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Carolyn Ho

Archit Baskaran

Northwestern University

At the height of the Arab Spring protests in 2011, Syrian civil society entered a downward spiral into chaos. Initially peaceful protests against President Bashar al-Assad eventually morphed into an armed rebellion. As the war has grown exponentially, so has the devastation of Syria and Iraq. The issue of healthcare is often left silent in the backdrop of issues prevalent in the war. Three years of government bombings and Daesh expansion have ravaged Syria’s health capacity. Daesh militants are embarking on a brutal campaign against health providers and infrastructure throughout Syria and Iraq in controlled territories. Meanwhile, Daesh is attempting to promote a healthcare delivery system among other social services in order to gain support from local populations in controlled territories, but these actions are inconsistent.1 This requires research into how Daesh attempts to create a functioning apparatus for healthcare delivery. Scholarly analysis on the topic of Daesh and its administration of healthcare remains sparse. This paper will explore the paradox in which the terrorist group operates, the bureaucracy it has created to deliver health services, the deficiencies preventing effective delivery and its governing philosophy on health. To win the war against Daesh, the traditional counterterrorism strategy advocating military force must be coupled with effective social service delivery to win over the hearts and minds of the local populations under Daesh control. In this strategy, healthcare is a crucial component of understanding and defeating Daesh.

A Diagnosis of the Problem: Health as an Instrument of Warfare

“One doctor in Mosul said that earlier this month, he witnessed a patient arguing with a physician affiliated with the Islamic State. The next day, militants brought the patient to the hospital lobby, where they whipped him and forced him to apologize to the physician. Of course, those of us who didn’t join them, we are all living in fear.”2

– Personal Account from a Syrian Physician

In Arabic, there is an adage, “المؤمن مصاب (il-mo’men muSaab),” which in English roughly translates to, “the righteous always suffer.” Since the onset of the Syrian Civil War in 2011, following what was at the time a peaceful protest by righteous civilians against an authoritarian regime, a variety of social structures—human rights and peaceful co-existence among differing demographic, income and racial groups—have collapsed, corroding the essential fabric that holds Syrian and Iraqi civil society together. Social dynamics, having been exploited by all actors in the conflict, have internally disintegrated, exposing brutal sentiments among government bureaucrats, civilians and insurgents engaged in warfare. Over the past four years, the power dynamics within Syria have transformed as Hezbollah, other non-state military groups and the Islamic State of Iraq and the Levant (ISIL, ISIS, IS, or Daesh) have entered the conflict. Civilians trapped in the middle of a war with no apparent solution have since been lost within the epicenter between government forces and terrorist factions. The tides have turned in favor of The Islamic State of Iraq and the Levant (ISIL), alternatively referred to as “The Islamic State (IS)” or “Daesh” in Arabic. This paper refers to the group as “Daesh” in order to de-legitimize the narrative that promotes their status as a state or as a valid Islamic entity.

Thus far, the West has heavily securitized the war. That is, the West has viewed the war primarily from a military perspective, concentrating on varied prescriptions of armed force to combat the growing extremist threat.3 Washington’s policies toward Daesh have centered on traditional counterterrorism strategies; in fact, the Obama administration recently convened a summit on countering violent extremism in which leaders reinforced that Daesh was “primarily a counterterrorism challenge.”3 However, Daesh has proven to be more than just a terrorist threat that can be addressed using only traditional counterterrorism strategies. Instead, “what’s needed now is a strategy of ‘offensive containment’: a combination of limited military tactics and a broad diplomatic strategy to halt ISIS’ expansion, isolate the group and degrade its capabilities.”3 This involves the use of soft power to win over the hearts and minds of the locals, i.e., coupling social services with military force.

Against the backdrop of military and politics within this conflict bubble, however, have existed largely ignored yet crucial narratives of civilian life, most notably in the health sector. One of the most distressing aspects of the war has been the sheer devastation of health architecture throughout Syria and Daesh-controlled regions in Iraq, alongside the persistent denial of aid delivery, access to care and health infrastructure as a means of protecting wounded and fleeing civilians.4 The injuries to both civilians and institutions have been catastrophic. In the past three years of the war, Syrian armed forces and Daesh extremists systematically targeted civilians followed by their health facilities and personnel, reflecting a new and horrific trend, a departure from previous wars—no longer indiscriminate devastation that affects health infrastructure, but rather, the destruction of health infrastructure as one of the primary goals of the oppressing faction.

