Since the end of May 2016, the Syrian and Russian government have attacked nine health facilities in Idlib province in a blatant violation of the laws of war. Syrian and Russian forces have failed to uphold their obligations under international law as attacks on civilian targets remain. Defenders for Medical Impartiality (DMI) welcomes the U.N. General Assembly Resolution establishing a joint investigative mechanism into serious crimes committed in Syria since 2011. DMI further calls on members of the U.N. General Assembly to adopt a resolution urging the Security Council to refer the situation in Syria to the International Criminal Court (ICC). Attacks on hospitals in Idlib, Aleppo, and throughout Syria should be investigated and perpetrators must be held accountable for their actions.

Medical Workers, Services, and Infrastructure Under Attack

Located in Northwest Syria, Idlib is the largest populated city under rebel control. In the last six months, there were nine separate attacks on health facilities in the province. Syrian and Russian forces have systematically targeted healthcare in Syria. As a result of these calculated and repeated attacks on medical facilities and healthcare workers, Syria became the most dangerous place for healthcare workers to operate in 2015.

On 30 May 2016, airstrikes hit Idlib’s national hospital and Ibn Sina hospital, killing around 24 people, including seven children. As a result, both hospitals went out of service. On 29 July, an airstrike hit the front of a maternity hospital in the town of Kafar Takharim, leaving six dead and several wounded, among them six newborn babies. The facility served an average of 1,300 women every month. The Syrian Observatory for Human Rights stated the hospital, supported by Save the Children, was barely operational following the attack… On 6 August, two aerial strikes hit an MSF-supported hospital in the town of Millis in Idlib’s governorate. Another two airstrikes hit the vicinity of the hospital. The attacks killed 13 people, among them four hospital staff, five women, and two children. Six other staff members were injured. According to MSF, the attack destroyed the hospital’s operating theater, intensive care unit, pediatric department, ambulances, generator and about 80 percent of the medical equipment, forcing the facility out of service. The facility provided emergency care or consultations for about 250 patients per day.

On 5 November, based on documentation the Syrian American Medical Society (SAMS) shared with DMI, an airstrike caused moderate structural damage to a primary health care center in the town of Abul Thohur. It is unclear as to whether the airstrike directly hit the center or its vicinity. The attack disrupted services at the facility, which provides an average of 3,800 consultations every month. On 13 November, airstrikes hit two hospitals: one in the town of Bennsh and another in Ma’arrat an Nu’man. The airstrike on the Bennsh hospital damaged the building of the facility and destroyed three hospital ambulances. Seven people were wounded, including two administrative personnel. Another airstrike hit a few meters away from a hospital in the town of Ma’arrat An Nu’man.  At least one person died and six others were injured, among them two health personnel. The attack forced the facility to temporarily close. The hospital provided an average of 5,816 consultations every month. On 14 November, an airstrike hit a mobile clinic in the town of Jisr-Ash-Shugur, which provides an average of 3,542 consultations every month. The attack caused minor structural damages and the clinic was temporarily out of service. On 25 November, four consecutive rockets hit a gynecology hospital in Termanin village on the border between Idlib and Aleppo provinces, forcing it out of service. The strikes destroyed the eastern side of the building and damaged the facility’s emergency and operating rooms.

The bombing and targeting of hospitals in the Idlib province has created a dangerous environment for health workers, who are risking their lives in efforts to save others. According to SAMS documentation, on 2 November, two medical staff were reportedly wounded by an airstrike on three ambulances in the town of Saraqeb. The attack destroyed one ambulance and partially damaged the other two. On 6 November, an airstrike killed an administrative health staff belonging to Idlib health directorate in the town of al-Dana.

Common Article 3 Violations

Warring parties are bound by the basic humanitarian rules and obligations set out in Article 3 common to all four Geneva Conventions of 1949, applicable to the armed conflict in Syria. The attacks on medical facilities in Idlib violate the key provisions of the article. 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. Attacking hospitals violates this protection as it deprived thousands of civilians who were being treated at the hospitals of their right to life. Thus, such attacks may amount to war crimes.

