The ruins of eastern Ghouta’s al-Ihsan surgical hospital, after it was targeted by regime shelling in November 2013. (Photo by Osama Abu Zayn)
2013-2014: ‘Everything Vanished’
Ihsan surgical hospital was shelled for the first time in November 2013. A series of attacks ripped through the building, leaving rubble everywhere. The airstrikes blasted gaping holes in the brick walls, exposing hospitals beds with crooked IVs hanging over them to the outside world.
The hospital, in a besieged district of Eastern Ghouta, had only been open five months. This was the rebel-held suburb of Damascus that had suffered the worst of the chemical gas attacks mounted by the Assad regime the previous summer. According to the hospital’s staff, it served the majority of the cases arising from the area’s population of about 500,000. The facility was now leveled. Three of the hospital’s medical staff died in the barrage.
“Everything vanished, everything,” said Abu Zayd, of the Union of Free Syrian Doctors.
Refusing to be deterred, Abu Zayd and his colleagues took what equipment remained from Ihsan to set up another hospital at a secret location in Eastern Ghouta. They tried to take precautions on safety: They reinforced the infrastructure and separated certain emergency wards in secret locations in basements, only known by hospital staff.
A few months later, it was hit in another series of airstrikes. Once again, the hospital was damaged. Once again, they had to rebuild.
Ihsan represented a new humanitarian dilemma for the Syrian opposition. Syria’s field hospitals have themselves come to pose huge health risks to the people who visit them — or even live near them. But the bombing campaigns also had the unintended consequence of helping usher in the next phase of Syria’s rebel medicine.
The Assad regime routinely uses barrel bombs, oil drums packed with high explosives that destroy indiscriminately when dropped from helicopters or planes, against rebel medical facilities. Araj’s hospital in Hama, the Kafr Zita Specialty Hospital, was hit 10 times in 2015. Three of the staff — an anesthesiologist, a desk clerk, and a lab technician — were killed last year. Two of the three floors were wiped out.
Rami Kalazi, the Aleppo neurosurgeon, says each barrel bomb attack causes “frantic panic” among civilians. He used to live next door to Sakhour Hospital, rebel-held Aleppo’s largest trauma center, before the airstrikes forced him to move. In just six months over the end of 2014 through the spring of 2015, the hospital was struck on three occasions, damaging Kalazi’s home in the process. The staff had to ship cement in from Turkey to rebuild on each occasion. The airstrikes have only continued: According to Kalazi, the hospital was hit more than 20 times in 2014 and 2015. Eight of those strikes temporarily put the hospital out of service.
“We’ve become used to being targeted,” he said.
Ambulances are also constantly under threat. Kalazi said Sakhour has lost all of its ambulances to airstrikes and now relies on ambulances from other hospitals in the district or civilian cars.
The Syrian government’s hospital bombing campaigns motivated international donors to redouble their efforts to aid Syria’s medical facilities. Syrian expat networks based in the United States, the Persian Gulf, and Turkey that previously operated on an ad hoc basis have come together as large-scale nonprofits, like SEMA and the Syrian American Medical Society (SAMS), collecting millions of dollars in private donations and state funding to keep the hospitals running. These nonprofits have received money from the United Nations, the United States, Canada, and several European countries. Money and aid have also come from individuals in the Persian Gulf and organizations like the Qatar Red Crescent. To vet recipients, aid groups rely on the guidance of local Syrian medical bureaus or on their own longtime relationships with medical staff. International organizations such as the International Committee of the Red Cross and Médecins Sans Frontières (MSF) also provide funding and supplies for medical facilities in Syria’s opposition territory.
With greater assistance from international donors, Syria’s domestic opposition started designing medical facilities able to evade, or withstand, the regime’s relentless attacks. “It became clear that we needed to set up secure hospitals, underground, in a way that the airstrikes wouldn’t affect them, whether it’s barrel bombs or missiles,” Dbis said. And that, in turn, allowed rebel doctors to move beyond short-term emergency medicine and begin providing long-term medical care.
The “Central Cave” hospital was constructed inside a mountain in the governorate of Hama. The patients and medical workers are protected from air strikes by 55 feet of rock and dirt. (Photo by Zaher Sahloul)
2015: ‘The Place Will Endure’
From the inside, it could be any hospital. Men in scrubs tend to an emergency room. There are beds and sterilized equipment, and the floors are ceramic tile. But look up at the dome-shaped ceiling. The jagged rocky edges and gaping holes reveal the inside of a mountain in Hama.
