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Life and death at his fingertips: watching a brain surgeon at work

Henry Marsh is one of the country's top neurosurgeons and a pioneer of neurosurgical advances in Ukraine. Erica Wagner witnesses life on a knife-edge.

Hands of a craftsman: surgeon Harry Marsh describes neurosurgery as bomb disposal work. Photo: Tom Pilston

It is just after lunchtime on a wet Monday in February when Henry Marsh is finally able to return to the operating theatre in the Atkinson Morley Wing of St George’s Hospital in Tooting, south London, and begin the work that will save a young woman’s life.

Jenny is not long out of her teens; the previous week, she had collapsed – from a haemorrhage, the result of an abnormality in the veins and arteries of her brain. She had been close to death: late at night, Henry had operated to remove a blood clot and save her life. But a later scan showed that the abnormality remained. If the problem was not corrected, she could suffer another bleed at any time. So this will be the second time he has been inside her skull.

While Jenny is prepared, Henry paces the hospital’s long corridors. There is time for us to sit and have a sandwich. He is restless: he wants to get on. He didn’t get this right the first time. He needs to get it right now.

I first encountered Henry Marsh late one night on my sofa. I was too tired to go to bed, and so kept the television on as one programme ended and another started. This was The English Surgeon, a 2007 documentary by Geoffrey Smith about the work that Henry has been doing for over 20 years now at the Lipska Street Hospital in Kyiv, Ukraine. Following a meeting with Igor Kurilets, a Ukrainian neurosurgeon struggling against the post-Soviet culture of poor resources and entrenched, old-fashioned thinking about medical care, Henry began volunteering his time in Kyiv. He brought not only his skills but equipment that had been discarded – generally for no good reason – by the NHS, packed up in wooden crates he made himself.

It is a remarkable, moving film and I was struck by the humane, caustic eloquence of its subject, which seemed unusual for a man in his profession. At the time I was running the books pages of the Times; I thought that he would make a fine reviewer. I emailed him, care of the hospital, not really expecting an answer, but he replied by return. Sure enough, he proved an excellent addition to my stable – and this month he’s published a fascinating memoir, Do No Harm: Stories of Life, Death and Brain Surgery, which is why I’m here with him now, waiting to stand beside him as he operates on Jenny.

Henry is 64: he will retire next year. He is tall and white-haired; outside the operating theatre he is given to wearing battered leather boots and a long duster coat. You read in books of people with “surgeon’s hands”, long, tapered and delicate. Henry’s hands are not like that, but rather like the hands of a skilled woodworker, a keen gardener and an energetic beekeeper, all of which he is. He wears round, owlish spectacles that give him the air of the don he might have been; his first degree, from Oxford, was in philosophy, politics and economics. Medicine came later – he didn’t become a junior doctor until the relatively late age of 29, after spells as a teacher in West Africa and a hospital porter in Ashington, Northumberland.

When he finally went to medical school, at the Royal Free Hospital in London, he wasn’t sure about his choice. “I thought medicine was very boring,” he says bluntly. Henry is not a man to refrain from speaking his mind. “I didn’t like doctors. I didn’t like surgeons. It all seemed a bit dumb to me.” In Do No Harm he writes of his revulsion at what much surgery generally entails: “long bloody incisions and the handling of large and slippery body parts”. But while working as a senior house officer, he observed a neurosurgeon use an operating microscope to clip off an aneurysm – a small, balloon-like blowout on the cerebral arteries that can cause catastrophic haemorrhages. It is intensely delicate work, using microscopic instruments to manipulate blood vessels just a few millimetres in diameter. It is also, as Henry says, like bomb disposal work, in that it can go very badly wrong – with the crucial difference that it is only the patient’s life at risk, not the surgeon’s. If this or any other kind of serious neurosurgery goes right, however, the doctor is a hero. “Neurosurgery,” he smiles, “appealed to my sense of glory and self-importance.”

Most senior surgeons are pretty vain; few, in my experience, are as aware of their vanity as Henry is. As Jenny is wheeled in to the theatre, he acknow­ledges his desire to be “an alpha male”, whether he’s performing surgery or riding his bicycle recklessly along the now-flooded towpaths in Oxford, where he lives with his wife, the anthropologist Kate Fox. (Henry never wears a helmet when he cycles. He has seen too many brain-injured cyclists, even those who’ve been wearing helmets, to wish to survive, should he ever get knocked off his bike.) The young woman’s brain scans are up on the big flat screens on the walls of the operating room; when Henry and his team begin, what they see through the operating microscope will also be projected on these screens.

