Syria Notes Autumn 2019

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Editor: Kellie Strom. Contributing Editor: M. Yafa. Published by Superpower Partners®. Printing of this issue part funded by Lush Charity Pot. All contents are copyright © the individual contributors.

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The red carpet

The Editors

Introduction to the Autumn 2019 issue of Syria Notes.

When the makers of the film For Sama took their documentary to Cannes, they made their appearance on the Cannes Film Festival’s red carpet holding up signs saying ‘stop bombing hospitals’. Co-director Waad al-Kateab told Syria Notes that this message was especially for Russia and the Assad regime, together responsible for over 90% of attacks on medical facilities in Syria, according to Physicians for Human Rights.

Waad was joined in the demonstration by co-director Edward Watts, and by her doctor husband, Hamza al-Kateab. Hamza said that this message, ‘stop bombing hospitals’, was ‘just something no-one can say no to.’

The film For Sama shows life and death in a hospital during the 2016 siege of Aleppo. Today in nearby Idlib, the bombing of hospitals is the biggest challenge to the health sector, Dr Munther al-Khalil of the Idlib Health Directorate told Syria Notes. But medics are not best placed to prescribe a solution to military aggression. ‘Politicians should know what to do, not me,’ Mohamed Katoub of the Syrian American Medical Society told us.

For Waad and Hamza, their film’s purpose is to bring change. They found the experience of bringing the film to the United Nations in New York frustrating. UN officials ‘thought they were doing their best,’ because ‘they are using strong language with the regime and all of that,’ Hamza said.

The campaigners and diplomats supporting their visit told them that the most they could aim for at the UN as an achievable goal was to open an investigation. ‘It was very disappointing for us,’ Waad said. ‘How can you think the world still needs to open an investigation to know who is bombing these hospitals? It’s a very huge gap between the reality and what’s happening in the corridors of the UN.’

‘We still, both of us, struggle between what we want to happen really on the ground, and what are the achievable things,’ Waad said.

Looking beyond the limits of the UN, they see hope in how the film has connected with audiences, and they are working to develop ways to help audiences turn emotional engagement into practical action.

Illustration by Amany Alali.

Dr Munther al-Khalil suggested to Syria Notes that people in Britain can help to show the extent of the crimes happening in Syria. Beyond the urgent need to stop the bombing, he pointed to a lack of medical staff because they had been killed, maimed, or had fled. Doctors in the UK can help by getting involved in NGOs working in Syria, Dr al-Khalil said, or by training medics in Syria via the internet, or by giving courses in neighbouring Turkey.

Most donors have suspended projects in southern Idlib, Dr al-Khalil told us, leading to a severe lack of medical services, as well as of other services which help people stay in an area. The need isn’t only for medical support, he said, as there is now a lack of projects which support stability generally.

‘A focus only on projects tied to humanitarian donors has weakened the structure of the government in the area, and weakened its capacity to govern the health sector and coordinate emergency responses,’ Dr al-Khalil said. ‘We believe that it’s not possible to have an effective humanitarian response and protect these interventions without stability in the structure of the government, especially given the complicated and really difficult situation in the area.’

But stability requires an end to bombing. On the call to stop bombing hospitals, Waad says that she and Hamza want ‘to put this red line back, to make that not acceptable any more.’

That phrase ‘red line’ is a loaded one for Syria, evoking the chemical weapons red line which the UK and US failed to enforce in 2013, and which is now the sole element of Assad’s killing campaign where they set a boundary.

In this issue we look at what we might expect from the recently announced United Nations Headquarters Board of Inquiry, and how NATO and Coalition members like the UK might help provide vital evidence.

We also look at how hospital attacks fit into Assad and Putin’s wider strategy, and ask what a red line on hospital attacks might require.

And we talk to a mother in Idlib, to a dentist, and to doctors: the people on the front line of Assad and Putin’s war on civilians.

In this issue:

Editor: Kellie Strom. Contributing Editor: M. Yafa. Published by Superpower Partners®. Printing of this issue part funded by Lush Charity Pot. All contents are copyright © the individual contributors.

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The doctor covered in dust

A Syrian medic talks to Syria Notes.

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

In the photograph, he sits on the floor, his back to the wall, looking exhausted, his blue healthcare scrubs covered in dust and stained with blood. The picture was taken in July, in Arihah, a town in Idlib province, northwest Syria, an area under constant bombardment since April by the Russian air force and the Assad regime. He talked to Syria Notes about working under fire to provide medical care, and living as a target.

Syria Notes: Please tell us about yourself.

I was born in 1966 and I’m 53 years old. I’m from a small village in in the suburbs of Daraa, a village called Tasil. I lived and grew up in Damascus where I went to school. In 1986 I travelled to the Soviet Union, as it was then, to study dentistry. After graduation I went back to Syria and opened a private practice.

When the Syrian revolution started I worked as a paramedic during protests, and when the regime forces raided and besieged Daraa city and its suburbs.

