Vanja Kovačič is a Medical Anthropologist. After having worked for several years as a researcher at the Crash, she is now working for the Manson Unit in MSF UK.

3. Patients and their history

Thus far we have seen that war-injured patients do not use the hospital environment only to fix their bodies; they also attempt to reconstruct their emotional wellbeing and their sense of social identity. To fully understand the scope of the recovery they are seeking, we must have a closer look at their pasts, and at the events related to their injuries and the treatment they received before entering the MSF hospital. Different staff members shared that they could only acknowledge a patient’s personal history in a way that made sense for themselves. Some who were not involved directly in patients’ medical care were willing to offer a compassionate ear; others thought that learning about a patient’s medical and personal history was necessary to be able to provide medical care; and others, in an attempt to protect their own emotional wellbeing, avoided hearing more than what they perceived was absolutely necessary for medical decision-making. Inevitably, the heaviness of what my participants reported on touched the world of human emotions.

Hearing patient stories, particularly the way they framed them, provided insight. Their stories were statements on the brutality of war, described not only as direct violence, but also as an undeniable change in the social environment making it impossible to access proper medical treatment. Let us start with the narrative of a Syrian patient, who I call Ali. He described how he was injured, how his situation after the injury gradually deteriorated, how risky it was to access medical care in Syria, and how he eventually entered the MSF hospital. Not only was his narrative informative: it was enriched with comments from his family members, who indicated the larger impact the injury had had on all aspects of their family unit. The grandfather emphasized how “they [the injured] were still teenagers when they shot at them”; the father expressed his pain when he found “the pieces of bone on the clothes they brought him as a proof of his son’s injury”; the mother worried when her son called her but “the line was closed” (it went dead). Through this narrative, it is important to keep in mind that patients carry a double burden: their own injury and the disruption of the family environment caused by their injured body.

Ali’s narrative

[Participant (P)RSP12, twenty-one years old, Syrian, M, transcript (questions and repetitions omitted).speaks in a calm tone; grandfather and participants’ parents occasionally add details to the narrative.]

P: The situation in our village was complicated. One day before my injury happened, there were demonstrations, and they killed a number of people. The next day was normal. We went to school. We were there for a half day, then the teachers told us: “You should go home. There is demonstration near the school. You should go back home (it is dangerous).” Because the teachers were concerned about us. They knew that people [army] would come to mess with the demonstrators and there will be shooting. [They told us] “It’s for your own sake.” We really left the school and wanted to go home. We were a group of pupils and the teachers were with us. Once we went out of the gate and walked for 50 metres, there was shooting. The army came and they didn’t distinguish between the young and old or pupils and teachers: they were just shooting. They started shooting everyone! They didn’t want to have people gathering in the street.

Grandfather: There was random gun strike.

P: The shooting was [carried out] randomly.

Grandfather: Wherever they shot at, they shot. [They shot] the old [person], young, boy, child, or woman. His [my grandson’s] friend got injured in his leg. When he collapsed, they shot him again and killed him.

Mother: The shot was in his head.

Father: That was the regime army [shooting at them].

Grandfather: In his head [they fired the final shot]! He [grandson’s friend] got injured in his leg first and fell down. Why couldn’t they just leave him alone?! But, no they killed him!!

Mother: They followed him [to kill him].

Grandfather: He was a school student at his [my grandson’s] age. He was [only] fourteen years old.

[Father searches for a video on his phone; shaky video shows teenagers running and sounds of screaming in panic. One of the teenagers was recorded when falling down on the ground, with an obvious bleeding wound in his chest.]

Father: There is a video on YouTube that was taken when my son was shot. [comments while showing us the video] These are the school students. They are wearing the school uniforms. This is when my son was injured. This is his voice [a voice screaming on the video]. All the people who were there had mobile phones and they were taking videos. They sent it to Orient TV channel.

P [continues]: I was shot in the right leg. Then there was a large number of people who were running away. Some of those people carried me and took me away from the street. Because their [the army’s] goal was to kill. When the army saw people carrying us, in addition to the shooting they asked around for the assistance of people to collect our names, the names of all injured people. They knew our names in five minutes. They knew our names! There were me, Omar, and other injured people who got blacklisted. It was only the matter of a moment when I got injured and then carried away [and they managed to collect our names]. One couldn’t wait for one minute! People who helped us took us to their houses and moved us from one house to another to be away from [the army] because we couldn’t go out to the street [we were under severe risk]. There was no time at all! They [the army] could come anytime, and it would be risky not only for us, but also for the owner of the house.

Immediately after the injury they let us take off our outfits and they tied them around the injury – [this was the only first aid] there was no doctor to assist us. They took out a fridge door and let me lie down on it. And they took out a window that was serving as an opening for the passage with the next house. They moved us in this way [from house to house] until we were on the other side of the village. They brought a car and took us to a farm. And here, a new episode [of struggle] has started.

Grandfather: He was bleeding!

P: We were prohibited from going to a hospital. Because it was very risky. 90% of the people were killed there. What would people do to us [in the hospital, we wondered]? It was dangerous even for those who were hiding the injured to stay at their homes. So, they [people who helped us] were transferring us from one house to another [to reduce the risk]. There was no other way than moving us between the houses but through narrow passages between the buildings. They [people who helped us] were thinking of how to let us run away. I didn’t know them [but they were willing to help us].

Father: We didn’t know where he was for fifteen days. We knew that he was injured. They brought us the clothes he had on when he got injured. But, we didn’t know where he was. There was a piece of bone remaining on the clothes because the shot was an explosive one. There were blood stains on them too.

Grandfather: There was no bone left in his leg. Everything was destroyed in the explosion.

Mother: There was no first aid in the houses [where he was hiding]. Only later he received the treatment. All the movements were without him receiving even first aid. The houses [where he was kept] were just a mean of getting him out of the village that was under siege.

P [clarifying]: For the first fifteen days there wasn’t [any first aid] in the houses. We didn’t think about receiving anything, not even painkillers. We only thought about how not to die [how to survive].

