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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

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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 2. Medical Discourse, Propaganda and Scientific Myth……………………………... 45 2

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

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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

1 Elaine Scarry, The Body in Pain: The Making and Unmaking of the World (New York: Oxford University Press, 1987),44. 4

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. 5

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. 6

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. 18 Robert J. Lifton, The Nazi Doctors: Medical Killing and The Psychology of Genocide (New York: Basic Books, 1987),433-466. 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). 8 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. 9 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 ﻲﺿﺎﻤﻟا دﻮﺳﻷا ) period my informants often referred to euphemistically was “the forgotten black past While perpetrators in exile refrained from talking due to fear of accountability, such as the ”.( ﻲﺴﻨﻤﻟا 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. 10 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. 11

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.

ﻲﻓ مﻮﯾ ﺔﯾﻮﻨﺳ أ ﻮﺑ ا ءاﺮﻘﻔﻟ “ ,Dr. Eid was assassinated in Al Zahraa neighborhood in Homs in September 25, 2011. Homs News Voice 40 The anniversary of the father of poor, martyr“ ” ﺪھﺎﺠﻤﻟا ﺪﯿﮭﺸﻟا رﻮﺘﻛﺪﻟا ﻦﺴﺣ ﺪﯿﻋ اﺬھ ءﺎﻘﻠﻟا ﻊﻣ ﺖﺧأ ﺪﯿﮭﺸﻟا ﻲﺘﻟا ﺖﺛﺪﺤﺗ ﮫﯿﻓ ﻦﻋ ﺪﯿﮭﺸﻟا ﻒﯿﻛو ﻢﺗ ﮫﻟﺎﯿﺘﻏا ﻢﺗ ﻒﯿﻛو ﺪﯿﮭﺸﻟا ﻦﻋ ﮫﯿﻓ ﺖﺛﺪﺤﺗ ﻲﺘﻟا ﺪﯿﮭﺸﻟا ﺖﺧأ ﻊﻣ ءﺎﻘﻠﻟا اﺬھ ﺪﯿﻋ ﻦﺴﺣ رﻮﺘﻛﺪﻟا 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. 43 Steven Heydemann, Authoritarianism in Syria: Institutions and Social Conflict, 1946–1970,1-4,10-12. 12

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. Intellectuals in the politics and Society: Doctors (Damascus: Al-Ahli,1996),107- نﻮﻔﻘﺜﻤﻟا ﻲﻓ ﺔﺳﺎﯿﺴﻟا :ﻊﻤﺘﺠﻤﻟاو ﺒطﻷا ءﺎ ,47Abdullah Hanna 118. 13

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 The Ba’ath party distorted the ethos of Syrian medicine by 51.( ﺔﻘﻋﺎﺼﻟا ) party training camps 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 which is also taught in Syrian primary " ﺔﯿﻣﻮﻗ “ students were required to take a course called National 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 Doctors must respect“ , جﺎﮭﻨﻣ ﺚﻌﺒﻟا ﻲﻔﯿﻘﺜﺘﻟا ”the party preparation book “The Ba’ath Education Curricula 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. .Intellectuals in politics and Society: Doctors (Damascus: Al-Ahli,1996),133 نﻮﻔﻘﺜﻤﻟا ﻲﻓ ﺔﺳﺎﯿﺴﻟا :ﻊﻤﺘﺠﻤﻟاو ﺒطﻷا ءﺎ ,Abdullah Hanna 49 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. The Syrian Education Between Politicization and Militarization,” Haramoon“ " ﻢﯿﻠﻌﺘﻟا ﻲﻓ ﺎﯾرﻮﺳ ﻦﯿﺑ ﺲﯿﺴﺘﻟا ةﺮﻜﺴﻌﻟاو " . ,Wajeh Hadad 51 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. 14 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 ,Furthermore 59.( تﺎﻤﻈﻨﻤﻟا ﺔﯿﺒﻌﺸﻟا ) ”the Ba’ath party organization umbrella the “popular organizations 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. 15

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

.The Motherland Houses (Beirut: Baitelmouwaten, 2017),27-31 ﻨﻣ لزﺎ نﺎطوﻷا ,Najat Abd Al Sama 62 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 West, February 15, 2018. 16 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. 80 Khaled Shabib, A Hospital in Homs (London: E-Kutub, 2015),22, 50-60. 17

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 .( دﻮﮭﺠﻤﻟا ﻲﺑﺮﺤﻟا ) ”effort

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

,Shut Down Hospitals and Bakery Increased the Severity of Siege,” Enab Baladi vol.26, July 29 قﻼﻏإ ا ﻟ ﺎﺸﻤ ﻲﻓ او ﻟ ﺎﺨﻤ ﺰﺑ ﯾﺰﻟ ﺎ ةد ﻟ رﺎﺼﺤﻠ “ 81 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. 18

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. 19

Following the eruption of the 2011 uprising, the regime's violent response, pushed medical institutions to the forefront of the conflict. Medical professionals failed to create a genuine movement that would neutralize the healthcare sector. They instead diverged on political, social, and sectarian bases, in which the provision of healthcare became a subject of political manifestation. In hospitals, few joined underground networks to treat injured demonstrators, and later dissented and established a parallel system of networks of field hospitals. Dozens of others willingly adhered to the regime. Half of the healthcare professionals fled the country.94 But, the majority of healthcare professionals that remained were silent and indifferent towards the regime’s violations against both their colleagues and patients. The regime systematically targeted health professionals for their provision of healthcare to demonstrators.95 A policy that marked continuity of Assad’s regime since 1979, but this time Bashar al-Assad issued the counter-terrorism law No. 19 in June 2012, that criminalized the provision of healthcare in opposition-held areas.96 The legal act was the final stage to end the independence of healthcare, stressing the cleavages between healthcare professionals. While some health professionals were arrested, tortured and persecuted in regime detention centers, other medical professionals joined regime rallies, showing support to Assad’s regime.97 At medical faculties, medical students also divided between who demonstrated and joined underground field hospitals.98 And students collaborated willingly or forcefully with the regime during their residency training. The regime manipulated medical students, especially the graduates of the academic years of 2015, 2016, and 2017.99 These groups of students were vulnerable to the rigid hierarchy of medical institutions and its presentation as a higher authority to medical personnel. These doctors had neither the agency of “normal” medical doctors nor the independence to leave their positions. This was due to the fear caused by the militarization and permanent security presence in medical facilities and its effect it had on their lives and families. At the level of medical institutions, the medical association maintained its silence on the violations against doctors and healthcare facilities by the regime. They legitimized the complicity of doctors with violence by finding excuses such as “national war against terrorism” and “the right of doctors to defend the country” [Figure 1.1].100 Dr. Abd Al Qader Hasan, the director of the Syrian National Medical Association, wrote a letter dated March 25th, 2011, where he invited doctors and professionals to unify and back the regime:

94 Fouad M. Fouad, Annie Sparrow, Ahmed Tarakij, Mohamad Alameddine, Fadi El-Jardali, Adam P.Coutts, Nour El-Arnaout, Lama Bou Karroum, Mohammed Jawad, Sophie Roborgh, Aula Abbara, Fadi Alhalabi, Ibrahim AlMasri, Samer Jabbour, “Health Workers and the Weaponization of Health Care in Syria: A Preliminary Inquiry for The Lancet- American University of Beirut Commission on Syria,” The Lancet vol.390, no.10111 (March 2017): pp.2516-2526. 95 Rayan Koteiche, Serene Murad, Michele Heisler, “My Only Crime Was That I was A Doctor: How the Syrian Government Targets Health Workers for Arrest, Detention, and Torture,” Physicians for Human Rights, December 4, 2019. 96 “Assault on Health Care in Syria,” Commission of Inquiry on the Syrian Arab Republic, April 13, 2014. 97 “Damascus Medical Association Facebook Page: Doctors’ rally with Assad,” August 25, 2011, https://www.facebook.com/Damascus.medical.Association/photos/a.251788664854015/251788784854003 98“Attacks on protest in medical faculty in Aleppo,” March 14, 2012, https://www.youtube.com/watch?v=rt0MlvGZCOo. “An Anti-Assad protest took place at Damascus Medical Faculty,” November 2, 2011, https://www.youtube.com/watch?v=Vw6VhAJk3aY. Interview with dr. Ahmad via WhatsApp, July 15, 2016. Interview with Sami via Skype, February 23, 2018. 99 Interview with Dr. Haetham, August 17, 2019. Conversation with Amir via Facebook, April 30, 2020. 100 See the letter from Dr. Abd Al Qader Al-Hasan on the medical association Facebook page, https://www.facebook.com/Syria.Medical.Association/videos/1303168903093939/ Interview with General Dr.Nizar Ismael at Sabahna Ghyer, “The Role of the Military Medical Directorate in the Syrian Arab Army ,AliKhbaria Al Surya, August 1, 2019 ”, رود إ د ةرا ا ﻣﺪﺨﻟ تﺎ ا ﻟ ﺒﻄ ﯿ ﺔ ﻲﻓ ا ﺶﯿﺠﻟ ا ﻟ ﻲﺑﺮﻌ ا يرﻮﺴﻟا ﺑﻌﻟا ﯿﻟا ﻓ ﺔﯿﺒ https://www.youtube.com/watch?v=UyoYunCcQ48 20

Our ambitions are giant, we hope that the collaboration of all our colleagues each in his position will advance the association’s services together. We should address our weakness and strengthen our gains until our beloved country retains its health and comes salient against conspiracies and challenges. Our slogan is always, as it was since the start, that doctors have to be loyal to the Progress and Development Process Under the doctor president, the first doctor of Syria, president Bashar al-Assad.101

The Syrian National Medical Association was also involved in legitimizing regime violence by organizing events propagating the regime’s narratives on the Syria fight against terrorists.102 They showed the emergence and politicization of these acts in the prominent presence of the Ba’ath party. This was also seen with military personnel and their participation in various local and national associations [Figure 1.2].103 The Ba’ath party, in a way, conquered again the intermediary power between the medical institutions as it did in the 1980s. The head of the Ba’ath party, Hilal Hilal, known for his pivotal role in establishing the Ba’ath militias, acknowledged how important the role of doctors was in the Syrian “War on Terror” in a speech before the Medical Association Second Scientific Conference, “Who Doesn’t Engage Doesn’t Learn, and Who Doesn’t Learn Doesn’t Progress,” in 2017. He said:

From the great leader Dr. Bashar al-Assad, I am honored to transmit his gratitude to you and doctors working in the health sector.” He added, “I appreciate the doctors' patriotism and services to the society, homeland and the army.104

Both Hilal and Dr. Hasan neglected the great damage done to the medical sector and the misuse of medical human resources. They instead propagated on the unity of the profession, which was in contrast to an earlier announcement made by Dr. Hasan where he dismissed doctors from the association because of their work in opposition-held areas.105 The medical association failed to oversee the neutrality of the medical profession. It instead acted as part of the regime's political apparatus by propagating and legitimizing state violence and medical perpetration. The medical association policy emphasized the polarization and dual loyalty in the profession.

3.2. Militarization and Medicalization: Discourse, Facilities, and Profession

The military extended its authority over civil medicine in addition to its traditional authority in military hospitals. Hospitals and medical personnel were considered as “the second army” or the “supporting

101 A letter written and posted in Syria Medical Association Facebook page, https://www.facebook.com/photo?fbid=445473048863533&set=a.149500571794117; last checked on June 10, 2020 102 Some doctors propagate for the regime violent policy on international and national TV channels, Dr. Taleb Ibrahim, a dentist known as a propagandist, frequently used pathological religious discourse to mobilize loyalists, https://www.memri.org/reports/syrian-regime-mouthpiece-dr-taleb-ibrahim-urges-president-assad-massacre-anti-regime عﺎﻤﺘﺟا - ﺔﺌﯿﮭﻟا - ﺔﻣﺎﻌﻟا - ﺖﺤﺗ - ﻌﺷ ﺎ ر -/For example, check the news page of Medical Association in Homs: https://med-homs.com/news 103 /أ ﺒط ﺎ ؤ ﻧ ﺎﻧؤﺎﺒ 104 Hilal Hilal’s address to doctors at the first day of the medical conference of Syrian medical syndicate, https://www.facebook.com/Syria.Medical.Association/videos/1303168903093939; last checked on June 01, 2020 The Medical Association: Dismissed about 150 Doctors for ﺔﺑﺎﻘﻧ :ءﺎﺒطﻷا ﻞﺼﻓ ﻮﺤﻧ ﺎﺒﯿﺒط ﻦﻣ ﺔﺑﺎﻘﻨﻟا ﻢﮭﻠﻣﺎﻌﺘﻟ ﻊﻣ ﻦﯿﺤﻠﺴﻤﻟا “ ,Al Khaber 105 Collaboration with the Gangsters,” Al Khaber TV, August 11, 2017, / ﺔﺑﺎﻘﻧ - ﺒطﻷا ءﺎ - ﻞﺼﻓ - ﻮﺤﻧ -150-طﺒﯿﺒﺎً- ﻦﻣ - ﺎﻘﻨﻟا /https://alkhabar-sy.com 21 frontline.”106 At the beginning of the conflict, the secret police stormed hospitals to arrest and kidnap injured demonstrators. Later, the military turned hospitals into stations for their activities. Each branch would have office and personnel that permanently served in the hospital. These offices functioned as a liaison between the civil management of the hospitals and the military authority. They worked together in organizing, securing, and supervising detention. They also ensured complete discreteness of the medical staff, who perhaps would be tortured in case they offended the code of secrecy.107 Some civil doctors collaborated with the Republican Guards and militias to work in special sections in civil hospitals for either social benefits or additional salaries. This suggested that the regime actually created a hybrid healthcare system or parallel military system in civil hospitals.108 For example, from 2013 and onward, the Republican Guards stationed and controlled a special section in the Internal and Pulmonology department on the second floor in Al Mujtahid hospitals called “the friends department.” This is where the Iranian National Guard Basij militia received treatment.109 The fact that Bashar al-Assad was both a surgeon and the chief of military is an important element in explaining the militarization of the healthcare system and medical perpetration. Although doctors who assisted in torture were present in Syria for decades, Bashar al-Assad influenced healthcare professionals and contributed to the weaponization of medicine. His identity consisted of three layers: the power of medicine, military power, and decision-making. His identity emphasized the symbolic example of the “regime scientists.” Bashar al-Assad often compared the medical task to that of the ruler.110 He repeatedly stressed his will to “scientize” Syria. Assad used medical terminology and metaphors on several occasions.111 In Bashar al-Assad’s first speech before the People’s council in April 2011, described demonstrators as “bacteria” and “germs” in the Syrian body that need to be eliminated or sterilized.112 The militarization of the healthcare system and medicalization of the military went hand in hand: the mutual involvement of the military in civil medicine happened from both sides. Many perpetrators combined the same multi-layered identity of military and medical professions. They sought more influence in civil institutions by positioning themselves in the middle. Military doctors gain additional power when they infiltrated and took over the leadership of medical association and civil medical institutions. This was exemplified by the appointment of Major General Dr. Mores Mouas, the former director of the Military Medical Directorate and a well-known perpetrator, as the secretary of the National Medical Association on February 21, 2020. As well as when Dr. Yousef Asaad, the former director of Damascus Medical Syndicate, received a reward from Al Quds Brigade, Mohammad Al Saed, for collaborating and treating their wounded troops.113

”,The Role of the Medical directorate in the Syrian Arab Army رود إ د ةرا ا ﻣﺪﺨﻟ تﺎ ا ﺒﻄﻟ ﯿ ﺔ ﻲﻓ ا ﺶﯿﺠﻟ ﻲﺑﺮﻌﻟا يرﻮﺴﻟا “,Sabahna Kheir 106 Ekhbariya News, August 2019, https://www.youtube.com/watch?v=UyoYunCcQ48 Ogareet Dandashi, “From the Field, Harasta Hospital: The angles,” Al-Mayadeen tv, March 21, 2019, https://www.facebook.com/police.of.syria/posts/1320653724778360 107 Interview with Ahmad via Skype, August 27, 2019 & June 23, 2020. 108 Interview with Ahmad via Skype, August 27, 2019.n 109 Ibid. 110 “ARD tv Interview with Bashar al-Assad,” March 2, 2016, https://www.youtube.com/watch?v=e3HmnhaBsQ0 111 “Syria Conflict BBC exclusive interview with Bashar al-Assad,” February 9, 2015, https://www.youtube.com/watch?v=yiC4w7Erz8I 112“Bashar al-Assad’s speech before the parliament 2011,” March 30, 2011, see: https://www.c-span.org/video/?298760-1/syria-president-bashar-al-assad-speech-parliament 113 “Damascus Doctor Syndicate,”December 22, 2019, check: https://www.facebook.com/Damascus.medical.Association/posts/2970505902982264 22

3.3. The Fear and Security Dilemma

Syrian healthcare professionals thus shared a set of community beliefs and values, as defined and shaped by the Ba’ath party and the rule of Hafez and Bashar al-Assad. Additionally, they also shared a sense of collective fear, given the threats made – and often acted upon – to the existence of the group.114 This was regardless of whether they were workers in institutional or individual healthcare professions. Healthcare professionals were from areas where sectarian and social prejudices existed. Acts of violence committed by healthcare professionals were especially common in areas where sectarian tension and violence occurred. In some cases, healthcare professionals extended their work to fight alongside militias and paramilitary groups.115 Dr. Bahjat was a middle-aged Alawite doctor from Al Nuzha, a neighborhood in Homs. Homs was a city that witnessed devastating sectarian fighting.116 Dr. Bahjat joined the Shabiha, the Syrian paramilitary group later known as NDF, as a commander of a battalion along the frontline of Homs from June 2012 until 2014. He returned to his position as a medical technologist at Hamish Military Hospital 601. For three years he worked with militias that committed massacres, sieges, and torture. He explained that his relentless acts were out of fear and the urgency to protect his family and community from the monstrous Islamist threat.117 Healthcare professionals were subjected to constant threats from the opposition fighters who took hospitals as military bases to launch missiles and hunt civilians in neighboring areas. 118 the regime exposed healthcare professionals to a tremendous amount of violence. My informants often spoke of augmented fear and how it caused them to become senseless and indifferent, like “machines.”119 Fear provoked violent instincts. The deception of how they perceived “others” as either an imaginary or real threat needed to be eliminated. The victims were seen as undefeatable monsters who deserved no mercy. There was a causal relation between the intensity and extent of medical violence. Medical violence in the Syrian conflict is outlined in three phases. The first phase was the security solution (March 2011-October 2011): the deprivation of treatment, ill-treatment, and arrest from facilities. In this phase, which lasted six months to a year depending on the geographic zone, the participation of healthcare professionals was an individual choice whether they rejected treating patients or collaborated with the secret police and reported patients. During this phase, injured demonstrators could receive emergency or proper treatment, but the fact that demonstrators were at risk of arrest as well as limited medical skills, left many of those treated with permanent consequences.120 Healthcare professionals were able to restrain violence, and agreed on frame of security intelligence interventions in the medical services at the hospital.121

114Ibid. 115 Interview with X, May 18, 2019. Another example of doctors-soldiers is the case of Dr. Ali Wajeh Shadoud a pharmacist joined NDF in Tartous and was killed in 2013, check Facebook page: https://www.facebook.com/ali.w.shadod. 116Aziz Nakkash, “The Alawite Dilemma in Homs: Survival, Solidarity and the Making of a Community,” (Berlin: Friedrich- Ebert-Stiftung, March 2013). 117 Interview Bahjat via Facebook, May 01, 2020. 118 Alex Thomson, “Inside Syria’s Military Hospital” Channel 4, July 22, 2012, https://www.youtube.com/watch?v=JamomTyJNrg 119 Ogareet Dandashi, “From the Field, Harasta Hospital: The angles,” Al-Mayadeen, March 21, 2019, https://www.facebook.com/police.of.syria/posts/1320653724778360. Zena Makhlouf, “Tishreen Military Hospital in Damascus: Between Soldiers,” Syria Al-Ekhbariya News, April 22, 2019, https://www.youtube.com/watch?v=duKXZWzLfnA. 120 “Syria: Medicine as a Weapon of Persecution: Testimonies,” Doctors without Borders, February 8, 2012. 121 Interview with Omar via Skype, April 22, 2020. Interview with Abdullah via Facebook, May 12, 2020. 23

The second phase (October 2011- April 2012): The regime succeeded in crippling a collective response from medical professionals. They failed to challenge cumulative discriminatory policies (stretching as far back as the 1970s) and the massive oppression of the healthcare sector that characterized Syria’s descent into conflict. In this phase, the medical role became integral to the process of violence. The regime utilized both human resources and facilities of military and civil medicine. The third phase after (June 2012-December 2018): with the regime losing control of territory and manpower a decision was made to centralize medical decision-making in the hands of military doctors. The selection of victims, the killing, and the legitimization of violence towards detainees were taken by military doctors.

4. The War on Terror and Medical Torture

Preceding regional and international events in the region, which stimulated the instrumentalization of science and medicine for political purposes, were considered in order to understand the rise of medical torture and killing in Syria. After the 9/11 attacks, the United State formed an alliance against terror. They launched military campaigns and the CIA established a secret program of torture. This program included secret prisons in Iraq and Afghanistan and cooperation with countries known for their brutal torture and human rights violations, including Syria. The program was the catalyst which re-legitimized the scientific involvement in human rights abuses after the Nazi crimes and Nuremberg Code.122 American psychiatrists designed an enhanced torture guideline to extract information from victims of torture. It included instructions on techniques and phases based on neuroscience. Several American physicians also supervised, legitimized, and tortured the victims.123 US officials argued that “enhanced interrogation techniques” or “clean torture” were legitimate because they did not cause physical or psychological harm to the prisoners. It was also considered by American courts as a form of “suffering” and not torture.124 The War on Terror re-established scientific involvement with violence, implicating the medical profession again with the state’s political purposes. The CIA shared its guidelines and information with other states and their security apparatuses; Syria was one of those states.125 The first known instance of the direct incorporation of American torture guidelines by Syrians was at Saydnaya Military Prison. They use of loud music to instigate suffering of prisoners, as well as the techniques used by doctors in Tishreen Military Hospital in torturing and killing ten prisoners.126 The regime referred to advanced psychological techniques of manipulation of sensation was used to subjugate prisoners, a popular technique was often used often in Abu Ghriab to intimidate prisoners.

5. Conclusion

122 Wanda Teays, Doctors and Torture: Medicine at Crossroads (London: Springer,2019),25-29. 123 Steven Miles, Oath Betrayed: America’s Torture Doctors (California: University of California Press,2006),10-25. 124 Thomas W. Simon, Genocide, Torture, and Terrorism: Ranking International Crimes and Justifying Humanitarian Intervention (New York: Palgrave Macmillan,2016),23, 26,148-151. 125 Ishaan Tharoor, “The Sad Echo of CIA Practices in the Syrian Regime’s Prisons,” The Washington Post, December 10, 2014, http://t.co/oRDGmdn0oD?amp=1 Ayham Saqer a Witness on The Systematic Killing and Torture in ﻢﮭﯾأ ﺮﻘﺻ ﺪھﺎﺷ ﻰﻠﻋ ﺔﯿﺠﮭﻨﻣ ﻞﺘﻘﻟا ﺐﯾﺬﻌﺘﻟاو ﻲﻓ ﻦﺠﺳ ﺎﯾﺎﻧﺪﯿﺻ “,Ya Huria 126 Saydnayya Prison,” Syria TV, June 13, 2019, https://www.youtube.com/watch?v=5aswYU7ervA. ,Massacre of Saydnaya Prison: Omar Al Abdullah ‘part 2’,” Orient TV, March 5 ةرﺰﺠﻣ ﻧﺪﯿﺻ ﺎ ﯾ ﺎ . . ﺮﻤﻋ ا ﺪﺒﻌﻟ ﷲ ا ءﺰﺠﻟ ا ﻟ ﺜ ﺎ ﻲﻧ “,Tghyrana 2015, https://www.youtube.com/watch?v=_QihCb3adNk 24

This chapter has shown that medical violence in Syria is not accidental, but rather an outcome of a long process of subjugation and manipulation of medical profession, as well as systematic modification of institutions, which deepened divisions between health professionals and withheld any attempt to restrain violence from within. Furthermore, this chapter showed that multiple factors have contributed to the compliance of medical professionals during the war.

