"For us, doctors there is no such
thing as an enemy, whoever steps over the threshold of our hospital has
no nationality, no creed, no special skin colour: Here is a wounded person
who need our help."
Dr. Oumar Khamblev, former Chechen
minister of health.
In Chechnya, the medical personnel in caught between two fires: the Russian military forces on one hand and the Chechen fighters on the other. Doctors are accused or collaboration or treason. They are on front line on this war, which has no front. They enjoy no protection.
In July 1995, the Russian Constitutional Court considered that the first Chechen conflict was a domestic armed conflict and fell under the Additional Protocol to the Geneva Conventions on the protection of civilian victims of no n international armed conflicts (Protocol II) and common article 3. The Russian authorities described the second offensive as an "antiterrorist operation", a large police operation which involved the presence of no less than 80.000 military troops, intense air bombing, and the daily intervention of heavy artillery of all kinds. There were tens of thousands of victims since September 1999. 120.000 Chechen refugees are still in Ingushetia, the consequence of a mere police operation carried out within the framework of the world fight against terrorism.
Disagreement on the legal term to describe this conflict leaves the door open to many abuses. and the civilian population bears the brunt. Humanitarian and Human Rights organisations constantly denounce this situation.
Once again Médecins du Monde (Doctors of the World) is sounding the alarm signal by drawing the attention of the international community on the fate of the Chechen medical personnel which is not spared the cruelty of the Russian army. There is nothing new in this situation, but what is indeed new is that it is being talked about. The non-respect of the rights of the health personnel is a serious violation of international humanitarian law and of Human Rights. Yet another violation in this region of the world where there are so many and perpetrators remain unscathed.
Testimonies gathered during the first months of 2003 with about thirty Chechen physicians prove once again that the restoration of normalcy in this tiny Caucasian republic as claimed by the Kremlin is mere propaganda and is entirely disconnected from reality. The violence, which has been playing havoc in the area for three and a half years, is still going on behind closed doors, unimpeded and against all international Conventions to which the Russian Federation is a party.
Those serious violations of International humanitarian law and of human Rights concerning doctors have direct bearing on the civilian population access to health care in a region where the armed conflict is still affecting the most vulnerable, despite the official claim of return to normalcy.
All the doctors and nursing staff that we met asked to remain anonymous. Dates and places are not mentioned for safety reasons.
Relevant articles of the Additional Protocol to the Geneva conventions (Protocol II) which the Russian forces and the Chechen fighters are supposed to abide by.
Extract 1. Article 9 - Protection of sanitary and religious personnel
1. Medical and religious personnel shall be respected and protected and shall be granted all available help for the performance of their duties. They shall not be compelled to carry out tasks which are not compatible with their humanitarian mission.
2. In the performance of their duties medical personnel may not be required to give priority to any person except on medical grounds.
Why they keep silent
"We are first Chechen an then doctors, therefore inevitably guilty. If we want to remain alive we can but keep quiet."
"For us talking to you is not a simple matter, for years we have been working in extremely difficult conditions, we are used to it and we no longer know what is normal"
The health personnel working on Chechen territory is not protected. The mere fact of being suspected of having treated independence fighters justifies arrest and questioning by the Russian Federal forces.
Threats, blackmailing, impediments at work, constant watch, denunciations are part and parcel of their daily life. Doctors are regularly questioned; others disappear, are tortured or exiled. Such cruelty remains unmentioned. Retaliation and intimidation attempts by the federal forces are frequent, less so by the Chechen fighters. Doctors are practising and risk their own lives as well as their families'. They provide care in fear and silence.
R. A doctor
" Doctors should be protected and untouchable, but here in Chechnya, it is exactly the opposite, a doctor is more at risk than anybody else. We are hostages of our own profession. When we leave the hospital, we are still doctors. We live in fear day and night. Fear of practising our profession, of providing care, of being arrested, of being accused. We provide the same care to everyone without distinction; we are not there to go in for politics. The act that we are not protected forces us to conceal the truth. If we talk and what we say is published, they will find us and there will be retaliation. I could talk about our problems for days, but I do not feel like dying or put my family in danger. If I talk, I shall never sleep again"
When doctors are outside health structures they prefer not to mention their profession to protect themselves. S. is not the only physician who invented another trade for himself when going through the checkpoints, which are still dotting the territory. "Unless I really have to, I never say that I am a doctor, even less that I am a surgeon, it is too dangerous, I would immediately be accused of providing care to the fighters and I would be arrested.
