The Death of the Clinic

This is the fifth in a new series of posts on military violence against hospitals and medical personnel in conflict zones. It follows directly from my analysis of the situation in Syria here.

President Bashar al-Assad has consistently denied that his forces have attacked hospitals or doctors.  In an interview with SBS Australia on 1 July 2016 he asked his interviewer:

‘… the very simple question is: why do we attack hospitals and civilians?… No government in this situation has any interest in killing civilians or attacking hospitals. Anyway, if you attack hospitals, you can use any building to be a hospital. No, these are anecdotal claims, mendacious statements …’

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There are at least four answers to Assad’s disingenuous question (if you falter at the adjective, see here).

(1) Silencing the witnesses

When Widney Brown from Physicians for Human Rights testified at the Tom Lantos Human Rights Commission on 31 March 2016 she provided one clear and compelling rationale for Assad’s attacks on doctors:

‘… attacks on doctors silence particularly powerful witnesses. When the Syrian government denies its use of chemical weapons, cluster munitions, starvation, or torture, doctors can bear witnesses to these violations because they have seen and treated the victims.’

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To be sure, there are other witnesses and even paper trails and photographic records.  Ben Taub, who has done so much to bring ‘Syria’s war on doctors‘ to the attention of a wider public, has also provided a detailed account of the work done by Bill Wiley and the Commission for International Justice and Accountability whose volunteers have smuggled over 600,000 documents out of Syria detailing mass torture and killings by the regime.

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The war crimes have not been confined to attacks on hospitals in opposition-held areas.  A photographer known only as ‘Caesar’, who had been attached to the Defence Ministry’s Criminal Forensic Division, smuggled out thousands of high-resolution digital images exposing the horrors of the regime’s own military hospitals:

The pictures, most of them taken in Syrian military hospitals, show corpses photographed at close range – one at a time as well as in small groupings. Virtually all of the bodies – thousands of them – betray signs of torture: gouged eyes; mangled genitals; bruises and dried blood from beatings; acid and electric burns; emaciation; and marks from strangulation…

These unfortunates may have lived and died in different ways, but they were bound in death by coded numerals scribbled on their skin with markers, or on scraps of paper affixed to their bodies. The first set of numbers (for example, 2935 in the photographs at bottom) would denote a prisoner’s I.D. The second (for example, 215) would refer to the intelligence branch responsible for his or her death. Underneath these figures, in many cases, would appear the hospital case-file number (for example, 2487/B)…

[T]he system of organizing and recording the dead served three ends: to satisfy Syrian authorities that executions were carried out; to ensure that no one was improperly discharged; and to allow military judges to represent to families—by producing official-seeming death certificates—that their loved ones had died of natural causes. In many ways, these facilities were ideal for hiding “unwanted” individuals, alive or dead. As part of the Ministry of Defense, the hospitals were already fortified, which made it easy to shield their inner workings and keep away families who might come looking for missing relatives. “These hospitals provide cover for the crimes of the regime,” said Nawaf Fares, a top Syrian diplomat and tribal leader who defected in 2012. “People are brought into the hospitals, and killed, and their deaths are papered over with documentation.” When I asked him, during a recent interview in Dubai, Why involve the hospitals at all?, he leaned forward and said, “Because mass graves have a bad reputation.”

(2) Multiplying the casualties

This is a radicalisation of an old strategy.  As Sam Weber pointed out in Targets of opportunity (2005), ‘every target is inscribed in a network or chain of events that inevitably exceeds the opportunity that can be seized or the horizon that can be seen.’  So, for example, when the United States or Israel bombs a power plant it often as not explains that it has been careful to bomb in the small hours when only a skeleton staff was in the building in order to minimise collateral damage.  But this begs the question: why bomb the power plant at all?  In most instances the degradation of the electricity supply means that it becomes impossible to pump water or treat sewage; refrigerators fail and food perishes; hospitals are forced to use unreliable generators. The result – the intended, carefully calculated result – is that casualties rise at considerable distances from the target and over an extended period of time.

Similarly, Dr Abdulaziz Adel notes:  ‘Kill a doctor and you kill thousands.’  Simply put, patients who are sick or injured then go without treatment and in many cases their lives are put at risk.  (The images below are from Collateral Damage: more here).

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Dr Rami Kalazi, a neurosurgeon from East Aleppo, agrees:

‘They are the artery of life in the city. Can you imagine a life in city without hospitals? Who will treat your kids? Who will make the surgeries for the injured people? So, they are targeting these hospitals because they know, if these hospitals were completely destroyed, the life will be completely destroyed.’

(3) ‘Moral[e] bombing’

This too is an old strategy.  The architects of ‘area bombing’ during the combined bomber offensive against Germany during the Second World War described it as ‘moral [sic] bombing’: a sustained and systematic attempt to undermine the morale of the enemy population so that they would demand their leaders sue for peace.  If this was a tried and tested strategy, however, the test showed that it was a complete failure (see my ‘Doors into nowhere’: DOWNLOADS tab).