25

Chapter 2: The Masquerade of Syrian Hospitals: Medical Atrocities and Mass Graves

1.Introduction

For the medical professionals within the Assad regime, medicine was a weapon to be used alongside the army in its supposed ‘’holy war’’ against “terrorism”. Hospitals were turned into frontlines as a byproduct of this.127 My conversations with Syrian health professionals expose how hospital spaces were experienced during the conflict and how they were imagined or represented. Perpetrators provided differing statements and instead associated the regime’s use of hospital spaces with or compliance and collective pride. Survivors and victims on the other hand, saw the same space as a symbol of tyranny and death, where they experienced physical, mental, and psychological violence. There are peculiar similarities between spaces of healing and ones for torture and murder. Both spaces find themselves in a myriad of robust surveillance, under close observation, and tight restrictions.128 They subjugate people and their bodies while placing physical boundaries to isolate people and break down solidarity.129 There is a connection between the use of hospitals as detentions centers and how perpetrators perceived victims as enemies or terrorists.130 In Syria, for example, President Bashar Al-Assad classified demonstrators as “biological hazards” who posed as a threat to Syrian society.131 The Syrian regime took advantage of hospitals in order to deploy and exert power and incite violence. Hospitals as spaces produced and reproduced violence. Since 2012, the regime has been using hospitals as extermination sites, where clinicide, torment, and torture were normal medical practices.132 The scale of violence and the massive mobilization of sources and human resources suggests that incidents of medical violence in Syria were not isolated, but were rather a deliberate policy.133 It was a top-down process instigated by higher political, military, and medical authorities in the country. Leaked documents from the regime intelligence apparatus and crisis unit, a committee established in 2011 that included top military and security authorities in Syria, suggests the involvement of the Syrian president and top army leadership, the National Security Bureau, and other security apparatus in carrying out a genocidal campaign and clinicide.134 A draftee, who worked at the chief of

127 Interview with Dr. Bahjat via Facebook, May 1,2020. Interview with Mohammad Hasan via Facebook, April 25,2020, interview with Sulieman via WhatsApp, April 25,2020. Interview with Darwich via Facebook, May 15,2020. Interview with Emad, May 12, 2020. 128 Thomas A. Markus, Buildings and Power: Freedom and Control in the Origin of Modern Building Types (London and New York: Routledge, 1993),889,896,2909-2016,2025, 3223,3278, 3433, kindle. 129 Michel Foucault, Discipline and Punish: The Birth of the Prison (New York: Vintage Books, 1995),177-78. 130 Thomas A. Markus, Buildings and Power: Freedom and Control in the Origin of Modern Building Types (London and New York: Routledge, 1993),3455, kindle. 131 “Syria President Bashar al-Assad Speech to Parliament,” March 30, 2011, see: https://www.c-span.org/video/?298760-1/syria-president-bashar-al-assad-speech-parliament; Last accessed on June 25, 2020. 132 “Health Crisis: Syrian Government Targets the Wounded and Health Workers,” Amnesty International, London, October 25, 2011. “Syria: Medicine as Weapon of Persecution,” Doctors Without Borders, February 8, 2012. “Assault on Health Care in Syria,” Independent International Commission of Inquiry for Syria Arab Republic, September 13, 2013 (A/HRC/24/CRP.2). “Syria: Attacks on Doctors, Patients, and Hospitals,” Physicians For Human Rights, December 1, 2011. 133 “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. “The photographed Holocaust: Analytical Study about the Leaked Pictures of Torture Victims in Syrian Military Hospitals,” Syrian Network for Human Rights, October 15, 2015. 134 Mark Mackinno, “Al-Assad’s Nuremberg moment: Page by Page, an NGO and its Canadian founder build a case for Syrian war crimes,” The Global and Mail, July 21, 2019, https://www.theglobeandmail.com/world/article-al-assads-nuremberg-moment-page-by-page-an-ngo-and-its-canadian. Enab Baladi’s Investigation Team, “Al-Assad’s crimes in millions of documents: When will accountability start?,” Enab Baladi, October 03, 2018,

26 staff office in Damascus from 2010 - 2012, claimed that a weekly report of 300 pages containing the names and detention centers was shared between a security committee of the three power centers: the president, the army chief of staff, and the National Bureau director.135 A study of the regime’s leaked archives shows that the regime’s bureaucracy was essential for organizing mass arrest.136 I argue that a similar conclusion applies to medical violence. Based on painstaking analyses of interviews with perpetrators and documents available in open sources, I argue that there were three levels of decision-making with regards to medical violence in Syria: (1) a national level, which was the authorization and organization of medical violence by the government; (2) a middle level that consisted of medical authorities who acted as intermediary entities, implementing the orders of superiors between various institutions; and (3) a micro-level that represented the decision- making process at medical facilities, and consisted of actions and choices of individual perpetrators, which likely engaged both medical and intelligence personnel. This chapter explores the regime’s weaponization of both military and civil medical facilities for political purposes as they were constructed and experienced by both survivors and perpetrators during the conflict.

2. Military Hospitals

Under normal conditions in most other countries in the world, when sick detainees or POWs are sent to a military hospital, they have the right to receive equal treatment as combatants.137 In the Syrian case, human rights organizations reported systematic violations, torture, and persecutions in medical military facilities directed towards sick detainees.138 Leaked evidence suggested massive exploitation of military hospitals as sites of violence. Photos taken by Caesar, a defected military forensic photographer, were just pieces of evidence showing the final step of a process taking place at military hospitals.139

2.1 Brief History

Syrian medical professionals and their involvement with regime violence preceded the conflict in Syria. Syrian physicians abetted in torture and oppression during the 1980s.140 Prison doctors committed

https://english.enabbaladi.net/archives/2018/10/al-assads-crimes-in-millions-of-documents-when-will-accountability- start/#ixzz6RUodX3Ow 135 Interview with Slaf via WhatsApp, June 12, 2020. 136“Wall Have Ears: An Analysis of Classified Syrian Security Sector Documents,” Syria Justice and Accountability Center, Washington, May 2019. 137Anicée Van Engeland, Civilian Or Combatant? A Challenge for the 21st Century (New York: Oxford University Press, 2011),48- 49. 138 “Health Crisis: Syrian Government Targets The Wounded and Health Workers,” Amnesty International, October 25, 2011. Hilly Moodrick-Even Khen, Yael Siman, “Scorched Earth in Syria: Between Crimes against Humanity and Genocide,” in The Syrian War: Between Justice and Political Reality, eds. Hilly Moodrick-Even Khen, Nir T. Boms, Sareta Ashraph (London: Cambridge University Press, 2020),119-120. “Syria: ‘Shoot to Kill’ Commanders Named,” Human Rights Watch, December 15, 2011. 139 “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. Susie Linfield, “Syria’s Torture Photos: Witness to Atrocity,” The New York Times Book Reviews, February 09, 2019, https://www.nybooks.com/daily/2019/02/09/syrias-torture-photos-witness-to-atrocity/ 140 British Medical Association Oath Betrayed: The Participation of Doctors in Human Rights Abuses (London: Zed Books Limited,1992),153-155. “Syria: Torture, Despair and Dehumanization in Tadmur Military Prison,” Amnesty International, September 18, 2001. “Syria: Torture by Security Forces,” Amnesty International, September 24,1987. ِAyman Al Atoum, 1980- :They could hear the slightest sounds': Ordeals of a prisoner in Tadmur 1980-1997 (Beirut نﻮﻌﻤﺴﯾ ﺎﮭﺴﯿﺴﺣ : ﻌﻣ ﺎ تﺎﺸﯾ ﻦﯿﺠﺳ ﺗ يﺮﻣﺪ 1997 Arab Foundation for Studies and Publications, 2012),78-89. Hiba Al Dabagh, Just Five minutes only: Nine years in the Syrian prisons: Nine Years in the Prisons of Syria, trans. Bayan Khatib (Toronto: B.Khatib, 2007),160-161. 27 crimes of medical negligence while aiding and legitimizing violence.141 For example, Dr. Mohammad Younes Al-Ali killed three of his colleagues at Aleppo Medical School at Tadmur Prison in 1984. The motives of his crime were unclear, although informants referred to his actions as influenced by greed and revenge.142 Another example is Dr. Samer Muhsen, an Alawite doctor from the coastal town of Wadi Al Uyun, who studied medicine at the University of Aleppo and served as the Tadmur military prison doctor in 1988 to 1989. Dr. Muhsen was a content person and a sensitive poet. He deceived my informant, who shared the same interest in poetry and literature. One day, while under the influence of alcohol, Dr. Muhsen cried and confessed to violating detainees and manipulating their families. His friends were amazed by his emotional reaction and shift in mood, from a sad victim of a superior’s orders into a sadistic perpetrator. He joked about the obedience of his victims after giving them the wrong instructions, such as “I gave him medication for scabies with instructions to drink it twice a day.” According to his acquaintances, he never felt any kind of remorse or regret, despite knowing the harm it would cause the patient to drink a topical medicine.143 During 1980s, the medical sector was relatively autonomous in Syria, and hospital doctors provided prisoners with efficient medical care.144 Doctors would not beat or insult their patients, they relatively treated them relatively impartially. Nevertheless, medical ethics were still violated since medical treatment was provided in the presence of guards.145 Medical violence in the 1980s was of an oppressive nature in prisons and violence in hospitals was on a limited scale. In conclusion, medical violence that occurs today is a legacy of a pre-existing routine. The difference with more recent medical violence is the role of political leadership.

2.2 The Route to Agony: Forgotten Names, Unforgettable Journeys

2.2.1 Discourse and Process

Medical professionals often used legal jargon similar to that of the language found in official armed/ ﺴﻣ ﻠ ﺢ “ prisoner” or/ فﻮﻗﻮﻣ “ intelligence apparatus papers.146 They referred to victims as person”, a.k.a. “terrorist”. Using the word prisoner suggested that the person was arrested lawfully and was under investigation of a suspicious offense.147 This language offered a cognitive distance for perpetrators from victims, thereby easing the perpetrators’ ethical and moral burden. Perpetrators who

141 Aziz Abu-Hamad, Andrew Whitley, “Throwing Away the Key: Indefinite Political Detention in Syria,” Human Rights Watch, November 01, 1992. 142 Noteworthy, Dr. Mohammad Younes Ali attended executions of prisoners in the prison yard. Doctors’ supervision of death Shahid wa ﺪھﺎﺷ دﻮﮭﺸﻣو ,penalty and capital punishment is controversial in medical ethics literature. Mohammad Salem Hamed Mashhud (Syrian Center for Studies, 1998),45-49. Mustafa Khalifeh, The Shell: Memoirs of a Hidden Observer (Beirut: Dar Al- Adab, 2008). 143 Interview with Mustafa via WhatsApp, June 25, 2020. 144 Interview with Melhem, April 22 &24, 2019. “Syria: Torture by the Security Forces,” Amnesty International, September 24, 1987. James A. Paul, “Human Rights in Syria,” Middle East Watch, September 9, 1990. 145 Vivienne Nathansonm, “Medical Ethics in Peacetime and Wartime: The Case for a Better Understanding,” International Review of the Red Cross vol.95, no.889 (March 2013): pp.189-213. 146Adam Ciralsky, “Documenting Evil: Inside Assad’s Hospitals of Horror,” Vanityfair-Hive, June 11,2015, https://www.vanityfair.com/news/2015/06/assad-war-crimes-syria-torture-caesar-hospital 147 Syria Panel Code no. for year 1949, articles 195-199. For further read about circumstance of arrest in Syria at: “Torture Archipelago Arbitrary Arrests, Torture, and Enforced Disappearances in Syria’s Underground Prisons since March 2011,” Human The Legal Terrorism بﺎھرإ ا ﻢﻛﺎﺤﻤﻟ ﻲﻓ ﯾرﻮﺳ ﺎ “,Rights Watch, July 3, 2012. And for further reading on the legal process. Anwar Al Bouni at Syrian Court,” The Syrian Center for Legal Researches and Studies, October 11, 2018. “Breaking the Cycle of Enforced Disappearances,” Syria Justice and Accountability Center, August 20, 2019. “Without a trace: enforced disappearances in Syria,” International Commission of Inquiry for Syrian Arab Republic, December 19, 2013. 28 were doctors were convinced that their mission was integral to a licit process, and was merely a part of their job. This was then used as an excuse to systematically deny responsibility. One way in which doctors denied responsibility was by blaming others. They often responded ﻦﺤﻧ ﻣ ﻨ ﻞﻤﻌ ا ﻟ ﻠﻄﻤ بﻮ “ they were orders of the intelligence apparatus” or/ أواﻣﺮ اﻷﺟﻬﺰة ﻨﻣﻷا ﺔ “ with we do as we’re ordered.”148 Another means of denying responsibility was by pretending that they/ ﻨﻣ ﺎﻨ it/ ﺶﻣ ﺷ ﻐ ﻠ ﺘ ﻨ ﺎ “ we don’t know” or/ ﺎﻣ فﺮﻌﻨﻣ “ were ignorant of the whole process, often interjecting with does not concern us.”149 These statements offer an illustration of the manifold bureaucratic process of medical perpetration and sophisticated division of labor. Perpetrators explained this complicated bureaucracy by dividing it into three processes: 1) the referral of sick prisoners from detention centers; 2) the transfer of terrorists from the battlefield or detention center; and 3) the process of death.150

2.2.2 Shattering the Last Hope: “Am I Going to be Killed?”

The forensic photographer Caesar’s photos and documents offered a unique opportunity to understand the bureaucracy of victim deaths and the destruction of evidence. Yet, there was a gap in information regarding the medical handling of sick detainees in Syrian hospitals. This information was essential in understanding the organization of perpetration bureaucratic process. Gaps were then filled by perpetrators’ account and the experience of victims as they shed light on the silence of perpetrators. Medical referral was the first part of the bureaucratic process. The referral experience for detainees was slightly different from that of terrorists or gangsters. Referrals were influenced by the perpetrator’s perception and classification of a patient as either a prisoner or a gangster, and the source of the referral, whether it was from intelligence and detention centers or the battlefield.151 In the case of detention center, detainees were usually injured or became sick due to severe torture or improper conditions of detention such as poor hygiene, crowded cells, and deprivation of food and medical treatment. A branch or prison medical worker normally had to provide the prisoner with proper treatment or order their transfer to a medical center. However, Syrian prison doctors frequently made medical rounds escorted by a guard, asking questions like, “who is sick today, you animals!?” They deliberately neglected sick prisoners’ complaints, providing them with inefficient treatment. Doctors often ordered guards to beat sick detainees, which sometimes resulted in torturing. Therefore, detainees refrained from declaring sickness, as medical care became equivalent to torture, suffering, or even worse. Sick detainees often endured torture, humiliation, and insult from the prison doctor, sometimes leading to their death.152 A detainee, who wrote his memoir under the pseudonym Mohammad Seddek Othman, described the prison doctor’s behavior with patients in 2013. The doctor was irritated by two patients who were sick. He yelled while whipping their bodies, “I am beating you so your voices would be heard by Doctors Without Borders to come and treat you with a better medication.”153 That doctor

148 Interview with dr. Ous via Facebook, May 7, 2020. Interview with Dr. Emad via Facebook, May 12, 2020. Interview with Maan via Facebook, May 13, 2018. 149 Ibid. 150 Interview with Issa via Facebook, May 29, 2019. Interview with Haetham via Facebook, August 17, 2019. Interview with Hasan Ibrahim, May 18, 2020. 151 Interview with Haetham via Facebook, August 17, 2019. Interview with Hasan via Facebook, April 25, 2020. Interview Ous via Facebook, May 7, 2020. Interview with Ebrahim via Facebook, May 18, 2020. Interview with Jamal Yasin Al-Hasan via WhatsApp, November 1, 2018. Interview with Issa, May 29, 2020. Interview with Abudllah Al-Aslman via Facebook, May 12, 2020. Interview with Maan via Facebook, May 31, 2018. 152 Interview with Melhem via Skype, April 22, 2019. Interview with Taem in Paris, July 28, 2019. “‘It Breaks The Human’ Torture, Disease And Death In Syria’s Prisons,” Amnesty International, August 18,2016. As If It Is the Day of Resurrection (Beirut: Beitlmouwaten Publishing house, 2017),62- ﺄﻛ ﺎﮭﻧ ا ﻟ ﯿﻘ ﺔﻣﺎ ,Mohammad Seddek Othman 153 63. 29 not only beat detainees, but inflicted pain on the prisoner’s body to make a statement against the medical assistance provided for the opposition. This same doctor was the person who selected sick detainees to be transferred to a hospital. The prison doctor chose five to six patients out of dozens with acute medical conditions at the prison or the branch. The selection occurred regularly, every two to three days. The selected patients would first register at the prison infirmary, then a nurse fastened a tape on each detainee’s forehead, and proceeded to write on it with the prisoner number and the branch number.154 After enduring horrendous conditions at prison or detention center, they then were transferred ﻢﻗر “ to a military hospital, where the security office registered patients under the name Unknown-Number.” With the number, the office attached a record, with half the fields left/ ﻬﺠﻣ لﻮ ﺠ empty, including little detail of the illness, blood type, and abstract information about the person’s medical condition.155 The record included neither the medical history of the patients nor the cause of illness.156 Patients endured degradation and ill-treatment from medical staff, especially from nurses.157 Sick detainees were usually held at a special isolated department or part of the hospital, usually outside the main hospital building.158 This is where most sick detainees were shackled to a bed and blindfolded.159 The medical treatment and survival of patients at the hospital were determined by a number of circumstances such as timing, the severity of the illness, and most importantly, the doctor’s will, who represented the military medical services directorate and intelligence apparatus or prison’s administration. Although perpetrators often thought patients were “monsters! Unworthy of life,” keeping them alive was a matter of “usefulness” that depended on the “value” of the information they might provide to the security apparatus.160 The second process of the medical bureaucracy concerned the transfer of injured opposition ”.terrorists/ﻣﺴﻠﺤ “ fighters captured during military operations, whom perpetrators referred to as Injured fighters were brought to a hospital, escorted by security agents whose affiliation depended on which geographic zone the fighter was arrested in. The hospital security office then confiscated patients’ identification card and segregated the patients, registering their medical record under the Unknown-Number.” They would then go through normal medical procedures, such/ ﻢﻗر لﻮﻬﺠﻣ “ name as being admitted to the ER, ICU, or any other department according to the medical condition they were in.161 Perpetrators claimed that the security apparatus instructed them to treat those patients well in order to guarantee their fast recovery. However, they admitted that some of those patients were maltreated, blaming uneducated nurses.162 This was typical perpetrator behavior to blame others, depicting themselves as victims and not at fault of the mishaps that were part of regime bureaucracy.163 Issa was a young nurse in his mid-twenties, deployed to Hospital 601 in 2019. He denied the occurrence of medical complicity of torture and killing, and saw the allegations as a type of Western propaganda or a Hollywood-style action movie. He rejected accusations that terrorists and detainees

154 Interview with Mohammed in Amsterdam, July 04, 2020. Interview with Ismael via Skype, May 29, 2020. Interview with Bahjat via Facebook, May 1, 2020. 155 Interview with Bahjat, May 1, 2020. Interview with Ous, May 7, 2020. 156 Interview with Maan via Facebook, May 31, 2018. Interview with Haetham via Facebook, August 17, 2019. Interview with Bahjat via Facebook, May 1, 2020. 157 Ibid. Interview with Ismael via Skype, May 29, 2020. 158 Interview with Dr. Mohammad Whebi via Facebook, May 13, 2020. Interview with Haetham via Facebook, August 17, 2019. Interview with Dr. Khaled via Skype, August 18, 2018. 159 Interview with Ismael via Skype, May 29, 2020. Interview with Mohammad in Amsterdam, June 25, 2020. 160 Ibid. 161 Interview with Haethem via Facebook, August 17, 2020. Interview with Maan via Facebook, May 31, 2018, Interview with Ous via Facebook, May 7, 2020. 162 Interview with Bahjat via Facebook, May 1, 2020. Interview with Ous via Facebook, May 7, 2020. Interview with Jamel Al Hussien via WhatsApp, November 1, 2018. 163 Kjell Anderson, Perpetrating Genocide: A Criminological Account (New York: Routledge, 2017),15-19. 30 were maltreated. Mohammad’s confused response to the accusations reflected a conflict between his conscience and ethics, and orders from superiors. He stated, “When we receive a terrorist, I treat him till he recovers for the security agency … God didn’t give me a soul to kill others … Killing and maltreating a patient is a matter of superior order at the hospital … They forbade ill-treatment of terrorists; they instructed me to treat him in a humane way.”164 Elements of this second process recalled an old routine that had been in practice since before the conflict, such as the number system of patient detainees. Dr. Ali, the former director of Ministry of Interior Police Medical Service, explained that his directorate was responsible for treating sick detainees in intelligence branches affiliated with the Ministry of Interior, such as the political intelligence and the Public Intelligence Directorate. Dr. Ali was also detained for a short period at Al Khateeb Branch in 2012, giving him insight on the process as a victim too. He explained that knowing the names of detainees was a privilege few people in the branch had. These people were the branch director, investigator, and the administration. Before the conflict, when the doctor was called to attend to a sick detainee, he would receive a patient platform with his number and basic information. The doctor-patient conversation was limited to basic questions about the nature of pain. The numbering system was the same as the coding system followed by the army and police forces. The injured or sick combatants were registered in Number Soldier-officer.” The initial number or code/ ﻢﻗر ﻜﺴﻋ ﺮ ي - ﺎﺿ ﻂ“ hospital records as distinguished the foot soldier from the officer.165 The same bureaucracy was applied at military hospitals.166 This facilitated feelings of denial rather than guilt for perpetrators. Perpetrators often denied their abilities to distinguish detainees or POWs from the Syrian army injured personnel.167

2.3 Hospitals as Spaces of Tyranny: Silent Persecutions

Hospitals became integral to the Syrian regime's violent processes from late 2011. Military hospitals were placed as an intermediary in the process where medical staff aided in the regime’s oppressive response. As of mid-2012, the military hospital functioned as a permanent site of violence. Between March and October 2011, military hospitals were placed as mediators between various entities and institutions. Military hospitals in this period were spaces to assist illicit activities such as treating a detainee. They also legitimized state violence by issuing legal documents to conceal crimes. Military hospitals mediated between the secret police and military judicial system, civil registry, and sometimes with the extended families of victims, who were obviously searching for their loved ones.168 These desperate families were instructed to go to medical facilities to obtain medical reports of the deaths of their beloved ones.169 The Fourth Battalion, one of the Assad regime’s most elite and ruthless paramilitary forces, occupied Harasta Police hospital in late 2011. It has since then been used to collect bodies of victims who died in massacres in East Ghouta. Dr. Ali told the story of Yamen, a man from East Ghouta, who went to the hospital to collect his missing brother's body after a massacre in Douma in 2012. The guards showed him the first albums of the victims’ photos. When he struggled to recognize his brother they opened two reefer vehicles cars full of bodies and picked two bodies similar to the brother's

