It was April 13, just past noon, and Hasan al-Araj was behind schedule as he left an underground hospital for his next rounds. He was usually careful to check the skies above him in Hama, where he was the last surviving cardiologist in the province’s rebel-held territory, for the Russian and Syrian warplanes that regularly cruised overhead. But, in his haste, he did not use his walkie-talkie to confirm with colleagues that the skies were clear.
A missile exploded near his van as he drove away. In the wreckage, colleagues found body parts and pieces of his white medical coat.
“It was targeting,” said Ahmad al-Dbis, a pharmacist and medical aid worker who worked closely with Araj. “It’s known that that’s the location of a hospital, and it’s known that most of the people moving around there are medical staff.”
Since March 2011, at least 738 Syrian doctors, nurses, and medical aides have died in more than 360 attacks on medical facilities, according to Physicians for Human Rights (PHR). The independent human rights group holds the Syrian government and its ally, Russia, responsible for upwards of 90 percent of these attacks.
Medical aid workers accuse the Syrian government and Russia of seeking to demoralize and drive out civilians and fighters from opposition-held territory by depriving them of health care and battlefield medicine. The targeted attacks on hospitals have certainly depleted the supply of doctors in rebel areas. Earlier in April, a sniper bullet to the head killed the last doctor in the besieged town of Zabadani. Later that month, rebel-held Aleppo lost one of its last pediatricians when a regime airstrike flattened al-Quds Hospital. According to PHR, 95 percent of the medical personnel who were in Aleppo before the war have either fled, been detained, or were killed.
It is a war crime under international law to deliberately target hospitals, doctors, and nurses. In early May, after a series of airstrikes in Aleppo, the U.N. Security Council unanimously passed a resolution condemning what Secretary-General Ban Ki-moon described as “surgical strikes … hitting surgical wards.” But like so many other U.N. declarations about Syria, it had no teeth —there was no risk of punishment for violating the resolution. By the end of that month, two more hospitals were damaged as a result of air raids on rebel-held Idlib and Aleppo.
Araj, who was 46 at the time of his death, accepted the risks of his work. He sent his wife and five children to Turkey for their safety and visited his family there frequently. But he was dead set on remaining in his homeland: “Even if you give me all of Europe, I will not leave my country,” he told an assembly of doctors at a medical conference in Geneva last year, according to Dbis. “I don’t betray my country in these circumstances. And, inshallah, either I will die in Syria or we will triumph.”
Despite devastating losses, the medical system serving Syria’s rebels and the remaining civilians in opposition areas has proved resilient, like the rebellion itself. From the idealistic uprising in 2011 to the dystopian violence of 2016, Syrian health care workers have found ways to survive, adapt, and treat those wounded in horrific fighting, as well as to deliver babies and treat ordinary illnesses. Dodging arrest and torture, then missiles and snipers, they have built a clandestine health care system out of the one their government destroyed.
Timeline of key events in the Syrian war as well as reports on a few selected airstrikes on medical facilities. Credit: Shannon Najmabadi
Abu Ibrahim Bakr’s patient was not only at risk of dying — he was at risk of causing the deaths of anyone who treated him. It was June 2011, three months after the rebellion against President Bashar al-Assad’s rule erupted, in Saqba, a town near the capital of Damascus. A bullet wound in the patient’s belly marked him as a participant in the uprising. As far as the government was concerned, he was a criminal who should not be saved.
“We couldn’t move the patient around at all,” said Bakr, a general surgeon in the Damascus suburbs of Eastern Ghouta whose name is a professional alias.
In the earliest days of clandestine rebel medicine, the opposition to Assad’s rule largely consisted of nonviolent protests. The activists held no territory in the country; the only way they could treat their wounded comrades was to hijack the government’s health care system.
In Saqba, doctors sometimes smuggled injured protesters through the back door of a nearby hospital. But government forces that day had closed the roads, making the medical facility impossible to reach. A man volunteered his bedroom. Bakr unpacked one of the medical kits he and his colleagues, by then, had hidden in every town in the area. The doctors had, as he put it, “stuffed an operating room into a suitcase.” An anesthesiologist recommended dosages by cell phone.
“We put him on the bed, in the bedroom, and we opened up his stomach,” the surgeon recalled.
Syria once enjoyed an advanced medical system. The average life expectancy in the country in the years before the rebellion broke out had hovered around 73, roughly on par with that in neighboring Turkey, according to World Bank data. Some of the doctors, paramedics, and nurses who have assisted the opposition were driven by their own rejection of the Assad regime; others simply felt they should provide care to all, as a fulfillment of their professional and humanitarian duty. So the practitioners formed secret networks of trusted colleagues to treat the wounded and protect patients from government reprisals.
“We noticed that many of the people who were getting injured in the streets by the security forces and the military … when they were transported to a hospital, public or private, the intelligence services would follow,” said a founding member of the Union of Free Syrian Doctors, a loose association of doctors and medical activists who banded together in late 2011 to try to fill the gap in available medical services. The doctor, a radiologist now living in West Virginia, asked that his name be withheld to protect his family still in Syria.
“Of course, every person that the intelligence services discover had treated a patient from one of the protests, his fate is to be detained, absolutely,” said the radiologist, who says he was detained and tortured himself by one of the country’s most notorious agencies, Air Force Intelligence. “He’s even classified almost in the same group as the armed rebels.”
To evade Assad’s security forces, doctors treated patients in secret, in shops and other unconventional places that would briefly be converted into emergency rooms. In desperate cases, the only way to save a patient was to sneak him or her into a government hospital. That required daring help from a network of willing doctors, nurses, and friends.