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But the lesson was lost in Syria, where attacks on hospitals have had a central place.  As Samir Puri argues, the strategy behind the joint Syrian and Russian air campaign seems to be:

“If there is a total collapse of any kind of trauma care, those are the sort of things that can contribute to collapsing morale very suddenly. The morale of a besieged force can look robust until it collapses.”

And Syria is not unique in contemporary wars: Israel has deployed the same strategy in its repeated assaults on Gaza (see here, here and here for ‘Operation Protective Edge’ in 2014), and the Saudi-led coalition has attacked more than 70 hospitals and health facilities in Yemen since March 2015 (in this latter case Russian media have reported MSF’s objections to the ‘utter disregard for civilian life’ without dissent: see for example here).

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‘Preventing medicine’, as Annie Sparrow puts it, has become ‘a new weapon of mass destruction’.

(4) ‘Violence legislates’

Following the attack on the UN aid convoy delivering supplies to a Syrian Red Crescent warehouse outside East Aleppo on 19 September 2016, 101 humanitarian organisations issued a joint appeal to the United Nations on 22 September; in part it read:

‘Deliberate attacks on humanitarian workers and civilians are war crimes. This must mark a turning point: the UN Security Council cannot allow increasingly brazen violations of international humanitarian law to continue with impunity.

‘Heads of state are gathered in New York this week for the United Nations General Assembly. Each one that accepts a lack of accountability for perpetrators and facilitators of war crimes colludes in the ongoing dissolution of international humanitarian law’ (my emphases).

The first paragraph is damning enough.  Ben Taub in the New Yorker again:

Nowhere has the supposed deterrent of eventual justice proved so visibly ineffective as in Syria. Like most countries, Syria signed the Rome Statute, which, according to U.N. rules, means that it is bound by the “obligation not to defeat the object and purpose of the treaty.” But, because Syria never actually ratified the document, the International Criminal Court has no independent authority to investigate or prosecute crimes that take place within Syrian territory. The U.N. Security Council does have the power to refer jurisdiction to the court, but international criminal justice is a relatively new and fragile endeavor, and, to a disturbing extent, its application is contingent on geopolitics.

But the sting comes in the second paragraph.  As I’ve noted before, international humanitarian law is not a neutral court of appeal, a deus ex machina above the fray, but has always been closely entangled with military violence.  In many respects it travels in the baggage train, constantly pulled by the trajectory of the very violence it supposedly seeks to regulate (or facilitate, depending on your point of view).  In short, as Eyal Weizman has it, ‘violence legislates‘.

There is good reason to fear that the systematic violation of medical neutrality is intended to force its dissolution.  Thomas Arcaro writes: ‘Humanitarian principles like neutrality and impartiality that once seemed so self-evident have been drawn into question, especially on the politically and ethnically complex battlefields of Iraq and Syria.’

And not only there.  In the case of the US airstrike on the MSF Trauma Centre in Kunduz in 2015, I’ve suggested that some key Afghan officers and politicians chafed at the protections afforded to wounded Taliban combatants by international humanitarian law.  They also alleged that the Trauma Centre had breached its conditional immunity because the Taliban had overrun the hospital and were firing at US and Afghan forces from its precincts.  There is no evidence to support that assertion, but it is an increasingly familiar claim.  On 7 December 2016 US Central Command justified a ‘precision strike’ requested by Iraqi forces on a building within the al-Salem hospital complex in Mosul by claiming that IS fighters had used it as a base to launch heavy and sustained machine-gun and rocket-propelled grenade attacks.  That would certainly have compromised the hospital’s immunity, but international humanitarian law still requires a warning to be issued before any attack and a proportionality analysis to be conducted; Colonel John Dorrian said that the US Air Force did not ‘have any reason to believe civilians were harmed’ but conceded that it was ‘very difficult to ascertain with full and total fidelity’ whether any medical staff or patients were in the building at the time of the air strike.

But what the Syrian case suggests is a new impatience with medical neutrality tout court: not only a hostility towards the treatment of wounded and sick combatants but also an unwillingness to extend sanctuary to wounded and sick civilians.

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And that reluctance is not confined to the Assad regime and its allies.    A survey carried out for the International Committee of the Red Cross between June and September makes for alarming reading – even once you’ve overcome your scepticism about public opinion polls.  As Spencer Ackerman reports:

Areas in active conflict record greater urgency over questions of civilian protection in wartime than do the great powers that often conduct or participate in those conflicts. In Ukraine, 83% believe everyone wounded and sick during a conflict has a right to health care, compared with 62% of Russians. A full 100% of Yemenis endorse the proposition, as do 81% of Afghans, 66% of Syrians and 42% of Iraqis – compared with 49% of Americans, 53% of Britons, 37% of the Chinese and 67% of the French.

It’s that last clause that is so disturbing: for the last four states listed are all permanent members of the UN Security Council…

So what, then, are we to make of what I’ve been calling ‘the exception to the exception’?