After having been the object of threats at a checkpoint, Z. and R. have decided not to mention their profession. Z: " At present, I am afraid of stating that I am a doctor. Some do not hesitate in keeping us longer. One day a soldier told me that he was happy that by not letting me through, he knew that my patients would possibly dye."
R. "Whenever I go through a check point and produce ma card, they ask me what is my speciality is. When I admit that I am a traumatologist, I systematically get into trouble. As much as I can, I do not say that I am a doctor."
Abuse of power
"Russian soldiers break into hospitals without any warning, by day or night they come into the operating theatres with their big mudded boots, if they need some medicine, they just break the doors of our stocks without our having enough time to give them the keys. We spend a lot of time mending doors. They show respect for nothing, particularly for us. They want us to feel this lack of respect."
Several practitioners mentioned problems with the paramilitary groups of the pro Russian administration under Akhmad Kadyrov. "They misuse their power and they do not respect us anymore than the Russians. These militia men feel superior because the Russians give them weapons which they take away from them during cleansing operations, in case they used them to intervene."
"A militiaman gets 600 dollars to kill while we get 60 to save lives! We too take risks but we are not paid accordingly."
The monthly salary of a militiaman is between 6.000 and 18.000 rubbles, according to risks, while the salary of a physician is 2.700 rubbles per month, that is half the salary in other Republics of the Federation.
At the end of February, many doctors had not yet been paid for December, for reasons of ministerial changes.
Priority to wounded soldiers
"During the war, between 1994 and 1996, we were obliged to treat and operate the Russian soldiers, We performed up to 350 operations per week, of course with the equipment of the international NGOs, and nobody ever knew."
The federal forces often take their wounded to the Chechen civilian hospitals." Although they do not respect us, they trust us more that their own doctors who are constantly drunk."
Until last year they used to close the doors behind them when they arrived and prevented the staff and the patients to get in. Although this no longer seems to take place today, tanks and other military vehicles close to health structures deters people from seeking care.
When the military need a doctor, during the night, they simply go and collect him at his place with a BTR ( armoured vehicle for the transport of troops) and bring him to the hospital. Doctors have no choice, they have to go.
Extract 2. Article 10 General protection of medical duties
1. Under no circumstances shall any person be punished for having carried out medical activities compatible with medical ethics, regardless of the person benefiting therefrom.
2. Persons engaged in medical activities shall neither be compelled to perform action or carry out work contrary to, nor be compelled to refrain from acts required by, the rules of medical ethics or other rules designed for the benefit of the wounded and sick, or this protocol.
Arrests, interrogations and torture
S. was suspected of having treated a combatant. He was kidnapped at his home in the middle of the night by masked men and was tortured for two days.
"They arrived at one in the morning They knocked and kicked the door. They wanted to know who was living in this house. I answered it was my house and that I was a doctor. They told me that one of them was sick and that I had to go with them. They did not say who they were and did not produce any official document. We ere hardly out of the house when they pushed me into their car and hooded me so that I could neither see their faces or where we were going. They took me to the third floor of a building and threw me down. Then they handcuffed me and torture began.
There were two of them; one was hitting me on the back the small, of the back, in the belly with a kind of baseball bat, while the other was applying electric wires on my fingers. I was attached to a pipe and I could not move. My head was covered and they had scotched my eyes. They constantly asked me if I knew "boieviki" (Chechen fighters), if I had treated any, they wanted names and addresses. I kept telling them that I did not k now any, it made no difference. Then one of them tried to pull one of my eyes out with his own fingers. Then they started filing my lower teeth to bring out the nerves. I fainted several times. Eventually they dictated a letter in which I declared that I was going to help find fighters and forced me to sign. I no longer knew what I was doing. Blows alternated with cold water being poured on my head. After two days they took me to my village so that I showed them the house where I had given care to a man one month before. Indeed I had been called for a wounded man, but I could not remember, I had not even asked his name. He was wounded in the shoulder and I had nothing to treat him. I told him to go the nearest hospital, and that was all. They released me at dawn. When they left, they specified that they would be back one week later and they would kill me, if I did not find the house. I had to leave my village and since then I hide. I did nothing but my job, I never made any difference between a fighter, a Russian soldier, or a civilian, I treat everybody, all, the victims of this war."
