In 2011, the Syrian government cracked down with extreme violence on mass popular protests calling for sweeping economic and political reform after more than 50 years of dictatorship. The anti-government opposition responded to that repression by organizing both political and military resistance to the Syrian regime. By mid-2012, Syria was experiencing a full-fledged internal conflict. For the past eight years, the Syrian government and its allies have sought to systematically extinguish dissent through every means at their disposal, a strategy that has entailed massive human rights violations. The conflict has killed hundreds of thousands of civilians and displaced more than half of Syria’s population internally and across the country’s borders. The Syrian government has prosecuted the war by intentionally targeting civilian populations in restive areas and any perceived opposition supporters. It has imposed sieges on opposition-held areas, shelled and bombarded densely populated urban centers, and conducted a campaign of arrest, torture, and enforced disappearance of suspected insurgents and their supporters that has laid waste to much of the country and sparked an exodus of millions of Syrians seeking refuge in neighboring countries and beyond.
The Syrian government and its allies have also systematically targeted health facilities and health workers as part of a wider strategy of war aimed at breaking civilian populations and forcing them into submission. Since the beginning of the conflict, Physicians for Human Rights (PHR) has documented 583 attacks on health facilities; the Syrian government and its allies have been responsible for carrying out more than 90 percent of these attacks. Through their purposeful assault on health, the Syrian government and its allies have systematically denied access to medical care in areas outside of their immediate control and actively persecuted health workers who, in adherence to their professional ethics, courageously provide such care to the sick and wounded, including opposition supporters. The Syrian government has blatantly disregarded special protections afforded to medical units and personnel under international humanitarian law and has branded health workers – who provide nondiscriminatory health care in line with their legal and ethical obligations – as enemies of the state.
While much documentation and data have been presented to policymakers and the public regarding the relentless bombing and destruction of health facilities, less is known about the experiences and suffering of health personnel who have been targeted for their medical work during the conflict. For this report, PHR clinician researchers conducted semi-structured interviews and brief structured psychological assessments between June and August 2019 with 21 formerly detained Syrian health care workers, of whom two were women and 19 were men. These included people working in a wide range of health sectors: physicians (seven), pharmacists (four), medical volunteers (three), paramedics (one), and psychiatrists (one). While other parties to the conflict – including non-state armed groups – have perpetrated crimes, including arbitrary detention, this report focuses on detentions carried out by the Syrian government in order to provide further insight into its strategy of systematic targeting of health infrastructure and personnel throughout the conflict. While more data may be necessary to generalize knowledge about the targeting of Syrian health care workers since the start of the conflict in 2011, this report illustrates how the Syrian government has effectively criminalized the provision of nondiscriminatory care to all, regardless of political affiliation.
PHR research focused on the following key issues: To what extent, if at all, were health workers targeted for detention and ill-treatment due to their provision of nondiscriminatory care and other efforts to support the provision of care? What were their experiences in detention and what types of ill-treatment, if any, were they subjected to? What was the impact of the detention and ill-treatment of health workers on their decision to leave Syria, and their willingness to practice in their field, and on their desire to potentially return to Syria?
The study reveals that the majority of the formerly detained health workers interviewed by PHR were arrested by Syrian government forces specifically because of their status as care providers, and their real or perceived involvement in the provision of health services to opposition members and sympathizers. Through examination of health workers’ experiences in detention, the report shows the link between their involvement in the provision of nondiscriminatory health care and their arrest, imprisonment, and ill-treatment in detention. Although the interviewees’ detention experiences differed, their accounts point consistently to the Syrian government’s system of detention, interrogation, and torture of those providing health care, or supporting access to health care, for perceived opponents. The health workers whose experiences PHR has documented are among the many who continue to provide and enable health care, despite the associated risks. This report details the price they paid for doing so, while recognizing that they are among those fortunate enough to have survived Syrian government detention facilities.
In most of the cases documented in this study, Syrian security forces inflicted torture on detainees as an integral part of the interrogation process. Interviewees reported that Syrian security forces regularly beat, humiliated, and subjected them to stress positions. In some cases, they were burned, shocked with electricity, and sexually assaulted. Interviewees described an interrogation process aimed to force “confessions” to activities considered treasonous under the Syrian Counter-terrorism Law 19 (2012), as well as to gather information on other health workers and health care activities. In many cases, interrogations centered on the interviewees’ involvement in medical work. Syrian government interrogators and torturers accused many of the former detainees of working in or establishing field hospitals, providing medical treatment and material support to “terrorists,” and other acts considered to be subversive. Many of the interviewees who appeared in Syrian courts were confronted with confessions extracted under torture and reported that they were accused by judges of having been involved in providing or supporting medical care to “terrorists.”
Several interviewees reported long-term health consequences due to lack of access to medical care in detention after torture. In all cases, the interviewees were subjected to inhumane living conditions within detention: overcrowding; lack of sanitation; lack of access to food, water, toilets, and medical care; and lack of ventilation. The conditions described may also constitute ill-treatment and, in some cases, torture. The lack of medical care prompted some of the interviewees to provide health services to others in detention, even as they witnessed the deadly consequences of torture, abuse, and poor conditions, and often felt powerless in the face of disease and injury.
Based on voluminous documentation of the Syrian Government’s violent targeting of the health sector and its systematic use of detention and torture to suppress perceived dissent, Physicians for Human Rights finds that the Syrian government has violated both national and international laws as well as basic medical ethics and the obligation to care for the sick and wounded without discrimination in all circumstances. In this report’s recommendations, Physicians for Human Rights calls upon:
- Parties to the conflict, particularly the Syrian government and affiliated forces, to immediately and unconditionally release all arbitrarily or unlawfully detained individuals and allow unconditional access to official and unofficial detention sites;
- The Syrian government to respect the rights and dignity of all Syrian citizens, and particularly health workers on whom the country’s civilian population relies;
- United Nations member states, regional bodies, and the international community to hold the Syrian government accountable for its human rights and international humanitarian law violations.
Dr. Youssef: A Surgeon Tortured for Supporting “Terrorists”
Dr. Youssef’s interrogators repeatedly asked him about the medical point network he had helped to establish and the network’s members. Interrogators told him they detained him for supporting “terrorists” and working against the regime.
Dr. Youssef was in his fourth year of surgical residency when the conflict in Syria erupted. He joined several friends to create an anonymous network of volunteers who established medical points to treat individuals who were injured while peacefully protesting.
On August 21, 2011, seven plainclothes security officers arrested Dr. Youssef as he was treating a patient in a hospital in the Qalamoun region north of Rural Damascus governorate. They took him to the al-Nabek State Security Branch. There, the authorities took his personal effects, strip-searched him, and confined him in a 1-by-1.5 meter cell for the next 69 days. He was not charged or given any reason for his arrest and was not allowed to contact his family or seek counsel. State security authorities interrogated and tortured Dr. Youssef daily for periods of between one and three hours. The interrogators had detailed knowledge of his activities, including awareness of jokes he had told to certain individuals on specific days. Dr. Youssef’s interrogators repeatedly asked him about the medical point network he had helped to establish and the network’s members. Interrogators told him they detained him for supporting “terrorists” and working against the regime. The severity of the torture increased in each session. The initial torture sessions consisted of his interrogators beating his stomach and legs with heavy electric cables. They later applied electricity to his genitalia and administered electrical shocks to his body while he was submerged in water. They threatened to hang him on three separate occasions. Despite the constant torture, Dr. Youssef continued to deny all charges, both fabricated and real, in order to protect himself, his colleagues, and his friends.
A month into his detention, an interrogator told Dr. Youssef that authorities had already detained his colleagues, mentioning them by name. The guards nevertheless continued to torture him, apparently solely to punish him. They beat the soles of his feet with thick plastic pipes filled with concrete. He eventually confessed to various activities he was accused of having been involved in, including providing support to protesters, on the express condition that his captors improve the conditions of his detention. The authorities required that he write his confession three separate times.
On the 69th day of his detention, the authorities moved Dr. Youssef to a larger cell within al-Nabek State Security Branch for two weeks before transferring him to the General Intelligence Branch in Kafarsouseh, Damascus. At the end of these two weeks, and after almost three months of detention in intelligence facilities without charges, he was transferred to Adra Civilian Prison north of Damascus. In Adra, Dr. Youssef had more regular access to food, and could communicate with his family for the first time since his arrest. The authorities finally filed formal legal charges against him in the Civil Court of Damascus and subsequently released him on bail in December 2011 without rendering a verdict.
In September 2013, Dr. Youssef learned from members of the opposition that they had information from an agent working with an intelligence branch in al-Nabek that the authorities intended to re-arrest him. He immediately left for opposition-controlled Idlib, where he began working in a field hospital. In August 2014, Dr. Youssef left for Turkey. While he is not able to practice medicine in Turkey, he has continued to provide administrative and programmatic support to the medical sector inside Syria.
Physicians for Human Rights (PHR) has – through a rigorous methodology, that includes English and Arabic open-source research and field source corroboration – verified and mapped attacks on medical facilities and medical personnel by all parties to the conflict since 2011. By early September 2019, combatants had inflicted 583 attacks on at least 350 medical facilities. By PHR’s assessment, the Syrian government and its allies are responsible for 90 percent of those attacks. The systematic targeting of health facilities and health workers has been a crucial component of a wider strategy of war employed by the Syrian government and its allies to force civilian populations into submission. Through its purposeful assault on health, the Syrian government and its allies have systematically denied access to medical care in areas outside of their immediate control and actively persecuted health workers who, in line with their professional ethics, provide such care to perceived opposition supporters. The Syrian government has intentionally targeted Syrian health workers providing nondiscriminatory health care as enemies of the state. It has explicitly equated health workers who provide nondiscriminatory care with “terrorists” who can and should be detained, tortured, and killed. Through in-depth qualitative interviews with 21 formerly detained health workers, the following report provides evidence of the link between their arrest, imprisonment, and ill-treatment and their engagement in the medical field.
Overview of the Conflict
In February 2011, small-scale protests broke out in Syria opposing corruption, raising economic grievances, and calling for democratic rights and for the release of political prisoners. The largely peaceful protests expanded in March, when thousands of Syrian citizens in multiple locations across the country assembled in the streets, demanding sweeping economic and political reforms and adopting anti-government slogans. The Syrian government responded with a violent crackdown that fueled wider protests. At the end of April 2011, the Syrian government conducted its first large-scale military operation in what would become a full-fledged campaign to suppress dissent. Toward the end of summer 2011, the opposition began to organize itself into distinct political groupings. Those factions in turn organized their own military wings, bolstered in numbers by mass defections from the Syrian Arab Army as well as by a growing stream of foreign fighters. By July 2012, hostilities in Syria had transitioned from an insurgency to a full-fledged internal conflict. The number of armed groups grew, and many sought and began receiving material and operational support from foreign states with widely diverging agendas.
As armed anti-government groups proliferated, the violence increased exponentially. The Syrian government deployed a strategy that appeared primarily to target civilian populations of restive areas and any suspected opposition supporters. It imposed sieges on opposition-held areas, shelled and bombarded densely populated urban centers, used chemical weapons to target civilians, established extensive networks of security checkpoints, and led a widespread campaign of arrest, torture, and enforced disappearance of suspected insurgents and their supporters. The Syrian government’s practices drew international condemnation, including through UN Security Council resolutions 2042, 2118, and 2139. Anti-government armed groups perpetrated similar abuses, albeit on a significantly smaller scale. Despite the scale and intensity of the Syrian government’s repression and its effective monopoly on air power during the early phases of the war, by early 2015 it appeared to be drifting toward defeat with large tracts of territory falling to a variety of armed groups, including the self-declared Islamic State (ISIS). In September 2015, Russia intervened in support of the Syrian government, tipping the scale in its favor while compounding civilian suffering. The Syrian government and its allies, through relentless coordinated air and ground offensives, have since been able to recapture most opposition-held areas. As of the writing of this report, northwestern Syria (primarily the northern part of Hama and the entirety of Idlib) is the only area that remains under anti-government armed group control and has been the target of a concerted air campaign since April 2019.
