THE SHADOW DOCTORS

 'In the first weeks of March, 2011, the start of the insurrection in Syria, the security forces of President Bashar al-Assad detained and tortured children who had drawn anti-regime slogans on a wall in the southern city of Dara’a. Tens of thousands of protesters took to the streets, and on March 22nd Assad’s forces stormed into the city hospital, kicked out the nonessential medical staff, and positioned snipers on the roof. Early the next morning, the snipers fired at protesters. A cardiologist named Ali al-Mahameed was shot in the head and the chest as he tried to reach the wounded. Thousands of people attended his funeral, later that day, and they, too, were attacked with live ammunition. For the next two years, the snipers remained stationed on the roof, “firing on sick and wounded persons attempting to approach the hospital entrance,” according to the U.N. commission.

 As protests erupted all over the country, government-run hospitals basically functioned as an extension of the security apparatus, targeting demonstrators who dared to seek treatment. “Some doctors manage to treat simple cases and manage to let them flee without being seen or registered,” one doctor said, in testimony collected by Médecins Sans Frontières. “But if an admission is required for the patient, then the administration of the hospital is notified, and therefore it reaches security.” Pro-regime medical staff routinely performed amputations for minor injuries, as a form of punishment. Many wounded protesters were taken from the wards by security and intelligence agents, sometimes while under anesthesia. Others didn’t make it as far as the hospital; security agents commandeered ambulances and took the patients straight to intelligence branches, where they were interrogated and often tortured and killed. M.S.F. concluded that, for Syrians who opposed the President, the health-care system was “a weapon of persecution.”

 In the first year of the uprising, Physicians for Human Rights documented fifty-six cases of medical workers being targeted by government snipers; tortured to death in detention facilities; shot and set on fire while driving ambulances; and murdered by security agents at checkpoints, in their clinics, or at home. Several were killed while treating patients. In July, 2012, the regime enacted a new terrorism law, making it an offense to fail to report anti-government activity; according to the U.N. commission, this “effectively criminalized medical aid to the opposition.”

 By late 2012, a number of Syrian expatriates had established medical charities. Although they sent aid and ambulances from Turkey into Syria, they rarely coördinated their efforts. “It was really chaotic,” Roberts said. “You would turn up at a pharmacy with a kit of antibiotics to donate and find that they already had massive quantities of the same drug. And then you would go to another hospital and realize that they had practically no help at all, because the hospital manager didn’t have experience working with international organizations.” At that point, she said, the facilities that received support were “the ones that were shouting the loudest.”

 To handle the logistics, Aziz, of Light of Life, formed a group called the Aleppo City Medical Council. There were eight main medical facilities, and, with only twenty physicians and a handful of surgical specialists in the opposition-held half of the city, the staff used walkie-talkies to coördinate the distribution of patients. To evade detection, the doctors established sequential code names for each hospital, M1 through M8. Most of the staff had little, if any, formal training.

 Eventually, the doctors built other medical centers and gave them random names, like M20 and M30, to obscure the actual number of targets. According to Aziz, the best location for a medical facility is on a narrow street, flanked by tall buildings, so that, after an air strike, helicopters and jets have difficulty tracking the movement of wounded civilians. Ambulance workers were routinely targeted by snipers and helicopters, so many of them removed sirens and medical logos, and coated their vans with mud. At night, they drove with the headlights off.

 In early 2013, David Nott gave a presentation at the Royal Society of Medicine about M.S.F.’s work in Syria. After the lecture, he sat with Mounir Hakimi, a doctor who is the vice-chairman of a charity called Syria Relief, based in Manchester. Nott and Hakimi had met once before, at Alpha hospital, in Atmeh: when the Syrian doctor who had donated the villa was wounded by shrapnel, Nott treated him in his own former kitchen, and Hakimi came to pick him up. But, because Hakimi wasn’t a patient, Nott wouldn’t let him inside the operating theatre, and they got into a shouting match. Now, at the lecture, Nott said, “I realized he was quite a nice chap.” Hakimi, who had befriended Aziz, suggested that Nott travel to Aleppo with Syria Relief.

 Outside the entrance to M1, there was a large decontamination tent fitted with showers to rinse off victims of chemical attacks. A few weeks earlier, Syrian government forces had fired sarin-gas rockets into densely populated neighborhoods of Damascus, killing some fourteen hundred people; Western governments spoke of retaliation, but they quickly retreated, and since then the regime has habitually used chlorine as a weapon. On roads leading to the hospital, signs on lampposts listed chemical-attack survival tips. Aziz drove Nott to Aleppo, and introduced him to the medical staff at M1, where he lived for the next five weeks.

 Some surgeons at M2 and M10 travelled to M1 for Nott’s evening lectures. At the end of each class, the Syrians discussed the cases that had come in that day—“who lived, who died, and why they lived, and why they died,” Nott said. “And then, because we’d get air-to-ground missiles after dark, we’d still have patients coming in. I’d carry on operating until midnight. And it would go on like that every single day.”