In black and white, looking like the deltas of a river, are the veins and arteries of Jenny’s brain. The problem is that, in her case, arterial blood can escape into veins, which are not designed to cope with the high pressure of blood as it’s pumped from the heart. Arteriovenous malformation is the proper name for the condition.

“What proportion of the body’s blood goes to the brain?” Henry asks me – and for a moment my own heart is in my mouth, and I feel like one of the interns he questions in the meetings he holds every morning at 8am. He calls these “Hill Street Blues meetings”, after the American cop show, which always began with a similar gathering. They are, as far as Henry knows, unique to his hospital. I sat through one this very morning, six hours ago now, and watched a few young doctors quake under his interrogation. But, having read Do No Harm, I know the answer: 25 per cent; a quarter of the body’s blood feeds the engine of the brain. That is why this operation is so necessary, and so dangerous.

It has taken a while to get the patient ready for surgery because Henry has insisted that she have an angiogram – an injection of dye into her bloodstream which will show whether or not Henry has managed to seal off the vessels he is after – while still on the table. If the angiogram were to happen after surgery (which would make things much easier) and Henry hadn’t accomplished what he is setting out to do, he would have to go back in again, something he is less than keen to consider.

But setting up the angiogram so that it can be done during the operation isn’t simple. A few hours earlier, I’d watched Henry insist to another doctor that the procedure really was necessary. It was clear that he wasn’t going to take no for an answer; it was clear, too, just how insistent he had to be.

Henry’s persistence is probably his chief characteristic. “Zing”, he calls it, a restless energy that always looks for another problem to solve. It is this “zing” that got his patient the angiogram; it’s also what got him to Ukraine. It’s the force behind those morning meetings; and it enabled him to raise over £100,000 so that one of the balconies on the ward could be converted into a roof garden for the use of patients and staff.

Another few thousand pounds was raised to convert an unused biohazard lab into an “on-call” room for his fellow surgeons: a quiet place with a bed, and a desk, and a computer where they can rest between rounds and operations. (Most hospitals used to have these; the European Working Time Directive, which states that doctors must not work more than 48 hours a week, other than by choice, supposedly put paid to the need for such places. Unsurprisingly, Henry doesn’t have much truck with the European Working Time Directive, but not merely because he worked long hours in his youth and believes that “if it doesn’t hurt it’s not worth doing”. Shorter hours produce much less continuity of care, and much less training for young doctors.)

Although he is one of the most senior and experienced neurosurgeons in the country, and pioneered surgery performed under local anaesthetic in the UK, Henry insists that he is not a great surgeon. The surgery itself, he says, is not technically difficult. “It’s the decision-making that is complex and difficult; you are making very human decisions, about the quality of life and the way people will be affected.” This in turn requires a considerable emotional investment – in the patients, in the work. He knows that senior management believes neurosurgeons are arrogant. He does not disagree. “Neurosurgeons deal with life and death every day. It makes you pretty impatient with the tick-boxing that exercises managers.”

Do No Harm is in many respects a self-lacerating document: by and large, it contains stories not of triumph, or the author’s skill and expertise, but of the emotional and psychological toll exacted when things go horribly wrong. When patients are left paralysed or blind, or when they die, it is the surgeon who walks away. Because of this, Henry says fiercely: “Doctors cannot suffer enough.”

His understanding of the nature of suffering is deep and personal. When he had just qualified as a junior doctor, his three-month-old son, William, was diagnosed with a brain tumour. It had been a normal birth, but then one night, as Henry tells it, “My first wife felt he wasn’t quite right. His fontanelle, the soft spot, was very tight – which can be a sign of swelling in the brain. So she took him to the clinic, and they measured his head and said it was far too big. He was admitted as an emergency to the local hospital, in Balham, and she rang me to say that he’d been diagnosed as acute hydrocephalus”: swelling in the brain. A brain scan showed the tumour.