The aggregate consequences are clear when comparing the situation in Syria before and after the war. Prior to the conflict, “Syria’s healthcare system was thriving, with hospital and doctor levels equivalent to other middle-income countries such as Brazil, Turkey and China. Life expectancy was 76 years. Over three-quarters of the country’s disease burden was of the Western, non-communicable type (hypertension, diabetes and so forth).”5 Today, according to the Syrian American Medical Society and the World Health Organization, approximately 60% of hospitals and 90% of the local pharmaceutical industry have been destroyed, 78% of ambulances are severely damaged and 70% of the remaining medical staff cannot access their workplaces.6 In certain provinces, upwards of about 90% of all physicians have left or have been killed, and in the stronghold of Aleppo less than 250 physicians remain, creating a physician-to-patient ratio of about 1:500,000.6 This mass campaign against physicians has been wholly arbitrary, for physicians are either severely punished or killed for expressing even the slightest antagonism toward Islamic State fighters.7

Polio has returned to Syria after fourteen years, and infectious disease outbreaks—“hepatitis, measles, leishmaniasis, multi-drug-resistant tuberculosis, [and] typhoid”—are on the rise as the provision of vaccinations has fallen drastically.5,6 Daesh is not the sole culprit for the majority of these issues. Physicians for Human Rights found that the Syrian government is overwhelmingly responsible for the deaths of medical personnel throughout the country.8 Since 2011, the government has been “bombing hospitals in opposition-held areas and detaining, torturing and executing doctors who were adhering to medical ethics by treating the wounded regardless of their political beliefs.”9 The doctors who have risked their lives to remain in Syria and treat the injured have been decimated by Bashar al-Assad’s forces, which consider it a crime punishable by death to provide medical treatment to “the other side.”9 Simply put, medical personnel are the unfortunate victims of the Syrian civil war because they are viewed as allies of the rebel forces.5

Since its rise in 2014, Daesh has been compounding the government’s violence with destruction of its own. Daesh fighters have, to date, been attacking numerous civilian hospitals and foreign health providers serving with organizations such as Doctors without Borders, abducting and killing patients, doctors, nurses and international health aid workers, etc.10 Kurdish media reports indicate that Daesh militants have been targeting and killing physicians that refuse to provide treatment for wounded Daesh soldiers.11 Last December, a group of Daesh fighters executed two top emergency surgeons within the Mosul Health Department by firing squad for their unwillingness to transfer to a field hospital.12 Daesh’s “drive against hospitals has led to an exodus of doctors from Syria, adding to an already severely strained health care system.”10

The human rights situation for female physicians has been particularly concerning. Female doctors interviewed about conditions in Daesh-controlled hospitals explain that in Mosul, women are denigrated as objects of a religious will, and rather than being viewed as providers of service, women are objectified as receivers of the terrorists’ imposition of control. Women are forced to wear the veil against their will, and female practitioners who choose not to wear a veil over their face at health facilities are barred from entering hospitals. Such decrees are highly reminiscent of Taliban rule in Afghanistan.13 A Syrian, female gynecologist reflects on a time when she was scheduled to perform a surgery, but she was denied access to the surgical ward because she was not wearing a veil. The Daesh militants told her to “let the patients die…what matters is your veil.”13 Accordingly, in the Daesh stronghold of Raqqa, hospitals are almost completely devoid of female doctors, and the few female nurses there are forbidden to work in a healthcare setting without permission and physical company of a male mahram, a designated male watch guard.14 What’s more, Daesh militants have subjugated and sexually abused women and girls in controlled areas as documented by the United Nations.15 Clearly, from a human rights angle, the atrocities perpetuated and magnified by Daesh factions have created an exceptionally hostile environment for healthcare providers, fundamentally altering the dynamic of the war against civilians who are constantly barraged by government weaponry and militant barbarity. In many ways, there seems to be little hope for survival, ergo the only solution is to flee, intensifying many pre-existing spillover issues, such as refugee displacement, unstable medical geography and mass death. According to Amnesty International, more than 10 million people—45% of Syria’s population—have been displaced, and nearly 190,000 people have been killed. 10.8 million people require urgent humanitarian assistance in Syria alone.16