“We would communicate through a series of quick phone calls using phones linked to false names, which were bought from the black market with the IDs of dead people or fake IDs, to make it harder to trace,“ said Osama Abu Zayd, a medical equipment engineer with the Union of Free Syrian Doctors. Using the masked phones, Abu Zayd would describe the patient’s injury to a friendly hospital doctor using numeric codes for the location and type of wound.
Patients at risk of arrest were given fake names. Their doctors also worked under aliases. “Even two doctors in the same hospital, each wouldn’t know that the other is ‘revolutionary,’” Abu Zayd said.
“There are some doctors, until now, after four or five years of working with them, I still don’t know their real names,” said Mohammad Yasser Tabbaa, a co-founder of the nonprofit Syrian Expatriate Medical Association (SEMA). A Syrian expat living in Saudi Arabia, he has made more than two dozen trips to Syria since the beginning of the war to establish health care facilities there.
Friends and relatives provided referrals for new members of the network. “Between us, there is trust. We know who’s honest and who’s not,” he said.
The real danger came when someone was caught, Tabbaa added, because then the security forces would torture them until they gave up their friends’ names. “Every time, whenever anyone was caught, all his friends would go into hiding, or they would travel, or run away,” he said.
The radiologist living in West Virginia said some of the Free Syrian Union doctors had private clinics and could take in injured rebels.
“We didn’t differentiate the armed [soldier] from here or from there or whomever we found in the street — our goal was to treat people,” he said. “I don’t care, this person, what his background is.”
But even private facilities were not safe. In the early days of the revolt in 2011, security and military forces often barged into the Kafr Zita Specialty Hospital, which was owned by the cardiologist Hasan al-Araj, said his colleague Ahmad al-Dbis. When soldiers opened fire on protests in the small town, the injured would often be rushed to Araj’s private hospital in secret.
Araj and his staff performed protesters’ surgeries as quickly as they could. The demonstrators who were most wanted by the security forces were stabilized at the hospital and quietly transferred to local homes, including Araj’s house. When security forces came knocking at the hospital, Araj told them they were working on routine surgeries — like an appendix or abscess removal — and prevented them from entering the operating rooms.
“In those days, there was still a bit of respect for doctors,” Dbis said.
Over time, as the protests grew and turned more violent, government security forces became more aggressive in chasing down injured protesters and those who treated them. During the first year of conflict, an estimated 250 doctors were arrested or interrogated for treating injured protesters in Syria, according to a report published by PHR at the end of 2011.
Doctors and aid workers said Assad’s security forces examined orders for blood bags at the state-run blood banks or orders for tetanus shots, which are usually given to people with gunshot or shrapnel wounds, to track down doctors who were treating members of the opposition.
“The regime’s intelligence services have no mercy if they find out you’re working as a field doctor,” said Rami Kalazi, who was then completing his residency in neurology at Aleppo’s state-run Razi Hospital. “For them, this is even much worse than carrying a weapon.”
Kalazi, who worked with a group of colleagues to provide secret medical and humanitarian aid, ran a makeshift pharmacy out of the basement of the apartment building in which he lived, stocked with supplies he and colleagues took from the hospital, bought from pharmacies, or received as donations.
Eventually, the chief resident got word that the regime was after Kalazi and his wife, who also worked at the hospital. “He told us, ‘Take my advice: Pack up and leave, because you’re no longer safe,’” Kalazi recalled. He is still practicing medicine in Aleppo but in a different hospital in a rebel-held area.
F.J., a doctor working in the suburbs of Damascus during the early years of the uprising, was detained in 2012 by Assad’s security forces. He was taken to an underground room with what he estimated to be about 80 other people. There was no ventilation, no light, and no place to sit. He was tortured for seven days, he said. He and the other prisoners often found piles of dead bodies in the bathroom.
“Really, it was like hell,” he said. “Everyone was just praying to die.”
Araj, the Hama cardiologist, was arrested twice, said his wife, Najwa. The horrors of his detentions made him more vigilant about avoiding regime soldiers and checkpoints. He often told Najwa, “If a missile hits me and cuts me in two, it would be easier than spending 15 minutes in the infidel regime’s prison.”
The Syrian government’s war on healthcare is robbing civilians of their caregivers.
In the summer of 2012, fighting reached Aleppo and Damascus, the country’s two most populous cities. With many activists turning into rebels and the government shifting to heavier firepower, the pressure on medical providers grew.
As the rebels began carving out territory of their own, some medics no longer needed to sneak around regime hospitals. They set up their own field hospitals and makeshift medical facilities in opposition-held areas, ushering in a new era of rebel medicine.
In and around Damascus, the doctors were rushing to adapt to the Syrian government’s shelling of entire neighborhoods. They were now less exposed to arrest — but they were exposed to bombs, and they had to re-create operating and care facilities from scratch.
“We’re in a place where there are civilians and there’s shelling,” said Mouaffak, a surgeon in Douma, who described the beginnings of the field hospitals in Eastern Ghouta. “Put two or three beds on a farm; that’s a field hospital. Put consumables that would last a while in case the area is besieged; that’s a field hospital.”
This new phase required creating new regimes of care and medical supply on the fly. Staffing at the field hospitals was inventive: No expertise, no matter how tangential to medicine, could be wasted. Doctors and other professionals were fleeing the country in droves; they had to be replaced by ad hoc trainees.
As the Free Syrian Army rebels began gaining ground against government forces in Aleppo in the summer of 2012, medical personnel at the Dar al-Shifa Hospital in the rebel-held Shaar neighborhood put out a call for volunteers. “There were a lot of massacres at the time, and there were only 10 people at that hospital in the beginning,” said Modar Shekho, who began working at the hospital as a nurse.
