When you think of dictatorial regimes, you might think of state-controlled media, or of the army on the side of the state- but what about the healthcare sector? Do they side with the regime? And what does that even look like?
Since the uprising in Syria began, regime-aligned doctors have played a powerful role within Assad's torture apparatus. In this episode, we're taking a first look at the darker side of medicine within the context of war-torn Syria.
Article of Annsar Shahhoud in the Journal Of Genocide Research.
Annsar Shahhoud’s Master’s Thesis.
Follow Uğur Ümit Üngör on Twitter.
Research project of Ugur with a.o. Annsar on mass violence in Iraq and Syria.
2014 report of the independent international commission of inquiry on Syria.
2015 Human Rights Watch report on mass deaths and torture in Syria’s detention facilities.
Physicians For Human Rights on targeting of medical personnel in Syria.
2012 Guardian article on medical violence in Homs.
Article by Hannah on medical violence and the Al-Khatib trial.
SJAC update on the indictment of Alaa M.
Our episode on sexual violence, They Pay Twice.
Syria Justice and Accountability Centre's monitoring of the trial
Special thanks to Saleem Salameh for providing this episode's voice over.
Logo design by laurenshebly.nl -- Photo by James Lawler Duggan/AFP/Getty Images.
Music via Blue Dot Sessions
Support for our podcast comes from German Federal Foreign Office funds that are provided by the Institut für Auslandsbeziehungen IFA's zivik Funding Programme.
Pauline Peek: A listener's note. This episode deals with the topic of torture. While we've made a conscious effort to leave out any graphic descriptions of torture, we still want to point out that this episode might not be suitable for everyone. Please take care when listening.
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Naya Skaf: During the proceedings in Koblenz, the judges have been consistently asking witnesses about medical care in the Al-Khatib branch.
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Naya: A picture has a reason of neglect bordering on abuse. One witness testimony actually came from a doctor who was tasked with looking after detainees' health in Branch 251. He testified to the conditions of the detainees, both dead and alive.
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Noor Hamadeh: There's something seemingly paradoxical about the presence of doctors in a place that's designed to harm people. A man who worked for seven years as a guard at the Al-Khatib branch said he had to ask the head of the branch several times to get even one single painkiller for a prisoner.
Naya: Why are doctors even there, then? What are they doing in detention centers? How did we get here? What kind of doctor intentionally neglects, or hurts people?
Noor: On today's episode, we're taking a first look at a huge and complex topic, Medical Violence in Syria.
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Noor: Medical violence is silent, intimate, and secretive violence. Silent, because often it's a crime of omission, of neglect. Intimate, because the perpetrator knows you in a deeply personal and sensitive way. Secretive, because the traces are hidden, the evidence destroyed, the damage whitewashed, filed away as natural and inevitable.
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Noor: Syria's healthcare system has a long history of instrumentalization for political purposes. From the 1960s onward, with the Ba'ath Party in power, this was no different. At the time, marginalized areas were typically neglected, peripheral places such as Idlib, Daraa, and the countryside, most of Syria really had little to no medical services. Urban centers such as Damascus, on the other hand, had a high concentration of modern healthcare facilities.
The Ba'ath Party sought to change this and directed resources toward facilities and medical services in peripheral and rural areas. Clinics and hospitals sprung up where there hadn't been any before. Crucially, they brought Ba'athist healthcare professionals into these areas.
Naya: The Ba'ath Party's ambitious plan to reduce inequality was not necessarily bad. Tackling inequality also was not necessarily the goal. It was more a means to an end, political manipulation to gain popularity. The consequences intended or not, were disastrous. The party essentially politicized an entire sector, which is supposed to strive to be apolitical. Instead, boundaries were drawn along ideological and sectarian lines. Consequently, discrimination against and polarization of non-Ba'athist medical professionals ran rampant within the healthcare sector.
Noor: Now, we want to take a moment here to acknowledge that not a single health care system in the world operates in a vacuum. Bias and politics influence doctors worldwide. However, the instrumentalization, the politicization, and subsequent militarization of Syria's healthcare sector deserves our special attention. To this day, it plays an important role in Assad's deadly regime.