The potential short-term solutions to mass health catastrophe for most wars would be the obvious provision of healthcare by international agencies and relief organizations. This is not feasible with Daesh. Not only has Daesh refused to negotiate with international third parties to allow for foreign medical aid delivery, but they have also obstructed the importation of medicine for hundreds of thousands people, for example, in the Al-Hasakah governorate.7,17 Furthermore, Daesh has periodically and systematically been diverting food and health aid meant for the most disadvantaged Syrians to its own militants and militant families in order to maintain power. For example, Daesh militants have stolen German generators worth at least $300,000 and denied food aid for over 600,000 Syrians in Deir Ezzour and Raqqa provinces.18 Furthermore, when Daesh negotiates aid delivery convoys to territories under its control, it places at least one of its members in charge to work out the terms of the agreement with the other party. This leads to the diversion of aid to terrorists.

This paper focuses on Daesh’s violence because of the indiscriminate destruction of those healthcare apparatuses that remain following government bombardment. Daesh is committing violent atrocities against civilians and health providers in areas under its control. However, in order to assert their control, they are also trying to create an apparatus for social service delivery for civilians.19 Daesh cannot hope to both create a sustainable model of governance and embark on a killing campaign against the preexisting health infrastructure in order to establish said model. This is a fundamental weakness of the terrorist organization that the West must exploit to defeat them.

Rationalizing Daesh’s Psychology and Modus Operandi

The Qur’an’s preaching on health is extremely positive and peaceful. According to Islamic scholars, health is considered one of God’s blessings, for “He [Allah] formed humans both beautifully and in an environment of general well-being (Qur’an 40:64).” The hadith, literature that records the Prophet Muhammad’s quotes about the Qur’an (the hadith is considered significant for understanding the Qur’an and its commentaries), endorses similar views.20 Thus, the two holy texts used to develop Islamic jurisprudence only speak of health in a positive, humanitarian light.

Former Islamic Caliphates, or Islamic states, have endorsed these messages on health. The Abbasid caliphate, which ruled from 750 to 1258 AD, was based on “multiculturalism, science, innovation, learning and culture, in contrast to Daesh’s violent puritanism.”21 Even in the 1800s, Arab nationalists admired the West and what they perceived as the modern world.21 Terrorist groups like Daesh grew from the Western-created vacuums of instability following World War I.  First, following the war, Britain, France and Russia carved up the Middle East (Sykes-Picot Agreement) with little attention to social structures.21 Arab intellectuals lost faith in the European powers but continued to have faith in the United States. Following World War II, however, America began propping up a string of dictatorial autocrats, leading to mistrust and resentment toward the United States.21 The collapse of tolerance, peace and cohesion mirrored by growth in corruption, oppression and subservience to the West led to a backlash against secular politics. Islamic fundamentalism grew out of this tension with the goal of declaring jihad against foreign “unbelievers” and Arab society itself in order to create a pure Islamic state based on extremely conservative beliefs.21 The destruction of Iraq during the War on Terror created a power vacuum that “takfiri” groups such as Al Qaeda and Daesh have filled.21

Daesh has one ideological foundation that serves as its driving force: the 14th Century Scholar Ibn Taymiyya’s teachings of Salafism.22 The Salafist interpretation of Islam “demands the harsh and absolute rejection of any innovation since the times of the Prophet…diversion from puritanical precepts that they [individuals] draw from a literal reading of the Qur’an and the Hadith is blasphemy, and must be eradicated.”22 Also known as Salafi Jihadism, Salafism promotes violence, warfare and intolerance of pluralistic beliefs. Salafism thereby rejects Sufism, a mystical interpretation of Islam that believes in spirituality for inner purification; Shi’ism, an interpretation of Islam where a succession of scholars called Imams are revered as spiritual and political leaders; and any other interpretation or religion in favor of uniting the Muslim world under “truly Islamic rule” and “fulfilling God’s desires.”

Rationalizing every Daesh action under a lens of Salafism beings to put everything into perspective. Daesh sees no harm in executing physicians or other related healthcare providers because its aim is to create a healthcare apparatus that serves the interests of its fighters—this is to ensure that it has the necessary power to enforce its agenda, quell resistance among dissatisfied Sunnis and prevent rebellion. Daesh functions in a similar manner to an ineffective totalitarian dictatorship, but its foundation is derived from Salafi Jihadism and is thereby a caricature of Islam. Insertion of this pseudo-religion that preaches violence and intolerance into daily life makes Daesh an apathetic organization, incapable of empathizing with human emotions and thereby incapable of humanitarianism pursuits. In sum, Daesh attempts to fabricate an apparatus that treats its wounded fighters and falsely demonstrates to local civilians that it is a legitimate Caliphate with a capacity for bureaucratic administration, analogous to other states.  That said, Daesh’s philosophy on health fits within the context of the harsh, conservative amalgamation of Salafism and civil society.