“He was operated on a week later – and it was absolutely torment waiting. The main thing I remember was that at the end of the operation we didn’t know what had happened; we had to wait a few hours for the surgeon to find out. I learned a hugely important lesson from that: which is that when your nearest and dearest are undergoing brain surgery, it’s extremely miserable.” William’s tumour was removed, and he is fine. He is the eldest of Henry’s three children; there are also two daughters from the marriage, Sarah and Katharine.

Scrubs up: Marshs post-surgery decisions determine his patients quality of life. (Photo: Tom Pilston)

As a result of this terrible experience with his own son, Henry always rings the family as soon as possible after serious surgery and waits until the patient is awake in recovery. Only then can he be sure that an operation has been wholly successful. He doesn’t think many surgeons make these sorts of calls. “It’s a kindness; it shows you understand what relatives are going through. But also, if things go wrong, mostly people will forgive you.”

He is less willing to forgive himself. Most of the chapters in Do No Harm have titles taken from abnormalities of the brain: “Aneurysm”, “Meningioma”, “Astrocytoma”. But towards the end there is one called “Hubris”, which recounts the story of an operation that took place over two decades ago, on a man with a petroclival meningioma, a benign but extremely large tumour. The procedure took 15 hours – and towards the end of all those hours Henry, attempting to remove the last bit of the tumour, tore the artery that keeps the brain stem alive, causing catastrophic damage and leaving the patient in a permanent vegetative state. He no longer does 15-hour operations.

As Jenny’s prone form is brought into theatre, his team springs into life. “The quality of my working life is largely determined by the quality of my junior doctors. It’s in my interest that they’re happy,” Henry has said to me – and the same applies to everyone he works with: anaesthetists, nurses, technicians. Operating isn’t solitary work, and I am one of at least half a dozen people present. He greets hospital porters by name. He has worked with Judith Dinsmore, his anaesthetist, for over a decade; one of his aides in theatre has been assisting him since he became a consultant in 1987, as has his secretary, Gail Thompson.

This situation is now highly unusual in the NHS; as in so many other organisations, the perception is that centralisation brings benefits of streamlining and cost efficiency. The men and women who work with Henry Marsh think otherwise. A few days after this operation, Gail describes how she is supposed to schedule Henry’s clinics through a central booking service but does not. “A central booking service won’t keep slots aside for emergencies, for instance. I know Henry’s patients, so when they ring I know if it’s serious or not, and I can deal with it appropriately. Centralisation in the NHS is stopping all that.”

Tim Jones, the specialist registrar, begins to set Jenny’s head in a Mayfield clamp, an alarming-looking metal jaw that holds the patient’s head steady during surgery. Sharp pins drill bloodlessly through the scalp and grip the skull tightly.

Tim is 35, and the person Henry sees as his likely successor. A charming and energetic man – tirelessly helpful to a novice like me in the operating theatre – he took three years out of his medical training to do a PhD in physics because he is very interested in imaging technology, such as the scanner he will soon use to pinpoint where Henry will need to get to inside Jenny’s brain. Last year he won the Norman Dott Medal for outstanding performance in the Intercollegiate Specialty Examination in Neurosurgery, a rare honour. It’s worth remarking that four out of the immediate past five winners of the award have worked in the Atkinson Morley unit at St George’s.

Henry stresses that these surgeons have worked with many other doctors besides himself – but clearly Tim, at least, finds his boss an inspiring figure, not least because he is so open about discussing his own mistakes. This is extremely unusual, in Tim’s experience. “He calls it ‘the departmental hairshirt’,” he laughs. When I ask Tim if he is married, he laughs again. “No. I don’t even own a house. I’m a bit of psychopath, I guess. You have to be to do this job.” Performing surgery, he says, is “exhilarating” – a sentiment that Henry seconds.

Because Jenny has been operated on before, the incision in her head is already there. Tim cuts open her stitches. During surgery the patient is almost entirely draped in sterile sheeting, with only the area on which the surgeons will be working left visible, the edges of the wound held tight with small blue clamps that look almost like paper clips. There is a great deal of blood in the scalp, and the clamps keep the incision from bleeding. As Jenny’s head is opened Henry pulls up his chair, and the operating microscope leans over the patient like an inquisitive crane.

“Here,” he says. “Have a look.”

I come close to his shoulder and look down into the microscope’s second eyepiece. A glittering, undulating landscape of shining whites and greys and reds is revealed in vertiginous 3D; to look through this remarkable instrument (each one costs about £120,000) is to feel as if you could step right into the patient’s brain.