Father: The main concern was: “We must put him far away from the army.” The people of the village are like one big family. They all know each other. They know whose son was killed and whose son was injured. They immediately inform each other [so we knew he was injured]. It was in the midday when he got injured…

P: They [people who helped me] wanted to provide the treatment for us. They took us to a nearby village that was quiet [not under siege]. There was no first aid available there. I had bleeding and the foot was swollen. They [people helping us] called for a doctor from another village to check on us because they were friends with him. He looked at us and said: “I can’t do anything. He needs to go to the hospital. He certainly needs [to go to] hospital! What can I offer him [I have no means to treat him]?” He [the doctor] couldn’t do anything. They took us to another village and then again to another village; that was happening for eleven days. No doctor could do anything for me. Doctors just told people assisting us that we needed a hospital and nothing could be done otherwise.

Mother: Medicines and painkillers were provided at that stage.

P: Yes, they gave me medicines and painkillers that they had available. But they didn’t know what to do for eleven days [the wounds were too severe]. They cleaned the blood from the wound and gave me painkillers for eleven days. We were moved to eleven villages, eleven areas – and that was risky! They moved us in a closed car through the groves. There were checkpoints on the main streets so we couldn’t use them. We were travelling through the groves. And, our screams were [expression of severe pain; participant pauses and looks into the distance].

[continues] There was no family member with me yet. We travelled through the side streets. They put us to the car and there was a person driving us. He would take us to a village where he knew people, so that we could find a doctor or a hospital. But we couldn’t be at the big governmental hospitals.

Father: That was impossible.

Mother: They [the people helping him] asked my son for our phone number. They called me… His father was away… They told me, “Your son is good. He wants to talk to you.” He just said: “Hello, how are you? I’m good.” And he closed it. And when I called back the same phone number, nobody answered me.

Father: All the phone lines are monitored.

Mother: Because all the phone lines are monitored.

P: Then they took us to a village called Harra, in Deraa. A doctor came and cleaned our injuries from the dirt. The legs got swollen a lot.

Father: The injury was rotten [infected]. The injury was rotten!

Mother: He had infection in the blood.

P: He [the doctor] told people looking after me: “We should take them to the hospital in any way. No matter what we do [it won’t help]! We should take them to the hospital! They [the injured participant and others injured] shouldn’t be left like that.” They coordinated with my father because he was still working. He could find a route for us. He could let us pass the checkpoint without them inspecting the car. The doctor coordinated with him to get us to the hospital.

Father: It was a private hospital in Damascus. We paid money so that the staff there wouldn’t say anything about him [report him to the army]. The first hospital where we treated him was called Jaffa Hospital, in the area of Mazzeh. Of course, it was a private hospital and therefore there was a possibility for preventing the regime knowing about him.

P: There was the connection my father used for the route [access to the hospital]. We paid money for the doctor and the medical staff to let us in the hospital without having anyone know. They did the surgery. I woke up from anaesthesia at home. It was prohibited to stay in the hospital [for long].

Father: We paid a big amount of money just to let him go into the hospital for one hour to have the surgery. He had a surgery of cleansing [the wound] and inserting a metal plate, and he was discharged in one hour. We took him home when he was still under anaesthesia.

P: The money which was paid was to prevent reporting me. They [the hospital staff] had instructions to report to the security, police, or army about any injured person admitted there. There was another amount of money [paid] for the medical care. The two amounts were equal to each other.

Father: The amount of money was 4,000 USD for one hour [in the hospital] so that they don’t report him to the security. That was in addition to the 4,000 USD for the surgery of fixing the internal device [fixator], which they call nails. People who could not afford such amount of money just ended up with amputated legs! The hospital would not even receive you if you didn’t pay.

Grandfather: In such cases they would just amputate [somewhere not even in the hospital]!

P: My memory from the hospital is that I went into the OT. I woke up at home.

Father: Yes [we were together].

P: Then we went to my uncle’s place. We couldn’t go back to where we were living.

Grandfather: We hid him [at the uncle’s].

Mother: We hid him.

Father [explaining]: In the period after the surgery, we couldn’t go back to the village. We found a safe house in Damascus. This was under my supervision… It was my brother’s house. We let him stay there until we could coordinate our trip to Jordan. We started thinking about this only in that period. It was because we saw others. The injured person was either dying slowly [from the lack of medical care] or killed. There were inspections in all the houses, checkpoints on roads, and they took any injured person they found [and killed them]. I used all my power and potential connections just to let him out because he was injured [and under severe risk]. But the normal people [those not injured] could cross the regime checkpoints with me [without any problem]. But that was impossible for the injured one. We had to take roads that were…

Grandfather: Side roads!

Father: Not regular streets, but through the groves and bystreets to let him escape. It took us six months until we could coordinate his way out of Damascus to the Jordanian border. Six months! In the period, [uses son’s name] had a disease in addition to the injury. He suffered platelet infection; he had infection in the blood. He had another surgery in Damascus that was done at home [in the uncle’s house]. He had a surgery of transferring blood at home! The doctor removed the external device [fixator] for him. He fixed the internal plate during that time. And he treated the blood infection during that time.

P: There was a doctor that we didn’t know – [we knew] his name only. We called him Mohammad, Dr Mohammad only. He used to come to my home. He certainly didn’t come unless it was very urgent. He did the surgery for me by himself; there was nobody with him.

Father: I was assisting him because he asked me to. As I’m a father, he was afraid I would collapse [faint] and couldn’t bear it. But I was strong enough and assisted him.

P: When I recall the event, the doctor came and told me: “I have this injection that would let you sleep for half an hour. Tell me once you feel dizzy. Other than that, you will feel the pain. And I would remove all the device [fixator] for you.”

Father: There wasn’t any other anaesthesia. My son needed blood during the surgery, and by coincidence the doctor’s blood type was like his. He donated blood for him. After the surgery, we certainly were not brave enough to throw away the waste from the surgery or the blood waste in the garbage container that was close to home. We threw them away in a far place. Everything was difficult [extremely risky].

[continues] After that period we were able to leave Damascus for the Jordanian border. I had another brother who was an officer; we coordinated with each other. Because if I left the army, he would have been killed. So we informed all my siblings about the plan of leaving Damascus and going to Deraa [southern Syria, border area with Jordan]. Our [target] village was away from the regime control. We coordinated with my relatives and came altogether to the Jordanian border. That was of course through side streets in the groves. We came to a deep valley that is an area between Syria and Jordan. My brother and I carried him [the patient] on our backs when we entered Jordan. It was 100 kilometres from Damascus to the border; those 100 kilometres took us two days (that is how slowly we were able to move). When we reached the Jordanian border everything was done for us to enter. We just waited at the spot controlled by the Jordanian army at the Jordanian border. We waited for twelve hours until they could receive us.

