1. Introduction

Amongst the past seven years of conflict during the ongoing Syrian civil war, 2018 was the least lethal for civilians, with a death toll of 6,228 persons as reported by the Syrian Network for Human Rights (SNHR). However, the diminution of civilian deaths does not imply a decrease in violence. Indeed, more than 20 military offensives were led in various Syrian governorates, such as Deir El-Zor, Idlib, and Deraa that same year. To this day, institutions such as the Independent International Commission of Inquiry on the Syrian Arab Republic are still recording violations to International Humanitarian Law, committed by various parties to the war.

The World Health Organization (WHO) defines attacks on health care as any threat or violence that restricts the availability and delivery of health services. The repercussions of these assaults are severe, as they not only imperil the lives of medical staff but also affect people in crucial need of care.

Physicians for Human Rights (PHR), an organization of health professionals investigating the consequences of human rights violations on health, has documented 492 attacks on Syrian health facilities and 847 Syrian medical personnel deaths from 2011 until the end of 2017. According to PHR’s interactive map of Syria, the number of deaths of medical workers is highest in the Rif Dimashq, Aleppo, and Idlib governorates.

A report published in the Conflict and Health journal in early 2018 assessed the Syrian civil war as the most brutal conflict regarding health care, with the highest number of attacks on facilities and personnel. During the first and second quarters of 2018, the World Health Organization identified 156 health care related attacks in Syria. These onslaughts have inflicted heavy casualties, including on doctors and their patients, resulting in the death of 97 people and the injury of 165 others. In the first half of 2018, the assaults on health care in Syria amounted to 67% of the global number of health attacks.

In the recent context of conflict de-escalation, this paper covers the various attacks on healthcare perpetrated in Syria from June until September 2018.

  1. Attacks on healthcare
  1. June 2018

June 2018 saw the highest number of attacks on healthcare in Syria from June until September 2018. There were 17 attacks on medical, civil defense, and Red Crescent facilities, which caused the death of 13 medical and civil defense workers.

Most of the attacks and killings took place in the Deraa and Idlib governorates. The Syrian armed forces and its Russian allies launched a military offensive on the governorate of Deraa in late June using heavy bombardment and air strikes in an attempt to retake southern territories from Islamic State (IS) rebels.  A week earlier, Russian armed forces had conducted air strikes on IS strongholds in Idlib.

The government-led offensive on Deraa resulted in 14 attacks on health facilities, which were attributable to the Syrian armed forces, and the death of eight health and civil defense workers. On 28 June, aerial bombs and explosive barrels destroyed Al Ihsan Hospital in Deraa, which is supported by the Syrian American Medical Society (SAMS), rendering it out of service. Al-Ihsan Hospital was indispensable in the region and provided 15,000 medical services and 120 surgeries monthly. The assaults killed two SAMS employees, Asaad Zoubi, a medical worker, and Ali el-Rifai, a hospital security guard.

June was also fatal for the Syrian civil defence group, the “White Helmets”. The organization was subject to seven attacks on their facilities, which resulted in the death of seven of their workers.

2. July 2018

Syria witnessed a significant drop in health care related violence in July. As the military offensive in Deraa continued, Syrian and Russian armed forces attacked two medical facilities. The Martyr Walid Khattab Makeshift Hospital in Nawa city was completely destroyed by missiles and barrel bombs and put out of service. Similarly, the Nawa Public Hospital suffered partial damage and is now inoperative. The air strikes killed a civil defence worker, Suleiman al Maf’alani, as he was helping the wounded from another bombing. Medical workers in Nawa feared for their lives as they continued to work under attack. In an interview with Amnesty International, a nurse speaking anonymously declared that medical facilities were unsafe for staff and patients, as hospitals were “the government’s primary target”.

A third attack on a medical facility was reported in the governorate of Aleppo when a bomb planted in a car detonated next to the Jarablos Dispensary and rendered it out of commission. The centre was the last active medicine dispensary in Eastern Aleppo and provided medicine to the entire region.

3. August 2018

According to the SNHR, health care related violence remained relatively low in August. Six attacks were conducted by various warring parties against medical facilities, and one attack on an ambulance, all of which resulted in slight damage.

One of the attacks is attributable to the International Coalition forces. In an attempt to fight an IS stronghold in the Deir El-Zor province, the Coalition fired missiles near the Bwebdran Medical Dispensary in the city of Boukamal.

The Syrian regime was also responsible for the death of a doctor and a nurse. The doctor Abdul Ghafour Ibrahim Khlasi, co-founder of the Al Zarzour Hospital in Aleppo, was kidnapped in 2012 and tortured to death in 2018 by Syrian government forces in a detention centre. His fate remained unknown to his family until his name was found in civil records, registered as dead on 7 August 2018. Another report from the SNHR notes that 194 detainees died due to torture by the Syrian government’s forces in August.

4. September 2018

The Syrian and Russian allied armed forces declared an impending offensive on the governorate of Idlib, the last opposition and rebel stronghold in Syria, in early September. Syrian and Russian warplanes coordinated air strikes and fired missiles indiscriminately over the governorate, hitting health and emergency facilities. The three days of strikes resulted in the destruction of various emergency services, rendering the region’s readiness for emergency response low.