Daesh’s narrative is not a new phenomenon in history. One of the first groups to engage in anticolonial jihad and state-building was the fighters led by Abd al-Qadir, who challenged the French imperial invasion of North Africa in the 1830s and 1840s. Qadir declared himself ‘commander of the faithful’ — the title of a caliph — and founded an Islamic state in western Algeria, with a capital in Mascara, a regular army and an administration that enforced Shariah law and provided some public services.23 Likewise, the Mahdist state in Sudan, led by the self-proclaimed leader Muhammed Ahmad, called for Jihad while establishing state structures under a Sharia Law framework.23 Both conflicts had a common theme with Daesh today: a caliph, a theoretically disciplined state and a social service apparatus. They all believed in militant Islamism and denounced modernity and alternate faiths. Nevertheless, they were both completely destroyed by Western nations—France and Britain. Here’s why: “While jihadist networks or guerrilla groups are difficult to fight, a state, which can be invaded, is far easier to confront. And once there is a theocratic state, it often becomes clear that its rulers are incapable of providing sufficient social and political solutions, gradually alienating its subjects.”23

Dissecting Bureaucracy: The Daesh Governance Model and Medical Apparatus

How has Daesh adapted itself to the challenges of governance and disease growth? Documents obtained by German media outlets shed light on these complicated matters; a close look at Daesh’s structure reveals a highly organized bureaucratic system operating on many similar levels as would a state.24 After capturing municipalities through brute force, suicide bombings and calamitous violence, Daesh attempt to ensure an “egalitarian provision” of services, most applicable to infrastructural needs like electricity, water, gas and food.1 To expand its ravaged healthcare capacity, Daesh opened a “free” hospital (note that free largely pertains to fighters as outlined above) in Mosul after its capture.1 In many ways, Daesh has the fundamentals for a working state apparatus: Daesh manages its people through police and security forces, operates a health system (albeit very poorly), provides social services for individuals and operates a justice system based on sharia law. Daesh employs between 20,000 – 31,500 fighters alongside administrative staff who serve from abroad or who stay in their positions.22 To persuade workers in existing state apparatuses to retain their positions following Daesh-takeover, militants provide said workers with a consistent salary. However, to prevent disloyalty, essential staffs—Daesh supervisors—oversee operations in all facilities and departments.

Daesh hierarchy as it relates to healthcare is as follows: A single self-proclaimed caliph, or religious leader, (in this case, Abu Bakr al-Baghdadi) is the first in command. Abu Bakr has two deputies who respectively oversee operations in Syria and Iraq.22 Below Abu Bakr and his two deputies is a Cabinet comprised of eleven officials, one of which oversees civilian matters like health within The Council on Provincial Administration.22

Rationalizing the overall structure gives one a better understanding of how, much like a state, Daesh operates to provide healthcare for its citizens. The Provincial Council is divided into 18 provinces, with a governor for each province who presides over the local structure for civilian administration.25 Each governor is responsible for coordinating funding of infrastructure and capacity building projects along with running programs like healthcare.26 Out of all the cities under Daesh control, Raqqa, which has established itself as a de facto capital of Daesh, is the most developed governorate with the widest range of social service delivery.

The Provincial Administration is divided into its respective departments like education, healthcare, etc., but the enforcement of those departmental specifics lies within the jurisdiction of the governors for each region. Figure 3 shows a simplified diagram summarizing the power divisions as they relate to health within the Daesh governing apparatus.

The Health Department—The Diwan al-Siha—presents itself as a guarantor of health services along with establishing regulations for smoking, consumption of alcohol, recruitment of volunteers and medical personnel, pharmaceutical price controls, gender segregation, medical supply distribution, etc.27 The subdivisions of each governorate’s authority complicates the bureaucracy further, and for the purposes of time and relevancy this paper refrains from more specifically describing those agencies.