The exception to the exception

homo-sacerI think it’s a mistake to treat ‘the camp’, following Giorgio Agamben‘s vital work, as the exemplary, diagnostic site of the modern space of exception; the killing fields of today’s wars (themselves spaces of indistinction, where it is never clear where war stops and peace begins, where the geometry of the battlefield or, better, ‘battlespace’ becomes ever more fractured and blurred, and where the partitions between international and internal conflicts have been reduced to rubble) are also spaces within which groups of people are deliberately and knowingly exposed to death through the removal of legal protections that would ordinarily be afforded to them.  In short, killing and injuring become legally permissible.

Those exposed groups include both combatants and civilians, but their fate is not determined solely by the suspension of national laws (the case that concerns Agamben) because international humanitarian law continues to afford them some minimal protections.  One of its central provisions has been medical neutrality: yet if, through its serial violations in Syria and elsewhere, we are witnessing the slow ‘death of the clinic’ – which I treat as a topological figure which extends from the body of the sick or wounded through the evacuation chain to the hospital itself – and the extinction of ‘the exception to the exception’, the clinic as a (conditionally) sacrosanct space – then I think it’s necessary to add further twists to Agamben’s original conception.

As Adia Benton and Sa’ed Ashtan have argued, medical neutrality – the exception to the exception – represents a fraught attempt to restrict the state’s recourse to military violence: it is a limitation on and has now perhaps become even an affront to sovereign power and the state’s insistence that it is ‘the sole arbiter of who can live and who can die’.

Agamben describes the inhabitants of the space of exception as so many homines sacri – where sacer has the double meaning of both ‘sacred’ and ‘accursed’ – and it may be that in today’s killing fields doctors, nurses and healthcare workers are being transformed into new versions of homo sacer: once ‘sacred’ for their selfless devotion to saving lives, they are now ‘accursed’ for their principled dedication to medical neutrality.

 

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Yet the precarity of their existence under conditions of detention and torture, siege and airstrike, has not reduced them to what Agamben calls ‘bare life’.  They care – desperately – whether they live or die; they have improvised a series of survival strategies; they have not been silent in the face of almost unspeakable horror; and they have developed new forms of solidarity, support and sociality.

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‘Your turn, doctor’

This is the fourth in a new series of posts on military violence against hospitals and medical personnel in conflict zones.  It follows from my analysis of air strikes on base hospitals on the coast of France in 1918 here, and of the US air strike on the MSF Trauma Centre in Kunduz, Afghanistan in 2015 here and here.  This post, together with the next in the series, is about Syria.  They all derive from a new presentation – still in active development – called ‘The Death of the Clinic: surgical strikes and spaces of exception’ that will eventually become an essay in my next book, so I would appreciate any comments or suggestions.

The eye of the storm 

Syria’s civil war has multiple origins, but one of the most incendiary incidents took place on 16 February 2011 in the city of Dara’a 80 km south of Damascus near the Jordanian border.  Inspired by the spread of the Arab uprisings east across the Maghreb from Tunisia, and the threat they posed to a succession of autocratic regimes, a group of local teenagers decided to daub slogans on the wall of their high school.  One of them, a brave 15-year old (who now lives with his family in Jordan), painted this:

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‘Ejak el door ya Doctor’ – ‘Your turn, doctor’.

The doctor in question was Bashar al-Assad, Syria’s president, who had trained as an opthalmologist in Damacus and London.  In the months to come, Assad would give that slogan a viciously ironic twist.

The immediate response of the security forces to the graffiti was swift and draconian; the boys were rounded up, imprisoned and tortured (see herehere and here).  When their relatives protested to the officer in charge he told them:

‘Forget your children.  Just make more children. And if you don’t know how to make more, I’ll send someone to show you.’

hrw-weve-never-seen-such-horrorLocal people took to the streets, and as the demonstrations spread on 22 March security forces entered the National Hospital in Dara’a, cleared it of all non-essential medical staff and stationed snipers on the roof who were under orders to fire on protesters.  The hospital remained until military control until May 2013; admissions were restricted and snipers continued to fire on the sick and wounded who tried to approach the hospital.  On 8 April security forces opened fire on thousands of demonstrators approaching a roadblock; ambulances were prevented from reaching the wounded, and a doctor, a nurse and an ambulance driver were killed when they tried to get through (UN Human Rights Council: ‘Assault on Medical Care in Syria’, 13 September 2013: download here; see also the Human Rights Watch report, ”We’ve never seen such horror’ here).

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Others took up the cry, taking to the streets and chanting ‘Dara’a is Syria‘.  In many other areas the government stationed snipers, armoured personnel carriers, tanks and heavy artillery at hospitals; doctors suspected of treating protesters were arrested and tortured; security forces forcibly removed patients from hospitals, ‘claiming bullet or shrapnel wounds as evidence of participation in opposition activities’; and ambulances transporting casualties were attacked and pharmacies looted.

