The Syria Trials/
S1E3: The Doctors Who Resisted


While many doctors and medical staff sided with the Syrian regime after the protests began in Syria in 2011, there were, of course, many doctors, nurses and medical students who sided with the protestors calling for freedom and democracy. Field medical teams to help injured protestors, and later field medical hospitals and checkpoints to care for those wounded in the escalating war, were set up - only to become targets of the regime’s increasingly more violent tactics. We hear from physician Houssam al-Nahhas, who worked in hospitals in rebel-held East Aleppo, and from lawyer Steve Kostas and barrister Toby Cadman, about the case building efforts to hold the perpetrators of attacks on hospitals accountable.   

Please take care when listening - this episode talks about violence and war.

The Syria Trials is a 75 Podcast production. This episode is hosted by Fritz Streiff, and produced by Sasha Edye-Lindner, with editorial support from Mais Katt. It was mixed by Tobias Withers.

Support for our podcast comes from German Federal Foreign Office funds that are provided by the Institut für Auslandsbeziehungen IFA’s Zivik Funding Programme.

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Episode Transcript

Houssam al-Nahhas: So I was born and raised in Damascus, the Syrian capital. And that was in 1988. I've always wanted to be a physician. And that's how when I got the opportunity to study medicine, I moved to Aleppo. And that was in 2006, where I enrolled in the medical programme at Aleppo university. 


Fritz Streiff: ThisHoussam al-Nahhas, a physician from Syria. 


Houssam: When I grew up in Syria, I was raised by my family on fear. So they had clear instructions for us, to stay away from any political conversations or religious conversations. People who get involved in political activities might be detained, tortured or even disappear. 


Fritz: Houssam was in the final year of medical school in Aleppo when the revolution started in Syria, in the spring of 2011. 


Houssam: I never thought that Syrian people would dare to think about democracy or protest against the government calling for freedom. And I witnessed the amount of violence that were committed by security forces. This is when I decided that I cannot stay on the side anymore. I need to step in. I should from a humanitarian perspective, I should step in and help people. 


Fritz: Houssam’s decision to get involved in the Revolution put him, like all of the other demonstrators, at great risk of being targeted by the Syrian authorities. As a medical student, he was perhaps even more at risk. Like we heard in Episode 2, the Syrian regime used its medical sector, its doctors and hospitals to target, oppress and kill those protesting for democracy and freedom. 

Many doctors were complicit in this violence, but not all of them. So what was the fate of these other doctors? What happened to the doctors and medical students like Houssam who wanted to help the protesters? What happened to the doctors who resisted?

This episode is about those doctors. Welcome to The Syria Trials. Episode 3. The Doctors Who Resisted. 

On the other side of the world, in late spring of 2011, so very early after the Syrian regime started violently suppressing the revolution, English barrister Toby Cadman was in Washington, D.C. He was lobbying for international support to establish a war crimes tribunal, for the 1971 War of Liberation in Bangladesh. After hearing him speak, Toby was approached by two Syrians, who told him about a case they were filing in the federal court in Washington. All five plaintiffs - so a plaintiff being someone who brings a case against someone else - all five involved in this case had lost family members, after the Syrian regime had suppressed the revolution with violence and weapons. 


Toby Cadman: The one that I remember the most was a Syrian doctor who had been living in the United States for best part two years. His brother, who was also a doctor, had remained in Syria and his brother had come to visit him in early 2011. They attended some medical conference in Florida. Then when he returned to Syria, there was this movement by doctors in Damascus to sign a petition that they would help anyone who was affected by the conflict. And he signed onto this petition. He was then subsequently arrested, tortured and executed. Because they were convinced that he had spoken to the US government. And so that case sort of stuck with me. But what I was asked to do by this group was to review this legal filing. It was a strong case, but there was no real supporting or corroborating evidence. And so I said, Look, I'll go down to Turkey. I spent about a week on the border. I interviewed, I think, about 25 torture survivors, all coming with the most horrific stories I'd ever heard. And I'd been involved in war crimes prosecutions in Bosnia, in Bangladesh, in Iraq, different places. So it wasn't something that I had not heard before. It's just the sheer brutality of what I was hearing was and I hate to say it, unique. 