164 Interview with Issa via Facebook, May 29, 2020. 165 Interview with Ali via WhatsApp, June 01, 2020. 166 Interview with Ous via Facebook, May 7, 2020. Interview with Jamel Al Hussien via WhatsApp, November 1, 2018. Interview with Ali via WhatsApp, June 01, 2020. 167 Ibid. 168 Garance Le Caisne, Operation Caesar: At the Heat of the Syrian Death Machine (Cambridge: Polity Press, 2015),8-16, 17-23. 169 “Between Prison and The Grave: Enforced Disappearances in Syria,” Amnesty International, November 5, 2015. 31 described appearance. Eventually, he had to choose between the two. This was a traumatizing process in which he had to choose a body regardless of whether or not it was his brother.170 In mid-2012, hospitals became sites of violence, prisons, torture centers, and persecutions with systematic legitimization of violence. Hospitals became the place where perpetrators romanticized and fanaticized their violence.171 They were spaces in which medical procedures were about pain and suffering, and not healing. Hospitals were where creative forms of torture were combined with the unique skills and knowledge of hospital medical staff.172 Several military hospitals turned departments into solitary and collective confinements with interrogation rooms. Despite the gap of detailed information about the process and organization of medical violence in each of those facilities, there are patterns of organization and processes between military hospitals. The city of Homs is a unique, brutal example of the medical violence that the Assad regime visited upon Syrian society. The uprising in Homs turned violent fairly rapidly in the spring of 2011. Assad’s security forces, together with paramilitary groups, committed massacres, kidnappings, and torture. The conflict in the city took sectarian dimensions between Alawites and Sunnis, and was illustrated in the suffering and pain each tried to inflict onto the other.173 This event was a turning point for the institutionalization of medical violence in Syria, the regime used medical facilities to spread terror and fear in the city, in ways that differed from the broader picture in the wider Syrian society. For example, in 2012, leaked footage from Abd Al Qader Shaqfeh Military Hospital in Al Waer, Homs showed patients shackled to their beds, blindfolded, and naked, showing clear signs of all types of torture.174 The hospital general surgery department became a prison for sick detainees before they were transferred to the hospital’s military police prison, four meters from the main building of the hospital.175 The building was a prison for conscripted medical military services, such as army doctors. Patients were subjected to unnecessary medical interventions that exposed them to unbearable suffering and pain.176 Survivors were taken to one of the intelligence branches in the city to resume interrogation and torture. The dead were placed in plastic bags and buried with discretion. Another example is Tishreen Military Hospital in Damascus, once a symbol of the Al Ba’ath party's great achievement in medicine, but today an infamous extermination site for prisoners. Here, detainees were examined and tested for contagious diseases under constant beating and humiliation from doctors and nurses. The detainees were segregated into a separate building outside the hospital

,Aljumhuriya, July 18, 2018 " تادﺎﮭﺷ ا ةﺎﻓﻮﻟ تﺎﺌﻤﻟ ا ﻠﻘﺘﻌﻤﻟ :ﻦﯿ مﺎﻈﻧ ا ﺔﺤﺑﺬﻤﻟ ا ةﺮﻤﺘﺴﻤﻟ ".Interview with Ali via WhatsApp, June 01, 2020 170 ﮭﺷ ﺎ د تا - ﻓو ﺎ ة - تﺎﺌﻤﻟ - ﻦﯿﻠﻘﺘﻌﻤﻟا - ﺎﻈﻧ م - ﺔﺤﺑﺬﻤﻟا - ةﺮﻤﺘﺴﻤﻟا /https://www.aljumhuriya.net/ar/content ”, ﻦﯿﺣ ﺗ ثﺪﺤﺘ ا ﻧﺰﻟ :ﻦﯾزﺎ ﻦﻋ ﻌﻣ ﺘ ﻘ ﻠ ﻦﯿ ﻦﻣ إ د ﺐﻟ اﻮﻀﻗ ﺖﺤﺗ ا ﻟ ﺘ ﺬﻌ ﺐﯾ “,Raed Razouk, Waed Balkhi, Ghada Baker, Hala Al Haj Ali and Nour Abass Al Zaitoun Journal (Turkey: Al-Noun Publication House, 2018). 171 Michael Taussig, “Culture of Terror: Space of Death: Casement’s Putumayo Report and the Explanation of Torture,” Comparative Studies in Society and History vol. 26, no.3 (July 1984): pp.467-497. Syria: Death Under the Government Authority,” Daraj, September رﻮﺳ ﯾ ﺎ : ﻣ تﻮ ﻲﻓ ﺪﮭﻋ ة ا ﺔﻣﻮﻜﺤﻟ “ ,Shafak Kujak, Raed Al Salhani 172 04, 2018, https://daraj.com/9214/ 173Anthony Shadid, “Sectarian Strife in City Bodes Ill for All of Syria,” New York Times, November 19, 2011, https://www.nytimes.com/2011/11/20/world/middleeast/in-homs-syria-sectarian-battles-stir-fears-of-civil-war.html D. Biliad, N. Nasreldin, “Homs, a Syrian city plagued by sectarian killing,” AFPTV, November 26, 2011, https://www.youtube.com/watch?v=lARJEdMbd7o. Aziz Nakkash, “The Alawite Dilemma in Homs: Survival, Solidarity and the Making of a Community,” (Berlin: Friedrich-Ebert- Stiftung, March 2013). 174 Jonathan Miller, “Exclusive: Syrian doctors ‘torturing’ patients’,” Channel 4, March 4, 2012, https://www.channel4.com/news/exclusive-syrian-doctors-torturing-patients 175 Interview with dr. Mohammed Whebi via Facebook, May 13, 2020. ,Searching for Assad’s Torturers,” Al Jazeera Arabic, May 10, 2020 ﺚﺤﺒﻟا ﻦﻋ يدﻼﺟ ﺪﺳﻷا “ ,176Mahmoud Al Kin https://www.youtube.com/watch?v=Tt614Ar8cH0. “Syria: Health Crisis: Syrian Government Targets the Wounded and Health Workers,” Amnesty International, October 25, 2011. 32 main building.177 Medical negligence and brutality was a form of torment, used besides the manipulation of the prisoners’ need for food and water to subjugate and kill other victims, which led the victims to “kill in order to survive.” Doctors at Tishreen were experimenting with the human instinct to compete for food, in which you had to kill in order to eat and survive. It was a basic and instinctive process of competition and selection. The cuvee and cell leader would take the task of the torturer and kill his inmates. The perception of being in a healing house should ease a prisoner’s pain and increased his trust. The expectation of better conditions fell apart. They were at the mercy of senseless torturers and servitudes, as doctors dehumanized their victims to the extent of depriving them of treatment, food, and hygiene. Pain became a torture method in which the passivity of doctors would increase the likelihood of detainees’ torment and death.178

2.3.1 Al Sanamayn Military Hospital: Restrains of Violence

Inconsistency in regards to the regime’s use of hospitals as centers of violence existed. One such example was Al Sanamayn Military Hospital, officially known as Martyr Ismail Al Sa’adi Hospital. The hospital was a hybrid investment of both the Ministry of Health and the Ministry of Defense. It was an example of where doctors had the potential to restrain from using violence in hospitals. In 2011, the hospital director, doctors, and military intelligence agreed not to torture or kill people inside the hospital. Doctors treated patients and facilitated their escape. However, this did not prevent security forces from seizing the opportunity to arrest some patients at the hospital or when they departed, and occasionally tortured injured demonstrators. Medical professionals and guards took patients to an operating room at the end of the long corridor on the first floor, where Dr. Ahmed Suker, a cardiac surgeon, would perform unnecessary medical procedures. Sometimes sick detainees’ voices were heard by hospital workers on the ground floor wards.179 Dr. Suker because of his compliance in torturing demonstrators, was promoted to the General Director of the prominent Al Basel cardiac disease and surgery center in Damascus. Although the regime could not use the hospital as a site of violence, the intelligence forces used Al Sanamayn Hospital as a platform to propagate the regime narratives of terrorist threats to spread fear and uncertainty between various groups. They would arrest someone, torture him severely, and then throw him in front of the hospital, where he would receive treatment for a couple of weeks. Then the military intelligence would kidnapped him and leave his dead body outside the hospitals, claiming that he were kidnapped and killed by the terrorists in Dar’a Al Balad.180 This tactic created confusion among the medical staff and the population, allowing intelligence forces to be relieved and instead have “terrorists” blamed. A combination of factors may have prevented the complete weaponization of Al Sanamayn Hospital. These factors included the medical staff’s complex social and political backgrounds and its geographic location. First, the majority of doctors were from Dara’a, a city that has a complex social construction of tribes and blood relations. The doctors were mostly Sunni with some Shia from the local community, who belonged to the same family or tribe. This dual connection of patient-doctor, and doctor-doctor at Al Sanamayn Hospital had a second layer of connection that was family relations and tribal customs. This made it difficult for government intelligence to influence medical practices there.

177 “Human Slaughterhouse: Mass Hangings and Extermination at Saydnaya Prison, Syria” Amnesty International, February 7, :Saydnaya Prison throughout the Syrian Revolution ‘testimonies’,” (Ghaziantep ” ﻦﺠﺳ ﻧﺪﯿﺻ ﺎ ﯾ ﺎ لﻼﺧ ا ﻟ ةرﻮﺜ ا ﺔﯾرﻮﺴﻟ دﺎﮭﺷ تا “ .2017 Association of Detainees and The Missing in Sednaya Prison, 2019). 178 Ibid. 179 Interview with Omar via Skype, April 22, 2020. 180 Interview with Omar via Skype April 22, 2020. 33

Furthermore, the hospital was located in an environment hostile to the regime and its army. This was in spite of the strong presence of military divisions such as the Fifth Division. In addition, Dara’a was relatively far from the regime’s political centers, potentially making medical professionals more vulnerable to retaliation from locals.181 These elements of circumstance made the hospital an unsuitable environment for perpetration.

2.3.2 The Abyss: Yousef Al Azzmeh Hospital 601

Hospital 601 has a long history of normalizing daily medical violence, even before the conflict. It was a human slaughterhouse”.182 Soldiers/اﻟﻤﺴﻠﺦ اﻟ ي“ infamous between combatants and known as would reject their referrals to the hospital, fearing ill-treatment and improper healthcare conditions. The hospital consisted of two old buildings built in the French mandate era. One of the buildings was ( ﺘﺴﻣ ﻒﺻﻮ ) for the hospital’s administration and the staff’s housing. The other building was the clinic and prison where sick detainees were held captive in the 1980s.183 Located on Mount Qasioun, the hospital has a fascinating view of Damascus and served as a prison for sick detainees who were tortured and killed in silence during the conflict.184 During the conflict perpetrators referred to the the old trauma center.” Calling the building "the old trauma/ ﻢﺴﻗ ا ضﻮﺿﺮﻟ ا ﻟ ﻘ ﺪ ﯾ ﻢ “ hospital prison as center", a surgical term, should normally indicate the medical intervention in the center. It gave in this context certain image of militarized purpose and actions “a surgical operation.”185 In addition to the two original buildings, the hospital also contained two new buildings. One was the old-new trauma center, a five story building that opened its door shortly before the war. The second and the newest building was the internal diseases department, which was built and opened during the conflict in 2014. It mainly served as a recovery center for sick and wounded army soldiers.

2.3.2.1 Death Chambers: Medical Torture and Killing

Throughout the Syrian conflict, Hospital 601 can rightly be characterized as a death camp for sick detainees. The patients were first selected from the prisons of Air Force Intelligence, Military Branch 215, and Saydnaya Prison. The hospital security office and administration separated patients into two categories and different rooms depending on their referral source. Sick detainees from Air Force Intelligence and Saydnaya Prison detainees were placed in two wards, a small room of four beds and a mid-size room of six to seven beds. A third room was for patients transferred from the Military Raids 215 [Figure 2.1].186 This system of segregation was not based on the types of illnesses or medical intervention needed by patients, but instead by levels of cruelty and violence to be experienced by inmates. Inmates in the Branch 215 hospital room were likely to be subjected to extreme violence.187 The 601 medical staff spawned an expansion of the regime’s deliberate extermination policy of the detainees. In the hospital, a second round of selection took place, this time internally. Patients marked as useless or disobedient would be subjected to death. Medical doctor Colonel Dr. Mohammad selected victims of medical persecution in his weekly visit to the prison ward. He sometimes even decided the killing method, exploiting his knowledge of the detainees’ medical

181 Interview with Abdullah via Facebook, May 12, 2020. 182 Interview with Haetham via Facebook, August 17, 2020. 183 Interview with Melhem via Skype, April 22, 24, 2019. 184 “The Testimony of the Detainee: Mazen Besais Hamada on Air Force Branch-Mazzeh Military Airport And Military Hospital 601 in Mazzeh, Damascus,” Violation Documentation Center in Syria, October 2013. 185 Interview with Haetham via Facebook, August 17, 2020. 186 Interview with Mohammad in Amsterdam, August 25, 2019 & June 24, 2020. Interview with Ismael via Skype, May 29, 2020. 187 Ibid. 34 conditions and vulnerabilities. The selection was coordinated with the intelligence branches administrations and conveyed by Dr. Mohammad’s orders. In the winter of 2012, Dr. Mohammad was irritated by a young patient, Muhannad. Muhannad a traditional Syrian ,( ﻼﺣ و ة ) was a patient who suffered from type 1 diabetes. He deliberately ate halawa dessert heavy with sugar, distributed irregularly to detainees in prisons and hospitals. Eating halawa raised his diabetes test results so he could avoid interrogation. Dr. Mohammad deprived the patient of insulin as punishment and transferred him to solitary confinement at the old trauma center at the hospital, where he was interrogated and tortured for five days. When Muhannad returned to his cell he was in critical condition, covered in bruises, and hallucinating. He died in desperation of water, food, and medicine. Dr. Mohammad was please when he found out about of Muhannad’s death from he died sir!” and deliberately expressed it. The story of Muhannad is a/ ﺲﻄﻓ ﺳ يﺪ “ ,the prisoners good illustration of how doctor-perpetrators could behave as desensitized as non-medical perpetrators, and come to see killing defenseless people as normal.188 Guards also organized group persecutions at the hospital, often authorized by Dr. Mohammad who was the appointed doctor of the Air Force Intelligence Directorate. Perpetrators called these or ”, ﻔﺣ ﻠ ﺔ إ ﺪﻋ ا ﻣ تﺎ /persecution party“ ”, ﺤﻣ ﻤ ﺔ إ ﻟ ﻬ ﺔ /sessions by various names, such as “divine court They took place every night and the number of victims ranged from 189”. ﻔﺣ ﻠ ﺔ ا ﻮﺸﻟ ا ء /the “BBQ party one to five people each day. Perpetrators often used these euphemisms as a death threat during the torture, “remember this is the divine court.”190 Perpetrators not only tortured and murdered, but also made sure to psychologically exhaust their victims. They terrorized victims by humiliating them and their culture, as well as keeping them under a constant threat of death. This was done under the perpetrators’ words as “a reminder of their “shameful” fate”. The term “divine court” supposedly legitimized an unlawful act while insulting the victims’ religious beliefs. The terms “persecution party” and “BBQ party” were embedded in the perpetrators’ sadistic tendency and aided in their ability to terrorize detainees or break off their resilience. When Mohammad was told by the nurse in the Air Force Directorate that he was going to be transferred to Hospital 601, he crawled out of the infirmary, begging the nurse not to send him there. “I have heard of the horrors there, are they sending me to be killed?! Let me die here!” The assuring words of the guards did not calm the anxious Mohammad. Mohammad would witness maltreatment, torture, and collective persecutions.191 During Mohammad’s first night at Hospital 601, he witnessed Abu Shakoush’s “BBQ party” and Azreal’s “divine court.” Four inmates from Homs and Darrya were dragged out of Ward 215 and in to the corridor where they were then beaten and lashed. Abu Shakoush poured fuel on them, then set their bodies on fire, while kicking them on the head, chest, and abdomen. One inmate survived, so Abu Shakoush ordered Subhi, the forced laborer, to finish him off with a warning “one has to die today, will it be you or him?!”192 Medical staff often heard the horrific sounds of detainees’ screams of pain and agony, as the sound reached the dormitory. These sounds and voices became a myth attached to the hospital

188 Robert M. Kaplan, Medical Murder: Disturbing Cases of Doctors Who Kill (West Sussex: Allen & Unwin, 2009),201-221, Michael Gordin, George Annas, “Physicians and Torture: Lessons From the Nazi doctors,” International Review of the Red Cross vol.89, no.867 (June 2007): pp.635-654. Michael Foucault comprehensively criticized modern medicine and “biopolitics”, when he coined the term “clinical gaze”, read: Michael Foucault, The Birth of the Clinic (London: Routledge, 2013),111-117. 189 “The Testimony of the Detainee: Mazen Besais Hamada on Air Force Branch-Mazzeh Military Airport and Military Hospital 601 in Mazzeh, Damascus,” Violation and Documentation Center in Syria, October, 2013.Interview with Mohammad in Amsterdam, August 20, 2019. Interview with Ismael via Skype, May 29, 2020. 190 Interview with Mohammad in Amsterdam, August 20, 2019. 191Ibid. 192Ibid. 35 building and name. Issa, a nurse who began working at Hospital 601 in 2019, told of the rumors and stories, “A lot of people told me before I began the work that I would never sleep at night because of the voices coming from the old trauma center.”193 Additional contributing factors to detainee deaths in Hospital 601 were the imprisonment conditions of poor hygiene and sanitation. These circumstances were created to weaken the patients’ bodies and break them psychologically. Two or three patients shared one bed with their legs chained to the old iron beds and their eyes blindfolded. Four to six detainees shared the same bottle to urinate in, increasing the risk of contagious diseases and the spread of infection. Patients who had gastrointestinal diseases would use plastic bread bags and the bed sheets to clean themselves.194 Doctors and nurses did not sympathize with the detainees. Dr. Haetham, an orthopedic surgeon from Deir Ezzor, considered the conditions at the old trauma center as proper and suitable for healing.195 This was the same surgeon who had beaten the broken legs of patients.196 Hospitals are supposed to be a safe place of integrity, and medical staff should respect a patient’s will and dignity while easing their pain and suffering.197 Hospital 601 however, was not that type of place. At Hospital 601 patients were subjected to horrific conditions to their well-being, including humiliation, degradation, and death. Medical torture is the type of torture that involves medical expertise and knowledge in the actual torture process. The abovementioned Dr. Mohammad examined the patients, then instructed further medical intervention. The doctors treated patients without anesthesia. Nurses would not change patient bandages or give them medicine. Patients were beaten, lashed, threatened of death, and insulted along with medical treatment. These were not examples of incompetence, rather a policy from the hospital administration. Hospital 601 was infamous for legitimizing the extermination of the Syrian regime's political enemies. It has been an infamous site to document death from security branches. According to a leaked document from the crisis unit obtained by Commission for International Justice and Accountability (CIJA), the unit ordered to centralize the documentation and destruction of evidence in Hospital 601 in 2012.198 The majority of Caesar’s photos were taken at the hospital garage between 2011 and 2013.199 Bodies of patients who died at the hospital were dragged out to the corridor by their fellow inmates, then the guards pitched them into the garage, where the forensic pathologist supervised a process that included taking photographs, writing a medical report, and then proceeding with burials. Hospital 601 is the archetype of a regime death hospital, a name intertwined with brutality, cruelty, suffering, and death for many Syrians. It was a manufacturer of medical violence and gained a widespread reputation as a place where you should never end up. According to the accounts of perpetrators, choosing Hospital 601 as a center was for practical reasons. There are two dimensions that contributed to the regime’s selection of Hospital 601 as the center of its genocidal campaign. First, its secure location and approximate distance from security branches and the highly securitized

193 Interview with Issa via Facebook, May 29, 2020. 194 Ibid. 195 Interview with Haetham via Facebook, August 17, 2019. 196 Interview with Ismael via Skype, May 29, 2020. 197 Elizabeth Smythe, “The Violence of the Everyday in Healthcare,” in First Do No Harm: Power, Oppression, and Violence in Healthcare, ed. Nancy L. Diekelmann (Madison: University of Wisconsin Press, 2002),164-168,173-174,197-200. 198 Louisa Loveluck, “The Hospitals were Slaughterhouses: A Journey into Syria Secret Torture Wards,” The Washington Post, April 3, 2017, https://www.washingtonpost.com/world/middle_east/the-hospitals-were-slaughterhouses-a-journey-intosyrias-secret-torture- wards/2017/04/02/90ccaa6e-0d61-11e7-b2bb-417e331877d9_story.html 199“The Photographed Holocaust: Analytical Study about the Leaked Pictures of Torture Victims in Syrian Military Hospitals,” Syrian Network For Human Rights, October 15, 2015. “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015 36

Mazzeh Military Airport. Airplanes were used to transfer detainees from battlefields and other provinces. Second, the design of the facility, with separate buildings on sizable land, enabled the segregation of detainees from the other patients. Perpetrators referred to recent and extensive renovation which took place at Hospital 601 between 2014 and 2016. The building shapes were disguised until it became unrecognizable.200 It was likely an attempt to destroy evidence of mass atrocities.

2.3.2.2 Doctor Mohammad Barakat: The Killing Master

Colonel Dr. Mohammad stood in front of the cell at the Air Force Intelligence Directorate, selecting the next victims to be brought to Hospital 601. The victims of Dr. Mohammad were sick detainees who were arrested for allegedly carrying out anti-regime activities and were identified as terrorists or enemies of the state. The detainees were usually from diverse social strata, religions, and geographic zones. Dr. Mohammad chose the sick detainees based on a vague criterion of selection. Vague because some patients with acute health conditions were left to die. Sick and exhausted detainees waited for his weekly visit on Sunday. Dr. Mohammad maintained the protocol of his medical examination and was accompanied by a nurse. During his examination he joked and smiled at the patients. He then ended the inquiry with a threat and a cold smile, “You have three days, if you don’t heal by then, I am going to kill you!!!”201 Sometimes he would authorize an interrogation of a patient in a room right next door, where he would personally supervise the torture. The most shocking sentence Dr. Mohammad .”we are done with him/ ﺎﻨﺼﻠﺧ ﻦﻣ ﻨﻋ هﺪ “ ,said was This description refers to a successful interrogation process and authorization to persecute the patient. The victim, in other words, became “useless,” a mere liability since he had confessed. Dr. Mohammad’s behavior suggested that he formed a psychological defense mechanism called “doubling,” much like his Nazi counterparts. Doubling is a concept founded by Dr. Robert Lifton. This is when perpetrators compartmentalize themselves into two functions and distinct personality, a new self-separated perpetrator from the doctor’s itself.202 But what do we know of Dr. Mohammad? Who is he? Information suggests that Colonel Mohammad was just a disguise to cover the actual perpetrators [Figure 2.2].203 Perpetrators refrained from speaking of Colonel Mohammad and even denied any knowledge of such a person. After an exhausting exercise with my informants, some recognized Colonel Mohammad as the retired major general Dr. Mohammad Barakat. Barakat was a prominent Alawite doctor from Qardaha and the former director of Homs Military Hospital until 2007. The old man, in his mid-seventies, was not only a doctor, but also an Alawite cleric. He is one of few Alawite sheikhs, who actively participated in the regime’s violent repression of any opposition.204 The uniqueness of Dr. Mohammad is the complex configuration of his identity as a doctor, a torturer, a murderer, and a sheikh. He utilized his medical skills and knowledge to silently and efficiently incite violence, select, torture, and kill people for political purposes.

