by John Bedolla and Miguel Bedolla
The DAESH Health System: An Open Source Intel Report
John Bedolla and Miguel Bedolla
We found no evidence of an organized Combat Medicine system, although we did find isolated instances of battlefield care that at the same time reveal that the physicians and other personnel delivering battlefield care are not under a special protection and incur the same risk as combatants. Thus, according to one report, “In June ISIS put out a call to recruit military officers, judges, managers, engineers and doctors. The call has met with some success. A Saudi Arabian newspaper noted that a doctor from that country joined ISIS. While reports differ, he either died in a booby-trap or while providing care to injured combatants.”1
Meanwhile, as the following note reveals the physicians that have joined ISIS have received no special training and “lack experience treating battlefield injuries and the critically wounded have to be transferred to better medical facilities, although it is not clear if these facilities are designed to provide the care that the wounded need. And in these centers combatants are treated before civilians. This is the note: “In Raqqa, the staff of local hospitals has been supplemented by the many foreign doctors and new medicine graduates – both Arab and Western – who have traveled to support the Islamic State. But they usually lack experience treating war-zone injuries, so critically wounded IS fighters are transferred to Mosul, which has better medical facilities. And some medics take issue with how they handle emergencies. “They force medical staff to treat combatants before civilians,” says Abu Osama.”1
It is interesting to note that at least some of the wounded combatants have been transferred to Turkey for their medical care. “An ISIS commander told the Washington Post on August 12, 2014, “We used to have some fighters — even high-level members of the Islamic State — getting treated in Turkish hospitals.” “The Minister of Health (Turkey) said something such as, it’s a human obligation to care for the ISIS wounded.” Yet, we do not know anything about the adequateness and quality of the care the wounded receive there.1
The wounded combatants that are/were being transferred to Turkey “…are being treated in hospitals all across southeastern Turkey. More and more militants have been coming in to be treated since the start of airstrikes in August. To be more specific, eight ISIS militants were transported through the Sanliurfa border crossing; these are their names: “Mustafa A., Yusuf El R., Mustafa H., Halil El M., Muhammet El H., Ahmet El S., Hasan H., [and] Salim El D.”[i]
The possible absence of appropriate resources for combat medicine is highlighted by the following article headline: “Wounded ISIS fighters being treated in Israeli hospitals. US training them.[ii] However, the number of battle wounded being treated by the Israelis when the article was published in 2014 was 3, and we found no reports that the Israelis continue to treat similarly wounded fighters.
We found no evidence of the existence of field hospitals with one exception: “A woman residing in the Islamic State who calls herself As-Soomaaliyyah on Twitter claims to be a medic from Kenya. She tweeted a photo of a doctor in a field hospital sporting scrubs and an AK-47. Her caption reads, "Medics in the Khilafah in the forefront in saving the lions of this ummah! A field hospital in one of our frontlines!"
However, it is to be noted that the stained glass behind the “medic,” above and to his right, reveals that the “field hospital” is not a field hospital in the American sense: a portable installation relatively close to combat, where the wounded receive immediate care, rather, it is probably a permanent structure, either a civilian hospital adapted as a field hospital or a structure that was built for an entirely different purpose and is now being used as a field hospital. That it is an adapted civilian hospital does not seem likely because the scene pictured is lighted through the glass windows and the windows or doors below them, rather than from above as it would be expected in a regular hospital or a field hospital.
