In Syria, Doctors Risk Life and Juggle Ethics

Media Office of Douma City, via Associated Press

In Syria, an Ethical Quandary for Doctors

By SHERYL GAY STOLBERG and ANNE BARNARD

As Syria moves toward destroying its chemical stockpile, some say the credit lies with doctors who risked their lives and juggled medical ethics to expose the weapons’ use.

 | Video: Doctors Without Fear

Samuel Aranda for The New York Times

Doctors Without Fear: Amid the crisis in Syria, medical professionals have taken up a herculean effort to provide needed care, and played a critical role in exposing the use of chemical weapons to the world.

By SHERYL GAY STOLBERG and ANNE BARNARD

Published: October 21, 2013

WASHINGTON — Months before a chemical weapons attack killed hundreds of Syrians and prompted threats of an American military strike, an anesthesiologist named Majid heard an explosion near his home in a Damascus suburb. He rushed to the makeshift hospital where he works and found patients with itching skin, burning eyes and shortness of breath.

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Media Office of Douma City, via Associated Press

A Syrian man mourned over a victim of a poison gas attack in Douma, a city on the outskirts of Damascus, in August.

Majid, who gave only his first name to protect his safety, collected hair and urine samples, clothing, tree leaves, soil and even a dead bird. He shared it with the Syrian American Medical Society, a humanitarian group that had been delivering such samples to American intelligence officials, as proof of possible chemical attacks.

“We kept communicating with the State Department about what is next — they told us that these are limited attacks,” said the society’s president, Dr. Zaher Sahloul, adding that he had spoken with Robert S. Ford, the American ambassador to Syria, and Samantha Power, then a White House aide and now the United Nations envoy. “It was very important for us to get this information out, but it took time to gain traction, and for the world to react.”

Now the world has reacted. United Nations inspectors have taken the first steps to destroy Syria’s chemical stockpile. But while the Obama administration claims credit for pushing President Bashar al-Assad into giving up the arsenal, some experts say the real credit lies with the doctors who risked their lives — and confronted thorny questions of medical ethics — to bring to light the use of chemical weapons.

Syria’s civil war has been especially dangerous for health professionals; a United Nations report issued last month described the “deliberate targeting of hospitals, medical personnel and transports” as “one of the most alarming features of the Syrian conflict.” By varying estimates, more than 100 doctors have been killed and as many as 600 have been imprisoned.

The country’s once-functioning health system is in a shambles. More than half of its public hospitals have been damaged in the two-year-old civil war and 37 percent are out of service entirely, according to a recent report by the World Health Organization. Many Syrian doctors have fled; those who remain describe dire conditions where even the most basic care is not available.

Mothers are desperate to have their children vaccinated; patients with chronic conditions like heart disease and diabetes struggle to get medicine; and there is “huge anxiety in the population,” said Dr. Adi Nadimpalli, a 38-year-old New Orleans pediatrician and internist who runs two hospitals in northern Syria for the humanitarian group Doctors Without Borders.

Working among conflicting rebel factions has proved a delicate task. Dr. Nadimpalli cut a deal with the fighters: “They check their guns at the door.”

Chemical warfare — which appeared to begin with small-scale attacks this year and culminated in the sarin gas attack in August that killed hundreds of Syrians — made that difficult situation even more complex, posing ethical questions about whether, and how, to speak up.

Doctors Without Borders, also known as M.S.F. for its French name, Médecins Sans Frontières, is operating six makeshift hospitals in the rebel-controlled north, without permission from the Assad government. In January, it also began secretly providing technical advice, medical equipment and drugs — including atropine, an antidote to nerve agents — to hospitals and clinics in regions controlled by the government.

On Aug. 21, the group got word from some of its “silent partner” hospitals of a flood of patients with “neurotoxic symptoms” — roughly 3,600 in a period of three hours, including 355 who died. Within days, its leaders had convened a conference call to debate how to handle the sensitive information, said Sophie Delaunay, the executive director of Doctors Without Borders’ United States operations.

Any public statement, she and her colleagues knew, could put the group’s doctors and their Syrian partners at risk, exposing them to accusations of siding with rebels and leaving them vulnerable to retaliation from government forces. And they feared that Western governments, including the Obama administration, could use their words as grounds for a military strike.

The group issued a public statement nonetheless; the information, Ms. Delaunay said, was “too big” and “too credible” to be withheld. The carefully worded release asked for an independent investigation, saying Doctors Without Borders could “neither scientifically confirm the cause of these symptoms nor establish who is responsible for the attack.”

Soon, though, Mr. Kerry and Jay Carney, the White House press secretary, began citing Doctors Without Borders’ findings as justification for military intervention, just as the group had feared. It followed with a second statement, cautioning again that its information “could not be used as evidence” to assign blame.

A State Department official, speaking anonymously to discuss internal decision making, said that American officials had been gathering intelligence on chemical weapons, and that the work of doctors and humanitarian groups provided “just another indicator.”

But J. Stephen Morrison, a global health expert at the Center for Strategic and International Studies in Washington, said Ms. Delaunay and her colleagues “deserve an enormous amount of credit” for forcing the issue onto the international agenda. “They moved the global discussion forward,” he said. “It was very risky, and a tough call, and things could have gotten ugly for them.”

The debate over whether doctors should expose human rights abuses has long been “one of these inside baseball arguments within the humanitarian community,” said Len Rubenstein, an expert on human rights and medical ethics at Johns Hopkins University. While Doctors Without Borders has a culture of “bearing witness,” he said, not all humanitarian organizations do.

The International Committee of the Red Cross, for instance, adheres to a strict code of political neutrality; it works inside a country only with the approval of the host government and typically does not make public statements that could jeopardize its ability to provide medical relief. (Seven workers with the Red Cross and the Syrian Arab Red Crescent were abducted this month while assessing the medical situation in Syria; as of Monday, three were still being held.) 

  And experts say that doctors who opine on chemical weapons can get their information wrong. “Doctors are notoriously poor evaluators of chemical warfare injuries if they have never seen them before,” said Joost Hiltermann, the author of “A Poisonous Affair,” a history of chemical warfare during the Iran-Iraq war in the 1980s.

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Mr. Hiltermann said Iranian doctors played a critical role in publicizing Iraq’s use of nerve agents, but also put out mistaken information that Iraq had used cyanide gas. Those reports, he said, were later “cynically manipulated” by American intelligence officials to assert that Iran — not Iraq — was using cyanide. In fact, he continued, there is no evidence that either side was.

In Syria, government and opposition groups have each tried to marshal evidence against the other. The first evidence of chemical attacks emerged as early as December, said Dr. Sahloul, a medical school classmate of Mr. Assad’s, whose society provides support to Syrian doctors, including training in trauma care. But the reports were met with skepticism among analysts.

The conflicting claims made the collection of physical samples crucial. But Doctors Without Borders would not participate, Ms. Delaunay, said, explaining, “It’s not our role to collect samples for any government or investigative agency.”

Instead, Syrian doctors like Majid, the anesthesiologist, gathered samples under the guidance of expatriate groups.

The explosion that sent Majid scurrying to the hospital last spring took place in the middle of the night. In an interview afterward, he said he was able to take samples from two people; the crush of patients was too overwhelming to do more. He worried about preserving them; with electricity working only sporadically, there was no constant refrigeration.

“They are in a cool, dry place,” he said then.

That was on April 25. Hours later, Secretary of State John F. Kerry and Defense Secretary Chuck Hagel said for the first time that the American intelligence community had evidence — “with some degree of varying confidence,” Mr. Hagel said — that the Syrian government had used chemical weapons. 

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