By some estimates, the Syrian conflict has claimed the lives of more than half a million people. The Syrian Observatory for Human Rights reports at least 372,000 documented deaths by August 2019, an estimated third of whom were civilians. More than half of Syria’s pre-war population of 22 million has been displaced internally or has fled the country as refugees since 2011. The conflict has led to one of the most complex and dire humanitarian situations in recent history, with an estimated 11.7 million people currently aid-dependent for basic subsistence. Attempts by the United Nations and UN member states to end the Syrian conflict have repeatedly failed. Prospects for a negotiated settlement remain unlikely, given that the Syrian government and its allies can justifiably perceive the relative success of a military strategy premised on egregious violations of human rights and basic international norms.
Detention, Torture, and Ill-treatment
Among the host of harrowing abuses that have defined the Syrian conflict, arbitrary detention, enforced disappearance, and torture of Syrian civilians – primarily perpetrated by the Syrian government – are notable for their frequency and gratuitous cruelty. International and national human rights organizations and independent bodies mandated to investigate alleged human rights violations have extensively documented the Syrian government’s routine practice of arbitrary detention and torture of civilians. That documentation reveals an industrial-scale Syrian government incarceration apparatus that has enabled the detention, interrogation, torture, extrajudicial execution, and disappearance of tens of thousands of civilians perceived as opposition supporters or as insufficiently loyal to the regime. That apparatus is in many respects a natural extension of a system that has been in place since the inception of the Ba’athist regime, largely facilitated through the powers conferred on security forces by the establishment of a perpetual state of emergency and legislative decrees that provide security forces full immunity.
In 2011, anti-government protests caused the Syrian government to expand the detention system to stifle growing dissent. The Counter-terrorism Court, established by the 2012 Counter-terrorism Laws, provided judicial cover for a campaign of mass-arrests. As of the end of August 2019, information from the United Nations’ Independent International Commission of Inquiry on the Syrian Arab Republic (IICOI) and Syrian human rights monitors suggests that the number of people detained since 2011 – mostly at the hands of the Syrian government – now exceeds 100,000.
The Syrian government incarceration apparatus has enabled the detention, interrogation, torture, extrajudicial execution, and disappearance of tens of thousands of civilians perceived as opposition supporters or as insufficiently loyal to the regime.
The IICOI has determined that most detainees of the Syrian government are being held without due process and denied access to their families and to legal representation. The commission states that detainees
“… endure various forms of brutal torture and subsist in severely inhumane conditions. Many have died in detention, while others have been summarily executed. The bodies of those who have died as a result of torture, neglect, inhumane conditions, or from executions are rarely returned to their families, who are also not notified about burials.”
In its February 2016 report on deaths in detention in Syria, the IICOI concluded that Syrian government forces committed crimes constituting a “systematic and widespread attack against a civilian population” through their conduct of mass arrests, enforced disappearance, and subsequent ill-treatment and killing of detainees. The IICOI further concluded that the Syrian government is responsible for crimes against humanity and war crimes linked to detention.
While the Syrian government and its allies have been responsible for the majority of violations in the conflict, non-state armed groups have also perpetrated crimes, including arbitrary detention under brutal conditions, torture of detainees, and summary executions of perceived government supporters, humanitarian workers, and activists, among others. A range of anti-government armed groups have also been implicated in such acts, including Hayat Tahrir al-Sham (HTS, previously Jabhat al-Nusra), Kurdish forces (forces associated with the Democratic Union Party), and ISIS. The actions of these and other armed groups in depriving civilians of their liberty are reprehensible and rise in some cases to the level of war crimes. While the larger issue of detention practices by non-state armed groups lies outside the scope of this report, the interviews on which the report is based demonstrate the widespread and systematic use of ill-treatment and torture of health care workers in Syrian government detention facilities.
Physicians for Human Rights (PHR) used chain, or snowball, sampling to identify potentially eligible health workers for this study. While this method does not lead to a representative sample, it constituted the only sampling option that allowed for effective contact with eligible participants with whom outreach is otherwise extremely difficult. In addition, utilizing established networks and existing relationships helped with the development of necessary trust among potential participants, given ongoing threats to health care workers and medical communities remaining in Syria. The team sought to form as representative a sample as possible by engaging a wide variety of different professional groups within the health sector and individuals with links to a range of geographical areas in Syria. The participants in the research were all Syrian nationals above the age of 18; they were engaged in medical work as professionals or as volunteers during the Syrian conflict; and they had been detained by a party to the conflict after 2011.
Human Subject Protections
The PHR clinician researchers obtained consent from each interviewee following a detailed explanation of PHR’s work, the purpose of the investigation, and the voluntary nature of participation. To preserve the security and confidentiality of the participants, PHR has replaced their names with pseudonyms and taken their pictures in a fully de-identified manner.
PHR’s Ethics Review Board provided guidance to and approved this study based on regulations outlined in Title 45 CFR Part 46, which are used by academic institutional review boards in the United States. All PHR’s research and investigations involving human subjects are conducted in accordance with the Declaration of Helsinki 2000, a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data.
Clinician researchers conducted semi-structured interviews and brief structured psychological assessments between June and August 2019 with 21 health workers who had experienced detention in Syria. Some of the interviews were conducted in person in Beirut, Lebanon, and in Gaziantep and Istanbul, Turkey. Others were conducted remotely over secure connections with participants residing in France, Germany, Syria, and Turkey.
Interviewers sought to understand the extent to which health workers were targeted for detention and ill-treatment due to their provision of nondiscriminatory care and other efforts to support nondiscriminatory provision of health care; their experiences in detention and the types of ill-treatment to which they were subjected; and the impact of the detention and ill-treatment of health workers on their decision to leave Syria. Finally, the PHR team sought to understand the interviewees’ intentions to practice in the health care field and to return to Syria, as well as their perceived ability to do so.
At the end of each session, the clinician interviewers conducted brief psychological assessments using a form that adheres to Istanbul Protocol guidelines which form the international standard for the documentation of torture and ill-treatment. They assessed the interviewees’: 1) social functioning; 2) past and current psychological symptoms; 3) changes in psychological symptoms over time; and 4) current mental status.
Qualitative Data Analysis
Drawing on notes and full recordings of the interviews, PHR clinician researchers wrote case reports based on each interview. Clinicians provided diagnostic interpretations of the results of the psychological assessments, credibility of the accounts, and evaluation of the extent to which interviewees reported a connection between their medical and health care-related activities and their detention and subsequent treatment during detention. PHR analyzed all interview transcripts thematically, aiming to establish a causal link between health workers’ provision of care and their targeting for detention and ill-treatment.
PHR Clinical Team
All interviews were conducted by a highly experienced team of two physicians and one psychologist trained in the Istanbul Protocol: Sana Hamzeh, PsyD, Ahmad Banasr, MD, and Michele Heisler, MD, MPA. Two of the clinicians are fluent in Arabic.
In this report, the term “health worker” refers to individuals who at the time of detention were engaged professionally or as volunteers in the search for, collection, transportation, diagnosis, or treatment of the wounded and sick (including provision of first aid); in the prevention of disease; or in the provision of logistical or administrative support to health services. Health workers can include physicians, nurses, paramedics, ambulance drivers, search and rescue personnel, pharmacists, and others.
Allegations of torture and ill-treatment may be affected by recall bias and/or intentional exaggeration or misrepresentation by the former detainees for personal and/or political gain. PHR was not able to investigate and corroborate the statements made by the interviewees in this report. Interrogation and detention records were not available for examination. The highly trained clinician interviewers made independent determinations relating to the veracity and credibility of the testimony of the interviewees based on the internal consistency of the statements and how the details of the statements compare to available information on detention and ill-treatment in Syria.
PHR was able to interview only two formerly detained female health workers, despite extensive efforts. The relative shortage of Syrian women health care providers as the conflict has developed is a complex phenomenon that merits further study; this may contribute to the low numbers of women detainees willing to be interviewed. Additionally, the stigma associated with detention and especially the physical forms of ill-treatment and torture may be a further barrier to participation. Thus, the experiences of female health workers who were detained is under-documented.
Nevertheless, the report provides useful insights into challenges faced by health workers in Syria as a result of their direct or indirect involvement in the provision of care. Through an examination of the experiences of 21 health workers who survived detention in Syria, this report provides evidence of the link between their engagement in the medical field and their arrest, imprisonment and ill-treatment. The report cannot provide a comprehensive picture of how detention was used in the persecution of health workers in Syria and, based on sample size and composition, its claims are not generalizable. They do, however, illustrate the experiences of similarly situated individuals working in an oppressive legal and political environment. It is critical to remember that PHR was able to reach only individuals fortunate enough to have survived Syrian security branches and detention facilities. PHR believes these and other survivors represent a fraction of the health professionals subjected to abuses. The experiences of health workers still in Syrian detention facilities, who were killed in these facilities, or whose fates remain unknown are impossible to represent in this study.
The health workers interviewed by Physicians for Human Rights (PHR) all reported experiences consistent with being targeted for arrest by Syrian security forces because of their status as health workers. Syrian security forces arrested and detained all of the 21 health workers interviewed by PHR. Syrian security forces arrested more than three-quarters of those health workers between 2011 and 2013, with a third of these arrested in 2012.
Security forces detained the interviewees in facilities in Aleppo, Damascus, Rural Damascus, Daraa, Hama, and Homs. Syrian military units, the Syrian Ministry of Interior, and the four main security services operated the detention facilities.
Health workers PHR interviewed were often transferred multiple times between different security service branches, as well as between military and civilian detention facilities. On average, interviewees reported being transferred at least three times; some were relocated up to six times. The duration of detention in each facility between transfers varied from a few hours to more than a year.
Without exception, Syrian authorities subjected the interviewees to systematic interrogation and torture. Interviewees described experiencing identifiable patterns of violence and mistreatment that recurred as they were transferred from one detention facility to another. In most cases, torture was fully integrated into the interrogation process. In many cases, participants described how their captors used torture or the threat of torture to force them to “confess” to supporting or taking part in acts of violence against the state. In many cases, interrogations centered on the participants’ involvement in medical work. Syrian government interrogators and torturers accused many of the participants of working in or establishing field hospitals, providing medical treatment to “terrorists,” and/or providing material support to “terrorist” organizations and working to overthrow the Syrian government. Although some interviewees were charged in civil court, the majority of formerly detained Syrian health workers interviewed by PHR experienced judicial review of their cases by either military field courts, military courts, or Counter-terrorism Court, where due process protections are suspended in practice.
Health workers engaged in any activity perceived to benefit those characterized as opposition sympathizers would be targeted by Syrian government security forces for arrest at checkpoints, in their homes, and at their workplaces.
Involvement in Health Care Service Provision
All of the formerly detained health workers whom PHR interviewed reported a clear link between their role in provision of nondiscriminatory care and the circumstances leading to arrest and detention.
Dr. Jamal’s ordeal underscores the relationship between provision of such care and the Syrian security forces’ deliberate targeting of health workers suspected of aiding opposition forces or supporters. Dr. Jamal was a second-year medical student in 2011 when the first peaceful protests erupted. By 2013, ever-rising demands for medical care, due primarily to Syrian government attacks on civilian areas, motivated him to start volunteering in a field hospital in opposition-controlled Aleppo.
“When I got involved in 2013, I hadn’t even finished medical school yet. But the medical needs were so acute, there was such a clear shortage of doctors, that a friend and I decided to cross to the other [opposition-controlled] side of Aleppo – there was still an open crossing then – and start working at a field hospital there. We crossed back into government-controlled Aleppo about three months later to take our exams. We kept going back and forth to keep up with our studies. At the beginning we really didn’t know what we were doing. They put us in the emergency ward and taught us how to suture wounds, stop bleeding, insert IV lines.”