“There,” Henry says, pointing with a delicate instrument at a pulsing, slender cord to the right of my field of vision. “Artery. Mustn’t touch that. Touch that, the whole thing’s over.”

Looking down, I find myself thinking how impossible it is, finally, to comprehend that what I am observing – the matter of the brain – is everything we are. Here is the soul, here is the mind, here is every thought we might have or ever have had about the world around us. Nothing more than shining, pulsing matter. It seems far more difficult to consider than the idea that the pinpricks of light we see as stars in the sky are enormous burning balls of gas thousands of light years away. Our understanding of the universe, our understanding of those stars – it’s right here, under this microscope. From my earlier conversations with Henry, I know that despite his years as a surgeon (indeed, perhaps because of his years of work as a surgeon), he finds this notion as remarkable, and as puzzling, as I do.

See it through: Marsh performs delicate work inside a patient’s skull. (Photo: Tom Pilston)

When I first met Henry, he planned to work until he was 67. He changed his mind when he was threatened with disciplinary action for wearing a wristwatch as he walked through the hospital last year. The rule now is “bare from the elbows down” – not just in the operating theatre, obviously, but anywhere at work.

The episode still fills him with an ill-disguised anger. “If you treat people like naughty children, they’ll behave like naughty children. I love my work: I have my limits.” But it was the last straw in a long line of grievances he bears against the increasingly unwieldy machinery of the NHS in the 21st century. It’s much harder for him to raise money now, he says, for things such as the roof garden, or the beautiful photographs he has arranged to have hung in the ward so that his patients have something pleasant and distracting to look at, rather than peering out at the cemetery just beyond the building’s walls.

“People were willing to give money when they felt it was more like a charitable organisation – but now that the NHS is being privatised by the dumb fucks who run the government, people think: ‘Why should I give money to the NHS?’ Now the buses are owned privately, you think: ‘Why should I give way to the bus?’ Whereas when it was a public service, you thought: ‘I’ll let the bus go first.’ But I’m not going to do that now! You lose a lot that way.”

It is the failings of the NHS that make headlines, he knows, not its successes. “There’s all this mouthing off about how we have to have a ‘blame-free’ environment – but it’s blame, blame, blame all the time. One is no longer trusted. Of course, in any system there’s a certain small percentage of people who are freeloaders or incompetents; but if you design all your systems to deal with that percentage, you may end up so pissing off the 95 per cent of people who are the good guys that you lose more than you gain. I don’t know what the answer is. I’m glad I don’t run the NHS. But you have to trust people.”

Would I trust Henry if I were a patient, or a patient’s relative? I reckon I would. In the day I spend at the hospital I see two surgeries. Before Jenny’s operation in the afternoon, Henry and Tim work together on an older man, who, by a very peculiar coincidence, is suffering from the same kind of malignant tumour that killed my father a few years ago, a glioblastoma.

My father’s was deep in his brain and inoperable; this patient’s tumour is closer to the surface, though it has already cost him much of his eyesight. The operation will be no cure; Henry has made it clear it might buy him a bit of time, but not much. “More and more of modern medicine is palliative, anyway,” he says. “We are not curing people; we’re keeping people alive. These are quality-of-life issues. They are very hard decisions to make: do I want more chemotherapy? Should I have a double mastectomy? These are hard for patients, too.”

The radiotherapy my father was given was probably useless, Henry tells me as Tim opens the patient’s skull. And indeed, although my father spent nearly six weeks in hospital to have it, it didn’t seem to do much good. I have never discussed this with Henry before; now I consider the six weeks my father might have had at home, rather than in hospital – institutions that Henry compares baldly with prisons.

In the afternoon, Jenny’s operation took longer than expected. Henry had said he thought he would been done in an hour or so; in the end, he was working for about four hours. Not one, but three interoperative angiograms had to be done to check that he’d done the job. Sitting straight in his chair – its arms holding his own arms steady as he moved his instruments with finely calibrated delicacy – Henry peered through his microscope, using an electrical current to cauterise the three tiny blood vessels in her brain which were putting her in such danger. Often, he has said, there are many more blood vessels to seal off in such cases, but Jenny’s were tricky because they were so very tiny, and so close to a major artery, as I saw. (This is the stuff, remember, that he thinks is “not difficult”.) Jenny’s operation was a success. She went home from hospital two days later and her problem will not recur.