P: I couldn’t walk at all at the time. This was happening a couple of days after my surgery in Damascus. I had painkillers [to control the pain]. My mother, siblings, and I went to Al Za’tari [refugee camp]. We stayed there for one week then we left it.

P: When we arrived in Al Za’tari…

Father: We said, “We wish we had stayed in Syria.”

P: But, when we left Al Za’tari, the situations changed [improved there gradually]. Al Za’tari wasn’t Al Za’tari as it is today. There were only a few tents at the time we got there.

P: I received no medical care before entering the MSF hospital. There were only a few stitches in my leg that I had removed [before].

Father: A few stitches? They were forty-one [stitches]! I was taking them out.

Mother: We were also assisting, his uncle and me. All the family [was participating in the removal of the stiches]!

Father: By then, I was medically trained for everything.

[continues] By chance we heard of MSF. When the Syrians arrive here to Jordan, they try to look for another Syrian to ask him “How is the situation? Where shall we reside? Where shall we rent a house? How shall we live? How shall we get things? What could get us income?” One tries to ask a Syrian because he’s from his home country and has come here before. There was a person who told us, “There is a French organization that’s called Doctors without Borders which was in the Red Crescent [hospital] in Al Mesdar area in Amman. Go there.” There was a nurse whose name I remember: it was [gives a name of the nurse]. She was extremely humanitarian. She was a very good human. I always send my greetings to her. Her name was [gives a name]. We went there. We took [uses the name of his son] and the papers and applied. They immediately admitted him. And I send greetings to Dr [mentions the name], as well.

Ali’s story reports on multiple losses: of his health, social identity, loved ones, material objects, sense of security, and trust. His narrative was in many ways similar to narratives of other Syrian participants, but unique in comparison to the Iraqi participants I interviewed. Let us have a closer look at the difficulties and risks patients encounter before they can reach medical care at MSF.

An injury that changed life forever

The participants were injured in numerous ways. The majority of those from Syria were injured during air or ground bombing (twenty-one participants), while thirteen received a bullet wound. Two were victims of domestic accidents (burns), one was injured in a suicide attempt (self-immolation), one in a car explosion, and one fell accidently and suffered a bone fracture when she was a caregiver in Amman.

Iraqis were mostly victims of explosions (seventeen participants), in cars, buses, in front of a police station, a school, or a military checkpoint. One participant was the victim of a sticky bomb,A sticky bomb is an improvised, adhesive explosive device placed under a vehicle and detonated remotely.which was placed below his truck. Another was injured when an explosive device was thrown into the coffee shop where he was playing table games with his friends. And another was injured when a suicide bomber blew himself up during a funeral. Nine were injured during bombing raids, both from the air and on the ground; three received gunshot wounds; two were victims of traffic accidents; one stepped on a ground mine; and one suffered burns in a domestic accident.

When participants talked about the circumstances of their injuries it was obvious how vivid their memories were and how much emotional turmoil the memories still caused. The sense of horror, panic, and numbness was tangible during interviews. There was a big difference in the tone of the narrative between Syrian and Iraqi participants. A deep sense of sorrow and grief was communicated by Syrian participants, while Iraqis mostly expressed feelings of anger and frustration.

The narratives of Syrian participants were long and detailed; frequently they started by describing the change of political climate in Syria, before moving to the changes in their neighbourhoods, and finally to details of the day they got injured. DatesSyrian participants frequently mentioned the dates when they entered Jordan as refugees.and hours were frequently mentioned. For instance, “It was 6am or 5:30am and we were still sleeping. I woke up to prepare myself for work” (RSP2, Syrian, F). This indicates that their memory was made indelible by the intensity of events and then narrated as if the incident were happening in the moment. An exception to this was a participant (RSP4, Syrian, F) who had no injury-related memory. She described completely blacking out. She said that her only memory is that “they were running away, there were many people on the street and blood everywhere,” but she recalled no details of how she got injured or how her husband died there.

Iraqi participants talked about their injuries as “the event that changed their life forever,” because “I lost everything in my life”: health, house, a family member, limb, economic stability, opportunity to continue education, sense of security, future, hope, self-confidence, trust in humanity, beauty, marriage. But in contrast to the Syrians, their narratives were briefer and were articulated as a single event rather than as a series of events. For instance, “We were in a wedding party and an explosion happened.” Participant’s husband: “It was a car bomb” (RSP41, Iraqi, F).

Narrative style gives some indication of how a participant frames, understands, and feels about the event of an injury. Hence, the differences between Syrian and Iraqi participants suggest more detailed and intensive traumatic memories among Syrians. These observations are in line with the studies of recall of traumatic memories, which can either be detailed, accurate and persistent, or totally absent due to “traumatic amnesia,” a condition that can last for years after traumatic events (Van der Kolk and Fisler, 1995). According to the literature in psychology, the framing of traumatic events acts as a determining factor in the levels of war-related psychopathology and can still persist fifty years after the experience in war (Kraaij and Garnefski, 2006).

Experience of pain was largely absent from the patients’ narratives. Most participants did not mention pain at all when talking about receiving their injury, nor did it come up in describing their treatment – unless I probed them with a question about access to pain-relief medication. When they did mention pain it was often placed in a mix of descriptions of physical and emotional pain – for example, grief over loss of dear ones, property, and country. Many of the participants (both Syrian and Iraqi) reported losing children, spouses, parents, grandparents, brothers, sisters, cousins, nephews, and friends during the same incident that injured them. The way they reported it, the experience of emotional pain clearly exceeded the level of suffering caused by their physical pain.

During the injury event, many participants reported feeling completely numb, especially if they had witnessed an injury to somebody else around them. The narrative of a father illustrates this:

I didn’t feel anything, but something hit my leg and hand. My son was sleeping beside me. He was just beside me lying like this [indicates a short distance from him with a hand gesture]. He was bleeding from his mouth. He was about to die. And I couldn’t do anything. I lifted him and wanted to get him out; he got injured in his back. A shot passed through his shoulder and it hit his hand. I went out and my leg was bleeding. (RSP6, Syrian, M)

Some participants kept material evidence of their injury event and they would show it to me. Two of the participants – Ali was one of them – showed me videos recorded on their phones of events where their friends had been killed in front of them. Another video showed the dead body of a young man who was my participant’s friend. His face was covered with blood, he was lying on the ground, and a piece of metal was coming out of his skull. I was told that he was hit by a piece of shrapnel from a mortar shell. In both videos, the people recording them mentioned the exact date and the name of the person killed. As Ali’s father reported, they had passed these videos to the media as evidence of war crimes. Other material evidence that participants occasionally showed me included metal fixators that had eventually been taken out of their limbs during surgery. One family had them packed in a transparent plastic cover and stored in the cupboard of their living room.

