Medical Genocide:
Mass Violence and the Health Sector in the Syrian Conflict (2011-2019)
Annsar Shahhoud
Holocaust and Genocide Studies Universiteit van Amsterdam
Student no. 12474088
Prof. Uğur Ümit Üngör September 2020
Table of Contents
Abstract Introduction
1. Approaching Medical Perpetration in Mass Violence……….. 5
2. Methodology and Sources………...………... 8
Chapter 1: The Authoritarian Regime’s Health Sector Goes to War 1. Introduction……….11
2. The Assad regime’s Health Sector………...12
1) Politicization ………...12
1.1 Party, Ideology and Health Professionals………...12
1.2 Oppression: Violence as a Pattern of Control………...14
1.3 Party Clientelism-Patronage Network in Healthcare Sector………...15
2) Militarism, Militarization and Health Sector………...15
3) Sectarianism and Healthcare………17
3. Syrian War Medicine ………...18
3.1 Polarization, Criminalization and Violence………...18
3.2 Militarization and Medicalization: Discourse, Facilities and Profession……...20
3.3 Fear and Security Dilemma………...22
4. The War on Terror and Medical Torture………23
5. Conclusion………...23
Chapter 2: The Masquerade of Syrian Hospitals: Medical Atrocities and Mass Graves 1. Introduction………25
2. Military Hospitals………26
2.1 Brief History………26
2.2 The Route to Agony: Forgotten Names, Unforgettable Journeys…………...27
2.2.1 Discourse and Process………...27
2.2.2 Shattering The Last Hope: “Am I Going to Be Killed?” …………...28
2.3 Hospitals as Spaces of Tyranny: Silent Persecution………...30
2.3.1 Al Sanamayn Military Hospital: Restrains of Violence……….32
2.3.2 The Abyss: Yousef Al Azzmeh Hospital 601………...33
2.3.2.1 Death Chambers: Medical Torture and Killing ………..33
2.3.2.2 Doctor Mohammad Barakat: The Killing Master………36
2.3.2.3 The Guards: Rescuers or Killers……….36
2.3.3 Process of Death: Medical Destruction of Evidence………38
2.3.4 Major General Dr. Ammar Suliman: Mastermind of Medical Violence.38 3. Civil Hospitals: A Torture Archipelago. ………...40
3.1 Al Mujtahid Hospital: A Secret Detention Center………..41
3.2 The Perpetrators: Dr. Ghazi Al-Ali………42
4. Conclusion………...43
Chapter 3: Syrian Doctors in Genocide and War 1. Introduction ………...44
3. Direct Killing and Clinicide ………..47
3.1 Direct Killing ………...47
3.1..1 Political Murder………...47
3.1.2 Medical Professionals- Soldiers………48
3.2 Clinicide: Medical Murder……….49
3.2.1 Direct Medical Killing ……….49
3.2.2 Medical Negligence: A Silent Massacre……….51
4. Medical Torture………52
4.1 Torture Doctor……….52
4.1.1 Doctors and Torture Before the War in 2011……….52
4.1.2 Doctors and Torture after 2011 ……….53
4.1.2.1 Doctors and Interrogation in Detention Centers ……….53
4.1.2.2 Medical Professionals and Torture at Hospitals………56
5. Legitimization of Violence: Medical Reporting and Forensic Pathology………….58
6. Triage: Indirect Killing ………..60
7. Conclusion……….62
Conclusion Bibliography Appendices
Abstract
This thesis is a study of perpetrators and perpetration in the Syrian health sector under the Assad regime during the conflict (2011-2019) based on extensive fieldwork, both offline and digital. The thesis examines a specific population of perpetrators, defined according to its members’ professional practice, the group members’ behavior and dynamics in a context of mass violence. It engages in a discussion regarding three problematic issues: the circumstances and factors of professionals’ co-optation within state violence in a civil war; the instrumentalization of medical facilities in violence and normalization of perpetration; and the types of medical violence in state violence in a context of repression and civil war. I conclude this thesis with three arguments: (1) medical violence in Syria is not an incidental or accidental phenomenon, but rather a continuity of Hafez al-Assad regime’s legacy, as well as a result of policies of instrumentalization of healthcare inherited from the French-colonial era; (2) civil war and medical mass violence are intertwined, as the civil war dynamics shaped medical violence pattern, and vice versa; and (3) Syrian doctors’ roles were highly important and influential during the war. Finally, I propose a future discussion on challenges of perpetrators and medical perpetration research in authoritarian regimes and ongoing conflicts.
“Whether medicine merely provides the equipment or the name for a form of torture, whether
doctor ever was a doctor or has only assumed a role, whether he designs the form of torture used, inflicts the brutality himself, assists the process by masquerade of aid, the institution of medicine like that of justice is deconstructed, unmade by being made at once an actual agent of the pain and a demonstration of effects of pain on human consciousness”- Elaine Scarry, 1987.1
Introduction
“It is him... he is the doctor who tortured detainees with diabetes,” a former detainee at hospital 601 said when he saw a photo of Dr Ous.2 Dr. Ous is a man gives the one a wrong impression of a peaceful man and a successful doctor with principles. He is calm, modest, and decently behaved. He even criticized the regime:
We hated politicians because they made neighbors kill each other and destroyed cities for personal purposes. I frequently asked myself, “why do we fight each other?” What did we gain of it? We hated political slogans.3
Dr. Hammdan is from the third generation of doctors who graduated under the Ba’ath party, and the second from Tishreen Medical School in Latakia in 1994. He was born in a middle-class family in Qardaha in 1970 and grew up fully under Hafez al-Assad’s regime. Dr. Ous viewed his life as that of a “typical” Syrian doctor: he joined the Syrian Ba’ath party at a young age and served the mandatory military services at Tishreen Military hospital in Damascus. He was trained in military medicine and specialized in anesthesiology. He practiced medicine as a civil doctor with the military for fourteen years (1996-2010). He then returned to military medicine as a reservist doctor after the eruption of the Syrian conflict in 2011. For him, it was a rational decision out of a commitment to his family, community and the state:
It was my duty to family, community and the state…I don’t regret serving in the military, it has some great impact. I was an active subject to the country. As an individual, I had a positive impact on the society, it made me content… I helped in a collective meaning.4
He occasionally regretted his decision to stay and serve in the army because of- as he explained- serious mental consequences of numbness and desensitization: “I lost my connection to this world, life means nothing to me.”5 Considering himself a foremost victim of the regime’s ‘conspiracy’: “We discovered at the end that the ‘terrorists’ we were demanded to treat, were state agents sent to penetrate the opposition… The state sacrificed us.”6 The alleged conspiracy had exposed him to danger and caused enormous fear.
