of prisoners-of-war and of civilians caught in international conflict. There are two additional protocols to the Geneva Conventions called Protocol I and Protocol II. These protocols were adopted in 1977 and provide additional detail pertaining to the protections of civilians in conflicts of an international and non-international nature respectively.
As seen in Syria, conflicts are not always easily classified along national boundaries. In such cases, Common Article III – common to all Geneva Conventions – can be thought of as the prime number equivalent of legal texts, detailing the most fundamental, non-derogable rights of any human being: that, during war, the wounded and sick shall be collected and cared for.
What all of this means is that, in a war zone, any person who is not carrying a gun – a civilian or an injured prisoner of war or a combatant who has laid down arms or an unarmed doctor working in a hospital – has the right to be protected and, when injured, has the right to be collected and cared far.
In war, doctors, nurses, medics, pharmacists, ambulances and hospitals have further protection. The Red Cross and Red Crescent emblems are afforded particular and distinct protection. Any vehicles, any buildings and any individuals operating under a Red Cross or Red Crescent emblem are to be protected.
Inside Syria, there are no rules. The rule of law itself has been killed. In contrast to hostilities inside Bosnia and Afghanistan, for example, respect for even minimum standards of international humanitarian law inside Syria has been lost. In its July 2014 report titled “Syria’s Medical Community Under Assault,” Physicians for Human Rights (PHR) reported the direct assaults on doctors, patients and hospitals:
“Since the war began in Syria in 2011, hospitals, field clinics, ambulances, and vehicles transporting medicine and medical supplies have been deliberately targeted for destruction. While government forces have been largely responsible, the Islamic State of Iraq and Syria and various anti-government armed groups have also carried out attacks. Medical personnel have also been arrested, tortured, executed, and disappeared. These crimes against the principle of medical neutrality – which ensures safe access to medical facilities, protects health care workers and their patients, and allows medical workers to provide unbiased care – have compounded the suffering of civilians and hastened the devastation of an already fragile health care system.”
International Humanitarian Law did not protect Dr. Hassan Eid from being killed. Eid was a thoracic surgeon at Homs National Hospital and was killed in September 2011. Anthony Shadid, a New York Times journalist who would die traveling from Syria, in February 2012, wrote about Eid’s death:
“One of those killed was Dr. Hassan Eid, the chief of thoracic surgery at the National Hospital here and an Alawite from Al Zuhra, one of a handful of neighborhoods where his sect makes up a majority and where buildings and streets are still plastered with the portraits of Mr. Assad. He was shot to death in front of his house as he headed off to work, residents said.
Al Ouruba, a government-aligned newspaper, called him a “symbol of dedication” and said he treated victims of the violence “without discriminating between any of them.” But in Sunni Muslim locales, residents called him a government informer who helped security forces detain the wounded who were treated at his facility.
By nightfall, a hint of triumphalism echoed in parts of the city, as some people celebrated his death. “He was responsible for the death of many young men,” said a 65-year-old resident of Homs, who gave his name as Rajab. “He was killed because he deserved it.”
Doctors fear for their lives from all sides of the conflict. As reported by the United Nations Human Rights Council, Commission of Inquiry on Syria and Physicians for Human Rights, doctors who treat injured protesters may be killed by Syrian Army security forces and doctors who treat Syrian Army combatants may be killed by opposition fighters who allege that the doctor is a government spy.
Doctors of Syrian origin have returned to provide respite medical care to colleagues inside Syria. Dr. Adeeb Alshahrour is a Syrian-American obstetrician, from Chicago, Illinois, who trained in Syria and the United States. He returned to Aleppo in 2012 and again in 2013 for short-term relief work there. He reports that on his second trip, one of his former female Syrian colleagues left work with the Aleppo Medical Council to go work a short distance east in ISIS-controlled territory. ISIS has strict segregation of the sexes and wanted a female obstetrician to care for female patients. The female doctor left Aleppo and took the job with ISIS. The pay was better.
As their numbers are killed, detained and tortured away, despite failures in national and international legal protection, doctors continue to care for patients inside Syria.
Alalwa left the hospital. He got into his car, a sun-faded, red, 1997 Mitsubishi, and drove the short distance to where he stays in Inkhil with his sister and two brothers. His sister is two years older and is a teacher. When schools in the area were banned at the beginning of the uprising, he says she started teaching for free.
Alalwa shares a photo of the outside of their house in Inkhil. “U see the water tank?” he texts. A large, gray metal container sits in front of a ground entrance of a partially destroyed house. “We use it to protect the door,” he writes, adding that his home was bombed one year ago, “it was so nice and clean be4 revolution.”
Alalwa says his sister thinks he is boring. He is always at the hospital. Yesterday, he says he changed his normal schedule and took his sister shopping, in Jasim, just 8 kilometers southwest of his broken city. Alalwa wanted to shop too. He went to collect an order he placed five days before with delivery expected from Damascus. He ordered a new gold, 64 GB iPhone 6. It cost US$860 and Alalwa says he paid cash – only. If the shop owner were found selling the item, he would have been killed. “If the army check point will see it they will take it and arrest the shop man. They will tell him you are taking it for terrorist,” says Alalwa. The shop owner hid the iPhone 6 until Alalwa could collect it. He gave his old iPhone 5s to his sister. In Inkhil, Alalwa uses the satellite internet connection back at Shouhada Souria field hospital. He does not have a cell provider.