2.3.2.3 The Guards: Rescuers or Killers?

200 Interview with Ous via Facebook, May 7, 2020. Interview with Hasan via Facebook, April 25, 2020. Interview with Ebrahim via Facebook, May 15, 2020. 201 Interview with Ismael via Skype, May 29, 2020. 202 Robert J. Lifton, The Nazi Doctors: Medical Killing and The Psychology of Genocide (New York: Basic Books, 1987),433-466. 203 Interview with Abdullah via Facebook, May 20, 2020. 204 Uğur Ü.Üngör, “Alawite Warriors Sheikhs; Ali Khizam and the Specter of Sectarian Violence in Syria,” Routledge Handbook of Religion and Violence, ed. Stephen Smith (New York: Routledge, 2021), forthcoming. 37

Three torturers guarded the detainees at the Hospital 601 prison. They often used pseudonyms: Wassem Azrael Air Force Intelligence, Azrael 215, or Hussam Abu Shakoush.205 Their real names and identities were unknown. They were notorious because of their brutality and cruelty to victims. Each of them created a method of torture and killing and chose an illustrative pseudonym to fit it. They wanted to be a myth, their names and deeds haunted the victims’ bodies and nightmares. means ‘Hussam the Hammer’, a tall man who always wears ﻮﺑا شﻮﺎﺷ Hussam Abu Shakoush military shoes.206 Victims fearfully remembered the sound of his heavy shoes and their smell. Few victims saw his face. He had a firm policy that victims had to be blindfolded when he entered the room or he would kill them. It made identifying the man behind the torturer difficult. Some victims recognized a certain Moharram as the notorious Abu Shakoush, an Alawite from Masyaf town in North West Hamah. This young man was in his mid-thirties and married, with one son. Abu Shakoush was a nurse, probably in a mobile team, who worked for the Military Medical Directorate. As a field hospital nurse, he was appointed for a mission with Air Force Intelligence. He had an athletic build and the strength required to perform its mass persecution “parties”. Abu Shakoush would use a hammer to kill his victims by smashing their heads. Most victims saw Abu Shakoush as a restrictive, cruel torturer, and a brutal killer. Yet, Abu Shakoush as a man was mysterious, as were his views and perceptions of himself, his victims, motives, and the justification of his perpetration.207 “Divine court” was the rituals of killing associated with the guard Wessam Azreal. The nickname Azreal reflects a special meaning in the Islamic theology, the God’s servant who captures souls. Being the “angel of death” was how he wanted to be remembered by his victims, the man who would take their souls in his will not the God’s. The name Azrael is in itself intimidating for the victims’ culture and beliefs. It also entailed humiliation and threat to his victims. He often said “I killed many this night.” He wanted to deprive them of hope too, by saying: “I am the God here.” He was a sadistic killer and a trained torturer who normalized and habitualized murder.208 Wassem Azrael, as known by the victims, was a tall and thin man, with brown, short and stringy hair. He was also a nurse who worked for the Military Medical Directorate.209 Despite being a notorious killer, Azrael marked some sick detainees as “Azrael’s special.” This status was enough to protect them from Abu Shakoush and Azrael 215– the latter being a different Azrael who worked at the Branch 215. The victims also benefited from certain privileges in terms of food portion, hygiene, and services. While Azrael would mark other patients as dead in a subjugation of the body for promising punishment. He was the rescuer and hero for some, as a victim said: “he saved me, I would never forget his favor,” and a killer for others. Other victims would end up dead after Azrael tormented and tortured them at night. Azrael’s rescued victims had no moral engagement or ties with him. It was unclear why he rescued them. The notion of perpetrator is not a fixed category in mass violence research; it is a fluid concept, interwoven with other categories.210 The explanation of perpetrators rescuing victims in mass atrocities context can vary in circumstances and ties with victims. Also, perpetrators’ psychological needs factor in, as they need to distance themselves from the frame of self-identification as perpetrators, or the

205 Interview with Ismael via Skype, May 29, 2020. 206 Interview with Ismael via Skype, May 29, 2020. Interview with Mohammad in Amsterdam, June 25, 2020. 207 Interview with Ismael via Skype, May 29, 2020. 208 Ibid. 209 Interview with Ismael via Skype, May 29, 2020. 210 Kjell Anderson, “The Margin of Perpetration Shifting-role in Genocide,” in Perpetrators of International Crimes: Theories, Methods, and Evidence, eds. Alette Smeulers, Maartje Weerdesteijn, Barbora Holá (New York: Oxford University Press, 2019),134,137-139, Kindle. Timothy Williams, “Thinking beyond Perpetrators, Bystanders, Heroes: A Typology of Action in Genocide,” in Perpetrators and Perpetration of Mass Violence: Action, Motives, Dynamics, eds. Timothy Williams, Susanne Buckley- Zistel (London and New York: Routledge, 2018),54-56, Kobo. 38 self-fulfilling part, consequently bolstering a positive-self-image. In some other cases, rescue can be an act of opportunism.211 Azrael's case is probably a combination of these explanations, especially since he was a conscious and willing perpetrator with independent agency.

2.3.3. Process of Death: Medical Destruction of Evidence

The last step of the bureaucratic medical process was that of death. The surviving patients returned to the branch or prison which they had transferred from or sometimes to court or another branch. The dead cases were documented in a bureaucratic manner and buried in identified places or cemeteries.212 It was a silent systematic destruction of evidence supervised and devised by forensic pathologists. Each body had a piece of tape with the branch name, the dead person’s number, and the 213. ضﻮﺿر /number of their medical file. The ones who died in a hospital were labelled under trauma The bureaucratic routine and normalcy started with the registration of bodies in the hospital records, to writing medical reports stating, as is common practice in Syrian hospitals, that the patient Thereafter, a forensic pathologist examined ”.ﺗ ﻒﻗﻮ ﻗ ﺐﻠ و ﺗ ﺲﻔﻨ /’’died of ‘’heart or respiratory failure the bodies in a nonscientific manner nor in a suitable environment, accompanied by a military photographer from military police. The forensic report, issued for several patient numbers at once, would state that the cause of death was natural.214 This way, the denial of harm and violence was intrinsic into medical procedures. However, it seems that an amendment was made after the establishment of the Syrian Forensic Pathologist Corps in late 2014.215 Theoretically, the new entity was an independent body that had to investigate the death of war casualties regardless of their political affiliation. This means that the death certificate had to involve a detailed somatic description and the actual cause of death. The corps pathologists have been issuing detailed reports for a few well-known and mediatized cases like American journalist Mary Colvin or the child Hamzeh Al Khateeb, as well as mass graves, and massacres such those that took place in Rural Latakia.216 In some cases the pathology reports consisted of abstract truth, where the pathologist deliberately falsified and covered up pieces of information in the majority of the report. In cases which involved torture, their reports were biased and politicized, blaming the victims or covering up traces of torture. Pathologists also communicated inaccurate narratives of these incidents, legitimizing regime violence.217 Up until today, the only change in reports is that cause of death is no longer a general description of “heart and respiratory failure,” but to a more specific diagnosis of “heart attack” or “cardiac arrest.”

2.3.4 Major General Doctor Ammar Suliman: The Mastermind of Medical Violence in Syria

211 Kjell Anderson, Perpetration Genocide: A Criminological Account (London and New York: Routledge, 2018),277-279. 212“The Photographed Holocaust: Analytical Study about the Leaked Pictures of Torture Victims in Syrian Military Hospitals,” Syrian Network for Human Rights, October 15, 2015. “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. 213 “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. 214 Ibid. 215 The Supreme Corps of Syrian Forensic Pathology, Decree no.17 for 2014. 216“Syria: Executions, Hostage Taking by Rebels: Planned Attacks on Civilians Constitute Crimes Against Humanity,” Human Rights Watch, October 10, 2013. Interview with Bassam Mohmmad via WhatsApp, July 10, 2012. ,Min Al Aryd: Forensic Pathology: Body and Identity,” Al Maydeen tv channel ﻦﻣ ضرﻷا : ﺐﻄﻟا ﻲﻋﺮﺸﻟا : ﺜﺟ ﺔ و ﻮھ ﯾ ﺔ “ ,Ogarit Dandash 217 January 3,2019, https://www.youtube.com/watch?v=NG9uTW8UVeg ,War in the Eyes of Forensic Pathology,” AL Maydeen Tv, March 26, 2020 بﺮﺤﻟا ﻲﻓ نﻮﯿﻋ ﺐﻄﻟا ﻲﻋﺮﺸﻟا “ ,Ogarit Dandash https://www.youtube.com/watch?v=MKvdWSYQWDE 39

Dr. Ammar Munier Suliman was from Qardaha in Latakia, the same town where the Assad family is from, and the hometown of Dr. Mohammad Barakat. He was born in 1964, and led an early life full of suffering and scarcity during his childhood and youth, due to his family's impoverished economic conditions.218 He grew up under the Ba’ath party and Hafez Al-Assad’s rule, and had never experienced a different ruler or regime. Suliman belonged to a generation of Syrians who experienced defeat against Israel in a series of wars, the Six Days War in 1967 and the Yom Kippur War (Tishreen War) of 1973. These defeats created a collective sense of shame and frustration for the following Syrian generations.219 The regime’s repression of the Muslim Brotherhood (1975-1982) movement was another collective trauma that affected Suliman’s generation’s psyche. This time period included the Muslim Brotherhood’s attacks on Alawite militants, university professors, doctors, and others. These attacks were a real threat to the Alawite community.220 Major General Suliman was just 12 years old when the clash with the Muslim Brotherhood erupted and he was already 18 years old when it came to an end. His generation of Alawites shared a traumatic past with national failures that evoked fear and anxiety of the “other”. This generation of Alawites saw in Hafez Assad’s policy that excessive violence and massacre towards those who posed as a threat to the regime, or “the enemies of the state,” was the sole means of survival.221 General Suliman was raised in a militarized sphere, where he, like many other Syrians, received education in strict militarized schools. In these schools learning Ba’ath ideology and military training was mandatory. These circumstances were significant factors in the configuration of Suliman’s identity, both as a man and as a doctor. Dr. Suliman was 18 years old when the Hama massacre took place in February 1982. He was Bashar Al-Assad’s friend and colleague. Both graduated from the medical school in 1988, then Suliman joined the army as a medical doctor in 1984. He continued his military career as he trained in neurosurgery at Tishreen Military Hospital after graduation. Dr. Suliman's close friendship and affiliation with Bashar Al-Assad and his wife made him powerful and untouchable. He was the actual decision-maker in the Military Medical Service Directorate since he was a captain. This was even before he was officially appointed as the director of the Military Medical Service during the war in 2017.222 He enjoyed influencing military institutions due to personal and business connections with Major General Hasan Turkmani. He also built a vast network which included western diplomats and Arab activists. He was also active in human rights groups, such as the Arab Network for Child Protection [Figure 2.4].223 Ironically, children today are amongst the group of victims on whom Dr. Suliman practices medical violence. Dr. Suliman was a controversial figure. For some acquaintances of Dr. Ammar, he was a decent, discreet, and intelligent man. He was seen as a successful doctor and a loving father of two teenage daughters and a son.224 While for others and his subordinates, he was viewed as a dictator, an eternal director, a narcissistic, arrogant, and strict man who accepted neither disobedience nor critique from his subordinates.225 While some depicted him as a fanatic Alawite believer and sadistic torturer, others described him as an ardent Assadist. He has portrayed a different attitude towards each

218 Interview with X via WhatsApp, May 18, 2020. 219 Robin Yassin-Kassab, Leila Al-Shami, Burning Country: Syrians in Revolution and War (London: Pluto Press, 2016),09-13. 220 Raphael Lefever, “The Syrian Muslim Brotherhood Alawis’ Conundrum” in The Alawis of Syria: War, Faith and Politics in the Levant, eds. Michael Kerr, Craig Larkin (New York: Oxford University Press, 2015),27-49. 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 (London: Routledge, 2018),147-151. 221 Sam Dagher, Assad or We Burn the Country,22-27. 222Interview with Ous via Facebook, May 7, 2019. Interview with Hasan via Facebook, April 25, 2020. 223 Interview with Ali via WhatsApp, June 01, 2020. 224 Interview with Hasan via Facebook, April 25, 2020. 225 Interview with X via WhatsApp, May 18, 2020. Interview with Ebrahim via Facebook, May 18, 2020. Interview with Emad Suliman via Facebook, May 12, 2020. Interview with Ous via Facebook, May 7, 2019. 40 opposition group. Doctor X claimed that he tolerated some opposition groups, especially those from minority backgrounds or those who did not depict resentment towards Bashar al-Assad.226 Dr. Ammar Suliman is the Syrian example of SS doctors in the Holocaust. He was a military doctor and an intelligence agent. Our knowledge of his exact role was limited due to the regime’s discretion and censorship. However, both his colleagues and eyewitnesses asserted that Dr. Suliman had a key role in organizing and ordering medical violence in Syria, including torture, persecutions, and forging evidence. Dr. Suliman was pioneer of persuading the decision of using Syrian hospitals as extermination centers. Dr. Mohammad Wehbi, a former urologic surgeon in Abd Al Kader Shaqqfeh Hospital in Homs, claimed that Dr. Suliman ordered the security officer of the hospital, Dr. Haetham Ottoman, to torture and terrorize patients detained in the hospital.227 Dr. Suliman was responsible for the recruitment of medical staff in the army and deployment into hospitals and fields. This included deploying medical staff into security branches.228 He had the upper hand over the medical staff in various entities. He most likely organized, coordinated, and ordered torture and killing in hospitals. It is suspected he was the one who designed medical torture and organized medical violence in branches from negligence to process of selection, identification, and categorization of victims and their fate. Above all, Major General Dr. Suliman was a torturer, who carried out arrest and torture campaigns. He joined arrest raids with military intelligence in the neighborhood of Barzeh in 2012.229 Today, Dr. Ammar Suliman is a leading figure with First Lady Asma Al-Assad in their charitable NGO of Jarih Al-Watan project to treat and rehabilitate the war-wounded from the Syrian army [Figure 2.5].230

3. Civilian Hospitals: A Torture Archipelago

Civilian hospitals were strategically employed to engage in violence by actors who influenced and have been influenced by the relationship between the hospital and war. Specifically, three categories of actors intended to aggravate the implication of hospitals in violence. These categories were: 1) the Syrian army and intelligence forces; 2) paramilitary groups sponsored by the state, known as Shabbiha and organized under the name of popular committee and then NDF (National Defense Forces); and 3) medical staff of the hospitals. Civilian hospitals also produced and reproduced violence. Civilian facilities were sites of violence when they functioned as detention and torture centers. Medical staff, together with intelligence forces, performed physical torture on the detainees or prisoners of war (POWs). Public medical facilities developed into places of captivity and torment and secret gulags.231 Examples are plentiful. The security forces stole corpses and tortured people in Aleppo public hospitals.232 In Homs National Hospital, doctors were beaten to death because they protested and intervened to stop colleagues from torturing patients.233 Civilian hospitals incited violence, taking advantage of a hospital space to target vulnerable communities. The regime allocated resources and deployed troops to civilian hospitals in Dara’a. The national hospital in Al Mahatta evolved into a military base where the regime launched attacks against individuals and surrounding neighborhoods.234 The insurgence launched counter attacks on several hospitals and abducted medical staff. Rooftops

226 Interview with X via WhatsApp, May 18, 2020. Interview with Ebrahim via Facebook, May 18, 2020 227 Interview with Mohammad Whebi via Facebook, May 13, 2020. 228 Interview with Ous via Facebook, May 7, 2019. Interview with Hasan via Facebook, April 25, 2020. 229 Interview with X via WhatsApp, May 18, 2020. 230 See video of Dr. Ammar Suliman with Asma Al-Assad in a conference about Jarih Al-Watan project, https://www.facebook.com/jarihalwatan.sy/videos/168515414590372/:last checked on June 27, 2020. 231 Interview with Ahmad via Skype, August 27, 2019. Interview with Milad via Facebook, May 22, 2020. 232International Commission of Inquiry for Syria Arab Republic, A/HRC/23/58, A/HRC/25/65. 233 Interview with Dr. Mohammad in the Netherlands, June 12, 2018. 234“Health Crisis: Syrian Government Targets the Wounded and Health Workers,” Amnesty International, October 25, 2011. 41 of hospitals were used as sniper positions by regime snipers. All in all, the regime clearly abused the physical space of civilian hospitals to promote violence. Paramilitary groups made use of their influence in some cities, often making alliances with medical staff to torture patients. Several incidents of maltreatment, torture, and killing occurred in civilian hospitals across the country. Dr. Khaled eloquently described this phenomenon as a deviation of traditional power in medicine and a tremendous expansion of civil power over medical facilities in the Syrian conflict.235 The popular committees and its organized form, the NDF, in Homs abducted men from the Sunni neighborhood. Entirely in line with the increasingly sectarian confrontation in that city, militiamen secretly tortured and humiliated their victims in the Al-Abbasiyah clinic in the Alawite neighborhood of Al Zahraa. Medical professionals collaborated with Shabbiha, as they tortured the victims physically and psychologically. Victims were subjected to forms of degradation and humiliation based on cultural sensitivities, stripping them of clothes in front of female nurses and insulting them verbally: “Where This suggestive act entailed a sexual offense 236.( ﺎﻬﻨو ﻚﻣأ كﻻو ناﻮﻴﺣ ) ”?!is your mother, you animal aimed at dishonoring the victims. In another example, Salamiyah National Hospital was known for the first public exhibition of violence. In 2013, Nadim Salameh, a member of the Popular Committee, and Adeeb Salameh, the director of Air Force Intelligence in Aleppo, beheaded a Free Syrian Army (FSA) fighter and then hanged it for public display in front of the hospital for two hours.

3.1 Al Mujtahid Hospital: A Secret Detention Center

Damascus Hospital, Al Mujtahid, was built by the founders of the postcolonial Syrian state (1945- 1955). It was the hospital where figures of Democratic Syria were treated for generations. Today, it is one of Assad's notorious secret detention centers. Al Mujtahid is a public hospital affiliated with the Ministry of Health. In addition to medical services, the hospital is a center for medical education and training. In 2013, the hospital turned into a triage center for injured military and foreign militias, as well as POWs transported from East Ghouta and East Damascus. The emergency room was the place where medical staff classified and segregated patients based on their political affiliation. The patients were divided into three types: 1) injured Syrian army and militia personnel; 2) the “friends”, which included Iranian and Iraqi militia personnel; and 3) the POWs and detainees. Each of these categories held different codes consisting of a single word: military, friend, or unknown. Hospital security officers fixed the categories and confiscated IDs and personal belongings. This was the first step of segregation, which defined the following steps and level of medical care. The military and Syrian militia were transferred to Hospital 601 to receive care. The “friends” would be ﻢﺴﻗ ا ﻟ ﺮﺠ ا ﺔﺣ ) ,transferred to the second floor into the thoracic department, the friends’ wing under the direct supervision of Dr. Yamen. The friends’ wing was run by and ,( ﻢﺴﻗ ا ﻗﺪﺻﻷ ﺎ ء / ﺔرﺪﺼﻟا under the protection of the Republican Guards. The detainees and POWs, the ‘unknown’ category, always had their faces covered and were in the presence of three intelligence guards, and received lifesaving and primary care. Physicians or residents never addressed the patient or inquired about the cause of injury. They treated the patient hastily and silently, wrote a brief description in the logbook, and then signed the discharge form of the patient. The destination of the patients after was unknown. There is limited information about further steps of the process because of regime secrecy and many gaps in the medical staff’s knowledge of victims’ personal information. A possibility lies in their transfer to Branch 215 secret prison at the

235 Khaled Shabib, A War Hospital,24-25. 236 Interview with Abu Ali via WhatsApp, March 13, 2019. 42 orthopedics wing in the first floor of the same hospital building. The condition of detention does not differ from those at Hospital 601. The “room” is taboo, none of the medical staff discuss it, as well as further inspection of patient treatment and their progress or conditions. There are obstacles to our understanding of the violence that occurred at Al Mujtahid Hospital with regards to victims' identity and fate, or the violence practiced at the hospital building. There are many questions rather than answers in the case of Al Mujtahid Hospital. Dr. Ahmad, a vascular surgeon at the hospital, examined the detainees several times. He described the process of medical examination,

The superior specialist would instruct us to go to the 215 prison department, they never say prison. They would say follow the orders and go down. A soldier would stop me in an office room, and ask me to give my phone and sign my name. Then, they warned me not to address the patient or talk about what I have seen. There are 3 to 4 hospital beds, the patients are shackled to beds, their faces and bodies covered with blankets. They revealed just the infected part, the information is so basic. There is neither a detailed history of the patient nor any surgical report. Most of the cases I have seen are amputations and abdomen surgery. The guards would humiliate them before me and I didn’t act. They shout at them “animal!”. During the examination, the guards tested me, “what do you think is the cause of his wound?” It was a moment when my breathing would stop, I replied, “he must have injured himself.” They laughed and asked me to write treatment instructions and sign the logbook. Before I leave the room, they repeat the warning “don’t ever speak of what you have seen today.”237

Triage principles have been abused since 2011 in civilian hospitals across Syria and specifically in the case of Damascus’ main hospital, Al Mujtahid. Dr. Adeeb Mahmoud, the general director of Al Mujtahid Hospital, imposed rules to prioritize treating combats before civilians in order for them to return to the frontline. Civilians, whose treatment would be futile, were denied necessary treatment and suffered serious consequences. This was a breach of the Hippocratic Oath and indirect killing of ordinary civilians. It was impossible to determine the actual number of casualties due to these indirect killings resulting from the abuse of triage at Al Mujtahid Hospital.

3.2 A key perpetrator: Dr. Ghazi Al-Ali

Dr. Ghazi Al-Ali, the deputy general director for medical affairs, was a prominent figure of medical perpetration taking place at Al Mujtahid hospital. Dr. Al-Ali was a cardiac surgeon. The ‘Ironman’ was the name medical staff used when they spoke of him. This nickname represented the man’s power and his absolute authority and dictatorship at the hospital. Residents and specialists would hide in his sight, fearing any provocation of the man. The fear of Dr. Al-Ali was unprecedented. My informant, who had already left the country when I conducted the interview, still refused to pronounce his name and instead wrote it down. Dr. Al-Ali acted as a liaison with the Republican Guards and Branch 215. He was also the medical procedure supervisor of both Republican Guards and Branch 215 departments. Other information about the man and perpetrators were inaccessible. The secrecy surrounding Dr. Ali's past and his social and professional connections were further examples of silence of perpetrators. Dr. Ali is an example of challenges of researching medical perpetration in Syria, it perhaps a reflection of culture of perpetration. The perpetrators’ distrust of the other, fear of being victims of their colleague’s brutality, who were once part of and knew the best what they are capable of.

237 Interview with Ahmad via Skype, August 28, 2019. 43

4. Conclusion

This chapter examined the forms of weaponization of Syrian health facilities in the Syrian war, as hospitals became intermediary institutions in regime bureaucratization of mass violence. The doctors in these facilities produced documents and covered evidence. Subsequently, hospitals became centers of regime violence and changed into detention centers and extermination sites. For victims, hospitals were a clear symbol of the regime’s brutality and tyranny, while they are also symbols of power and control for perpetrators.

Chapter 3: Syrian Doctors in Genocide and War

1. Introduction 44

“I was not able to remain just a doctor. I abetted the Syrian army’s military campaign, first as a medic then as a fighter … I was a field commander.” That is how Dr. Bahjat introduced himself in our first conversation. A compelling statement that described the man’s perceptions and beliefs, and the perpetrator’s rationale for war and violence. Dr. Bahjat claimed that the war was a just war against the a necessary evil for a higher cause: “We struggled, foremost, for ,( ﺮﻌﻣ ﺔﻛ ا ﻖﺤﻟ ﺪﺿ بﺎﻫرﻹا ) ”terrorists“ our beliefs, then we did to defend the Syrian state, to defend the institutions … Terrorism does not differentiate between an intellectual and an ordinary citizen.”238 Dr. Bahjat was a young graduate of medicine living in Al Nuzha neighborhood in Homs when the Syrian uprising erupted. In late 2011 he joined local militias in Homs. For him joining a local militia was a rational decision driven by the dynamics of war in Homs and his traumatic personal experiences during the war. Violence escalated in Homs following massive repression of public protests in the first months of 2011, stimulating an existing sectarian resentment between the two communities, Sunni and Alawite. This resentment was mounted by kidnappings and killings in the city.239 During our conversation Dr. Bahjat suppressed the presence of sectarian rhetoric and instead emphasized the identity of his enemies and the victimization of this Alawite community, He stated, “We knew from the beginning that the demonstrations were just a camouflage of Wahabi.” His beliefs justified the war and killing as a necessity for survival. To Dr. Bahjat, the massacres, and he was sometimes present for such as Karm Al Zaitoun, were mistakes committed by a few incompetent militiamen and not by the regime. “From my experience as a field commander, we have some people ﻣﻦ ﻋﻨﺎ ﻧﺎس ﻤﺎن ارﺗﻜﺖ ) ”who committed ‘unjust’ crimes, but they were outnumbered and uneducated As he denied regime liability, he also repeated official regime .(ﺟﺮاﺋﻢ ﻏ ﻣﺤﻘﺔ ﺲ أﻓﺮاد ﻏ ﻣﺘﻌﻠﻤ ﺟﺮاﺋﻢ ) ”rhetoric, “The state is not responsible, these crimes were committed by arrogant individuals .(ارﺗﻜﺒﻬﺎ أﻓﺮاد ﻣﺎ ﺑﻔﻬﻤﻮا اﻟﺪوﻟﺔ ﻏ ﻣﺴﺆوﻟﺔ ﻃﺒﻊ Dr. Bahjat’s personal trauma of threat and loss strengthened his extreme view of the others, specifically demonstrators, and pushed him a step further towards perpetration. He lost two friends, both members of the Nabud Homs group. They were kidnapped and killed by the FSA in Baba Amr neighborhood in October 2011 and they survived another abduction attempt by the FSA in Al Brazil Street in Homs city in 2012. The transition from being a doctor to a combatant was a difficult experience that brought behavioral and psychological changes. He described it with self-pity:

It was not me, it was a tough time. I lost myself. I genuinely struggled to become harsh and tough. I forgot happiness, living on the edge between life and death, but it was worth it.