Islamic State Health Service/Formal Hospitals/Patient Clinics
The first feature of the Islamic State Health Service that needs to be mentioned is that, as the following headline reveals, it is a copy of the British health system; even its logo is so patterned: “Isis mimics Britain's NHS with 'Islamic State Health Service ISHS'”[iii] The content of the same article also begs the question whether the system really exists or its existence is only propaganda designed to convey the notion that ISIS is a functioning state meeting its obligations toward its citizens (Charlie Winter, a researcher for the London-based counter-extremism Quilliam Foundation Think Tank): “In an interview with The Atlantic, radical preacher Anjem Choudary said that according to a strict interpretation of Sharia law, Islamic authorities personified by the self-styled caliph have the onus to provide housing, food, clothing and all services to their subjects in return for their obedience.”[iv]
Thus, the first question about the ISIS Health System is about its creation and existence. A health system requires an infrastructure but the infrastructure does not seem to be there: “It is difficult to see how an operational health system that will provide services to all of the citizens can be built given the fact that according to “…statistics compiled by the Syrian American Medical Society and the WHO: approximately 60 percent of hospitals have been destroyed, 90 percent of the local pharmaceutical industry has been destroyed, 78 percent of ambulances are severely damaged, and 70 percent of whatever medical staff is left cannot access their workplaces (Al-Jadda). In certain provinces, upwards of about 90 percent of all physicians have left or have been killed, and in the stronghold of Aleppo, less than 250 physicians are left...”[v]
The article quoted above also reveals that the “System” lacks the human resources necessary to be effective. This is probably true of all the levels of the “System” from the Policy and Leadership level to the level of the healthcare providers. This has led to the emergence of three very significant epidemiological issues: Polio has resurged because lack of vaccination, AIDS has increased significantly, due to the use of IV drugs by foreign fighters that have joined ISIS and the existence of markets of women to be used as sex-slaves by multiple men. The appearance of an epidemic of Leishmanniasis, an easily controlled parasitic disease, among the fighters. “In Aleppo, more than 100,000 cases of Leishmaniasis have been reported, and a breakdown in access to pharmaceuticals has begun to internally cripple civilian populations and IS militants themselves (Cooper).”[vi]
“On the subject of manpower, numerous documents point to brain drain as the main cause of lack of qualified medical staff. For instance, in May 2015, the Diwan al-Siha, General Supervisory Committee (which can issue general directives to IS provinces and bureaucratic departments) and the Diwan al-Qada in Wilayat Ninawa issued a joint statement giving an ultimatum for doctors, pharmacists, medical and nursing professors and other health staff who had fled to return within 30 days or face confiscation of their homes as real estate under the Diwan al-Qada. The statement justifies this ultimatum on the grounds that many means of persuasion had been tried but to no avail. It should be noted that this was not the first ultimatum issued in response to the medical brain drain problem.”[vii]
However, assuming it exists and functions as a system then there are a number of questions, the first may be about access: who gets access to it? “In March however, Abu Mohammed an activist living in Raqqa said that under IS rule, Islamist fighers were granted free access to health care but common citizen not. Speaking to IBTimes UK Mohammed said that private health clinics in the city had been closed and the public hospital in Tel Abyad was open but with high prices for treatment.”[viii]
Making the same assumption as above, it may be said that the “System” coexists with a “private-non-governmental system” that seems ready to exploit the situation for its own benefit forcing the issuance of a decree from the Islamic State Office of Health” that attempts to control the profit being made. The following directive is noted:
“The Islamic State Office of health.
In the name of God the merciful
The Islamic Caliphate state/province of Nineveh/driven connector:
Given the realities of some low-income Muslims from tight in case material and poor families and families the brothers in the Islamic State after work to help those Muslims are open centres of Zakat and charity in Mosul and we have therefore already. and now the Muslims began complaining about a slight increase in the prices of medicines in particular medicines for chronic diseases. so start some owners but rather a lot of them, unfortunately, take this situation to raise prices, especially of chronic diseases (such as pressure, diabetes and diseases of the kidney, heart, etc) which Increased weightankle some Muslims and even some couldn’t buy these medicines. Consequently, and in the Office of the brothers discussed HD Hisba Sai decided the following:
:: Guidance to merchants and shopkeepers (pharmacy) to abide by the points and the following percentages:
1 _ when buying the medicine of the almzekhr price (IQD 1,000) is sold at the price (1,250 Iraqi dinars only).
2 _ when the drug is purchased from almzekhr price (10,000 Iraqi dinar) is sold at the price (11,500 Iraqi dinar only).