The prospect of retirement is rather alarming to Henry. He will keep his bees; he will build bespoke bookcases in his workshop; he will, no doubt, lecture (and continue to work as a surgeon) around the world. He plans to go back to Ukraine at the end of this month despite the trouble there.

His hospital in Kyiv is off Maidan Neza­lezhnosti – Independence Square, where the revolutionary protests took place. He is in touch every day with his friends there, all of them Ukrainians who dislike the Russians and hate Vladimir Putin, he says. “I’ve always believed very strongly that Ukraine was an incredibly important country. Because it is the focal point, the pivot between east and west, which goes back hundreds of years. You’ve got Asiatic Russia to the east, and western Europe to the west. It’s one of the most profound fault lines in Europe.”

His colleagues’ concern – for their safety, for their future – is tempered by a certain fatalism. “They’ve always lived in a country where the state is essentially against you. We in the civilised west may criticise our politicians and the state, but the default feeling is that the state is there to help you. In places like Ukraine and Russia, that has never been the case. The state is your enemy. It’s very hard for us to imagine that. It’s very much rulers and ruled.”

Henry says he doesn’t fear for his own safety: but playing it safe has never been his way. His seeming arrogance and self-regard (“Kate and I have been rehearsing a few interviews, so that when I’m asked, ‘Why did you write this book?’ I’ll say: ‘To draw attention to myself.’ That’s the honest answer”) are undercut by his sincere knowledge of his own fallibility – and the price that fallibility can exact. A rueful shrug. “My life is a succession of proving to myself that I’m not as frightened as I think I am.” 

“Do No Harm: Stories of Life, Death and Brain Surgery” by Henry Marsh is published by Weidenfeld & Nicolson (£16.99)

Erica Wagner is a New Statesman contributing writer and a judge of the 2014 Man Booker Prize. A former literary editor of the Times, her books include Ariel's Gift: Ted Hughes, Sylvia Plath and the Story of “Birthday Letters” and Seizure.

This article first appeared in the 12 March 2014 issue of the New Statesman, 4 years of austerity

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Brothers in blood: how Putin has helped Assad tear Syria apart

The Syrian catastrophe has created the worst humanitarian crisis since the end of the Second World War. And the world watches helplessly as Putin and Assad commit war crimes.

Sometimes we know the names. We know Omran Daqneesh, the five-year-old boy who, covered in mud and dust, was pictured on the back seat of an ambulance in the aftermath of an air attack. We know his name because pictures and a video of him were released on social media and travelled around the world. The outrage that followed was widespread and sincere, the image of the dazed little boy seeming to symbolise the greater plight of the beleaguered residents of Aleppo. But then the moment passed. Few will know that a few days later doctors announced that Omran’s elder brother Ali, who was injured in the same air strike, had died from his injuries. He was ten.

Sometimes we know the names of the babies pulled from the rubble of collapsed buildings – occasionally alive, but often dead; or the names of the children weeping over lost parents; or the women grieving over lost husbands and children; or the elderly simply waiting (and sometimes wanting) to die.

We know Bana Alabed, the seven-year-old girl trapped inside Aleppo whose Twitter account has gone viral in recent weeks. “Hi I’m Bana I’m 7 years old girl in Aleppo [sic],” reads the on-page description. “I & my mom want to tell about the bombing here. Thank you.”

A series of pictures depicts Alabed and her mother, Fatemah, struggling to live as normal a life as possible, one showing the little girl sitting at an MDF desk with a book. Behind her, in the corner, is a doll. “Good afternoon from #Aleppo,” says the caption in English. “I’m reading to forget the war.”

The conflict, however, is never far away. Alabed, whose mother taught her English, has repeatedly tweeted her own fears about dying, followed by stoic messages of defiance whenever the immediate threat of an impending air strike passes. On the morning of 3 October, her words were simply: “Hello world we are still alive.” On 17 October, Fatemah tweeted: “The airstrikes ended in the morning, all the last night was raining bombs.”

