Sustained and repeated attacks on civilian infrastructure in rebel-held Aleppo are contributing to a large number of civilian casualties and depriving thousands of adequate medical care. All parties to the conflict, especially the Syrian and Russian governments, must take all necessary precautions to spare civilians and civilian infrastructure, and allow for the delivery of needed humanitarian aid into besieged eastern Aleppo. Defenders for Medical Impartiality urges the international community to investigate unlawful attacks in Aleppo and hold perpetrators accountable.

Between September and November 2016, residents of Aleppo witnessed violence described as “catastrophic and unprecedented in modern history.” The Syrian government and its allies carried out attacks in rebel-held neighborhoods of Aleppo, which reportedly involved imprecise and unlawful weapons such as bunker-busting, incendiary weapons, and cluster munitions. There were at least 137 cluster bomb attacks in Aleppo from 10 September to 10 October. The Violations Documentation Center in Syria (VDC) reported this increase in attacks as a 791% increase from the previous eight-month average.

Infrastructure, including water and health facilities, and humanitarian aid were targeted in deliberate attacks during the reporting period. Between 22 September  and 22 November, 677 civilians, including 107 children, were killed in besieged eastern Aleppo due to airstrikes and shelling by the Syrian government and its allies, the Syrian Observatory for Human Rights (SOHR) said. On 30 September, U.N. Deputy Envoy for Syria, Ramzy Ezzeldin Ramzy, warned that as many as 600 wounded in besieged Aleppo needed medical evacuations. Mohamad Katoub, Syrian doctor and Advocacy Manager at Syrian American Medical Society (SAMS), told Defenders for Medical Impartiality that at least 200 wounded urgently require medical evacuation. Further, shortages of milk formula put the lives of 12,500 infants at risk. During an interview with Syria Direct, Ali Sheikh Omar, President of the Aleppo Relief Commission, said there are 5,000 cans of milk formula left in the city. “That’s hardly enough to cover a quarter of the city’s children and for one month at most,” he added. Prices of cans of formula at some pharmacies have gone as high as $15 a can. Mothers have reported resorting to cheaper alternatives. Miriam a-Zain began feeding her six-months-old baby Rahaf a mixture of water and rice three weeks ago.

Humanitarian Aid Under Fire

On 19 September 2016, the Syrian government unilaterally announced an end to the ceasefire, which began on 12 September. At the time of the announcement, aid convoys bound to rebel-held districts of Aleppo were stuck on the Turkish border. Two 20-truck aid convoys with enough to feed some 185,000 people for one month, had been waiting north of Aleppo in Turkey for almost a week for permission. In his statement, U.N. Under-Secretary General for Humanitarian Affairs and Emergency Relief Stephen O’Brien urged that all parties to the conflict allow these trucks to move into Aleppo. However, the situation deteriorated. A few hours after the end of the ceasefire, another U.N.-Red Crescent inter-agency aid convoy of 31 trucks was hit in an air strike while unloading food at a warehouse in opposition-controlled Urum al-Kubra, near the city of Aleppo, around 7:30 p.m. The convoy was among the first to try to deliver humanitarian aid with enough supplies for 78,000 people in besieged Aleppo. The attack destroyed at least 18 trucks. Around 20 people died in the attack, including the head of the Syrian Arab Red Crescent (SARC) in Urum al-Kubra.

According to witnesses and rescue workers, the attack consisted of “multiple airstrikes.” A SARC warehouse was destroyed and a SARC clinic was reportedly damaged in the attack. The first airstrikes targeted the trucks. Then, “two airstrikes or more hit rescue workers as they helped the wounded” in a tactic known as a double-tap strike, which has been used by Syrian and Russian warplanes. Following the attack, the U.N. suspended all aid convoys to besieged and hard-to-reach areas in Syria. Two days later, Jens Laerke, the spokesman for the U.N. Office for the Coordination of Humanitarian Affairs (OCHA) said the U.N. is ready to resume the delivery of humanitarian aid to besieged and hard-to-reach areas in Syria, yet no convoys would go into Eastern Aleppo. Humanitarian aid has not been able to reach eastern Aleppo since clashes started on 7 July  between the Syrian army and armed groups.

The director of Aleppo’s Bayan Children’s Hospital, Dr. Hatem, told the Today programme on 17 November that “the supplies for medical facilities will finish soon; in not more than two weeks.” One doctor told MSF that hospitals ran out of chronic disease medications. Painkillers and antibiotics were increasingly becoming difficult to find. The U.N. humanitarian adviser, Jan Egeland, confirmed on 18 November that medical supplies for the city’s besieged residents have run out.