The UN Human Rights Council concluded:

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This was, sadly, hardly novel.  In 2006, at the height of sectarian violence in occupied Baghdad, for example, Muqtada al-Sadr‘s Shi’a militia controlled the Health Ministry and manipulated the delivery of healthcare in order to marginalise and even exclude the Sunni population.  As Amit Paley reported:

‘In a city with few real refuges from sectarian violence – not government offices, not military bases, not even mosques – one place always emerged as a safe haven: hospitals…

‘In Baghdad these days, not even the hospitals are safe. In growing numbers, sick and wounded Sunnis have been abducted from public hospitals operated by Iraq’s Shiite-run Health Ministry and later killed, according to patients, families of victims, doctors and government officials.

‘As a result, more and more Iraqis are avoiding hospitals, making it even harder to preserve life in a city where death is seemingly everywhere. Gunshot victims are now being treated by nurses in makeshift emergency rooms set up in homes. Women giving birth are smuggled out of Baghdad and into clinics in safer provinces.’

He described hospitals as ‘Iraq’s new killing fields’, but in Syria the weaponisation of health care has been radicalised and explicitly authorized by the state.

Counterterrorism and the criminalisation of health care

Doctors were systematically targeted for treating anyone who opposed the government.  In April 2012 one surgeon from Idlib told Annie Sparrow:

‘We were detained in the hospital for several days. Tanks parked out front, artillery in the wards, snipers on the roofs shooting patients who tried to come. They took our names, and summoned three of the five security branches – state, political and military. I was interrogated and forced to sign several commitments not to treat anyone not pro-regime. Of course, as soon as I was released I violated it immediately…the city was full of wounded and sick people. Soon after that a friend who worked in military security let me know I was now “wanted” [for my work], the charge being that I was the leader of a terrorist group. So I went into hiding, and moved my family to Turkey. In retaliation my brother was executed.’

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The State of Emergency that had been in force in Syria since 1962 was abruptly ended on 21 April 2012.  But on 2 July a new Counter-terrorism Law came into force that criminalised all medical aid to the opposition.  Here is Annie Sparrow again:

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The parallels with the objections voiced by some members of Afghanistan’s security services against MSF’s work in Kunduz are only too clear: but in Syria they have been given explicit state sanction enforced through the law.

As Neil Macfarquhar and Hala Droubi reported for the New York Times in March 2013, doctors repeatedly found themselves in the cross-hairs.  Here, for example, is the case of Dr Mohamad Nour Maktabi:

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The Counter-terrorism Law also declared that all medical facilities operating in opposition-held areas without government permission were illegal – and thereby transformed them (under Syrian law, at least) into legitimate targets of military violence.

Air wars and ‘surgical strikes’

The nature of military and paramilitary violence has changed during the course of the war; shooting and mortar-fire have increasingly been supplemented by air strikes.

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Even in the early stages of the war doctors were confronting what one trauma specialist called ‘unimaginable injuries’.  Dr Rami Kalazi, a neurosurgeon in east Aleppo, explained:

‘In the beginning, we saw new injuries that we did not know how to treat. Fortunately, at the beginning of the revolution and when we began working in field hospitals, there was more freedom of movement. In 2012 and 2013, there was no such thing as “barrel bombs” and there was no violent shelling from airplanes, so many visiting foreign doctors came…

‘But even so, they told us that they were seeing injuries that they had never seen before in books or textbooks or in the hospitals where they worked in their home countries. Unfortunately, reality forces you to learn.’

But air strikes transformed the calculus of injury.  Many more casualties resulted from each attack, and the wounds of those who survived were often far more serious.

The US-led coalition has carried out multiple airstrikes primarily in areas controlled by IS, and the campaign has caused (minimally) hundreds and probably several thousand civilian casualties – see my analysis of specific US air strikes here and here, for example –  but the Syrian Arab Air Force has concentrated its fire on areas controlled by other rebel groups (see Jeffrey White‘s analysis here).

A favourite tactic has been the deployment of ‘barrel bombs‘ – in effect, aerial IEDs: oil drums filled with high explosive and cut rebar to act as shrapnel – dropped from helicopters (see Human Rights Watch here).  Basel al-Junaidi described witnessing their impact:

I saw the aftermath of a barrel bomb. I saw human remains scattered in the street; I heard the screaming. I’m trained as a doctor, but I was unable to act. I just stood there, petrified. The West thinks we’re used to this, but we aren’t of course. We’re like anyone else – we use computers and cars, not camels and tents…

Another doctor who worked in Syria said he kept ‘a drawing from a second grader in Aleppo, showing helicopters bombing the city, blood and destruction below.’  Chillingly, ‘the dead children are smiling while the living ones are crying.’