Dr. Ous tended to rationalize the war and violence in Syria, but he persisted in calling the victims “terrorists”, denying accusations of ill-treatment and torture of detainees, or the existence of a prison at the hospital, and portraying himself as a successful doctor with principles:
The truth is we provided medical care equally to loyalists and “terrorists”, they accused us a lot of killing “terrorists”. There were orders to keep them alive because they are of use in terms of information for the state. The hospital is a place where people from different backgrounds work, so you won’t implicate yourself openly. There are three reasons why did not kill the “terrorists”: the intelligence apparatus’ demands to keep them alive; the medical professional’s ethics prevented us from killing; and the doctor cannot violate a patient because the news would be revealed if the doctor killed someone openly. I was among doctors who treated oppositionists in the presence of their families in Jableh
2 Interview with Ismael via WhatsApp June 23, 2020 3 Interview with Ous via Facebook, May 7, 2020 4 Interview with Ous via Facebook, May 7, 2020
5 Interview with Ous via Facebook, May 7, 2020 & April 24, 2020. 6 Interview with Ous, May 7, 2020.
hospitals during the army’s ground offensive on the city. I can tell you straightforward there was strict order to keep the “terrorists” alive because they are an information bank for the regime, he will tell the names of his friends.7
Hammdan’s version of events widely conflicts with that of survivors. The former detainee I interviewed not only cast doubt on Dr. Ous’s story, but also his body responded physically to these memories when he saw the photo: “My hands are shaking…I feel as if my brain is trembling.”8 Today, Dr. Ous returned to normalcy as a civil doctor and a family man, where he lives with his wife and two children in his hometown of Qardaha. He works in a civil hospital, enjoying what he missed for years: “A freedom of civilian life away from rigid military institutions and orders.”9
This thesis will examine the phenomenon of medicalized violence during the Syrian conflict between 2011 and 2019. It outlines features of Syrian medicine under Syria’s authoritarian Ba’athist regime and its historical genesis in an attempt to understand the circumstances that led to the co-optation of medical professionals with the regime’s violence. It also identifies the extensive use of medical facilities as torture centers, and types and patterns of medical violence as a distinct category. The thesis is divided into three chapters, each tackling the above three problems. In the first chapter, it examines the perpetration of medical violence, its perpetrators and their motives. The second chapter is concerned with the use of military and civil medical facilities in the violence, including the process and organization of this violence. The third chapter shows the role of health professionals in violence and the type of medical atrocities that occurred in the Syrian conflict (2011-2019). Based on a range of primary sources, this thesis argues that medical professionals were instrumentalized in the Assad regime’s campaign against political opponents, by deploying health professionals’ medical expertise in killings, torture, and legitimizing state violence. Furthermore, it argues for the unique instrumentalization of Syrian health institutions in civil war, emphasizing that the dynamics of the war and the medical atrocities are intertwined.
1. Approaching Medical Perpetration in Mass Violence
This thesis started with a quest for determining to what extent the violence committed in the Syrian civil war is of a medical character. As such, the main research question is: How were Syrian medical professionals co-opted with the Assad regime’s violence? Furthermore, how were medical facilities instrumentalized in the violence? What are the processes of such violence, and how it is organized? Finally, I asked, most importantly, what types of medical violence occurred in Syria? How can we categorize the role of medical professionals? To understand the Syrian case, I looked at medicine in contexts of war, genocide and oppression, and its problematization in a broader sense, more specifically in oppressive regimes. After all, the Syrian case is not entirely unique, although aspects of it are rather unprecedented. I define ‘medical violence’ as the types of violence that involve medical professionals or any other health sector workers in any means: either by preparing, performing, or legitimizing violence in context of repression, war, or mass violence.
The problematization of medicalized violence can be developed in two approaches. First, scholars focusing on a sociological analysis of medicine, generally outline policies and circumstances that influenced the health sector and medical profession and distorted the ethos of medicine in a country. Medical sociologist Mark Field, for example, in his study of social systems and medicine in
7 Interview with Ous via Facebook, May 7, 2020. 8 Interview with Ismael via WhatsApp, June 23, 2020. 9 Interview with Ous via Facebook, May 7, 2020.
Soviet Russia, asserts that the communist party manipulated medicine for political purposes and economic development through a process that elicits inequalities through ideological incorporation into medical education, employment, incentives, and services, and marginalized the Other.10 The Nazi regime too, according to the German historian Michael Kater, exploited German doctors’ economic grievances and political ambitions to marginalize independent medical associations, and replace them with loyal and devoted supporters.11 The Nazi doctors are unique cases in many aspects, and the Nazi regime’s medicalized ideology, and the legal ban of Jewish doctors from practicing medicine was a crucial step towards the genocide.12 In medical crimes, the ideological component is a subject of controversy. Some scholars assert the ideological element behind German doctors’ enthusiastic crimes was justified by many as a “search for truth’’. Similarly, this can also apply to Japanese doctors of the infamous Unit 371.13 Others placed it in its political perspective, as American historian Robert Proctor proclaimed that even extreme ideology is impotent unless it is identified with a political regime.14 These policies which consist of coaxing and excluding medical professionals seemed to be similar between authoritarian and totalitarian regime in Nazi Germany, Latin America, and others.15
Medical mass violence occurs in militarized spheres or war in a climate of impunity. Militarism of medicine is a profound phenomenon which started in WWI and yielded mutual benefits for both medicine and military.16 Medicine by this period became essential to the efficiency of military performance, and it weaponized the historical moment of the rise of eugenic medicine and theory of race in the United States and Germany in the 1920s.17 These medical theories translated into racial ideologies, and became a notorious weapon to eliminate political groups. Steven Miles asserted that medicalized torture existed even before the modern state, yet militarization as a phenomenon commenced in 1933 with German doctors of the SS, SA, and Gestapo. Their crimes against German people with disabilities and innovations of enhanced torture techniques were widespread.18 Thereafter, medicine became an integral component of several mass atrocities and war such as the British war in Northern Ireland, or in an oppressive regime campaign in Chile, Argentina, and others. More recently, the debate on militarization of medicine was provoked by American physicians and psychiatrists torture of prisoners in Abu Ghraib and Guantanamo. Physicians’ dual loyalty in the military remains a prominent concept to explain medical atrocities in its practical, legal and situational aspects. It has been a controversy with some thinking that this duality is an “outcome” or others who proclaim that dual loyalty is a “cause” of violence.
10 Mark Field, Soviet Socialized Medicine: An Introduction (New York: Free Press, 1967),30,70.
11 Michael H. Kater, Doctors Under Hitler (Chapel Hill: University of North Carolina Press, 1989),13-25. And, Michael Burleigh also referred to connection between Nazi financial support to research and doctors’ involvement with the Genocide, in: Michael Burleigh, Ethics and Extermination: Reflection on Nazi Genocide (London: Cambridge University Press, 1997),138.
12 Raul Hilberg, The Destruction of the European Jews (Harper and Row, New York, 1961),11.
13 John J. Michalczyk, Medicine, Ethics, And the Third Reich: Historical and Contemporary Issues (Kansas: Sheed & Ward, 1994),36. Jonathan L. Maynard, “Ideologies and Mass Violence: The Justificatory Mechanics of Deadly Atrocities,” (PhD diss., Oxford University, 2014),79-80. Edward Weisband, The Macabresque: Human Violation and Hate in Genocide, Mass Atrocity,
and Enemy Making (New York: Oxford University Press, 2018),277-289.
14 Robert N. Proctor, Racial Hygiene: Medicine under the Nazi (Cambridge Mass: Harvard UP, 1988),30-38.
15 Eric Stover, “The Open Secret Torture and The medical Profession in Chile,” Committee on Scientific Freedom and
Responsibility Americans Association for the Advancement of Science, Washington D.C., July 1987. Jing Bao Nie, Nanyan Guo,
Mark Selden, Arthur Kleinman (eds.), Japan’s Wartime Medical Atrocities: Comparative Inquiries in Science, history, and ethics (New York: Routledge, 2011). Vahakn N. Dadrian, “The Role of Turkish Physicians in The War 1 Genocide of Ottoman Armenians,” Holocaust and Genocide Studies vol.1, no.2 (1986): pp.169-192.