Naya: In 1964, the Ba'ath Party waived the medical school tuition. Studying medicine would be free of charge. When the time came for those students turned doctors to treat people who demonstrated against the regime, they were branded, traitors. The intelligence services of the regime arrested nurses and doctors and interrogated them. People who were doing what they were trained to do, had to hear that they were ungrateful and disloyal to a state that educated them and provided them with the opportunity. Nothing is free.
Noor: Under Hafez al-Assad's rule, efforts to manipulate the healthcare sector became more brazen. Medical students use the Ba'ath Party salute to swear their oath of medical ethics. When applying for a job in health care, party membership was more important than professional qualifications. Practicing doctors that we're loyal to the regime would receive more government funding, grants, scholarships, government positions. Whatever one's career ambitions in the medical field were, if they weren't accompanied by fierce party loyalty, you could forget about them.
Naya: This is not just a story about politicization, it's also one of militarization. Militarization occurs when a regime increases the presence of the military in country's health care sector. In Syria, militarization was meticulously and patiently executed. Medical professionals and aspiring medical students were persuaded, if not coerced, to make a career within the military. Not before making sure military doctors were then deployed not to just military hospitals, but also military prisons and security branches, such as Branch 251. What we see today is a striking amount of army and security officials that are also doctors. Let's not forget here that the Syrian president himself was a doctor, a trained ophthalmologist.
Noor: Over time, the military and its sprawling intelligence agencies built an elaborate surveillance system that extended to all aspects of Syrian life. The healthcare sector was no exception. Within hospitals, ideological fault lines were reproduced. In the 1980s, the regime ramped up the marginalization of dissenting voices in the medical sector. Doctors, nurses, cleaners, and guards reported to intelligence services about their colleagues' suspicious activities.
Naya: Suspicious activities included disobedience, criticism of the government, affiliation with an opposition party, and refusal to participate in an election. Any and all of these supposed offenses could get a doctor or a nurse in trouble. By 2011, when the uprising began, the Syrian health care sector was largely run by regime loyalists. It was deeply intertwined with the military, and the security apparatus was ever-present.
In short, the healthcare sector was perfectly positioned to take on its deadly role. It wasn't just a breeding ground for perpetrators, of course, some doctors did everything they could to adhere to their ethical standards. Unfortunately, standing their ground was becoming more dangerous within the walls of increasingly politicized and militarized hospitals.
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Naya: In July 2012, with uprising in full swing, things reach a new boiling point. Bashar al-Assad introduced a sweeping anti-terrorism law. In regime-controlled areas, treating protesters was now considered an act of terrorism. Treating civilians in opposition-held areas was labeled terrorism as well.
Noor: According to the NGO Physicians for Human Rights, at least 930 medical professionals were killed between 2011 and 2021, with the first four years being particularly deadly. Hospitals where they worked faced targeted airstrikes, for example, or because they were detained and executed, or tortured to death.
Naya: The anti-terrorism law and intense violence forced many doctors to make an impossible choice, stay and risk your own life, or quit and leave countless people at the mercy of Assad's bloody regime.
Noor: Some estimates suggest that roughly 10% to 15% of healthcare workers including medical students rejected the regime. They left their jobs or their studies, but they didn't leave Syria. They went underground to help build a parallel network of health facilities to treat injured demonstrators. About half of Syria's medical professionals fled the country. The rest stayed either in silence or in support of the regime.
Naya: Let there be no mistake, plenty of medical professionals in Syria are victims of the regime. Doctors, nurses, and paramedics that continue to work despite relentless aerial attacks did and still do essential work, but they are fighting an uphill battle. Here is a 2012 quote from a highly trained surgeon in Homs called Abu Hamzeh that was featured in The Guardian article.
Abu Hamzeh: One day I treated a patient in the emergency room. The next day, he was sent to the CT room for a brain trauma he didn't have the previous day. That's how I discovered that they did things to him at night. After two days, the patient died from his brain trauma. He would not have died from the injuries I treated the first day.
Naya: Stories like Abu Hamzeh's deserve their own space. In this episode, however, we'll be focusing on the "bad doctors". The ones that weaponized their skills and expertise. Doctors that instead of doing no harm, did.