“This one was an engineering student, that one was a law student, another was an English student,” Shekho said. “Nobody came to teach us. There was no time.”
On his first day, he walked into the emergency room to find an orthopedic surgeon standing in a pool of blood, stitching up a patient injured by shelling.
“He said, ‘Come help me with drying the wound,’” Shekho recalled, remembering how he approached the bloodied patient and, feeling faint, went outside to collect himself.
“So I got some fresh air and then I went back to the emergency room,” he said. “I told the doctor, ‘I’ll continue with you.’… And since then, I continued. And that’s it. It became normal. My body got used to it.”
In Hama, Araj also watched his world change as Syrian army soldiers withdrew from the town of Kafr Zita around early 2013, leaving the area to the opposition.
“That’s when Dr. Hasan announced right away that his hospital would provide free surgeries for everyone,” Dbis, the pharmacist, recalled. “He announced that the hospital was for everyone, for free medical treatment, for battle injuries, and injuries from the shelling, and others.”
Attacks on medical infrastructure in Syria in the past year. Credit: Shannon Najmabadi and Lydia Namubiru. Data: Sarah Betancourt.
Ihsan surgical hospital was shelled for the first time in November 2013. A series of attacks ripped through the building, leaving rubble everywhere. The airstrikes blasted gaping holes in the brick walls, exposing hospitals beds with crooked IVs hanging over them to the outside world.
The hospital, in a besieged district of Eastern Ghouta, had only been open five months. This was the rebel-held suburb of Damascus that had suffered the worst of the chemical gas attacks mounted by the Assad regime the previous summer. According to the hospital’s staff, it served the majority of the cases arising from the area’s population of about 500,000. The facility was now leveled. Three of the hospital’s medical staff died in the barrage.
“Everything vanished, everything,” said Abu Zayd, of the Union of Free Syrian Doctors.
Refusing to be deterred, Abu Zayd and his colleagues took what equipment remained from Ihsan to set up another hospital at a secret location in Eastern Ghouta. They tried to take precautions on safety: They reinforced the infrastructure and separated certain emergency wards in secret locations in basements, only known by hospital staff.
A few months later, it was hit in another series of airstrikes. Once again, the hospital was damaged. Once again, they had to rebuild.
Ihsan represented a new humanitarian dilemma for the Syrian opposition. Syria’s field hospitals have themselves come to pose huge health risks to the people who visit them — or even live near them. But the bombing campaigns also had the unintended consequence of helping usher in the next phase of Syria’s rebel medicine.
The Assad regime routinely uses barrel bombs, oil drums packed with high explosives that destroy indiscriminately when dropped from helicopters or planes, against rebel medical facilities. Araj’s hospital in Hama, the Kafr Zita Specialty Hospital, was hit 10 times in 2015. Three of the staff — an anesthesiologist, a desk clerk, and a lab technician — were killed last year. Two of the three floors were wiped out.
Rami Kalazi, the Aleppo neurosurgeon, says each barrel bomb attack causes “frantic panic” among civilians. He used to live next door to Sakhour Hospital, rebel-held Aleppo’s largest trauma center, before the airstrikes forced him to move. In just six months over the end of 2014 through the spring of 2015, the hospital was struck on three occasions, damaging Kalazi’s home in the process. The staff had to ship cement in from Turkey to rebuild on each occasion. The airstrikes have only continued: According to Kalazi, the hospital was hit more than 20 times in 2014 and 2015. Eight of those strikes temporarily put the hospital out of service.
“We’ve become used to being targeted,” he said.
Ambulances are also constantly under threat. Kalazi said Sakhour has lost all of its ambulances to airstrikes and now relies on ambulances from other hospitals in the district or civilian cars.
The Syrian government’s hospital bombing campaigns motivated international donors to redouble their efforts to aid Syria’s medical facilities. Syrian expat networks based in the United States, the Persian Gulf, and Turkey that previously operated on an ad hoc basis have come together as large-scale nonprofits, like SEMA and the Syrian American Medical Society (SAMS), collecting millions of dollars in private donations and state funding to keep the hospitals running. These nonprofits have received money from the United Nations, the United States, Canada, and several European countries. Money and aid have also come from individuals in the Persian Gulf and organizations like the Qatar Red Crescent. To vet recipients, aid groups rely on the guidance of local Syrian medical bureaus or on their own longtime relationships with medical staff. International organizations such as the International Committee of the Red Cross and Médecins Sans Frontières (MSF) also provide funding and supplies for medical facilities in Syria’s opposition territory.
With greater assistance from international donors, Syria’s domestic opposition started designing medical facilities able to evade, or withstand, the regime’s relentless attacks. “It became clear that we needed to set up secure hospitals, underground, in a way that the airstrikes wouldn’t affect them, whether it’s barrel bombs or missiles,” Dbis said. And that, in turn, allowed rebel doctors to move beyond short-term emergency medicine and begin providing long-term medical care.
An injured baby received treatment after an airstrikes on Abtaa by the Syrian government in 2015. The Syrian government and Russia are responsible for more than 90 percent of attacks on medical facilities. © 2015 Reuters Limited | Alaa Al-Faqir
From the inside, it could be any hospital. Men in scrubs tend to an emergency room. There are beds and sterilized equipment, and the floors are ceramic tile. But look up at the dome-shaped ceiling. The jagged rocky edges and gaping holes reveal the inside of a mountain in Hama.