During our conversation, he entered in what seemed like a monologue, rationalizing his decision and blaming “others” while presenting himself as a victim of the opposition’s sectarianism:

I have videos of terrorists cutting a woman’s womb and raping women, I had to defend my neighborhood, my street, my family, my sisters’ honor.240

Growing up in a household where both parents were physicians, the young Bahjat picked up an interest in medicine. He majored in pharmacy and specialized in laboratory analysis. Dr. Bahjat

238 Interview with Bahjat via Facebook, May 01, 2020. 239 Interview with Bahjat via Facebook, May 01, 2020. 240 Interview with Bahjat via Facebook, May 01, 2020. 45 returned to the normalcy of medical practice at Hospital 601 in 2014, where he also worked in militant spheres for another four years. This change caused additional confusion and shook the doctor’s life:

I struggled to return to normal life, it was hard to act normal, to talk with and listen to people without getting suspicious of them … Each time an ambulance bought injured soldiers, my first thought was, “I am the wounded,” and my second reaction was to look for my rifle. It took me time before I could recover my medical identity.241

Dr. Bahjat seized any opportunity to describe the physical and psychological suffering perpetrators experienced, whether it was on a battlefield or at a hospital. He said, “You can’t imagine the tiredness and exhaustion of prolonged fighting.” The suffering was comparably less at Hospital 601, where he presumed perpetration using his unique skills as a blood analyst, examining blood samples of both soldiers and detainees. When talking about his experience at the hospital he distanced himself and disregarded allegations of torture at the hospital, suggesting them as part of Western misinformation and propaganda. He said, “We treated them like ordinary patients. There were strict orders not to harass any of them.” He continued to negate allegations of torture. He made sophisticated arguments by using his medical knowledge and skills when he was shown photos of dead detainees taken in the yard of Hospital 601:

Looking at the photos, the people in the photographs most likely died of trauma resulting from explosions, definitely not torture ... these photos are most probably of Syrian army casualties.242

Dr. Bahjat was an ordinary man. He was a doctor whose past did not show a tendency towards violence or perpetration. He became a perpetrator due to the complex political, cultural, and psychological circumstances. He provided an interesting account that dissected the psychology of a perpetrator’s as either a doctor or a militiaman. He is a primary example of intelligent Syrian doctors who took a conscious path into perpetration without any remorse or regret. He complied with state violence and medical violence through direct killing, torture, and more. Yet, he told little or nothing about the act of killing or torture, he admitted participating in violence, but he refrained from describing the means of the killing, place or time. Drawing from the example of Dr. Bahjat and others, this chapter outlines the patterns and types of violence committed by individual Syrian doctors, including clinical and non-clinical violence.

2. Medical Discourse, Propaganda, and Scientific Myth

French psychologist and historian Jacques Semelin proposed the concept of ‘massacre’ as a distinct term into the debate on genocide. According to Semelin, a massacre is a process of collective action to destroy a group by a series of actions; killing, raping, conquering property, and others. Massacres, at foremost, are a mental process of ideological and psychological perpetration committed by perpetrators and marginalized population’s capacity to restrain violence. This process is crystallized by political elites and intellectual entrepreneurs.243

241 Interview with Bahjat via Facebook, May 01, 2020. 242 Interview with Bahjat via Facebook, May 01, 2020. 243 Jacques Sémelin, Purify and Destroy: The Political Uses of Massacres and Genocide (New York: Columbia University Press, 2007),54-60,9-18, 322-327, 54-60. 46

Following Semelin’s definition, the Syrian doctors, as a professional category, are crucial in constructing propaganda and myth: they utilized medical language, skills, and knowledge to instigate a process of psychological manipulation of people through propaganda and myth to incite violence Mass violence in Syria. Doctors utilized medical terminology and metaphors to convey a political message that perceived protests as dangerous and that protestors posed as a threat to Syria. They exploited the ongoing rumors, history, and profound mistrust Syrians held of others, as well as their fears and desires. Conspiracies centered on the medical propaganda and myth, as well as the Islamic foundation of protestors’ identities. Protestors were fashioned as a suspicious group in Syrian society who were conspiring to destroy Syria.244 Doctors described protestors as a superfluous group “the others,” a group foreign to Syrian society. Bashar al-Assad, in the first speech before the People’s Council, described protestors as germs and bacteria, a strange substance to the Syrian society.245 The “othering” and alienation of the regime’s political opponents advanced with the conflict with the ideological affirmation of regime loyalists on political-sectarian or political-regional frames also strengthened. Doctors also constructed sophisticated scientific reasoning which legitimized violence to re- narrate the war. Forensic pathologists exploited human corpses and produced “manipulated evidence” to emphasize the “guilt” of the “terrorists.” Doctors believed in the myth and blamed “terrorists” as the cause of misfortune for Syrians. This belief allowed doctors to participate in acts of violence by legitimatizing their work as a duty. Dr. Bassam Mohammad, the Director of the Civil Forensic Pathology department in Homs explained the process of their myth: “We manufactured evidence...the work has to serve our cause and serve our rights.”246 He added, “we were targeted, so when it comes to this threat, it is a threat to our history and roots.”247 Forensic pathologists rationalized their actions, knowing it influenced the course of the war. Dr. Zaher Hajo said during an interview with Lebanese journalist Ogariet Dandash:

If the focus was on forensic pathology since the beginning of the war- as we provided the truthful accounts of events- we could disregard misinformation … many things could unfold the matter and lessen many victims and martyrs ... but if they would listen ... Unfortunately, some people did not want to listen to us.248

244 Taleb Ibrahim in an interview with the Syrian TV, June 11, 2011, https://www.youtube.com/watch?v=M1ytKHl7lQo. Taleb Ibrahim interview with Al-Jadeed/New TV and posted on the Internet on December 16, 2012, https://www.memri.org/reports/pro-assad-syrian-commentator-taleb-ibrahim-calls-opponent-ape-and-says-my-shoe-and-my-urine Speech by President Bashar al-Assad at Damascus University, 20 June 2011, https://www.c-span.org/video/?300198-1/syrian-president-bashar-assad-national-address 245Bashar al-Assad Speech to the People’s Council, https://www.c-span.org/video/?298760-1/syria-president-bashar-al-assad-speech-parliament. Such pathological speech were used again in early stage coronavirus crisis in Syria, the health minister in a public statement said, “‘I want to assure all Syrians amid this coronavirus outbreak that the Syrian Arab Army has cleansed all germs that exist on Syrian soil.’ Read: “Nizar Yazaji confronts coronavirus with Syrian Arab Army mindset …through luxury cars and provocative statements,” Enab Baladi, March 28, 2020, https://english.enabbaladi.net/archives/2020/03/nizar-yazaji-confronts-coronavirus-with-a-syrian-arab-army-mindset-through- luxury-cars-and-provocative-statements/ ,Al Modon, March 03, 2020", زو ﯾ ﺮ ا ﺔﺤﺼﻟ ا ﻟ يرﻮﺴ ﻦﻋ ﻧورﻮﻛ ﺎ : “ ا ﺶﯿﺠﻟ ط ّﮭﺮ اﻟﺒﻼد ﻣﻦ اﻟﺠﺮاﺛﯿﻢ" زو ﯾ ﺮ - ﺔﺤﺼﻟا - يرﻮﺴﻟا - ﻦﻋ - ﻧورﻮﻛ ﺎ - ﺶﯿﺠﻟا - ﺮﮭط - دﻼﺒﻟا - ﻦﻣ - ﻢﯿﺛاﺮﺠﻟا /https://www.almodon.com/media/2020/3/13 246 Interview with Bassam Mohammad via WhatsApp, July 10 & 24, 2020. 247 Interview with Bassam Mohammad via WhatsApp, July 10 & 24, 2020. .Al Mayadeen tv, March 26, 2020 ”, ﻦﻣ :ضرﻷا ا بﺮﺤﻟ نﻮﯿﻌﺑ ا ﺐﻄﻟ ا (ﻲﻋﺮﺸﻟ ا ءﺰﺠﻟ ا ﻟ ﺜ ﺎ ﻲﻧ )“ ,Ougariet Dandash 248 47

Syrian doctors “succeeded” in silencing a majority of the Syrian society, strengthening the perpetration process through propaganda and scientific myth.

3. Direct Killing and Clinicide

3.1 Direct Killing

3.1.1. Political Murder

Political murder committed by doctors reflected the importance of their role in the decision-making process of mass atrocities as members of local or national authorities. In Syria, the political role of doctors seemed omnipresent since the president was a former doctor. Bashar al-Assad graduated from Damascus University and trained as an ophthalmologist at both Tishreen Military Hospital in Damascus and Western Eye hospital in London. Assad’s dream was to be a humanitarian doctor, but this dream faded with the death of his brother. His brother’s death pushed Assad into a political and military career to prepare him for his eventual presidency. He succeeded his father in 2000.249 Assad’s first ten years of presidency witnessed several political upheavals and massive repression of political activists and civilians such as the repression of uprisings during the Kurdish uprising in Qamishli and Aleppo in 2004. In 2011, Bashar al-Assad utilized professional language, medical metaphors, and medical jargon to convey his political interests.250 He exploited his power and authority as both president and chief commander of the Syrian army to order the arrest, torture, and killing of Syrian civilians. Leaked documents from the regime archive unleashed evidence of his involvement that confirmed his responsibility in crimes against humanity and war crimes.251 He constantly denied any accusations of violence and casted doubt on the existence of evidence of his war crimes.252 This is despite his frequent visits to sites of violence during or after conflicts, whether it was the battlefield or hospitals. He shook hands with Syrian soldiers as a portrayal of gratitude for their sacrifices.253 Assad’s behavior matched his childhood friend’s, Manaf Tlass, description of Assad’s inconsistent acts, of such saying one thing and doing another.254 Assad’s actions aligned with psychologist Robert Lifton’s theory of the psychology of genocide “doubling” where perpetrators self-compartmentalize into the perpetrator’s personality and normal-self.255 Bashar al-Assad, as the president, acted like a surgeon whose hands were covered in blood, but he flaunted his “clean” hands to the public and enforced a positive image to the world.

249“A Dangerous Dynasty: House of Assad, episode 1” BBC, October 31, 2019, https://www.bbc.co.uk/programmes/b0bnfn0d 250 Michael Hanne, “Introduction to the “Warring with Words” Project,” in Warring with Words: Narrative and Metaphor in Politics, eds. Michael Hanne, William D. Crano, Jeffery Scott Mio (New York and London: Psychology Press, 2014),1-2. 251 Ben Taub, “The Assad Files: Capturing the Top-Secret Documents That Tie The Syrian Regime To Mass Torture And Killings,” The New Yorker, April 18, 2016, https://www.newyorker.com/magazine/2016/04/18/bashar-al-assads-war-crimes-exposed 252“Barbara Walters Interview with Syria's President Bashar al-Assad: 'There Was No Command to Kill',” ABC News, December 7, 2011, https://www.youtube.com/watch?v=bsyQ442Xvnw Nieuwsuur, “The full interview with president Assad of Syria,” NPO, December 18, 2015 https://www.youtube.com/watch?v=m- q9_Dsb2OE “Syrian President Bashar al-Assad denied the use of torture in regime prisons,” The New Arab, November11,2019, https://english.alaraby.co.uk/english/news/2019/11/11/syrias-assad-claims-no-torture-in-regime-prisons 253 “Syria: Assad pays rare frontline visit,” Euronews, June 27, 2016, https://www.youtube.com/watch?v=g3LJz7EZMNM: Last accessed on August2, 2020. 254Sam Dagher, Assad or We Burn the Country,192-3, 209-11, 222-24. 255Robert J. Lifton, The Nazi Doctors: Medical Killing and The Psychology of Genocide,433-466. 48

3.1.2. Medical Professionals-Soldiers

Syrian medical professionals were involved with the army or militias during the war. They were either deployed officers or volunteers with the militias and paramilitary groups sponsored by the Syrian regime or its allies. These groups emerged from localities on social, class, and sectarian banners following March 2011.256 The ratio of medical professional membership in these militias, as well as their roles in combat, are ambiguous. This is because of the complex structure and secrecy of paramilitaries, as well as the censorship kept by medical professionals, specifically physicians, regarding their involvement in combat and association with paramilitary groups. In reference to their association with militias and the provision of medical care to injured militiamen, both female and male medical professionals seemed open to disclose information.257 Dr. Bana Saleh was a dentist from Latakia and the emergency doctor of the Desert Hawks Wounded and The Desert Hawks was a notorious militia formed .( ﺐﺘﻜﻣ ا ﺪﻬﺸﻟ ا ء و ا ﺮﺠﻟ ﻘﺻ ﻮ ر ا ﻟ ﺮﺤﺼ ا ء ) Martyrs office in 2014, which fought alongside the Syrian army in various cities. The militia committed numerous mass atrocities such as massacres and arbitrary bombardment. Dr. Bana recruited female nurses from Alawite families to work with this militia.258 She often posted pictures of herself on Facebook wearing military uniforms and photos of her with the militia leader. She also publicly disclosed her leadership of the medical office and political support of the militia. There is, however, no information on her Facebook, or any other anecdotal evidence suggesting her direct involvement with violence. There are few accounts showcasing the role of medical professionals in combat violence. These cases were obtained either by interviews or through open-source investigation. This suggests that Syrian medical professionals, as members of Syrian forces and paramilitary groups, took part in the selective and intimate violence of slaughtering their neighbors and patients.259 Two of my sources revealed their participation in combat and presence during massacres and other violent events. Yet, they maintained silence on their role and shifted the blame on to others. Three others spoke about deployment to the battlefield and avoided discussion on the nature of their mission. Their Facebook pages showed photos of them carrying weapons in urban areas. Jamal Yassin Al-Hasan was a male nurse who joined the army medical services in 2004 at Hospital 601 and was then deployed to Homs Military Hospital in 2007. When the uprising erupted, al-Hasan volunteered with the popular committees, a pro-regime militia established in Homs in 2011. Jamal lived in the Karm Al Loz neighborhood, where notorious sectarian violence occurred. He engaged in both medical and military activities as he proclaimed the urgency to protect his family and his “daughter’s honor’’ from the “terrorists.” Jamal, as a popular committee member, took part in the Karm Al Zeitoun massacres between the 24 and 27 of January 2012, where dozens of civilians died.260 He never explained his exact role during the massacres and instead offered a justification for his deeds. He explained the justification of his actions through two themes. The first was that of the victimization of his group and the second was blaming victims for the crime inflicted on them. He said, “They attacked us first, they wanted to

256 Aron Lund, “The Shabbeha Phenomenon,” in The Alawis of Syria: War, Faith, and Politics in the Levant, eds. Michael Kerr, Craig Larkin (New York: Oxford University Press, 2015),215-221. Reinoud Leenders, Antonio Giustozzi, “Outsourcing State Violence: The National Defense Force, ‘Stateness’ and Regime Resilience in the Syrian War,” Mediterranean Politics vol.22, no.4 (October 2017): pp.157-180. 257 Interview with Jamal Yassin Al Hasan via WhatsApp, November 18, 2018. Interview with Hassan Ibrahim via Facebook, May 18, 2020. 258 Check Bana Al Saleh’s Facebook account; https://www.facebook.com/bana.saleh99 259 Interview with Bahjat via Facebook, May 1, 2020. Interview with Jamal Yasen Al Hasan via WhatsApp, November 18, 2018. 260 “In Cold Blood: Summary Executions by Syrian Security Forces and Pro-Government Militias,” Human Rights Watch, April 09, 2012. 49 kill us.” Jamal believed in the righteousness of the violence committed by regime forces because his economic stability and existence were threatened before the massacres when an FSA group forced him to flee his house. His sentiment grew with the death of his comrades and his subsequent disability due to a sniper bullet that hit his spine while he was at Homs Military Hospital in 2014. 261 He became a hero and received special treatment. Asma al-Assad personally visited the family, offering them therapeutic and financial support until he died in 2019.262 Jamal is an example of the paradox of perpetration-victimization. Doctors who died in combat were ranked as a martyr, “Lieutenant with honor, the hero They were portrayed in the Syrian media as “noble” doctors .(اﻟﺸﻬﺪ اﻟﻤﻼزم ف اﻟﻄﻞ اﻟﺪﻛﺘﻮر) ”doctor because they abandoned their medical duties to fight alongside the Syrian army.263 Official media and Facebook pages thoroughly described the doctor's alleged heroic deeds, enlisting their achievement in the battlefield to defeat the enemy “terrorists.” This consisted of evidence of doctors’ command of militias at the whilst massacres, bombardments, and other violent events were reported in an area. Another example of a doctor’s ‘martyrdom’ was Dr. Ali Shadood, an Alawite pharmacist from the coastal city of Banyias. He was a field commander with the NDF-Banyias branch. The deceased where he was killed in ,( ﺪﺳا كرﻮﻣ و ا ﻟ ﻘ نﻮﻤﻠ ) doctor was known as the Lion of Mourk and Al Qalamoun 2013. A video containing a collection of footage of the doctor in the frontline showed him standing on what appeared to be the corpse of a dead opposition fighter, saying to his comrades, “Today was possible because I am fighting with heroes.”264

3.2 Clinicide: Medical Murder

Clinicide denotes murder which uses medical skills, techniques, and knowledge in the clinical setting.265 This included the killing that occurred in the prison infirmary where prison doctors were responsible for maintaining the lives and the well-being of prisoners. The Syrian medical professionals took advantage of their positions at hospitals to eliminate opponents of the regime. Analysis of eyewitnesses, survivors, and perpetrators suggested that there was a systematic use of medical skills to exterminate regime political opponents during the conflict (2011-2019). Medical murder in Syria falls in two categories: 1) direct killing, and 2) medical negligence.

3.2.1 Direct Medical Killing

Medical skills and knowledge were efficient means to eliminate sick detainees in Syrian detentions centers or hospitals. Medical killing was a process that consisted of selection, subjugation, and then killing, in which doctors selected and killed or instructed the murder of patients. They used the vulnerability of patients to finish them off or they created circumstances that led to their death. In Syria, doctors used two methods in killing prisoners, surgical and pharmacological.

261 Interview with Jamal Yassin Al Hasan via WhatsApp, November 18, 2018 ﻦﻣ ةرﺎﯾز ا ةﺪﯿﺴﻟ ءﺎﻤﺳأ “ From lady Asmaa Al-Assad’s visit to houses of the injured Jamal Al Hasan and Jalal Razouk in Homs today 262 ,Syrian News, April 30, 2018 ”, ﺪﺳﻷا ﻟ ﻲﻟﺰﻨﻤ ا ﻦﯿﺤﯾﺮﺠﻟ لﺎﻤﺟ ا ﻦﺴﺤﻟ لﻼﺟو قوزر ﻲﻓ ﺪﻣ ﯾ ﻨ ﺔ ﺺﻤﺣ ا ﻟ مﻮﯿﻟاﺺﺣﺔﻨﯾﺪ ﻓ ورلﺟ ﺴﻟا ﺎﺟﻦﺤﺮﻟا ﻟﻨ ﺪﻷ https://www.youtube.com/watch?v=l46VNhK0Sro; last accessed on July 23, 2020. .Syrian Satellite Channel, March 26, 2014 ”, ﺪﯿﮭﺸﻟا ﻞﻄﺒﻟا رﻮﺘﻛﺪﻟا مزﻼﻤﻟا فﺮﺷ ﻲﻠﻋ دوﺪﺷ “ 263 https://www.youtube.com/watch?v=_OzlwjXj2dU: Last accessed on August 2, 2020. 264 Please watch: https://www.facebook.com/AIHAM.Al3ATKI/videos/576177535809632; Last accessed July 15,2020. 265 Clinicide, according to Kaplan, defines the death of numerous patients during treatment by a doctor. Like any crime, clinicide is a complex forensic phenomenon. Just as the classification of illness and the practice of doctors reflect the society in which they occur, so do the circumstances of clinicide. Robert M. Kaplan, Medical Murder: Disturbing Cases of Doctors Who Kill (Chichester: Allen & Unwin, 2009),11. 50

Surgical methods refer to unnecessary operations or related deterioration after surgical intervention due to negligence. Dr. Ali witnessed the death of some sick detainees under surgery or absence of surgical follow up for “acute cases requiring close observation and care at Al Mujtahid civil hospital.”266 At Hospital 601, Ismael witnessed the death of his cellmates, whose health condition deteriorated after surgery in the abdomen.267 Survivors told of their cellmates’ agony, but they have neither the experience nor the mental health to explain the causes of death. Pharmacological methods refer to the deliberate and sudden withholding or withdrawal of medicine.268 This deeply affected patients in need of regular medication, such as patients with chronic diseases related to blood pressure, diabetes, and more. Leaked photos of detention centers showed that some detainees in the photos were subject to medical intervention preceding their deaths. Neither the reason for medical intervention nor the cause of death was disclosed. The fact that the patient died was unexpected, considering the age and health of victims prior to their arrest or death.269 Analysis of these photos by perpetrators oscillated between confusion and denial. A perpetrator questioned the need for intervention in some cases, specifically the use of central venous catheters (CVC) in some cases where bodies that depicted no malnourishment or damage to the veins.270 Cases for thanatology study to understand the role of medical intervention in the death of patients to prevent manipulation and discretion of evidence or testimonies of eyewitnesses.271 The patterns of the killing showed inconsistencies between hospitals in terms of selection and decision making. In some hospitals killing followed strict structures, such as Hospital 601 and Al Mujtahid, where a single doctor coordinated and organized the torture and killing process. The situation in other hospitals seemed more chaotic, specifically in Homs Military Hospital. Doctors were enthusiastic killers, they took the initiative to perform medical procedures on victims, used the detainees as guinea pigs, and justified it with eagerness and medical passion to advance their medical training, techniques, and skills. Some survivors underwent major and complex surgeries without sufficient anesthesia. It was unknown whether these procedures were necessary or not.272 Operating on patients without consent and without anesthesia consists of grave violations of medical ethics.273 There are many factors to consider when explaining the behavior of doctors in Homs Military Hospital. First, the demonizing and pathological construction of the opposition allowed doctors to abandon their duty of care. Second, the political and ideological tensions in the city and mobilization against the regime's political opponents created a space for military doctors to experiment on the victims. Violence originated from the perpetrator’s private grievances and reinforced by the political elite’s narratives of the conflict in the city. Medical professionals were killed and tortured to gain