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Naya: The shape that this harm take on varies widely. Regime-aligned doctors could be working in the context of civilian hospitals, clinics, prisons, detention centers, military hospitals, or intelligence branches. They might be, reluctantly or wholeheartedly, anti-opposition. They might be deeply and actively involved in interrogation and torture. They might be tasked with actually treating people, or they might not really do much of anything at all.
Noor: Before we get into it more, let's talk for a bit about what medical violence is. Medical violence is a category of violence that involves systematic use of medical professional skills. Much like with, for example, the category of domestic violence, the definition says less about the specific type of damage that's being inflicted or the methods used, and more about the context of the violence and the dynamic between the perpetrator and the victim.
Naya: It's not just limited to straightforward perpetration either. Facilitating, supervising, and legitimizing, can all fall under medical violence.
Noor: For example, there are cases of doctors writing up false medical reports about detainees that died. The doctor's failure to investigate the real cause of death and instead come up with a natural cause of death is considered medical violence.
Naya: Medical violence, in general, is a unique category of violence because it revolves around the medical professionals' identity and actions. It's a process more than an act. It can be enabled by a political decision, then lead perpetrators down a path of torture and killing. Each step of this path is shaped by medical knowledge and skills.
Noor: Since medical violence is such a broad term, and because it is such a widespread practice in Syria, we have to narrow our scope a bit. For now, we'll focus on the role of medical professionals in prisons and intelligence branches like Branch 251.
Naya: Before the uprising in 2011, the role of doctors in prisons was limited. Typically, it was their job to monitor detainees and only intervene to keep them alive and conscious during their interrogation and torture.
Noor: In fact, many times it's what doctors don't do that can be just as deadly as what they do. For example, depriving a hurt or sick detainee of care means that the smallest injury could be fatal.
Naya: Since it's standard procedure to collect information on the detainee's health, prison doctors usually have an idea of the preexisting conditions of the prisoners. It's valuable knowledge that can be easily exploited. For example, a prisoner could have asthma. The doctor knows full well that this person requires certain living conditions as well as treatment. Just by understanding this, he can hand the people in charge of interrogation an invisible weapon, perfectly tailored to this specific prisoner. Because, why go through the trouble of beating someone if you can trigger the same amount of stress by simply denying them care?
Noor: Practices like these are intentional. They are systematic and they're an efficient regime tool. While neglect is still the most common form of medical violence in intelligent branches, since 2011, it seems that doctors have taken on a more active role as well. We should bear in mind, however, that every branch is different. In some branches, doctors provide a bare minimum of care, whereas, in other branches, doctors actively participate in torture. In some branches, there are no doctors at all. The following quote belongs to a former detainee. Upon arrival, he was examined by a doctor.
Detainee: They blindfolded me and stripped me of clothing. Then, they called the doctor. The doctor did not talk to me. He touched my limbs, chest, then pressed my stomach. Then, he said, "He has strong muscles. Start with three."
Naya: Three is a number that corresponds to a level of intensity on a sliding scale. It was the level of torture the doctor thought would be appropriate for this detainee.
Noor: There are reports of doctors actually performing torture on prisoners, as well. Survivors of Syrian detention centers and hospitals have told shocking stories of doctors torturing and killing other inmates. Broadly speaking, we've learned that doctors in prisons and intelligence branches consciously created circumstances that increased the likelihood of death. So many detainees suffered and died in detention centers, and not despite the presence of doctors, but rather because.
Naya: For perpetrators in Syria, these tactics of medical neglect and violence were not just cheap, they were also an effective form of psychological torture. In our episode on sexual violence, They Pay Twice, we already discussed how psychological and emotional stress can effectively break a person with minimal effort on the part of their perpetrators.
Noor: This is a dynamic that we see in the context of medical violence in Syria, as well. The relationship between a patient and a doctor, or a patient and a nurse, is unique in how intimate it is. There's this other person who knows a lot about you, personal intimate facts. They're supposed to be someone you can trust, someone who cares for you and cares about you, someone who once sworn an oath to treat the ill to the best of one's ability. It begs the question, how do people who are supposed to be healers, end up doing so much damage?