Dr. Jamal’s involvement in emergency medical care provision mirrors that of many of the health workers interviewed for this report. Many interviewees described first responding to the needs of individual injured protestors, then, as the conflict escalated, digging through rubble for survivors, tending to torn limbs, and treating multiple trauma victims. In a growing organizational vacuum, many professionals and volunteers became involved in the administrative and logistical sides of health care: they procured and distributed medical supplies, secured funding, and established medical points and field hospitals on emerging front lines. Describing his work in northeastern Syria, Ali, a pharmacist from Hama, said, “I was a pharmacist, a nurse, a doctor, a receptionist. Everything.”
“We treated injured people – civilians, opposition soldiers, captured regime soldiers – we didn’t care who they were.”Wessam, describing his provision of nondiscriminatory care in field hospitals in Rural Damascus
The formerly detained health workers PHR interviewed come from diverse professional backgrounds. Most of the participants received varying levels of professional training as doctors, nurses, and pharmacists. A few had no medical experience prior to 2011; they entered the health sector as volunteers for reasons of conscience. Their roles ranged from first responders who treated victims at the site of incidents of mass violence to logisticians who coordinated administrative tasks in field hospitals.
Most interviewees told PHR that they became aware early in the crisis of the risks associated with their work – being beaten, detained, or shot while tending to injured protestors. They also learned that health workers engaged in any activity perceived to benefit those characterized as opposition sympathizers would be targeted by Syrian government security forces for arrest at checkpoints, in their homes, and at their workplaces. All the participants, many of whom lost colleagues to death and detention long before becoming victims themselves, articulated recognition that the nondiscriminatory provision of health care services was officially forbidden by the Syrian government under Counter-terrorism Law 19, in which health care was seen as “material support for terrorism.”
In the face of a violent crackdown that rapidly evolved into an internal conflict, concerned health workers responded with a form of makeshift medical response, spurred by necessity and surrounded by constraints and danger that persist to this day in some areas of Syria. Importantly, it shaped how individuals injured as a result of violence perpetrated by the Syrian security forces were provided with treatment. Health workers organized anonymous coordination structures, established clandestine medical response cells, smuggled medical supplies, and furtively raised funds to support health care service provision. Surgeons surreptitiously operated on the injured in makeshift wards inside people’s homes. The health workers whose experiences PHR documents are among the many who continued providing and enabling health care despite the associated risks of arrest, detention, and torture.
Circumstances of Arrest
Most of the formerly detained health workers interviewed by PHR reported they were arrested by Syrian government forces specifically because of their status as health workers and their (real or perceived) involvement in the provision of health services to the opposition. Those arrests and subsequent detentions were the result of either targeted security force intrusions into health workers’ homes or workplaces or resulted from the exposure of their status as health workers at military checkpoints or during other random sweeps by security forces.
In the majority of cases documented by PHR, health workers were arrested at their places of work. Doctors, nurses, and other health workers were taken by security forces from hospitals, clinics, and offices. In a particularly alarming case, Air Force Intelligence members arrested Dr. Ahmad, a surgeon from Hama, in the surgical ward of his hospital while he was operating on a patient with a thigh injury.
“You have a field hospital here! This is going to send you to your death.”Ali, a pharmacist, quoting the soldier who arrested him after searching his vehicle at a checkpoint in Hama
“On October 27, 2011, I finished my shift at the Hama National Hospital, and I drove back home. My hometown is about 45 km away from the city of Hama. I got there around 3:30 in the afternoon. I got a phone call from a local man telling me that one of my relatives was injured. So, I drove to the hospital in town to treat him. I was in the surgical ward when they [Air Force Intelligence] came in. There was a huge raid on the hospital. They took me along with a lab technician. Of course, they also took the patient. I was surprised to learn later that he was still alive. The way they pulled him off the respirator, I thought he wouldn’t last 10 minutes in their custody.”
Dr. Ahmad subsequently learned during interrogation that the patient with the thigh injury was suspected by authorities of being a “terrorist.” Air Force Intelligence arrested Dr. Ahmad merely because he was treating him. “My only crime was that I was a doctor,” he said. In a similar case, in August 2012, Air Force Intelligence arrested Dr. Loay, a general physician from Damascus, while he was treating a patient at a field hospital in the town of Jobar, east of the capital. Dr. Loay recalls that a large number of Air Force Intelligence personnel raided the small facility and arrested him along with two nurses. He and the nurses had managed to remove the patient from the facility right before they were arrested. The Air Force Intelligence personnel took Dr. Loay to the Mezzeh Military Airport Intelligence Branch in Damascus and detained him there for more than 14 months. In yet another example, Hassan, a nurse from Homs, was arrested from the hospital in which he worked by Political Security.
“I was working in the emergency ward, changing a patient’s dressing. I felt a tap on my shoulder. I said ‘One moment.’… I was pulled back by the shoulder, my arms were twisted behind my back, and I was slammed against a wall. I was handcuffed, blindfolded, and quickly loaded into a vehicle…. The entire medical staff was arrested on that day.”
“I remember it was morning. I was working in the emergency ward, changing a patient’s dressing. I felt a tap on my shoulder. I said, ‘One moment.’ As soon as those words came out of my mouth, I was pulled back by the shoulder, my arms were twisted behind my back, and I was slammed against a wall. I was handcuffed, blindfolded, and quickly loaded into a vehicle. The vehicle was full and very noisy. There were many people yelling, asking where they were being taken. Later, when I was released, I was told the entire medical staff was arrested on that day.”
A significant number of former detainees interviewed were arrested at military or security checkpoints. Those arrests were the result of the inclusion of their names on official government wanted lists, or due to behavior deemed suspicious by security forces. In March 2015, Passport and Immigration officials arrested Omar, a health volunteer from Harasta, Rural Damascus, while he was applying for a passport. Prior to his arrest, Omar had been involved in a network of volunteers who procured and transported medication into government-besieged areas. He later learned that one of his associates had given him up to interrogators under torture, resulting in the addition of his name to an official wanted list apparently disseminated across Syrian government agencies.
Soldiers arrested Dr. Hadi, a 34-year-old pediatrician from Daraa, after a chance discovery that he was delivering supplies to a field hospital providing nondiscriminatory medical care.
“On August 9, 2012, in the late afternoon, I was stopped at a military checkpoint on the main highway between Daraa and Damascus. It was a 9th Armored Division checkpoint. They’re based out of Sanamein in that same area. In early 2012, I and a group of other doctors started secretly setting up medical points to respond to injuries, especially in Eastern Ghouta.… On that day, I was with a driver and we were transporting a quantity of medical supplies – saline, antibiotics, gauze, medical plaster, etc. – to a field hospital in Daraa. That was the third time we did that. The first two times we went through side roads. But on that day, they caught us on the highway.”
Dr. Hadi and the driver were both arrested and sent to the 9th Division base in Sanamein, Daraa. That same evening, an interrogator at the base accused Dr. Hadi of intending to equip an anti-regime field hospital. Five days later, he was transferred into the custody of Military Intelligence. The circumstances of Dr. Hadi’s arrest point to a government-wide policy criminalizing the provision of health care to perceived supporters of the opposition. Syrian authorities detained him without legal justification for nearly six months, during which he was repeatedly interrogated and tortured before he was finally released after managing to bribe a judge in Counter-terrorism Court.
“There was a huge raid on the hospital. They took me along with a lab technician…. They also took the patient. I was surprised to learn later that he was still alive. The way they pulled him off the respirator, I thought he wouldn’t last 10 minutes in their custody.”Dr. Ahmad, a surgeon arrested while operating on a patient in Hama
The health workers interviewed by PHR described interrogation as a routine part of their experience in detention. The interrogation sessions varied significantly in frequency, process, and length, but were almost always accompanied by torture. Interrogators accused many of the interviewees of providing medical care to “terrorists” or of establishing or providing material support to “terrorist” organizations. Interrogators demanded details about detainees’ specific role in the medical sector, their patients, their colleagues, and their sources of funding.
In some cases, interrogators appeared to be equipped with accurate information about the detainees’ medical activities. In July 2014, Military Intelligence arrested Samer, a pharmacist from Damascus involved in transporting/delivering medical supplies into Eastern Ghouta. He remembers being surrounded by Military Intelligence personnel as he was leaving his office and one of them saying, “We finally caught you.” During his first interrogation at Military Intelligence Branch 215 in Damascus, his interrogators gave him a pen and paper and instructed him to provide an account of his life “from birth until detention.” To protect his colleagues, Samer wrote a vague account of independently providing treatment to injured protesters. Two hours later, his interrogators brought him back for more questioning and asked about his colleagues by name, with obvious knowledge of their roles in the network and his relationship to each of them. Interrogators told him that one of his colleagues had already been detained and had told them everything about Samer’s activities. Although Samer decided to cooperate with his interrogators after deducing that his colleague had likely confessed all relevant details under torture, his captors still subjected him to severe beatings and threats of torture and death. Samer eventually confessed to distributing medication to besieged towns in the eastern suburbs of Damascus and disclosed information that led to the eventual arrest of one of his associates.
“You [doctors] are far more dangerous than terrorists. We kill them, you bring them back.”Dr. Loay, quoting his interrogator at al-Mazzeh Air Force Intelligence Branch in Damascus
In other cases, the interrogators did not appear to possess information about the detainees but showed clear interest in their work as health professionals once such information was disclosed. In October 2014, Third Armored Division soldiers arrested Dr. Hussam, a surgeon from Rural Damascus, at a checkpoint in the town of Qutayfah, north of Damascus. His arrest was apparently linked to his town of origin – Harasta, an opposition stronghold. When Dr. Hussam’s interrogator learned he was a physician, he reacted gleefully, muttered “excellent,” and shifted his line of questioning to specific questions about Dr. Hussam’s workplace, patients, and colleagues. The interrogations even strayed to granular details about his profession, including about his hospital’s intake process and patient records’ storage details. Dr. Hussam concluded that the interrogator was seeking actionable information on medical facilities and medical personnel working in opposition-held areas.
“He kept saying that you are a group of organized doctors and you have your own field hospitals and your own warehouses … He wanted names of doctors and where the field hospitals and warehouse were … They charged me with ‘supporting terrorism by medical supplies.’”Wessam, a health volunteer from Rural Damascus, describing his interrogation during detention
Syrian security authorities also consistently sought to extract confessions from the interviewees. Interrogators repeatedly urged detainees to “confess” to a variety of charges that ranged from fact-based allegations to nonsensical accusations. In numerous cases, “confessions” didn’t even require specific allegations or charges. Four-and-a-half months into the detention of Majd, a surgical assistant from Idlib, at the Air Force Intelligence branch in al-Leramoun, Aleppo, a prison guard forced him to fingerprint blank pages. The following day, a Military Court judge informed him that he had confessed to crimes including killing 12 Syrian Arab Army officers and 17 soldiers, planning to bomb the military academy, and treating “terrorists.” Majd described those fabricated accusations as an essential part of the interrogation process. “It’s a negotiation with your interrogator,” he told PHR. “He accuses you of carrying a certain number of weapons and munitions. Then, as you cry out in pain while you’re being tortured, he says: ‘Fine, you were carrying fewer weapons.’” Most health workers interviewed were forced to sign or fingerprint prepared confessions or blank papers. The authorities used these documents, collected under torture or its threat, as evidence against them. Amin, a surgical assistant from Homs, explained: “During one of the torture sessions, while handcuffed, they forced me to fingerprint a number of papers. When I asked what I was confessing to, the officer told me to shut my mouth and to be thankful to be leaving the branch alive.”
In the cases of the health workers interviewed by PHR, the extraction of confessions rarely ended their torture. While in some cases confessions led to a temporary lull in ill-treatment, the interrogation and torture process often repeated itself following transfer to other facilities. These transfers appeared arbitrary in nature and the interviewees rarely knew where they were being taken until they reached their destination. The length of detention in each facility varied and the reason for transfer was never apparent to the interviewees. From the sample of 21 interviewees, it was difficult to deduce any pattern or meaning behind the transfers, although arbitrary and repeated transfer could have been used to induce psychological distress.