266 Interview with Ahmad via Skype, June 23, 2020. 267 Interview with Ismael via Skype, May 29, 2020. 268 This thesis refrains from discussion on organ harvesting and death result from it because of lack of information, in addition to great challenges to distinguish the political crime and organized crime in case of Syria. 269“If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015 270 Interview with Ahmad via Skype, June 23, 2020. Interview with Bahjat via Facebook May 01, 2020. As explained, that CVC used in very specific case when a patient needs an administration of extensive liquidation or medicine such as kidney failure or cancer or major operations, or in cases of severe malnutrition. 271 “Rihab Allawi, #CaesarPhotos Victim Profile,” Massacre Monitor, December 25, 2015. 272Janine Di Giovanni, The Morning They Came for Us: Dispatches from Syria (New York, London: Liveright Publishing Corporation A Division of W.W. Norton &Company, 2016),60-76. “Documentation of 72 Torture Methods the Syrian Regime Continues to Practice in its Detention Centers and Military Hospitals,” Syrian Network for Human Rights, October 21, 2019. For more accuracy, these allegations should be questioned further from specialists to determine whether indeed victims could tolerate ﺔﻐﻟ ,the pain without anesthesia, especially in cases of major surgeries normally requiring general anesthesia. Mohammad Wahbi .The Siege Language (online book),119,134. Interview with Dr. Mohammad in the Netherlands, August 23, 2018 رﺎﺼﺤﻟا 273 Michal T. Kluger, William B. Runciman, “Incident Monitoring in Anesthesia,” in Wylie Churchill-Davidson’s A Practice of Anesthesia, eds. Thomas Healy, Paul Knight (London: Arnold, 2003),674,675. 51 medical knowledge. The violence at Homs Military Hospital can be understood within the dynamic of the civil war in the city.274

3.2.2 Medical Negligence: A Silent Massacre

Medical negligence is killing by deprivation of medical care for patients with acute medical conditions, including inadequate and irregular treatment of chronic and communicable diseases such as tuberculosis (TB) or coronavirus. In other words, it is a crime of omission. Prison doctors were responsible for the health of prisoners in a broader context of public health. They had to properly treat the prisoners and improve safety within the prison environment. Their responsibilities of providing medical treatment as well as imprisonment conditions were inseparable.275 Human Rights Watch studied the Caesar photos and determined six causes of death that occurred in Syrian custody, five of them medical in nature: gastrointestinal infections, sickness involving severe diarrhea and dehydration, skin disease leading to infection, mental distress that led detainees to refuse to eat and drink, chronic diseases (like hypertension, diabetes, asthma or kidney disease), and starvation.276 Prison doctors deliberately neglected to treat sick detainees and created conditions that forced hesitation amongst detainees for requesting medical care. They were aware of pre-existing vulnerabilities and illnesses of some sick detainees since collecting information on a detainee’s health condition was a bureaucratic practice even in the most notorious detention centers.277 The doctors, willingly and wittingly, failed to protest against prison conditions, which increased the vulnerability of prisoner health and the likelihood of death caused by even the most minor of infections.278 Prisoners with dialysis in Saydnaya Prison received treatment but, died a short period after the treatment session. They were prone to death due to allegedly improper conditions of poor hygiene and sanitation in the prison. They were also deprived of food, medicine, and proper rest.279 Ismael counted the death of about twenty of his Saydnaya inmates who were taking regular dialysis sessions. He explained:

then their health would ,(ﻣﺸﻘﺮﻗ ) When they returned, they were relaxed and healthier suddenly deteriorate and then they died within days … We did not know what happened, but I can tell their catheters were uncovered, maybe they had infections. 280

The two prison doctors regularly visited the prison cells, but they declined treatment for those patients, providing neither medicine nor the proper care and conditions required in these cases. Doctors, despite their duties towards the patients, deprived them of essential rights, including the right to healthcare. Whether they had the intent to kill or not, their deeds do not seem spontaneous

274 As Kalyvas asserted, based on a territorial and micro-level study of civil war, collective violence involves privatization in which individuals take advantage of the political rationale behind the war for personal gain and interest. Stathis Kalyvas, The Logic of Violence in Civil War (New York: Cambridge University Press, 2006),174-176. 275 Lars Møller, Heino Stöver, Ralf Jürgens, Alex Gatherer, Haik Nikogosian, “Health in Prison: WHO guide for essentials health in Prison,” WHO Regional Office Europe, 2007.British Medical Associations, The Medical Profession and Human Rights (London: Zed book, 2001),112-117. 276 “If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. 277 Interview with Ismael via Skype, May 29,2020. Interview with Saed via Skype, October 11,2019. Interview with Mohammad in Amsterdam, June 23, 2020. Interview with Melhem via Skype, April 24, 2019. 278 Ibid. 279 Masashi Suzuki, Nobuhiko Satoh, Motonobu Nakamura, Shoko Horita, George Seki, and Kyoji Moriya, “Bacteremia in hemodialysis patients,” World J Nephrol vol.05, no.6 (November 2016): pp.489–496. “Saydnaya Prison During the Syrian Revolution: Testimonies” (Gaziantep: Association of Detainees and Missing in Saydnaya Prison, 2019). 280 Interview with Ismael via Skype, May 29, 2020. 52 or as an isolated incident. They are rather a policy in which prison doctors deliberately killed and supervised a silent killing process. Medical negligence in Syrian prisons and detention centers has been an intentional policy and efficient tool for extermination, a notorious weapon in eliminating political prisoners.

4. Medical Torture

Edward Peters argued in his book, Torture, that medical and professional intervention with torture aims to subjugate the body and to control pain and suffering to a limit that persuades a prisoner to confess.281 Medical torture, as a concept, was often used to refer to psychological torture techniques. Both physical and psychological torture can be considered medical because both have consist of psychological consequences, the break of a prisoner’s agency.282 Furthermore, psychological torture (PT) entails manipulation of the prisoner’s body such as asphyxia torture, sexual abuse, or deprivation from sanitization.283 Syrian perpetrators often combined physical and psychological techniques as well as sexual torture.284 There is no evidence on the use of pharmacological torture during the conflict since Syrian torture history indicates the negative use of drugs in torture.285 Within the Syrian context, disregarding the characteristics of psychological and psychical torture techniques is important to comprehend the medical personnel’s role in torture as whole.

4.1. Torture Doctors

Torture doctors is a concept which is about the abuse medical professionals committed with the use of their medical knowledge and skills to abet, monitor, or supervise torture. It also denotes doctors’ abuse of duties as stipulated in their medical oath either by negligence or by legitimizing the violence.286

4.1.1. Doctors and Torture Before the War in 2011

In the 1980s, Syrian doctors and their role in torture was limited to monitoring and assisting torture in security branch detention centers. The doctor would silently observe the torture unless his intervention was demanded. Their role was to help sustain torture and interrogation by maintaining the detainee’s health during the session.287 Doctors rarely engaged in torturing prisoners in security branch detention centers. This differed in Tadmor Prison, where doctors did humiliate, torture, and kill prison inmates. Torture at Tadmor entailed persistent physical harm with isolation preceding interrogation. Torture was likely used to extract information. In a report published in 1987, Amnesty International listed some torture methods which were practiced in Syrian detention centers. These methods included falaqa (bastinado/foot whipping),

281 Edward Peters, Torture (Philadelphia: Pennsylvania University Press, 1996),162-163. 282 J. Jeremy Wisnewski, Understanding Torture (Edinburgh: Edinburgh University Press, 2010),8-12. 283 J. Jeremy Wisnewski, Understanding Torture,20-23 284“Syria: ‘I wanted to die’: Syria’s torture survivors speak out,” Amnesty International, March 14, 2012. “Documentation of 72 Torture Methods the Syrian Regime Continues to Practice in its Detention Centers and Military Hospitals,” Syrian Network For Human Rights, October 21, 2019. “They Treated us in Monstrous Ways: Sexual Violence Against Men, Boys, and Transgender Women in the Syrian Conflict,” Human Rights Watch, July 29,2020. “Voices from the Dark: Torture and Sexual Violence Against Women in Assad’s Detention Centers,” Lawyers and Doctors For Human Rights, July, 2017. 285 Darius Rejali, Torture and Democracy (New Jersey: Princeton University Press, 2007),207-8, 283-4. 286 Steven Miles, The Torture Doctors: Human Rights Crimes and the Road to Justice (Washington D.C.: Georgetown University Press, 2020),31. 287 Ibid. 53 beating, Bisat Al-Rih (flying carpet), and restraint torture (shabbeh/strappado). The most common Medical 288.(اﻟﺪوﻻب) ’suspension torture practiced in Syria was the ‘Palestinian hanging’ and the ‘tyre negligence was also a systematic practice where a patient’s medical needs were subject to manipulation to receive treatment in some cases.289 Ibrahim Bayraqdar was arrested and imprisoned at the Palestine branch in 1987 for suspicion of membership in the Marxist Labor Communist Party. The interrogator tried to convince him to confess and torture him with electric shock, suspension, and beat him when he resisted. Ibrahim testified later in a documentary that the doctors attended the sessions and intervened to stop torture when the detainee nearly collapsed, “the doctor would give a hand gesture to stop the torture.”290 Melhem, the prominent figure of Marxist Labor Party, underwent different ordeals at the Military Raid Branch, known today as Branch 215. He was subjected to persistent torture for six hours. He was tortured by beating, whipping, drowning in water, in conjunction with electric shocks. When Melhem collapsed, a doctor treated him:

I woke up wrapped in a blanket, a doctor next to my head. He warned them it wouldn’t be long before I die. Then, he made me swallow pills then injected me with a substance – I do not know what the medications were. When I recovered a bit, they carried on torturing me.291

The doctor did not take any interest in explaining to Melhem about his condition or the medication he was given. Rather he made sure that Colonel Kamel could resume the interrogation.

4.1.2 Doctors and Torture in the War (after 2011).

4.1.2.1 Doctors and Interrogation in Detention Centers

Since the beginning of the Syrian uprising, arbitrary arrests and torture have been a policy of the regime. Civilians suspected of participation in activities against the regime were detained and brutalized.292 The ratio of arrests though declined with the regime losing territory. Human rights organizations reported an increase of brutality in both prisons and detention centers.293 A painstaking analysis of victim testimonies and human rights reports suggested the tendency towards medicalized torture and further scientific involvement with interrogation and torture. Medicalized torture and scientific involvement can be explained in three different categories. The first category is the pattern of doctors’ actions during torture and interrogation, the second category is torture methods, and finally, the third category is on torture manuals and guidelines.

288“Detention Centers in Syria,” Amnesty International, October 01,1987. “Tyre” is an exclusive method of torture in Syria, according to a comparative forensic study done on patients from Center for Trauma victims in Stockholm (KTC): Read: Sherien Salah Ghaleb, Kholoud Samy Alsawayigh, Mostafa A Hamad and Agdy Kharoshah, “Legal Aspects and Examination of a Torture Survivor” in Recent Advances in Forensic Medicine and Toxicology (Volume 2), ed. Gautam Biswas (New Delhi: London: Panama: The Health Sciences Publisher, 2018),282. 289 “Torture by Security Forces,” Amnesty International, October 01,1987. ,Syria TV, May 10, 2018 ”, ﻢﯿھاﺮﺑإ :راﺪﻗﺮﯿﺑ رﺎﺗوأ دﻮﻌﻟا تﺮﺴﻛ ﺔﻤﺘﻋ ﻦﺠﺴﻟا ﮫﺘﺑﺂﻛو ",290Ya Huria https://www.youtube.com/watch?v=ACKwAameX0Q 291 Interview with Melhem via Skype, April 24, 2019. 292“Torture Archipelago: Arbitrary Arrests, Torture, and Enforced Disappearances in Syria’s Underground Prisons since March 2011,” HRW, July 3, 2012. 293“Torture Archipelago: Arbitrary Arrests, Torture, and Enforced Disappearances in Syria’s Underground Prisons since March 2011,” HRW, July 3, 2012. 54

First, medical professionals abetted, supervised, tortured, and devised torture in security branch detention centers and prisons. Three detainees were arrested in different security branches, place and time. Detainees faced doctors or medical intervention at least in one stage of the interrogation and torture process. The first victim encountered a doctor who assessed his physical tolerance had to torture and declared him fit for a certain level to begin with. Qutaiba, who was first arrested in 2011 at the Air Force Directorate, described his experience:

In 2011, they arrested me at the Mazzeh military airport in the unit under the command of Colonel Suheil Al Hasan. They blindfolded me and stripped me of clothing. Then they called a doctor. The doctor didn’t talk to me... he touched my limbs, chest, then pressed my stomach... then he said ‘he has strong muscles, start with three’. I didn’t understand what he was doing, was he abusing me or what? And what did he mean by three?

Three was a level of torture Qutaiba subsequently experienced. He underwent seven hours of beating and hitting on the body, soaking with water with electric shocks, then a threat of de-nailing with a medical tool. Using medical equipment reduced the physical effort for the perpetrators, the guard explained to Qutaiba, “It is easy now, I had just to press it a little.” The second victim witnessed a doctor assisting the interrogation at the air force intelligence directorate. A doctor was present in the interrogation room by mere chance when the interrogator asked the doctor to assess his medical condition:

They didn’t want me to collapse, so they would stop the torture before I did…I didn’t know how. The interrogator asked me to take off the blue suit they had given us to wear at Air Force Intelligence. My body was covered with scabies and rash, it seems the interrogator noticed and said, “Doctor! Can you check-up him?” The doctor examined me and reported, “It is contagious, don’t touch him.294

Saed, a Homsi man arrested for an accusation of smuggling defected soldiers into an opposition-held area, was imprisoned at different branches in Homs, Branch 215, and then to the Palestine Branch in Damascus (2012-2014). He suffered from an aggressive cardiac disease with a high risk of a fatal heart attack. In the Palestinian branch, a guard prevented his colleagues from whipping him at count twenty- five due to his heart illness, shouting, “The doctor said to stop, or he would die.” He spared him from a practice of persistent ,( ﻔﺣ ﻠ ﺔ اﻻﺳﺘﻘﺎل) ”the hundred lashes which are part of the “reception party beating when new detainees arrive at a branch or prison.295 Doctors also shared the medical information of detainees with torturers in various branches. Detainees who were asked to provide their history of illness and medication were often given nothing and sometimes paracetamol irregularly or before interrogation.296 This information was probably collected as a bureaucratic procedure to determine the tolerance of detainees to torture and to maintain the prisoner’s life to resume interrogation. An example of this is when Qutaiba became seriously sick after days of sleep deprivation and isolation in solitary confinement at the political intelligence directorate in Damascus. After examination, a doctor explained Qutaiba’s condition to the

294 Interview with Khaldoun via Skype, April 9, 2019. 295 Interview with Saed via Skype, October 11, 2019. 296For my informants in exile, prescription of paracetamol always triggered frustration or anger towards physicians and the health sector amongst former detainees. 55 interrogator and advised him to transfer him to a collective cell or he would soon die, and added: “If you still need him!”297 The second category of torture methods and types indicated that medicine became integral to torture in Syria. A study of forensic and legal experts examination of twenty-four Syrian torture survivors from the Center for Trauma Victims in Stockholm (Kris-och Traumacentrum, KTC) showed that victims had few to no scars, but suffered from back pain, had symptoms of sexual torture, electric torture, and trauma to the gastrointestinal tract.298 This implied an increased dependency on ‘clean’ torture techniques. These sorts of psychological techniques included numbering, hooding, stress torture like sleep deprivation, sound, music, threats, or isolation preceding interrogation, and intimidation. Language was also used as a common practice of psychological torture. Doctors insulted detainees and their cultures, traditions, and beliefs.299 They used jargon to demonize the prisoner, ,By referring to prisoners as animals .( ﺒﺷ ﻮ ا ﻴﺤﻟ ﻮ ا ن ) ”!?addressing prisoners, “What is up with the animal dehumanization was both a technique and cause of torture. It reinforced the powerlessness of detainees and broke their resistance and resilience. This was especially so when insults came from medical personnel since medicine was a symbol of healing and prosperity in the Syrian society. Detainees often stressed the differences in language in their determination of prison doctors or interrogators’ cruelty. Language as torture has devastating effects on the agency of prisoners. This includes damaging the ability of victims to interact properly with other. As Elaine Scarry eloquently suggested the impact of torturer’s language:

Through the torturer’s language, his actions, and the physical setting, the world brought to the prisoner in three rings; the random technological and cultural embodiments of civilization overarch the two primary social institutions of medicine and law… Civilization is brought to the prisoner and in his presence annihilated in the very process by which it is being made to annihilate him.300

In Saydnaya prison, there were two military doctors assigned to treat and supervise the medical condition of prisoners. They regularly visited prisoners every day and were accompanied by guards ,report sick prisoners. Both doctors were torturers ﺶوﺎﺸﻟا who usually demanded the cell leader treating prisoners inhumanly and in a degrading way. Yet, they still differed in the way they perceived sympathetic attitudes. To some former detainees, a “good” doctor was one who often hurled verbal insults, but also provided medicine on some occasions. He never restrained the guards from beating prisoners though. The “bad” doctor tortured and ordered guards to torture prisoners, treating prisoners with inhuman and degrading way, with never a moment of care or mercy.301 The detainee’s view reflected the complex relation between victims and torturers.302 Victim accounts implied that the third category of torture and interrogation techniques varied between branches, and that they seemed neither strictly structured nor chaotic. This suggests that

297 Interview with Qutaiba Idlibi via Skype, May 26, 2020 298 Sherien Salah Ghaleb, Kholoud Samy Alsawayigh, Mostafa A Hamad and Agdy Kharoshah, “Legal Aspects and Examination of a Torture Survivor” in Recent Advances in Forensic Medicine and Toxicology (Volume 2), ed. Gautam Biswas (New Delhi: London: Panama: The Health Sciences Publisher,2018),294. 299 Interview with Ismael via Skype, May 29, 2020. Interview with Melhem via Skype April 24, 2019. 300 Elaine Scarry, The Body in Pain: The Making and Unmaking of the World (New York: Oxford University Press,1987),44. 301 Interview with Ismael via Skype, May 29, 2020. 302 Primo Levi described language and the complicity of relationships between perpetrators and victims at Nazi concentration camps. Primo Levi, Survival in Auschwitz (New York: Simon and Schuster,1996),731, 685-697. 56 torture followed an order or a sort of guideline and manual which framed the limit of coercion and torture techniques at each stage of interrogation.303 Manuals and guidelines were not designed to protect the prisoner, rather they organized and structured the interrogation to guarantee the efficiency of the process. Therefore, a detainees’ death under torture was not unexpected, despite the existence of manuals and guidelines in Syrian detention centers. The existence of manuals deduced from a comparison of victim's experiences in formal detention centers and informal prisons (e.g. Shabbiha prisons). Three victims shed light on the difference between torture methods and cruelty between the two types of prisons. In informal prisons such as Deir Shamil and Hama Airport, victims described a chaotic situation where torture methods varied with the torturer. Guards, who were civilians, showed more enthusiasm and determination in torture. Victims were blindfolded and subject to unprecedented cruelty of persistent physical harm. Upon leaving their imprisonment, victims were left with scars and serious physical consequences. Guards invented forms of collective torture such as gathering victims in airplanes hangars then splashing them with cold water to be left to suffer in cold weather.304 In formal prisons such as with the military intelligence or air force intelligence, victims noted differences in the torture method between the two branches. For example, political intelligence used persuasion by weakening the detainee’s will through solitary confinement, sleep deprivation, sounds, or darkness. While air force intelligence utilized more coercion and brutality in torture and interrogation with persisting beating, suspensions, electric shock, rape, and stress torture (long- standing, death threat, and voices of torture). Victims; however, spoke of the hierarchy of interrogation and similarities of the torturer’s attitude at both branches.305 Overall, Syrian doctors were the shadow agents behind the big machinery of torture. The intervention of doctors with torture in security branches was not for saving and treating sick detainees, rather devise and support the torment process.

4.1.2.2 Medical Professionals and Torture at Hospitals

A small cluster of this research revealed a considerable number of medical professionals who abetted with torture and the ill-treatment of detainees. Out of twenty-one interviewees, who were from diverse backgrounds, specialties, and ages, sixteen confirmed that they assisted in torture by maintaining the life of a detainee. While three others denied any involvement with torture for practical reasons and three maintained silence.306 This cluster is by no means representative, but instead illustrates the extent to which medical professionals collaborated with torture in the Syrian health sector. Health professionals believed in the righteousness of assisting security branches. They were transparent about their role of maintaining the life of detainees saying, “Yes! I did attend to prisoners.” They, however, distanced themselves from all sorts of torture or ill-treatment of sick detainees. These answers were ambiguous since their understanding of the boundaries of ill-treatment and torture remained untested. In Homs Military Hospital, four health workers were at the hospital around the same time (2011-2012): two perpetrators, a victim, and a bystander. Each testimony elucidates a perspective on perpetration at the hospital and the view of its owner on what was considered torture. Jamal, a nurse

303 Salwa Ismail, The Rule of Violence: Subjectivity, Memory and Government in Syria,41. 304 Interview with Ammar via Skype, Feb 3 & January 6,2019. Interview with Suhaib via Skype, January 9, 2019. Interview with Aman via WhatsApp, June 10, 2019. 305 Ibid. 306They are according to specialty: (13) surgeons, (7) nurses, (1) Laboratory Analyst and (1) anesthesiologist (see table no.1.1), and according to sector: (5) civil medical professionals, and (16) military medical professionals. 57 at the military hospital in Homs, denied the allegation of torture and killing there, shifting the blame to the victims, and portraying the Syrian army and regime as victims. He said:

The only victims are the Syrian army, they were killed by the terrorists. Nobody was harmed at the military hospital unless he [the patient] got shot by the terrorists … they constantly fired at the hospital and the highway. The opposition snipers killed some nurses.307

Dr. Mohammad contested Jamal’s accounts on torture in Homs Military Hospital. He was a gynecologist arrested by Air Force Intelligence in Homs and transferred to Homs Military Hospital for treatment from injuries due to torture in May 2012. He stayed there for two weeks for what was supposed to be recovery from an injury inflicted by torture. The hospital doctors and nurses tortured and maltreated him. Dr. Mohammad was blindfolded, restrained to the bed, and beaten constantly. He explained:

A doctor standing near the bed told Rakan, a guard, to urinate in the food and let him eat. Rakan did, then pointed the gun to my head and forced me to eat. The doctor was in the room watching ... It happened every day. I cannot forget the humiliation of those moments.308

Dr. Mohammad Wahbi, a urology resident, worked at Homs Military Hospital during the same time period (2011-2012). He witnessed brutal and cruel treatment, torment, and killings committed by his colleagues. Dr. Mohammad, regardless of whether he was a passive bystander or perpetrator, witnessed two colleagues operating on a healthy patient and killing him on the surgical table. He also heard his colleague Dr. Alaa Mousa speaking of torturing sick detainees on different occasions. Dr. Alaa, a surgery resident, proudly spoke to his colleagues about how he operated on a patient without anesthesia and added, “We could learn something.”309 What Dr. Alaa considered as an act to learn was cruel torture, brutality that cannot be justified by a desire to learn. Some procedures, like burning a young man’s genitalia using fuel, are no by means a medical necessity or of medical nature as such. Medical ethics prohibits experimenting on patients without consent. Dr. Mousa denied complicity with torture in an email to Al Jazeera Channel and repeated his denial before German prosecutors when he was arrested for suspicion of committing war crimes in 2020.310 He stated that his involvement with torture was an allegation made out of the imagination of Islamist Jihadists who were against him as a “Christian” doctor.311 Dr. Mousa’s argument is constructed on his view of the vicitms’ identity, perceiving them as a threatening elements to his person and community. Dr. Mousa’s argument aligns with other medical professionals’ perceptions of victims and construction of victims’ identity, which had been borrowed to justify the regime’s violence and their own perpetration. The trial in Germany was an opportunity to explore whether Syrian doctors would resort to the complex moral foundations of justification of torture such as “self-defense”, “lesser evil”, “ticking bomb”, or “conformity”. It was an example of the challenges in proving medical violence and the