But in most cases we never know the names of the victims of air assaults led by Presidents Bashar al-Assad and Vladimir Putin. One of the most haunting images to emerge in recent weeks was that of a mother and child, killed while sleeping in the same bed. The scene had an eerily preserved-in-amber feel to it: a snapshot of snatched lives, frozen in the act of dying. Pictures of ruined buildings and distraught civilians have become routine now, holding our attention briefly – if at all.

As many as 500,000 people are believed to have been killed since the beginning of the Syrian uprising in early 2011. According to a report released in February this year by the Syrian Centre for Policy Research, a further 1.9 million have been wounded. Taken together, those figures alone account for 11.5 per cent of Syria’s pre-revolutionary population. Combine that with the number of Syrians who have been displaced – more than ten million (almost 50 per cent of the population) – and the sheer scale of the disaster becomes apparent.

The conflict has become the worst humanitarian crisis since the Second World War. Today it centres on Aleppo, in north-west Syria, one of the oldest continuously inhabited cities in the world, and a cradle of human civilisation. Various conquerors from the Mongols to the French have fought battles there but none, so it would seem, has been quite as ruthless or committed to the city’s annihilation as Bashar al-Assad.

Aleppo remains the most significant urban centre to have been captured by the anti-Assad rebels, most of whom will (by now) be strongly influenced by an Islamist world-view. Indeed, the most prominent fighting groups on the rebel side are overwhelmingly Islamist in their troop composition and beliefs, a sad marker of Western failures to support secular forces that led the anti-regime resistance in the incipient phases of the uprising.

Yet Aleppo remains too important to fail. Although rebel forces succeeded in capturing only half of the city – the western side remained firmly in the control of the regime – the symbolism of anti-Assad forces holding ground in Syria’s second city (which also served as the country’s economic hub) has buoyed the rebel movement.

Assad is more brazen and bullish than at any other point since eastern Aleppo fell into rebel hands in July 2012. That optimism is born of a strategy that has already worked in other parts of the country where the regime’s troops have slowly encircled rebel-held areas and then sealed them off. Nothing can leave, and nothing can enter. Once the ground forces seal off an area, an aerial campaign of barrel bombs and missile attacks from both Syrian and Russian fighter jets inevitably follows.

To get a sense of just how terrible the aerial campaign has been, consider that the United States accused the Russian air force of potential war crimes when a UN aid convoy was bombed just west of Aleppo last month. It was carrying food and medicines when it was hit. Since then, the UK and France have said that Russia’s bombardment of Aleppo amounts to a war crime.

Putin’s support has come as a boon to Assad ever since Russia formally entered the conflict in September 2015. Despite his administration already using Iranian forces and aligned groups such as the Lebanese Shia militia Hezbollah, rebels had continued to make significant gains throughout the early months of 2015. The most important of these was the capture of Idlib city, 40 miles from Aleppo, which presented Assad with two problems. The first was that it dented the official narrative of revanchist military successes by his forces. The ­second was that it handed the rebels power in a province adjoining Latakia Governorate in the west, where Syria’s Alawites are largely concentrated (Russia has an airbase in an area south-east of the city of Latakia). The Alawites are a heterodox Shia sect to which the Assad family belongs, and which forms the core of their support base.

Keen to reverse these gains – and others made elsewhere – Assad enlisted Putin, given Russia’s long-standing interests in, and ties to, Syria. The Kremlin has long regarded Syria as an important ally, and has served as the country’s main arms supplier for the past decade. There are important assets to preserve, too, such as the Russian naval base in the port city of Tartus on the Mediterranean, which was first established during the Soviet era.

For his part, Putin has felt emboldened by events. The world is changing – not just in the Middle East and North Africa, where the
contours of power continue to be recast, but also closer to home in Ukraine, where the pro-Russian president Viktor Yanukovych was overthrown in 2014.

The West is still haunted by the 2003 invasion of Iraq and has been reluctant to be drawn too deeply into the Syrian War. In 2013, the Assad regime used chemical weapons against its own people. This was a violation of President Barack Obama’s so-called red line against the use of chemical weapons, but no retaliatory action came and there was nothing to prevent the Kremlin from using force to shape events in Syria – as it had done in Ukraine.

All of this has marked a new phase of brutality in a conflict already noted for its barbarism. Civilians who avoid death from combined Russo-Syrian air assaults suffer under Assad’s strategy of “starve or submit”, in which supplies are withheld from besieged areas, slowly choking off those ­inside. It has been used to devastating effect against civilians in towns such as Madaya and in Daraya, on the outskirts of Damascus, both of which fell to government control after being sealed off from the outside world for several years. Such a strategy is not designed to deliver quick victories, however. Consider how the residents of Daraya defied Assad’s forces for four years before capitulating in August 2016.