16 Mark Harrison, “Medicalization of War-Militarization of Medicine,” The Society for Social History of Medicine vol.09 no.02, (August 1996): pp.267–276. Melissa Lamer, James Peto, Nadine Kathe Monem, Deutsches Hygiene-Museum Dresden, War and
Medicine (Berlin: Black Dog, 2008),230.
17 Francis R. Nicosia, Jonathan Huener (eds.), Medicine and Medical Ethics in Nazi Germany: Origins, Practices, Legacies (New York: Berghahn Books, 2002),5-7.
Second, others focused on the medical profession as group dynamics, and the individual’s motives and the psychology behind it. American psychologist Robert Lifton pioneered the concept of “doubling” to explain German doctors’ genocidal crimes. Doubling is the dissociation into two selves, the normal self, and the perpetrator’s self, which allows perpetrators to suppress their consciences towards their crimes and their victims.19 Michael Gordin proclaimed that medical atrocities are not caused by single factors but rather by overlapping psychological, social, cultural and political factors.20 Looking at the similarities between military and medical institutions, the study of historian Christopher Browning on German auxiliary Battalion 101 is important in respect to peer pressure in shaping individual behavior in mass violence context.21 Finally, it is important to stress that medical violence and regime types are not intertwined: it has been practiced in totalitarian, authoritarian and democratic regimes. For instance, psychological torture developed in Nazi Germany, the Soviet Union, colonial France, the United Kingdom, and the United States of America, where it evolved to torture schools.22 These skills were transmitted to other countries like Latin America, where torture became a systematic practice.23 Yet, regime type is a factor that should not be marginalized: it is a factor that determines the circumstances and the extent of medical crimes.24
After the Nazi doctors’ crimes in Germany and the Holocaust in Eastern Europe, the Nuremberg code has been a symbolic declaration to restrain medical personnel participation in mass violence and genocide. It initiated an extensive attempt to restrain medical violence, imprinting human rights into medical ethics banning doctors’ compliance with torture and other violence for political purpose or scientific ambitions. A series of manuals and declaration defined the boundaries of medical professionals’ acts in certain circumstances. Medical professionals’ actions that breach obligations were stated in these protocols or manuals, in order to determine their compliance and liability.25 For instance, the rules of examination of a person in custody in private and safe environment were clearly defined. Within these frames, I tackled Syrian medical professionals’ complicity with state violence in the conflict between 2011 and 2019, taking into account the historical, cultural, political characteristics of the Syrian society. This thesis refrained from the discussion on the legal, philosophical and moral aspects of violence in healthcare. Therefore, it is not engaged in the debate on the neutrality and impartiality of the health sector in conflicts such as civil war. This objective here is a proper understanding of the medical profession in Syria, statecraft and the health sector, and both individual and institutional complicity in the oppression.
There are three important points with regards to the analytical framework of this thesis. The title and the ‘G word’ (genocide) does not imply that medical violence in Syria is a form of genocide; I do assert that the G word here is an illustration of the process and organization, and pattern of violence: identity affirmation, selection, subjugation, and destruction – physically and psychologically. The Syrian regime after Assad’s 1970 coup d’état gradually locked its grip on the Syrian society and institutions through violence and persuasion. Salwa Ismail even argued, convincingly, that violence was a style of governance in Syria, that the Syrian regime maintained violent methods to divide the Syrian society by humiliation and repression, not only for its political activities, but also in a broader
19 Ibid.
20 Michael Gordin, George Annas, “Physicians and Torture: Lessons from the Nazi doctors,” International Review of the Red Cross vol.89, no.867 (September 2007): pp.635-654.
21 Christopher Browning, Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland (New York, HarperPerennial, 1998),189.
22 Pau Perez Sales, Psychological Torture: Definition, Evaluation and Measurement (London: Routledge,2016),148-196. Sidney Bloch, Peter Reddaway, Russian’s Political Hospitals: The Abuse of Psychiatry in the Soviet Union (London: Victor Gollancz LTD,1977),30-31.
23 Ibid.
24 Robert N. Proctor, Racial Hygiene: Medicine under the Nazi (Cambridge Mass: Harvard UP,1988),31,75. 25 British Medical Associations, The Medical Profession and Human Rights (London: Zed book Limited, 2001).
sense of daily life, spreading a deep sense of distrust and fear in the society.26 The Syrian regime changed institutions and restructured them to conform to its political agenda. Regime control over institutions translated into a flexibility to face internal and external challenges and consolidate its power.27 The regime’s control of institutions meant ideological penetration and prioritization of Ba’athist principles, repression, and exclusion of elements considered suspicious to the regime. The Syrian regime manipulated social, economic, and political diversity in the society to that end, yet, control over institutions was its distinguishing feature.28
Medical ethics is concerned with the practice of medicine. It specifies terms to be put forward in certain instances by medical professionals. Medical ethics encompasses the moral and philosophical structures, influenced by cultural, religious, and legal variations in each society.29 For Syrian doctors, though from diverse cultures and religious backgrounds, the Islamic ethos has always been dominant. Therefore, in this thesis three dimensions are considered in analyzing Syrian medical professionals’ perception of medical ethics: the understanding of universal medical ethics and bioethics, components of Islamic medical ethics as stated in the Islamic code of ethics issued in the Kuwait Conference in September 2015, and medical ethics in connection to human rights.30 I followed the example of Robert Kaplan and adopted the broad categorization of medical violence, including medical professionals’ clinical, political and military roles.31 This frame embraces the complicity of perpetrators’ identities and actions rather than a single explanation of clinical crimes.
2. Methodology and Sources
This thesis is based on a combination of methods: oral history and digital covert ethnography. Due to the extreme challenges of conducting research on and in Syria, covert ethnography was perhaps the least desirable method, but I resorted to it only because other methods were impossible to obtain data. The Syrian regime’s close surveillance of society, in general, and researchers, in specific, made these topics truly unresearchable. Also, researchers and journalists were subject to questioning or arrests by security apparatus in Syria even prior to the conflict, which hindered their access to research subjects. Therefore, scholars such as Torstein Worren followed covert methods in their research, a necessary way to obtain access to informants and understand the topic. He emphasizes the implication of fear and threats on informants and him personally due to the intelligence agencies’ tight surveillance.32 The uprising and the subsequent war opened the window of inquiries on the Syrian refugee crisis with hundreds of thousands of Syrians fleeing to Europe and neighboring countries. However, studying Syrian perpetrators remains a challenge due to secrecy of the regime, and accessibility to research groups, whether with the diaspora or inside Syria. The regime banned researchers and foreign journalists from entering the country, and a few of them left the country under warning of arrest.33 At
26 Salwa Ismail, The Rule of Violence: Subjectivity, Memory and Government in Syria (London: Cambridge University Press, 2018),41.
27 Steven Heydemann, Authoritarianism in Syria: Institutions and Social Conflict,1946-1970(Ithaca: Cornell University Press, 1999),30-31.
28 Ibid.
29 Chris Durante, “Philanthropic Healthcare: Christian Conceptions of Social Responsibility and Healthcare,”in Religious
Perspectives on Social Responsibility in Health: Towards a Dialogical Approach, eds. Joseph Tham, Chris Durante, Alberto García
Gómez (New York: Springer,2011),11.Abdulaziz Sachedina, Islamic Biomedical Ethics: Principles and Application (New York: Oxford University Press,2009),25-27.
30 First International Conference on Islamic Medicine, Islamic Code of Medical Ethics, Kuwait Document (Kuwait: 1981). 31 Robert M. Kaplan, Medical Murder; Disturbing Cases of Doctors Who Kill (West Sussex: Allen & Unwin, 2009),10-15. 32 Torstein Schiøtz Worren, “Fear and Resistance: The construction of Alawi Identity in Syria” (MA. diss., University of Oslo, 2007),11-25.