Araj called it the “Central Cave” hospital. It opened in late 2015, as shells fell on his hospital aboveground. The bombardment couldn’t harm them now. The cardiologist, his colleagues, and the hospital’s patients were sheltered under 55 feet of rock and dirt. Najwa, his wife, called the buried hospital “magnificent.”
“No matter how much they shell, shell, shell it, nothing will happen,” Mohammad Yasser Tabbaa, the SEMA co-founder, said of Central Cave. “Maybe it will shake the place, but the place would endure.”
“This is the trend we’re trying to push for,” he added.
The financial barriers to going underground are high. “It’s not easy for all the money to go and pour into one single place,” Tabbaa said.
Central Cave cost about half a million dollars to build, underwritten by an array of aid organizations, including SEMA, the Union of Medical Care and Relief Organizations, and the Assistance Coordination Unit, the humanitarian arm of the Syrian National Coalition. The health directorate in rebel-held Hama also funneled some of the money it had received from the British government into the project, according to Dbis.
Medical workers in Hama led the initiative, bringing in local labor to tunnel into a mountain in the northern countryside, where smaller caves already existed, to make way for the hospital. After around a year of drilling and shaping rock into rooms and hallways, Central Cave now sits at the base of the mountain. It welcomes around 1,500 patients a month from Hama and Idlib, mostly for free. The hospital includes operating rooms for general and orthopedic surgery, an intensive care unit, a pharmacy, a lab, a medical ward, and X-ray facilities. SAMS, the U.S.-based aid group, still pays nearly $50,000 a month in operating costs, including the salaries for the full-time staff who live in the hospital.
All across Syria, the need to protect hospitals has become acute. Moscow’s decision to join the air campaign in 2015 has only heightened the risk: Russian warplanes brought with them stronger weapons and more destructive power. PHR has called 2015 the deadliest year yet for Syrian health care, with 122 attacks on medical facilities.
Yet the Russian escalation has failed to destroy the rebel’s infrastructure. Central Cave isn’t the only example of rebel medicine moving underground: Many hospitals have by now moved into reinforced basements, cellars, or abandoned factories. In cases where it’s impossible for medical facilities to completely move their operations, the most sensitive units, like surgical and emergency rooms, have been relocated to a subterranean level.
For some hospitals, like Eastern Ghouta’s Ihsan, the huge loss brought on by airstrikes led them to disperse their facilities. An emergency room might be almost 1,000 feet from the operating room and similarly distant from the intensive care unit.
“Our strategy was to select unknown areas, so we stayed away from governmental buildings completely,” said Abu Zayd, the representative from the Union of Free Syrian Doctors. “We settled for commercial basements, from factories, sewing shops, or other similar places.”
Patients are ferried by ambulance or sometimes travel through tunnels that connect the facilities.
Doctors in the United States are only a text message away from their patients in Syria.
“If one location is hit, not all of the departments are destroyed,” said Mouaffak, the surgeon in Douma. “If we’re in the emergency room and it’s shelled, God forbid, there are people in other departments who could still rescue us.”
Medicine in opposition areas has become increasingly sophisticated as it has evolved from its earlier state of triage and improvisation. Underground hospitals also treat civilians suffering from routine ills. Several doctors said much, if not all, the care they provide is free. The nonprofit organizations now foot the bill for their salaries, though some reported working without pay for at least the first year after the spring 2011 revolt.
“The patient is usually poor here,” Mouaffak said. “If there’s only one doctor who can do this surgery and the doctor wants the patient to pay him, it basically means the patient won’t make it.”
Doctors have also developed a methodical approach to the influx of patients that an airstrike brings. “Right away, we keep the dead on one side,” said Kalazi, the neurosurgeon in Aleppo. The most serious cases are quickly sent to the operating rooms. Sometimes patients are sent to other Aleppo hospitals and even into Turkey. Kalazi recalled working 40 hours straight in early 2014 during a day of particularly intense shelling, when Sakhour Hospital admitted around 200 patients.
Doctors report that vaccines, antiseptics, and antibiotics are often unavailable, especially in besieged areas like Eastern Ghouta that have been cut off from supply routes since 2013. In regions like Idlib and Hama, medical tools and supplies come in trucks from neighboring Turkey. Yet in Eastern Ghouta, where international aid deliveries are erratic and insufficient, underground tunnels provide an alternative lifeline. Medical supplies are smuggled in across regime lines at great financial cost and great personal risk.
If medical workers can’t get the supplies they need, they’re forced to improvise. Three doctors said small-scale factories began springing up in 2014 in the Damascus suburbs to produce materials like gauze or serum that were too difficult to import from outside areas.
Some hospitals have medical equipment, such as CT scanners, salvaged from prewar facilities. The sandbags placed around the expensive machines suggest a constant threat of destruction.
There is still not enough anesthesia, however. “Without anesthesia, the surgery doesn’t happen,” said an anesthesiologist in Eastern Ghouta, who goes by the assumed name Abu al-Zaher. “The patient would die from the pain.”
The constant shortages have also spurred innovation. Zaher began producing a low-cost anesthetic out of ingredients he had available. He tested his formula on 50 patients receiving cesarean sections and reported the results were on par with the standard version. Basic household items, like olive jars, have been repurposed as medical instruments. Civilians and medical staff alike are trained to work outside the boundaries of what they knew.
“We held nursing workshops for the people in the towns,” Zaher said. “So now in every town, most people have some knowledge of nursing procedures.” More formalized nursing schools and academies have recently emerged: A school that opened in Idlib last year has already graduated 70 paramedics, and this June, an Eastern Ghouta health institute graduated its first cohort of 35 students.