Health workers PHR interviewed described in gruesome detail the forms of torture Syrian security services subjected them to. The beatings and humiliation often began shortly after arrest and rose and fell in intensity and cruelty through cycles of interrogation and transfers between detention facilities. In some cases, the torture only ended after authorities transferred detainees to civilian prisons. PHR interviewees were unambiguous in their assertions that their torturers sought to viciously and repeatedly punish them for their provision of health care to people the Syrian government had decreed were forbidden from receiving such treatment.
Torture methods varied from one detention facility to another. Most of the formerly detained health workers whom PHR interviewed described being subjected to prolonged beatings and forced stress positions, including hanging by the arms for extended periods of time. Humiliation tactics, including prolonged nudity and insults to family and faith, were also common throughout all mentioned detention facilities. Interviewees also described Syrian guards and interrogators inflicting burns with cigarettes, electrical shock, sexual assault, and a variety of psychological stress methods, including staging mock executions.
Most interviewees reported the use of falaqa (also known as falanga), which entails lashes to the soles of the feet with electrical wire, silicon tubes, or blunt sticks. Interrogators employed this torture technique across all mentioned security branches. Detainees subjected to falaqa reported intense and prolonged pain, bleeding, infections, and an inability to walk or stand following falaqa sessions. Mohannad, a pharmacist from Idlib who Military Intelligence detained and repeatedly tortured for seven days in August 2011, recalled that the pain from falaqa lingered for more than a month after his release. Most interviewees reported being subjected to various stress positions, the most common of which was the shabeh method, whereby the subject is suspended from a ceiling or pipe by the wrists for prolonged periods of time. The balanco method, in which the subject is hung by the wrists while they are tied behind his or her back, was also reported as common. “Sometimes it took me months to regain full use of my hands after I was subjected to these hanging sessions. You need someone to feed you and clean you. Your hands become useless,” one interviewee said. In addition, being beaten with thick PVC pipes, a method labeled “al-Akhdar al-Brahimi” (the name of the UN Special Envoy to Syria at the time) was reported by several interviewees, as was being lashed with steel wire or electrical cables.
“Losing consciousness was a blessing because it was a break from all the physical and psychological torture.”Tareq, a health activities coordinator from Aleppo, describing his treatment during interrogations
A few of the interviewees reported sexual assault and torture by Syrian security personnel. The abuses included groping, electrical shocks applied to their genitals, the burning of their genitals with boiling water, and threats of rape. Dr. Ibrahim, a pediatrician from Daraa, stated that the soldiers and interrogators of the 9th Armored Division used a combination of physical and psychological methods when torturing him. “They would force us to torture ourselves,” he related. Dr. Ibrahim’s torturers forced him to grab live electrical wires and hold them while the current was on. If he refused, he would be beaten until he complied. If he let go of the cables while being electrocuted, he would be beaten until he grabbed them again. “Every cell of my body writhed from the pain. You feel like you can’t stop shrieking. The shocks bounced me around the room. Even after it was over, the pain persisted as if I was still being electrocuted.”
PHR research does not indicate that Syrian government authorities subjected health workers to any distinctive form, intensity, or duration of torture. Instead, PHR’s interviews reconfirmed that Syrian authorities use torture systematically. Regardless of what type of activities they are involved in, those detained by the Syrian government for political reasons are subjected to torture and interrogation as a matter of course. PHR research provides compelling evidence that health workers who provide or facilitate nondiscriminatory medical care are subject to the same brutal torture regimen as political prisoners, suspected insurgents, and those deemed “terrorists” by the Syrian government.
“Every cell of my body writhed from the pain. You feel like you can’t stop shrieking. The shocks bounced me around the room. Even after it was over, the pain persisted as if I was still being electrocuted.”Dr. Ibrahim, a pediatrician from Daraa
Tareq: Brutalized for Volunteering as a Medic
Before the conflict, Tareq worked in marketing in Aleppo. He had no previous medical training. Soon after the government crackdown began in 2011, he trained in first aid and started working as a paramedic, transferring patients between medical facilities. He eventually joined a group of doctors as a member of a non-profit organization that offered medical services in eastern Aleppo and became the administrative director of one of the main trauma hospitals in opposition-controlled East Aleppo.
Toward the end of May 2013, Military Security arrested Tareq at home and placed him in solitary confinement at the Military Security Branch of Aleppo until the end of the summer. In addition to a raft of accusations related to “undermining” the Syrian state, Tareq’s interrogators charged him with “membership in a terrorist organization,” in reference to the Aleppo City Medical Council. About four months into his detention, Military Security transferred Tareq to Damascus, where he was imprisoned underground in al-Mazzeh Military Airport for one week before being transferred to the Palestine Branch of Military Intelligence in Damascus. They placed him in solitary confinement in cell number 56. He was interrogated and tortured three months later and then again two months after that.
Tareq’s interrogators subjected him to a broad range of torture methods including a variety of stress positions, beatings, electrocution, burning of the body – including the genitalia – with boiling water, and sexual assault. Tareq described how he often fainted from the pain during interrogation sessions. “Losing consciousness was a blessing because it was a break from all the physical and psychological torture,” he said. At one point during his detention in the Palestine Branch, Tareq was hung naked by the arms in front of a female detainee placed in the same position.
“They brought me in and hung me from the ceiling and, in a second, removed all my clothes. I suddenly realized I was completely naked. I was unable to understand what was happening until I saw a naked woman one meter in front of me. Her nipples were burnt. There were cigarette burns across her chest. Her hair was unkempt. There was dried up blood between her thighs. I felt a deep shame. For three days, the woman was hung in front of me. It was the most difficult period of the past four years. The prison guard used to enter and insult us. He did not touch us with his hands because he was disgusted by us. He used to molest the woman with a plastic tube and tell me: “Why don’t you defend her? Where’s your honor?” In the same way, he used to molest me while interrogating me to get me to have an erection. Ultimately, he would insult her and ask her: “Is it enough? Is its size large enough for you? Are you satisfied?” She would cry.”
In addition, he witnessed several other instances of sexual violence against other detainees.
“They brought in two women and the soldiers on duty raped them right in front of us. One of them fainted from screaming. I thought she was dead. She was a nurse from Qusair in Homs. Confronting those kinds of atrocities and feeling powerless in front of this inhumanity is much harder than physical torture.”
In total, Tareq was detained in the Palestine Branch for 14 months. After numerous cycles of torture, they took his fingerprints, which he interpreted as a sign that he would go to court. Instead, he was transferred to the Military Police prison in Qaboun, Damascus, where he was detained for nearly one month. On October 29, 2014, Tareq was transferred to Adra Prison, which he described as a “five-star hotel compared to the previous detention facilities.” While at Adra Prison, he appeared in Counter-terrorism Court about once every six months. He was charged with “supporting a terrorist organization” (the medical board) and plotting to overthrow the Syrian regime. The court sentenced him to 10 years in prison, revoked his Syrian nationality, confiscated his assets, and fined him 1,800,000 Syrian pounds (the equivalent of $3,500 at the time). With the help of a lawyer provided to him by the International Committee of the Red Cross, he was released after having been detained for four years, five months, and ten days.
“They brought in two women and the soldiers on duty raped them right in front of us. One of them fainted from screaming. I thought she was dead. She was a nurse from Qusair in Homs. Confronting those kinds of atrocities and feeling powerless in front of this inhumanity is much harder than physical torture.”Tareq, a health activities coordinator who was subjected to extreme torture, including sexual violence, during more than four years of detention
Inhumane Conditions in Detention
“We got used to the smell of dead bodies.”Omar, describing how frequently fellow detainees would die in custody in the Kafarsouseh Military Intelligence Branch, Damascus
Beyond the systematic torture they endured, each of the interviewees reported extremely poor living conditions across all detention centers. Those conditions, according to numerous human rights instruments, including a 1992 ruling by the Human Rights Committee, may amount to torture. Interviewees consistently encountered overcrowding, extremely poor sanitation, lack of access to medical care, insufficient food, and lack of access to clean drinking water. Interviewees told PHR that these conditions appeared to be intentional and designed to compound detainees’ misery. Following his arrest by Air Force Intelligence in Aleppo, Majd was held for a single night at the Kweires Military Aviation Institute about 30 km east of Aleppo city. Air Force Intelligence then transferred him to its branch in al-Leramoun, and detained him there for four-and-a-half months.
“They walked us in to the facility and stripped us all of our clothing. They stood us on a wall naked, both arms and one leg up for about half an hour. Then they distributed us into cells. Mine was cell number three – a room that’s about six meters long and four meters wide. There was a single square window no bigger than 25-by-25 centimeters. It was covered with a steel plate with three holes drilled into it and a very small fan.… We were 125 people in that space. Everyone was in their underwear. The smell was horrendous. You would have to lift your head above the crowd to be able to breath. The cell itself was filthy and we were not allowed to clean it. We were allowed to go the bathroom three times a day. However, they only gave us 60 seconds to relieve ourselves and they beat us with silicone sticks on the way there and back.”
Wessam, a health volunteer from Rural Damascus, described trying to cope with the severe overcrowding in the al-Fayha Political Security Branch in Damascus, where more than 60 prisoners were placed in a four-by-five-meter cell. “We assigned three men to each tile and divided our days into three shifts,” Wessam explained. “One detainee would sleep on his side with his legs on the second detainee who would be sitting, while the third detainee would be standing. We took turns: eight hours standing, eight hours sitting, and eight hours sleeping.”
All 21 interviewed health workers said that the authorities rarely provided sufficient quantities of food, and the food that was provided was frequently inedible. Most participants described receiving two to three meals a day that usually consisted of a piece of bread or a few bites of rice. In a few cases, detainees were given olives or a bit of marmalade. Interviewees said that this scant diet often led to malnutrition, dramatic weight loss, and long-term constipation. One interviewee reported weighing 90 kg before being detained. His weight upon release was 54 kg. Food deprivation was also used by Syrian security services as a form of punishment. Tareq, the 44-year-old health activities coordinator from Aleppo, recalled how food was used to manipulate and humiliate detainees in the Palestine Branch.
“Most of the time we would eat and never be full. We just wished that one day we would get that feeling of satisfaction after a meal again. For a time, they cuffed our hands behind our backs during meal time so we would have to eat like animals. All I wished for then was to be able to use a spoon. Then they deprived us of food altogether and dumped our meals in the toilet in front of us. My only wish then was to be able to eat.”
“When we came out [of detention], we were two men and 12 corpses.”Tareq, a health activities coordinator who endured more than four years of torture, describing how few prisoners survived the dire conditions of detention
Hassan, a nurse from Homs, described the first week of Ramadan in 2012 at the Riot Unit in Homs Central Prison, when prison authorities cut off food, water, and electricity in response to detainees protesting poor conditions. Hassan spoke of how blockaded detainees resorted to drinking stagnant water from an old reservoir and to hunting mice and rats and cooking them over burning blankets to break their fast.
The majority of interviewees described being denied regular access to showers and soap. Omar, the health volunteer from Harasta, explained that in his 63 days of detention in the Kafarsouse Military Security Branch in Damascus, prison authorities allowed him to shower only twice. Describing the process, he said:
“They told us to take our clothes off and rounded us up by groups of 50. They led us from our building to another and then down into a basement. There, we were led into the showers three at a time. The water was boiling hot. They gave us 60 seconds to shower. Anything over that and we would get the whip. They gave us one bar of soap and the three of us would try to lather each other up as quickly as possible. That shower space was also a toilet and the kitchen where the prison’s food was cooked.”