33 Sam Dagher, Assad or we burn the country: How One Family's Lust for Power Destroyed Syria (New York: Little, Brown and Company,2019), xvii.
a later stage, it became even more difficult due to perpetrators’ distrust of foreign researchers, security fears, and foremost, perpetrators’ group, indeed almost cult-like, behavior and code of secrecy. The period my informants often referred to euphemistically was “the forgotten black past (دﻮﺳﻷ اﻲﺿﺎﻤاﻟ
اﻟ ﻤ ﻨ ﺴ
ﻲ ).” While perpetrators in exile refrained from talking due to fear of accountability, such as the case of Dr. Alaa Mousa in Germany, covert methods have been in use since the 1950s, with Dr. William Caudill’s study on a mental hospital a most prominent example: he simulated mental illness symptoms to enter and observe the hospital.34 Furthermore, Scheper-Hughes conducted “undercover ethnography” research on illegal organ harvesting by international networks, and she advocates the use of covert ethnographic research. She argued that “all the normal rules of fieldwork practice and ethics seemed inadequate.”35 Another example is Julia Ebner’s recent book Going Dark: The Secret Social
Lives of Extremists, a case study of neo-Nazi in Germany. Ebner used a digital ethnographic covert
method to penetrate the group online and offline. She asserted that inventing identities in both social media and reality to assimilate the groups was key to penetrate and understand such closed groups.36
The security risks ethically compromise the research due to the fact that the researcher has to provide informants with a safe environment to express themselves without any sort of pressures.37 These conditions are impossible in Syria right now; therefore, social media were the safest space to scrutinize perpetrators without risking their well-being. It was even a necessary element of perpetrators’ acceptance to talk to me. Perpetrators were informed that the interviews were conducted for the purpose of research, but the real purpose of perpetrator research remained uncommunicated. The questions were explicit and provocative. Confronting perpetrators with direct questions on violence generated denial or rejection: “We didn’t torture, we didn’t kill” they would often say to me. Therefore, best way to touch the sensitive theme of violence was to downplay the routine and injustice in the health system, and also look into daily life.
My interviews differed in length and importance, some perpetrators were talkative and provided great insights into perpetration, transition, and consequences. Other perpetrators were silent, their answers were concise and informative, while some, especially in high positions or those named by the media, rejected firmly to speak. Therefore, I argue that some media approaches to Syrian conflict impacted negatively on my attempts to research perpetrators. Throughout the interview process two things mattered: first, the careful construction of my covert identity as a pro-regime educated female from a middle-class family and living outside the country with no ties to the Syrian regime. This combination of factors gave my informants enough safety and trust to speak to me. Secondly, distance was a crucial element that created a safe environment for perpetrators to open up about their lives of the past nine years. For me, it was crucial to maintain objectivity, mental health, and above all security, allowing me to listen without prejudice. I often struggled with the ethical dilemma of deceiving perpetrators, but looking back on two years spent interviewing them, I listened respectfully to their doubts and problems, and accustomed myself to their culture, beliefs, and experiences. These two years were a relatively short experience in comparison to other researchers on the topic, it has a psychological burden of isolation, stress, and sometimes anger. Yet, the experience was worthwhile.
Oral history interviews were conducted with victims who were informed properly on the research theme and its purpose, and regularly updated on its outcome. Accounts of victims provide
34Michael Bloor, Fiona Wood, Keywords in Qualitative Methods: A Vocabulary of Research Concepts (London: Saga Publications,2006),35-36. William Caudill, The psychiatric hospital as a small Society (Boston: Harvard University Press, 1985),7. 35 Nancy Scheper-Hughes, “Parts Unknown: Undercover Ethnography of the Organs-Trafficking Underworld,” Ethnography vol. 5, no.1, (March 2004): pp.29-73 (41).
36 Julia Ebner, Going Dark: The Secret Social Lives of Extremists (London: Bloomsbury,2020),12-16, Books.
37 Martin Bulmer, “The Ethics of Social Research,” in Researching Social Life, ed. Nigel Gilbert (London: Sage Publications, 1992),55-57.
insights on medical professionals’ violence and deeds. In analyzing victims’ accounts, I considered the impact of private trauma, time, and personal beliefs and social backgrounds.38 In addition to the discretion of medical perpetrators, doctors usually disguised and concealed their identity during interrogation sessions, which made it difficult for victims to identify their presence or role.39 Therefore, I conducted waves of interviews, stimulating victims’ memories with exposure to triggers like photos. The downside of this thesis is the lack of gender balance between informants, as my interviewees were all male perpetrators, bystanders or survivors. Three attempts to approach female perpetrators in Hospital 601 and Tishreen Hospital failed. However, questions on perpetrators’ gender and behavior were frequently asked to the victims and bystanders. This research is based on triangulations of information and data from a variety of sources: primary sources, observations during ethnographic research on perpetrators, and oral history (interviews with bystanders and victims, see table 1.1). Also, secondary sources were used, such as media reports, human rights reports, interviews, memoirs, and social media material. The interviews were semi-structured, conducted via social media or in person, with perpetrators in Syria, and bystanders and victims in Syria and from the diaspora between June 2018 and July 2020. This combination of both perpetrators and victims aimed to fill gap of understanding of perpetrators’ deeds and silences.
This thesis is divided into three chapters: chapter 1 explains how the Syrian regime restructured and changed the Syrian health sectors before the war, and factors contributing to doctors’ involvement with violence during and before the conflict. Chapter 2 is on the use of health institutions in violence, and chapter 3 outlines types of violence and doctors’ forms of compliance with violence.
38 Martyn Hammersley, Anna Traianou, Ethics in Qualitative Research: Controversies and Contexts (London: Sage Publications, 2012),01-74.
39 Steven High, ed., Beyond Testimony and Trauma: Oral History in the Aftermath of Mass Violence (Vancouver, Toronto: UBC Press, 2015),03-13.
Chapter 1: The Authoritarian Regime’s Health Sector Goes to War 1.Introduction
I met Dr. Mohammad in the Netherlands at a gathering of former detainees and their families. Coming from an impoverished family in rural Hamah, Dr. Mohammad studied medicine out of passion and urge to climb the social strata. Before the war, dr. Mohammad was a successful surgeon and co-owner of a private hospital in the city center of Homs. In 2011, he was arrested at Air Force intelligence checkpoint in Al Waer neighborhood for allegedly illicit provision of medical aid to injured protesters at his clinic, “You are treating the “terrorists”.” During his imprisonment, Dr. Mohammad was subject to harsh torture, and beating on the head required a medical intervention. At Homs military Hospital, a fellow doctor, Dr. Hasan Eid surgically removed Dr. Mohammad’s left eye.40 A medical report revealed this operation was not a medical necessity and was rather a deliberate act to inflict harm upon dr. Mohammad. Dr.Eid’s action eliminated his colleague’s hopes and ambitions, foremost, for dilemma of being violated and deprived of his medical identity by people he operated together with for years. Dr. Mohammad negotiated his release with General Manoun, the personal assistant of air force intelligence Jamel Hasan, who ensured him that what happened was within acceptable measures.
Within months of his release, dr. Mohammad’s hospital was hit by artillery missiles for twelve hours straight and completely destroyed.41 Violence in the healthcare system in Syria was not odd nor an isolated event as Dr. Mohammad recalled the daily oppression and humiliation he endured during his time at Al Walid Ministry of Health Hospital in Homs. The director of the hospital gathered residents each morning, shouting “You animal! Stand in line!” Daily humiliation was exacerbated by extreme discrimination and severe punishment. At one point, Dr. Mohammad was sent to Al Sikhni Hospital in the desert for a period lasting two to six weeks for objecting to or irritating his superior.42 Medical identity is constructed through training and interaction between medical professionals in a health institution within frames of institution policies, structure, power dimensions and culture. Doctors’ sub-identity held certain functions in mass violence context, they perhaps manipulated to drew exclusionary boundaries by designating the roles of “us” and the “other” during political upheavals or in situations of perceived threat.
The Syrian regime had long consolidated its power through authoritarian policies that combined coercion, sectarianism, single-party politics, and more importantly, institutional reforms that created social conflict.43 The healthcare sector, including medical education, was no exception to the regime’s authority. Since the 1960s, the healthcare sector was instrumentalized for political purposes and used to restructure economic and class relations.
This chapter outline the features that characterized the healthcare system in Syria under the Ba’ath regime before the conflict (1963-2010). Furthermore, it outlined certain features and characteristics that emerged or were strengthened during the conflict at the level of individual hospitals or even citywide settings. It discusses these features in conjunction with the violence that has been committed during the conflict.
40 Dr. Eid was assassinated in Al Zahraa neighborhood in Homs in September 25, 2011. Homs News Voice, “ءاﺮﻘﻟﻔ اﻮﺑ أﺔﯾﻮﻨﺳمﻮ ﯾﻲﻓ اﻟ ﻤ ﺠ ﺎ ھ ﺪ ا ﻟ ﺸ ﮭ ﯿ ﺪ ا ﻟﺪ ﻛ ﺘ ﻮ ر ﺣ ﺴ ﻦ ﻋ ﯿ ﺪ ھ ﺬا ا ﻟﻠ ﻘﺎ ء ﻣ ﻊ أ ﺧ ﺖ ا ﻟ ﺸ ﮭ ﯿ ﺪ ا ﻟﺘ ﻲ ﺗ ﺤ ﺪ ﺛ ﺖ ﻓﯿ ﮫ ﻋ ﻦ ا ﻟ ﺸ ﮭ ﯿ ﺪ و ﻛ ﯿ ﻒ ﺗ ﻢ ا ﻏ ﺘﯿ ﺎﻟ
ﮫ ” “The anniversary of the father of poor, martyr
mujahid Dr. Hasan Eid in an interview with the martyr’s sister about his death and how he was assassinated,” September 25, 2018, https://www.facebook.com/HOMSNEWSVOICE/videos/2247538865481437
41 “A video of bombardment of Al Amal hospital in Juret Al Shayah neighborhood in Homs,” April 6, 2012,
https://www.youtube.com/watch?v=3g20iZ1_PCU; last checked on June 01, 2020. 42 Interview with Dr. Mohammad in the Nertherlands, August 2018.
2. The Assads’ Health Sector 1) Politicization44
The colonial experience prior to independence instrumentalized healthcare systems and existing medical networks to address social and political grievances at community and individual levels.45 In the 1960s and onward, the Syrian Ba’ath party also statecrafted the healthcare system to consolidate its power and reconstruct Syrian society through discrimination, persuasion and coercion. Ba’ath governments redesigned Syria’s healthcare to socialize medicine for social and economic development of a group- the group identity configuration shaped of multi-layers of socio-economic, sectarian and political identification, took different interpretations over the years-, promoting the living conditions and health of those residing in periphery regions outside of historical urban centers. The party expanded the geographic distribution of healthcare to the peripheries and marginalized of healthcare providers in the main urban centers of Damascus and Aleppo; and imprinting party ideology into medicine, producing inequalities and discriminatory in the medical system, as a whole process, including education. The party built clientelism – patronage networks and increased the production of perceived “loyal” doctors from the peripheries. The Ba’ath party policies of equalization in theories were reasonable. But, the practice of Ba’ath government of manipulation of so called “achievements” and oppression, specifically by the Assad regime, resulted in disastrous consequences; discrimination and polarization between health professionals, drew the boundaries of inclusion and exclusion in the healthcare sector in time of crisis.46 For instance, removing the unjust fees of medical school enrollment was a good decision to allow students of qualifications to study medicine.Yet, it has been the foundation of accusations of treason towards doctors for provision of health care to demonstrators. These doctors were branded as traitors and ingrates to a state that “educated and provided them” with the opportunity to enroll in medical school. In other words, any doctor who expressed criticism towards government policies was no longer simply a dissenting voice but denounced as a ‘ungrateful traitor’.
1.1 Party, Ideology and Health Professionals:
Syrian healthcare professionals were leading members and co-founders of the Ba’ath party (1920- 1970).47 Doctors organized, alike church missionaries, the sending of medical professional to rural areas to promote the party ideology and recruit peasants. Doctors, among prominent party members, opened clinics in Dara’a, Deir Ezzor, and the coast, where they established connections with locals, emerged later to be the strongest networks of the Ba’ath regime. Doctors’ role in the party marginalized significantly after the Ba’ath party coup d’état and control of government from 1966 onwards. An assumption contested with the growing number of healthcare professionals. When the Ba’ath party ousted the government in 1963, membership of doctors in the party consisted of 0.2%.
44 I adopted Politicization as conceptualized by Peters and Pierre as, “the substitution of political criteria for merit-based criteria in the selection, retention, promotion, rewards, and disciplining of members of the public service.” Read in: Guy Peters, Jon Pierre, “Politicization of the Civil Service: Concepts, Causes. Consequences,” in Politicization of the Civil Services in Comparative
Perspective: The Quest for Control, eds. Guy Peters, Jon Peters (London & New York: Routledge,2004),2.
45 Joint Committee on the Near and Middle East, War, Institutions, and Social Change in the Middle East (California: University of California Press,2000),65-66,90-91.
46 Ibid.
47Abdullah Hanna, ءﺒﺎطﻷا: ﻊﻤﺘﺠﻤاﻟوﺔﺳﯿﺎﺴﻟ اﻲ ﻓنﻮﻔﺜﻘﻤاﻟ Intellectuals in the politics and Society: Doctors (Damascus: Al-Ahli,1996),107-118.
It then rose to 0.23% in 1984. This consisted of 15-17% of Syrian doctors in 1984.48 But with comparison with other occupations such as teachers, judges, or engineers revealed that doctors were below average co-opted by the Ba’ath Party.49
The number of healthcare professionals from the peripheries grew significantly and declined in urban centers. For example, medical students in Latakia increased by 166.2%, while Damascus registered a drop-in growth of 258%.50 The increase of Ba’ath party membership among medical students was attributed to the privileges provided by membership. Some students benefited from exceptions or reductions in the mandatory military service requirement while they attended Ba’ath party training camps (ﺔﻘﻋﺎﺼاﻟ).51 The Ba’ath party distorted the ethos of Syrian medicine by marginalizing medical ethics for ideological training. The regime deliberately produced generations of doctors ignorant of medical ethics and instead focused on producing doctors loyal to the Arab National Socialist ideology. Courses on the Arab National Socialist ideology were mandatory. Medical students were required to take a course called National “ﺔﯿﻣﻮﻗ" which is also taught in Syrian primary and secondary schools and universities.52 The course was a combination of the Ba’ath party ideology and propaganda of the Ba'ath “achievements” at national and international levels. These courses were a burden on medical students, who could not obtain their degrees without completing the course.53 These “achievements” became a central justification for healthcare professionals to use in order to defend their collaboration with the regime
The Ba’ath party distorted ethics and the traditional values of the medical profession. Healthcare professionals were ignorant and had poor knowledge of medical ethics. At the medical faculty in Damascus, medical ethics curricula were insufficient as lectures disregarded any reference to human rights and medical ethics.54 Syrian Medical professionals interpreted medical ethics as the economic fairness of the healthcare services. An ethical and humane doctor is one who does not exploit the patient economically and treats him/her at a fair cost.55 This departure from conventional medical ethics reflected the Ba'ath vision of what made a qualified Syrian doctor. An ethical Ba’athist doctor is a doctor who is a member of the medical association that operates under the party banner and respects the ethics and rules of medical profession of financial fees with care, as it was stated in the party preparation book “The Ba’ath Education Curricula” ﻲﯿﻔﺜﻘﻟﺘ اﺚﻌﻟﺒ اجﺎﮭﻨﻣ, “Doctors must respect the profession code, tradition, and ethics, refraining from the commercial exploitation and maintaining the professional privacy.” 56 The financial aspect is an increasingly important component and ethical challenge to promote equality and efficiency in health care, but it does not marginalize other values
48 Raymond Hinnebuch, Syria Revolution from Above (London & New York: Routledge: Taylor & Francis Group,2001),77. Hanna Batatu, Syria’s Peasantry, the Descendants of its Lesser Rural Notables and Their Politics (New Jersey: Princeton University Press,1999),183-184.
49 Abdullah Hanna, ءﺒﺎطﻷا: ﻊﻤﺘﺠﻤاﻟوﺔﺳﯿﺎﺴﻟ اﻲ ﻓنﻮﻔﺜﻘﻤاﻟ Intellectuals in politics and Society: Doctors (Damascus: Al-Ahli,1996),133. 50 Drysdale, Alasdair. “The Regional Equalization of Health Care and Education in Syria since the Ba'thi Revolution,” Middle
Eastern Studies vol.13, no.01 (February 1981): pp.93-111. Hanna Batatu, Syria’s Peasantry, the Descendants of its Lesser Rural Notables and Their Politics,66-67.
51 Wajeh Hadad, . "ةﺮﻜﺴﻌاﻟوﺲﯿﺴﻟﺘ اﻦﯿ ﺑﯾﺎرﻮﺳﻲ ﻓﻢﻠﯿﻌﺘاﻟ" “The Syrian Education Between Politicization and Militarization,” Haramoon
Center for Contemporary Studies, 2018.
52 Ibid.
53 Interview with Ahmad via Skype, August 27, 2019. Interview with Ous via Facebook, May 7, 2020. Interview with Taem Paris, July 28, 2019.
54 Tarif Bakdash, Inside Syria: A Physician’s Memoir: My Life as a Child, a Student, and a MD in an Era of War (Seattle: Gune Press,2016),133-135. Forensic pathologist Dr.Hussien Nufal’s lectures on Medical Ethics and Principles,” Damascus University, 2011-2019.
55 Interview with Bahjat via Facebook, May 1, 2020.
56 The Arab Socialist Ba’ath Party, The Party Country Perpetration Office, The Party Education Curricula Vol.2 (Damascus: The Ba’ath Publication House, 1982),345.
and commitment to medical ethics that articulated around four principles; beneficence, non-maleficence, autonomy and justice.
The lack of regard towards human rights and medical ethics manifested itself in pathological discriminatory conceptions of victims that emerged with the escalation of the conflict. Medical professionals involved in violence repeatedly addressed their victims with jargons reflecting cognitive incompetency “stupid,” and dehumanization “They disgust me! Animals!” Sometimes they picked on their physical appearances, “tall, color, and clothing.” The of language and discourse used by healthcare professionals towards victims differed depending on the professional’s age and role. For example, young and middle-aged doctors and nurses showed more prejudices towards prisoners or the “enemy” than older doctors, who were more decent and careful when addressing patient. It shows that doctor was educated on standard medical ethics before the Ba’ath regime.
1.2 Oppression: Violence as a Pattern of Control
Oppressed and violence of health professionals was associated to political unrest or a threat to Assad’s power. Hafez al-Assad took advantage of the civil war with Muslim brotherhood to eliminate political threats of professions’ association (1979-1986), doctors were subjected to torture, humiliation, long imprisonment and some persecuted in 1980, 1983, 1986.
Following Hafez al-Assad’s coup d’état in 1970, Syria witnessed a civil war due to the military confrontation between the Assad and the Muslim Brotherhood (1976-1986).57 Hafez Assad gradually turned the country toward a state of civil war, adapting serious of legalization and measures tightened his grip on the institutions and political groups and public activities.58 Civil society organizations, medical associations, together with lawyers, organized a strike to protest against Assad’s oppressive policies in 1979. The regime responded to this attempt with extreme violence, arresting fifty healthcare professionals, and tortured and persecuted them in 1981. In March 1980, the regime disbanded the medical association and appointed Ba’athist to the association management and incorporated it under the Ba’ath party organization umbrella the “popular organizations” (ﺔﺒﯿﻌﺸﻟ اتﺎﻤﻈﻨﻤاﻟ).59 Furthermore, the regime deliberately targeted health professionals during the Hama Massacre in 1982. Eyewitnesses recalled how the regime soldiers degraded doctors. One account described how an ophthalmologist was forced to kneel and then executed. Afterward, his body was thrown onto a bridge and left for days.60 Hafez al-Assad, who symbolically took the title of the first “doctors” of the nation, succeeded in marginalizing the medical association, controlling the profession and eliminating future threat posed by medical professionals.61 Bashar al-Assad sustained similar oppressive policies towards medical professionals. They were arrested, mistreated, tortured, and some killed during political unrest; Damascus Spring in (2001-2005), the Bedouin-Druze confrontation in As-Suweida in 2000, and the
57 Volker Perthes, “Managing modernization Domestic Politics and the Limits of Change,” in Reform in Syria Between Domestic
Politics and Regional and International Changes,eds.Radwan Ziadeh(Jaddeh: Al-Raya Center For Intellectual Development,2004),
9.
58 Salwa Isamil, The Rule of Violence: Subjectivity, Memory and Government in Syria,57.
59 British Medical Association Medicine Betrayed: The Participation of Doctors in Human Rights Abuses (London: Zed Books Limited,1992),153-155. Volker Perthes, The Political Economy of Syria Under Asad (London: I.B. Tauris,1995),170-180. “Scientists and Human Rights in Syria,” National Research Council (Washington, DC: The National Academies Press,1993). 60 Sam Dagher, Assad or we burn the country, 227-230. James A. Paul, “Human Rights in Syria,” Human Rights Watch, April 01, 1990. “Human Rights in Syria,” A Middle East Watch Report, September 9,1990. Michel Seurat, Syria:L'état De Barbarie (Paris: Presses Universitaires de France, 2012),100.
61 Lisa Wedeen, “Acting “As If”: Symbolic Politics and Social Control in Syria,” Comparative Studies in Society and History vol. 40, no. 3 (July 1998): pp.503-523.
Kurdish uprising in 2004.62 It showed a continuity of violence against health professionals under the Assad regime.
1.3 Party Clientelism- Patronage Network in Healthcare Sector
Syrian professionals pondered to Assad’s regime also for economic advantages, status, and other benefits. Hafez Assad’s regime introduced discriminatory rules of employment, where the party membership was prioritized over the qualification. The regime allocated sources to medical professionals who sympathized with party, especially the one who had social, regional and religious ties with its personnel. The party also secured loyalists with positions and employment, grants, scholarships, and incentives.63 Following Bashar al-Assad’s succession of his father, the party's institutional role as power intermediary between the doctors and the regime weakened for more sectarian, economic and social ties. The patronage networks that were framed by both Ba’athism and Alawism, were replaced with illicit networks of collation between security forces, including military doctors and businessmen.64 These reformed networks held power and key positions in the healthcare sector. For example, Dr. Ammar Suliman, the director of the Military Medical Directorate and a personal friend of Bashar al-Assad, and General Hasan Turkmani who was the partner of the first lady Asma al-Assad in a private business.65 Despite the growing influence of sectarianism-mafiosi networks, the Ba’ath ideology’s presence over the ethos of medicine and medical institutions remained notable. Ba’athist rituals were present in official events organized by the medical association. The new graduates of medical ethics used the Ba’ath party salute to swear their oath, a scene reminiscent of the authoritarian rituals in Syria and other dictatorships.66
2) Militarism, Militarization and the Healthcare Sector
The militarization of the healthcare sector and medicalization of the military are two deviant phenomena. Militarization of medicine happens when a regime positions medicine as intermediary between the military and civilians. The military also extends its authority to civil medicine institutions and personnel.67 Medicalization of the military occurs when professionals take interest in politics, using medical skills and knowledge to defend or promote an ideology. This abuse of medicine as a source of power and its instrumentalization to eliminate unwanted groups flourished during WWII.68
In general, the medical and military sectors share patterns of structure and discipline: a rigid hierarchy and clear division of labor. Medicine became integral to the military after WWI. The militarization of medicine enhanced the management and structure of the military while increasing the efficiency and discipline of the military personnel. The military offered space and resources for scientists and doctors to advance medical techniques and cures.69 The military has always attracted
62 Najat Abd Al Sama, نﺎطوﻷ الزﻨﺎﻣ The Motherland Houses (Beirut: Baitelmouwaten, 2017),27-31.
63 Sami Moubayed, The Makers of Modern Syria: The Rise and Fall of Syrian Democracy 1918-1958 (London: Bloomsbury Publishing,2018),135. Raymond Hinnebusch, Syria: Revolution from Above,65-66.
64 Joseph Daher, Syria After the Uprisings: The Political Economy of State Resilience (London: Pluto Press, 2019),18-19. 65 Interview with X via WhatsApp, May 18, 2020.
66 You can watch the following video of the conference:
https://www.facebook.com/Damascus.medical.Association/videos/2604818446217680; last checked May 27, 2020.
67 Mark Harrison, “Medicalization of War-Militarization of Medicine,” The Society for Social History of Medicine vol.09 no.02, (August 1996): pp.267–276.
68 Ibid.
69 Melissa Lamer, James Peto, Nadine Kathe Monem, Deutsches Hygiene-Museum Dresden, War and Medicine (Berlin: Black Dog,2008),230. Raymond E. Tobey, “Advances in Medicine During Wars: A Primer,” Center for the Study of America and the
physicians because of the legal and financial protection it provided.70 Medicine and military equally influenced each other through structure, practice, codes of conduct, and were both significantly dominant in peacetime but especially wartime societies.
Militarization is not accidental or temporary in Syria. It began with the establishment of the modern healthcare sector and took on its lethal role during Hafez Assad’s era. Healthcare professionals were encouraged to join the army through persuasion or coercion. The army provided students from impoverished backgrounds with the opportunity to study medicine through a separate admission process. Students benefited from lower grade requirements and grants conditioned with army conscription after graduation, “lend his/her expertise to the army.”Some informants in this study took this path after high school.71 In some cases students seeking educational opportunities chose to complete their residency in military hospitals. Military hospitals were oftentimes more advanced in terms of financial support and medical techniques.72 Students reluctantly chose military hospitals for the opportunity to pursue a certain specialty.73
The Syrian Military Medical Service Directorate that managed human resources, put in place that healthcare professionals, whether they were conscripted, contracted (a hybrid), or recruited, should all pass a security scan and “reputation” profiling. This included a check on their political activities to determine if they had participated in any “activities” against the state before conscripting or working with the military health directorate.74 There should be no doubt of the candidate’s loyalty, which may explain the low number of dissent from professionals in military hospitals.75 Military doctors were deployed to all institutions functioning under the Ministry of Defense, including military hospitals, security forces, or military prisons such as Saydnaya or Tadmour (Palmyra). Since 1984, military doctors were allowed to practice civil medicine and have private clinics.76 They, as part of the military, benefited from legal immunity enshrined in the emergency law No. 14 of 1969, and legislation No. 69 of 2008.77 These acts extended protection of security and military personnel for offensive of law or human rights.
The military and its intelligence agencies extended their authorities to all aspects of Syrian life. Throughout the years, intelligence agencies built a surveillance network in civil and private hospitals and medical facilities.78 These networks consisted of healthcare professionals (mainly nurses), cleaners, guards, and appointed members of the intelligence agency.79 They monitored and reported any suspicious activity of other healthcare professionals and patients. This facilitated an atmosphere of distrust and fear amongst healthcare professionals, creating obstacles for the harmony and collaboration required in medical work. Dr. Khaled Shabib, in his fiction novel, described the enormous influence these networks had on decision-making in medical institutions through manipulation and threat.80
70 Jack E. MoCallum, Military Medicine: From Ancient Times to the 21st Century (California: ABC-CLIO, 2008),155. 71 Interview with Adel via Facebook, May 25, 2020.
72 Interview with Ahmad via Skype, August 27, 2019. interview with Maan via Facebook, August 8, 2018. 73 Interview with Dr. Wahbi via Facebook, May 14 &15, 2020.
74 Ibid.
75 A former General in Military Medical Directorate estimated 3000 doctors (400 of them works in field hospitals) working with military and 70,000 health, civil and military workers with the Military Medical Directorate in 2011. Conversation with Dr. Ali via WhatsApp, June 1, 2020.
76 Mark Harrison, “Medicalization of War-Militarization of Medicine,” The Society for Social History of Medicine vol.09 no.02, (August 1996): pp.267–276.
77“Human Rights in Syria during Bashar al-Asad’s First Ten Years in Power” Human rights watch, July 16, 2010.
78 Hanna Batatu, Syria’s Peasantry, the Descendants of its Lesser Rural Notables and Their Politics,238,240. Volker Perthes, The
Political Economy of Syria Under Asad,169-170. George Allan, Syria: Neither Bread Nor Freedom (London: Zed Books Limited,
2003),144-146.
79 Interview with Ahmad via Skype, August 27, 2019.
The expansion of military control over the healthcare system extended to strategic medical services such as the Blood Transfusion Bank, which made the military medical directorate the sole supplier of blood in the country. It was weaponized from early on in the conflict. Hospitals had to explain the reason behind their requests and some hospitals were deprived of blood supplies,81 while individuals had to donate blood to obtain a blood bag. Running the blood bank had economic advantages for the army, the fees obtained from blood supplies consisted of revenue for the “military effort” (ﻲﺑﺮﺤﻟ ادﻮﮭﺠﻤاﻟ).