307 Interview with Jamal Yasin Al Hasan via WhatsApp, November 1, 2018. 308 Interview with Mohammad in the Netherlands, August 23, 2018. The Siege Language (March ﺔﻐﻟ ا رﺎﺼﺤﻟ ,Interview with Mohammad Wahbi via Facebook, May 13, 2020. Mohammad Wahbi 309 2020),118,132. ,Al Jazeera, May 10,2020 ”, ﺚﺤﺒﻟا ﻦﻋ يدﻼﺟ ﺪﺳﻷا “ ,Mahmoud Kin 310 https://www.youtube.com/watch?v=Tt614Ar8cH0 .Al Modon, July 30,2020 ”, ﺎﻧأ ﻲﺤﯿﺴﻣ ﻢھو نﻮﯾدﺎﮭﺟ “ ,Omar Qadour 311 ﺎﻧأ - ﺴﻣ ﯿ ﻲﺤ - ﻢھو - ﮭﺟ ﺎ د ﯾ نﻮ /https://www.almodon.com/opinion/2020/6/30 58 fragility of evidence even though some witnesses were part of the system. This is partly due to the secrecy of the crimes and absence of victim records. As Dr. Wahbi explained that he heard him talking, he never saw him in an act of torture. Complicity would make the coming trial a milestone to future accountability of medical violence in Syria. At hospitals, both physical and psychological abuse were normalized and made routine. Doctors abused their medical knowledge to inflict suffering. The most common methods of torture were improper doses, or not using any at all, of anesthesia, or interrupting treatment, such as by reducing or eliminating medication doses, or hitting on a wound or fractured leg. Medical professionals aimed to facilitate the suffering and despair of detainees. Jeremy Wisnewski argued that torture is more about suffering rather than pain. He asserted that pain is something that could be normal in human life, such as an illness, but suffering is abhorrent.312 Mohammad was a physician who defected from Hospital 601 in 2012 because of increasing peer-pressure for him to torture patients. He said:

One time I was working in the emergency (ER) department as the doctor responsible for ER. Security forces brought a lot of people arrested from the street to the ER. They started to beat them, kicking them, saying bad words. Of course, they were using weapons, but not shooting with weapons but just beating them with weapons. Then they asked us as doctors – sorry to say that, but they said, “Don’t treat them, just fuck them.”313

In civilian hospitals, doctors failed to prevent or report torture and ended up colliding with it. Dr. Ali, a vascular resident at Al Mujtahid Hospital, showed remorse and regret in being part of the torture machine at the hospital. He explained how he violated medical ethics, the rights of sick detainees, and assisted in the torture process:

Sometimes, we operated on detainees while they were shackled to bed. We didn’t address them, we talked to the guards … we didn’t obtain consent… I became a robot, I felt I had lost my medical professional identity…. I fled the country to retain my humanity, sympathy, and medical identity. I am an accomplice with torture!?314

5. Legitimization of Violence: Medical Reporting and Forensic Pathology

In the last phase of violence, the regime borrowed medical expertise to produce medical documents in the legal medical process to systematically and deliberately falsify the cause of death as part of a coherent process of burying evidence. Doctors wrote medical reports of dead detainees stating the cause of death as an apparent death such as heart or respiratory failure.315 Doctors neglected their duty to investigate the death in custody and falsified the circumstances of death (time, cause, and other), therefore faking death certificates of dozens of tortured victims in regime custody.316 Forensic pathologists systematically falsified forensic reports of dead detainees in custody. Syrian forensic pathologists, either civilian or military, breached the protocols of documenting torture and death in custody. Protocols usually required clinical investigation concerning several subjects such

312 J. Jeremy Wisnewskim, Understanding Torture,57-58 313 Interview with Dr. Mohammad in the Netherlands, August 18,2018. 314 Interview with Ahmad via Skype, May 15, 2020. 315“Death Notices of Government Held Detainees in Syria,” Monthly Human Rights Digest, November 2018. 316“If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. 59 as history, clothing, weapon, or type of injuries.317 The leaked report in the Syrian case revealed that doctors neglected their duties and issued collective reports, stating that the victims died of natural causes such as respiratory and cardiac failure or heart attack. They deliberately disregarded the history of death and a corpse’s status regardless of apparent signs of torture, inhumane and degrading treatment.318 Syrian forensic pathologists were only assigned to bury evidence in case of death in custody. This was because Syrian courts never investigated allegations of torture in regime custody or invited forensic pathologists as expert witnesses when they received such allegations.319 Syrian pathologists were trained by the International Red Cross to document war crimes, so they were aware of the differences between torture and other forms of violence.320 Regardless, Syrian pathologists were accomplices in the omnipresent and systematic falsification and destruction of evidence. Their attitudes and behaviors were explained neither by their lack of experience nor by fear of reprisal. In forensic protocols, forensic pathologists were not compelled to name perpetrators, but they manipulated the history of the crime and contributed to the ambiguity of circumstances to shift the blame on to the victim or the opposition. This helped to produce narratives aligned with the official rhetoric. This occurred in individual cases and maneuvered public opinion such as the death of Hamzeh al-Khatib, and later the American journalist Marie Colvin. Hamzeh al-Khatib, a thirteen-year-old teenager from Dara’a, was killed by security forces in May 2011. He became the symbol of the Syrian uprising: a chubby, innocent-looking preteen boy tortured to death by the Syrian intelligence agencies.321 There were two conflicting narratives of the circumstances of his death. Although both narratives agree that the Syrian regime forces killed the teenager, they conflicted with the specific details of his death. Both parties borrowed the expertise of forensic pathologists to elaborate on their version of the story. The family and eyewitnesses claimed that the child died under torment and torture in regime custody at Tishreen Military Hospital.322 This version was supported by a local forensic pathologist on a YouTube video, who pointed out torture traces, three gunshots, a broken neck, and a cut of the genitals.323 Following the escalation created by Hamzeh’s death, Bashar al-Assad established a committee of forensic pathologists including Dr. Akram Al Sha’ar, Bassam Mohammad, and Zaher Hajo. The committee claimed that the teenager was killed on site by three gunshots as an act of defense against the demonstrators’ attack on military housing in the village. It claimed that demonstrators aimed to kill the Syrian combatants and rape the women.324 That might explain their claim that Hamzeh was a sixteen-year-old, not thirteen.325 They also dismissed torture contusions, fractures, and genital harm

317For further read on Medical documentation of torture: read Michael Peel, Vincent Iacopino, eds., The Medical Documentation of Torture (London: Green Medical Media Limited, 2002). 318“If the Dead Could Speak: Mass Death and Torture in Syria’s Detention,” Human Rights Watch, December 16, 2015. “The Photographed Holocaust,” SN4HR, 2018. ,Arab Reform Initiative, March 20, 2018 ”, ءﺎﻀﻘﻟا ﻲﻓ ﺎﯾرﻮﺳ “ ,Ali Al Zeer 319 http://www.syrianlegalforum.net/publications/view/42 320 Interview with Bassam Mohammad via WhatsApp, July 10 & 24, 2020. 321 Liam Stack, “Video of Tortured Boy’s Corpse Deepens Anger in Syria,” The New York Times, May 30, 2011, https://www.nytimes.com/2011/05/31/world/middleeast/31syria.html 322 Zamanalwsl,“Hamzeh Al Khatib's Torture Photos revealed,” Zamanalwsl, March 27, 2015, https://en.zamanalwsl.net/news/article/9479 323 “Hamzeh Ali Alkhateeb 13 Years Old Murdered by Syrian Security Forces,” May 27, 2011, https://www.youtube.com/watch?v=WjwC_-bKGhs. 324 Uri Friedman, “On Syrian State TV Hamza Ali Al-Khateeb Is No 'Child Martyr' Assad's regime is seeking to discredit a story that's rallied protesters,” The Atlantic, May 31, 2011, https://www.theatlantic.com/international/archive/2011/05/syrian-tv-issues-its-account-hamza-al-khateebs-death/351273/ . ,Al Mayadeen tv, March 26, 2020 ”, ﻦﻣ :ضرﻷا ا بﺮﺤﻟ نﻮﯿﻌﺑ ا ﺐﻄﻟ ا (ﻲﻋﺮﺸﻟ ا ءﺰﺠﻟ ا ﻟ ﺜ ﺎ ﻲﻧ )“ ,Ougariet Dandash https://www.youtube.com/watch?v=MKvdWSYQWDE 325Ibid. 60 claiming they were normal consequences of decomposition as they showed a photo of Hamzeh’s corpse number (23). The same photos appeared in Caesar’s file which Dr. Bassam Mohammad claimed as fakes, taken at the morgue in Tishreen Military Hospital.326 The committee violated the forensic pathology mandate which concerned the body by not establishing the intent. They manipulated the uncertainty of the circumstance and history of the victim to impose an imaginary intent onto the victim in order to legitimize violence. Syrian forensic pathologists today are working on mass atrocities cases. They were exhuming mass graves in areas the regime conquered from the opposition, where Assad’s forces and militias were accused of committing massacres. The whole process of moving corpses for the investigation was done while premediating the perpetrators’ identity [the terrorists].327 This process has substantial consequences for the future of transitional justice in Syria, where evidence is compromised with the deliberate changes inflicted on the crime scene. This includes the location, condition, and history of the mass graves and victims’ identification and context. Syrian forensic pathologists are willingly using their knowledge and skills to re-write narratives in the Syrian conflict. Besides their violation of their professional mandate and politicization, Syrian forensic pathologists are also ethically responsible for the psychological suffering of the families of victims.328

6. Triage: Indirect Killing

Triage, according to the Manchester Triage group, refers to “a system of clinical risk management employed in the Emergency Department worldwide to manage patient flow safely when clinical need exceeds capacity.”329 During disasters, Andrew Reisner defines triage as “the utilitarian sorting of patients into categories of priority to rationally allocate limited resources; it is, proverbially to do ‘the greatest good for greatest number.’”330 Triage is an evaluation process of patients based on the same types and criteria consisting of knowledge on the nature and number of casualties.331 In Syria, medical staff showed a gap in knowledge on triage processes in military hospitals.332 Medical staff at civilian hospitals referred to orders to prioritize military personnel over civilians regardless of the medical situation and urgency of the case. Such protocols based on identity and profession was a breach in triaging and necessary evaluation of a patient’s condition.333 There are additional factors that contributed to triage breach and indirect killing. First, conditions evolved during the war. The health sector was overwhelmed with the war casualties and lacked expertise with new staff. The regime targeted the health sector and consequentially lost human resources because of violence or exile. Secondly, pre-existing factors reinforced by war dynamics, such as the privatization of the health sector, corruption, and the extended influence of pharmaceutical companies owned by businessmen who had partnerships with Syrian intelligence. These circumstances substantially increased the vulnerability of low-income Syrians before the war. Thus, patients were

326Ibid. 327 Interview with Bassam Mohammad via WhatsApp, July 10 & 24, 2020. 328“Death Notifications for Hundreds of Detainees in Syria: Families with Broken Hopes,” Enab Baladi, July 14, 2019, https://english.enabbaladi.net/archives/2019/07/death-notifications-for-hundreds-of-detainees-in-syria-families-with-broken- hopes/#ixzz6TuGV40h7 329 Paulo Freitas, “Introduction,” in Emergency Triage, eds. Kevin Mackway-Jones, Janet Marsden, Jill Windle (Oxford: Blackwell Publishing &PMJ Books,2006),01. 330 Andrew Reisner, “Triage,” in Disaster Medicine, ed. Gregory R. Ciottone (Philadelphia: Mosby Elsvier,2006), 283. 331 David E. Hogan, Julio Rafael Lairet, “Triage,” in Disaster Medicine, eds. David E. Hogan, Jonathan L. Burstein (Philadelphia: Wolters Kluwer: Lippincott Williams & Wilkins, 2007),16-17. 332 Interview with Ous via Facebook, May 7, 2020. Interview with Milad via Facebook, May 22, 2020. 333 Interview with Ahmad via Skype, August 27, 2019. Interview with Amir via Facebook, April 20, 2020. 61 often victims of clinical violence at public hospitals, resulting in serious consequences on people’s lives and health. Some incidents of triage breach stirred public discussion, for instance, a medical network was accused of organ harvesting in 2008.334 Another example was the theft of chemotherapy doses in Bayrouni Hospital, impacting dozens of patients in critical conditions.335 Medical negligence of civilians was practiced across public hospitals in the years between 2012 and 2018. This was when the war was at its peak in most of the Syrian territory, resulting in serious consequences for patients from diverse ethnic, religious, regional, and economic strata in Syria. Determining the number of victims requires further investigation based on hospital medical data. This deliberate policy enforced by the highest medical authorities in the country and at the hospital level, including the health ministry and management, are primarily responsible for the medical protocols and policies. Also, a substantial number of medical staff, specifically specialists, were also involved with neglecting their medical ethics and duty of care. Violation of triage in Syria is indirect killing with significant consequences in terms of longevity, scale, and responsibility and perhaps the largest victim group of medical violence. Furthermore, such violence results in long-term impacts such as public distrust of the health sector. The attitudes of patients during the coronavirus pandemic are a reflection of the ten years policies which endorsed the violation of patient rights. Sick patients refrained from seeking medical intervention because of negligence or improper treatment. Rumors of security solutions of the pandemic, patient arrests, and increased uncertainty of receiving care exacerbated the situation.336 The violation of triage and medical negligence of civilians generated resentment and violent reactions against doctors inside medical facilities. It became a manufacturer of violence in the Syrian health sector where domestic attacks on health professionals escalated. Patient escorts punched and publicly humiliated medical professionals at medical facilities.337 Al Mujtahid Hospital is the third public and education civil hospital in Damascus. It was turned into a triage point for the military in 2013. Dr. Adeeb Mahmoud, the director of the hospital in the period between 2011 and 2017, instructed the hospital staff to prioritize combatants of either members of the Syrian army or militias[Figure 4.1]. Staff was threatened with penalties if a report to the security apparatus appeared for allegedly refusing to treat a Syrian soldier.338 Dr. Mohammad Al Husseni, the general director of Damascus Hospital (Al Mujtahid), on behalf of the hospital, received an appreciation from Al Quds militia leader (Mohammad Saed) for unprecedented help for the combatant [Figure 4.2]. His staff described how civil patients were abandoned and humiliated in the hospital corridors, “I cast off to a civilian, I even, sometimes, shouted at the patients or his companions. But I cannot reject a soldier.”339 Dr. Mahmoud imposed new protocols, breaching the patient rights for political gains. In this sense, violation of triage was a form of collective punishment to Syrian society.

,SyrianDays, February 18, 2008 ”, ﻢﯿﻣﺄﺗ ﺔﻋارز ..ﻰﻠﻜﻟا فﺎﺸﺘﻛاو ﺔﻜﺒﺷ رﺎﺠﺗﻼﻟ ءﺎﻀﻋﻷﺎﺑ ﺔﯾﺮﺸﺒﻟا ﻢﮭﻨﯿﺑ ءﺎﺒطأ “334 http://www.syriandays.com/print_details.php?page=show_det&id=7985&num_page_det=1 ,Institute for War And Peace Reporting, August 28, 2010 ”, ﻜﺣ ﺎ ﯾ تﺎ رﻮﺳ ﯾ ﺔ ”,؟ دﺎﺴﻔﻟا ﺪﯾﺰﯾ ﻦﻣ ضاﺮﻣأ ﻦﯿﯾرﻮﺴﻟا “335 /؟ دﺎﺴﻔﻟا - ﯾﺰﯾ ﺪ - ﻦﻣ - ضاﺮﻣأ - ﻦﯿﯾرﻮﺴﻟا /https://syriastories.net 336 Mazen Gharibah, Zaki Mehchy, “COVID-19 Pandemic: Syria’s Response and Healthcare Capacity,” (London: The London School for Economic and Policy Studies & Conflict Research Program, March 25, 2020). ,Bawabat Syria, April 25, 2019 ”, ”ﺢﯿﺒﺸﺘﻟا ﻰﻠﻋ رداﻮﻜﻟا ﺔﯿﺒﻄﻟا ةﺮھﺎظ ﻰﺸﻔﺘﺗ ﻲﻓ ﻞﺣﺎﺴﻟا "يرﻮﺴﻟا 337 / ﺢﯿﺒﺸﺘﻟا - ﻰﻠﻋ - رداﻮﻜﻟا - ﺔﯿﺒﻄﻟا - ةﺮھﺎظ - ﻒﺘﺗ /https://bawaba-sy.com/2019/04/25 ,Al Modon, August 18, 2019 ”,ﻓﯿﺪﯾﻮ ﯾﻔﺘﺢ ﺳﺠﺎﻻً ﺣﻮل ﺳﻼﻣﺔ ﻛﻮادر اﻟﻤﺴﺘﺸﻔﯿﺎت اﻟﺴﻮرﯾﺔ" ﻮﯾﺪﯿﻓ - ﺢﺘﻔﯾ - ﺠﺳ ﺎ ﻻ - لﻮﺣ - ﻼﺳ ﻣ ﺔ - ﻮﻛ ا رد - تﺎﯿﻔﺸﺘﺴﻤﻟا - ﺔﯾرﻮﺴﻟا /https://www.almodon.com/media/2019/8/13 338 Interview with Ahmad via skype, July 23, 2019. Interview with Amir via Facebook, April 30, 2020. 339Ibid. 62

6. Conclusion

This chapter looked into medical professionals’ role in violence, and the types of violence they committed. It described medical professionals’ actions that breached medical ethics and standard protocols, and consisted of compliance with violence. It showed that doctors had a crucial role in the violence in the Syrian civil war, affecting the course of the war. Doctors, as members of the Syrian intellectual milieu and regime elite, psychologically manipulated the masses through propaganda. They instigated fear, uncertainty, and diversion within the Syrian society. The Syrian president, a former doctor, incited, supervise and instructed the killing, massacres, torture and bombardment of hundreds of dozens of civilians. Bashar al-Assad is a case of misconception of medical identity with political identity. Furthermore, medical professionals in detention centers and hospitals abetted with torture, tortured, and killed detainees. They used medical means of direct intervention or withheld of treatment to destroy their victims. Most of their deeds targeted political group, but the impact of the perpetration extended to the Syrian society as whole, and specifically the groups with social and economic vulnerabilities. Finally, they violated their duties when they involved themselves in the legitimization of violence through forging documents and destruction of evidence. To sum up, doctors’ crimes during the Syrian conflict continue to have a profound effect on the Syrian society in terms of physical and psychological destruction, and most importantly the distortion of the truth.

63

Conclusion

The primary objective of this thesis has been to provide insights on medical violence in the Syrian health sector directed by the regime during against civilians during the ongoing conflict (2011-2020). This goal was pursued via a detailed study of the circumstances and backgrounds of medical violence in Syria and a specific examination of the role of the health facilities in the process of genocidal policies since 2011. This thesis aimed to contribute to four strands of literature: the study of the health sector in authoritarian regimes, perpetrator studies, the nature of the Syrian conflict, and the debate on medical perpetration in civil war. This conclusion briefly discusses the thesis’ main points before providing concluding remarks. This thesis broadly confirms the general arguments in perpetrator research on the ‘ordinariness’ of perpetrators, from the early findings of Hannah Arendt to the famous study of Christopher Browning. The majority of Syrian medical perpetrators are ordinary Syrians who showed no violent tendencies before the war. They all grew up and were trained under the Assad regime’s ideological orientation. They do not seem to hold strong Ba’athist ideological beliefs, in any case not more than a basic acceptance, but not a particularly fanatical obedience or conformity to the regime rhetoric. They are from diverse social, political, religious, and regional backgrounds, and their identities encompass multi-layered national-religious, socio-economic and regional components. Religion, religious identity, or sectarian beliefs were not a sole factor explaining medical perpetration, but it also cannot be ignored when determining the scale, cruelty, and willingness of perpetration. Syrian medical perpetrators showed similar characteristics to other perpetrators in previous cases of mass violence in terms of their silences, the paradoxes of victimization and perpetration, and variations of perpetration willingness. Perpetrators are not born to perpetrate, and doctors too, were subject to long processes of manipulation, indoctrination, and other factors that generated violence within the profession and institution of healthcare. A few of them were victimized before or during their acts of perpetration, and victimization does not excuse the cruelty of their actions, but it is an important factor to explain the move from oppression towards destruction. Syrian medical professionals, in general, maintained silences on their acts of perpetration, and even those who showed remorse and regret avoided detailing the means and details of torture or killing. This thesis therefore closely follows Lee-Ann Fujii in considering perpetrators’ silences, rumors, and myths in times of perpetration as intrinsic to the violence itself.340 In determining the willingness to perpetrate, three categories of health workers can be considered based on my observations, the specifics of the Syrian health sector, and health workers’ feedback: specialists (including surgeons), nurses, and residents. Medical perpetrators, especially specialists and nurses, had a choice not to participate in the violence: they could reject or request not to tend to detainees without consequences for their own lives. Perpetration was mostly a choice of those who stayed on and worked in regime hospitals. However, an important aspect in determination of willingness and enthusiasm to perpetrate was social ties with the regime. Medical professionals who had social, economic, and religious-sectarian ties with the regime or its personnel were pioneers of violence and enthusiastic torturer and killers. The violence was clearly restrained where the regime had less ties (e.g. in Sanamayn), and in those areas medical individuals dissented and refused to be involved in violence in a collective sense. In chapter 1, I conclude that medical violence is a result of the inherited feature of colonial legacy and policies of the Syrian Ba’ath party. The health sector, since its establishment, was instrumentalized for political purposes and power consolidation. Yet, Hafez al-Assad instigated the

340 Lee Ann Fuji, Killing Neighbors: Webs of Violence in Rwanda (Ithaca: Cornell University Press, 2011),41-43. 64 use of medical skills and knowledge in oppression and massacres with the political unrest in Syria between 1979-1990. In typical fashion for authoritarian regimes, the Assad regime manipulated health professionals through a combination of persuasion and oppression. It subjugated health professionals through security surveillance and patronage networks, which were prominent mechanisms in the violent processes before and during the war. Those networks generated discriminatory policies based on ideological preferences, sectarian backgrounds, and personal ties. Prioritizing members of such networks in employment, positions, and providing incentives in medical schools or health facilities, enabled the regime to oversee the decision-making process in health institutions. Along with party favoritism, the Assad regime repressed health workers. This pattern shows the continuity of violence against medical professionals, in which the regime utilized legal instruments to set the boundaries of acceptable behaviors and identities: the counterterrorism laws (June 2012), and the Emergency Law (1976), among others. Legal criminalization deepened the segregation of the health sector and smoothed the co-optation of doctors with state violence. Legal criminalization amplified invisible polarization and affirmed exclusionary identity. Medical violence in Syria should be understood within the context of militarization and war. The militarization of the health sector distorted the ethos of medicine and damaged the patient-doctor relationship. I argue that the militarization of the health sector was both a vertical and horizontal phenomenon. It is primarily a top-down national policy to expand medical military services’ authority over civil medicine and the security apparatus’ power over health professionals. Yet, civil war dynamics and civilians’ engagement with violence impacted the health sector as well. Paramilitary groups and other militias extended their de facto authority into health sectors, they exploited hospitals and health facilities as sites of violence or for treatment advantages. Health professionals, as well, took initiative to devote their facilities to war efforts. I conclude in chapter 1 that medical violence was not pre-planned. Rather, it was generated by regime responses and changes of its perception of “the opposition”, in addition to the nature of the social movements and its advancement. The regime perceived the uprising as an existential threat, so medical violence, as part of regime violent strategy, was a means to oppress demonstrations from the very first couple of months of the protests. But it evolved to destructive means with the advancement of demonstrations and the militarization of the opposition. The regime incorporated medical institutions into its repressive strategy to eliminate and destroy this supposed existential threat of a vast and unwinnable political enemy. This argument overlaps with Scott Straus’ theory of mass categorical violence based on his comparative study of five cases of mass violence in Africa in the book The Making and Unmaking of a Nations. Straus contends that a regime would resort to mass violence when it is confronted with imagined or real threats to its power from an alienated group, in which it perceives itself as outnumbered by an invincible enemy.341 Chapter 2 showed the Assad regime’s institutional adaptation to threats with the advancement of the war, a flexibility which distinguished the dictatorship by giving it an edge to deal with the crisis.342 Health institutions, both civil and military, were incorporated in the process of violence. Using health facilities for practical reasons paved the way for the normalization and continuity of violence as a bureaucratic routine and process. Hospitals, in that sense, were an ideal space of violence because they are private spaces where a level of suffering and pain is expected, and they are equipped with efficient and skilled professionals. In addition, medical institutions’ rigid hierarchy and structure, and division of labor was also conducive to incorporation into the regime’s apparatus of violence. These structural similarities with military institutions made for a smooth integration in military operations. This was

