It was April 13, just past noon, and Hasan al-Araj was behind schedule as he left an underground hospital for his next rounds. He was usually careful to check the skies above him in Hama, where he was the last surviving cardiologist in the province’s rebel-held territory, for the Russian and Syrian warplanes that regularly cruised overhead. But, in his haste, he did not use his walkie-talkie to confirm with colleagues that the skies were clear. A missile exploded near his van as he drove away. In the wreckage, colleagues found body parts and pieces of his white medical coat. “It was targeting,” said Ahmad al-Dbis, a pharmacist and medical aid worker who worked closely with Araj. “It’s known that that’s the location of a hospital, and it’s known that most of the people moving around there are medical staff.” Since March 2011, at least 738 Syrian doctors, nurses, and medical aides have died in more than 360 attacks on medical facilities, according to Physicians for Human Rights (PHR). The independent human rights group holds the Syrian government and its ally, Russia, responsible for upwards of 90 percent of these attacks. Medical aid workers accuse the Syrian government and Russia of seeking to demoralize and drive out civilians and fighters from opposition-held territory by depriving them of health care and battlefield medicine. The targeted attacks on hospitals have certainly depleted the supply of doctors in rebel areas. Earlier in April, a sniper bullet to the head killed the last doctor in the besieged town of Zabadani. Later that month, rebel-held Aleppo lost one of its last pediatricians when a regime airstrike flattened al-Quds Hospital. According to PHR, 95 percent of the medical personnel who were in Aleppo before the war have either fled, been detained, or were killed. It is a war crime under international law to deliberately target hospitals, doctors, and nurses. In early May, after a series of airstrikes in Aleppo, the U.N. Security Council unanimously passed a resolution condemning what Secretary-General Ban Ki-moon described as “surgical strikes … hitting surgical wards.” But like so many other U.N. declarations about Syria, it had no teeth —there was no risk of punishment for violating the resolution. By the end of that month, two more hospitals were damaged as a result of air raids on rebel-held Idlib and Aleppo.

Araj, who was 46 at the time of his death, accepted the risks of his work. He sent his wife and five children to Turkey for their safety and visited his family there frequently. But he was dead set on remaining in his homeland: “Even if you give me all of Europe, I will not leave my country,” he told an assembly of doctors at a medical conference in Geneva last year, according to Dbis. “I don’t betray my country in these circumstances. And, inshallah, either I will die in Syria or we will triumph.” Despite devastating losses, the medical system serving Syria’s rebels and the remaining civilians in opposition areas has proved resilient, like the rebellion itself. From the idealistic uprising in 2011 to the dystopian violence of 2016, Syrian health care workers have found ways to survive, adapt, and treat those wounded in horrific fighting, as well as to deliver babies and treat ordinary illnesses. Dodging arrest and torture, then missiles and snipers, they have built a clandestine health care system out of the one their government destroyed.

Syrian doctors treat a wounded man in a field hospital in Qusayr, Syria, on July 10, 2012. (Photo by ANTONIO PAMPLIEGA/AFP/GettyImages)

2011: ‘No Mercy’ for Doctors

Abu Ibrahim Bakr’s patient was not only at risk of dying — he was at risk of causing the deaths of anyone who treated him. It was June 2011, three months after the rebellion against President Bashar al-Assad’s rule erupted, in Saqba, a town near the capital of Damascus. A bullet wound in the patient’s belly marked him as a participant in the uprising. As far as the government was concerned, he was a criminal who should not be saved.

“We couldn’t move the patient around at all,” said Bakr, a general surgeon in the Damascus suburbs of Eastern Ghouta whose name is a professional alias.

In the earliest days of clandestine rebel medicine, the opposition to Assad’s rule largely consisted of nonviolent protests. The activists held no territory in the country; the only way they could treat their wounded comrades was to hijack the government’s health care system.

In Saqba, doctors sometimes smuggled injured protesters through the back door of a nearby hospital. But government forces that day had closed the roads, making the medical facility impossible to reach. A man volunteered his bedroom. Bakr unpacked one of the medical kits he and his colleagues, by then, had hidden in every town in the area. The doctors had, as he put it, “stuffed an operating room into a suitcase.” An anesthesiologist recommended dosages by cell phone.

“We put him on the bed, in the bedroom, and we opened up his stomach,” the surgeon recalled.

Syria once enjoyed an advanced medical system. The average life expectancy in the country in the years before the rebellion broke out had hovered around 73, roughly on par with that in neighboring Turkey, according to World Bank data. Some of the doctors, paramedics, and nurses who have assisted the opposition were driven by their own rejection of the Assad regime; others simply felt they should provide care to all, as a fulfillment of their professional and humanitarian duty. So the practitioners formed secret networks of trusted colleagues to treat the wounded and protect patients from government reprisals.