Views on perpetrators

Without being directly questioned by me, the vast majority of participants shared who had caused the injury. In this way they politically positioned themselves, but also disclosed how they perceive their perpetrators. Syrian participants, for instance, made statements referring to Bashar Al Assad, such as “He wants to finish us all,” or “the government army has done this to us,” or “we were scared of government military.” The context in which the army was mentioned was typically as follows: “We were staying in an area called Al Mahatta, which is the new Daraa [southern Syria], and there was another area called Daraa Al Balad [Daraa downtown]. There was fighting between the two areas. We went there to check on the injured people and give them the first aid. Then the army of Bashar Al Assad shot at me” (RSP8, Syrian, M). None of the participants from Syria referred to ISIS as a source of injury, but some mentioned Iran as a source of political conflict.

Iraqi participants were mostly injured in random explosions. Hence any reference to the perpetrators was absent or presented more loosely. Those who were injured during sectarian violence, however, either by the US Army or by ISIS, specifically mentioned that. Those in Iraq who were injured during sectarian violence indicated personal knowledge of their perpetrators, making those accounts some of the most painful that I heard: “These people were from our community; they knew us.” These participants were the ones who generally expressed the highest degree of fear and suspicion against us, the interviewing team, which indicates that their general trust in human beings has been severely damaged by events.

US troops were mentioned in patients’ narratives as ruthless. “During the US invasion, a bomb exploded near my secondary school, in the area near Muhammed al-Qassim Street between Sileikh and Adhamiyah [the highway to the west of Baghdad]. At that time US troops were still in Iraq, and after the explosion, the forces opened fire randomly at people who were there so even those who hadn’t been injured in the explosion were injured by the US attack” (RSP56, Iraqi, M).

Or another example:

So once I was driving, and the US Army was deployed in the area. All I knew is I got shot by a bullet while driving. I knew afterwards that I was shot from a distance of 300 metres. The US Army had written in their report that I crossed their checkpoint, while there wasn’t actually a checkpoint and I was shot from a far distance and I wasn’t near them nor did I see them. They did not give a warning [such as] a bullet in the air, nor a bullet in the car or its engine as a warning sign. The bullet was intended for me as a target, aimed to KILL me. (RSP71, Iraqi, M)

Some other participants clearly identified ISIS as a causative agent in their injury: “I got shot by ISIS” (RSP59, Iraqi, M), and “We were sitting like this [like us in a living room] at home, and across the river – the river you’ve seen when you came here – at the other bank there were the terrorists of ISIS. At 3am they crossed the river to this bank [where the patient’s house is], and they attacked this area. There was fighting here and my son got injured. It was a mortar shell that fell on our living room” (RSP60, Iraqi, M). Those who indicated they were injured by ISIS (participants from Anbar) appeared cautious and talked about the incident in whispers. In comparison to those injured in sectarian violence, they did not express a high degree of mistrust towards myself nor my team.

What was surprising, however, was a lack of anger, blame, or any kind of resentful emotion towards the individual that specifically caused the injury. For example, the participant who received a gunshot from an American soldier and later met him in the hospital expressed no harsh feelings towards the perpetrator at the time nor at any later time:

I saw the one who shot me [while I was] in the hospital. He was a kid; he was trembling and shaking [when he saw me]. Maybe he was about nineteen years old. The damage was already done. I was only thinking about myself [and how to get better] at that moment. Even if he would come to me now, there’s nothing I would do to him, I would not tell him anything [harsh]. It’s up to God to make him pay back. (RSP71, M, Iraqi)

The narrative of another participant, who got shot by while working in his field in Syria, illustrates how he too remained “neutral” when talking about the soldier who fired the gun against him. The only reference that this participant made to account for the soldier’s violent act was simply “not knowing what was on soldier’s mind.” This participant appeared almost apologetic when he explained the necessity of using his motorbike to work in his fields, which in his opinion triggered the shooting. A larger segment of his narrative illustrates his interpretation of the event:

The injury happened on 22.6.2012. I had a farming project that was across the highway. It was (relatively) far from the highway. It is a double lane highway; the cars never stop there. The highway was the main travel route for everybody [in that area].

On 22 June it rarely rains. I am a man [a farmer] that planted ten acres of potatoes, and thirty acres of cucumbers. I planted twenty acres of watermelon. I planted fifty-five acres of tomatoes. In addition to that, we wanted to use an opportunity and double the planting project. We planted eggplants with cucumbers. We planted tomatoes with watermelon. We planted bell peppers with tomatoes. To benefit [from this], I planted one hundred and ten acres in that way. We planted the same amount as would otherwise be planted in two hundred and twenty acres. We had better products this way. This is what was happening to us.

On 22 June I collected cucumbers with the workers. I had thirty workers. We collected the cucumbers and it started raining. And it rarely rains at that time. It rarely rains on 22 June. It rained. When we send the cucumbers to Damascus, it should be shiny and clean. It shouldn’t be muddy. Nobody would buy it if it was muddy. It should be clean. You should pick it up in the morning and there should be no water on it. I remember it rained on that day. But I collected cucumbers [we were in a hurry to harvest them]. I went [there to the field] towards the end of the project [harvesting]. I saw a village that was three kilometres away from us which is called Mahajjeh. It was two and half or three kilometres away from me. There was fighting in it but I didn’t know between whom. I heard shootings and bombings. The workers were afraid. I told them, “Be patient! Let me prepare the delivery. Be calm. Be patient. The situation is fine. It will be solved now.” Then, I suddenly saw a group of tanks and soldiers’ cars and BMB [vehicle type used by military] crossed nearby us on the highway. They crossed nearby us. My brother who is in the US [now], my three sons, my two nephews, and the third brother and me were there. I told them to pretend they were collecting the potatoes so that we avoid them [the military]. The potatoes were the closest to the road. It was right next to the highway. They [my family members] turned and went away fifty metres away from me. Fifty metres away from me! My three sons, two nephews, and my brother were obliged to be next to the road [harvesting potatoes]. I went fifty metres away from them. Why was I away from them? Because I had a motorcycle. They [the military] didn’t like that motorcycle. They were bothered. The one who had a motorcycle was a terrorist [in their eyes]. The [planting] project needed a motorcycle and it wouldn’t work well without it. A car wouldn’t work well. There were narrow paths [between fields] that couldn’t be driven on by a car, but only by a motorcycle. The project was big. When it is of one hundred and ten acres, you are forced to have a motorcycle. I went away from them and started collecting potatoes. That military man thought I would bomb them [do something harmful to them]. I don’t know what happened to him [what was in his mind]. He got further from me and shot me twice! I was shot. He shot me twice and I got injured by one shot. (RSP13, Syrian, M)