Araj called it the “Central Cave” hospital. It opened in late 2015, as shells fell on his hospital aboveground. The bombardment couldn’t harm them now. The cardiologist, his colleagues, and the hospital’s patients were sheltered under 55 feet of rock and dirt. Najwa, his wife, called the buried hospital “magnificent.”
“No matter how much they shell, shell, shell it, nothing will happen,” Mohammad Yasser Tabbaa, the SEMA co-founder, said of Central Cave. “Maybe it will shake the place, but the place would endure.”
“This is the trend we’re trying to push for,” he added.
The financial barriers to going underground are high. “It’s not easy for all the money to go and pour into one single place,” Tabbaa said.
Central Cave cost about half a million dollars to build, underwritten by an array of aid organizations, including SEMA, the Union of Medical Care and Relief Organizations, and the Assistance Coordination Unit, the humanitarian arm of the Syrian National Coalition. The health directorate in rebel-held Hama also funneled some of the money it had received from the British government into the project, according to Dbis.
Medical workers in Hama led the initiative, bringing in local labor to tunnel into a mountain in the northern countryside, where smaller caves already existed, to make way for the hospital. After around a year of drilling and shaping rock into rooms and hallways, Central Cave now sits at the base of the mountain. It welcomes around 1,500 patients a month from Hama and Idlib, mostly for free. The hospital includes operating rooms for general and orthopedic surgery, an intensive care unit, a pharmacy, a lab, a medical ward, and X-ray facilities. SAMS, the U.S.-based aid group, still pays nearly $50,000 a month in operating costs, including the salaries for the full-time staff who live in the hospital.
All across Syria, the need to protect hospitals has become acute. Moscow’s decision to join the air campaign in 2015 has only heightened the risk: Russian warplanes brought with them stronger weapons and more destructive power. PHR has called 2015 the deadliest year yet for Syrian health care, with 122 attacks on medical facilities.
Yet the Russian escalation has failed to destroy the rebel’s infrastructure. Central Cave isn’t the only example of rebel medicine moving underground: Many hospitals have by now moved into reinforced basements, cellars, or abandoned factories. In cases where it’s impossible for medical facilities to completely move their operations, the most sensitive units, like surgical and emergency rooms, have been relocated to a subterranean level.
For some hospitals, like Eastern Ghouta’s Ihsan, the huge loss brought on by airstrikes led them to disperse their facilities. An emergency room might be almost 1,000 feet from the operating room and similarly distant from the intensive care unit.
“Our strategy was to select unknown areas, so we stayed away from governmental buildings completely,” said Abu Zayd, the representative from the Union of Free Syrian Doctors. “We settled for commercial basements, from factories, sewing shops, or other similar places.”
Patients are ferried by ambulance or sometimes travel through tunnels that connect the facilities.
“If one location is hit, not all of the departments are destroyed,” said Mouaffak, the surgeon in Douma. “If we’re in the emergency room and it’s shelled, God forbid, there are people in other departments who could still rescue us.”
Medicine in opposition areas has become increasingly sophisticated as it has evolved from its earlier state of triage and improvisation. Underground hospitals also treat civilians suffering from routine ills. Several doctors said much, if not all, the care they provide is free. The nonprofit organizations now foot the bill for their salaries, though some reported working without pay for at least the first year after the spring 2011 revolt.
“The patient is usually poor here,” Mouaffak said. “If there’s only one doctor who can do this surgery and the doctor wants the patient to pay him, it basically means the patient won’t make it.”
Doctors have also developed a methodical approach to the influx of patients that an airstrike brings. “Right away, we keep the dead on one side,” said Kalazi, the neurosurgeon in Aleppo. The most serious cases are quickly sent to the operating rooms. Sometimes patients are sent to other Aleppo hospitals and even into Turkey. Kalazi recalled working 40 hours straight in early 2014 during a day of particularly intense shelling, when Sakhour Hospital admitted around 200 patients.
Doctors report that vaccines, antiseptics, and antibiotics are often unavailable, especially in besieged areas like Eastern Ghouta that have been cut off from supply routes since 2013. In regions like Idlib and Hama, medical tools and supplies come in trucks from neighboring Turkey. Yet in Eastern Ghouta, where international aid deliveries are erratic and insufficient, underground tunnels provide an alternative lifeline. Medical supplies are smuggled in across regime lines at great financial cost and great personal risk.