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From September 2015) the Russian Air Force, often acting in concert with the Syrian Arab Air Force, has also concentrated on targets in areas controlled by other opposition groups:

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Russia has routinely denied these charges, but from 30 September to 12 October 2015 its Ministry of Defence published videos of 43 airstrikes. Bellingcat, aided by crowdsourcing, identified the exact location of 36 of them and overlaid them on the ministry’s own map identifying which groups controlled what parts of the country (see the full report, ‘Distract, Deceive, Destroy’, here):

‘The result revealed inaccuracy on a grand scale: Russian officials described 30 of these videos as airstrikes on Isis positions but in only one example was the area struck in fact under the control of Isis, even according to the Russian MoD’s own map.’

The effect of these air strikes has been devastating on the population at large.  To make matters even worse, air strikes cannot target individual doctors and have instead frequently been directed against hospitals and other medical facilities.   This compromises not only trauma care for the wounded but also the treatment of chronic and infectious diseases:

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(You can find a discussion of the problem of infectious diseases in Sima L. Sharara and Souha S. Kanj, ‘War and infectious diseases: challenges of the Syrian Civil War’, PLOS Pathogens 10 (11) (2014) here).

Hospitals and bomb sights

Doctors and other medical staff had to adjust to a new, sickening vulnerability.  Here is one OB/GYN who was still working in a hospital in East Aleppo when she was interviewed on Public Radio International in August 2016:

Carol Hills, PRI: Doctor Farida, did I just hear a noise there? Was that some sort of attack that I just heard?
Dr Farida Almouslem: It’s attack. [Laughs]. It’s normal. It’s away from me. Not next to me. These noises are all the time.
Hills: Do you and the doctors and patients you work with feel safe inside the place where you’re working?
Dr Farida: No. It’s not safe. I work at the third floor in my hospital. And many times the wall was perforated. So every woman came to the hospital, she knows that there is a danger on her life. So they just give the delivery, or give the birth, and then go home. She escapes to home because she knows our hospital is always targeted.

Other doctors in opposition-held areas said the same.  Here is Dr Mohamed Tennari, director of an above-the-ground field hospital in Idlib:

‘When I am in the hospital, I feel like I am sitting on a bomb. It is only a matter of time until it explodes. It is wrong − a hospital should not be the most dangerous place.  I wish I could say that targeting a hospital in Syria is unique, but is not.’

In fact, it’s far from unique: Physicians for Human Rights has issued a report detailing Attacks on Doctors, Patients and Hospitals hospitals and provided a interactive map of attacks on healthcare in Syria.

In the face of these escalating attacks, hospitals in opposition-held areas have tried to conceal their locations from the Syrian government.  In contrast to the protocol adopted by the MSF Trauma Centre in Kunduz, they have been markedly reluctant to provide their GPS coordinates (and see MSF’s explicit comparison between what happened in Kunduz and the situation in Syria here):

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But this has trapped them in a grim Catch-22.  Michiel Hofman of Médecins sans Frontières – which is not permitted to operate in government-controlled areas in Syria – explains:

‘Hospitals that MSF supports in Syria are bereft of the possible protection of being clearly marked as a hospital or sharing of GPS coordinates, as the Syrian government passed an anti-terrorist law in 2012 that made illegal the provision of  humanitarian assistance – including medical care – to the opposition, forcing most health structures to go underground and operate without governmental medical registration. The bombing parties can then conveniently claim they were unaware it was a hospital they hit.’

More often, the Syrian government and its allies routinely describe the bombed building as a ‘so-called hospital’.  After an air strike on an MSF-supported hospital near Maarat al-Numan in Idlib on 15 February 2016 Bashar Jaafari, Syria’s ambassador to the United Nations, made this statement:

‘The so-called hospital was installed without any prior consultation with the Syrian government by the so-called French network called MSF which is a branch of the French intelligence operating in Syria… They assume the full consequences of the act because they did not consult with the Syrian government. They did not operate with the Syrian government permission.’

The allies of the Syria government are not confined to Russia and Iran.  On 27 April 2016 the Al Quds hospital in Aleppo was hit by two air strikes that killed 55 people  – among them two specialists, including Dr Muhammad Waseem Maaz, Al Quds’s pediatrician – and severely damaged the hospital. When it partially reopened 20 days later its capacity was reduced from 34 to 12 beds.  MSF conducted a detailed review of the operations of the hospital and the circumstances of the attack:

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Here is Professor Tim Anderson on what he calls ‘The “Aleppo Hospital” Smokescreen‘ (and for reasons that will become obvious I am so tempted to put scare-quotes around the title that adorns his post; the Department of Political Economy at the University of Sydney lists him as a Senior Lecturer not a Professor, but perhaps anxiety over the appellation ‘Doctor’ is contagious):

‘…the story of Russian or Syrian air attacks on the ‘al Quds hospital’ gained prominence in the western media… CCTV showed people leaving this ‘hospital’ before an explosion.

‘The building is in the southern al-Sukkari district, which has been a stronghold of Jabhat al Nusra for some years. Many Aleppans had never heard of ‘al Quds hospital’. Dr Antaki [Aleppo Medical Association in Western Aleppo] says: “This hospital did not exist before the war. It must have been installed in a building after the war began”…. This facility was not a state-run or registered facility.’