Now, S. is exiled with his family. He nearly lost his life and the village dwellers have lost their doctor.
R. was guilty of having treated the wounded after a cleansing operation, he spend twelve hours in a ditch.
"I was called after a cleansing operation with a lot of bloodshed, two young men were wounded. I treated them whether they were fighters or anything else, I also treated women and other people, Then the inhabitants set fire on anything that could leave traces, bandages, and blood covered clothes. The following day, the Russians came, somebody had told them that I had attended the wounded. Again they searched all the houses and found nothing. But soon after they came to fetch me at my place. They took me to the Kommandature where I was questioned for a long time. I do not want to talk about what happened there. I did tell them that I had attended an old woman. Then they threw me into a ditch with other men where I was left for 12 hours before they released me. Since then I am under permanent watch, my house, my family, what I do and where I go. I am a doctor, everybody knows it here, and I attend everybody without distinction. I cannot do otherwise in any case, but now, I am constantly afraid.
Tortured and raped
Quite recently a nurse was accused of having looked after Chechen fighters during the first war (1994-96). She and her husband were arrested. Hooded men arrived at her house at 4 in the morning. She was taken away and kept in seclusion for a week, seven days of nightmare during which Z. was the victim of the most appalling cruelty, rape and electricity torture. Z. recently went into exile. She had to flee from Chechnya.
Accused of doing his job
"We received several wounded persons at the same time. Some needed urgent surgery. I was asked to operate on of them. I only learned later that he was a Chechen fighter, but it would not have made any difference anyway. But the Russians saw things otherwise. They were rapidly informed I was immediately called up at the Kommandature for questioning. I do not chose the wounded I attend, I do not ask them to produce documents before I operate, in fact we are accused of doing our job. I am unable to make the difference between a rogue and ordinary people. Th right place for this is a court of justice, not a hospital.
The Russians are accusing us of letting people out of the hospital A hospital is not a prison! If families want to bring their wounded to the hospital, we cannot prevent them. A young man blown by a mine would soon be accused of having laid it himself. In such conditions, it is quite clear that he is afraid of staying in the hospital, it is simply not in his interest."
Extract 3 Article 10 - General protection of medical duties
3. The professional obligations of persons engaged in medical activities regarding information which they may acquire concerning the wounded and sick under their care shall, subject to national law, be respected.
4. Subject to national law, no person engaged in medical activities may be penalised in any way for refusing or failing to information concerning the wounded and sick who are, or have been, under his care.
Under surveillance
In Chechnya doctors must immediately report all bullet and knife wounds or any other "suspicious wounds" to the military authorities and the police. Failing to do so may lead to arrest. Besides they are strictly forbidden to operate in any other place but a hospital.
"We know what the rules are and what may happen if we do not respect them. In any case we are under very close watch. We are not free, for any medical act we have to report the military, which learn nothing from us as in general they are informed of the state of the patient before we are. They know exactly who is coming to the hospital and for what problem. They are very well informed; the number of informants is steadily increasing. We cannot trust anyone. Our own neighbours may denounce us because we are doctors. We know that anything can happen at any time, we are never safe. If they wish to arrest a doctor, it is enough for them to hide forbidden medicines in his belongings, they are quite prompt at resorting to this type of method."
The corpus delicti
Medical equipment is also under close watch by the Russian forces, radiology equipment, surgical instruments, emergency kits, and even used compresses. All this material could be used to serve the cause of the enemy. In certain areas, 50% of primary care kits have been confiscated during cleansing operations under the pretext that they could be used to treat combatants.
During the famous cleansing operations, always largely performed by the federal forces, soldiers systematically remain long in the houses of the nursing staff. "In my district, cleansing operations take place once a week, they have had ample time learn that I am a nurse, but checks are always stricter at my place than at my neighbours'. They are looking for nursing, surgical or anaesthesia material, trying to accuse us of treating combatants."