The White Helmets organization declared that their Tamana Emergency Response Centre in Southern Idlib was completely destroyed following bombardment by Russian jets on 6 September. However, the civil defence workers recorded no casualties among their staff and indicated no damage to their equipment, as they had evacuated the building beforehand.

The Union of Medical Care and Relief Organizations (UOSSM) reported the attack on another civil defence facility in Khan Sheikhoun in the Idlib governorate. The response centre was put out of service and two White Helmets workers were wounded. A day later, the Idlib Ambulance System, which was established by the Idlib Free Health Directorate, was rendered out of commission. The ambulance system comprised of 50 vehicles and had only been running since June.

On 8 September, the city of Haas in Idlib was also targeted, resulting in the complete destruction of the Nabd el Haya Underground Hospital. The shelling severely damaged the building’s structure and destroyed the medical equipment and vehicles. One doctor and two visitors were injured following the attack, but no deaths were recorded among the staff or patients.

Simultaneously, air strikes were conducted over Hama in order to fight the opposition-controlled areas of the province. The shelling caused the demolition of two medical facilities, the Latamneh Surgical Hospital and the Dr. Hassan Al-Araj Underground Hospital.

  1. Conclusion and recommendations

Despite the drop in civilian mortality in Syria from June to September 2018, the observation of this period is far from optimistic given the many violations to International Humanitarian Law. Although all parties to the conflict are implicated in the surge of violence, Syrian and Russian coalition forces inflicted the biggest share of damage, especially by recurrently striking hospitals and civil defense facilities.

The repeated targeting of hospitals in Syria is seen as a war tactic designed by Syrian and Russian armed forces in order to provoke massive civilian displacement. The government aims to “punish” civilians residing in opposition-held areas by depriving them of healthcare and forcing them to move. The evacuation makes it easier for the Syrian and Russian coalition to successfully eliminate opposition strongholds from the affected territories. This tactic flouts international norms, as the Rome Statute clearly states that the intentional displacement of civilians amounts to war crimes. However, Syrian and Russian officials have denied these accusations, claiming that rebels in Syria used hospitals as bases and civilians as human shields.

Rule 28 and Rule 35 of International Humanitarian Law (IHL) call for the respect and protection of hospitals. Deliberate attacks on hospitals are therefore considered a war crime. Rule 28 also clearly states that hospitals lose their protection if they are being used outside their humanitarian function. The Al-Ihsan Hospital, the Martyr Walid Khattab Makeshift Hospital, the Nawa Public Hospital, the Nabd el Haya Hospital, the Latamneh Surgical Hospital, and the Dr. Hassan Al-Araj Hospital all retained their original humanitarian purpose and targeting them can thus be considered a war crime.

The deliberate kidnapping, torture, and killing of medical staff, such as the cases of Asaad Zoubi, Ali el-Rifai, and Abdul Ghafour Ibrahim Khlasi, by the Syrian government are a direct violation of Rule 25 of IHL, which calls for the protection and respect of doctors, nurses, and all other staff of medical facilities. The attacks on medical personnel and facilities are a clear violation of the principle of non-interference of medical impartiality.

The Syrian regime has adopted an overtly aggressive stance regarding the Syrian civil defense organization, the White Helmets. The government accuses them of being linked to terrorist groups such as the Islamic State, in an attempt to discredit them and their work. Counterterrorism laws in Syria legalize the detainment, torture and execution of individuals deemed as terrorists or as being tied to terrorists. However, through the seven years of conflict in Syria, the White Helmets organization has helped and worked to relieve the population in opposition-held areas. As civilians conducting humanitarian work, the legal status of members of the White Helmets is unclear, yet they remain protected under Rule 31 and Rule 87 of IHL, relating respectively to the protection of humanitarian personnel and to the humane treatment of civilians.

Defenders for Medical Impartiality (DMI)calls upon the Syrian government to take responsibility of their violations to International Humanitarian Law. According to Rule 158 of IHL, the Syrian government is under the obligation to investigate war crimes committed on its territory, as well as to prosecute those deemed responsible.

We call on the international community to condemn all war crimes, especially attacks on healthcare, being perpetrated in Syria, and to be more vocal about the implication of the Syrian and Russian governments in these attacks. We encourage the international community to be more active regarding medical and humanitarian aid and relief to the Syrian population.

The international community cannot force Syria to prosecute individuals for war crimes in front of the International Criminal Court (ICC), considering that Syria has not signed the 2002 Rome Statute. However, chapter VII of the United Nations’ charter allows the Security Council (UNSC) to refer cases of war crimes to the ICC, regardless of the concerned state’s signatory status. DMI urges the Russian government to cooperate with the rest of the UNSC and the international community on the prosecution of war crimes, including health care attacks, in Syria.

DMI also calls on the UNSC to renew the authorization for cross-border and cross-line humanitarian access in Syria, which expires on 10 January 2019.