The multiple losses my participants reported carried no personal blame for the perpetrators; the blame was collective. This was important for me to keep in mind when reviewing my participants’ reflections on their rehabilitation process. Before moving to the rehabilitation phase at the RSP, there is another important aspect of patients’ histories that requires our attention: their struggle to access healthcare after suffering their injuries.

Multiple risks

In the interim between suffering an injury and arriving in Amman, Syrian participants in particular endured a number of events that influenced how they perceived the treatment at the MSF hospital. For instance, in Syria, being injured increased one’s personal risk dramatically, especially for men. Suddenly they were living under the suspicion that they collaborated with anti-government forces. This meant they could be killed at home or at any checkpoint along the road. One participant described this dire situation:

When I got injured in Syria I stayed at home, and there was always fear, because they were attacking and checking the houses, and they shot any injured person. They killed him [the injured] and his family. I was always afraid of that, of them attacking our house, arresting my father, arresting my brother, arresting me or anybody. It was like a horror movie and the ghost would come up at any time. (RSP8, Syrian, M)

Another participant, a farmer who reported being shot when the army passed by as he worked in the fields with his children, explained:

And here [once I got shot] the misery happened. If you went to the checkpoint while you had a shot wound, then you were under suspicion of either participating in a demonstration and you were shot there, or you were [collaborating] with the armed terrorist gangs who fight and call themselves rebels. There was no solution. Only God knows about you [and your truth]. I had to be treated in a hidden hospital away from the government. (RSP13, Syrian, M)

This risky situation compromised access to medical services. Initial first aid was given mainly in improvised field hospitals where often nobody was medically trained and medical supplies were scarce. One of the participants (RSP1, Syrian F) reported that the only treatment available for her deeply infected hand was honey. “The goal of this treatment,” she reported, “was to heal the wound regardless of how it looked or if it was good [functional any longer].” The available “hospitals” were reported as operating in abandoned schools and private houses. First aid was occasionally given by friends or relatives who had some limited medical training. One participant, who was injured in a bomb explosion in his house, described his friend treating him after he suffered severe burns and injuries to his face: “I remember that when my friend was stitching my face, he was trying to joke with me to make me laugh. We were always joking and laughing. I remember he was the one who was always joking with me [to try to lift my spirit]. But every time he felt tired while working on me, he went away and cried” (RSP25, Syrian, M). Participants often reported feeling shaken by observing others dying while they were receiving the improvised treatment: “In the field hospital there was a boy who was fourteen years old. He stayed there until the morning and died. He had a simple wound in his tummy, but it turned out that it was internal bleeding. But there was no X-ray or anything. He was bleeding until he died” (RSP25, Syrian, M).

Sometimes surgeries were performed in patients’ homes under high secrecy, as Ali’s story indicates. Some participants reported that travelling to a larger hospital for surgery was simply not an option and their only treatment for a long period of time was what was available under improvised conditions. A female patient, who was injured when her house was bombed, described the situation as follows:

They took me to the hospital of the village where I received care. I had an X-ray for my head and arm. They told me that the joint was fractured. There was a doctor from the village who put a temporary cast [on my hand] and told me to keep it. Then he died in Syria before I finished the treatment. The treatment that I received was painkillers and the temporary cast. This is the only treatment that I received! We could not go from that village to the capital city, Damascus, for treatment. It was dangerous [to go there]. We were under siege for more than one month. We had no food and could not receive anything from outside. (RSP2, Syrian, F)

Even those who managed to access hospitals in Damascus faced severe risk. A patient spoke of the risk he and his brother took every time they made the trip to the capital:

From the capital city, Damascus, to our countryside, where we lived, there were around fifty checkpoints. When they saw somebody injured, they took him [arrested him]. I left the hospital and went back home. While going back home, a regime-controlled checkpoint stopped us. They saw me in the car with the cast on my leg from here [points at the ankle] to here [points at the end of the thigh]. I was lying in the car. One of the solders told me: “Your ID!” We gave him the ID. My beard was like this [indicating very long]. They used to arrest injured people. He thought I was one of the armed people. I told him: “No, sir. I have nothing to do with them.” He told them [other solders]: “Bring him [out]!” I told him: “I swear, I have nothing to do with them, sir!” They wanted to arrest both my brother and me. Then we finally called the hospital. Hospital staff told them: “This is the true story. He was here. You could leave him alone.” After fifteen days, I went back to the hospital. My brother and I woke up early. He told me: “Let’s go to the hospital to see the X-ray. And check if the infection is gone.” We went to the hospital. They did the X-ray. They told me: “You still have infections. Go back home. Come back after fifteen days.” The checkpoints were the same. They were not removed. There were the same things [problems at the checkpoints]. They wanted to arrest me at the checkpoint. I arrived at the house and told my brother: “I won’t go out there again even if I was dying.” (RSP6, Syrian, M)

Not only was travel to the hospital dangerous, staying there was too. According to participants, hospitals were frequently targeted by the army, and patients were killed on the spot. The hospital staff in government hospitals were told to report any patient “under suspicion” and to account for any patients suffering from gunshots, regardless of the circumstances under which the shots had occurred. One of the patients described the situation: “Then I had one surgery for my leg there [in Syria]. But it was not successful. The hospital was attacked. There was bombing. The soldiers attacked [invaded] the hospital and wanted to take [to kill] the war-injured [people]. They [the hospital staff] made us run away. And I didn’t continue with the treatment” (RSP3, Syrian, F). Another participant reported being hidden in the female ward until the morning when he had surgery, because “the army of Bashar was in the hospital” (RSP8, Syrian, M). Another one reported that his friend smuggled him in by using a fake name (RSP9, Syrian, M). Surgeries were described as being done in a rush: “The surgery was extremely fast so that they could let me run away from the hospital. Because if the people of Bashar Al Assad came in, they would shoot at me and kill me” (RSP8, Syrian, M). Patients still under anaesthesia were sent out of the hospitals to reduce the risk to them and the medical staff who let them enter in the first place.