One month's detention for a scalpel
Very few doctors dare keep an emergency kit at home or in their car, it is much too dangerous. If such a kit is found by the federal forces, they are immediately arrested. "I was stopped at a check point, soldiers searched my car and found my case where I kept small instruments used for circumcision and two small tweezers. I was accused of giving care to fighters and taken to a filtration camp where I was interrogated. They detained me for one month. Certain prisoners needed urgent care, particularly young men who had been shot at. I could give the care, I became the camp doctor."
Torture and interrogation for saving medical material
Certain doctors, T. for example take the risk of taking certain pieces of equipment home to clean them or save them from bombing.
"They found this equipment during a cleansing operation. I was arrested. They wanted to know what I intended to do with it. I explained that I only wanted to save this equipment from destruction, besides, accompanying documents were in order. They kept me for 36 hours during which I was interrogated and tortured. They released me at curfew time. At the first check point soldiers threw me down and hit me. One of them wanted to kill me, but he changed his mind when another soldiers told him that they would have to dig a hole to hide my body. . . which they did not really feel like, and they eventually let me through. I rushed to the first house, the people there took me in and I spent the night there before going bake home the following day. Since then I am under close watch and some people are always ready to denounce me; in Chechnya, doctors are not considered as civilians."
Arrested for treating his brother
"My brother had a serious car accident. I was looking after him at my place, which means I had some surgical instruments. I could not save him and when he died, I did not immediately think of getting rid of the instruments. I was arrested on the market place. They thoroughly searched my house and of course found my material. They took it away and I was driven to the Kommandature. They would not listen to my explanations. They accused me of helping the "terrorists". They eventually let me go under the condition that I found proofs of what I was saying. I spent weeks trying to find the documents proving that I had purchased this material legally in another republic, that I had kept it at my place in case of major problem, and it so happened that I had used it to treat my brother."
Extract 4. Article 11 - Protection of medical units and transports
1. Medical units and transports shall be respected and protected at all times and shall not be the object of attack..
2. The protection to which medical units and transports are entitled shall not cease unless they are used to commit hostile acts, outside their humanitarian function. Protection may however cease only after a warning has been given, setting whenever appropriate a reasonable time limit, and after such warning has remained unheeded.
Much was said about the Nord Ost hostage-taking, but we are hostages of our own profession and of the hospitals which are often fired at. Russian soldiers do nothing to spare us."
Recently, the raids of the Russian army in hospitals have decreased but not entirely stopped. Last autumn, hooded men broke into an operating theatre to kill a patient who was already under anaesthesia. After shooting the man, they destroyed the material and all the surgical equipment.
Raids into care centres are Usually rough and does happen that the members of the medical staff are ill-treated. All rooms are searched, inspected, there are identity checks, equipment is regularly damaged and soldiers hardly leave empty handed. Any patient suspected of being a fighter is taken away whichever state he is in.
Risk specialities
In the plain, surgeons, traumatologists and anaesthetists are most exposed. In case of wounds, Chechen fighters and Russian soldiers call on them first. Once again, whichever the circumstances, those specialists cannot refuse to treat them. Recently a surgeon was threatened with death by a whhabite fighter as he had refused to go and attend one of them and had to go into exile. One of his colleagues who had accepted was denounced and arrested by the federal forces. He disappeared and never found again.
In the mountains and in the villages where Chechen fighters are more numerous, all doctors are in great danger. Paediatricians, gynaecologists, surgeons run the same danger. Many disappear and arrests are quite common.
Extract 5. Article 7 - Protection and care
1. All the wounded, sick and shipwrecked, whether or not they have taken part in the armed conflict, shall be respected and protected.
2. In all circumstance shall they be treated humanely and shall receive to the fullest extent practicable and with he least possible delay, the medical care and attention required by their condition. There shall be no distinction among them founded on any grounds other than medical ones.
"After an explosion or an attack, soldiers must take the wounded to hospital, they cannot leave them on the road. Often, they just throw them in the entrance hall and wait. They observe to see what our reaction is. If we rush to the wounded, they suspect we know them and they demand their names and addresses. If we do not rush they ask us why we do not do our job. They take pleasure in lingering there while patients loose their blood. If they could let them all dye at the reception, they would do so .It is terrible for us. Whatever we do we are guilty of something."
Access to health care
In Chechnya, access to health care is always seriously hampered. Going through a number of check points delays access to medical structures. Cleansing operations organised by the Russian army with the purpose of closing a district or a village to carry out raids or proceed to identity checks prevent access to care totally for a few hours or a few days.