Fritz: Back in Aleppo, Houssam was asking around his university looking for volunteering opportunities, where he could use his skills to help injured protesters. He eventually joined the Light of Life medical team Noor Alhayat in Arabic. 


Houssam: We heard many reports of people being detained or even tortured in the hospitals because of their participation in these protests. So that's why people did not consider going to hospitals after getting injured safe. So that's why these field medical teams were established. I volunteered in a medical team and on June of 2012, three of the team members were detained for a few weeks and then were released, but they were dead. So the Syrian government under detention, they tortured them and then burned their bodies. 


Fritz: In the first year of the Syrian revolution, the NGO Physicians for Human Rights documented 56 cases of medical workers being targeted, tortured or murdered. Then in July 2012, the Syrian regime enacted a new terrorism law. This law made it a crime for civilians to fail to report anti-regime activity. According to the United Nations, this “effectively criminalised medical aid to the opposition”. 


Houssam: A few weeks after, and that was early August 2012, myself and my friend were in a governmental side of Aleppo city when security guards approached the car, searched me, searched my friend and the car as well. And then they found my student ID as a medical student. And they also found a list of medical equipment on a notebook. These were supplies that we needed, and that was for them the indicator that we were participating in providing healthcare to those who were against the government. They decided to detain us. And they took me and my friend to the Military Intelligence Branch in Aleppo city, where I stayed for 16 days. 


Fritz: Houssam was in a cell full of political prisoners, demonstrators and anyone who had been even suspected of anti-regime activity. 


Houssam: A person who was beaten very hard on his head and he had an internal bleeding in his head. And the officer in the prison brought me to see him. And I told the officer, if you don't get him to the hospital, he will die. And he just kicked him and said, Yeah, go to hell then. And this person died a few days after. When I was under detention, I realised that it's now the main goal for the government to end this movement and to suppress people no matter what it takes.


Fritz: After being released, Houssam went back to his hometown, Damascus, to spend a few months with his family. At the end of 2012, Houssam returned to Aleppo. 

Houssam moved into the Al-Zarzour Hospital in East Aleppo. East Aleppo was now a non-governmental zone controlled by the opposition force, the Free Syrian Army. Houssam worked, ate and slept at the hospital. Although still not a fully qualified doctor, Houssam was working as an emergency room physician and surgeon's assistant. 


Houssam: In terms of how the daily work looked like, it mainly depended on the government's strategy and the intensity of the attacks on the city. 


Fritz: By this point in 2012, as areas of Syria slipped out of their control, the Syrian regime had stepped up violent attacks on opposition held areas like East Aleppo. The first barrel bombs, which are particularly horrible, indiscriminate weapons - oil barrels packed with explosives, metal and shrapnel - were dropped on parts of Aleppo in September 2012. 


Houssam: People who get injured after being targeted by a barrel bomb or an airstrike. Kids who get injured when their school is targeted. Some days we did not treat any patients and others we responded to mass casualty events, with more than 50 or 70 victims arriving to the emergency department at the same time. And you can imagine the amount of stress on the medical teams to provide healthcare to those in need, do some hard decisions and block care on some hopeless cases, to preserve our resources for others who might have a better chance to stay alive.

It was a huge shift for someone like me who get easily afraid from seeing blood or bad injuries. It was quite challenging. But after a period of time, I used to it first and second, and most importantly, it was vital for people in the city back then knowing that they can find healthcare when they need it.

It was, of course, challenging, knowing that the Syrian government was constantly and deliberately targeting healthcare facilities and hospitals. So whenever we hear an aircraft, we rush to the emergency department, we try to hide in case the hospital got targeted. 


Fritz: Under the international laws of armed conflict, it is illegal to attack civilian hospitals. Medical units, medical personnel and the wounded or sick are all specifically protected under these laws. The global standard for humanitarian conduct in war is defined by international humanitarian law. Amongst which are the Geneva Conventions of 1949. These have been signed by every nation on Earth. It is illegal to attack healthcare providers and to interfere and complicate their ability to work safely.