A marked distinction with Daesh when compared to other terrorist organizations like Al-Qaeda, the Taliban, etc. is Daesh’s use of local bureaucrats already in charge of hospitals, law enforcement and municipal services to remain in their positions as to avoid inadvertent placement of a fighter in a position of administrative authority—a situation that could prove deleterious to the welfare of both fighters and civilians.28

The Dual Identity of Daesh

Daesh is an anomaly among all terrorist organizations that have operated following the commencement of the War on Terror. Wherever Daesh gains territory, they seek to consolidate control in a central governing body and declare the rule of law over the local population.29 For example, following the takeover of Mosul, Iraq in June 2014, Daesh gunmen paroled the streets enforcing strict sharia law, and imams sympathetic to Daesh’s cause preached at the mosques.

In their fight to win over the support of the locals, Daesh attempts to project an image that it cares about them. For example, while executing doctors, bombing hospitals and sexually oppressing females, Daesh militants attempt to demonstrate to local people that they are capable of running a city and thereby provide social services for the locals.30 More specifically, immediately following the takeover of territory, Daesh militants begin instituting services by policing streets; performing community outreach by repairing damaged electricity infrastructure, operating bulldozers to remove garbage and concrete, planting flowers for beautification projects, apologizing to residents for gaps in certain social services, giving money to beggars and distributing food to needy people.30

To further its image and expand recruitment of foreign medical professionals, Daesh, in April 2015, Daesh released a new propaganda video boasting a new healthcare system with advanced medical schools and emergency care equipment to treat citizens in controlled areas. Analogous to the North Korean’s state-sponsored totalitarian propaganda scheme, Daesh marketing and promotional strategy radically exaggerates its healthcare capacity in an attempt to grow its “service” and recruit foreign physicians to operate in Daesh-controlled areas.31 The service, modeled after the British National Health Service, features a savvy commercial featuring high-end graphics, a foreign physician and innovative medical technologies that appear to rival those of advanced hospitals in Western countries. The strategy has been working effectively: Nine British medical students and graduates recently traveled to Syria to work in controlled areas.32

The healthcare system itself is predicated on a lie, for the majority of the benefits accrue to fighters instead of local civilians. In Al-Raqqa, foreign Daesh fighters receive free health care while local Syrians are treated like slaves; in fact, private health clinics are closed and the public hospital in Tel Abyad had exorbitant prices for different treatments, discriminating against the socioeconomically disadvantaged.33 Daesh-only hospitals are home to the best doctors—many of them are doctors who could not or chose not to flee due to fear of reprisal, or they are foreign physicians recruited via savvy propaganda videos—and most advanced technologies.34 Citizens in Raqqa report that even in the areas with the most optimal healthcare facilities and capacity, militants are given priority in special areas restricted for their families.35 Civilians are left outside the system.

On one hand, Daesh systematically targets and eradicates any healthcare infrastructure that could otherwise serve its own interests; on another hand, Daesh attempts to recruit doctors and showcase to the people under their control that they will receive the health services they request (this is, of course, a false promise for militants have always been given priority over civilians). One face of Daesh is callous and calculative; the other exemplifies compassion.

Success or Caliphate Fantasy? Straddling Between Two Competing Narratives

To effectively analyze a group as advanced as Daesh, this paper digresses from cherry-picking arguments and rather holistically examines those who both claim and defame the model upon which Daesh operates.

Individuals who support the model believe that Daesh’s ability to deliver services and regular paychecks for professionals such as doctors make them a better administrative body than the Iraqi or Syrian governments.26 Rather than functioning as a mere terrorist network, such as Daesh’s predecessors or peer terrorist networks like the Tablian, al-Nusra Front and Al-Qaeda in the Arabian Peninsula, Daesh has been able to take over and subordinate many existing government healthcare institutions to the Daesh bureaucracy.