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Naya: For this, we spoke to Uğur Ümit Üngör. He is a professor of Holocaust and Genocide Studies at the University of Amsterdam and the Institute for War, Holocaust, and Genocide Studies in Amsterdam. He's also the author of the book Syrian Gulag: Assad’s Prisons, 1970 to 2020, which is scheduled to be published in March 2022, in which he discusses the immense power doctors have in the context of Syria's prison system.
Uğur Ümit Üngör: First and foremost, as an authoritarian government, the Assad regime has ambitions to overtake large parts of its professional workforce. That includes not only doctors, but also journalists, or peasants, or lawyers. These particular professional sectors in society, the regime has ambitions to draw them into its own orbit by politicizing them. By having these types of groups be loyal, first and foremost, to the regime rather than to their own profession. One other important factor in the mobilization of Syrian doctors or in the commission of very serious crimes against humanity is the particular class and sectarian structures of Syria.
We had, starting from the 1970s and the 1980s, the gradual rise of Alawite doctors in the system and the graduate almost takeover of the medical profession in Syria by military doctors on Alawite background mostly, very loyal to the regime. In the eyes of these particular doctors, the profession should not be ceded to the bulk of the Syrian population but should be controlled by them. This particular mentality also has led them to be mobilized in the commission of world violence.
In principle, there's nothing that made medical professionals particularly vulnerable to mobilization for violence in Syria. It is important to look at the cultural context in which doctors in Syria operated. Namely, historically, in the past half-century, Syria has developed immensely. Doctors and the medical profession has grown exponentially, which has also meant that doctors have received much more respect. Doctors have relative power in society. That power, of course, is something that the regime is aware of, and that can be at any time, used or abused for various purposes.
Of course, the key moment was in 2011, when people started demonstrating in Syria massively, and the regime started considering any medical support to wounded demonstrators as a form of support to those demonstrators politically. By driving that wedge into society, by pulling the medical profession into a profoundly politicized direction, pulling them away from what they're supposed to be doing, this is one way the regime really made it impossible to provide any humanitarian support to anybody outside of those groups that were approved by the regime.
Naya: History is full of examples of medical violence. From the German doctors experimenting on prisoners in concentration camps during World War II to American and British psychological torture programs following 9/11. The common denominator between any instances of medical violence is the presence of a regime with exclusionary policies. Is there anything unprecedented about the Syrian case though?
Uğur: What is unique or unprecedented about medical violence in Syria is the absolute disrespect for medical neutrality. That includes medical neutrality in the sense of the medical facilities under the control of the regime, so those were thoroughly militarized. Also, the medical neutrality in terms of the facilities under the control of the opposition. Those were, of course, attacked and assaulted deliberately. Of course, in civil wars, it often happens that hospitals end up in the line of fire. The very specific politicization and targeting of medical facilities, of medical personnel, of the profession, in general, that is really unique and unprecedented in this case.
Noor: We could list many forces that drive medical violence. The similarities between the medical profession and military institutions, doctors efficiency, organization, and abilities to select victims, to instill fear and make threats, the appearance of legitimacy, the gravitas of the title, and the access to tools and medication. Medical violence is of significance because it has a lasting impact on victims and on society as a whole. It shatters their trust in humanity and trust in what medicine represents for civilization and its well-being.
Naya: Before we end this episode, we want to address a very sticky dimension of medical violence and its perpetrators. We mentioned before that we are discussing "bad doctors." This doesn't fully capture, of course, the complexity and the elusiveness of perpetration. What we have been discussing today is violence that takes place among more violence, mass violence. With that come difficult questions of motivation, responsibility, and choice.
Noor: Just like in any other context of mass violence, scholars, judges, and the people swept up in the bloodshed themselves are confronted with people who don't fit neatly in the category of victim or perpetrator. Some people are a bit of both. This is also the case when it comes to medical violence. It's really hard to figure out what to make of these people.
Naya: If nothing else, the tales of healers turned perpetrators underline the Assad regime's deliberate policy to implicate entire sections of Syrian society by poisoning, manipulating, and destroying institutions and communities, promoting acceptance and indifference towards victims and the regime's continuous genocidal violence.