Health Facilities Under Fire

On 19 November, the World Health Organization’s (WHO) representative in Syria, Elizabeth Hoff, confirmed that all hospitals in rebel-held eastern Aleppo are no longer functioning. SOHR said some hospitals were still operating, but people were reluctant to use them because of the attacks on health facilities. WHO said it documented 126 attacks on health facilities across Syria in 2016. According to Doctors Without Borders (MSF), 29 of those 126 attacks in 2016 targeted functioning hospitals in eastern Aleppo between the beginning of July and 16 November. Defenders for Medical Impartiality documented 24 separate attacks on at least nine health facilities in Aleppo between 23 September and 18 November. Some of these attacks targeted structures around health facilities, causing damage. In other cases, hospitals were subject to repeated attacks and resulting in forced closure of the medical facilities.

According to SAMS documentation shared with Defenders for Medical Impartiality, on 18 November, the Omar Ibn Abdul-Aziz Hospital in eastern Aleppo was hit with a surface-to surface-weaponry on 18 November. At least two people died, seven were injured. Among those injured and killed were two health care workers. An ambulance was partially destroyed; the extent of the damage to the facility is unknown.

Based on SAMS documentation, on 17 November, the Az-Zarzour facility was impacted by an attack, causing moderate damages to the facility. The emergency unit and hospital entry were reportedly destroyed.

On 16 November, Al-Bayan children’s hospital, and the Central Blood Bank in besieged Aleppo city were hit by barrel bombs. At least 20 civilians were killed, including two children and an ambulance driver. The attack destroyed two ambulances. A video footage captured by Al Jazeera shows hospital staff and nurses trying to rush patients out of the only specialized hospital for children in the besieged area of Aleppo moments after being attacked. Nurses were forced to relocate babies from damaged incubators to a blanket on the floor following the attacks. A second hospital specializing in neo-natal and pediatric services was also bombed on 16 November, MSF said. Both facilities went out of service.

In addition to those in besieged eastern Aleppo, there were three separate attacks in the rebel-held west Aleppo countryside. The attacks left 600,000 people with no access to medical care. On 14 November, a hospital in Atareb was reportedly bombed with 12 missiles, causing approximately $50,000 in damages and temporarily suspending medical services. Shortly after the attack on the hospital, airstrikes completely destroyed the Baghdad Hospital in the town of Awaijel. On 15 November, 10 airstrikes struck the Beauty Hospital, putting it out of service. According to the WHO, all three hospitals provided more than 10,000 consultations and more than 1,500 major surgeries on a monthly basis.

Based on SAMS documentation, on 11 November an airstrike launched nearby hit a hospital in Atareb, rural Aleppo. The extent of the hospital’s damage was unknown, and there were no reports of casualties.  On 3 November, according to SAMS, a hospital in Darret Azza, rural Aleppo was also hit causing structural damage.

On 28 September, SAMS-supported M2 and M10 hospitals were targeted at around 4 a.m. Both facilities are among the largest in the rebel-held eastern side of Aleppo. M2 and M10 hospitals were put out of use due to repeated attacks. Syrian government forces and its allies shelled M2 hospital with air-to-surface missiles. Approximately twenty people were wounded, among them were three staff members. Five staff members died. The attack destroyed the hospital’s fuel tanks and generator, leaving it without electricity. The bombing also destroyed the hospital’s last ambulance. According to SAMS, civilian cars were used to transfer patients to nearby clinics. The second hospital, M10, was hit by an airstrike. Two patients and three employees were injured including a nurse, an accountant, and an ambulance driver. The hospital’s laboratory and patients’ wing were destroyed. The airstrike damaged the hospital’s intensive care unit and its oxygen generators. Additionally, the electricity and water supplies were cut off, forcing the hospital to suspend operation. M10 hospital was targeted again on 1 October, 3 October, and 14 October. The attack on 1 October was carried out using barrel bombs. During the latest incident, M10 hospital was hit three times with airstrikes and a bunker buster bomb. According to SAMS, four medical staff were injured, including the M10 hospital director and a pharmacist. The already nonfunctional hospital remains permanently out of service following the attacks.

The use of indiscriminate weapons on civilian infrastructure also caused damage to health facilities in eastern Aleppo. On 30 September, a bunker buster bomb and a white phosphorous munition hit areas around the central square in the al-Shaar neighborhood. Three medical facilities, a central blood bank, al-Zahra maternity hospital, and Bayan children’s hospital, all run by the Independent Doctors Association (IDA), were damaged during the attack. Doctors inside al-Zahra maternity hospital, which was targeted at least four times in the past, were reportedly “putting out the fires” that ignited inside the building.

On 23 September, the Syrian government targeted SAMS-supported M2 hospital in al-Maadi neighborhood, east of Aleppo, with cluster bombs. There were no casualties, but the attack damaged the water tanks and the refrigeration unit of the facility. Syrian government forces and its allies attacked M2 hospital again on 26 September with four barrel bombs, four naval mines, and two air-to-surface missiles later that day.