3 _ a profit of price (250 dinars) to 1,000 Iraqi dinar 35%
4 _ a profit of price (1000 dinars to 10,000 Iraqi dinar) of 25%.
5 _ a profit of price (10,000 Iraqi dinar and above) of 15%.
And Please abide by the brothers pharmacy owners for cooperation between Muslims on the righteousness and piety and to foster a spirit of collaboration and love among Muslims and the violator will be subject legal accountability.
And God disposes
The Islamic State/Office of health.”[ix]
The situation of the “System is so chaotic, and the “System” itself is so important for the survival of ISIS that an article that has already been quoted suggests that it “provides a crucial avenue of understanding and, ultimately undermining and destroying, the Islamic State.”[x]
One more question to be asked at this time is: How is the Health System financed? The only note that we found is that many of the providers, those who served under the Syrian Health Ministry, have been allowed to continue receiving their salaries from said source.
Survivability After Injury
There is no available data on the casualty rate and survivability on the ISIS forces. What is absent may be more telling than what is present. Analysis of ISIS posted videos shows that battlefield casualties receive little in the way of medical care. The injured received basic superficial wound cleansing and simple dressing. Advanced wound care techniques are not evident, Additionally the grievously injured and newly dead show no evidence of any battlefield interventions, such as IVs, chest tubes, endotracheal intubation. ISIS is exhibitionistic about any resource it possesses or can claim to possess. The absence of any advanced battlefield medical interventions should not be attributed to discretion or desire to guard operational details. Combat medics are never seen. And while ISIS infantry are heavily armed, their battle kit does not appear to include any medical equipment or supplies. Casualties are not treated on the field. When removed from the battlefield they are transported without paramedic interventions such as IVs, supplemental oxygen or airway management. The ambulance in ISIS territory is essentially a taxi for recumbent passengers, not a mobile medical care unit. The “golden hour” of trauma care is non-existent for ISIS combatants and civilians. Survivability for all but the most minor injuries is likely low. The casualty attrition rate for ISIS infantry is probably, making frequent replenishment of its ranks an existential imperative.
As mentioned in a previous section, there are three emergent infectious diseases that are occurring at an epidemic level in the ISIS: Polio, AIDS and Leishmaniasis.
“Starting in 2012, as civil unrest led to a violent government crackdown and finally to all-out war, drugs were denied to rebel-held parts of the country, leaving millions of young children and infants exposed to a range of infectious diseases and creating a gap in the country's immunity.
This immunity gap, say scientists, is what allowed the polio virus to return to a country that hadn't seen an outbreak in nearly two decades. And fighting polio amid the chaos of war, as infrastructure breaks down and people are displaced, quickly becomes a health worker's worst nightmare.
Once polio reemerges within a population, the highly contagious virus is extremely difficult to eradicate. It's resistant to common disinfectants, including alcohol (though not bleach), and able to survive for long periods in food, water, and sewage. Most troubling is its ability to hide unnoticed in the vast majority of its carriers. Health experts estimate that each diagnosed case of polio correlates to roughly a thousand infected people, who can silently spread the virus for weeks.
By October 2013, when the World Health Organization confirmed the first polio cases in Aleppo, Syria's largest city, the conditions for an epidemic were in place.
Sixteen months of fighting had left much of the city with limited or no access to clean water and electricity. Open sewage ran through neighborhoods. And local clinics and hospitals had been destroyed or abandoned.[xi]
“But the limitations are evident in the response to a potential outbreak of AIDS in IS ranks. The activist group Raqqa is Being Slaughtered Silently, says it has documented two civilian cases of AIDS infection in the city. One involved a Tunisian woman who gave birth in late July. An earlier case involved a French female migrant of Moroccan origin. The activist network says several factors have contributed to an increased risk of HIV infection among IS fighters and their sexual partners. These include transfusions of blood without proper screening; the prevalence of injecting drug users among some foreign and local fighters; short-term marriages and a high turnover of partners. Wahda, who has rebuffed several IS suitors interested in her daughter, says the new marriage patterns are a concern.