Alalwa uses his new iPhone 6 to Skype photo the new MacBook Air he got 10 days ago. He is excited about the Core i5 – a fifth generation Intel microprocessor. He says it took one month to get the laptop. It was paid for by his brother-in-law in Saudi Arabia and carried up through Jordan and through a Syrian border checkpoint to Alalwa. The laptop sits on a small, off-white metal table in the basement of Shouhada Souria filed hospital. He also has an HP iCore7. “But I like Apple,” he says.
The phone and the laptops are Alalwa’s link to the outside world through Skype, Facebook, Gmail, WhatsApp and Viber. Although he is physically constrained by war inside Syria, his virtual access to the outside world communicates that experience in seconds. He uses his electronic devices to write reports and order medical supplies. He also uses them to try and understand what is going on in the rest of Syria and how the opposition is perceived by the rest of the world.
From his bulwarked crypt, Alalwa believes that the outside world supports the internal actions of Bashar Al Assad. He feels the rest of the world has forgotten about the civilians of Syria. Why else is there no intervention? – particularly in besieged areas.
He says he has colleagues in Damascus who are aware of the shortages for doctors in Dara’a but that they are afraid to help. He says the same is true of his experience with international NGOs. Alalwa says he made requests for medical support from major international organizations in Damascus but that they hold back from providing humanitarian assistance to opposition controlled areas – so-called cross-line aid – a violation of the humanitarian principle of impartiality these organizations avow support. He says they are afraid of experiencing President al-Assad’s wrath first hand – that they themselves, international humanitarian actors will be detained, arrested, tortured or killed.
Effectively, many international humanitarian actors inside Syria practice self-censorship, giving aid only where the government will be permit it. Although these aid agencies have a physical presence in Damascus, their aid is not reaching large areas inside Syria. Alalwa says his humanitarian actor friends tell him they wish they could help but that they are afraid. “I respect him. I know why he can’t and I excuse him,” he says.
The international right of doctors to care for the sick necessarily implies a coordinated chain of interaction between patients, doctors, other healthcare providers, hospitals, ambulances, pharmaceutical entities and home. The government of Syria is a signatory to treaties that would safeguard doctors’ endeavors to secure these links. But, on the ground, the opposite is happening.
In December 2014, the UN estimated that everyday inside Syria, 1,480 women give birth in desperate conditions. The WHO reported Syrian outbreaks of tuberculosis, typhoid, polio and measles due to unsanitary conditions and drops in childhood vaccination rates. Inside Syria, in 2014, there were 6,500 cases of typhoid and 4,200 cases of measles. In November, the Syrian Arab Red Crescent reported three cases of myiasis in opposition-controlled, and besieged, Ghouta. Myiasis is a parasitic maggot infection spread by flies and treatment requires surgical removal of fly larvae from the patient’s skin. It had never before been reported inside Syria. These health concerns emerge from desperate water, sanitation and hygiene conditions.
The war has changed everything but the networks of Customary International Law, Human Rights Law and International Humanitarian Law, that are supposed to be the legal lines in the sand, have failed to safeguard even minimum respect for the rules of war, and the protection of doctors and medical care, inside Syria.
Abdullah communicates back and forth with laughter and jibes on Skype. The emoticon with the broad-smiling yellow head, that rocks back and forth, is a favorite. “You will not believe it,” he writes, replying to a question on what life is like inside Syria. “You will not believe it.” Smiley face emoticon, smiley face emoticon.
Alalwa texts a link to a new Facebook page that, from March 6th, 2015, began posting thousands of photos of dead, tortured men allegedly from inside Syria, “for the page containing 11000 photo still they r publishing till now they publish about 2500 photos and videos.” (https://www.facebook.com/pages/%D8%AB%D8%A7%D8%A6%D8%B1-%D8%A8%D9%84%D8%A7%D8%B3%D9%84%D8%A7%D8%AD/804038986341568?fref=nf) They are gruesome photos of dead men who are TVT-positive – with evidence of trauma, violence and torture. There are hundreds of photos: all men, all dead, all head shots, many enucleated (with eyes torn out) or with missing skin from their upper eyelids, many with extensive evidence of head trauma, many with missing teeth, many with open neck wounds and broken faces, many emaciated (suggesting that they were detained and starved for a prolonged time), many with fresh blood and the majority with Arabic numbers or lettering on their foreheads.
They look like photos taken by Syrian informant “Caesar,” a photographer for the Syrian military police, who distributed the images to Christiane Amanpour and the The Guardian in January 2014. “He killed them,” asserts Alalwa, “You will see how he punished them. The animal can cry for them. Not the human. How for humans? Really, you can’t image at this.”
Alalwa says he and colleagues recognize eight of the tortured dead as men from Inkhil. “One of them, he is brother of one dentist,” says Alalwa, “and, you know, he didn’t cry because it became normal for us to see die people every day. Now, he is laughing now,” he says, referring to the dentist, “Because we don’t have feeling, really. Our feeling died.”
But it is the long-suffering hopelessness of it all that fuels Alalwa’s laughter, not joy. He compares his fate to the uprising in Libya. Compared to President Al-Assad, Alalwa says, “Qaddafi was very nice to his people.”
“That’s why I tell you that I am very happy here because, guarantee I will not be arrested,” says Alalwa, “Maybe, I will die. It’s ok for me. But, arrested – no. You will not feel that feeling. You’ll not imagine that feeling. Everything easy for us but not to be arrested. Here, we are, you know, there is no electricity, no water, no phone, power connection, nothing here, but, you know, still that, we are happy.”