Anderson is joined in his disinformation effort by Eva Bartlett writing in the ‘OffGuardian’:

Dr. Zahar Buttal, Chairman of the Aleppo Medical Association … said: “The media says the only pediatrician in Aleppo was killed in a hospital called Quds. In reality, it was a field hospital, not registered.”

As for the pediatrician, “We checked the name of the doctor and didn’t find him registered in Aleppo Medical Association records.”…

… central to the lies were the bias and propaganda of the very partial, corporate-financed Médecins Sans Frontières (MSF), which supports areas in Syria controlled by terrorists, specifically Jabhat al-Nusra…’

To repeat: the Syrian government has refused to register or recognise any hospitals operating in areas outside its control – hence the snide reference to ‘so-called hospitals’ and Anderson’s meretricious scare-quotes – and it does not permit MSF to operate in areas under its control (despite repeated requests).  As for the disappearance of Dr Muhammad Waseem Maaz from the Syrian government’s registry (though I have no doubt he was on other lists maintained by the regime) the director of the Children’s Hospital in Aleppo provides a graceful tribute to him here.  And here is the doctor whose death these commentators dismiss so lightly (if you have the stomach for it, you can see his last moments caught on CCTV here):

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What, apart from the grotesque stipulations of the Syrian state, makes them think it proper to withdraw medical care from those living – surviving – in rebel-held areas?  International humanitarian law is unequivocal: they are entitled to medical treatment and to be protected whilst it is provided to them.

In rebel-held areas medical care has increasingly moved outside what were once established hospitals into the clandestine ‘field hospitals’ referred to above, which have been given numbered code-names to conceal their locations.  Some, like those established by MSF, follow strict medical protocols and, according to a study of one operating in Jabal al-Akrad by Miguel Trelles and his colleagues, they have (for a time) been able to provide high-quality medical care with remarkable survival rates (‘Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria’, Conflict and Health (December 2015)).  As the attacks on them have increased and qualified personnel and medical supplies have become scarce, however, many have become exercises in improvisation:

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Some of these hospitals have literally gone underground.  ‘‘In our worst dreams – in our worst nightmares – we never thought we would have to fortify hospitals,’ declared Dr Zaidoun al-Zoabi of the Union of Medical Care and Relief Organizations. ‘It’s not humane. It’s impossible to comprehend.’

Subterranean locations have been used not only to protect the hospitals but also to protect local populations.  Charles Davis reported that

‘whether it’s a vehicle or a building, anything that’s identifiable as providing medical care is ripe for an airstrike, so that staff have now taken to covering up any distinguishing characteristics. Even so, [Dr Abdulaziz Adel, a surgeon in East Aleppo, admits that] local residents are “always begging us to go away, take your hospital away from us or otherwise we’ll be a target.”‘

When the Syrian-American Medical Society proposed to build a hospital in Hama in 2014, local people begged them to locate it outside the city and so SAMS excavated what became the Dr Hasan al Araj Hospital, better known as ‘The Cave’:

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Supply chains and kill-chains

As the civil war ground on, even the most basic medical supplies became scarce and obtaining them ever more dangerous.  In March 2015 MSF reported that:

‘Even if it is available, many suppliers do not want to risk selling material like gauze or surgical threads when they know it is going to be sent into North Homs. Gauze is considered synonymous with war surgery, and often a supplier is not willing to take the risk of being arrested or shut down for supplying a besieged area.’

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You can read more here and here.  One doctor told MSF:

‘It is precious, dangerous, incriminating. There are secret outlets supplying us with gauze.’

At the end of last year the Guardian provided this image of one of the secret factories:

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In East Aleppo, hospitals have been forced to use tunnels to bring in medical supplies (more from Ellen Francis and her colleagues here):

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The risks are formidable and the costs have been almost prohibitive.  Ellen Francis and her colleagues at Columbia’s Graduate School of Journalism report that in January 2014 the Free Syrian Army and the Syrian Arab Army agreed an uneasy and ragged cease-fire in Barzeh, a small town on the northern edge of Damascus. There a team from the Union of Free Syrian Doctors was able to buy medical supplies from merchants who travelled out from the capital.

The merchants paid a 20 per cent ‘customs fee’ to Syrian Army soldiers; the agents for the doctors then paid a ‘tax’ to get the supplies through the Harasta checkpoint on the Army-controlled highway, and then a ‘toll’ to the rebels (‘tunnel lords’) who controlled the tunnels into Ghouta.

The combined fees inflated the price of medical supplies.  A litre of serum used to help the body replenish lost blood cost $1 in government-controlled areas and $3.50 to $10 via the tunnel route. Ghouta was using about 10,000 litres of serum per month.  The supply chain was subsequently severed once Barzeh itself came under siege and was cut off from Damascus.