“No one is doing health controls or tests,” she says, “whereas in the later years of the Assad regime everyone was getting checked for HIV/AIDS before marriage.”
In response to the threat, IS has begun to bring in testing equipment from its Iraqi stronghold, Mosul. “AIDS represents a major fear for [Islamic State] due to the lack of AIDS detection devices (in Raqqa),” says Doctor Abu Osama Al-Raqqawi, a pseudonym. “There are many reasons that can lead foreign fighters to contract AIDS. One of them is the blood transfer between fighters or people without any prior analysis for contagious diseases.”[xii]
Along with their “cultural cleansing,” the Islamic State is known for their implementation of sex slavery, horrific executions, and their genocide of Christians, especially those with Middle Eastern ethnicity. However, their atrocities may be coming back to them full circle as reports now show the Islamic State are in danger of being destroyed, not by any nation’s military, but by a flesh-eating disease.
According to Opposing Views and followed-up mostly by conservative sites like Mad World News and Clash Daily, the disease known as Leishmaniasis has surfaced in Syria and has now infected hundreds of Islamic State (ISIS and ISIL) fighters, especially in the city of Raqqa. Symptoms of the disease includes large gaping wounds in which the flesh around it is also eaten, low red blood cells, fever, and a swollen spleen and liver. If not treated correctly, Leishmaniasis is proven to be fatal.
The aforementioned circumstances have left the country of Syria to fend for themselves, where medical situations are left to inexperienced medical personnel. However, the worst part is that the Islamic State is actually refusing treatment. That, along with the fact the disease is most prevalent in areas suffering from poverty, malnutrition, and deforestation (conditions amplified by the Islamic State’s destruction) may possibly guarantee the death of at least 20,000 people within the year. However, if conditions are optimized for Leishmaniasis, the number of deaths may increase up to 50,000 people.”[xiii]
Management of Chronic Care (Cancer, Diabetes, Routine Illnesses That Can Be Fatal Without Treatment)
We found only one article on children’s cancer. Nothing at all in the treatment of diabetes, hypertension, asthma and so on.
Cancer Treatment for Children in Ninawa: http://media.clarionproject.org/files/islamic-state/islamic-state-isis-magazine-Issue-4-the-failed-crusade.pdf
Cases of Foreign Medical Staff Leaving the West to Join the IS Medical System and Pleas To Skilled Professionals From The West To Migrate To Islamic State
The third issue of the Islamic State's English-language online magazine Dabiq, released August 29, 2014 called for emigration to Muslim lands. Its message was directed to Muslims in the West and invited them to come and aid in the formation of this nascent Islamic state. Perhaps the basic argument in favor of coming said, "Therefore, every Muslim professional who delayed his jihad in the past under the pretense of studying Shari'ah, medicine, or engineering, etc., claiming he would contribute to Islam later with his expertise, should now make his number one priority to repent and answer the call to hijrah, especially after the establishment of the Khilafah [caliphate]. This Khilafah is more in need than ever before for experts, professionals, and specialists, who can help contribute in strengthening its structure and tending to the needs of their Muslim brothers. As for the Muslim students who use this same pretense now to continue abandoning the obligation of the era, then they should know that their hijrah from darul kufr [land of unbelief] to darul Islam [Islamic lands] and jihad are more obligatory and urgent than spending an unknown number of years studying while exposed to doubts and desires that will destroy their religion and thus end for themselves any possible future of jihad." Public appeals for skilled workers come from higher-ranking ISIS officials and from individuals serving as online recruiters who already reside in the Islamic State.[xiv]
To attract foreign medical professionals, besides the religious argument, ISIS promotes a health care system and services it is operating out of the Syrian city of Raqqa,. It uses a video in which the central character is an Australian man who is said to be a physician and runs the pediatric ward. The video shows an ambulance belonging to “Iraq Civil Aviation,” not ISIS, speeding up to a hospital and a man on a stretcher being rushed inside. “All the interviews are conducted with men purporting to be doctors, but no real names are given. One man, Abu Mukatil al Hindi, says there are doctors from Russia, Tunisia, Sri Lanka and Australia, and that women are treated by female physicians.