Paramedics used to attend peaceful protests. When the regime forces violently broke up the protests using live bullets, we would attend to the injured and take them to hospitals in Daraa city, or to field hospitals in nearby areas.

The regime cracked down on the opposition and went after everyone who was connected to the revolution. No matter what role they played, even if all you did was humanitarian work or aid you were wanted by them. My work led to my arrest and detention in Daraa. I was detained by the military security branch along with other doctors. Some of these doctors were killed under torture, and some were let out and then assassinated, some were let out and then they fled the country, some are still in detention until today. Some of us got out of detention and went back to do our jobs.

After I got out of detention I went back to work, but I couldn’t do that in Daraa. So, I went to Damascus. In Damascus I was helping injured protesters on the streets or in local homes, and tending to them until I could transport them to a makeshift medical facility. While working in Damascus the security forces attempted to detain me again, so I fled to areas controlled by the opposition.

Syria Notes: You are originally a dentist, but now you are helping the injured in a general hospital. Tell us about the work you are doing in Idlib right now.

When I took refuge in areas controlled by the opposition I noticed how these areas suffered from a severe shortage of medical staff. In some places there was not a single medical worker. Because of this I was forced to take on more responsibilities outside my expertise. I worked very hard, and did my best to help the people there. I did good by people there, but sometimes I made a few mistakes, but I had no other choice.

I kept working like this for a while until a team of doctors arrived to the area. At that point my work became limited to working as paramedic and assisting surgeons in operations. The doctors gave the people working in the field hospital courses in advanced trauma life support.

Syria Notes: Why do you think hospitals are being targeted? When a hospital is attacked, how is the local community affected?

Targeting hospitals and medical facilities and is systematic, and it aims to eliminate medical staff. So civilians will be left with no help. It also aims to destroy infrastructure. Hospital targeting terrorises civilians living in the area. The attack on medical staff leads to the spread of diseases, and for the general health of the population to decline. People with long term illness suffer a lot.

Syria Notes: Have you witnessed a direct attack while working in a hospital? Can you describe it?

Throughout my work I was an eyewitness to attacks on medical facilities and hospitals in Daraa and Damascus. Many times hospitals were targeted, without any warning and deliberately. In 2018, we were displaced from the suburbs of Damascus to the north of Syria, and specifically to Idlib city.

At the beginning, it was a calm and safe area, but three months ago the vicious military campaign started targeting the north of Syria, in Idlib and its suburbs, and the provinces of Hama and Aleppo. During the last three months several medical facilities were targeted, such as hospitals in Ma’arat al-Nu’man, Kafranbel, Hass, and other areas.

When I was displaced to Idlib, I continued my work providing medical care to civilians. On Sunday the 29th of July the regime targeted the hospital where I work with air bombardment which caused massive destruction. They destroyed a hospital providing medical care to women and children and those who are most vulnerable.

One time I was working in a field hospital. On that day we were in the middle of responding to a recent bombardment in the area, and to the stream of victims that were coming to the hospital. Then the hospital was bombed, part of hospital collapsed, and some of our patients lost their lives, and some sustained new life-threatening injuries.

When the bombs fell, a state of panic came over everyone there. As staff, we had a massive job of attending to the injured and evacuating everyone to safety, as well as trying to save as much of the precious medical equipment and supplies as we could. The hospital was out of service after the bombing.

Most of the medical facilities targeted with bombardments are forced to go out of service. The attack is intended to render the targeted medical facility helpless. It will be targeted repeatedly to stop it completely. Targeting hospitals is issuing a death sentence to civilians, those who are already injured and those who will be injured in future bombardment, especially those with advanced truma. Targeting hospitals also kills medical staff, or injures them, so they are not able to provide help to others. In all cases, the goal is to eliminate any medical help providers.

Syria Notes: Do hospitals get warning of attacks? How much warning? What do they do if they get warning?

There is a very basic system. There are observatories in every area. They tell us via radio or the internet. They issue warnings about incoming attacks. For example, they say, ‘Aeroplanes have taken off from Hama, they are flying toward the north and have passed Ma’arat al-Nu’man, the likely target seems to be Arihah city, civilians there should take cover.’ The warning is issued for a whole city. It’s difficult to say where in the city the bombs will fall. So, when a warning is issued, we take precautions like everyone else.

Video images from the 28 July 2019 airstrike on Arihah. Via Facebook and Storyful.

Syria Notes: Tell us about the day that photo was taken.

On the 28th of July, I was working in my dental clinic. I heard a loud explosion coming from somewhere very close to the clinic. I rushed to the place of the explosion, and I found out it was an airstrike that had destroyed many of the civilians’ homes.

I was one of the first who arrived on the scene. The situation was dire, massive destruction of buildings, and bodies of those who had died everywhere. I saw pieces of children scattered around the area.

We helped injured civilians on the streets, and then we tried to rescue those who were trapped under collapsed buildings.

I was working with the White Helmets to to rescue five trapped children. All of the trapped children were under ten years old. When we pulled out the first child I noticed that half of his head was missing. Next to him lay his two sisters, one we managed to save and the other had already passed away.

The situation was unbearable, men, women, and children were crying, and blood was everywhere. It hit me really hard, and I felt powerless and grief-stricken. I was helpless in front of the harm that fell on these children. After the rescue effort was over, I took a small break, and that is when someone took that photo of me.

Syria Notes: What name would you like for us to use in reference to you?

Just call me the doctor who was covered in dust.

Syria Notes: Is there anything else you would like to add?

As a doctor, I never in my life held a weapon. My life mission is to help those who need my help. Help those who are injured and those who are ill. My work has cost me a lot, I was detained, the medical facilities I worked in were bombed and targeted.

I want to address those who take upon themselves to defend human rights in the world. Those who have the power to act. Protecting the Syrian people is far overdue, stop the bloodshed in Syria, stop the Russian and Assad killing machine. As Syrians we are still hopeful of a better future and we will strive every day to reach freedom. After the night, the morning will come for sure.

Next: Investigating hospital attacks — Can a new UN inquiry achieve results?

Investigating hospital attacks

Can a new UN inquiry achieve results?

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

1. Demarche

For several years, human rights organisations have been documenting attacks on hospitals in Syria, mainly by the Assad regime and by Russian forces. On 30 July 2019, following a briefing by UN aid chief Mark Lowcock, the UN Security Council heard Susannah Sirkin of Physicians for Human Rights explain the scale of these attacks.

Up to July 2019, Physicians for Human Rights corroborated 578 attacks on 350 separate medical facilities, and documented the killing of 890 medical personnel. Of those 578 attacks, 521 were by the Assad regime and its allies: 297 by by the Assad regime and 224 by either Russian or Assad regime forces.

‘Since the beginning of the conflict in Syria, the ongoing assault on health care facilities and personnel has been a defining factor,’ Susannah Sirkin told the Security Council, ‘a deliberate, inhumane, illegal strategy of war.’

After the Physicians for Human Rights presentation, ten of the Security Council’s fifteen members delivered a demarche, a diplomatic petition in person, to UN Secretary-General Antonio Guterres, calling on him to launch an inquiry into attacks on medical facilities in Syria. The ten petitioners were the United Kingdom, France, the United States, Germany, Belgium, Peru, Poland, Kuwait, Dominican Republic, and Indonesia.

According to Reuters news agency, the petitioners highlighted that ‘at least fourteen UN-supported facilities on the list of deconflicted facilities have been damaged or destroyed in northwest Syria since the end of April.’

Mark Lowcock listens to Susannah Sirkin at the Security Council, 30 July 2019.
Image via UN video library.

This UN deconfliction list is a list of civilian facilities such as hospitals and schools which have chosen to share their locations via the UN to make clear that they are civilian objects and therefore protected under international humanitarian law.

Medical units are particularly protected. They can only lose protection if they are used to commit acts harmful to the enemy, outside their humanitarian duties, and protection may cease only after due warning has been given, with a reasonable time limit, and after such a warning has remained unheeded.

The ten petitioners pointed to the precedent of the previous Secretary-General Ban Ki-moon using his discretionary power to open an inquiry into an attack on a UN-coordinated humanitarian convoy in Aleppo in 2016. Following the demarche, the Secretary-General decided to establish an internal United Nations Headquarters Board of Inquiry to investigate ‘a series of incidents’ in the Idlib area of northwest Syria since the September 2018 de-escalation agreement between the presidents of Russia and Turkey.

The investigation is to cover destruction of, or damage to facilities on the UN’s deconfliction list and UN-supported facilities in the area. The Board is to report to the Secretary-General upon completion. The Secretary-General urged all parties to cooperate with the Board once it had been established.

2. Deconfliction

The UN’s deconfliction approach has been controversial, and often misunderstood. In his 30 July 2019 briefing to the Security Council, Mark Lowcock, the UN’s aid chief, explained the basics of how deconfliction is supposed to protect civilian locations such as hospitals, and told of how it is failing:

‘Through that system, humanitarian agencies, mainly NGOs, provide information to OCHA to identify static civilian locations or humanitarian movements. The United Nations then shares the coordinates with the International Coalition Forces, the Republic of Turkey and the Russian Federation.

‘When there is an incident on a deconflicted site, we notify the parties and request an investigation be undertaken.

‘As I said to you last week, whether the information provided through the deconfliction system is is being used by the parties to protect civilian facilities from attack or to target them for attack is an extremely important question.

‘As you know, I have asked the Russian Federation for clarification of what it does with the information we give them. I continue to hope to receive further clarification.

‘We have also sent Notes Verbale to parties to the conflict in respect of six different attacks in northwest Syria in 2019 in relation to deconflicted locations or movements. While we have received a formal response from Turkey, we have not yet received one from the Russian Federation.

‘In spite of our efforts to work with parties to the conflict to prevent attacks on civilian objects and humanitarian workers, I have come to the conclusion that in the current environment deconfliction is not proving effective in helping to protect those who utilise the system. I have asked my team to meet again with the humanitarian organisations who would like their activities to be deconflicted to update them on the current situation and determine again whether we should continue to provide information to the parties on new sites or humanitarian movements.’

There is a clear reason to share coordinates of hospitals and schools in conflicts where military forces are making some effort to observe international humanitarian law: the set of rules in the Geneva Conventions and other agreements which seeks to limit the humanitarian impacts of war.

The war in Syria, however, began with the Assad regime using military force against peaceful demonstators, and it has continued as a war waged primarily against civilians. From the start, medics were targeted, beginning with anyone giving first aid to injured demonstrators, and continuing with blocking medical supplies to besieged areas, and then with bombing hospitals.

Despite the Assad regime’s manifest strategy of targeting civilians, UN agencies and some NGOs followed the same practice in Syria as in other conflicts, sharing coordinates for hospitals and other civilian locations with OCHA, the UN Office for the Coordination of Humanitarian Affairs.

Syrian humanitarians greeted this practice with astonishment. In early February 2016, Marcell Shehwaro of Kesh Malek told a meeting in the House of Commons about her experience of receiving a request from OCHA for locations of schools run by her NGO:

‘Four months ago, the UN sent us an email saying, please can you locate your schools so we can send their location to the Russian air force, for protection? And I was shocked by the email. Seriously? That’s why we need the UN? To send the location to the Russian air force, and pray to God that the Russian air force won’t use the locations that we send them to bomb us?

‘And in the email there is this explanation of, “We can’t promise anything, but we can hope that they are not going to bomb them.” To me, I think that as long as we are doing this at that level of managing the conflicts around the conflict itself, the Russians are not going to stop.

‘What we should do is a no-fly zone for sure, and that’s been done somewhere else, and we should do it for civilians that have been asking it for years now. And who can do it? I think those who are claiming to be the Syrian people’s friends. And in the London Conference I said that I wish we had his [Assad’s] friends. His friends are much better.

Yes, we need a no-fly zone. I used to say we don’t need it, but yes, we need it. We need it to survive. We need it to be able to work. We need it to open the battle of personal freedom together with each other. Right now, the only thing we talk about is death.’

On 18 February 2016, Médecins Sans Frontières announced that they were stopping sharing the location of hospitals. In a statement, MSF’s Dr Joanne Liu said, ‘Healthcare in Syria is in the crosshair of bombs and missiles.’

Dr Liu described an air attack days earlier, on 15 February 2016, in Ma’arat al-Numan, Idlib Province. At nine in the morning, aircraft fired four missiles, destroying a hospital supported by MSF. At least twenty-five people were killed, among them nine medics and sixteen patients.

‘Forty minutes later, after rescuers arrived, the site was bombed again. These secondary strikes—in military jargon known as “double taps” —that target rescue and medical personnel trying to save the injured are outrageous.

‘But it didn’t stop there. A nearby hospital that received many of the wounded from the first strike was itself hit an hour later.

‘This attack can only be considered deliberate.’

In the following months, attacks on hospitals and humanitarian workers escalated as Assad regime and Russian forces lay siege to east Aleppo city.

In March 2016, speaking at a meeting in the House of Commons, Hamish de Bretton-Gordon, a chemical weapons specialist who had trained Syrian medics, argued that as Russian and Assad regime forces already knew where hospitals were, it was better to share locations via the UN in order to establish the fact that these were known to be hospitals. (Syria Notes no. 8.)

‘… I think first of all the Russians and Assad know exactly where these hospitals are, that’s my point, they know where they are anyway. At the moment, the Russians are saying, “well we are not targeting, we didn’t mean to target”—we all know that they are. If we reinforce publicly, in the UN Security Council and elsewhere, these are the hospitals Putin and Assad, they are designated safe areas, you are not to attack them, and they are attacked, then that’s irrefutable.’

On 27 April 2016, the MSF-supported Basel Aslan (Al Quds) hospital was hit. The attack began with an airstrike on a building across the road. Then the nearby staff residence was hit. Minutes after, a third strike hit the entrance to the emergency room, killing and injuring medical staff who were bringing in patients wounded from the first strike. Five minutes later a fourth strike hit the hospital, destroying the top two floors.

Dr Hamza al-Kateab told Syria Notes that this attack was clearly carried out by Russian forces as it took place in the evening darkness, and in that period the Assad regime air force wasn’t capable of night attacks.

The Atlantic Council report, Breaking Aleppo, said that by the time the 2016 siege began, east Aleppo city was served by only ten hospitals and seventeen clinics, staffed by just over thirty doctors. These were repeatedly bombed. Aleppo residents said that Russian forces were using more powerful weapons than had been seen in earlier regime attacks, including bunker-buster bombs able to destroy basement shelters. The Syrian American Medical Society (SAMS) reported that bunker buster bombs were used to destroy the underground M10 Hospital in Aleppo, and in other hospital attacks.

According to SAMS, there were seventy-three attacks on medical facilities and personnel in Aleppo city between June and December 2016. During the final offensive from September 2016 on, ‘the limited hospital facilities were overloaded, trauma patients littered the floors and hallways, and the few remaining doctors worked around the clock with dwindling supplies,’ according to the Atlantic Council’s report.

And air attacks on hospitals continued after the fall of east Aleppo city. By the end of 2017, SAMS was reexamining the question of sharing hospital locations, and on 12 March 2018, they, along with eleven other humanitarian organisations working inside Syria, shared coordinates of sixty health facilities in Syria with UN OCHA, for OCHA to then share with the parties involved in the war. In a statement on 4 April 2018, they wrote:

‘After more than seven years of relentless and systematic attacks on healthcare across Syria resulted in no meaningful accountability, this measure represents a last-resort decision on the part of our combined organisations, as we seek to protect our staff and their patients and deter future attacks, and to potentially implement a process for investigating every alleged attack on healthcare throughout Syria in the future.

‘Although health care facilities throughout Syria have been targeted consistently and deliberately, particularly those in non-government areas, this decision was a result of lengthy consultations with, and full endorsement by, our teams inside Syria and doctors working in these hospitals. Coordinates were only shared after the staff in each facility agreed to the process.

‘Since the beginning of the conflict in Syria, medical personnel have braved continuous bombardment to care for the sick and injured in a blatant violation of international humanitarian law. Hospitals are considered among the most dangerous places, often discouraging patients from seeking treatment. In February 2018 alone, twenty-six medical facilities in East Ghouta, and at least ten in Idlib were targeted, forcing twelve to interrupt their services. Doctors and nurses have repeatedly come under attack while trying to save lives with the limited resources they have. Between February 18-20, thirteen medical facilities in East Ghouta were attacked in 48 hours, resulting in the death of three SAMS medical staff.’

Dr Munther al-Khalil, head of the Idlib Health Directorate, told Syria Notes that there was no unanimous decision on deconfliction. Most medical staff weren’t confident that this move would provide protection, but some agreed. Believing they would be subjected to attacks anyway, they hoped that sharing locations might at least reduce the frequency of the bombing. There was also pressure from UN institutions, Dr al-Khalil said, with constant encouragement to provide hospital coordinates.

It was soon clear that a theoretical threat of future war crimes trials wasn’t going to deter Assad regime or Russian forces. Within the first month, two hospitals on the new deconfliction list were attacked: Arbin Surgical Hospital on 20 March 2018, and Hamdan Hospital on 7 April 2018.

According to Mohamad Katoub of SAMS, there were six attacks in all on medical facilities on the UN deconfliction list in 2018. And 2019 has been worse. Out of a total count of thirty-eight attacks on medical facilities between 26 April and 22 July 2019, fourteen were on sites on the UN list.

Dr Katoub told Syria Notes that, while of course local staff give the approval to share their own coordinates, they are desperate for this to bring some result. By only doing the sharing coordinates part, this mechanism will not work, he wrote, not without ‘a very serious investigation on every single incident report and every single attack.’

3. Aircraft tracking

Amongst those states that petitioned the UN Secretary-General for the new investigation are members of the anti-ISIS Coalition and of NATO. These states seem to be in a position to provide valuable evidence to the UN Board of Inquiry. They have military technology able to show whose aircraft were present when hospitals and other civilian locations were attacked.

According to Justin Bronk, Research Fellow, Airpower and Technology at the Royal United Services Institute, NATO AWACS aircraft and other Coalition aircraft ‘will track and share the locations of Russian and Syrian aircraft from the time that they take off to the time they land.’

RAF Boeing E-3D Sentry. Photo: Adrian Pingstone via Wikipedia.

NATO’s AWACS inventory includes Royal Air Force E-3Ds, US Air Force E-3Gs, French Air Force E-3Fs and the NATO pooled E-3A fleet. These are the cornerstone of the Coalition’s airspace surveillance and management over Syria, including deconfliction with Russian and Syrian aircraft, Justin Bronk explained to Syria Notes.

Coalition aircraft typically broad­cast a radio transponder signal which can be picked up by any radar controller, including by those in Damascus, and by the E-3 AWACS. Also, Coalition aircraft will be on Link 16, an airborne datalink network which allows all aircraft on the link—from fighters, tankers, surveillance aircraft to AWACS themselves—to share sensor data to build collective situational awareness. This means that all Coalition aircraft are typically well aware of allied aircraft and what those can see, with the AWACS fleets providing overall coordination as well as contributing a lot of situational awareness from their on-board wide-area surveillance radar.

For deconfliction and tracking of Russian and Syrian aircraft, which typically do not broadcast a transponder signal, more traditional tracking and radio communications are used. AWACS and fighter assets where available will track and share the locations of Russian and Syrian aircraft from the time they take off to the time they land. If there is a need to deconflict for flight safety, the AWACS crew will typically contact these aircraft via the internationally recognised ‘guard’ frequency—243.0 MHz for military operations—to advise or warn them.

To positively identify these non-transponder broadcasting aircraft, many Coalition assets such as AWACS aircraft and the US Air Force’s F-15 and F-22 fighters can use techniques such as Non-Cooperative Threat Recognition (NTCR) which involves using onboard radar to focus on and classify unknown aircraft by identifying distinctive features like engine fan blade size and engine spacing.

In the UK, MPs of different parties have in recent years called on the Government to consider using this kind of tracking data to identify which parties are responsible for attacks. Up to now, these calls have been rejected.

4. The inquiry

While the UK, the US, and their allies might be able to provide valuable evidence to the UN Headquarters Board of Inquiry from military tracking data, past form suggests they may withhold this information.

In the case of the earlier UN Headquarters Board of Inquiry into the 19 September 2016 attack in Urum al-Kubra, or Big Orem, in western Aleppo province, where a UN-coordinated aid convoy was bombed, it seems that the US military withheld radar tracking data from the UN inquiry.

Twenty people were killed in that attack, which lasted from 8pm until near midnight. One of those killed was Omar Barakat, director of the town’s local branch of the Syrian Arab Red Crescent. US officials briefed journalists that two Russian fighter jets were in the air at the location of the attack.

Louisa Loveluck and Thomas Gibbons-Neff of The Washington Post gave a particularly detailed account in their story dated 24 September 2016:

‘US radar and satellites equipped with thermal sensors detected two distinct heat signatures leaving Russia’s Khmeimim air base that evening, a senior defense official said, speaking on the condition of anonymity to discuss intelligence matters. The two Su-24 swing-wing bombers took off and banked northeast, heading for Aleppo. They were the only jets in the area of the convoy, the official said.

‘He said the US military is confident Syrian helicopters also participated.’

At a hearing of the US Senate Committee on Armed Services on 22 September 2019, in reply to a question from Senator Richard Blumenthal asking whether there was any any doubt that Russian planes were responsible for attacking the convoy, the chairman of the US Joint Chiefs of Staff, General Joseph Dunford, said:

‘What we know are, two Russian aircraft were in that area at that time. My judgment would be that they did. There were also some other aircraft in the area, that belonged to the regime, at or about the same time; so, I can’t conclusively say that it was the Russians, but it was either the Russians or the regime.’

Aftermath of the 19 September 2016 aid convoy attack. Photo: Ammar Abdullah, AMC.

It appears that the UN Headquarters Board of Inquiry on the convoy attack was not given access to any US radar or satellite data that might have confirmed the presence of Russian jets.

Only a summary of the report was publicly released. Then-Secretary-General Ban Ki-moon wrote to the UN Security Council that, ‘as with all United Nations boards of inquiry, the Board’s report is an internal document and is not for public release.’ On attributing responsibility, the published summary said the following:

‘The Board indicated that it had received reports that information existed to the effect that the Syrian Arab Air Force was highly likely to have perpetrated the attack and, furthermore, that the attack had been carried out by three Syrian Mi-17 model helicopters, followed by three unnamed fixed-wing aircraft, with a single Russian aircraft also suspected of being involved. However, the Board did not have access to raw data to support those assertions and, in the absence of such data, it was unable to draw a definitive conclusion. Moreover, the Governments of both the Russian Federation and the Syrian Arab Republic denied all allegations of their involvement in the incident.

‘The Board noted in this connection that there were technical issues pertaining to a hypothesis of the incident having been a result of a joint Syrian Arab Air Force Russian Federation strike. The Board was informed that that the Russian Federation did not conduct joint strikes. A high degree of interoperability and coordination would be required for two air forces to operate in the same airspace, targeting the same location.’

So from the precedent of the 2016 Board of Inquiry, we can see that Coalition and NATO forces may decide to withhold evidence from this new Board of Inquiry on attacks in northwest Syria, despite having called for its establishment; that as a consequence its report may well be inconclusive; and that in any case the UN will most likely not publish the report in full.

5. Other investigations

The potential for the UN’s new Board of Inquiry to have an impact may seem limited, but there are other avenues to investigate hospital attacks, inside and outside the UN.

First among these is the UN Commission of Inquiry on Syria, established in August 2011 by a Human Rights Council resolution, with a mandate to investigate all alleged violations of international human rights law since March 2011. This Commission of Inquiry is already investigating hospital attacks. For example, its June 2018 report, The siege and recapture of Eastern Ghouta, reported multiple attacks by Assad regime forces on medical facilities in the last months of the siege of eastern Ghouta. It found ‘a pattern of attacks against hospitals and medical facilities’ by pro-Assad forces, ‘repeatedly committing the war crime of deliberately attacking protected objects, and intentionally attacking medical personnel.’

Then there is the IIIM: the International, Impartial and Independent Mechanism to assist in the investigation and prosecution of persons responsible for the most serious crimes under International Law committed in the Syrian Arab Republic since March 2011. This was established by a UN General Assembly resolution in December 2016, with a mission to ‘collect, consolidate, preserve and analyse evidence,’ and to ‘prepare files in order to facilitate and expedite fair and independent criminal proceedings.’ The IIIM can’t prosecute cases itself, but prepares cases to be tried in any suitable courts or tribunals that have jurisdiction, or that may have jurisdiction in the future. There is little immediate prospect of international tribunals taking on Syria cases, so national courts may be more likely venues.

Mohamad Katoub of SAMS told Syria Notes that humanitarian NGOs have been asking for timely investigation, not for another investigation body.The new Board of Inquiry has no further mandate or authority beyond what the Commission of Inquiry or IIIM already have, he points out:

‘We just need their reports to be issued in a timely manner, not months or years after a hospital is hit, or a school is targeted, or a humanitarian worker is killed, and this is because we lost hope that the international community will do a concrete action, so our hope is just to point fingers to perpetrators while they are still doing their crime. Our hope is just to make some pressure on the perpetrators by those reports, so they think twice before the next attack.

‘States members to the UN Security Council should make all the efforts to make those three investigation bodies work in a timely manner.

‘They should point fingers to perpetrators, and use the Commission of Inquiry reports which lay the responsibility of the majority of those attacks on the Syrian regime and its allies, to make the needed pressure to stop those attacks.’

Dr Munther al-Khalil of the Idlib Health Directorate told Syria Notes:

‘The most important thing in these investigations is that they are continuous and that they clearly and directly specify the party which committed these crimes even if there are currently no mechanisms to try the criminals. But at least the perpetrators should be identified as criminals for future reference, and this may be the best available at this time to reduce the frequency of these crimes.’

Outside of the UN, states can in some circumstances mount their own investigations of crimes in Syria, as is happening in Germany and France where international arrest warrants have been issued for senior Assad regime figures accused of mass torture and murder. While prospects of arrest are remote, such warrants can be a strong counter to any moves to normalise relations with the Assad regime.

In some countries, private citizens may be able to take legal action, as happened in the US when the family of journalist Marie Colvin, killed by Syrian regime forces in 2012, successfully brought a civil case against the Syrian government.

Finally, governments can impose sanctions against individuals and organisations they accuse of crimes. This doesn’t require bringing a legal case, but may demand presenting a case strong enough to withstand parliamentary scrutiny, and for joint sanctions with international allies, a case strong enough to convince other governments.

Dr Munther al-Khalil of the Idlib Health Directorate suggested to Syria Notes that given the failure of UN institutions, because of the Russian veto, the US and the UK should carry out investigations outside the UN, and publish their results directly or through organisations specialising in documenting war crimes and crimes against humanity. ‘In this way we can have evidence that can be used in the future,’ he said.

Fearing that a number of countries might reestablish relations with the Assad regime and restore legitimacy to it, Dr al-Khalil argued that for this reason it was important to highlight the criminality of the regime, and to bring to trial those involved in war crimes and crimes against humanity.

6. Early warning

As well as providing evidence in connection with attacks on civilian targets, the Coalition’s ability to track Russian and Assad regime aircraft could also provide more accurate early warning to civilians. In early 2015, The Syria Campaign publicly called on the US to share radar information with Syria Civil Defence—the White Helmets—but to no avail. The Syria Campaign quoted Khaled Khatib of Syria Civil Defence as saying, ‘if we could only get warning that the planes were coming, we could warn families, tell people to run from the markets, get the children out of the schools, let the medical centres know so that they can take cover.’

At that time Syrians were already using some technology for early warning of air attacks. Radios were used to listen in to Assad’s pilots, and aircraft observers would watch Assad’s bases to call in warnings of helicopters and jets taking off. In the town of Kafranbel in Idlib province, activists launched Radio Fresh in mid 2013 in part to broadcast air raid warnings.(Syria Notes Spring 2019.)

These efforts to warn civilians had limited accuracy and cover. In the absence of any sharing of radar data, more was needed to give timely effective warning. In 2016, Hala Systems launched Sentry Syria, a digital network that takes input from human aircraft spotters and from remote acoustic sensors, calculates where and when an airstrike is likely, and then sends out warnings via Syria Civil Defence networks.

On early warning systems, Dr Munther al-Khalil told Syria Notes that they help to a degree, so in some cases it’s possible to evacuate hospitals, or bring patients and medical staff down to the shelters. Mohamed Katoub of SAMS told Syria Notes that early warning can reduce risk, along with building hospitals underground, but that as long as attacking hospitals is a tactic in this war, ‘with no reaction from the international community,’ the attacks will not stop.