Paying large sums of money to bribe hospital personnel and paying again for the surgeries was reported. This placed an additional constraint on access to medical care. One of the patients commented that he could not afford the amount they were asking: “I had an infection and they cleaned it for me. Then, the doctor who did the surgeries came and told me: ‘We will put a device [external fixator] and nails. It cost 300,500 Syrian pounds [600 USD]. I told him: ‘I don’t have [money]. I don’t have [money]! Where could I get [money]? I don’t have [any].’ My brother was next to me … Then, in the end, my brother told me: ‘They are not going to do the surgery’” (RSP6, Syrian, M). Another participant reported paying equivalent of 8,000 USD in a private hospital in Damascus for a one-hour surgery. Half of this amount was to bribe the hospital staff and prevent them from reporting the patient to the army, and the other half was paid for the actual medical care (RSP12, Syrian, M).

Some patients reported that surgeries were done under such severe time pressure that anaesthesia was not given at all. One of the patients described this in detail:

There were two plates here in my fingers. They were inserted from here [points at the top of the finger] to here [points at the end of the finger]. They were taken out when I was in Syria. They [surgeons] took them out without giving me anaesthesia. It was so painful that I can’t even describe it. I asked the doctor to give me anaesthesia, but he told me: “There’s no time to give you anaesthesia. Because it will take long until you are ready [for a surgery if I do it]. And there are many things [procedures to do].” So, he took the plates out without giving me anaesthesia. It was very painful. (RSP1, Syrian, F)

Another participant had a similar experience involving the lack of pain management:

My leg was injured. They took me to the doctor. He removed the bullet. He removed the bullet without [giving me] anaesthesia. He said: “There are still shrapnel in her leg. I can’t remove them now. Because she would scream, and the army would come.” Most of the surgical operations were done without anaesthesia. Because the army could come any time and they would take the doctor and patients! He didn’t give me anaesthesia so that the army didn’t come in while I was still under anaesthesia. He did the surgery while I was awake. (RSP37, Syrian, F)

Another participant confirmed: “No, there was not pain control in the hospital. Patients shouted so loudly. There was no treatment and painkillers for the pain” (RSP3, Syrian, F).

Some participants, however, reported having access to Tramadol or Ibuprofen. And some drugs seemed to be available as painkillers as well. One of the participants mentioned:

Thank God he did not take Pentagone [most likely the drug called Captagon]. There were people who were taking these drugs to be able to live and walk [after the injury]. It was a problem for those who took it. Those taking these drugs don’t have any religion or life [they make one to lose a sense of everything]. When a person takes it, he loses his mind and could do anything, like go out on the street while there were shootings and bombings [completely losing sense of control]. (RSP9, Syrian, M)

Captagon® is an amphetamine-based drug which has euphoric and analgesic properties and induces aggression, alertness, and detachment. It is reported to be frequently used by militia groups in the Middle East, including in Syria and Iraq. It is presumably manufactured in Syria (Arslan et al., 2015; Al-imam et al., 2017; Lutfi, 2016). But according to my participant, it was also used to cope with pain induced by injuries.

For many participants, the injury event triggered their decision to leave Syria and travel to Jordan as refugees. This decision was frequently accompanied by other deeply distressing events and the threat of dying. Some Syrian participants who were injured near the Jordanian border, however, were transported to Jordan within a couple of hours, still unconscious. They faced no difficulty in crossing the border. Indeed, there is a large variation in the number, severity, and types of distressing event MSF patients face before they enter the RSP.

Since the beginning of the war in Syria, several organizations have independently reported on the Syrian authorities targeting medical facilities, killing medical staff and arresting, torturing, and killing patients admitted for treatment (Cousins, 2015; MSF International, n.d.; Sankari et al., 2013; SOHR, 2015). The establishment of field hospitals – operating in basements, deserted buildings, mosques, factories, all under improvised conditions as described by my participants – is well documented (Sankari et al., 2013). Participants’ testimonies and medical records at the RSP provide additional evidence of related war crimes.

Entering Jordan could mean obtaining further treatment for many, but it was not always successful or satisfactory. There are reported incidents of up to thirty surgeries being performed before MSF took over an individual’s care (RSP6, Syrian, M). Some participants reported that the amputation of a limb was suggested in Jordanian hospitals, but that their limbs were eventually saved after treatment in the RSP. One of the participants described how desperate he felt: “I asked to be discharged [from that hospital in Jordan], because they brought me a counsellor to convince me in amputating both legs from above the knee. But I told them I wanted to be discharged and go back to Syria as the treatment there was better” (RSP7, Syrian, M). Patients were sometimes discharged from hospitals in Jordan that provided free services, because the hospitals had run out of funding in the middle of the treatment. Some participants who illegally left the refugee camps in Jordan reported being stripped of any access to medical treatment in that country until the RSP stepped in and admitted them.

In contrast, Iraqi participants, regardless of the period in which they were injured, did not report having to struggle to access hospital care. The quality of care, however, varied greatly depending on the political context at the time of injury. Participants from Anbar, for instance, gave examples of how, during ISIS control, their movements were compromised. They could not easily pass government military checkpoints and, additionally, they were required to obtain a special permit from ISIS to leave Anbar. Hence, they could not reach hospitals in Baghdad and had only limited treatment available nearby.