3) Sectarianism and Healthcare
Favoritism towards Alawites became a source of resentment in the healthcare sector and a baseline of polarization later in the conflict. The liquid identity of healthcare professionals, on the other hand, was constructed of meta-identities. Besides their medical identity, healthcare professionals as members of the society gained a social identity through interaction with a community or a group. This identity was rooted in an ethnic, national, or religious identity in which healthcare professionals shared “life and fate” with the community.82 Doctors shared beliefs with a group or community, who had influence on them, and vice- versa. Religious beliefs are just another of these component medical professionals shared with a group or community, it impacts their emotions, rational and behavior as individual. But, when politics intervene, religious identity takes a sort of political manifestation. Therefore, the religious identity takes several interpretations within the institutional structure, power, and authority, as well as in the idea of individual health professionals, and cultural perceptions of sectarian identity.83 Political instrumentalization of sectarian identity is not accidental in Syria. Before Ba’ath coup d’état, governments depicted favoritism towards Sunni. The healthcare sector, like the military and public institutions, was dominated by the Arab Sunni bourgeois healthcare professionals from urban centers. Healthcare personnel and facilities were concentrated in the hands of Sunnis from the urban centers of Damascus and Aleppo.84 Financing and expensive fees were obstacles for many of those who sought to pursue medical studies. Hafez Assad was one of the students whose family could not afford to study medicine, although he got a scholarship in Beirut.85
The Ba'ath regime’s healthcare sector also exhibited polarization and favoritism, discrimination framed by sectarian-class features, dominated by Alawites. The ratio of geographic distribution of both healthcare facilities and human resources to the number of populations was greater in the coastal areas than in Damascus or Aleppo.86
81 “رﺎﺼﺤﻟﻠة دﯾﺎﺰ ﻟﺰﺎﺑﺨﻤاﻟوﻲﺎﻓﺸﻤﻟ اقﻼﻏإ Shut Down Hospitals and Bakery Increased the Severity of Siege,” Enab Baladi vol.26, July 29, 2012,
https://enabbaladi.net/archives/2696
“Health crisis: Syrian government targets the wounded and health workers” Amnesty International, October 25, 2011. 82Zygmunt Bauman, Identity: Conversations with Benedetto Vecchi (Cambridge: Polity Press, 2004),11,12,13,15,18-22. 83 Fanar Haddad, Understand Sectarianism: Sunni–Shi’a Relations in the Modern Arab World (London: Hurst, 2020),20-27. Claire Mitchell, Religion, Identity and Politics In Northern Ireland: Boundaries of Belonging and Belief (Burlington: Ashgate Publishing Company, 2006),16-17.
84 Hanna Batatu, Syria’s Peasantry, the Descendants of its Lesser Rural Notables and Their Politics,66-67. Drysdale, Alasdair. “The Regional Equalization of Health Care and Education in Syria since the Ba'thi Revolution,” Middle Eastern Studies vol.13, no.1(February 1981): pp.93-111. Hicham Bou Nassif, “Turbulent from the Start: Revisiting Military Politics in Pre-Baʿth Syria,”
International Journal of Middle East Studies vol.52, no.2 (May 2020): pp.1-20.
85 Patrick Seale, Maureen McConville, Assad of Syria: The Struggle for the Middle East (Berkeley: University of California Press, 1989),38.
86 Hanna Batatu, Syria’s Peasantry, the Descendants of its Lesser Rural Notables and Their Politics,66-67. William Harris,
Quicksilver War: Syria, Iraq and The Spiral of Conflict (New York: Oxford University Press, 2018),19. According to Syrian Center
of Statistic, the number of doctors registered in the Medical Association between 2006-2011 in Damascus is 5130 (a doctor to 340), while in Latakia is 1891 (a doctors to 528), and in Tartous is 4253 (a doctor to 186), Source: http://cbssyr.sy/yearbook/2012/Data-Chapter12/TAB-2-12-2012.pdf.
Additional layers and sources of discrimination included how scholarships or grants were distributed, the employment opportunities made available, and who decision-making positions were given to. For example, all key positions during the time of writing were held by Alawite doctors: Ammar Sulieman (the chief Military Medical Directorate), Ali Al-Hasan (Tishren hospital director), Ali Assi (601 director), Nawal Ibrahim (Blood Bank), Ibrahim Daher (Abd Al Kader Shaqfi Homs Military Hospital), Samer Kheder (Al-Mujtahed), and Adeeb Mahmoud (director of the Syrian Scientific Networks and the husband of Dr. Hala Bilal the chief of Wounded Programs in the Military Medical Directorate).
The sectarian identity of Alawite doctors took implicit socio-economic and communal features. It illustrated loyalty to the state and its institutions, specifically the military. These institutions offered them the opportunity to climb up the social ladder. Such discourse, to a large degree, was aligned with the secular façade of the regime.87 The second feature appeared more in the context of membership of the community and the duty to protect “Alawite.” The religious configuration clarifies itself in the ideas and thoughts of the “others” as mainly a religious threat to the “community.” From the perspective of victims, the sectarian identity and hatred was more conspicuous. It presented itself in the use of insulting phrases to the Islamic culture or a victim’s social status.88 This helped to clarify the self-esteem of healthcare professionals and its interplay with scarcity and shame, “I am from a poor family.
The assumption that the actions of some doctors were motivated by religious biases must be put in its historical, cultural, and local contexts. The memory of oppression and discrimination during the war emphasized the image of the “other” as a threat.89 However, we cannot assume conformity between Alawite doctors and the regime, in that they are destined to reproduce existing social relations of authority and inequality, and that then explains their capacity to perpetrate.90 The personality traits and agency of healthcare professionals were essential factors in determining their participation, despite religion, in violence. There were signs indicating cases of disobedience or avoidance. Few of the Alawite informants refused to be involved with state violence.91 Some Alawite doctors treated injured demonstrators or victims, and some victims sought their expertise.92 Overall, the perpetrators were from the entire spectrum of Syrian society, and healthcare professionals with Ismaili, Sunni, and Shia backgrounds were also accomplices in medical violence.93
3. Syrian War Medicine
3.1 Polarization, Criminalization, and Violence
87 Mahmud A. Faksh, “The Alawi Community of Syria: A New Dominant Political Force,” Middle Eastern Studies vol.20, no.2 (April 1984): pp.133-153. Hicham Bou Nassif, “Second-Class’: The Grievances of Sunni Officers in the Syrian Armed Forces,”
Journal of Strategic Studies vol.35, no.5 (August 2015): pp.626-649.
88 Interview with Qutaiba via Skype, May 26, 2020. Interview with Ismael via Skype, May 29, 2020. Interview with Mohammad in Amsterdam, August 29, 2019.
89 Leon Goldsmith, “Syria’s Alawis: Structure, Perception and Agency in the Syrian Security Dilemma,” in The Syrian Uprising:
Domestic Origins and Early Trajectory, eds. Raymond Hinnebusch, Omar Imady (Routledge; Taylor & Francis Group,
2018),144-147.
90 Guy Elcheroth, Stephen Reicher, Identity, Violence and Power: Mobilizing Hatred, Demobilizing Dissent (London: Palgrave Macmillan,2019),57.
91 Interview with Hasan via Facebook, May 18, 2020. Interview with Milad via Facebook, May 22, 2020.
92 Interview with Saed via Skype, October 11, 2019. Nir Rosen, “Assad's Alawites: The guardians of the throne Syria's Alawite community have a history of persecution but dominate the ruling family's security forces,” Al Jazeera Net, October 10, 2011,
https://www.aljazeera.com/indepth/features/2011/10/20111010122434671982.html.
93Interview with Haetham via Facebook, August 17, 2019. Interview with Abdullha via Facebook, May 12, 2020. Interview with Dr. Wahbi via Facebook, May 16, 2020.