If medical workers can’t get the supplies they need, they’re forced to improvise. Three doctors said small-scale factories began springing up in 2014 in the Damascus suburbs to produce materials like gauze or serum that were too difficult to import from outside areas.
Some hospitals have medical equipment, such as CT scanners, salvaged from prewar facilities. The sandbags placed around the expensive machines suggest a constant threat of destruction.
There is still not enough anesthesia, however. “Without anesthesia, the surgery doesn’t happen,” said an anesthesiologist in Eastern Ghouta, who goes by the assumed name Abu al-Zaher. “The patient would die from the pain.”
The constant shortages have also spurred innovation. Zaher began producing a low-cost anesthetic out of ingredients he had available. He tested his formula on 50 patients receiving cesarean sections and reported the results were on par with the standard version. Basic household items, like olive jars, have been repurposed as medical instruments. Civilians and medical staff alike are trained to work outside the boundaries of what they knew.
“We held nursing workshops for the people in the towns,” Zaher said. “So now in every town, most people have some knowledge of nursing procedures.” More formalized nursing schools and academies have recently emerged: A school that opened in Idlib last year has already graduated 70 paramedics, and this June, an Eastern Ghouta health institute graduated its first cohort of 35 students.
Training also comes from overseas. In October 2012, Anas Moughrabieh, a Syrian-American doctor in Detroit, worked with SAMS to get two nurses from Syria’s Idlib province smartphones and internet-enabled cameras. Moughrabieh then became the virtual doctor to 40 patients almost 6,000 miles away.
The program has since spread to seven hospitals. A network of more than 20 volunteers in the United States and Canada now take formal shifts to provide 24/7 medical advice using apps like Viber, WhatsApp, and Skype. What the doctors see can be overwhelming.
“I asked them to stop streaming pictures,” Moughrabieh said. “I don’t want to see. I open the camera, and I see them dying, blood everywhere, patients on the floor. This is too much for me.”
The Syrian doctors and medical workers who decided to defy Assad have come a long way from bedroom surgeries. But their work teeters on a knife-edge, always at the mercy of the next air raid.
“When the planes don’t show up,” said Abu Zayd, of the Union of Free Syrian Doctors, “we wonder, ‘What’s wrong, and what’s coming?’”
Still, they stay, even as the dwindling number of doctors paints a foreboding picture. For some, it’s too late or too difficult to leave now. But in reflecting on what keeps them in Syria, most cite their religious faith, frustration with the regime’s injustices, or dedication to the medical oath they took years ago.
“The people who live here, they’re our families and our people,” said Abu Ibrahim Baker, the general surgeon in Eastern Ghouta. “How would I leave my family, my people, in this situation, under shelling?”
“I can’t tell you I didn’t think of leaving,” said Mouaffak, the surgeon in Douma, who often writes eyewitness accounts of particularly brutal days in a digital diary titled Memories of Tragedy. “But … this is my city.”
With every chapter of political, diplomatic, and military developments, Syrian doctors in the field have found ways to keep going. But no matter how deep underground these doctors go, or how much international support they garner, they are not safe.
Ahmad al-Dbis and Abdallah Darwish, two of Hasan al-Araj’s colleagues in Hama, were in Turkey for a war surgery workshop on April 13, when they learned of Araj’s death.
“‘Ahmad, we have to go to Syria right away,’” Dbis recalled Darwish saying.
“Dr. Hasan—” Darwish said, but couldn’t continue his sentence.
“I had a semi-breakdown,” Dbis recalled. “During the revolution, we became more than brothers.… Even the secrets we didn’t tell our wives, we told each other.”
Passport in hand, he rushed to his car half-dressed and crossed the border into Syria for the funeral.
“Of course, there was nothing for us to see,” Dbis said. “I mean, a lump of severed limbs in a bag — that was buried.”
Najwa and her children, who still live in Turkey, don’t have the authorization to regularly cross the border back to their home country. They couldn’t attend the funeral or visit the modest grave: a small concrete tile sitting atop a pile of soil and gravel, with patches of green sprouting around it. In black felt, the cardiologist’s gravestone reads, “The martyr Dr. Hasan Mohammad al-Araj.”