An Australian man, who gives his name as Abu Yusuf al-Australi, says he was happy he’d come here and sad he hadn’t made that decision to come and work in the Islamic State sooner and asked for other Muslims living in the West to come and join him. It’s a good system that they’re running here, everything lived up to my expectations completely,” he told the cameras. “We really need your help, any little thing gives the local people who are truly suffering a lot of benefit.” He said they didn’t lack equipment, only the staff. “Please consider coming, please don’t delay,” he said. “Inshallah see you soon.”[xv]
Among those who have gone are at least one American and one Canadian: Mohammad Maleeh and Ismail Hamdoun. However, their parents insist their children have not crossed Syrian border to fight for Islamic State. They insisted that the group did not plan to fight, and had no links to Isis. Speaking on condition of anonymity, they said their children only had humanitarian motives. “One parent told the Guardian: “We haven’t found any connection with Isis or other groups. They went to help for medical purposes, not to join Isis. There is no link whatsoever between these children and ‘Daesh’, they have good intentions and came to give medical help.”[xvi]
The number of medical professionals immigrating to ISIS, numbering maybe a few dozen, is insignificant in terms of altering the medical landscape.[xvii] For obvious reason, they have value as propaganda.
The lack of trained medical professionals is evidenced in many fatwas and declarations by ISIS. Examples include threats to confiscate property of doctors and nurses who don’t return to work, as well as other more ominous threats. [xviii],[xix]
Battlefield Mortuary/Burial Methods
An exhaustive recursive search combining “ISIS” or “ISIL” or “Daesh” with “burial” or “funeral” or “mortuary” was negative. There was one report of ISIS infantry having to dump hurriedly dump their dead into sewage pits during airstrikes.[xx] By contrast there are a significant number of Pro-Kurdish videos showing funerals for their dead. By contrast, the commemoration of the ISIS dead can only be found in videos or pictures that display them in their newly dead state.
Report of the Security-General on the Implementation of Security Council resolutions 2139 (2014), 2165 (2014) and 2191 (2014). October 2015, August 2015. A good overview of the situation on the ground in the various provinces of the Syrian Arab Republic (SAR).
“The Chaos of Syria’s Civil War.” Jason Motlagh. National Geographic, March 2015
“Syrian female doctor who escaped Isis: 'Our lives in Raqqa turned to black,'” L Smith, International Business Times, Nov 18, 2015
Infographic shows the number of hospitals and medical centers in DeirEzzor and Raqqa. http://www.raqqa-sl.com/en/?p=1219
“Under Islamic State's strictures, health care falls on harder times.” D Soguel. Christian Science Monitor, Aug 3. 2015
“How the Islamic State makes its money. A Swanson. Washington Post. November 18, 2015. https://www.washingtonpost.com/news/wonk/wp/2015/11/18/how-isis-makes-its-money/ Details credible claims that Turkey provides medical supplies to ISIS and even medical care to ISIS personnel.
“Health care in the Islamic State” C Klugman Medical Bioethics Blog. Feb 25, 2015.
“Islamic State Scrambles to Stem Exodus of Skilled Workers” M Bradley, M Alakraa. Wall Street Journal. Oct 16, 2015.
[iii] (at http://www.ibtimes.co.uk/isis-mimics-britains-nhs-islamic-state-health-service-ishs-1498183 , published in April of 2015)
[x] (The Islamic State Healthcare Paradox: A Caliphate in Crisis by By Archit Baskaran 2015, VOL. 7 NO. 07 | PG. 1/3) http://www.studentpulse.com/articles/1054/the-islamic-state-healthcare-paradox-a-caliphate-in-crisis