During the US occupation of Iraq, participants described how hospitals were completely overwhelmed and access to medical equipment was scarce. One of the patients, who was brought to the hospital in a coma, reported being placed together with dead bodies:

I didn’t get that much of a treatment. You know our country was busy with all kinds of explosions. At that time [when I was brought to the hospital] I was unconscious. As I was told, I had been thrown together with corpses [in the hospital], and when my family was trying to talk with the doctors, they were saying to my family that I was a lost cause [I will die anyway] and they should give up on me. It was a horrible thing! I mean the corpses, you cannot imagine. (RSP69, Iraqi, M)

This participant ended up with amputation of both legs but had no hard feelings towards the Iraqi medical staff: “Honestly, I don’t blame them. With the horrible events in 2008 or 2009, I don’t blame the medical staff back then. They had a heavy workload on them because of what was happening in Iraq. They couldn’t cover all the casualties. It was like 300 casualties a day.” Another participant similarly reported that, after being in coma, his treatment was neglected. He, however, was more bitter about it: “There were also wounds in my leg; these wounds got worse because of the neglect of the hospital, because they expected me to die when I was in a coma and assumed the percentage of my death would be 98 or 99% and that’s why they didn’t take care of my injuries and they got worse over time. If they would have taken care of them [my wounds], then the amputation maybe would never have happened” (RSP54, Iraqi, M).

Things were particularly severe when the injured were under suspicion of collaborating with the “terrorists.” One of the participants described how he was arrested in the hospital, along with dozens of others, just two days after he suffered injuries caused by an explosion in the street:

I was on a visit to Baghdad like today, I was shopping for my mechanic workshop, and then the explosion happened, and they took me to the hospital. After that the US Army and Iraqi commandos [collaborating with them] arrested us in the hospital [arrested people who were injured in the explosion]. The second day they [the US Army] arrested us and imprisoned us with these severe injuries. Yes, you can imagine that two tubes were connected to my chest because of the bleeding, and my arm was sagging, with so much shrapnel in my back they even reached the heart. Despite all that they imprisoned me! Only God rescued me and saved me! I received no medical care in the prison! It was a miracle from Allah [to stay alive despite the severe injuries]. My arm was bandaged with a plastic sac and because of the lack of care it was stinking so that everyone was staying away from me because of this horrible smell. Also, the tubes were left in my chest for three days after the arrest, and then prisoners pulled them out and threw them [away]. It was a miracle from God that I survived. (RSP46, Iraqi, M)

He reported that only occasionally, when “the committee from the US Army visited the prison,” did they deliver painkillers to “the most severe cases.” This treatment and the absence of adequate meals caused him to develop a chronic stomach ulcer. Of the eighty-seven people who were arrested with the participant, he reported that only four survived the “two years’ imprisonment”: “God has written a new life for us. Only after two years we were able to prove that we were innocent, so they released us.” Participants’ narratives correspond with published reports on human rights violations and the lack of medical care for detainees held in US prisons in Iraq (Allen et al., 2006; Jassam et al., 2015).

The participant who reported being shot by an American soldier while driving said that later the army took responsibility for the shooting and transported him to a US Army base for treatment. His narrative was rather unique:

Actually, right after the injury I was taken to Heet hospital. It was a very humble hospital with no capacities. My injury [after the gunshot to the face] was a very difficult, unusual injury that required special treatment. The hospital’s manager referred me to Ramadi Hospital. The [US] forces that shot me came to the hospital. Yes, they came in to see me, but I’m not sure why! Did they want to check on [me]? Or just wanted to check if I was a terrorist? There was an American officer standing by me and I was lying on a stretcher. He was carrying a pen in his suit. I was not able to talk, so I tapped on his hand and pointed at his pen. I wrote on my hand in English: “If you keep me here, I will die.” The officer tapped me on my shoulder and told me: “Don’t worry.” After that they put me in an ambulance, escorted by two American hummer vehicles, and took me to the US Army base which was near to Heet. Then they took me by helicopter to Ain Al Asad base [US base] … I was conscious until I reached Ain Al Asad US base, then I passed out. I remained unconscious for three days. I opened my eyes, and it was the Eid al Fitr [Muslim feast at the end of Ramadan]. They had made me an initial surgery [by then]. They connected an external piece of plate to my chin, as my jaw was totally destroyed, and there was another surgery where they connected a tube to my stomach. So they were inserting food through this tube to reach my stomach. Then I was transferred to another [military] base with a limited capacity in terms of providing medical services and surgeries. And then I was relocated [again] to Balad base. It was an enormous base with great medical potential that was not available in any Iraqi hospital. They started making surgeries by working on internal soft-tissue implantation. And they were very successful surgeries. Whoever saw their work was impressed by their achievement. (RSP71, Iraqi, M)

This participant had exclusive access to specialized healthcare that was not available to any other participant I interviewed.

Some patients who had been treated in Iraq during times that were relatively more peaceful complained that the hygiene conditions and the specialized surgeries there were far from the MSF standard. The father of a young male burn victim described this:

After my experiences with many hospitals I realized that we don’t have access to sterilized hospital [at all], and we also lack a hospital specialized in burns [in Iraq]. I haven’t studied medicine, but I know that this [procedure they have done on my son in Iraq] is wrong because while I was accompanying my son during his surgeries – he had about eighty surgeries – I have not seen such surgeries. There was something like slight peeling of the skin to do skin transplantation. Please [mentions the name of his son] stand up and show your back [son lifts his shirt; superficial scar marks run across a large part of his back]. This is peeling [pointing at the scars on son’s back]. They peeled the skin and transplanted it on to the legs. They didn’t use an expanding device like in Amman to expand the skin and take the extra skin to cover the injured areas. The difficulties we have faced here in Iraq were the things I mentioned; their treatment was not good. They don’t take care of the patients. (RSP43, Iraqi, M)

Many participants also described acquiring infections in the Iraqi hospitals, which had severe consequences for their health. The husband of a burn victim reported:

I remember in February when we were going to the hospital [in Iraq]. At that time there was a germ that affected the patients’ wounds and was widespread in Iraqi hospitals. This germ was especially [dangerous] for burns cases. These germs are transmitted from the hospital [to the patients], not from the patient to patient. My wife was infected by this germ and suffered a lot after that. One of her ears was swollen, so they had to do some surgical intervention and amputate it. Even her whole body was swollen because of blood poisoning: the germ reached the blood, and these were the late stages of infection. (RSP44, Iraqi, F)

Furthermore, many Iraqi participants mentioned how treatment for bone infections in Iraq did not improve their condition, “I wasn’t able to walk, there was an inflammation in my leg, and I didn’t get any better here [in Iraq]. I was going to doctors for an entire year, but I didn’t get any better” (RSP45, Iraqi, F).