Some humanitarian aid has crossed the lines by more conventional routes – conventional for a war zone at any rate – but medical supplies have routinely been removed from aid convoys.  On 19 May 2016 the UN Secretary-General reported to the Security Council:

‘[By May] 2016, WHO [had] submitted 21 individual requests to the Government of the Syrian Arab Republic to deliver medical supplies to 82 locations in 10 governorates. The Government approved five requests [while] 16 requests remained unanswered.

‘The removal of life-saving medicines and medical supplies continued, with nearly 47,459 treatments removed from convoys in April intended for locations in Homs, Aleppo and Rif Dimashq governorates. Removed items included surgical supplies, emergency kits, trauma kits, mental health medicines, burn kits and multivitamins. Removals extended to basic items, such as antibacterial soap, which was removed from midwifery kits. Items were also removed from other kits, notably surgical tools…’

Even then, aid convoys are not safe.  Four months later to the day a UNICEF aid convoy delivering supplies to a Syrian Red Crescent warehouse at Urum al-Kubra in Aleppo was attacked from the air, killing at least 18 people and destroying 18 of the 31 trucks.  Most analysts have concluded that the Russian Air Force was responsible, perhaps acting in concert with the Syrian Arab Air Force – see for example here and here– but the Russian Ministry of Defence and the usual suspects have variously blamed spontaneous combustion, a ground attack by rebels and a US drone attack.

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These shortages are threaded into dispersed and precarious siege economies that gravely affect the health of local populations.  In December 2015 an estimated 400,000 people were surviving without access to life-saving aid in 15 besieged locations across Syria; the figures gathered by Siege Watch are even higher.

Surrounded by 6,000 land-mines and 65 sniper-controlled checkpoints, Madaya’s 40,000 inhabitants have been under siege since July 2015; 32 people died of starvation and malnutrition in December 2015 alone.  One resident interviewed by Amnesty International in January 2016 described the catastrophic situation:

‘Every day I wake up and start searching for food. I lost a lot of weight, I look like a skeleton covered only in skin. Every day, I feel that I will faint and not wake up again… I have a wife and three children. We eat once every two days to make sure that whatever we buy doesn’t run out. On other days, we have water and salt and sometimes the leaves from trees. Sometimes organizations distribute food they have bought from suppliers, but they cannot cover the needs of all the people.

‘In Madaya, you see walking skeletons. The children are always crying. We have many people with chronic diseases. Some told me that they go every day to the checkpoints, asking to leave, but the government won’t allow them out. We have only one field hospital, just one room, but they don’t have any medical equipment or supplies.’

An aid convoy was allowed in four days after this interview.

There are also grave shortages of skilled medical personnel.  The doctors who remain in opposition-held areas have all had to learn new skills sometimes far beyond their original training.  In March 2015 one young surgeon working in an MSF-supported hospital east of Damascus recalled:

‘There was a pregnant woman who was trapped during the time we were under full siege. She was due to deliver soon. All negotiation attempts to get her out failed. She needed a cesarean operation, but there was no maternity hospital we could get her to, and I had never done this operation before.

A few days before the expected delivery date, I was trying to get a working internet connection to read up information on doing a C-section. The clock was ticking and my fear and stress started to peak. I wished I could stop time, but the woman’s labour started…’

In 2015 OCHA estimated that more than 40 per cent of pregnant women in these areas now scheduled C-sections to reduce the risk of an attack preventing them from obtaining care.

In some cases doctors can call on skilled overseas help via Skype from consultants on call 24/7 in the United States, Canada and the United Kingdom.  Ben Taub has written movingly of the extraordinary efforts of what he calls ‘the shadow doctors’ enlisted in ‘the underground race to spread medical knowledge as the Syrian regime erases it.’  One of the most active is Britain’s Dr David Nott:

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But not all those seeking specialist help are qualified surgeons.  In the field hospital serving the besieged town of Madaya medical care has been provided by a dentist, a dental student and a veterinarian.  Avi Asher-Schapiro reports:

‘The five-year civil war has plunged the Madaya clinicians into the deep end, forcing them to perform medical procedures that push them far beyond their training. They have treated countless gunshot victims, performed seven amputations, over a dozen C-sections, and diagnosed everything from meningitis to cancer.’

As he explains, this remarkable trio has also relied on remote medicine:

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These are all extraordinary responses to near-impossible, life-threatening situations.  But their successes have been short-lived.

The Madaya clinic was forced to close in November 2016:

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And the M10 hospital where Nott helped direct surgery – the largest trauma and ICU centre in East Aleppo – was hit by successive, catastrophic air strikes.  First, an attack on 28 September 2016 left only half the hospital operational.  On 1 October Xisco Villalonga, MSF’s Director of Operations, reported that

‘Bombs are raining from Syria-led coalition planes and the whole of east Aleppo has become a giant kill box.’

That night multiple strikes on M10 killed two people and injured ten others; the hospital had to be evacuated because one crater was so deep there were fears that the rest of the building would collapse.