Health personnel, the wounded and the sick are frequently detained in this kind of operations. Moreover, after cleansing operations, the number of hospital admissions increases. As a general rule, people prefer to avoid hospitals or remain there as little as they can for fear of being arrested. They often leave after receiving emergency care. "A patient was brought in with seven bullets in his body, and both arms broken. We immediately operated. The following day, that is 12 hours after admission, his family took him away. We do not know whether he is dead or alive. This happens quite often, people do not want to stay in hospital, Although raids are not so frequent as in 2000, they are still terrified."
Ambulances cannot run freely, several have come under fire in spite of special authorisations. Curfew runs from 9 p.m. to 6 a.m., so night interventions are virtually impossible. Any person moving about at night may be sot at without warning. In Grozny it is strongly recommended not to come to a hospital after 5 p.m. In winter the night falls early and the federal forces do not wait for the official curfew time to open hostilities.
In Grozny, like anywhere else on the territory, civilian means of communications have not yet been restored. In hospitals, the Chechen militia make the situation worse. "A pregnant woman was attended to in our hospital. One evening, contractions began. As our gynaecologist was not on duty, we wanted to take her to the maternity hospital. We went to the nearest militia point and asked them to escort us. Which they accepted while pointing out they had no radio contact with the snipers on roofs, which meant, no means of asking them not to shoot at us. . ."
It is impossible to guarantee the supply of indispensable medical material to hospital. This supply is entirely in the hands of the military authorities: they decide to open or close the roads and may refuse to deliver the authorisations which the NGOs need on the territory.
"If access to hospitals was normal, hospitals would be full" This is what Chechen doctors unanimously say. "People are afraid of coming to hospitals, civilians die for want of access to health care. I keep an emergency kit at my place and I am beginning to set up birth kits, but I know this is dangerous. Too many women die because they have not been able to go to a hospital or a maternity hospital. Sometimes people come to ask for me at my place during the night. I know my life is in danger, but I cannot let them die.. Certain patients will not survive if they are not given immediate care. Waiting is impossible. Often at 6 o'clock in the morning it is too late."
During an enquiry covering the period from September 1999 to August 2002 it was possible to go through the epidemiological ant traumatology data connected with the armed conflict in 7 hospitals and medical centres, namely Gudermes, Urus Martan, Argun, Grozny hospital 9 and Grozny paediatrics hospital, Tsotsan Yurt and Nojaï Yurt. A recapitulation of the surgical activity directly connected with the conflict was also set up. A comparison between these data and the health data of Chechen population displaced in Ingushetia was also made.
The study has established that:
- In most hospitals in Chechnya important
variations occur in the number of out- patients as well as in traumatology
and surgery wards;
- Such variations are attributable to the increased or decreased intensity of the conflict as well as to the frequency of "cleansing operations" carried out by the Russian army (closing of districts and villages during the cleansing operations).
The very marked variations in hospital or medical centres attendance still persist particularly in traumatology and surgery wards.
Reliable indicators show that the situation is far from normal, contrary to what was officially announced by the Russian authorities.
Important decreases in the number of patients such as in Grozny hospital 9 are often directly attributable to Russian military incursions in this hospital and frequent raids in the centre of Grozny.
Hospitalisations even for serious wounds are very short. Patients leave care centres before their condition should allow them.
This is due to the fear of being arrested, to the permanent suspicion that a wounded person might be a fighter, and to the danger of being arrested in hospitals at any time by the Russian forces.
The men/women ratio is not very significant (5.3 men for every 10 women coming for consultations).
A substantial part of men above 15 have left Chechnya for fear of being arrested (as potential combatants).
Men avoid going to hospital, even when seriously wounded or in need of urgent care, for fear of being arrested at any time by the Russian forces.
Many pathologies have an obvious psychogenic cause (various functional disturbances).
The permanent atmosphere of war, the frequent "cleansing operations" by the Russian army foster fear and terror, which tends to explain the steady increase of psycho-traumatic and depressive syndromes.
A high proportion of children is clinically anaemic or has pathologies attributable to poor hygiene.
Such pathologies are the result of food deficiencies, and to the fact that families find it very difficult to move about to find food. Water and sanitation infrastructure, already destructed by the