 M1 is in the neighborhood of Bustan al-Qasr, a few hundred yards from the only crossing point between the rebel and the regime sides of the city. (The route has since been closed.) Each day, thousands of locals crossed from one side to the other to buy food, visit relatives, and take school exams. Corrupt fighters on the rebel side extorted those desperate to cross; snipers on the regime side used the alley for target practice. Bystanders who dared to retrieve the victims were often shot, too.

 “Every day, we’d receive about twelve to fifteen sniper wounds,” Nott told me. Many of the victims were children, and the patients coming in from the crossing point arrived with eerily consistent injuries. “It was very strange,” Nott said. “You’d know that, at the start of the day, if you got a patient shot in the right arm, you’d have six or seven more shot in the right arm. And if somebody got shot in the abdomen you’d have six or seven shot in the abdomen.” Nott suspected that snipers were targeting specific areas of the body, as part of a sadistic game. He consulted with Aziz, who claimed that the gunmen were making bets over whom they could hit, and where. Aziz told me, “We used to sometimes listen to the walkie-talkies of the regime. And they used to listen to us.” One day, he said, “we heard a man say, ‘I bet for a box of cigarettes . . .’ ”

 Even pregnant women were targeted, the doctors suspected. “This is a pregnant lady who’s just about to deliver,” Nott explained, in London, as he clicked through a series of ghastly photographs on his laptop. “She was forty weeks pregnant and was about to have a breech delivery, and was shot in the uterus.” A Syrian physician filmed Nott performing an emergency Cesarean section. Only the mother lived; an X-ray of the fetus showed a bullet lodged in its skull.

 Nott returned to M1 in September, 2014. Every hospital in the opposition-held eastern half of the city had been attacked. At M10, pieces of ceiling, glass, and concrete covered broken beds in a former ward, while a leftover bag of serum dangled near an electrical outlet. Medical staff at both facilities crammed equipment and patients into the basements and stacked sandbags around the entrances. The upper floors were deserted, serving only as shields against bombardment.

 For almost a year, Syrian government helicopters had been lobbing barrels filled with shrapnel and TNT onto markets, apartment blocks, schools, and hospitals. Welded tail fins guide the barrels to land on top of an impact fuse. The methods of targeting are so rudimentary and indiscriminate that, in Aleppo, many residents have moved closer to the front lines, risking sniper fire and shelling, because the helicopters don’t drop barrels near government troops.

 When a large bomb explodes, it destroys bodies in consecutive waves. The first is the blast wave, which spreads air particles at supersonic speeds. This can inflict internal damage on the organs, because, Nott said, “the air-tissue interface will bleed. So your lungs start to bleed inside. You can’t breathe. You can’t hear anything, because your eardrums are all blown out.” A fraction of a second later comes the blast wind, a negative pressure that catapults people into the air and slams them into whatever walls or objects are around. “The blast wind is so strong that in the wrong place it will actually blow off your leg,” Nott said. He showed me a photograph of a man on the operating table, whose left leg was charred mush and mostly missing below the knee. “It’ll strip everything off your leg. And that’s why people have such terrible injuries. It’s the blast wind that does that, followed by fragmentation injuries,” from bits of metal shrapnel that rip through flesh and bone, and the flame front, which burns people to death.

 In the aftermath of a barrel-bomb attack, Nott said, “as you walked down the stairs to the emergency department, you just heard screams.” Barrel bombs blow up entire buildings, filling the air with concrete dust; many people who survive the initial explosion die of suffocation minutes later. Every day, patients arrived at the hospital so mangled and coated in debris that “you wouldn’t know whether you were looking at the front or the back, whether they were alive or dead,” he said. “Every time you touched somebody, the dust would go into your face and down into your lungs, and you’d be coughing and spluttering away as you were trying to assess whether this patient was alive.”

 Since Nott’s last trip to Aleppo, Syrian government forces have dropped barrel bombs on all three trauma hospitals in the city. In separate missile strikes, they killed several of Nott’s friends, including an anesthetic technician and a paramedic. Physicians for Human Rights has catalogued and corroborated three hundred and sixty-five attacks against Syrian medical facilities, more than ninety per cent of which were perpetrated by Syrian and Russian government forces. Many of them are “double-tap” strikes: around twenty minutes after the first bomb falls, a helicopter or a jet returns to the scene and blows up the rescuers.

 In the first week of June, Syrian and Russian aircraft carried out more than six hundred air strikes on the opposition side of Aleppo, and Assad vowed to take back “every inch” of Syria. The next day, pro-Assad warplanes bombed three medical facilities, including a health center for newborn babies, in the span of three hours. M2, M3, M4, M6, M7, and M9 have been destroyed.'