Since March 2011, Syria has seen increased rate of attacks on medical facilities, services and infrastructure. Health care has become a weapon of war, and targeting medics a strategy. Between March 2011 and December 2016, there were no less than 411 attacks on medical facilities and personnel. At least 814 medical workers have been killed and thousands injured since the beginning of the Syrian conflict, mainly in hospital bombings, shootings, torture and executions. Direct attacks on medical facilities were responsible for 55% of the deaths of medical professionals, the shootings accounted for 23%, torture for 13% and executions for 8%. Last year alone, more than 200 medical facilities were indiscriminately targeted, killing hundreds of medical workers, patients and civilians. This trend is still present in 2017, and the first few months of the year have already seen similar attacks.

Attacks in 2017

On 13 February 2017, in southern Syria, the International Rescue Committee (IRC) reported Dara’a Al Balad hospital was hit by a rocket attack and put out of service. The attack caused huge damage to the hospital and injured four medical workers. This hospital provided more than 5,000 consultations every month and was treating more than 60 injured before it was targeted. Another IRC-supported hospital, also in southern Syria, was forced to shut down due to increased risks of attacks. The IRC’s senior director, Amanda Catanzano, noticed that “attacks on medical facilities precede intense military action, making this an extremely dangerous moment for civilians in southern Syria.” She also regretted the use of the same strategies “that resulted in so many civilian deaths in Aleppo” elsewhere in the country.

Additionally, the Syrian American Medical Society (SAMS) reported the death of 52 civilians, including one nurse, in the heavy bombardment and airstrikes on medical and civilian infrastructure between 13 and 20 February in Dara’a, south of Syria. These indiscriminate attacks carried out by the Syrian Government severely damaged many medical facilities in the region. In a single day, one facility was hit by thermobaric rockets, shelling and airstrikes, resulting in serious damage to its structure, equipment and medications.

Such increased violence prevented civilians in Dara’a from accessing health care. Hospitals limited their services to emergency cases so that civilians would not gather in the vicinity and risk being caught in a bombardment. Prices of basic goods highly increased, including medications such as antibiotics, pain killers and pediatric medication. Medical facilities had to close because of considerable damages, high risk of attack, or curfews. Wounded patients had to seek treatment elsewhere, further putting their lives in danger.

On 25 March, the Médecins sans frontières (MSF)-backed Latamneh hospital in Hama governorate, northern Syria, was hit by a bomb dropped by a helicopter. The attack targeted the entrance of the building, killing two people, including the hospital’s orthopedic surgeon, Dr. Darwish. Further, the bombing caused severe respiratory complications among staff and patients, including burning of mucous membranes. These symptoms highly suggest the use of chemicals in the attack. The attack put the Latamneh hospital out of service for three days, before it reopened its emergency room. The death of Dr. Darwish also left the population in Hama with only two remaining orthopedic surgeons.

According to information SAMS shared with Defenders for Medical Impartiality (DMI), on 2 April 2017, around 7:30 p.m., two airstrikes targeted Ma’ara hospital, one of the main hospitals in Maarrat Al-Nu’man District, Idlib Governorate. According to eyewitnesses, it appeared that Russian warplanes carried out the attacks, which injured at least 10 people. The airstrikes destroyed most of the facility’s emergency and surgery rooms, forcing Ma’ara hospital out of duty. According to a Syrian Civil Defense official, Russian warplanes are suspected to have used the double-tap tactic in this attack, as a second airstrike struck the hospital while the rescue team was inspecting the damages.

More recently, al-Rahma hospital was targeted by an air raid shortly after the suspected chemical attack of 4 April on Khan Sheikhoun in Idlib governorate took place. The hospital was severely damaged and put out of service.