Unsatisfactory experiences during hospitalization were reported by other burn victims. One of the fathers, whose son was injured in an explosion, talked about it while crying: “On one of the moments when we were in Kindi Hospital [in Iraq] they were cleaning the [burn] wounds of my son with Aleppo soap [a soap traditionally made with olive and laurel oils] and vinegar. I remember he [my son] said to me: ‘Baba [father, affectionately], I’m so tired, I hope God takes my soul’ [I wish I was dead]. He was only ten years old, and you can see how difficult life was for him” (RSP43, M, Iraqi). Another burn victim reported: “I stayed in the hospital for a month; they did nothing for me. We were not able to afford treatment [elsewhere]. Where I was treated it was a hospital where treatment was free. They were just applying oils on the burns of my body, and because of that I was suffering from fibrosis [thickening and scarring of connective tissue as a result of burns] and this increased over time” (RSP50, Iraqi, F).

Some Iraqi participants reported paying for their surgeries, but they were mostly disappointed by the final outcome: “Let’s be realistic and honest, because I’m an old guy. The [successful] surgeries and medications are not guaranteed in Iraq. I have tried for my son to have a paid-for surgery. Despite that, they didn’t guarantee the results, including a specialized dermatologist! He asked for 3 million Iraqi dinars [2,500 USD] and mentioned that the success is not guaranteed” (RSP43, Iraqi, M). One of the participants reported spending a total equivalent of 21,000 USD, an amount he borrowed from neighbours, to treat his leg. After this investment and eleven surgeries he still reported that “They wanted to amputate my leg [in the Iraqi hospital] but, thank God, I travelled to Amman and they treated me until I got better” (RSP53, Iraqi, M). For some, all of their livelihood was sacrificed for treatment in Iraq. One interviewee described how paying these large sums impoverished him and brought him to the brink of disaster. He now illegally occupies one of the abandoned government buildings in Anbar, where he lives with his wife, children, and orphaned nephews.

Some Iraqis managed to travel to other countries (Syria, the US, India, Iran) to receive treatment. They reported spending large sums of money on their surgeries (“I spent everything I had”), but none of them reported being satisfied with the treatment or its final outcome. One of the fathers whose son was severely burned as a child went, based on recommendations, for treatment in Syria (before the crisis). He reported:

In Syria we rented a room for him and the person responsible for treatment was yelling and treating him in a cruel way while my son wasn’t even able to speak or do anything because of the injury, as his burns were of third degree [very severe]. They bandaged his entire body with gauze while his burns were still raw, and this is something really wrong. The gauze then stuck to his skin, as when they removed them, the skin was coming out with the gauze until the bones were shown. The cost of the treatment in this hospital was around 6,700 USD with this poor treatment. (RSP57, Iraqi, M)

Previous medical treatment and its impact on patients at the RSP

After such difficult events, many Syrian patients reported reaching MSF feeling emotionally exhausted – so much so that undergoing medical procedures was seen as an additional stress that was difficult to deal with: “The situation was horrific. The surgery was big. There were many stitches. And I was already emotionally tired” (RSP15, Syrian, F). Traumatic moments during previous treatment left emotional traces and clearly influenced participants’ responses when they faced treatment in the MSF hospital.

Some reported that their troubled memories re-emerged in the critical moment right before entering the OT. Female participants most often reported experiencing anxiety and panic when facing those moments. For instance, participants remembered severe conditions during surgeries in Syria: “The injured people were operated on in front of each other! So, of course, I remembered those surgeries when I was having my surgery in Amman. And those memories are painful and difficult” (RSP1, Syrian F). Another woman reported that she remembered how the hospital was bombed when she was waiting for her surgery in Syria and how the hospital staff made patients run away. She recalled that when she entered the OT in the MSF hospital, “I was crying. My feelings were so bad. I was so afraid” (RSP3, Syrian, F). In contrast, male participants mainly worried at the time of their surgery in Amman, that the surgery would not be successful or that they would die because of the anaesthesia.

Those who had undergone surgical procedures without anaesthesia in Syria had an acute fear of pain. One female participant reported being severely afraid of physiotherapy, but on listening to her narrative it became clear that her fear was actually associated with the memory of the terrible pain she had previously experienced. Even the colour of iodine was enough to trigger a memory of pain for a burn victim:

After we got out of the operation [at the RSP] we had to take a bath in order to get rid of the red iodine. I felt afraid when I saw the red iodine on the wounds! They [nurses] were trying to convince me to wash it off and not to be scared. I was scared because when I was burned, this iodine was painful for me, when they were cleaning the wounds [with it in Iraq]. So I was scared of it! I was worried that what happened in the past [the pain] will happen again. (RSP44, Iraqi, F)

The same participant also recalled memories of post-surgical pain: “They are difficult [the surgeries], the anaesthesia, and the post-operation time. Like when they cut my ear here [in Iraq] I was suffering for a long time after the surgery because of the pain” (RSP44, Iraqi, F).

Not only experience with pain but also experience with persistent infections caused a state of anxiety. One of the Iraqi patients who acquired an infection before arriving in Amman was paranoid about being near patients with infections. He attended the MSF psychosocial support sessions to try to rid himself of this fear, but unsuccessfully: “They [psychosocial team] are good, and they reassure people, but they never convinced me to get closer to those infected people. I only felt comfortable if I kept a distance from them” (RSP45, Iraqi, M).

The fear and threats related to their exposure to war also left strong emotional traces, which could be triggered by the hospital environment. I recall one patient whom I approached when I was organizing the focus group. He thanked me for “gently” knocking on his door and reported another staff member abruptly entering his room, which caused a sense of panic related to his fear of potentially being arrested in his house at any time. Patients silently dealt with such emotional reactions, and the hospital staff were surprised when I communicated this example to them.

Experience with traumatic previous treatment contributes to feelings of anxiety among RSP patients that far exceed the usual anxiety associated with medical procedures. This is in line with some pain-experience models that propose that the fear of pain exaggerates the pain experience and pain perception (Lethem et al., 1983). Furthermore, medical guidelines for the care of burn victims highlight that during treatment burn patients may re-experience the trauma and even post-traumatic stress disorder (PTSD), not linked to the initial burn but rather to the subsequent painful care of their wounds (Greenhalgh, 2016).