Assad and his allies (Putin, Iran, Hezbollah) have decided to punish and brutalise, deliberately, civilian populations in rebel-held areas. To invert the famous aphorism attributed to Chairman Mao, they hope to dredge the sea in which the revolutionaries swim. And so, it is the 300,000 residents of eastern Aleppo who must suffer now.




It’s easy to lose track of precisely what is happening in the Syrian War as parcels of land swap hands between rebels and the regime. Assad’s forces first began encircling Aleppo at the start of July this year and succeeded in imposing a siege by the middle of that month, after cutting off the last of two rebel-controlled supply routes into the city. The first was the Castello Road, which leads from the town of Handarat into the north-western part of ­rebel-controlled territory. The second route, via the Ramouseh district (which led into the south-western end of the city), had already been sealed off.

The closure lasted for roughly four to five weeks before the rebels re-established access. Aleppo is too important for them, and the siege has forced various groups to work together in breaking it. The effort was led by Jaish al-Fateh (JaF, the “Army of Conquest”), an umbrella group and command structure for several of the most prominent jihadist and Islamist groups operating in northern Syria. JaF also co-ordinated the Idlib military campaigns. One of its key members is Jabhat Fateh al-Sham (JFS, “the Syrian Conquest Front”), which was previously known as Jabhat al-Nusra (JaN or “the Supporters’ Front”) and was recognised as al-Qaeda’s official chapter in Syria.

Several months before the regime began its assault on Aleppo, rebel groups in the north recognised the deteriorating situation there, stemming principally from Russian air strikes. As a result, al-Qaeda urged the various factions to merge and work together to counteract not just Assad, but also Putin. Even the global leader of al-Qaeda, Ayman al-Zawahiri, issued a speech last May titled “Go Forth to Syria”, in which he called on all fighting groups to unite in order to consolidate their control across the north. This opened the way at the end of July for Jabhat al-Nusra to declare that it was formally severing its links with al-Qaeda. It “rebranded” as Jabhat Fateh al-Sham.

There are two reasons for doing this. The first is to erode partisanship among the Islamist groups, forcing them to set aside differences and narrow their ambitions in favour of the greater goal – in this case, the breaking of the siege of Aleppo, while also deepening rebel control across the north. The second aim of rebranding is to win popular support by portraying themselves as fighting in the service of ordinary civilians.

Groups such as JFS and others are succeeding in both of these goals. Responding to the abandoned and assaulted residents of Aleppo, they have repeatedly demonstrated their commitment to alleviating the humanitarian crisis. Much of their messaging echoes this theme. The group’s English-language spokesman is Mostafa Mahamed, an Egyptian who previously lived in Australia. “[JFS] is deeply embedded in society, made up from the average Syrian people,” he explained on Twitter, after the group decoupled from al-Qaeda. “We will gladly lay down our lives before being forced into a situation that does not serve the people we are fighting for . . . jihad today is bigger than us, bigger than our differences.”

It is indisputable that this ethos of “fighting for the people” has endeared the group to civilians living in besieged areas – even when those civilians don’t necessarily agree with the full spectrum of its religious beliefs or political positions. That goodwill was only reinforced when the group helped break the siege of Aleppo (in which approximately 500 rebels were killed) in August, if only for a few days. Assad reasserted control within a week, and entrapped the residents again in the middle of that month. The rebels are now planning how to break the siege decisively, but have not yet launched a major counteroffensive.




A freelance American journalist and film-maker, Bilal Abdul Kareem, who has reported on rebel movements inside Syria more intimately than most, has found himself among those trapped inside eastern Aleppo since the siege was restored seven weeks ago. “We came here expecting a two- or three-day trip,” he told me during an interview over Skype.

Life inside is becoming insufferable for civilians, Abdul Kareem said; every building is potted and scarred by shrapnel damage. Those whose homes remain standing are the lucky ones. “Your day consists of nothing,” he said. “There’s no work, there’s no fuel, no industrial zone, no food to sell. ­People sit around and chit-chat, drink tea, and that’s all they do.”