But from early on in the war, the Syrian regime's methods demonstrated a total disregard for these laws and the norms of conducting warfare.

It may seem strange that there even is such a thing as humanitarian conduct in war, but these laws mainly aim to protect civilians. Those who are not fighting, but who are tragically caught up in conflict zones. They're there really to prevent total and utter barbarity. And so Houssam and his colleagues should have been able to carry out their very intense and stressful work in a relatively safe place. Instead, they were working under the constant threat of being shelled. 

Okay, so I'm in London, going to see Steve to talk about his Syria work. Steve Kostas is senior legal officer at the Open Society Justice Initiative, where I worked as well for a number of years and we worked together on some of the Syria stuff. So lots, lots to talk about. 

What can you tell us about the hospital attacks category of crimes that has occurred in Syria? 


Steve Kostas: The estimates of the number of hospital attacks is really high. So Physicians for Human Rights in one publication documented more than 600 hospital attacks, and the number is surely much higher than that. Those are the ones that they could confirm through multiple sources. So in the Syrian context, there are formal hospitals, there are medical checkpoints that are established. There are even more informal sort of medical care points. All of those are protected under international law, and we've seen systematic and large-scale attacks on those hospitals. The attacks vary from airstrikes using missiles to barrel bombs, which is a frequent weapon used against hospitals. In early usage, they were sort of like oil barrels that were stuffed full of explosives and shrapnel, and then rolled out of the back of a helicopter, inflicting massive damage. We've seen ground-based sort of mortar shelling, cluster munition attacks. 


Houssam: Usually you see an indicator that the hospital will be attacked by seeing a helicopter above the hospital or an aircraft. You hear the aircraft sound flying in the sky and you keep wondering whether you will be targeted or not. And then at one point you hear this rocket or the barrel bomb falling from the sky with a very distinguishable sound that it has. And then as you hear it coming closer, you just keep wondering whether you will be the target.

In one event, when I was in the hospital, we were eating our breakfast when a missile hit the other side of the street where the hospital is located. The entire floor, doors and windows cracked and the entire floor was full of dust. The explosion was remarkable. It was very strong. We all were trying to rush downstairs to avoid being killed. And as we were heading down, we started hearing people arriving to the hospital from the building that was directly hit by the missile. And we just had to operate on them and provide them with lifesaving services. Ignoring or forgetting why in the first place we were rushing down to protect ourselves. It's just a lot of conflicting feelings. 

Back then on a personal level, I was engaged to my wife. Each one of us was in a different room and we would rush to each other's rooms when we hear an aircraft. Knowing that if if the hospital got targeted, at least we either die together or we live together. 


Fritz: From 2015 onwards, the Syrian regime wasn't alone in bombing hospitals. At the end of September 2015, Russia's parliament approved President Vladimir Putin's request to launch airstrikes in Syria. This was a major turning point for the war in Syria, providing strong support to the Assad regime and helping to turn the tide of war in their favour. 

Barrister Toby Cadman. 


Toby: One of the things that has always stuck with me and that was the targeting of hospitals, medical workers and frontline responders, from the first experience I had with the doctor who lost his brother. And you have to ask the question, why would you target hospitals? The immediate response was, well, it's not a hospital it’s being used to house Islamic fundamentalists, Islamic State fighters. 


Fritz: Making it a military target in their view? 


Toby: In their view, yeah. 


Fritz: This is an excuse the Syrian regime has used consistently that they were targeting civilian infrastructure like hospitals in opposition areas, because extremist terrorist groups were living there. They also argued that these groups were using these facilities and the civilians in and around them as human shields. 


Steve: You can lawfully carry out an attack that's targeted at a military objective, but have an incidental effect on civilians. So you could kill a civilian as long as you're not targeting them. And if it's proportionate to the military objective, so it's this principle of proportionality, then it could be lawful. So that means that in the case of like an attack on a hospital, there are a few conditions in which an attack on a hospital could be lawful. And there are also conditions where it might not be an attack targeting the hospital, but it has an incidental impact on the hospital, that it could be lawful. 