Violations of Common Article 3

The conflict in Syria is categorized as a non-international armed conflict. Article 3, Common to all four Geneva Conventions of 1949, applies in this situation, and provides protection to all persons taking no active part in the hostilities. Common Article 3(1) states 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 shall be treated humanely. Further, Common Article 3(2) provides that an impartial humanitarian body collects and cares for the wounded and sick. The attacks on MSF-, SAMS- and IRC-supported hospitals violate this provision, as they deprive these organizations of their right to care for the wounded and sick. Attacking medical facilities prohibits civilians from accessing a vital human right: health care. The warring parties in Syria are thereby entirely breaching Common Article 3, and the attacks listed above could amount to war crimes.

Violations of customary international humanitarian law

The rules of customary international humanitarian law (CIHL) are derived from Additional Protocol II to the Geneva Conventions, which Syria did not ratify. Additional Protocol II offers more specific protection to medical units and medical personnel compared to Common Article 3. Whereas this Protocol fails to hold perpetrators accountable in Syria, CIHL does in some way. The rules under CIHL explicitly denounce attacks on civilian objects, infrastructure and services, including medical facilities and personnel. Rule 28 provides protection to medical units, and Rule 25 affords protection to medical personnel in all circumstances. These protections under both rules only cease when medical units and workers are no longer “exclusively assigned to [their] medical duties”. Since there’s no evidence that all of these medical facilities and personnel attacked were operating outside of their humanitarian duties, the warring parties in Syria – and particularly the government – are thereby breaching the aforementioned rules under CIHL, and international law.

Violations of medical impartiality

Targeting health care facilities constitutes a clear breach of medical impartiality. The non-interference principle 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. This principle also affords protection to medical facilities, personnel, and services. The Syrian Government and other parties to the conflict are violating the concept of medical impartiality by attacking medical facilities, personnel and services, and ultimately impeding civilians’ right to access health care.

United Nations  response to these violations

The international community has condemned human rights violations in Syria, with the United Nations Security Council (UNSC) alone adopting 21 resolutions. These resolutions have strongly condemned the indiscriminate attacks on civilian infrastructure and services, including medical facilities, and called for the alleviation of humanitarian suffering in the country, as well as for an end to the conflict. Another thematic resolution, resolution 2286 adopted by the UNSC in May 2016 strongly condemns attacks on medical facilities and personnel in conflict situations, including Syria. However, SAMS concluded that this resolution failed to protect health care facilities and workers based on evidence of attacks before and after the passing of the resolution. Resolution 2286 has so far not been implemented as planned.

Moreover, the United Nations Human Rights Council (HRC) adopted 22 resolutions condemning the human rights violations in the Syrian Arab Republic since 2011. In almost all the HRC sessions held in March, June and September of every year, as well as during special sessions, the Council dedicated a dialogue on the human rights situation in Syria, calling for an end to the conflict, hostilities and severe human rights violations, including violations of the right to health. For instance, the most recent HRC resolution adopted this year, in March 2017, urges all parties to the Syrian conflict to refrain from attacking civilians and civilian objects, including medical facilities, personnel and transport. The resolution additionally condemns the war crimes committed by the Syrian government and its allies when intentionally targeting medical personnel and transport, as well as the indiscriminate use of heavy weapons and aerial bombardments against civilian infrastructure, including medical facilities, and humanitarian aid convoys. Further, the resolution strongly condemns the denial of medical services in all prisons and detention facilities in Syria, and demands the immediate release of all persons arbitrarily detained, including medical personnel and humanitarian aid providers.

The United Nations General Assembly adopted eight resolutions on Syria since the beginning of the conflict in 2011, generally condemning the violence in Syria, calling for ending attacks on civilians and civilian objects, including medical facilities, urging the UNSC to take measures to end violations there, and regretting the failure of UNSC resolutions to refer the situation in Syria to the International Criminal Court (ICC).