Food supplies are already running low, with most people limiting themselves to basics of chickpeas and groats – crushed grains such as oats or wheat. Sealed off from the rest of the world, those inside preoccupy themselves with survival and wait for the next wave of attacks.

It is tempting to ask why the inhabitants of Aleppo did not flee when they had the chance. Indeed, the Assad regime routinely accuses the rebels of preventing civilians from leaving besieged areas, though there is no evidence to support this view. On 17 October Russia and the Syrian regime said they would halt their bombardment for eight hours on 20 October to allow rebels and civilians to evacuate the city.

In truth, what choice do the civilians have? Most do not trust Assad and they are therefore unwilling to move into regime-administered areas. The alternative is to become refugees, with all the uncertainties and trials associated with that. For instance, refugees have found themselves subject to sectarian violence in Lebanon, and they have few opportunities to find employment in Lebanon, Turkey or Jordan, the three countries where most of the fleeing Syrians have found shelter.

For them, merely to exist in rebel territory is an act of defiance, which is precisely why Assad’s forces make no effort to distinguish between combatants and civilians in rebel areas. To be present is a crime.

The effects of this have been devastating. A spokesman for the Syrian American Medical Society told Middle East Eye, an online news portal, that in July, Syrian and Russian jets had hit medical facilities in rebel-held territory every 17 hours.

Only a few hospitals and medical staff remain. The physical conditions are primitive and perilous. Doctors work in makeshift facilities – a former flat, a commercial garage – which makes them unable to provide anything beyond basic emergency care. In-patient facilities are non-existent, not just because of high demand from those newly injured in fresh attacks, but also from fear that the facility itself will be targeted. “People are literally shuffled out of the hospital with IV [intravenous drips] in their arms,” Abdul Kareem says.

The West’s indifference to all this – coupled with its occasional pious pronouncements and diplomatic dithering – has squandered any goodwill Washington might once have had among Syria’s beleaguered civilians. When Sergey Lavrov, Russia’s foreign minister, and John Kerry, the US secretary of state, agreed a ceasefire in September it lasted barely two days because they overlooked the fears of those trapped inside eastern Aleppo.

The deal had stated that no party would try to capture any new territory. That might seem reasonable enough but given that the ceasefire came into effect just days after Assad re-established the siege of Aleppo, those on the inside were being asked, in effect, to acquiesce to their own starvation.

Deprived of food and medication, no one trusted Assad to negotiate access in good faith, especially after he thwarted UN efforts to deliver aid. “People saw it as a conspiracy,” Abdul Kareem told me. Moreover, there were no significant groups inside eastern Aleppo that claimed to have accepted the terms of the ceasefire in the first place. Kerry had negotiated on their behalf without approval and without securing any humanitarian concessions.

“What planet are these people on?” Abdul Kareem asked. “[Do] they think people will turn on their protectors, for people who didn’t do them any good? They look to JFS and Ahrar [Ahrar al-Sham is one of the Islamist groups fighting in JAF]. Western intervention is pie in the sky.”

The rise of these reactionary rebels is a direct result of liberal elements not being strongly supported at any stage in the conflict. Left to fend for themselves, many have deserted their cause. Those who have persisted not only risk the constant threat of being killed by Russo-Syrian bombs, but are also at threat from jihadist elements operating in rebel areas. That much was clear when remnants of the secular opposition protested against the leader of JFS, Abu Mohammed al-Golani, in the southern Idlib town of Maarat al-Nouman earlier this year. Many of those who did were arrested by jihadists and intimidated into silence.

Whereas liberals are fragmented and frayed, the Islamist rebels continue to coalesce into an ever more coherent unit. The overwhelming might of Russian airpower has convinced them of the need to form a united front in order to pool their resources and co-ordinate their efforts. That is one of the reasons why a jihadist group called Jund al-Aqsa (“Soldiers of al-Aqsa”) announced early this month that it was disbanding and being absorbed into JFS.

Herein lies the real story of how Aleppo – and, indeed, Syria itself – has been delivered to the jihadists. A conspiracy of all the external parties has forged a menacing millenarian movement that is embedded in civil society and communities across the north. Whether Aleppo falls or not, the jihadists will endure.

Shiraz Maher is a contributing writer for the New Statesman and a member of the war studies department at King’s College London

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood