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Case files

This article is from the Autumn 2019 issue of Syria Notes.


For this issue of Syria Notes, we have collected reports on more than twenty recent attacks on hospitals and other medical facilities. We have concentrated on those events where reporting most strongly suggests that air attacks were deliberately targeted against hospitals.

The cases collected here span from 28 April 2019 up to 10 July 2019. Even as we prepared this issue, reports of further attacks came in. One attack on 14 August 2019 targeted a SAMS-supported ambulance centre in Ma’aret Hurmah, Idlib province, killing two paramedics. A Syria Civil Defence volunteer who tried to recue them was killed in a follow-up ‘double tap’ strike. Mohamed Katoub of SAMS told Syria Notes more about the attack:

‘The 14th of August was a holiday in Syria, but warplanes don’t take a rest, so the ambulance with its staff were on standby in a small facility, which is a triage midpoint between some small towns around Ma’aret Hurmah, a town in the northwest of Syria. We have WhatsApp groups to chat with staff in Syria, and the alarm came there that this point was targeted, and the staff are under rubble.

‘In half an hour, the news came that they were killed, and the bodies were recovered, and a civil defence volunteer was killed in the same location.

‘One of the killed staff started working just twenty days before the attack. You can imagine the feelings of his parents.’

The Syria Civil Defence volunteer who was killed trying to rescue the medics was named as Younis Balouz.


HOSPITAL ATTACKS   28 APRIL – 10 JULY 2019


28 APRIL 2019
 Attack on Hospital 111, Qalaat al-Madiq.
At approximately 01:30 local time on 28 April 2019, Hospital 111 near Qalaat al-Madiq (Madiq Castle) in Hama was attacked by a Russian fixed-wing aircraft, according to reporting from Shaam Network, and also from Hama Health Directorate.

The hospital, a specialty hospital for women and children, shut down following the airstrike. Damage to the building and to medical equipment was significant. No casualties were reported.

According to Hala Systems, observers for the Sentry Syria early warning system reported multiple Russian fixed-wing aircraft circling in the vicinity of Qalaat al-Madiq prior to the attack; see the map on the next page for details. No Syrian regime aircraft were observed in the area at the time.



01.11: Russian fixed-wing aircraft observed circling near Madiq Castle, Hama.
01.24: Russian fixed-wing aircraft observed circling near Madiq Castle.
01.28: Russian fixed-wing aircraft observed flying southwest near Jabal Shahshabo, Idlib.
01.28: Russian fixed-wing aircraft observed flying southwest near Ma’arat al-Nu’man.
01.30: Local media organisations report an airstrike on Hospital 111 in Madiq Castle, Hama.
01.33: Russian fixed-wing aircraft observed flying southeast near Kafranbel.
01.47: Russian fixed-wing aircraft observed circling near Madiq Castle.

Data courtesy of Hala Systems.



28 APRIL 2019
 Attack on Al-Latamna surgical hospital.
At 18.30 on 28 April 2019, in the second hospital attack on the same day, Russian warplanes targeted the Al-Latamna surgical hospital with multiple strikes, according to reports from Hama Health Directorate and from the Union of Medical Care and Relief Organisations, UOSSM.

The strikes caused major damage to most parts of the hospital, to the hospital’s structure, and to the ambulance.

The hospital provided emergency services to areas in the northern Hama countryside, and included a surgical department and a pharmacy.


29 APRIL 2019
 Attack on Alhbeit Primary Health Care Centre.
At 22.00 on 29 April 2019, the Alhbeit Primary Health Care Centre in Southern Idlib, Syria was hit by ground rockets and mortars, causing significant damage to the structure, according to UOSSM. No injuries or casualties were reported. The facility served 2,500 beneficiaries monthly and was the only medical facility in a city with a population of more than 15,000 local and displaced people.


1 MAY 2019
 Attack on Kastoon Primary Health Care Centre.
At 11.45 on 1 May 2019, the Kaston Primary Health Care Centre in Hama, Syria was hit by mortars and shelling. The facility, supported by UOSSM, was damaged. No injuries or casualties were reported.


5 MAY 2019
 Attack on Kafer Zeita Cave Hospital, Hama.
Between approximately 11.00 and 12.00 on 5 May 2019, Kafer Zeita Cave Hospital was hit by at least four bombs by Syrian regime aircraft, two medical workers reported to Amnesty International. The attack caused severe damage to the hospital and put it out of service.

A nurse who was in the hospital at the time described to Amnesty four successive strikes which began around 11 am. He told Amnesty:

‘We were very afraid the Syrian army would invade the town and enter the hospital… We relied on God and exited the hospital. After we evacuated, the fourth strike happened.’

Kafer Zeita Cave Hospital’s location coordinates were shared through the UN deconfliction mechanism, according to UOSSM.

Physicians for Human Rights have published a case study on Kafer Zeita Cave Hospital, also known as Martyr Hassan al-Araj Hospital. The Cave Hospital was established in response to repeated attacks on the nearby Kafer Zeita Specialty Hospital. Thirteen attacks on Kafer Zeita Specialty Hospital were verified by Physicians for Human Rights.

Toward the end of 2015 Dr Hassan al-Araj and a number of other medical providers established a hospital seventeen metres deep into a mountain, expanding on a natural cave previously used by shepherds to shelter their flocks. Whenever Kafer Zeita Specialty Hospital was bombed out of service, the Cave Hospital became the primary care provider in the area.

Dr Hassan al-Araj was killed in April 2016 when his car was hit by a missile outside the hospital, reportedly fired by a Russian jet.

Between 2016 and 2018, the hospital was reportedly subjected to dozens of direct air attacks by the Assad regime and its allies. Physicians for Human Rights verified six of those attacks, in October 2016, December 2017, January 2018, February 2018, and September 2018.



Above: Images from a 2016 video on Kafer Zeita Cave Hospital, with Dr Hassan al-Araj.

Physicians for Human Rights case study on Kafer Zeita Cave Hospital:
http://syriamap.phr.org/#/en/case-studies/4

Amnesty International report:
https://www.amnesty.org/en/latest/news/2019/05/syria-security-council-must-address-crimes-against-humanity-in-idlib/


5 MAY 2019
 Attack on Nabad Al-Hayat Hospital, near Hass, Idlib.
At approximately 14:45 on 5 May 2019, local media reported an airstrike destroyed Nabad Al-Hayat Hospital near Hass, Idlib. There were no casualties. Hala Systems report that multiple Russian aircraft were observed departing Hmemim Airbase and circling in the vicinity of Hass prior to the attack.

This was the second hospital attacked on 5 May, following bombing of Kaferzita Cave Hospital a few hours earlier.

Nabad Al-Hayat Hospital had previously been bombed on 8 September 2018. That earlier attack was reported to have been carried out by Assad regime helicopters—see the Autumn 2018 issue of Syria Notes for details.



A number of videos and photos of this latest attack were analysed in a report by the Syrian Archive. In particular, Orient News published a video showing munitions penetrating the hospital, and the hospital exploding.

The hospital was supported by Syria Relief & Development SRD. According to a statement from SRD, the hospital’s coordinates had previously been shared with UN OCHA as part of its formal deconfliction mechanism.

Syrian Archive report:
https://syrianarchive.org/en/investigations/hass.html




14.27: Russian fixed-wing aircraft observed departing from Hmemim Airbase to the southeast.
14.28: Russian fixed-wing aircraft observed departing from Hmemim Airbase to the southeast.
14.31: Russian fixed-wing aircraft observed departing from Hmemim Airbase to the southeast.
14.38: Russian fixed-wing aircraft observed circling near Kafranbel, Idlib.
14.38: Russian fixed-wing aircraft observed flying southwest over Jarjanaz.
14.39: Russian fixed-wing aircraft observed circling near Heish.
14.45: Initial report of an airstrike on Nabad Al-Hayat Hospital in Hass.

Data courtesy of Hala Systems.



5 MAY 2019
 Attack on Kafranbel Surgical Hospital, Kafranbel, Idlib.
At approximately 17.30 on 5 May 2019, the surgical hospital in Kafranbel, Idlib was bombed. Local sources reported that Russian aircraft carried out the attack. According to Hala Systems, observers in the area reported both Russian fixed-wing aircraft and Syrian regime Su-24 aircraft in the vicinity. One person was reported killed, later rising to two.

This attack took place on the same day as the earlier airstrikes on Kaferzita Cave Hospital, Hama, and on Nabad Al-Hayat Hospital, near Hass, Idlib. According to UOSSM, Kafranbel Hospital also had its location coordinates shared with military actors through the UN deconfliction mechanism to prevent accidental targeting.

The Syrian Archive produced an extensive report analysing videos and photographs of this attack, showing that the hospital was hit four times during the attack. Amnesty International included this attack in their 17 May 2019 report covering several airstrikes on hospitals in Syria. Physicians for Human Rights have also published a case study on Kafranbel Hospital.

According to Physicians for Human Rights, the history of Kafranbel Hospital goes back to July 2012, when a group of local activists established a medical point and pharmacy. In June 2013, it was turned into a hospital under the name of Orient Hospital. In November 2016, the British NGO Hand in Hand for Aid and Development took control of the hospital.

Physicians for Human Rights has verified several attacks on the facility from June 2014 on. The earliest was a Syrian regime airstrike on 29 June 2014, which killed a newborn baby, a doctor, and an anesthesia technician, and caused major damage to the hospital. The hospital was attacked twice more that year, with the last 2014 attack killing fifteen people. The hospital was attacked four times in 2015, twice in 2017.

Funds raised by Hand in Hand allowed an underground facility to be built, after which the hospital was bombed again in February 2018.

After the 5 May attack, the hospital was attacked again on 4 July 2019.



Above: Images from a Macro Media Centre video of survivors emerging after the attack.

Syrian Archive report:
https://syrianarchive.org/en/investigations/kafrnabel.html

Physicians for Human Rights case study on Kafranbel Hospital:
http://syriamap.phr.org/#/en/case-studies/6



17.20: Syrian regime Su-24 observed flying southwest near Ma’arat al-Nu’man, Idlib.
17.22: Syrian regime Su-24 observed flying west near Kafranbel.
17.30: Syrian regime Su-24 observed circling near Ma’ret Hurma.
17.30: Local media organisations report an airstrike on Kafranbel Surgical Hospital in Kafranbel, Idlib.
17.33: Syrian regime Su-24 observed circling near Heish.
17.34: Russian fixed-wing aircraft observed flying east near Maarat al-Numan, Idlib.

Data courtesy of Hala Systems.




Above: From a Halab Today video showing three of the munitions that struck Kafranbel Surgical Hospital on 5 May 2019. Via Syrian Archive.

Hand in Hand for Aid and Development, the UK NGO that supports Kafranbel Surgical Hospital, provided Syria Notes with more background.

The building is an underground facility that HIHFAD funded through UK public donations, with the aim of allowing safe and uninterruped service even under heavy airstrikes. That was put to the test in February 2018 when the hospital was hit by four targeted airstrikes. The airstrikes destroyed the hospital above ground, but the underground hospital survived intact and ensured no staff member or patient was injured in the attack.

In the 5 May 2019 attack, the hospital suffered at least six direct hits from 17.25 local time, according to the NGO, killing two patients and inflicting significant damage on the hospital.

On 4 July 2019, the hospital was again targeted; the second major attack in eight weeks, despite the hospital being registered through the UN deconfliction mechanism. The hospital sustained not one but two offensives on 4 July: the first by military helicopters at 14:52, and the second just short of an hour later at 15:40 by air to surface missiles. The attacks were directed at the entrance to the hospital, and all services had to be suspended.

The hospital team worked hard to get the hospital running again after the 4 July attack, Hand in Hand told Syria Notes, and it is back in operation.


6 MAY 2019
 Attack on Al-Amal Hospital, Kansfara, Idlib.
At approximately 02.00 on 6 May 2019, the Al-Amal Orthopedic Surgical Center in Kansafra, Idlib, was disabled by an airstrike. Multiple Russian fixed-wing aircraft were observed circling in the vicinity of Kansafra prior to the attack. No Syrian regime aircraft were observed in the area at the time or for at least an hour before and after the approximate time of the attack.



01.58: Russian fixed-wing aircraft observed flying west over Ma’arat al-Nu’man, Idlib.
01.59: Russian fixed-wing aircraft observed circling near Ziyara, Hama.
02.00: Approximate time reported for the airstrike on Al-Amal Hospital in Kansfara, Idlib.
02.01: Russian fixed-wing aircraft observed flying east over Jabal Al-Zawye, Idlib.
02.05: Russian fixed-wing aircraft observed flying west over Ma’arat al-Nu’man, Idlib.
02.05: Russian fixed-wing aircraft observed flying northeast over Khan Sheikhun, Idlib.
02.07: Russian fixed-wing aircraft observed circling near Ziyara, Hama.

Data courtesy of Hala Systems.



6 MAY 2019
 Attack on Alzerbah Primary Health Care Centre.
At 09.00 on 6 May 2019, the Alzerbah Primary Health Care Centre was hit by airstrikes. The facility was damaged and put out of service with no injuries or casualties reported, according to UOSSM. This was the second hospital attacked in Syria on that morning.


7 MAY 2019
 Attack on Kafr Nbouda Dispensary, Kafr Nbouda, Hama.
On 7 May 2019, Syrian regime forces attacked with bombs and missiles near Kafr Nbouda Dispensary in Kafr Nbouda town in Hama province northwestern suburbs, partially destroying its building and damaging its equipment, according to Physicians for Human Rights.

8 MAY 2019
 Attack on Kafr Zeta Primary Health Care Centre.
At 06.00 on 8 May 2019, the Kafr Zeta Primary Health Care Centre in Hama province was hit by an airstrike, according to UOSSM. The facility was heavily damaged and put out of service. No casualties were reported.


11 MAY 2019
 Attack on Sham Hospital, Kafranbel, Idlib.
At 01.20 on 11 May 2019, the Sham hospital in Kafranbel, Idlib, was hit by an airstrike, according to UOSSM. The hospital was damaged and put out of service. No casualties were reported as the hospital had been evacuated.


11 MAY 2019
 Attack on Alghab Primary Health Care Centre, Hama.
At 05.45 on 11 May 2019, the Alghab Primary Health Care Centre in Hama was hit by an airstrike, according to UOSSM. It was heavily damaged and put out of service. No casualties were reported.


11 MAY 2019
 Attack on Alhawash Hospital 112, Alghab area, Hama.
At 09.10 on 11 May 2019, Alhawash Hospital 112 in Alghab area, Hama was hit by airstrikes, according to UOSSM. The facility was damaged and put out of service. No casualties were reported.


15 MAY 2019
 Attack on Tarmala Maternity and Children’s Hospital.
At approximately 14.00 on 15 May 2019, Tarmala Maternity and Children’s Hospital in southwest Idlib was hit by an airstrike and completely destroyed, UOSSM reported. The hospital served 6,000 beneficiaries monthly, providing incubators and a dialysis department. The hospital had been evacuated, and there were no injuries.

Photo by Suhail al Ali, via Syrian Network for Human Rights.

According to Hala Systems, observers in the area reported at least one Yak-130 fixed-wing aircraft and multiple Mi-8 helicopters departing from nearby airfields and in the vicinity of the target area before the reported time of the strike.

Following the attack, the Syrian American Medical Society recovered some equipment and medical supplies and re-established the hospital in Kah, over eighty kilometres away on the northern edge of Idlib province, in an area hosting hundreds of thousands of people displaced from Hama and southern Idlib province. Below are images from a SAMS video about the move.