Some interviewees reported not being allowed access to the toilet, forcing them to relieve themselves in their cells. The cells were often described as filthy, with grime, blood, and dirt covering the ground and the walls. Unsanitary conditions led to chronic diarrhea, widespread lice, scabies, and a range of severe skin infections. Describing conditions in Military Intelligence Branch 215, Omar said:
“Lice was itself a form of punishment because they didn’t even try to treat it. Eleven of us would need to share a single blanket, even though some of us would have lice or scabies. It was a tactic they used to transmit these diseases and make us feel even more depressed.”
These conditions exposed detainees to a range of health risks that were compounded by the lack of adequate medical care available to them. Many of the interviewees reported that authorities denied them medical care or provided inadequate, incompetent, and even hostile services. Hazem, a 28-year-old nurse from Aleppo, was released from detention permanently disabled as a result of a brutal beating to his knee that went untreated. Although he did receive medical attention, an injection a nurse gave him at the State Security Branch in Aleppo where he was injured left him temporarily paralyzed, and his injury never healed. Hazem spent time in the Military Hospital in Aleppo as well as Damascus Hospital, where he reported that detainee patients were often neglected, beaten, and ill-treated. One interviewee summarized detainees’ fear of the quality of medical care in detention by stating that “people would prefer to die in prison than go to the hospital and have to suffer through more torture.” Almost all interviewees recalled witnessing the death of fellow detainees as a result of torture, poor prison conditions, and/or a lack of adequate medical care. Referring to his 14 months of detention at the Military Intelligence’s Palestine Branch in Damascus, Tareq stated that those who made it out of the facility alive were the lucky few. “When we came out, we were two men and 12 corpses.”
Since medical care was either unavailable or inadequate, many interviewees provided health care while in detention in order to fill the gap, either with the consent of the detaining authorities or in secret. As health workers, they witnessed the impact of prevalent abuse and neglect and did what they could to counter it with the limited resources available to them. In the Jameeliyeh Military Police Branch in Aleppo, prison guards would often bring medical cases to Majd for treatment. “They would only bring them to my corner if they were dying,” he said. “I watched 14 detainees die and the only thing I could do for them was pray.” In Homs Central Prison, authorities allowed Hassan to establish a medical unit in the prison to offer medical services to prisoners. It had 10 beds and received medications from the Syrian Red Crescent. When detainees arrived at the civilian prison from other branches, Hassan and other health volunteers, including an anesthetist and a pharmacist, would conduct a preliminary assessment, provide medications for scabies and lice, and address wounds when possible. The situation was drastically different in security branches. Hassan explained:
“In the security branch, I tried to provide some medical care – in secret, naturally. If I was caught providing consultations or care to anyone, the consequences would have been dire. Given conditions in the detention site, we saw a lot of skin ulcers. The infections were horrible. We tried to treat them. With an infected skin ulcer, you must make a small incision to drain the pus. We used to make those incisions with whatever was available. We tried to get our hands on what little soap and salt was available around us to make disinfectants.”
Interviewees described the conditions to be far worse – more violent, more crowded, more inhumane – in security branches than in civilian prisons. Even in facilities where conditions were described by some interviewees as “less intolerable” – primarily in Adra Central Prison and Homs Central Prison – the most fundamental international standards relating to the treatment of prisoners were ignored.
As documented by various human rights organizations and monitoring bodies, including the United Nations Independent International Commission of Inquiry (IICOI), Syrian authorities have been aware of these conditions and of their devastating and often deadly impact on individuals in their custody. This awareness, in addition to the effective control the Syrian government exerts over all regime-affiliated official and unofficial detention sites, has led the IICOI to conclude that these conditions have been inflicted on detainees “in the pursuance of a state policy to attack a civilian population.”
Most detention cases documented by PHR can be qualified as enforced disappearances., In most cases, and unless relatives were at the scene of arrest, the families of the interviewees had no information about their whereabouts or fate for months. During their detention in security branches, none of the detainees were allowed any contact with the outside world. Many were only able to contact their families once they were transferred to civilian prisons. The gravity of enforced disappearances and their impact on the families of detainees was palpable in Dr. Jamal’s description of the scene outside the Civilian Court in Damascus on the day he was released:
“As soon as I came out of the courthouse – and this is a something I will never forget – about 50 women rushed me. Each one of them had a picture in her hand. ‘This is my son,’ ‘This is my husband,’ ‘This is my brother,’ they would tell me. ‘Have you seen my son?’ I tried to look at the pictures, but I couldn’t recognize any of the faces. There was a man there who told me to leave before more of them showed up. And that’s what I did. I ran away. It was such a difficult moment. They’re just standing there, and they show these pictures to every detainee who gets released out of that courthouse.”
Arbitrary Detention by Non-Government Armed Groups
Anti-government armed groups detained three of the 21 health workers interviewed by PHR following their release from Syrian government detention facilities. The groups included the Islamic State (ISIS) and Hayat Tahrir al-Sham (HTS). In all three cases, the detentions had no relation to the detainees’ medical work. Their captors subjected all three interviewees to varying degrees of ill-treatment. An ISIS security cell arrested Tamer, a pharmacist who coordinated vaccination campaigns in northeast Syria, in June 2017 for carrying a satellite phone. ISIS detained him for seven days in the basement of an unknown makeshift facility, where guards repeatedly threatened him with execution. HTS detained Tareq, the health activities coordinator from Aleppo, toward the beginning of May 2017 for four days on charges of being secular and of “delaying victory.” His captors forced him to listen to sermons on HTS’s expectations of public conduct in areas under its control, but otherwise did not mistreat him. An unknown armed group abducted and detained Dr. Loay in Western Aleppo and held him for one week, during which he reports no torture. He was released after his family paid $28,000 in ransom. It should be noted that these three cases are not representative of documented patterns of more extreme abuse carried out by non-government armed groups – specifically ISIS and HTS. ISIS and HTS have perpetrated serious violations in territories under their control, including detention, torture, and summary executions.
Leila: Beaten for Providing Medical Assistance
Leila is a certified physical therapist and natural healer from Damascus. When protests began in 2011, she started treating injured demonstrators at a clinic in her opposition-sympathetic neighborhood. As the conflict escalated, Leila’s neighborhood came under increased government attack, driving out most physicians in the area. This created an immense shortage in medical practitioners, especially female professionals. Leila and her colleagues used her clinic to treat war casualties. “The government noticed what we were up to and shelled the clinic almost immediately,” she recalled.
In early 2012, Leila began volunteering as a paramedic with the Red Crescent. In the fall of that year, Leila and other volunteers received a call that one of her son’s friends had been injured in a particularly unsafe area of her neighborhood. She volunteered to go tend to him, thinking that she ran a lower risk of targeting as a woman. She left on foot, because ambulances were being targeted by government forces. Before she reached the injured boy, she was shot by a government sniper. The bullet entered her shoulder, ruptured her lung and exited her back. Severely injured and struggling to find help, Leila was arrested by soldiers from the Syrian army’s 4th Armored Division. They took her to al-Mujtahed Hospital in al-Mujtahed neighborhood in Damascus, where she was held for 12 days under arrest and guarded while she was treated. When she had partially recovered, she was transferred from the hospital to the Air Force Intelligence Branch. Air Force Intelligence detained Leila for a full day before releasing her. In the few hours she spent at the branch, interrogators beat her, verbally abused her, and accused her of providing support to “terrorists.”
Following her release and recovery, Leila continued her work in the health sector. During a trip with her sister to buy medical equipment and medication in Damascus in October 2015, she was arrested again, this time by the police. Her sister was immediately released but the police transferred Leila to the Air Force Intelligence Branch in al-Mezze Military Airport in Damascus. For the next 11 days, Air Force Intelligence personnel interrogated and beat Leila on a daily basis. They accused her of providing medical assistance to armed combatants, smuggling explosives into Damascus, and providing material support to “terrorists.” They showed her maps of the city and asked her to share the locations of the field hospitals she knew about. Leila tried to explain to her interrogators that she only did humanitarian work but was often threatened with violence when she made that claim. After almost five months in detention, interrogators forced Leila to fingerprint a stack of papers she was not allowed to read. She was then moved to the Airforce Intelligence Branch in Harasta, where she was held for eight days before being released.
Almost immediately after being released, Leila returned to her work in field hospitals as the government’s bombing campaign on opposition-held areas around Damascus intensified. When her neighborhood fell to Syrian government forces, Leila left Syria for Turkey.
PHR interviews with formerly detained health workers reveal the absence of legitimate judicial processes to which Syrian authorities subjected detainees. In multiple cases, interviewees reported that judges specifically designated nondiscriminatory medical activities as crimes. In many other cases, medical activities were not explicitly referenced as accusations in court but were instead couched under generic “support for terrorism” charges.
The role of the Syrian judiciary in perpetuating arbitrary detention is underscored throughout the testimonies of the health workers PHR interviewed for this study. Three-quarters of the interviewees experienced some form of judicial process during their detention. They appeared in court and usually faced formal charges. More than half of those who passed through the Syrian court system appeared in Counter-terrorism Court. The remainder appeared in military courts, military field courts, civil courts, or a combination thereof. Those interviewees whose cases were tried in Counter-terrorism and military courts reported a consistent, almost exclusive, reliance by judges on “evidence” that had been wholly fabricated by security services, or confessions obtained through torture.
All interviewees described a highly unpredictable experience of the court system, with no discernible rules or procedures. Pre-trial detention periods varied from one interviewee to another. The interviewees’ interactions with the judges were described as perfunctory, and sometimes lasted less than a minute. Some of the interviewees were able to appoint lawyers to represent them. However, even when assisted by counsel, interviewees stated the lawyers were not present in every court session and, when they were, they seemed powerless to raise a defense.
Many interviewees stated that the sole “evidence” presented in court proceedings were confessions either extracted under torture or entirely fabricated by interrogators. In at least five cases, judges dismissed or ignored allegations of torture raised by the detainees in their court hearings. In his first session in the Military Court of Homs, Hassan reported that he told the military judge that he had been forced to confess under torture, pointing to his blue, swollen face as proof. Hassan said the judge responded, “You look fine to me.” After nine months in the Homs Central Prison, Hassan was released into forced conscription into the Syrian army.
Few of the interviewees who passed through the court system were released, even when the court dismissed their cases or rendered not-guilty verdicts. In at least five cases, interviewees secured their release by bribing judges through their lawyers. After his case was referred to the criminal section of the Counter-terrorism Court, Samer, the 33-year-old pharmacist from Damascus, stated that a string of lawyers extorted him and his family with the promise of a not-guilty judgment in return for a payment. Finally, he and his family reached an agreement with a lawyer whereby they paid him the sum of $10,000 only after the judge released Samer on bail. Similarly, the Harasta health volunteer, Omar, paid a bribe of $8,000 to the Counter-terrorism Court in return for being granted bail. Both Samer and Omar fled government-controlled territory before the sentencing phase. Dr. Loay characterized his experience in the First Military Field Court of Damascus as a “farce”:
“You walk into the courtroom and stand in front of a judge, your arms and legs bound with chains. He asks for your name, your date of birth, and goes on to sentence you. I was convicted of six offenses: financing terrorism, abduction, murder, working to undermine patriotic sentiment, working to bring about the downfall of the Syrian regime, and conspiring against the state. I was sentenced to death by hanging. The presiding judge was a general in military uniform.”
After being released from detention, almost all of those whom PHR interviewed sought in some way to continue humanitarian work, despite their detention ordeals. Many returned to work in field hospitals in opposition-controlled parts of the country, with some of those who were interviewed remotely still living and working in these areas. The decision to leave Syria was difficult for many interviewees, with a number noting their desire to keep their family members safe as the main factor. Several interviewees provide clinical care for Syrian refugees in neighboring countries. Others have moved into coordination or administrative roles to continue providing support for health care facilities within Syria, for displaced populations, or for broader public health efforts in their countries of residence. Many reported continuing to derive a strong sense of meaning and purpose from their current work, even if their professional goals had to change.
All interviewees currently living in exile reported that they would not consider returning to live and work in Syria without a change in regime and guarantees for their security. Some described this as “only if Assad left power,” others as “only when there is safety, complete safety.” Many participants expressed their ongoing fear of returning to government-controlled areas of Syria, as they had information that gave them credible reasons to believe they were still wanted by different security apparatuses. Mohannad, the Idlib pharmacist who worked with a humanitarian organization, explained:
“I would never even think of going near an area controlled by the Syrian government. I know that the minute I go near a government-controlled area I will be detained, and I am sure killed.… I know I am still wanted because I worked with what they consider to be a ‘terrorist organization.’ Many of my friends and colleagues have been detained. Some are still in detention. Others have been killed. There is a high risk. This is not just a fear, this is a reality and a nightmare.”
Psychological Impact of Detention
All the health workers interviewed had experienced multiple traumatic events since the Syrian conflict began. In addition to their shared experience of detention, almost all had also experienced the death of friends or family members, direct bombings and shelling, or other attacks. It is thus impossible to disentangle the impact of detention from these other experiences. While the duration of detention and severity and frequency of torture during detention varied among interviewees, most described a similar temporal course of psychological symptoms after release from detention. Most reported nightmares, hypervigilance, and feeling depressed, withdrawn, and avoidant immediately after release, with the severity of symptoms diminishing over time for those now living outside of Syria. Many evinced a high level of self-awareness, describing positive strategies they used to cope with painful memories of what they had experienced, such as employing humor or trying to recount their experiences to others. A few noted that they continued to grapple with feeling emotionally detached, socially withdrawn, or needing to avoid certain situations that reminded them of events during detention. One respondent had been tortured on his birthday and avoided all mention and celebration of his and others’ birthdays; another had difficulty providing treatment for patients who had also been prisoners.
The most frequently reported continued negative emotion was a sense of guilt for being alive while other health worker detainees had died. Even those who suffered long detentions with repeated, brutal torture described feeling guilty that they had not suffered as much as other people had, such as friends and colleagues who had been killed. As Dr. Youssef explained: “I always feel guilty. After I was released from detention, I felt I should do more. Then I felt guilty that I should have taken responsibility for mobilizing the opposition. Since I have come to Turkey, I have felt guilty for being safe in Gaziantep. Four of my friends who stayed in Idlib to work at a field hospital were killed by a bombing of the hospital in 2013; I feel guilty that I didn’t encourage them to leave.”
“In Syria, those who issue judgements are the intelligence services and not the judges.”Dr. Ahmad, who appeared in Counter-terrorism Court 16 months after he was first arrested
All those interviewed generously provided hours of their time to recount their experiences and share their stories. Despite their ordeals, their defining characteristic was resilience. Dr. Ziad, a psychiatrist from Rural Damascus, stated “I hit the bottom after detention. Now I am granted new life so I must do more and live differently.” Their commitment to their medical work was also evident in their continuation in the medical or humanitarian field post-detention. As one physician explained, “I did have a lot of hopelessness and guilt but working with detainees transformed my bitterness to energy.”
Armed Conflict Classification and Applicable International Humanitarian Law
This report focuses on detention and abuse by the Syrian government and non-state armed groups; for the purpose of legal analysis, the conflict in Syria may be characterized as primarily a non-international armed conflict in which obligations arise under both international treaty and customary law.
The body of treaty law outlining States parties’ obligations under international humanitarian law (IHL) are the Geneva Conventions of 1949, which Syria ratified in 1953. Significantly, they contain provisions related to protecting civilians, regulating detention, and safeguarding medical personnel. Common Article 3 of the Geneva Conventions applies to all parties to the conflict in Syria and contains specific stipulations on the equal and humane treatment of persons taking no active part in hostilities. Common Article 3 prohibits mutilation, torture, humiliating and degrading treatment, and the passing of sentences and the carrying out of executions without previous judgment by a “regularly constituted court.” In addition to the IHL obligations arising under treaty law, the Syrian government and other parties to the conflict in Syria are bound by customary international humanitarian law (CIL), including, but not limited to: Rule 99, prohibiting the arbitrary deprivation of liberty; Rule 90, prohibiting torture and other cruel and inhumane punishment; Rule 98, prohibiting enforced disappearances; and Rule 89, prohibiting murder.
CIL also protects the provision of medical care. Rule 25 of customary international humanitarian law provides for the protection and respect of medical personnel engaged exclusively in medical duties, with the idea that they should not be knowingly attacked or prevented from discharging their functions. Rule 26 of CIL prohibits the punishment of a person for performing medical duties in line with medical ethics.
Applicable International Human Rights Law
In addition to its obligations under IHL and CIL, Syria has ratified multiple international treaties containing articles relevant to the detention, abuse, and torture of health workers in Syria. Critically, Syria has ratified the International Covenant on Economic, Social and Cultural Rights, which codifies the right to physical and mental health in Article 12. The obligation to extend the right to health in a nondiscriminatory manner is articulated in Article 2.2, which states that “the rights enunciated in the present Covenant will be exercised without discrimination of any kind” (emphasis added).
The International Covenant on Civil and Political Rights (ICCPR) was ratified by Syria in 1969. Article 7 of the ICCPR prohibits torture or cruel, inhuman, or degrading treatment or punishment. Significantly, Articles 9, 10, and 14 of the ICCPR also pertain to aspects of the abuses alleged: prohibition of arbitrary arrest or detention (Art. 9); the humane treatment of detainees (Art. 10); and provision of fair trials (Art. 14). Of particular interest for this report, Syria ratified the Convention against Torture (CAT) in 2004. Article 2 of the CAT requires States parties to actively prevent acts of torture in territories under their jurisdiction, allowing for no derogation under any circumstances, including in a state of war, internal instability, or public emergency.
While Syria is not party to the Rome Statute, which established the International Criminal Court, the court may obtain jurisdiction to investigate and prosecute acts proscribed therein through a number of mechanisms including potentially through the discretion of the Prosecutor, though this has not yet proved possible. Of note, Article 7 of the Rome Statute provides that imprisonment or other deprivation of physical liberty, torture, and enforced disappearance may be considered crimes against humanity when committed as part of “a widespread and systematic attack directed against any civilian population.”
Applicable Domestic Law and Abrogation
In theory, the Syrian Constitution of 2012 provides for a range of protections against arbitrary detention and torture. In practice, however, these guarantees are all but invalidated through the judiciary’s effective capture by the executive and security branches. In its section on the rule of law, Articles 51-53, the Constitution spells out human rights and principles that include the presumption of innocence in trials, the right to counsel, the right to fair trial, the prohibition of torture and cruel treatment, and the prohibition of false imprisonment. The Syrian Penal Code and the Code of Criminal Procedures provide for similar procedural protections.
A permanent, nation-wide state of emergency established in 1963 enabled the creation of a parallel judicial system which has been used to quell dissent and preserve regime stability. Exceptional courts, including military courts and the Supreme State Security Court, funneled untold numbers of people perceived by the Syrian government as threats into both official and unofficial detention sites. The state of emergency was lifted in April 2011 only to be replaced by sweeping counter-terrorism measures that included the promulgation of Counter-terrorism Law 19, and the establishment of the Counter-terrorism Court through Decree 22 in July 2012. The Counter-terrorism Court has enabled the Syrian government to circumvent the handful of constitutional and procedural protections provided to civilians under domestic law and has facilitated a campaign of widespread human rights abuses.
This study’s findings indicate that the government of Syria has targeted health workers for arbitrary arrest, detention, and torture for the ostensible “crime” of honoring their professional codes of ethics, which require them to provide care to the sick and wounded without discrimination. Syrian security forces have purposefully conflated provision of medical care to civilians who live in opposition-controlled areas and to those whom they consider direct opponents with “terrorism.” They have subjected health care workers to brutal and unlawful punishment, resulting in severe trauma and, in some cases, permanent disability. Additionally, removing these health workers from areas in which patients are desperately in need of lifesaving care may have resulted in large numbers of preventable illnesses and fatalities. Together, these actions violate both national and international laws and demonstrate profound disrespect for universally recognized norms of medical ethics: the obligations of health professionals to care for the sick and wounded without preference or discrimination. Within methodological limitations, these findings provide compelling evidence of the targeting of health workers in Syria.
This study provides evidence of patterns of arbitrary arrest of health workers in their homes and workplaces. In some cases, these arrests were based on evidence of “criminality” obtained during the torture of those health workers’ colleagues or associates. In other cases, health workers were detained after medical supplies or equipment – materials associated by the Syrian government with nondiscriminatory care provision – were discovered on their persons at security checkpoints. While the cases documented in this report are not recent, ongoing PHR investigations indicate that the Syrian government’s practices of detention, torture, and enforced disappearance continue to affect health workers, among many others targeted by the regime as political enemies.
Medical facilities and health workers are both particularly vulnerable to attack and essential to community health during times of violent conflict. They represent a safety net that is obligated to support the community and treat all wounded and sick individuals, regardless of their affiliations. This duty by necessity places health workers on the front lines of conflict and human suffering. Physicians and other health workers in Syria have been arrested and detained in the course of fulfilling their obligations to provide medical care both inside and outside medical facilities. This purposeful and unlawful mistreatment aims to prevent physicians from participating in the care of opposition forces and civilians who live in areas dominated by those forces. In line with the extensively documented strategy of attacking health care facilities, the targeting and mistreatment of health workers also serves to decrease vital health care capacity, erode trust in the safety of health institutions, and weaken health systems in the short and long term.
The Syrian government and its allies have consistently demonstrated contempt for human rights and international humanitarian law. During the eight years of the conflict to date, they have deployed a strategy directed first and foremost at civilian populations of restive areas and persons perceived to be supporting the opposition. They have imposed sieges on opposition-held areas, shelled and bombarded densely populated urban centers, established extensive networks of security checkpoints, and led a widespread campaign of arrest, torture, and enforced disappearance of suspected insurgents and their supporters.
For years, evidence of abuses carried out by the Syrian security forces has been reported by numerous human rights groups. Torture, including beatings, sexual violence, solitary confinement, electrical shocks, and food deprivation are commonly used against detainees suspected of anti-government sympathies, including health workers. Physicians for Human Rights calls upon the Syrian government to respect the rights and dignity of all Syrian citizens and particularly the health workers on whom the country’s civilian population desperately relies.
The situation of detainees in Syria, including those targeted because they are health workers, forms a crucial part of a human rights crisis of enormous proportions. Resolving this crisis is critical for Syria’s future. The issue of arbitrary detention has been widely perceived as a precondition to any political solution to the conflict. It figures prominently in four UN Security Council resolutions on Syria (UNSC 2139, 2254, 2268, 2474), is seen by the Special Envoy for Syria as a critical element of trust building to support the political process, and is notably present in the third Brussels Conference Co-Chairs declaration. Nevertheless, this stated interest has yet to translate into substantive progress. The only current negotiation platform for discussing the release of detainees – the Astana Working Group on Detentions and Abductions – has never evolved beyond its limits as a prisoner swap mechanism, leaving the issue of detainees within a framework that has been seen by many as supporting the interests of the Syrian government and its allies. With thousands of people still detained or missing, and the pace of arrests reportedly rising in areas recently re-taken by the Syrian government, the issue requires urgent action by a range of actors implicated in the Syrian conflict. Physicians for Human Rights therefore calls on all concerned parties to implement the following recommendations without delay:
To the Syrian Government and Affiliated Forces, and All Parties to the Conflict:
- Immediately and unconditionally release all arbitrarily or unlawfully detained individuals from official and unofficial detention sites, starting with the most vulnerable, including children, women, the elderly, and the disabled.
- Take immediate and systemic measures to prevent the torture and ill-treatment of detainees and ensure that allegations of abuse are investigated and abusers held accountable.
- Disclose the locations of all official and unofficial detention sites and provide comprehensive lists of all those held in those sites.
- Disclose information to families on the location and status of detained and abducted relatives, notifying them of the circumstances of death and location of burial when applicable.
- End the use of “exceptional” courts, including military field tribunals and the Counter-terrorism Court. Suspend all sentences passed through these courts and guarantee fair trials for the accused under UN supervision.