The HRC did establish in August 2011 an International Commission of Inquiry to investigate the alleged violations of human rights law is Syria. However, the Syrian Government has not yet granted the Commission official access to the country. More recently, in December 2016, the General Assembly adopted a resolution that establishes an independent panel to assist in the investigation and prosecution of those responsible of war crimes and crimes against humanity in Syria since March 2011. This mechanism shall work hand in hand with the International Commission of Inquiry in order to “facilitate and expedite fair and independent criminal proceedings, in accordance with international law standards, in national, regional or international courts or tribunals that have or may in the future have jurisdiction over these crimes, in accordance with international law”. However, it is still not clear whether and how investigations will address allegations of attacks on health care.

These encouraging steps taken by the international community have nevertheless failed to stop the war against health care in Syria, and more stringent measures are urgently needed. The United Nations (UN) might choose again to take serious actions in response to the worsening humanitarian situation in Syria by referring cases to the ICC. Yet, having one of Syria’s closest ally, Russia, at the UNSC will likely result in a veto of any such action, as has been the case since the start of the conflict.

Proposed actions

The international community can impose sanctions on a country in order to change the behavior of the government in cases where there’s a serious breach of human rights. The UNSC, European Union (EU) and individual states can choose to impose sanctions individually. Sanctions vary by situation and country and can include an arms embargo, embargo on some trade activities, travel and visa restrictions, freezing assets and restricting loans, etc. When military intervention is not an option, and diplomatic tools seem to be insufficient, the UN might resort to imposing comprehensive and/or targeted sanctions. The latter have been used more widely to minimize the negative humanitarian impacts on innocent civilians linked with comprehensive sanctions. Targeted sanctions are more focused on leaders and decision makers, or a single sector, rather than on the general population or an entire economy. The UN generally imposes targeted sanctions in response to threats to international peace and security, to prevent conflicts, to consolidate peace agreements, to protect civilians, to support democracy, and to limit the proliferation of weapons of mass destruction. A study conducted by the Targeted Sanctions Consortium on the effectiveness of the UN targeted sanctions found that targeted sanctions are more effective in signaling or constraining a target than they are in coercing a change of behavior. The study also found that targeted sanctions are unique and complex -having very different regimes’ backgrounds, are always combined with other measures, and are enhanced and supported by regional groups.

Russia and China have both used their veto power seven and six times respectively to block serious UNSC measures on Syria since the beginning of the conflict in 2011. More recently, in February 2017, both countries blocked the adoption of a UNSC resolution sanctioning Syria over alleged gas attacks. The draft resolution would have banned the sale or supply of helicopters to the Government of Syria after the UN Organization for the Prohibition of Chemical Weapons (OPCW) inquiry found that Government forces had used helicopters to drop barrel bombs containing chlorine gas. The draft also proposed imposing sanctions in the form of travel ban and asset freeze on 11 Syrian military commanders and officials, and on 10 Government and related entities.

Moreover, the United States ordered a freeze on all assets of 271 employees of the Syrian Scientific Studies and Research Centre (SSRC) in the country. This measure was imposed in response to the suspected chemical attack on 4 April 2017, because it is believed that the SSRC develops chemical weapons for the Government of Syria. Further, the EU has imposed similar sanctions on Syria that include an oil embargo, restrictions on some investments, a freeze of assets of the Syrian central bank in the EU, export restrictions on equipment and technology that could be used for internal repression, and on equipment and technology for the monitoring of internet or telephone communications. These sanctions are in place until 1 June 2017.

Conclusion

In Syria, indiscriminate attacks on health care are increasing by day, affecting thousands and threatening the lives of millions. The destruction of medical facilities and the death of medical workers render survivors of these attacks helpless, and limit and obstruct their access to medical care. With the increased targeting of medical facilities, personnel, and services in Syria, the actions adopted by the international community seem to be insufficient for stopping the war against health care in the devastated country. After six years of war, and after adopting more than 50 UN resolutions and decisions condemning violence and human rights violations in the country, including violation of the right to health, the international community might consider adopting more stringent measures after exhausting all the possible diplomatic solutions for the Syrian conflict.