“We noticed that many of the people who were getting injured in the streets by the security forces and the military … when they were transported to a hospital, public or private, the intelligence services would follow,” said a founding member of the Union of Free Syrian Doctors, a loose association of doctors and medical activists who banded together in late 2011 to try to fill the gap in available medical services. The doctor, a radiologist now living in West Virginia, asked that his name be withheld to protect his family still in Syria.

“Of course, every person that the intelligence services discover had treated a patient from one of the protests, his fate is to be detained, absolutely,” said the radiologist, who says he was detained and tortured himself by one of the country’s most notorious agencies, Air Force Intelligence. “He’s even classified almost in the same group as the armed rebels.”

To evade Assad’s security forces, doctors treated patients in secret, in shops and other unconventional places that would briefly be converted into emergency rooms. In desperate cases, the only way to save a patient was to sneak him or her into a government hospital. That required daring help from a network of willing doctors, nurses, and friends.

“We would communicate through a series of quick phone calls using phones linked to false names, which were bought from the black market with the IDs of dead people or fake IDs, to make it harder to trace,“ said Osama Abu Zayd, a medical equipment engineer with the Union of Free Syrian Doctors. Using the masked phones, Abu Zayd would describe the patient’s injury to a friendly hospital doctor using numeric codes for the location and type of wound.

Patients at risk of arrest were given fake names. Their doctors also worked under aliases. “Even two doctors in the same hospital, each wouldn’t know that the other is ‘revolutionary,’” Abu Zayd said.

“There are some doctors, until now, after four or five years of working with them, I still don’t know their real names,” said Mohammad Yasser Tabbaa, a co-founder of the nonprofit Syrian Expatriate Medical Association (SEMA). A Syrian expat living in Saudi Arabia, he has made more than two dozen trips to Syria since the beginning of the war to establish health care facilities there.

Friends and relatives provided referrals for new members of the network. “Between us, there is trust. We know who’s honest and who’s not,” he said.

The real danger came when someone was caught, Tabbaa added, because then the security forces would torture them until they gave up their friends’ names. “Every time, whenever anyone was caught, all his friends would go into hiding, or they would travel, or run away,” he said.

The radiologist living in West Virginia said some of the Free Syrian Union doctors had private clinics and could take in injured rebels.

“We didn’t differentiate the armed [soldier] from here or from there or whomever we found in the street — our goal was to treat people,” he said. “I don’t care, this person, what his background is.”

But even private facilities were not safe. In the early days of the revolt in 2011, security and military forces often barged into the Kafr Zita Specialty Hospital, which was owned by the cardiologist Hasan al-Araj, said his colleague Ahmad al-Dbis. When soldiers opened fire on protests in the small town, the injured would often be rushed to Araj’s private hospital in secret.

Araj and his staff performed protesters’ surgeries as quickly as they could. The demonstrators who were most wanted by the security forces were stabilized at the hospital and quietly transferred to local homes, including Araj’s house. When security forces came knocking at the hospital, Araj told them they were working on routine surgeries — like an appendix or abscess removal — and prevented them from entering the operating rooms.

“In those days, there was still a bit of respect for doctors,” Dbis said.

Over time, as the protests grew and turned more violent, government security forces became more aggressive in chasing down injured protesters and those who treated them. During the first year of conflict, an estimated 250 doctors were arrested or interrogated for treating injured protesters in Syria, according to a report published by PHR at the end of 2011.

Doctors and aid workers said Assad’s security forces examined orders for blood bags at the state-run blood banks or orders for tetanus shots, which are usually given to people with gunshot or shrapnel wounds, to track down doctors who were treating members of the opposition.

“The regime’s intelligence services have no mercy if they find out you’re working as a field doctor,” said Rami Kalazi, who was then completing his residency in neurology at Aleppo’s state-run Razi Hospital. “For them, this is even much worse than carrying a weapon.”

Kalazi, who worked with a group of colleagues to provide secret medical and humanitarian aid, ran a makeshift pharmacy out of the basement of the apartment building in which he lived, stocked with supplies he and colleagues took from the hospital, bought from pharmacies, or received as donations.

Eventually, the chief resident got word that the regime was after Kalazi and his wife, who also worked at the hospital. “He told us, ‘Take my advice: Pack up and leave, because you’re no longer safe,’” Kalazi recalled. He is still practicing medicine in Aleppo but in a different hospital in a rebel-held area.

F.J., a doctor working in the suburbs of Damascus during the early years of the uprising, was detained in 2012 by Assad’s security forces. He was taken to an underground room with what he estimated to be about 80 other people. There was no ventilation, no light, and no place to sit. He was tortured for seven days, he said. He and the other prisoners often found piles of dead bodies in the bathroom.

“Really, it was like hell,” he said. “Everyone was just praying to die.”

Araj, the Hama cardiologist, was arrested twice, said his wife, Najwa. The horrors of his detentions made him more vigilant about avoiding regime soldiers and checkpoints. He often told Najwa, “If a missile hits me and cuts me in two, it would be easier than spending 15 minutes in the infidel regime’s prison.”