- Allow unconditional access to all places of detention, official and unofficial, by designated international bodies and humanitarian organizations.
- Improve detention conditions in compliance with international standards, including through ensuring detainee contact with families, access to medical care, and sufficient water and food, as well as preventing torture, ill-treatment, and sexual violence.
- Respect health services and protect medical personnel, patients, facilities, and transport from attack or interference.
To the Russian Federation:
(As the main supporter of the Syrian government and a party to the conflict in Syria)
- Use influence to press the Syrian government to implement the above-listed recommendations, focusing on the unconditional release of those arbitrarily detained, disclosing information to families on the fate and whereabouts of detained relatives, and granting access by international monitors to detention sites.
- Support UN Security Council measures to accelerate the release of the arbitrarily detained, including medical personnel, in accordance with resolutions 2139 and 2254.
To the United Nations Security Council:
- Address non-implementation of prior UN Security Council resolutions by adopting a stand-alone resolution on the situation of detainees and missing persons, setting out in detail the steps that the government of Syria is required to take under international law.
- Enforce accountability by referring the situation in Syria to the Prosecutor of the International Criminal Court.
- Adopt targeted sanctions against persons, agencies, and groups credibly suspected of being responsible for or complicit in conduct leading to arbitrary arrests, custodial deaths, torture, and enforced disappearances.
- Encourage all parties to the conflict to abide by UNSC resolutions 2139, 2254, 2268, and 2474 and draw specific attention to the targeting of medical personnel.
To the UN Special Envoy for Syria:
- Ensure that discussions of human rights and international humanitarian law violations, including arbitrary detention, torture, enforced disappearances, and attacks on health, are prominent within the political process.
- Re-insert the issue of detainees, abductees, and the missing under the framework of the Geneva peace process and push the Astana Guarantors to widen the scope of the Working Group on Detainees and Abductees beyond its current focus on low-level one-to-one prisoner exchange and into a scalable release of civilian prisoners.
To UN Member States:
- Refrain from forcibly returning Syrian refugees to their country of origin, given the ongoing risks of targeting, detention, abductions, enforced disappearance, torture, and ill-treatment.
- Strengthen targeted sanctions against Syrian officials credibly implicated in the ongoing serious violations of international humanitarian law and international human rights law.
- Exercise international and domestic law, including universal jurisdiction principles, to investigate and prosecute Syrian military and civilian officials responsible for carrying out war crimes and crimes against humanity against detainees in Syria. Ensure cooperation among states, including sharing of evidence bilaterally, where possible, with national prosecutors who are pursuing these cases in domestic courts.
This report was written by Physicians for Human Rights (PHR) staff members Rayan Koteiche, MENA researcher, and Serene Murad, associate researcher, with co-authorship by Michele Heisler, MD, MPA, medical director. Phelim Kine, PHR deputy director of programs and director of research and investigations, also contributed to the writing of the report. External review was provided by Adrienne Fricke, JD, MA, senior fellow at the Harvard Humanitarian Initiative.
The clinical evaluations for this report were conducted by Michele Heisler; Ahmad Banasr, MD, head of the Clinical Forensic Department in Tunisia; and Sana Hamzeh, PhD, head of treatment and rehabilitation of torture and trauma survivors at Restart Center, Lebanon.
PHR leadership and staff contributed to the writing and editing of this report, including DeDe Dunevant, director of communications; Derek Hodel, interim program director; Donna McKay, executive director; Michael Payne, interim director of advocacy; and Susannah Sirkin, director of policy. The report benefitted from review by PHR Emeritus Board Member Robert S. Lawrence, MD. The report was reviewed, edited, and prepared for publication by Claudia Rader, MS, senior communications manager. Multimedia associated with the report was coordinated by Hannah Dunphy, digital communications manager. Research was contributed by Isabelle Clements, MENA intern. Theresa McMackin and Maya Tessler, communications interns, helped prepare the report for publication.
PHR would also like to thank Syria Relief and Development, the Union of Medical Care and Relief Organizations, the Syrian American Medical Society, the Assistance Coordination Unit, the Center for Victims of Torture, and Restart Center for the support they provided to the research. PHR is also grateful to Ali Barazi and his associates for translating the report. PHR is especially indebted to all the survivors of detention and torture who shared their stories.
This report is supported in part with German Federal Foreign Office’s funds by ifa (Institut für Auslandsbeziehungen), Funding Programme zivik.
 Joseph Holliday, “The Assad Regime: From Counterinsurgency to Civil War,” The Institute for the Study of War, March 2013, 9, http://www.understandingwar.org/sites/default/files/TheAssadRegime-web.pdf.
 “Sieges as a Weapon of War: Encircle, starve, surrender, evacuate,” Independent International Commission of Inquiry on the Syrian Arab Republic, May 29, 2018, https://www.ohchr.org/Documents/HRBodies/HRCouncil/CoISyria/PolicyPaperSieges_29May2018.pdf.
 United Nations General Assembly, “Report of the Independent International Commission of Inquiry on the Syrian Arab Republic*,” February 5, 2015, 4-5, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G15/019/37/PDF/G1501937.pdf?OpenElement.
 Physicians for Human Rights, “The Syrian Conflict: Eight Years of Devastation and Destruction of the Health System,” March 12, 2019, https://phr.org/our-work/resources/the-syrian-conflict-eight-years-of-devastation-and-destruction-of-the-health-system/.
 Physicians for Human Rights, “Illegal Attacks on Health Care in Syria,” http://syriamap.phr.org/#/en.
 “On Eighth Anniversary of Syria Conflict, PHR Renews Call for Accountability, Cessation of Attacks on Health Care Infrastructure,” Physicians for Human Rights, March 12, 2019, https://phr.org/news/on-eighth-anniversary-of-syria-conflict-phr-renews-call-for-accountability-cessation-of-attacks-on-health-care-infrastructure/.
 Physicians for Human Rights, “Illegal Attacks on Health Care in Syria.”
 Law 19 defines “terrorism” in an overly broad manner as: “every act that aims at creating a state of panic among the people, destabilizing public security and damaging the basic infrastructure of the country by using weapons, ammunition, explosives, flammable materials, toxic products, epidemiological or bacteriological factors or any method fulfilling the same purposes” (emphasis added).
 Emergency response units/centers with limited staff and equipment usually established on the front lines or in particularly volatile areas for emergency stabilization of trauma cases and referral to larger medical facilities.
 Physicians for Human Rights, “Illegal Attacks on Health Care in Syria.”
 Physicians for Human Rights, “The Syrian Conflict: Eight Years of Devastation and Destruction of the Health System.”
 Mazen Eyon, “Russia, China Veto a draft resolution that aims to protect terrorists in Idleb,” Syrian Arab News Agency, September 19, 2019, https://www.sana.sy/en/?p=173708.
 Human Rights Watch, “Syria: Counterterrorism Court Used to Stifle Dissent,” June 25, 2013, https://www.hrw.org/news/2013/06/25/syria-counterterrorism-court-used-stifle-dissent. Accessed on October 23, 2019.
 Khaled Yacoub Oweis, “Syria protests spread, authorities pull back,” Reuters, 21 March 2011, https://www.reuters.com/article/us-syria/syria-protests-spread-authorities-pull-back-idUSTRE72K4CD20110321.
 Katherine Marsh, Haroon Siddique, and Matthew Taylor, “Syria’s crackdown on protesters becomes dramatically more brutal,” The Guardian, April 25, 2011, https://www.theguardian.com/world/2011/apr/25/syria-crackdown-protesters-brutal.
 “Thousands of Syrians chant anti-regime slogans at protesters’ funerals,” The Telegraph, December 21, 2011, https://www.telegraph.co.uk/news/worldnews/middleeast/syria/8970985/Thousands-of-Syrians-chant-anti-regime-slogans-at-protesters-funerals.html.
 United Nations General Assembly, “Report of the independent international commission of inquiry on the Syrian Arab Republic,” November 23, 2011, 8,https://undocs.org/A/HRC/S-17/2/Add.1.
 “Guide to the Syrian Opposition,” BBC News, October 17, 2003, https://www.bbc.com/news/world-middle-east-15798218.
 United Nations General Assembly, “Report of the Independent International Commission of Inquiry on the Syrian Arab Republic*,” February 5, 2015, 5, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G15/019/37/PDF/G1501937.pdf?OpenElement.
 Holliday, “The Assad Regime,”9.
 Joost Hiltermann, “The Syrian Conflict and International Support for Rebel Groups,” International Crisis Group, September 28, 2018, https://www.crisisgroup.org/middle-east-north-africa/eastern-mediterranean/syria/syrian-conflict-and-international-support-rebel-groups.
 Independent International Commission of Inquiry on the Syrian Arab Republic, “Sieges as a Weapon of War: Encircle, starve, surrender, evacuate,” May 29, 2018, https://www.ohchr.org/Documents/HRBodies/HRCouncil/CoISyria/PolicyPaperSieges_29May2018.pdf.
 United Nations General Assembly, “Report of the Independent International Commission of Inquiry on the Syrian Arab Republic*,” February 5, 2015, 4-5, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G15/019/37/PDF/G1501937.pdf?OpenElement.
 United Nations Security Council, “Resolution 2042 (2012),” April 14, 2012, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/Syria%20SRES%202042.pdf.
 United Nations Security Council, “Resolution 2118 (2013),” September 27, 2013, http://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_res_2118.pdf.
 United Nations Security Council, “Resolution 2139 (2014),” February 22, 2014, http://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_res_2139.pdf.
 Hiltermann, “The Syrian Conflict and International Support for Rebel Groups.”
 Kareem Shaheen, “String of losses in Syria leaves Assad regime increasingly precarious,” The Guardian, June 11, 2015, https://www.theguardian.com/world/2015/jun/11/syria-losses-east-assad-regime-precarious.
 Andrew Osborn, “Russia begins Syria air strikes in its biggest Mideast intervention in decades,” Reuters, September 30, 2015, https://www.reuters.com/article/us-mideast-crisis-russia/russia-begins-syria-air-strikes-in-its-biggest-mideast-intervention-in-decades-idUSKCN0RU0MG20150930.
 “Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, Mark Lowcock Press Statement on Northwest Syria, 18 July 2019,” ReliefWeb, July 18, 2019, https://reliefweb.int/report/syrian-arab-republic/under-secretary-general-humanitarian-affairs-and-emergency-relief-93.
 “More than 570 thousand people were killed on the Syrian territory within 8 years of revolution demanding freedom, democracy, justice, and equality,” Syrian Observatory for Human Rights, March 15, 2019, http://www.syriahr.com/en/?p=120851.
 “In the highest monthly death toll in 17 months, 1520 people were killed in August 2019,” Syrian Observatory for Human Rights, September 1, 2019, http://www.syriahr.com/en/?p=139262.
 “Quick facts: What you need to know about the Syria crisis,” Mercy Corps, accessed October 23, 2019, https://www.mercycorps.org/articles/iraq-jordan-lebanon-syria-turkey/quick-facts-what-you-need-know-about-syria-crisis#idlib
 United Nations Office for the Coordination of Humanitarian Affairs, “Syrian Arab Republic,”https://www.unocha.org/syria.
 Three UN envoys who tried and failed in quest for Syria peace,” France 24, January 15, 2019, https://www.france24.com/en/20190115-three-un-envoys-who-tried-failed-quest-syria-peace.
 Anne Barnard, “Syrian Government Documents Show Widespread Abuses, Rights Center Says,” New York Times, May 21, 2019, https://www.nytimes.com/2019/05/21/world/middleeast/syrian-government-documents-abuses.html.
 Amnesty International, Human Rights Watch, the Syrian Network for Human Rights, the Violations Documentation Center, and the United Nations Independent International Commission of Inquiry on Syria have all documented the various facets of detention in Syria.