341 Scott Straus, Making and Unmaking Nations: War, Leadership, and Genocide in Modern Africa (Ithaca: Cornell University Press, 2015),25-31. 342 Steven Heydemann, Authoritarianism in Syria: Institutions and Social Conflict, 1946–1970,07 65 shown in the examples of Hospital 601 and Al Mujtahid Hospital, where the hospitals’ management was able to establish a separate department as torture centers and assigned medical workers in collaboration with intelligence apparatus to carry out the violence. I argue that the regime exploited hospitals as intermediary institutions to assist and legitimize violence since April 2011. Subsequently, hospitals, as spaces of healing, produced and proliferated violence in a very serious transgression and inversion of moral boundaries. On the one hand, hospitals became spaces of profound psychological and physical torment of regime opponents. On the other hand, they became symbols of the distortion of social norms, by departing from their role of promotion of health care into a process of violence. This spread a sense of injustice among ordinary Syrian civilians, amplifying their frustration and distrust, which in turn only fed more violent reactions during the crisis. This also means that the utilization of hospitals as killing and torture centers sent shockwaves through Syrian society beyond its immediate impact; its true long-term effects remain to be fully evaluated. Chapter 3 offered an outline of the type of violence committed by Syrian medical professionals throughout the Syrian conflict. Syrian health professionals from diverse political, religious and regional backgrounds abetted in the elimination process of the regime’s opponents. The community of doctors and the health sector took part in gross violence in both clinical and non-clinical environments. Medical professionals, as members of the Syrian intelligentsia, were involved in perpetration of violence, and incited, organized, and ordered violence, and buried evidence. They supervised mass atrocities, abetted in torture and murder of prisoners in prisons, detention centers, and hospitals. They used their skills directly or indirectly to invent a wide array of methods and environments to increase the likelihood of prisoners’ deaths. Bashar al-Assad’s era also witnessed an expansion of medical professionals’ activities in the battlefield alongside military and paramilitary groups. The later were involved in massacres and other forms of violence right under the watchful eye of those embedded health professionals. Above all, doctors like Bashar al-Assad himself, were political pioneers of the organization of this violence and its related processes. I argue that medical violence that is associated with a civil war has specificities distinct from other forms of violence during wars and genocides. It is selective and private, and influenced by the micro dynamics in a given neighborhood or town, since medical professionals are part of a community, where they share their emotions, beliefs, and fate. Besides serving as a regime tool to destroy opponents, medical torture was also directed against civilians for private vendettas. Doctors killed and tortured civilians from certain neighborhoods or areas where they believed their relatives were killed. This relation between medical violence and micro dynamics appears clearly in cases like Sanamayn, where there were elements of restraint because of medical professionals’ social and religious ties with the community. Furthermore, hospitals’ vertical distribution and networks at the level of city, town, and neighborhoods (along with the general geographic distribution of civil war), translated into social and economic ties between health professionals and the community. Complex emotional and practical influences contributed to the extension of violence into the health system and the implication of a significant number of medical professionals from diverse groups. Finally, medical violence is a collective responsibility of any medical society as a whole. This thesis is limited to the health sector in areas held by the Syrian regime. Hence, for a better comprehension of medical perpetrators and medical violence phenomenon, I urge for further investigation of the violence committed in parallel health systems either by opposition-held areas, Kurdish-controlled areas, or previously areas under ISIS.

66

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“The Testimony of the Detainee: Mazen Besais Hamada On Air Force Branch-Mazzeh Military Airport And Military Hospital 601 in Mazzeh, Damascus.” Violation Documentation Center in Syria, October 2013.

“Syria: Executions, Hostage Taking by Rebels: Planned Attacks on Civilians Constitute Crimes Against Humanity,” Human Rights Watch, October 10, 2013.

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Enab Baladi’s Investigation Team. “Al-Assad’s crimes in millions of documents: When will accountability start?.” Enab Baladi, October 03, 2018, https://english.enabbaladi.net/archives/2018/10/al-assads-crimes-in-millions-of-documents-when- will-accountability-start/#ixzz6RUodX3Ow Linfield, Susie. “Syria’s Torture Photos: Witness to Atrocity.” The New York Times Book Reviews, February 09, 2019. https://www.nybooks.com/daily/2019/02/09/syrias-torture-photos-witness-to-atrocity/ Ciralsky, Adam “Documenting Evil: Inside Assad’s Hospitals Of Horror.” Vanityfair-Hive, June 11, 2015. https://www.vanityfair.com/news/2015/06/assad-war-crimes-syria-torture-caesar-hospital Syria: Death Under The Government“ ” رﻮﺳ ﯾ ﺎ : تﻮﻣ ﻲﻓ ﺪﮭﻋ ة ا ﺔﻣﻮﻜﺤﻟ “ .Kujak, Shafak, Raed Al Salhani Authority.” Daraj, September 04, 2018. https://daraj.com/9214/ Shadid, Anthony. “Sectarian Strife in City Bodes Ill for All of Syria.” New York Times, November 19, 2011. https://www.nytimes.com/2011/11/20/world/middleeast/in-homs-syria-sectarian-battles-stir- fears-of-civil-war.html Loveluck, Louisa. “The Hospitals were Slaughterhouses: A Journey into Syria Secret Torture Wards.” The Washington Post, April 3, 2017. 76 https://www.washingtonpost.com/world/middle_east/the-hospitals-were-slaughterhouses-a- journey-intosyrias-secret-torture-wards/2017/04/02/90ccaa6e-0d61-11e7-b2bb- 417e331877d9_story.html Min Al Aryd: Forensic Pathology: Body and ﻦﻣ ضرﻷا : ﺐﻄﻟا ﻲﻋﺮﺸﻟا : ﺜﺟ ﺔ ﻮھو ﯾ ﺔ “ .Dandash, Ogarit Identity.” Al Maydeen Tv, Jan 3,2019. https://www.youtube.com/watch?v=NG9uTW8UVeg War in the Eyes of Forensic Pathology, “ALMaydeen / بﺮﺤﻟا ﻲﻓ نﻮﯿﻋ ﺐﻄﻟا ﻲﻋﺮﺸﻟا “ .Dandash, Ogarit Tv Channel, March 26, 2020. https://www.youtube.com/watch?v=MKvdWSYQWDE ,Searching for Assad’s Torturers.” Al Jazeera Arabic, May 10 ﺚﺤﺒﻟا ﻦﻋ يدﻼﺟ ﺪﺳﻷا “ .Al Kin, Mahmoud 2020. https://www.youtube.com/watch?v=Tt614Ar8cH0. .Aljumhuriya, July 2018 ”. ﮭﺷ ﺎ د تا ا ﻟ ﻮ ﻓ ﺎ ة ﻟ ﻤ ﺌ تﺎ :ﻦﯿﻠﻘﺘﻌﻤﻟا مﺎﻈﻧ ﺔﺤﺑﺬﻤﻟا ةﺮﻤﺘﺴﻤﻟا " . ﮭﺷ ﺎ د تا - ﻓو ﺎ ة - تﺎﺌﻤﻟ - ﻦﯿﻠﻘﺘﻌﻤﻟا - ﺎﻈﻧ م - ﺔﺤﺑﺬﻤﻟا - ةﺮﻤﺘﺴﻤﻟا /https://www.aljumhuriya.net/ar/content Biliad, D., N. Nasreldin, ‘Homs, a Syrian city plagued by sectarian killing.” AFPTV, November 26, 2011. https://www.youtube.com/watch?v=lARJEdMbd7o. Enab Baladi, March 28, 2020, https://english.enabbaladi.net/archives/2020/03/nizar-yazaji- confronts-coronavirus-with-a-syrian-arab-army-mindset-through-luxury-cars-and-provocative- statements/ ,Al Modon, March 03, 2020 ",وزﯾﺮ اﻟﺼﺤﺔ اﻟﺴﻮري ﻋﻦ ﻛﻮروﻧﺎ:"اﻟﺠﯿﺶ ط ّﮭﺮ اﻟﺒﻼد ﻣﻦ اﻟﺠﺮاﺛﯿﻢ" زو ﯾ ﺮ - ﺔﺤﺼﻟا - يرﻮﺴﻟا - ﻦﻋ - ﻧورﻮﻛ ﺎ - ﺶﯿﺠﻟا - ﺮﮭط - دﻼﺒﻟا - ﻦﻣ - /https://www.almodon.com/media/2020/3/13 ا اﺮﺠﻟ ﺛ ﯿ ﻢﯿﺛاﺠ “A Dangerous Dynasty: House of Assad, episode 1” BBC, October 31, 2019, https://www.bbc.co.uk/programmes/b0bnfn0d Taub, Ben. “The Assad Files: Capturing The Top-Secret Documents That Tie The Syrian Regime To Mass Torture And Killings.” The New Yorker, April 18, 2016, https://www.newyorker.com/magazine/2016/04/18/bashar-al-assads-war-crimes-exposed “Barbara Walters Interview with Syria's President Bashar al-Assad: 'There Was No Command to Kill'.” ABC News, December 7, 2011, https://www.youtube.com/watch?v=bsyQ442Xvnw Nieuwsuur, “The full interview with president Assad of Syria.” NPO, December 18, 2015 https://www.youtube.com/watch?v=m-q9_Dsb2OE “Syrian President Bashar al-Assad denied the use of torture in regime prisons.” The New Arab, November 11, 2019, https://english.alaraby.co.uk/english/news/2019/11/11/syrias-assad-claims- no-torture-in-regime-prisons .Al Modon, July 30, 2020 ”, ﺎﻧأ ﻲﺤﯿﺴﻣ ﻢھو نﻮﯾدﺎﮭﺟ “ .Qadour, Omar ﺎﻧأ - ﺴﻣ ﯿ ﻲﺤ - ﻢھو - ﮭﺟ ﺎ د ﯾ نﻮ /https://www.almodon.com/opinion/2020/6/30 “Death Notices of Government Held Detainees in Syria.” Monthly Human Rights Digest, November 2018. Stack, Liam. “Video of Tortured Boy’s Corpse Deepens Anger in Syria.” The New York Times, May 30, 2011. https://www.nytimes.com/2011/05/31/world/middleeast/31syria.html Hamzeh Al Khatib's Torture Photos revealed.” Zamanalwsl, 2015. https://en.zamanalwsl.net/news/article/9479 1 Uri Friedman, “On Syrian State TV Hamza Ali Al-Khateeb Is No 'Child Martyr' Assad's regime is seeking to discredit a story that's rallied protesters,” The Atlantic, May 31, 2011, 77 https://www.theatlantic.com/international/archive/2011/05/syrian-tv-issues-its-account-hamza-al- khateebs-death/351273/ . “Death Notifications for Hundreds of Detainees in Syria: Families with Broken Hopes.” Enab Baladi, July 14, 2019. https://english.enabbaladi.net/archives/2019/07/death-notifications-for-hundreds-of-detainees-in- syria-families-with-broken-hopes/#ixzz6TuGV40h7 .Syrian Days. February 18, 2008 ”. ﻢﯿﻣﺄﺗ ﺔﻋارز ..ﻰﻠﻜﻟا فﺎﺸﺘﻛاو ﺔﻜﺒﺷ رﺎﺠﺗﻼﻟ ءﺎﻀﻋﻷﺎﺑ ﺔﯾﺮﺸﺒﻟا ﻢﮭﻨﯿﺑ ءﺎﺒطأ “ http://www.syriandays.com/print_details.php?page=show_det&id=7985&num_page_det=1 ,Institute For War And Peace Reporting. August 28, 2010 . ﻜﺣ ﺎ ﯾ تﺎ رﻮﺳ ﯾ ﺔ ”,؟ دﺎﺴﻔﻟا ﺪﯾﺰﯾ ﻦﻣ أ ﺮﻣ ضا ا ﻟ رﻮﺴ ﯾ ﯿ ﻦ “ /؟ دﺎﺴﻔﻟا - ﯾﺰﯾ ﺪ - ﻦﻣ - ضاﺮﻣأ - ﻦﯿﯾرﻮﺴﻟا /https://syriastories.net .Bawabat Syria. April 25, 2019 ”. ”ﺢﯿﺒﺸﺘﻟا ﻰﻠﻋ رداﻮﻜﻟا ﺔﯿﺒﻄﻟا ةﺮھﺎظ ﻰﺸﻔﺘﺗ ﻲﻓ ﻞﺣﺎﺴﻟا يرﻮﺴﻟا " / ﺢﯿﺒﺸﺘﻟا - ﻰﻠﻋ - رداﻮﻜﻟا - ﺔﯿﺒﻄﻟا - ﺎظ ةﺮھ - ﻒﺘﺗ /https://bawaba-sy.com/2019/04/25 /Al Modon. August 18, 2019 ”.ﻓﯿﺪﯾﻮ ﯾﻔﺘﺢ ﺳﺠﺎﻻً ﺣﻮل ﺳﻼﻣﺔ ﻛﻮادر اﻟﻤﺴﺘﺸﻔﯿﺎت اﻟﺴﻮرﯾﺔ" ﻮﯾﺪﯿﻓ - ﺢﺘﻔﯾ - ﺠﺳ ﺎ ﻻ - لﻮﺣ - ﻼﺳ ﻣ ﺔ - ﻮﻛ ا رد - تﺎﯿﻔﺸﺘﺴﻤﻟا - ﺔﯾرﻮﺴﻟا /https://www.almodon.com/media/2019/8/13 .Syria TV, May 10, 2018 ”. ﻢﯿھاﺮﺑإ :راﺪﻗﺮﯿﺑ رﺎﺗوأ دﻮﻌﻟا تﺮﺴﻛ ﺔﻤﺘﻋ ﻦﺠﺴﻟا ﻛو "ﮫﺘﺑﺂ .Ya Huria https://www.youtube.com/watch?v=ACKwAameX0Q ,Al Jazeera TV Channel, May 10, 2020 ”. ﺚﺤﺒﻟا ﻦﻋ يدﻼﺟ ﺪﺳﻷا “ .Kin, Mahmoud https://www.youtube.com/watch?v=Tt614Ar8cH0 Tghyrna, “Massacre of Saydnaya Prison: Omar Al Abdullah-part 2.” Orient, March 5, 2015, https://www.youtube.com/watch?v=_QihCb3adNk

Others “Bombardment at Al-Amal Hospital in Homs.” April 6, 2012. https://www.youtube.com/watch?v=3g20iZ1_PCU https://www.facebook.com/Damascus.medical.Association/videos/2604818446217680 “Attacks on protest in medical faculty in Aleppo.” March 14, 2012. https://www.youtube.com/watch?v=rt0MlvGZCOo, “Protest in Damascus Medical Faculty.” Nov 02, 2011. https://www.youtube.com/watch?v=Vw6VhAJk3aY “Interview with Bashar al-Assad,” ARD TV. March 2, 2016. https://www.youtube.com/watch?v=8_E5lvdDtEI “Syria Conflict BBC exclusive interview with Bashar al-Assad.” February 9, 2015. https://www.youtube.com/watch?v=yiC4w7Erz8I “Dr. Taleb Ibrahim’s interview with Al Dunia Tv.” June 5, 2011. https://www.memri.org/reports/syrian-regime-mouthpiece-dr-taleb-ibrahim-urges-president-assad- massacre-anti-regime “Syria President Bashar al-Assad Speech to Parliament.” March 30, 2011. https://www.c-span.org/video/?298760-1/syria-president-bashar-al-assad-speech-parliament “Taleb Ibrahim in an interview with the Syrian TV.” June 11, 2011, https://www.youtube.com/watch?v=M1ytKHl7lQo, “Taleb Ibrahim interview with Al-Jadeed/New TV and posted on the Internet on December 16, 2012.” https://www.memri.org/reports/pro-assad-syrian-commentator-taleb-ibrahim-calls-opponent-ape- and-says-my-shoe-and-my-urine, “Speech by President Bashar al-Assad at Damascus University.” 20 June 2011. https://www.c-span.org/video/?300198-1/syrian-president-bashar-assad-national-address “Hamzeh Ali Alkhateeb 13 Years Old Murdered By Syrian Security Forces.” May 27, 2011. 78 https://www.youtube.com/watch?v=WjwC_-bKGhs “From lady Asmaa Al-Assad’s visit to houses of the injured Jamal Al Hasan and Jalal Razouk in Homs ,Syrian News ”. ﻦﻣ ﯾز ةرﺎ ا ةﺪﯿﺴﻟ ءﺎﻤﺳأ ﺪﺳﻷا ﻲﻟﺰﻨﻤﻟ ا ﯿﺤﯾﺮﺠﻟ ﻦ لﺎﻤﺟ ا ﻦﺴﺤﻟ لﻼﺟو قوزر ﻲﻓ ﺪﻣ ﯾ ﻨ ﺔ ﺺﻤﺣ ا ﻟ مﻮﯿ “ today April 30, 2018. https://www.youtube.com/watch?v=l46VNhK0Sro .Syrian Satellite Channel, March 26, 2014 ”. ﺪﯿﮭﺸﻟا ﻞﻄﺒﻟا رﻮﺘﻛﺪﻟا مزﻼﻤﻟا فﺮﺷ ﻲﻠﻋ دوﺪﺷ " https://www.youtube.com/watch?v=_OzlwjXj2dU “Syria: Assad pays rare frontline visit.” Euronews, June 27, 2016, https://www.youtube.com/watch?v=g3LJz7EZMNM “Damascus Medical Association Facebook Page: Doctors’ rally with Assad.” August 25, 2011. https://www.facebook.com/Damascus.medical.Association/photos/a.251788664854015/25178878 4854003.

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Appendices

Table (0.1): List of Interviews Perpetrators and Bystanders No.of Name Provision Civil/Military Date of Interview Interviews 80 Haetham Resident /Orthopedic Surgeon Hospital 601 M. 1 August 17, 2019 August 28, 2019 & May 15 & June 23, Ahmad vascular surgeon/Resident Al Mujtahid hospital C. 3 2020 Tishreen Ous Anesthesiologist Military hospital/Hospital 2 April 24,2020 & May07, 2020 601/civil hospitals Bahjat Laboratory Analyst NDF/Hospital 601 1 May 01, 2020 Emad Orthopedic surgeon Tishreen Military hospital 1 May 12, 2020 military hospitals Latakia, Maan Orthopedic surgeon/ Resident 1 May 13, 2018 Tartous, & Damascus Hospital 601/Tishreen Adel cardiologist surgeon 2 May 02, 2020 & May 12, 2020 Hospital

Dr. Wahebi Urologic surgery/Resident Homs Military Hospital 1 May 13, 2020

Darwich cardiologic surgeon Al Basel H 1 May 15, 2020 Sulieman Maxillofacia Surgeon al-Assad University H 1 April 24, 2020 Hospital 601, Deir Ez zor Abdullah Nurse/ER H, Al Sanamyeen Military 2 May 12, 2020 Hospital Issa Nurse Hospital 601 1 April 04, 2020 & May 29, 2020 Hospital 601, Hama Hasan Nurse/physiotherapy Military Center for 1 April 25, 2020 Artificial limbs

Jamel Yasin Al Hussien Chief of Nurses Homs Military Hospital 1 Nov 01, 2018

Civil/ Milad General Surgeon 2 May 22, 2020 Damascus/Latakia

Anas Nurse Aleppo Military hospital 1 April 23, 2020 Tishreen Military Bassam Barakat Surgeon Hospital/Private Clinic 1 April 23, 2020 Latakia Amir urologic surgeon/Resident Al Mujtahid Hospital 1 April 13. 2020

Ebrahim Nurse Hospital 601 1 May 18, 2020 Homs Center for Forensic Bassam Mohammad Pathologist 1 July 10, & July 24, 2020. Pathology Civil Resident at Khaled General Surgeon 1 Augist 18, 2018 military hospitals 601

Hazem Nurse Hospital 601 1 May 05, 2020 Tishreen Mansour Nurse 1 Jun 21, 2020 military hospital AlKhateebBran Dr. Ali Doctor ch/Former Director of 1 June 1, 2020 Police medical services Victims & Eyewitnesses

Tadmour/601/ 215/ Melhem Politician 2 April 22, 2019 & April 24 2019 Sydnaya, etc Tadmour Saraj Student 1 18/Aug/18 1984-1995 HomsMilitary Saed Smuggler 3 October 9 &11, 2018 branch/253/215 Khaldoun Journalist Air Force Intelligence/215 1 April 9, 2019 81

Hama Airport Clinic/Deir Ammar Student Shmaeel intelligence 2 Feb 3, 2019 & Jan 6,2019 Hamah Air Force Ismael Sydnayaa/Mazeh Airport/601 2 May 29, 2020 & May 2, 2020 Intelligence/01/Saydnaya August 4, 2019, June 25, 2020, & July Mohammad 601 Businessmen 1 15, 2020. Air Force Qutaiba Student intelligence/ Political 1 May 23, 2020 intelligence Homs Military /Air Force Dr. Mohammad Surgeon 1 Jun 23, 2018 intelligence Homs Military Nabil NGO/State Intelligence 1 March 15, 2020. Hospital/hospital 601 I chose x to not use any name Ammar Suliman’s X could harm any of Suliman’s 1 May 18, 2020 acquaintance acquaintance. informal Prison+Air Ayman - 1 January 6, 2019 Force intelligence Informal Prison, Military Suhaib Hama Medical Directorate 1 January 9, 2019 intelligence in Hama Al Sanamyeen Military Omar Defected Soldier 1 April 22, 2020 Hospital Mustafa Writer Eyewitness 1 June 25, 2020 Resistance doctors (Personal information erased, and names were changed for security considerations.) Dr.Ahmed Aleppo/ Al Raqqa Civil/ Pediatrician July 15, 2016 Civil/Daraa, Hamah, Sami Neuroweapon/Resident 1 Feb 23, 2018 Aleppo Taem Doctor Civil/ Damascus 2 July 28 &29, 2019 Mohamad Medical student Aleppo 2 April 16, 2018

Ayham S Anesthesia technician Civil/Damascus 1 December 18, 2019

Mohamad Medical Student Civil 1 January 14, 2018.

Majed SARC Civil 1 August 15, 2018

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Figure 1.1: A statement by the National Medical Association calling for an end to the insult on doctors, claiming that the violence they committed was medical complicity, September 2011.343

Figure 1.2: The 33rd Annual Meeting of the Syrian Medical Association General Assembly: “Our Only Choice is to Continue the Fighting Against Terrorism, 25 April, 2016.”

343 The Facebook page of the Syria Medical Association, https://www.facebook.com/photo?fbid=278328205578019&set=a.149500571794117 83

Figure 2.1: The Hospital 601 Old Trauma Center (prison) drawn by victims

84

Figure 2.2: Photo of Dr. Mohammad Barakat with Alawite sheikh Sha’aban Mansour and other followers, posted on his Facebook page in June 9, 2018

85

Figure 2.4: Photo of Dr. Ammar Suliman at the meeting of the Arab Network for Child Protection in Yemen in 2004

Figure 2.5: Major General Dr. Ammar Suliman during the Jarih Watan workshop in 2020

86

Figure 4.1: Photo of Dr. Adeeb Mahmoud with Major General Dr. Moures Mouas, the former director of military medical services directorate, and Dr. Abd Al Qader Hasan, the former director of Syria Medical Union. Taken at a conference “Advanced diagnosis and treatment in Lung Cancer” at the Sheraton Hotel, Damascus, October 8, 2015.

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Figure: 4.2: A photo of Mohammad Saed, the commander of Al Quds Brigade militia, together with Dr. Mohammad Yousef Al-Husseni taken at Al Mujtahid hospital on December 22, 2019.