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But the ordeal was not over: there were further, devastating strikes on 3 October:

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The underground hospitals have fared no better.  ‘The Cave’ – 15 metres inside a mountain, remember – was hit by two ‘bunker-buster’ bombs at 1500 on 2 October 2016. After 35 staff and patients had been evacuated a second strike occurred in the early evening involving missiles and cluster bombs. The E.R. was wrecked, ceilings collapsed, cement walls crumbled and generators, water tanks and medical equipment were destroyed (see image below).  Nobody was seriously injured but the hospital sustained critical damage and has been closed indefinitely. It used to treat 300 patients and perform 150 surgeries a month.

Cave Hospital hit by bunker-buster bombs

The exception to the exception

Once safe places under the protection of international humanitarian law – the exception to the space of exception that is the conflict zone – hospitals have become the targets of a new and extraordinarily vicious modality of modern war.  The systematic attacks on hospitals have not only threatened the lives of patients and healthcare workers; they have also made many patients reluctant to seek medical treatment at all.  In February 2015 a report from the Centre for Public Health and Human Rights at Johns Hopkins University was already warning of the consequences:

‘Unless they feel their life is in danger, many people won’t go to hospital because it is targeted for bombardment’ [Physician, Aleppo]. Two physicians reported that fear of travel and an understanding that the hospital is a target has led to a 50% decrease in clinic visits and surgery cases, even though the level of violence has not decreased.

Dr Farida, the OB/GYN in East Aleppo interviewed earlier, no longer has a hospital to work in – the last remaining hospital was reduced to rubble and closed on 18 November – and she now provides what medical care she can from a basement:

‘People know it’s a basement, but they are afraid to come here because they know any health facility is deliberately targeted by the regime. For women, they are afraid to come — but they don’t have any other option. When they don’t have a car or fuel to come here, they have to give birth at home. Women are bleeding at home and babies are born dehydrated without oxygen.’

Those that do make the precarious journey to a field hospital or other medical facility almost always now find that their care is compromised by the shortage or even the absence of doctors, nurses, medical supplies and even the most basic medical equipment.  So doctors use ordinary sewing cotton instead of surgical thread; local anaesthetic where they would normally use a general, or even home-made, improvised variants.  Dr Zaher Sahloul, who still tries to provide help to colleagues in Syria from his home in Chicago via WhatsApp, explains:

‘We operate on the mindset that they have basic things we take for granted… The reality is, they don’t have 90 percent of the things we think they have. They know better what they have and what they can do with it. These people are facing decisions we will never face in our lives. If you have 10 patients dying, who will you see first? Do you use spoiled gauze and dirty tubes at the risk of infection? It’s Hell for them.’

As I write, the Syrian Arab Army and its supporting militias are advancing into East Aleppo, where air strikes and artillery bombardments have left more than 250,000 people without access to any form of advanced medical care.  The World Health Organisation announced that ‘although some health services are still available through small clinics, residents no longer have access to trauma care, major surgeries, and other consultations for serious health conditions.’

The final irony – although in this catalogue of horrors it probably isn’t the last at all – is that the Kremlin has announced that it will send two mobile hospitals to treat patients from East Aleppo.  The Defence Ministry will operate ‘a special 100-bed clinic with trauma equipment for treating children’ and the Emergencies Ministry will provide a 50-bed clinic capable of treating 200 outpatients a day.

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While the Kremlin congratulates itself on its ‘humanity’, we need to remember that this minimalist contribution would not have been necessary at all had medical neutrality been respected and doctors and nurses, hospitals and clinics not been so ruthlessly, systematically and deliberately targeted in the first place.

UPDATE:  On 5 December the Defence Ministry’s mobile hospital (set up in West Aleppo to treat patients from East Aleppo) came under mortar fire from the crumbling opposition-held area to the east; one Russian doctor and two paramedics were killed.  It’s not clear whether the hospital was deliberately targeted – there have been accusations that the co-ordinates of the hospital must have been given to the militants for it to have been hit ‘right at the moment when it started working‘ – or whether it was caught in the indiscriminate shelling and mortar-fire that has hit other hospitals in West Aleppo.

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But I should make two things clear.  First, attacks on hospitals in West Aleppo – even though I don’t think they have exhibited anything like the scale or the systematicity of those directed against medical facilities and healthcare workers in opposition-held areas – are as reprehensible as those on hospitals in the East.  Second, the muted response from the US-led coalition to the shelling of the Russian field hospital is deeply disturbing.  The International Committee of the Red Cross announced after the attack that ‘all sides to the conflict in Syria are failing in their duties to respect and protect healthcare workers, patients, and hospitals, and to distinguish between them and military objectives.’  The Russian Ministry of Defence dismissed this as a ‘cynical’ display of indifference to the deaths of its doctors, but I don’t read it like that at all – what is cynical is the partisan appeal to medical neutrality when it suits, and its systematic violation when it doesn’t.

To be continued