 Office of the High Commissioner for Human Rights (OHCHR), “Out of Sight, Out of Mind: Deaths in Detention in the Syrian Arab Republic,” February 3, 2016, 4, https://www.ohchr.org/Documents/HRBodies/HRCouncil/CoISyria/A-HRC-31-CRP1_en.pdf.
 Syria’s Arab Socialist Baath Party came to power in a military coup in 1963 and legislated a state of emergency that gave the government unchecked authority to curb individual freedoms when matters of national security were thought to be at stake.
 Amnesty International, “Syria: Torture by the security forces,” October 1987, 1, https://www.amnesty.org/download/Documents/200000/mde240091987en.pdf.
 Human Rights Watch, “A Wasted Decade: Human Rights in Syria during Bashar al-Asad’s Ten Years in Power,” July 16, 2010, https://www.hrw.org/report/2010/07/16/wasted-decade/human-rights-syria-during-bashar-al-asads-first-ten-years-power.
 As discussed in the Legal Standards section of this report, the counter-terrorism laws (June 28, 2012) and the Counter-terrorism Court promulgated in July 2012 largely replaced the state of emergency that had been lifted by President Assad in April 2011.
 Human Rights Watch, “Syria: Counterterrorism Court Used to Stifle Dissent,” June 25, 2013, https://www.hrw.org/news/2013/06/25/syria-counterterrorism-court-used-stifle-dissent.
 United Nations Security Council, “Security Council Failing Thousands of People Detained, Abducted in Syria, Civil Society Speakers Say, Demanding Information about Missing Persons’ Whereabouts,” August 7, 2019, https://www.un.org/press/en/2019/sc13913.doc.htm
Independent International Commission of Inquiry on the Syrian Arab Republic, “Detention in the Syrian Arab Republic: A Way Forward,”March 8, 2018, https://www.ohchr.org/Documents/HRBodies/HRCouncil/CoISyria/AWayForward_DetentionInSyria.pdf.
 Ibid, 2.
 OHCHR, “Out of Sight, Out of Mind,” 16.
 Ibid, 17.
 Amnesty International, “Amnesty Report: Abductions, Torture and Summary Killings at the Hands of Armed Groups in Syria”, July 3, 2016, https://www.amnestyusa.org/press-releases/amnesty-report-abductions-torture-and-summary-killings-at-the-hands-of-armed-groups-in-syria/.
 Ibid, 16.
 Amnesty International, “Syria: Arbitrary detentions and blatantly unfair trials mar PYD fight against terrorism,” September 7, 2015, https://www.amnesty.org/en/latest/news/2015/09/syria-abuses-mar-pyd-fight-against-terrorism/.
 OHCHR, “Out of Sight, Out of Mind,” 14; Ibid.
 Ibid, 1 and 18.
 Physicians for Human Rights, “Shot While Fleeing: Rohingya Disabled by Myanmar Authorities’ Targeted Violence,” June 25, 2019, https://phr.org/our-work/resources/shot-while-fleeing-rohingya-disabled-by-myanmar-authorities-targeted-violence/#_edn30.
 The semi-structured interview protocol covered eight broad domains: 1) background demographic, educational, and professional information; 2) pre-detention work and experiences; 3) events leading to detention and circumstances of arrest; 4) experiences during detention and, if relevant, of judicial processes, sentencing, and imprisonment; 5) circumstances and experiences of release; 6) post-detention work and experiences in Syria; 7) current living situation, work, and circumstances; and 8) conditions under which the interviewees would return to live and work in Syria.
 OHCHR, Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 2004, https://www.ohchr.org/Documents/Publications/training8Rev1en.pdf.
 Three of the interviewees also reported arrests and detention by non-government armed groups, including the Islamic State and Hayat Tahrir al-Sham, following their release from government detention facilities.
 The main security services are the Department of Military Intelligence (Shu`bat al-Mukhabarat al-`Askariyya); the Air Force Intelligence Directorate (Idarat al-Mukhabarat al-Jawiyya); the Political Security Directorate (Idarat al-Amn al-Siyasi); and the General Intelligence Directorate (Idarat al-Mukhabarat al-`Amma).
 Established by Legislative Decree No. 109 of 17 August 1968, for use during armed conflict, either against the enemy or to prosecute soldiers who deserted the battlefield. Later, Legislative Decree No. 109 of 17 August 1968 was amended to expand the court’s jurisdiction to also cover periods of “domestic unrest.” Mikael Ekman, ed, “ILAC Rule of Law Assessment Report: Syria 2017,” International Legal Assistance Consortium, http://www.ilacnet.org/wp-content/uploads/2017/04/Syria2017.pdf.
 Established to deal with all cases involving members of the military or police; Ibid.
 Established in July 2012, the Counter-terrorism Court has exclusive jurisdiction over all cases concerning terrorism in Syria with the authority to also try civilians for state security offenses, including activists, demonstrators, and related personnel; Ibid.
 Torture is defined by the Convention Against Torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.”
 Human Rights Watch, “Torture Archipelago: Arbitrary Arrests, Torture, and Enforced Disappearances in Syria’s Underground Prisons since March 2011,” July 3, 2012, https://www.hrw.org/report/2012/07/03/torture-archipelago/arbitrary-arrests-torture-and-enforced-disappearances-syrias.
 Torture in prisons run by Syrian authorities has been an entrenched practice for decades – one that has been scaled up since the beginning of the conflict, but whose methods have changed very little over time. So far-reaching has this practice of torture been, that terms describing its methods – falaqa, shabeh, balanco and many others – have become elemental to the Syrian lexicon. Torture is banned under a number of international treaties to which Syria is party. When torture is committed as part of a widespread and systematic attack against civilian populations, as has been the case in Syria, it amounts to a crime against humanity under international customary law and the Rome Statute of the International Criminal Court.
 Office of the High Commissioner for Human Rights, ‘‘CCPR General Comment No.21 : Article 10 Humane Treatment of Persons Deprived of Their Liberty,’’ Refworld, April 10, 1992, 1, https://www.refworld.org/docid/453883fb11.html.
 Military Intelligence Branch 235 in Damascus is known as Palestine Branch.
United Nations Office on Drugs and Crime, Standard Minimum Rules for the Treatment of Prisoners, https://www.unodc.org/pdf/criminal_justice/UN_Standard_Minimum_Rules_for_the_Treatment_of_Prisoners.pdf.
 United Nations Human Rights Council, “Out of Sight, Out of Mind.”
 Ibid, 17.
 The International Convention for the Protection of All Persons from Enforced Disappearance defines a person as “disappeared” if they are: “Arrested, detained or abducted against their will or otherwise deprived of their liberty by officials of different branches or level of Government, or by organized groups or private individuals acting on behalf of the Government, followed by a refusal to disclose the fate or whereabouts of the persons concerned or a refusal to acknowledge the deprivation of their liberty, which places such persons outside the protection of the law.”
 United Nations, International Convention for the Protection of All Persons from Enforced Disappearance, https://www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_RES_47_133.pdf.
 United Nations Human Rights Council, “Out of Sight, Out of Mind,” 14.
 International Committee of the Red Cross, The Geneva Conventions, August 12, 1949, 36, https://www.icrc.org/en/doc/assets/files/publications/icrc-002-0173.pdf.
 International Committee of the Red Cross, “Rule 99. Deprivation of Liberty,” Customary International Law, July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule99#Fn_B4BD78D1_00002.
 International Committee of the Red Cross, “Rule 90. Torture and Cruel, Inhuman or Degrading Treatment,” Customary International Law, July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule90.
 International Committee of the Red Cross, “Rule 98. Enforced Disappearance,” Customary International Law, July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter32_rule98.
 International Committee of the Red Cross, “Rule 89. Violence to Life,” Customary International Law, July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter32_rule89.
 International Committee of the Red Cross, “Rule 110. Treatment and Care of the Wounded, Sick and Shipwrecked,” Customary International Law, July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule110.
 International Committee of the Red Cross, “Rule 25: Medical Personnel,” Customary International Law, updated July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule25#Fn_E202BFDC_00002.
 International Committee of the Red Cross, “Rule 26. Medical Activities,” Customary International Law, updated July 2019, https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule26.
 UN General Assembly, International Covenant on Economic, Social and Cultural Rights, January 3, 1976, https://www.ohchr.org/EN/professionalinterest/pages/cescr.aspx.
 United Nations General Assembly, International Covenant on Civil and Political Rights, December 19, 1966, 5-6, https://treaties.un.org/doc/publication/unts/volume%20999/volume-999-i-14668-english.pdf.
 Syria has declared its reservation to the competence of the committee of the CAT: “In accordance with the provisions of article 28, paragraph 1, of the Convention, the Syrian Arab Republic does not recognize the competence of the Committee against Torture provided for in article 20 thereof. United Nations General Assembly, Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, December 10, 1984, https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IV-9&chapter=4&lang=en.
 United Nations General Assembly, Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 3.
 International Criminal Court, Rome Statute of the International Criminal Court, July 17, 1998, 3-4, https://www.icc-cpi.int/NR/rdonlyres/ADD16852-AEE9-4757-ABE7-9CDC7CF02886/283503/RomeStatutEng1.pdf.
 Ibid, 13.
 Syrian Arab Republic’s Constitution of 2012, “Chapter II: Rule of Law,” 11, https://www.constituteproject.org/constitution/Syria_2012.pdf?lang=en.
 Human Rights Watch, “A Wasted Decade: Human Rights in Syria during Bashar al-Asad’s First Ten Years in Power,” July 16, 2010, https://www.hrw.org/report/2010/07/16/wasted-decade/human-rights-syria-during-bashar-al-asads-first-ten-years-power; Amnesty International, “Syria: End Human Rights Violations in Syria,” October 2011, 3-4, https://www.amnesty.org/download/Documents/32000/mde240342011en.pdf
 Mikael Ekman, ed, “ILAC Rule of Law Assessment Report: Syria 2017,”46-7.
 Syrian Arab Republic Constitution of 2012, “Article 1 of Law 19, Anti-Terrorism Law,” http://www.parliament.gov.sy/arabic/index.php?node=55151&cat=4306.
 PHR is in the process of documenting a number of recently reported cases of Syrian security forces’ arrest and enforced disappearance of health workers, including doctors and first responders from the Damascus suburb of Eastern Ghouta and the southern governorate of Daraa.
 Physicians for Human Rights, “Illegal Attacks on Health Care in Syria.”
 Independent International Commission of Inquiry on the Syrian Arab Republic, “Sieges as a Weapon of War.”
 Human Rights Watch, “Torture Archipelago.”
 United Nations Security Council, “Resolution 2139 (2014).”
 United Nations Security Council, “Resolution 2254 (2015),” December 18, 2015, https://undocs.org/S/RES/2254(2015).
 United Nations Security Council, “Resolution 2268 (2016),” February 26, 2016, https://undocs.org/S/RES/2268(2016).
 United Nations Security Council, “Resolution 2474 (2019),” June 11, 2019, https://undocs.org/S/RES/2474(2019).
 Special Envoy Pedersen has mentioned that addressing the issue of detainees, abductees, and the missing is a priority and would help “heal wounds and build confidence” and move the political process in the right direction; Oslo Forum Interview, “Moving Forward: Geir O. Pedersen on developments in Syria,” Centre for Humanitarian Dialogue, May 9, 2019, https://www.hdcentre.org/wp-content/uploads/2019/06/Moving-forward-Geir-O-Pedersen-on-developments-in-Syria.pdf.
 “Brussels III Conference on ‘Supporting the future of Syria and the region’: co-chairs declaration,” European Council, March 14, 2019, https://www.consilium.europa.eu/en/press/press-releases/2019/03/14/brussels-iii-conference-on-supporting-the-future-of-syria-and-the-region-co-chairs-declaration/, point 11.
 Human Rights Watch, “Syria: Detention, Harassment in Retaken Areas,” May 21, 2019, https://www.hrw.org/news/2019/05/21/syria-detention-harassment-retaken-areas.