Additional Protocol II Violations

Additional Protocol II, which Syria did not ratify, further extends the essential rules of the law of armed conflicts. It includes the prohibition of attacks on civilians, the obligation to respect and protect medical personnel, medical units and transports, and the prohibition of the forced movement of civilians. Compared with Common Article 3, Additional Protocol II offers more specific protection to medical units and medical personnel. The documented attacks on health facilities in Idlib violate Article 11 of the 1977 Additional Protocol II, which provides that “medical units and transports shall be respected and protected at all times and shall not be the object of attack.” The deaths of medical personal and hospitals’ staff violate Article 9(1), which afford that “Medical […] personnel shall be respected and protected and shall be granted all available help for the performance of their duties.”

Customary International Humanitarian Law Violations

Many of the provisions of Additional Protocol II are considered to be part of customary international humanitarian law (CIHL). CIHL rules explicitly prohibit attacks on medical workers, facilities, and infrastructure. These rules include the prohibition of attacks on civilians and the obligation to respect and protect medical personnel, medical units, and transports. Attacks on Idlib’s hospitals violate Rule 25 of CIHL: “Medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances.” Further, these attacks also violate Rule 28 , which mandates protections for medical units: “Medical units exclusively assigned to medical purposes must be respected and protected in all circumstances.” Rule 25 and Rule 28 of CIHL are explicitly mentioned in Article 11 of Additional Protocol II, which states that intentionally directing attacks against “hospitals and places where the sick and the wounded are collected, provided they are not military objectives” and against “medical units… using the distinctive emblems of the Geneva Conventions in conformity with international law” constitutes a war crime.

The protections afforded to medical facilities only cease when these units are used outside their humanitarian function. There is no indication that hospitals in Idlib are used in any manner to carry military acts. Despite this, these hospitals continue to be a target.

Assuming that these hospitals were used in a manner that is not in line with their humanitarian duty, under CIHL, these facilities would lose IHL protection only after a due warning has been given. Presuming that armed rebels had used these health facilities in direct support of a military operation, the reported attacks would still violate international law because no warning was given prior to the assault, allowing civilians and medics to escape. Of course, this argument is moot, as the medical facilities that were targeted were not being used for combat-related purposes.

Medical Impartiality Violations

The Syrian government campaign of targeting health facilities in Idlib is a clear breach of the principle of medical impartiality. The principle of non-interference of medical impartiality states that every person has the right to the highest attainable standard of living adequate for their health and well-being, including medical care. Civilians and those placed hors de combat sickness, wounds, detention, or any other cause should be able to access adequate medical care. The non-interference component of medical impartiality also provides protections for medical personnel, medical facilities and transportation.  Medical personnel, hospital staff, patients and their families, and medical facilities and transportation must not be a target. These protections are in line with and enshrined in Common Article 3 of the Geneva Conventions and CIHL rules. Violations of these principles may amount to war crimes.

Conclusion

Attacks on health facilities reduce the availability and the quality of health care. These attacks not only lead to the loss of immediate life but also have far-reaching consequences in the future as they affect access to healthcare. Further, the constant threat of being attacked has led indivdiuals to fear going to a hospital. Additionally, medical workers in Idlib have reported being under-equipped, as a result of the war. These reports are especially alarming as thousands are expected to arrive from eastern Aleppo. Given the lack of adequate health resources in Idlib, more than 90 patients in need of urgent medical attention were evacuated to Turkey since the evacuations in eastern Aleppo began. Another 300 patients who arrived in Idlib from eastern Aleppo await medical evacuations.

On 21 December, the U.N. General Assembly adopted Resolution A/71/L.48 establishing an investigative body to “collect, consolidate, preserve and analyze evidence” as well as to prepare cases on war crimes and human rights abuses committed in Syria since 2011. DMI welcomes this investigation into alleged war crimes in Syria. The war has involved repeated and systematic attacks on healthcare and has resulted in the deaths of hundreds of doctors and medical workers, along with the destruction of hundreds of hospitals. The international community must hold the perpetrators of these crimes accountable as violations of international human rights and humanitarian law cannot and must not be taken lightly. DMI calls on the UN General Assembly and the UN Security Council to reiterate its commitments to protecting and upholding medical impartiality.