The other narrative argues that Daesh has managed to replace the state with sufficient results in the fields of justice and education, but “one of the organization’s major policy failures lies in the health sector.”34 The public clinics are reserved for the impoverished, and hospitals suffer from power shortages and resource undersupplying. Their abusive treatment of female personnel in Mosul Hospital triggered a strike in August 2014, and, as a result, Daesh was forced to compromise and tone down the severity of certain restrictions.34 When civilians want medicine, they must shuttle to regime-controlled areas to purchase said medicine that is unavailable in Daesh stronghold cities like Raqqa and thereafter smuggle them through special corridors at upwards of two or three times the average price.34 Moreover, Daesh charges civilians for any medical service it provides; this is a marked deviation from the former decades living under the authoritarian Baath Party, which had offered free healthcare.36 In al Mayadeen, Daesh charges 15,000 Syrian pounds for a Caesarean birth, or about $80, which is very costly in a nation where the gross domestic product per capita is only $1,700.36 For blood tests, Daesh charges the equivalent of $10 in public hospitals and $20 in private hospitals (provided Daesh allows doctors to provide these services). Shortages of wheelchairs and high-end biomedical technologies have rendered long-term treatments and care for paraplegic and elderly patients impossible, among other treatments.2 With the advent of the United States-led coalition bombings, hundreds of Daesh fighters have been regularly injured, and doctors have since been ordered to use blood for transfusions solely for fighters; civilian patients have been ordered to supply their own blood by contacting donors privately.7 This is highly ineffective, for not only is it the patient’s obligation to seek out a donor, but much of the blood cannot be stored safely in a lab setting due to haphazard electricity.34 With dire circumstances, Daesh recently issued an ultimatum to physicians that had fled to return to their work or have their property seized.7 These actions have collectively compromised the quality of care for civilians, ultimately alienating and stigmatizing patients without proper access to medical resources. By enforcing rigid, segregationist and gendered divides between physicians, the efficacy of hospital management has declined, as females cannot treat males unless given very specific permission, and men until recently could not perform any services for women. As consolation, Daesh maintains the health system by compromising on certain measures for women and men. For example, Daesh permits a single hospital employee to travel to a city hospital controlled by the Kurds in order to acquire cash from government-approved banking facilities; likewise, Daesh has begun allowing certain female patients to see male physicians for concerns that do not relate to sexual organs, such as a broken arm.2

Local residents are largely displeased with the quality of care they are receiving. According to civilians living under Daesh control in Raqqa, “health services were better when the city was still under control of President Bashar al-Assad’s regime. For one thing, the Assad regime would cover most medical costs, whereas now the national hospital in Raqqa charges for services. Drugs are hard to find at pharmacies. And Daesh-governed hospitals can’t carry out more complex surgeries and procedures, or cope with cancer patients.”37 The lives of civilians whom Daesh understands it must gain support from are deteriorating largely due to the implications of haphazardly applied Daesh decisions. The rhetoric is pretty, in that the organization is “providing social services” and “promoting its own health architecture,” but the voices on the ground paint a very grim portrait that indicates that by all standards, Daesh-run healthcare is complicating the refugee exodus and the pre-existing health crisis in Syria and Iraq.

Conclusion and Further Discussion: Exploiting Existing Social Dynamics to Degrade and Destroy the Caliphate

Healthcare is a critical, overlooked component of the Syrian Civil War that feeds into a wide gradient of new research that could reap innovative solutions to defeating and degrading Daesh. The current state of healthcare throughout Syria and Iraq lies in broken shackles, and the role of Daesh in desecrating health providers and infrastructure plays a role in propagating a humanitarian crisis. Daesh’s two-faced nature, one which seeks to coddle and cajole people under its rule into holding faith in the caliphate’s ability to deliver promises of universal welfare, all while hypocritically denying important services to people or perhaps destroying said services entirely, has poisoned its ability to govern justly and effectively.

The question now becomes how to find a solution.  There is no singular policy solution to this crisis. However, this paper hopes to generate further discourse on this overlooked topic that could lead to policy solutions over time. In Inside Rebellion, Jeremy Weinstein argues that terrorist organizations face a core dilemma when they attempt to govern: they cannot attain their goals if they do not govern; yet, they repeatedly fail at governance efforts, exposing their greatest weaknesses.38 The international community should begin implementing a strategy that exploits Daesh’s key weaknesses in healthcare and social service delivery to internally cripple the organization as a whole.

More specifically, this evidence suggests that to defeat Daesh, the United States must work in tandem with the international community to advise local governments, aid agencies and nongovernmental organizations to outcompete the insurgents’ attempted provisions of social services in controlled regions. Healthcare is one of the most crucial social services, partially due to its emergency condition, but also because healthcare is a fundamental security necessary for enjoying the value all other freedoms such as free speech; freedom of movement; and freedom of thought, conscience and religion.