Training also comes from overseas. In October 2012, Anas Moughrabieh, a Syrian-American doctor in Detroit, worked with SAMS to get two nurses from Syria’s Idlib province smartphones and internet-enabled cameras. Moughrabieh then became the virtual doctor to 40 patients almost 6,000 miles away.
The program has since spread to seven hospitals. A network of more than 20 volunteers in the United States and Canada now take formal shifts to provide 24/7 medical advice using apps like Viber, WhatsApp, and Skype. What the doctors see can be overwhelming.
“I asked them to stop streaming pictures,” Moughrabieh said. “I don’t want to see. I open the camera, and I see them dying, blood everywhere, patients on the floor. This is too much for me.”
Airstrikes by the Syrian government damaged the main field hospital in Douma in 2015. Since 2011 more than 350 attacks on medical facilities took place, killing hundreds of Syrian medical personnel. © 2015 Reuters Limited | Bassam Khabieh
The Syrian doctors and medical workers who decided to defy Assad have come a long way from bedroom surgeries. But their work teeters on a knife-edge, always at the mercy of the next air raid.
“When the planes don’t show up,” said Abu Zayd, of the Union of Free Syrian Doctors, “we wonder, ‘What’s wrong, and what’s coming?’”
Still, they stay, even as the dwindling number of doctors paints a foreboding picture. For some, it’s too late or too difficult to leave now. But in reflecting on what keeps them in Syria, most cite their religious faith, frustration with the regime’s injustices, or dedication to the medical oath they took years ago.
“The people who live here, they’re our families and our people,” said Abu Ibrahim Baker, the general surgeon in Eastern Ghouta. “How would I leave my family, my people, in this situation, under shelling?”
“I can’t tell you I didn’t think of leaving,” said Mouaffak, the surgeon in Douma, who often writes eyewitness accounts of particularly brutal days in a digital diary titled Memories of Tragedy. “But … this is my city.”
With every chapter of political, diplomatic, and military developments, Syrian doctors in the field have found ways to keep going. But no matter how deep underground these doctors go, or how much international support they garner, they are not safe.
Ahmad al-Dbis and Abdallah Darwish, two of Hasan al-Araj’s colleagues in Hama, were in Turkey for a war surgery workshop on April 13, when they learned of Araj’s death.
“‘Ahmad, we have to go to Syria right away,’” Dbis recalled Darwish saying.
“Dr. Hasan—” Darwish said, but couldn’t continue his sentence.
“I had a semi-breakdown,” Dbis recalled. “During the revolution, we became more than brothers.… Even the secrets we didn’t tell our wives, we told each other.”
Passport in hand, he rushed to his car half-dressed and crossed the border into Syria for the funeral.
“Of course, there was nothing for us to see,” Dbis said. “I mean, a lump of severed limbs in a bag — that was buried.”
Najwa and her children, who still live in Turkey, don’t have the authorization to regularly cross the border back to their home country. They couldn’t attend the funeral or visit the modest grave: a small concrete tile sitting atop a pile of soil and gravel, with patches of green sprouting around it. In black felt, the cardiologist’s gravestone reads, “The martyr Dr. Hasan Mohammad al-Araj.”
This piece was originally published on foreignpolicy.com.
As the needs of Syria’s civilians become greater, in the deprivation and violence of war, the Syrian government is waging a deliberate campaign against the nation’s healthcare. But medical providers are tenacious. In hospitals deep underground, sheltered from the bombs above, doctors and nurses in opposition-held Syria are continuing on with their mission to protect life.
As Wartime Syria Becomes Illicit Drug Hub, ISIL Cashes In
By Max Siegelbaum
With Nina Agrawal, Seth Harp, Mazin Sidahmed, and Joelle Dahm
The Islamic State and some of Syria’s fractured opposition militias are partly funding themselves by manufacturing or taxing illicit amphetamine drugs, according to United Nations and American anti narcotics investigators.
The trade threatens to complicate international efforts by choking off Islamic State finances. Guerrillas that enter narcotics trafficking are sometimes able to fund themselves for decades by collaborating with organized crime groups.
The product in Syria is Captagon, an addictive amphetamine banned in the United States but popular across the Middle East, especially in Egypt and Saudi Arabia. Eighty percent of all seizures occur in the region, according to the Dublin Group, a loosely based coalition of countries that monitors trends in narcotics trade.
The U.N. and American investigators say that war-shattered Syria has emerged as a manufacturing hub. The Islamic State is among many groups smuggling Captagon through its territory, according to Drug Enforcement Administration investigators, and may also be producing the drug.
“We do believe that ISIL is involved in the Captagon trade,” said DEA spokesman Russell Baer. Although no arrests have been made or prosecutions brought, he said, “We know this through strategic analysis.”
In collaboration with local investigators from Turkey and Iraq, DEA officers have used seizure data, interviews with captured traffickers and geographic information to determine the Islamic State’s involvement in the trade. However, no official arrests have been made or prosecutions brought against Islamic State members implicated in the trade.
Courtesy of the Lebanese Internal Security Forces.
On some occasions, in order to produce the substantial amount of Captagon that was seized, traffickers would need to use facilities equipped with professional machinery. Therefore, the Captagon—in some cases—can only be coming from a select few buildings in Islamic State controlled areas in Iraq and Syria, Baer said, specifically in Mosul, Iraq.
The Islamic State “seized territory that includes pharmaceutical plants. For some of this scale production, you would need to have to have massive pill presses,” said another DEA official currently investigating Captagon production in Syria, who asked not to be identified. “We know the producers [of Captagon] in Islamic State territory are being taxed.” The Islamic State uses taxation on businesses and civilians in it’s territory as an important funding mechanism.
There is local demand on the battlefield. In Syria and Iraq, soldiers take Captagon to “to stay up for days and to fight fear,” said Ghassan Chamseddine, the head of Lebanon’s counter narcotics unit. Captagon pills were discovered at one of the safe houses used by the perpetrators of the Paris attacks last November.
Karim Nammour, a Beirut-based lawyer who has represented several Lebanese charged with Captagon trafficking, described the drug as “one of the main sources of income for anyone who is fighting in Syria.”
Captagon is a popular name for fenethylline, a pharmaceutical once used to treat hyperactive children in the 1960s. Shortly after it reached the market, the Food and Drug Administration banned the pill because it was found to be addictive.
Now banned under global treaties, Captagon is most widely used as a recreational drug.
Small-scale producers operate from basic laboratories, mixing commonly found chemicals, feeding a powder through pill presses or modified chocolate-making machines, which are easier to obtain and less conspicuous than industrial pharmaceutical equipment. The Syrian government has reported that a large number of Captagon labs are clustered around Homs.
Trained chemists operate “super labs,” out of pharmaceutical plants abandoned because of the war, the DEA’s Baer said. “A cook is someone who can make Captagon from a recipe,” Baer explained, “A chemist can improvise, and turn different chemicals into Captagon.”
Syrian officials, report that “armed opposition groups of Islamic origin, [are] also involved in drug trafficking in Syria,” according to a report issued by the EU. Yet, while D.E.A. officials say they are confident the Islamic State taxes Captagon trafficking, there is no hard evidence that the Islamic State has gone directly into manufacturing.
Captagon is sometimes described as an emotional suppressant, designed for soldiers to use to become fearless and willing to kill. In reality, the drug is a rudimentary cocktail of low-grade stimulants. Most producers design their own recipes. Pills labeled as Captagon might contain high-grade amphetamines or merely a strong dose of caffeine.
The history of Captagon production in Syria dates to the Cold War, when Syria was an ally of the Soviet bloc. Captagon production was a state economic policy of the Bulgarian regime, starting in the late 1970s. A Syrian expat named Ismet Shaban set up trade routes from Bulgaria to the Middle East, according to Hristo Hristov, a Bulgarian investigative journalist.
Atanas Rusey, a Senior Security analyst for the think tank Center for the Study of Democracy in Sofia, said that the drug’s popularity grew during the war between Iran and Iraq. “Pilots used Captagon as a stimulant,” he said, adding it was popular amongst infantry troops as well.
In the 1990s, after Bulgaria’s communist government fell, its democratic successor banned Captagon production. Bulgarian criminal groups took up the trade. Chemists moved their factories towards Turkey, Lebanon and other countries in the Middle East. “Former employees of the state factory were started working with these new organized crime groups,” Rusev said. Shaban passed the trade on to his son Fatik Shaban, Rusev explained. The younger Shaban was shot and killed in Downtown Sofia in 2003.
In 2004, Turkish police seized $7 million worth of Captagon tablets from employees of the Bulgarian embassy of North Korea – another country whose government has a track record of illegal smuggling as a means of raising its foreign currency reserves.
Graphic showing the quantity of Captagon seized between the years 2012 and 2014. Design: Shannon Najmabadi. Data: Nina Agrawal and Mazin Sidahmed.
The Syrian war’s chaos created a new era of opportunity for Bulgraian experts. In 2014, a Bulgarian chemist named Boris Karbozov was arrested in Beirut, according to Chamseddine. Karbozov traveled regularly to Beirut to help set up Captagon labs and teach others how to produced the drug. is currently being held in a Lebanese jail, according Lebanese authorities.
Other evidence about the drug’s role in Syria’s war can be found in Jordan, where the government regularly reports seizures of Captagon near al-Mafraq, a city roughly half an hour away from the border with the Syrian Regime controlled Deraa province.
On August 31, 2015, border guards at the al-Mafraq crossing stopped a truck carrying a herd of cattle while it was passing from Syria into Jordan. Captagon was “concealed inside small plastic bags wrapped in a piece of cloth and sheep excrements, then sewed and fixed with a tape on the butt of the cattle,” according to a Interpol notice detailing the incident.
Traffickers use increasingly complicated methods to transport drugs. In 2011, Saudi border guards intercepted a man flying over the border in a glider, a small open plane powered by a fan. Captagon has been hidden inside tomatoes, potatoes, peanut shells, power tools and furniture. In 2012, Kuwaiti authorities reported two incidents of dealers driving boats deep into the ocean, dropping the drugs into the water, and selling the GPS coordinates to perspective buyers.
According to the DEA, drug-producing groups establish shell companies around the Maghreb and the Levant to legally purchase barrels of chemicals, eventually diverting them to Captagon producers. This obscures the trail precursors take from manufacturers in Mumbai, India, and China.
The same report explained that law enforcement officials in Basrah, Iraq, claim that the city has become a major distribution center for the country. It said, "Border authorities are concerned terrorists could be turning to increasingly lucrative narcotics trafficking as a revenue stream."
In 2014, a graduate school class of Special Forces soldiers conducted a study on Captagon while undergoing training with the John F. Kennedy School for Special Warfare. In a Powerpoint presentation posted on the Internet, they concluded, “Currently Drugs are seen as the major contributing factor to the functioning of the Syrian Civil War, especially the amphetamine Captagon,” Many parties, they continued, profit from the Captagon trade, including the Syrian government, opposition groups and transnational criminal organizations.
The cost to produce one pill is about five cents. Pills sell for $3 to $30 dollars on the street. Most of the pills end up in Saudi Arabia, according to seizure data, where people take Captagon at parties or as a study aid or work aid. Profits from the entire trade of Captagon are estimated to be between $500 million and $1.6 billion dollars.
Cocaine profits helped Colombian rebels thrive for decades and opium money helped the Taliban outlast a long and costly American-led military campaign to defeat them.
“I think that its sowing the seeds for a long term challenge,” said Matt Herbert, Senior Program Officer at Strategic Capacity Group, Herbert believes Captagon usage could spread to countries where a substantial number of foreign fighters with the Islamic State have come from.
In Rebel-Held Syria, Medical Aid Workers Tunnel for Help
By David Iaconangelo, Annie Hylton, and Ellen Francis
With David Roza
Beneath a highway controlled by the regime of Syrian President Bashar Assad, Osama Abou Zayd shuttles back and forth in hidden, underground tunnels spanning miles around Damascus. When headed in one direction, out of the rebel-held suburbs of Eastern Ghouta, he carries cash. On the way back in, he carries medicine and supplies.
“With money, we can get anything,” said Abou Zayd. “Just like the soldiers can get their weapons, we bring in our medical supplies.”
Abou Zayd belongs to the Union of Free Syrian Doctors, a network of medical professionals who have resolved to pay a high price in money and risk to supply hospitals in besieged Eastern Ghouta, where aid deliveries from international donors are erratic. The tunnels provide an alternative lifeline.
Armed groups built the tunnels in 2013, when the siege pressed by Assad’s forces was worsening. The underground network today carries food, fuel and even people, according to aid workers. Regime forces sometimes bomb the passages, but they have yet to choke off smuggling altogether.
Five years into Syria’s protracted war, Abu Zayd’s risky journeys have become typical of the lengths to which medical groups in opposition areas must go to serve patients living in hellish conditions.
In interviews with some two-dozen physicians, advocates and aid workers, nearly all said that medical supplies tend to reach rebel areas, especially those under violent siege, by secretive and extra-legal means, often involving bribes and smugglers. In explaining the emergence of the networks, experts pointed to the Assad regime’s persistent refusal to let humanitarian aid into opposition areas, but also to the inability of U.N. and Western powers to establish reliable paths for humanitarian supplies.
Almost since the war began, the U.N. has pondered establishing safe zones where civilians could take refuge and where aid workers might more reliably stage deliveries to besieged areas. But the idea has never materialized because it would almost certainly require the U.S. or Europe to commit military forces to protect the safe zones, entangling Western governments in Syria’s bitter conflict. The West’s aversion to intervention has left Syrians in opposition territory to improvise as best they can.
“During the period of negotiations with the regime and the period of bringing in aid through the U.N., we asked for a passageway,” said Mahmoud al-Sheikh, administrative director of The Unified Revolutionary Medical Bureau in Eastern Ghouta. “We didn’t get any positive responses. So we’re forced to go through the tunnels.”
In February 2014, the Security Council adopted a resolution demanding that all parties in Syria allow the delivery of humanitarian aid – and the evacuation of civilians -- across conflict lines.
Last April, a U.N.-backed humanitarian task force managed to negotiate aid to reach 40 percent of people in besieged areas in Syria, but while Assad’s regime has let a few convoys through, it has continued to block the movement of aid groups. A ceasefire in the war broke down in May.
Assad’s position is that the U.N. efforts provide “logistical backing to terrorists,” as the Syrian ambassador put it in a 2014 letter. Although the majority of Syria’s population has rebelled against Assad, the government routinely refers to all rebels as terrorists.
The government warned that delivering aid to rebel-held areas without its permission could warrant retaliation against aid convoys. Since then, convoys have been attacked even after being granted permission. In April, a U.N. official told the Security Council that a mortar hit one convoy into Homs and air raids targeted another.
The regime has also been known to remove or deny essential supplies from convoys.
Rebels drive in front of a Syrian Arab Red Crescent aid convoy in the Idlib province in 2016. International donors largely fund the aid that goes to Syrian rebels. © 2016 Reuters Limited | Ammar Abdullah
Samantha Power, the U.S. ambassador to the U.N., has said the regime removed more than 4.5 metric tons (almost 10,000 lbs) of medical aid from convoys in March alone. Citing the disappearance of scissors and anesthetics from midwifery kits bound for rebel-held areas, Power called the removal of medical supplies a “rule that is enforced across the board by the Syrian government’s bureaucracy.”
“The people who do this are people who don’t give a damn what this Council prescribes,” she said in a speech in early May.
According to al-Sheikh, who helped oversee 26 aid vehicles entering eastern Ghouta, the medical supplies the regime did allow in included, “chlorine tablets, nylon bags, infection medicine for children, syrups for diarrhea and constipation.”
“What did they bring in?” he asked, laughing sarcastically. “Nothing at all.”
Abu Zayd recounted that convoys reaching eastern Ghouta have been full of anti-lice medicine, empty water cans and children’s toys. “Honestly, when you’re on the outside, maybe when you see that 52 trucks entered the besieged Ghouta,” he said, it seems like a lot. “But the content is embarrassing,” he added. “Yes, of course Ghouta needs children's toys, but it needs medicine more...much more, there’s no comparison,” he said. Medical supplies, he said, are a “red line” for the regime.
“Aid is being used deliberately by the Syrian regime as a weapon,” said Jomana Qaddour, the co-founder of Syria Relief & Development, an organization that provides food and medical care for Syrians and Syrian refugees.
“You have the U.N. body that refuses aid unless Assad allows it, which he won’t do in areas that oppose his rule,” she said. “It makes the UN look as though it is an accomplice.”
Nor has the U.S. accomplished much on its own. Recent accounts of fraud and corruption involving U.S.-backed programs raise questions about the U.S. government’s strategy and oversight. On May 6, the Office of the Inspector General for USAID announced that it had opened an investigation into bribery and kickback schemes related to USAID-funded humanitarian aid programs run out of Turkey and Jordan.
“The United States doesn’t have an articulate policy to date about which authorities we’re dealing with,” said a director of a relief organization with funding from the State Department. “If you don’t have established corridors, or no support to move your goods, the only way to do it is, you have to comply with the local structure.”
A man carries a parcel of aid supplies from a Red Crescent convoy in the rebel-held town of Jesreen in 2016. The destruction of infrastructure makes locals heavily reliant on foreign aid. © 2016 Reuters Limited | Bassam Khabieh
Sometimes, that entails paying the regime for access.
“To get from point a to b, you have to go through corridors, and you have to pay people,” said the director.
Abou Zayd and other medical workers navigate such corridors. Each one carries a price.
Barzeh, a small town on Damascus’ northern outskirts, is a relatively neutral zone in Syria’s war. The Free Syrian Army and Assad regime agreed to a truce there about two years ago, and merchants from Damascus now serve it as a marketplace. A ten-person team from the Union of Free Syrian Doctors is set up in Barzeh working “around the clock,” as Abou Zayd put it, to buy supplies from the capital’s merchants.
Corruption and bribery are endemic. Merchants have to pay bribes to regime soldiers, about 20 percent the value of the item, said Abou Zayd. He described the bribe as a “tax” or “customs” payment. “It’s not a secret,” he said.
To get the supplies back to Eastern Ghouta, healthcare workers must go through a city called Harasta, but the highway between Barzeh and Harasta is regime-controlled. The geographical problem is solved with more cash.
The underground tunnels into Harasta are controlled by the rebels, who charge a smaller fee than do the regime checkpoints aboveground, but still collect about five percent of the value of smuggled items – described by one aid worker as a “toll.”
By the time all the fees are paid, the price of medical supplies in Eastern Ghouta “is three times higher, sometimes as much as five times, than what’s in the north or south of Syria,” said al-Sheikh. A liter of serum, which is used to help the body replenish lost blood, goes for about $1 in regime-controlled areas (one liter is about one fluid quart). But health workers say they’ve paid anywhere from $3.50 to $10 for one liter of serum brought in from Barzeh.
Abou Zayd estimates that Ghouta, with its many neighborhoods, needs about 10,000 liters (more than 2,600 gallons) of serum per month.
“If there’s no siege, of course we wouldn’t have to use the tunnels,” said al-Sheikh. “Of course. But we’re forced to do this.” He believes that the regime avoids completely destroying the tunnels to preserve a smuggling network that has become profitable for the regime’s soldiers, and even the government.
U.S. officials acknowledge the ethical dilemma faced by medical staff on the ground.
“Obviously, I don’t approve of anything that enriches the regime,” said Stephen Rapp, former U.S. ambassador-at-large for war crimes issues. “But something that enriches an individual soldier, who’s probably barely being paid anyway, to get somebody past the checkpoint: that falls in a kind of grey category, where you can imagine being in that situation and making a decision for the greater good.”
In general, Abou Zayd said, the cost of operating field hospitals in areas under siege can be upwards of ten times more expensive than elsewhere in Syria. That cost, which includes the endemic bribery, ends up being passed on to the outside aid groups that provide financing, including those with funding from the U.S. government.
In more accessible regions, like Idlib, Hama and sometimes Aleppo, supplies come from Turkey. But even that route is prone to road closure and the threat of attacks against transporters. With the violence in Aleppo intensifying in recent weeks, the only road to provide assistance to eastern Aleppo is under steady attack. “There is really no way for aid to reach it, because the only road is essentially down,” said Kathleen Fallon of the Syrian American Medical Society.
The dilemma grows even starker when donors and aid groups consider sending cash across the border, especially to areas where extremist Islamist groups such as al-Nusra or the Islamic State are active among the anti-regime brigades. To vet cash recipients, international groups tend to rely on the guidance of local citizens’ councils, or on their own longtime relationships to medical staff.
The United States does not provide cash disbursements out of wariness that the money could end up in extremists’ hands. And U.S. banks, subject to laws that hold them accountable if they allow terrorist finance, can be tough on anyone proposing transfers that might reach Syria.
“It’s so difficult to get money anywhere,” said Matthew Chrastek, a coordinator for the American Relief Coalition for Syria, an umbrella group for Syrian-American medical charities. NGOs with the word “Syria” in their name, he said, often have trouble opening up accounts with U.S. banks.
“The Treasury Department will give money to charities, but the bank still won’t work with them, even though the money is from the U.S. government.”
Aid groups stress the high stakes involved.
“In the end, we receive documentation and verification,” said Mohammad Yasser Tabaa, co-founder of the Syrian Expatriate Medical Association. “We receive videos showing that ‘these are the tools or supplies we bought, and this is how we’re using them’. And anyway, we know the doctors through our connections...That’s it, we trust them.” An international community that has allowed Syria’s war to devolve into horror – almost 500,000 dead and many millions forced from their homes – may not have the credibility to enforce its rules on the Syrians who remain.
“They have their ways, smuggling,” Tabaa said. “This is the only way for them to keep surviving.”