Noor: While the trial and Koblenz is in its final phase, other new trials are on the horizon. This summer, the German federal prosecutor general indicted Alaa M, for crimes against humanity. Alaa M is a doctor.
Naya: The allegations against him are very serious. His alleged crimes are unspeakably cruel and horrific.
Noor: If the court accepts the prosecutor's indictment, and decides to allow the case to go to trial, then the proceedings against Alaa M are set to start soon in Frankfurt, Germany. It will likely bring a lot more attention to the role of medical professionals in the torturous Assad regime.
Naya: Once again, it will be through the brave testimony of Syrian survivors that the world will find out more about the inner workings of Bashar al-Assad Syria.
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Hannah El-Hitami: The last days in court in Koblenz actually turned out to be quite interesting. We actually heard some witnesses that were requested by the defense, who, I guess, had something good to say about Anwar R or something in his favor. One of them was an officer from the German Federal Police. This story is a little bit complicated. [chuckles] I'm going to try to break it down. Actually, almost all the witnesses in Koblenz have-- they were interrogated by the police before they were later summoned to court. This police officer had interrogated one of the plaintiffs, a filmmaker, who was detained in Al-Khatib branch and who later testified in Koblenz.
He testified in September. Back then when this police officer interrogated the witness, the plaintiff, that plaintiff had told him that he had met the famous Syrian human rights lawyer, Anwar al-Bunni, to make a film about his work. They met in Germany. The witness said to the police officer that Al-Bunni showed him a picture of Anwar R, told him his name, and told him that he had worked in Al-Khatib branch. Back then, the witness said he recognized Anwar R on that photo because he had seen him in the branch before. He recognized him again when he was shown pictures at the police station during his police interrogation.
We have a witness who talked to Anwar al-Bunni first, saw a picture, potentially of Anwar R, later went to the German Federal Police was shown more pictures, recognized Anwar R again, and now he was in court. The problem is that in court last month, he changed his testimony. He said that no one had ever shown him any photos. Anwar al-Bunni had not shown him any photos. There was a contradiction, and that's why the court summoned that police officer to find out what happened during the interrogation. The police officer confirmed that that was the story; that he had heard that the photo had, in fact, been shown to the witness before he ever came to the police.
We're not really going to know what actually happened, but it seems that the defense is trying to prove that witness testimonies in this trial have been manipulated by Anwar al-Bunni. We'll see what the court makes of this and how the court evaluates the credibility of these witnesses and their testimonies. Another testimony that I found very interesting was a Syrian novelist who's apparently quite successful and famous. He was detained in the branch back in February 2011. He was interrogated by Anwar R personally, but he remembered that encounter to be quite friendly. He said that they talked a lot about literature and that Anwar R, actually told him that it had been his dream to become a writer.
I guess this is another example of what we talked about recently, that Anwar R is very fond of culture and arts, and he wishes to be a writer himself. These two, Anwar R and this witness, they met again later in Turkey, and they even developed a friendship. I guess this witness also didn't really say much about Anwar R's political position, whether he was with the regime or with the opposition. He did say that when they met in Turkey, Anwar R told him that they would have liked to defect much, much earlier, but he couldn't, because he couldn't have left his family. They met several times. Anwar R actually stayed at this witness's home for a few nights when he was in a difficult situation, stranded in Istanbul.
The witness once or several times asked him why he wasn't sharing all the insider information he had with international courts and investigators. Anwar R responded that one day, he will write a book about it, but he's not so fond of being in touch with the media and so on. Perhaps he will have time to write that book if he goes to prison. We're still not sure when or if he will be convicted, but there are some new motions by the defense so the trial could be prolonged a bit, but the verdict is still expected to happen till the end of the year.
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Pauline: Branch 251 is a 75 Podcast Production. Today's episode was hosted by Noor Hamadeh and Naya Skaf. Editing, production, and mixing by myself, Pauline Peek, with help from Hannah El-Hitami and Fritz Streiff. The script was written by Annsar Shahhoud and myself. Annsar did all the groundwork for this episode and her expertise and insight into this topic were absolutely invaluable. A special thanks to Professor Dr. Uğur Ümit Üngör. Support for our podcast comes from German Federal Foreign Office funds that are provided by IFA's zivik funding program.