Daesh has faced little resistance from local Sunni populations for two reasons: the discriminatory sectarian policies under former Prime Minister Nouri Al-Maliki and the lack of social services.39 The goal of outcompeting the insurgents in social service provisions would be to shift the attitudes of local citizens within communities under Daesh control in favor of the Iraqi government or the international coalition aiming to destroy Daesh. In a research study published in Foreign Affairs, Professors Eli Berman, Joseph Felter and Jacob Shapiro from the University of California, San Diego, explain that “this objective is often termed ‘winning the hearts and minds’ of the population, and its logic is simple.”40 Insurgents cannot operate without civilians learning something about their location and identities: recruiting, raising funds and preparing weapons and explosives all entail observable actions. The more effective the government is at providing services to civilians, the more likely it is that they will prefer the government over the insurgents. In turn, the population will provide the government with a steady stream of tactically useful information — calls to anonymous tip lines about the location of weapons caches, for example — that the government can use not only to defeat the insurgents but also to prevent their reappearance.”40

As military forces combat Daesh fighters on the ground, Provisional Reconstruction Teams, NGOs, the Iraqi Government and the coalition governments can finance the construction of social service apparatuses. As forces recapture towns and cities, for example, they can provide social services—electricity, water, food, health and other humanitarian aid—in tandem with one another. United States forces and partners can work in conjunction with the Iraqi government and Iraqi military to coordinate social service provisions in conflict-ridden areas. In Daesh stronghold cities like Raqqa, Syria, it is more difficult to directly implement this strategy given the lack of Syrian government cooperation and situation on the ground. To stymie Daesh’s progress, its propaganda machine must be deconstructed. As shown in this paper, foreign physicians are flocking to Syria and Iraq because they perceive the system to be flourishing. By demonstrating weaknesses in Daesh’s healthcare system, foreign medical personnel would theoretically be less inclined to go to work for the caliphate. Furthermore, the international coalition can provide salaries for workers in Daesh-held areas as to outcompete the terrorists’ control on people. There are a plethora of additional strategies; this paper’s primary focus is to incite discussion on an area of further study and debate.

The quantitative research on this topic corroborates a direct relationship between increased social service spending and reductions in violence. In the Journal of Political Economy, the same group from the University of California, San Diego calculated that during the Anbar Awakening in 2007—the Anbar Awakening describes the military strategy in Anbar Province in which social services were coupled with targeted military force in order to win over the hearts of locals and ultimately oust Al Qaeda from the region—for every dollar per capita spent (calculated using their model) after 2007, there were 1.59 fewer violent incidents per 100,000 (statistically significant) population per half year.41 In other words, the “combination of military operations and the provision of social services [in Al Qaeda controlled areas] was effective in reducing insurgent violence in affected areas by bringing local Sunnis back into the fold.”39   The implications of these findings resonate with potential policy frameworks for the fight against Daesh. This paper hopes to introduce ideas that generate further discussion on this niche focus area.

Many Muslims living under the caliphate’s rule regard Daesh as the better option when compared to the government, and thereby those individuals tacitly consent to the systematic oppression and brutality. An extensive research study involving over one million interviews across Iraq and Syria both before and after Daesh assumed control found that “the Islamic State is ideologically incompatible with many of the residents of the territory it now occupies.”42 Unlike Hezbollah in Lebanon or Hamas in Palestine, which are sufficiently able to provide social services in areas that the government was unable to provide those same services, Daesh is widely disliked; survey results indicated that more than 90% of Sunni Muslims living under Daesh control view Daesh as a terrorist organization—not a state—and 80% of citizens support the international coalition effort to degrade and destroy Daesh.42 This feature of the caliphate is a vulnerability that Western nations and the coalition must exploit in order to win this war. Rather than prescribing solely military solutions to extremist problems, nations must amplify group resistance against Daesh control by outcompeting the terrorists on social service provisions.

In order to replicate the results witnessed during the Anbar Awakening on a grander scale, it is crucial that the United States and its partners begin to shift their strategy away from a “counterterrorism” operation toward a holistic perspective that takes into account the impact of social services and population dynamics on the organization’s ability to command control. As the Daesh power dynamics shift with growing resilience among Sunni Muslims under Daesh-control, and as new outbreaks of disease and maltreatment of medical professionals is exacerbated by greater violence, Western powers can begin framing discourse under a light of health and humanitarianism coupled with military decision-making.


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