Fritz: But from anecdotal evidence, eyewitness testimonies, photos, videos and investigations by organisations from Physicians for Human Rights to the New York Times, it is clear that a huge number, if not the majority, of attacks on hospitals were deliberate. They show clear indicators of being intentionally targeted. Unfortunately, in legal terms, responsibility for attacks like these where crimes are committed during the course of carrying out a military attack, is very hard to prove. These crimes are called conduct of hostility crimes. Even if the evidence seems staggeringly obvious on the ground, the command hierarchy and ultimate liability is often difficult to show. 


Toby: The reason why you would target hospitals, schools, markets, as we've seen, is because you want to force the civilian population out of those areas. And one of the more brutal - they're all brutal - but one of the more brutal members of the Syrian regime, Jamil Hassan, he had made this comment that he would rather have 1 million kneeling in front of him than 10 million opposing him. So that's what they want, it’s to kneel and serve. So those that will not kneel and serve, you need to move them out. And you do that in the most brutal way by targeting the civilian infrastructure, by bombing hospitals, by bombing schools. 


Fritz: Toby have been trying to find a way to bring a case to the International Criminal Court, the ICC, against the perpetrators of hospital attacks. Which is quite an impossible task when you consider the Russian and Chinese vetoes at the United Nations Security Council, that have blocked the ICC, being able to really start investigating the crimes committed in Syria. And not to mention that Syria is not a member state of the ICC. But then Toby and his colleagues thought of something. What if the hospital attacks could be linked to the forced deportation of Syrians? After years of these attacks and with no infrastructure left in some parts of Syria, many Syrians had no choice but to leave the country altogether. This could be seen as forced deportation. The idea came about after Toby's chambers, a group called Guernica 37, filed a legal brief to the ICC in 2018 regarding the situation in Myanmar. 


Toby: So in Myanmar you have half a million Rohingya who were forced out of Myanmar into neighbouring Bangladesh. Myanmar is responsible for that. But of course, Myanmar is not a member of the International Criminal Court - but neighbouring Bangladesh is. And the argument being that forcible deportation is a crime which occurs on the territory of two states and only one of them has to be a member of the ICC. 


Fritz: In the series of Syria communications they then filed with the ICC, Toby and his team argued that if the court has jurisdiction for Myanmar, then it also has jurisdiction for Syria. 


Toby: At that point, there were at least one and a half million documented Syrians who had been forced out of Syria into neighbouring Jordan. We are now in the process of finalising a fourth communication which will go to the new prosecutor, Karim Kahn, on the basis that the targeting of hospitals in particular, was a significant contributing factor in the forcible deportation. The Syrians were not leaving of their own volition. They were not going into Jordan for a better life. They were going to Jordan to stay alive. 


Houssam: So I think the Syrian government was strategically targeting healthcare facilities and healthcare providers to show the Syrian people and the international community that there is no red line in this war. The other one, of course, is what we witnessed in Aleppo when I was working. This is to break people's resilience in areas that are not under the government control. Knowing that the hospital is no longer there, the hospital is a constant target, your doctor is dead, this will not give you some basic sense of safety. You cannot stay in a place where there is no doctor. 


Fritz: But the regime underestimated the power of people like Hossam. And what fighting for an actually worthy cause can give people. 


Houssam: I think I went out of the presence stronger than the way I entered it. When you see these crimes and you see how you are perceived as an enemy. It actually motivates you to give more. I felt that now I have an obligation to support my people in their call for freedom and democracy and also to fulfil my ethical obligations as a healthcare provider. 


Fritz: Houssam finished his medical education in Turkey in 2018, before moving to the United States, where he now works for Physicians for Human Rights. 


Houssam: Honestly, on a personal level, at one point I felt that I start to experience the burnout because of this work and the constant witnessing of these injuries. And even now, after ten years, if you ask me if I'm willing to get back to clinical practice, my short answer would be no. I don't think I'm yet ready to see patients. 