13.33: Mi-8 (Hip) helicopter observed departing north from Jeb Ramleh Heliport.
13.35: Yak-130 (Mitten) observed departing northwest from Hama Military Airbase.
13.36: Yak-130 (Mitten) observed circling near Qalaat al-Madiq, Hama.
13.41: Yak-130 (Mitten) observed flying north near Khan Sheikhun.
13.43: Yak-130 (Mitten) observed circling near Khan Sheikhun.
13.45: Mi-8 (Hip) helicopter observed departing north from Hama Military Airbase.
13.56: Mi-8 (Hip) helicopter observed circling near Qalaat al-Madiq, Hama.
14.00: Local media organisations report an airstrike on Tarmala Maternity and Children’s Hospital in southwest Idlib.

Data courtesy of Hala Systems.



28 MAY 2019
 Attack on Al-Hikma Hospital, Kafranbel, Idlib.
At 10:40 on 28 May 2019, the Dar al Hekma Hospital in Kafranbel city, Idlib province, was hit by and airstrike and destroyed, according to UOSSM. No injuries or casualties were reported. The Syrian Network for Human Rights reported that Syrian regime fixed-wing warplanes fired missiles on the hospital, partially destroying the building and damaging equipment. As a result, the hospital went out of service.


28 MAY 2019
 Attack on Hazarin Community Health Care Centre.
At 10:40 on 28 May 2019, the Hazarin Community Health Care Centre in Idlib was hit by an airstrike and completely destroyed, UOSSM reported. No injuries or casualties were reported.


14 JUNE 2019
 Attack on a medical facility in Ihsem town, Idlib.
On 14 June 2019, Syrian regime fixed-wing warplanes fired a missile on the medical point in Ihsem town in Idlib province, completely destroying the point’s building, according to the Syrian Network of Human Rights.


20 JUNE 2019
 Attack on ambulance and crew in Ma’arat al-Nu’man.
At 10.50 on 20 June 2019, an airstrike in Ma’arat al-Nu’man hit an ambulance operated by the NGO ‘Violet’, killing three staff and one female patient. The NGO named the three volunteers killed as Sa’er Bahloul, Mahmoud Al Mustafa, and Abdul Kader Nahtan.


4 JULY 2019
 Attack on Kafranbel Surgical Hospital, Kafranbel.
At 14.30 on 4 July 2019, the underground Kafranbel Surgical Hospital was hit by three rockets, just two months after the 5 May attack. Medics and patients were present, but no one was killed, according to UOSSM.


10 JULY 2019
 Attack on al-Kelawi Hospital, Jisr al Shughour, Idlib.
At 09.40 on 10 July 2019, al-Kelawai Hospital, also known as Jisr al-Shughour Surgical Hospital, was hit by an airstrike and damaged. Also hit was a UOSSM ambulance centre. Six civilians living nearby were killed, and five staff were injured, according to UOSSM.


10 JULY 2019
 Attack on Saraqib Primary Health Care Centre, Idlib.
On 10 July 2019, Saraqib Primary Health Care Centre was targeted by an airstrike, which landed directly in front of hospital. Damage was minor, and no casualites were reported. Coordinates had been shared via the UN.


10 JULY 2019
 Attack on Ma’arat al-Nu’man Central Hospital, Idlib.
At 18.30 on 10 July 2019, Ma’arat al-Nu’man Hospital was targeted by four aerial missiles, causing considerable material damage. One missile struck the hospital directly, while the other three hit the park outside the entrance, according to SAMS. Coordinates had been shared via the UN.

On the day of the attack, the hospital had already received 34 injured patients from Kafroumah. The staff continued to receive and treat these emergency cases, even though warplanes were flying overhead. They refused to leave their patients behind.

There were about 250 people in the hospital, including 70 in the patient rooms and 48 children and infants in the pediatric and neonatal department, as well as their family members and staff. Within two hours, medical personnel started to evacuate patients to other nearby hospitals. No staff or patients were injured in the attack.


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