Water Distribution Plants Under Fire

Water facilities were subject to deliberate targeting. On 22 September, Syrian government forces attacked Bab Al-Nayrab water pumping station in eastern Aleppo, which serves as a water supply for roughly 250,000 people, including 100,000 children. In retaliation, armed opposition groups switched off the water supply from Sulayman Al Halabi water pumping station, which provides water to roughly 1.5 million people living in government-controlled western Aleppo. However, following negotiations between UNICEF and armed groups, the water pumping from Sulieman Al Halabi resumed. The ongoing fighting in eastern Aleppo prevented repairs of the Bab Al-Nayrab station. On September 30, Sulieman Al Halabi water pumping station was switched off again. On 5 October, UNICEF managed to fix Bab Al-Nayrab station allowing water to flow into eastern Aleppo again. Sulieman Al Halabi was also in operation.

Up to 80 percent of the Aleppo’s water network has been damaged in the course of the fighting. Fierce clashes in Aleppo damaged electricity cables causing severe cuts in power. This, in turn, contributed to a shortage in water, given that water generators depend on electricity. The lack of fuel exacerbated the problem. Prices of water surged in the city, ranging between $5 and $12 for one liter of water. Some people in eastern Aleppo have reportedly resorted to well water. A 2016 Water Quality Assessment Report found E.coli contamination and a high concentration of nitrate in well water, putting civilians at risk from waterborne disease.

Common Article 3 and Customary International Humanitarian Law

Attacks on civilian infrastructure violate the key provisions of Common Article 3 of the Geneva Conventions. Common Article 3 provides that civilians, members of the armed forces who are no longer participating in the hostilities, and those placed hors de combat by sickness, wounds, detentions, or any other cause be treated humanely. The deliberate targeting of civilian infrastructure, including health and water facilities, violates the protections civilians are entitled to in times of conflict.

The rules of customary international humanitarian law (CIHL) prohibit attacks on medical workers, facilities, and infrastructure. Many of the provisions of Additional Protocol II, which Syria did not ratify, are considered to be part of CIHL. These rules include the prohibition of attacks on civilians, the obligation to respect and protect medical personnel, medical units and transports, and the prohibition on the forced movement of civilians. The attacks on hospitals violate Rule 25 of CIHL: “Medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances.” This rule is explicitly stated in Article 11 of Additional Protocol II “intentionally directing attacks against… personnel using the distinctive emblems of the Geneva Conventions in conformity with international law” constitutes a war crime. Attacks on hospitals also violate Rule 28 that mandates protections for medical units.

Rule 31 mandates that humanitarian relief personnel be spared in times of conflict. According to the rule, safety and security must be granted to humanitarian relief personnel in order to deliver critical aid to civilians in need. The targeting of the U.N.-Red Crescent aid convoy in opposition-controlled Urum al-Kubra with multiple strikes is a blatant violation of the laws of war and is considered a war crime. Furthermore, no aid was delivered in residents of besieged east Aleppo city since fighting began in July. Parties barring the delivery of aid or failing to provide enough security guarantees for the passage of safe and impartial aid are violating Rule 53, which prohibits starvation as a method of warfare.

Medical Impartiality

The targeting of civilian infrastructure and humanitarian aid violates medical impartiality’s component of non-interference. The principle of non-interference means every person has the right to the highest attainable standard of living adequate for his health and well-being, including medical care. Access to medical services falls under the non-interference component, and includes medical personnel, medical facilities and transportation. Non-interference is a legal obligation on state and non-state actors alike. It prohibits any obstruction to medical services, such as temporarily stopping personnel, transportation, or supplies from reaching the sick or injured, in addition to more obvious violations such as bombing a hospital or attacking an ambulance.

Conclusion

Bombing civilian infrastructure is a war crime. All parties to the conflict, especially the Syrian government and Russia, must refrain from targeting civilians, their properties, and objects indispensable for their survival. The international community must push for an investigation into attacks against civilians and civilian objects, including hospitals, in order to identify and try those who ordered and carried out these attacks. Further, using imprecise weapons on crowded civilian neighborhoods must stop. The Syrian and the Russian governments, who have monopoly of air power over the city, have used these weapons on a regular basis, causing unbearable suffering to civilians and civilian infrastructure.

Earlier this month, Canada called on the U.N. General Assembly to convene an urgent meeting of all member states to take urgent action to alleviate the deteriorating humanitarian situation in Syria and especially in Aleppo. A global coalition of 223 civil society organizations urged U.N. member states to join the initiative. Defenders for Medical Impartiality welcomes this initiative. U.N. member states must act on behalf of civilians and doctors in Aleppo and elsewhere in Syria.