Steve: We've been working with a large coalition of Syrian and international NGOs to build criminal cases concerning these attacks. And we've focussed in significant part on describing the use of barrel bombs in attacks on hospitals and also in some of the attacks that we think really demonstrate sort of specific targeting. We haven't filed those complaints yet, and so the work is still very much under progress. I can't be as definitive about what work will show. 


Fritz: Is there anything you can say about where and under what kind of legal instrument those cases may be filed? 


Steve: With all of these sort of criminal cases, there are a few options. One is what we might call a strict universal jurisdiction case, where you file in, let's say, Germany or Sweden, and there's no perpetrator in Germany or Sweden, the victims aren't German or Swedish, and the crimes obviously were not committed in Germany or Sweden. So Germany and Sweden don't have a connection to the crime, but they can still investigate. 


Fritz: So these are the technical legal bits of how cases are actually filed. The first, as Steve just explained, is universal jurisdiction, which is how the Koblenz trial and the Alaa M trial came about. 


Steve: The other is if you had a victim who was a national of a country. If they were a national of the country at the time of the crime, then that country often has jurisdiction to investigate. And we could look for perpetrators who are available for arrest and prosecution. And wherever they're found, the country would have jurisdiction over them. 


Fritz: There are a number of cases based on this principle of nationality currently happening in the Syria space. For example, another of Toby Cadman’s cases. Toby is leading an investigation into the abduction, torture and murder of Dr Abbas Khan, a British national, by the military intelligence of the Syrian Arab Republic. So the UK authorities have jurisdiction because the victim here is a British national. Legal efforts are being made. But justice means different things to different people. And in some cases, international justice is just bound to fall short. 


Houssam: I don't think anything would bring those who I lost to life. The three volunteering students who were burned and killed and tortured to death won't be brought to life again, no matter what justice and accountability process we went through. The sadness, the sorrow will always be there. For me, it might be satisfying again to see that those who were involved in the entire chain of command, starting from Bashar al-Assad and anyone who was responsible for giving instructions for others to kill and attack people, to be held accountable for what they did and what they are continuing to do. Rather than that, I don't think there's anything that can fulfil justice to all Syrians as we would hope.


Steve: Whoever you want to hold accountable that isn't the direct perpetrator, you have to show how they're connected to the crime, how they're responsible. And one way would be to show that they ordered it. Another way would be…


Fritz: Which is hard.


Steve: …which is hard because you often would need direct evidence of the order. That means, like, you'd have to have the order itself. You can prove things by circumstantial evidence as long as no other reasonable conclusion is available. For example, if the attacks are systematic in nature, then you can understand from that that there is a command structure behind the attacks. 


Fritz: The systematic attacks on hospitals and healthcare sent a clear message to Syrians and the world - the Syrian regime was not going to adhere to even the most basic rules of war. And the regime did not only systematically target medical workers and bomb hospitals, which, as Steve has told us, could be lawful in some very particular cases. It went even further and used a weapon that is outright illegal, no questions asked. 


Steve: Chemical weapons are distinct. So chemical weapons are never allowed. So there are no circumstances in which the use of a chemical weapon would be lawful. And the use of chemical weapons is certainly a systematic attack in the Syrian context.


Fritz: Chemical weapons are insidious. The poisonous gases contained within the missiles can spread over a large area, inflicting huge damage to unknowing civilians, who haven't heard the missile explode, because they don't, and who can't see or smell the invisible, odourless gases coming. As there's absolutely no excuse the Syrian regime could provide to justify using chemical weapons, and especially against its own civilians, they have repeatedly denied using these weapons, but numerous attacks have been documented, and investigations into the Syrian Scientific Studies and Research Centre have uncovered secretive and highly illegal programmes - like the manufacture of chemical weapons. 

Next time, in Episode Four of The Syria Trials, we look at what is perhaps the biggest red line the Syrian regime crossed in the course of the war, its use of chemical weapons. I am Fritz Streiff. Thank you for listening.