‘It is like a pain relief medicine to a patient who suffers from cancer. But do we have other options? Those tools saved lives, and protected humanitarian workers, but this should not be our call—our call should be to stop those attacks.

‘I would like people of the UK to send letters to their parliament, and government, and ask each of them to do what they would do if the attacked hospital is the place where their children are being delivered to life, receiving vaccinations, and treated. What will they do then? Just imagine that the hospital in your town, where you take your kid to get treatment is attacked, what will you do then?’

7. Evidence

The years of war in Syria have seen the pioneering of new open source investigation techniques. The potential of collective online investigations was first demonstrated when Eliot Higgins and fellow enthusiasts identified Croatian weapons being supplied to Syrian opposition forces in early 2013. Later that year, the same methods helped unravel details of the Assad regime’s Sarin nerve agent attack on two suburbs of Damascus on 21 August 2013.

These methods continue to be applied and developed to examine events in Syria and in other conflicts, and to be linked to other disciplines. The Global Legal Action Network cooperates with Bellingcat on investigating airstrikes in Yemen, where they combine GLAN’s legal expertise with Bellingcat’s open source techniques. Airwars have worked with Amnesty to bring their database of open source casualty reports together with Amnesty’s on the ground investigations, and their joint Strike Tracker project has added to the picture through crowdsourcing analysis of satellite imagery.

Early warning data has added a useful extra layer to investigations into hospital attacks by the Syrian Archive, Bellingcat and the Syrian Network for Human Rights. Data gathered by Hala Systems for early warning can’t fully replicate the detail gathered by NATO and Coalition aircraft tracking systems, but it does provide an alternative source of evidence for identifying parties responsible for particular attacks.

In a very recent attack, when a market in Ma’arat al-Nu’man was bombed on 22 July 2019, killing 39 civilians according to the Syrian Network of Human Rights, witnesses on the ground said that Russian aircraft were responsible for four initial strikes, with Assad regime aircraft conducting follow up attacks in the hours afterwards.

Russia’s Ministry of Defence immediately denied that its planes had carried out the airstrikes, saying they had not flown any missions in Idlib that day. Allegations of Russian involvement were ‘a fake’ by the White Helmets, the Ministry said in statement reported by Reuters.

Syria Civil Defence—the White Helmets—responded to the Russian accusation with their own statement, saying that the Sentry Syria system had reported a Russian aircraft taking off from Hmeimim airbase at exactly 08.03 that morning, and that further observations were made of the Russian warplane circling Ma’arat al-Nu’man at the time of the first attack at 08.36, and that it remained in the area until 09.03. Later a Russian surveillance plane played a support role to Assad regime warplanes that arrived from the T4 and Hama airbases to conduct five further airstrikes, intended to target rescue teams and roads leading to the site.

According to a report by the Syrian Network for Human Rights, the first two Russian strikes hit the vegetable market, each time firing a missile:

‘The same warplane then headed to the east of the city and carried out a third air raid, again using a missile, this time in the vicinity of Ma’arat al-Numan Prison near the Uwais al Qarni Mosque in al Sharqi neighborhood. The air raid caused moderate material damage to both the mosque and to al Salam Hospital, which is supported by the Syrian American Medical Society (SAMS), located 100 meters from the raid site. It was followed by a fourth air raid on the building that formerly housed the Cultural Centre.’

This attack illustrates that the bombing by Russian and Assad forces is a joint campaign not just against hospitals, but against all key elements of civilian life, including markets, mosques, and rescue workers.

Given the Russian Ministry of Defence’s denial, this attack is also a good example of where NATO or Coalition tracking data could play a useful part in verifying Sentry Syria evidence, and verifying reports from witnesses on the ground, in order to build a case for legal action or sanctions.

Next: The men who give the orders — Officers responsible for Russia’s airstrikes

Case files
Hospital attacks, 28 April–10 July 2019.

The men who give the orders

Officers responsible for Russia’s airstrikes

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

Assad’s ministers and generals are all targets for UK sanctions, but amongst those in Russia’s top leadership responsible for crimes in Syria, it seems only two, General Gerasimov and Colonel-General Kartapolov, are under UK sanctions, and they are sanctioned not for actions in Syria, but because of Putin’s war in Ukraine.

Ultimate responsibility for Russia’s military campaign in Syria lies with the political leadership, Vladimir Putin, President of Russia, and Sergey Shoigu, Russia’s Defence Minister. These two are joined by Chief of the General Staff of the armed forces General Valeriy Gerasimov in commanding the National Defence Management Centre (NTsUO), a centralised command and control centre created in 2014.

General Valeriy Vasilevich Gerasimov has been subject to EU sanctions since 29 April 2014 over Russian actions in Ukraine.

Russia’s direct military intervention in Syria began with deploying military forces to Syria in Summer 2015, and with bombing from September 2015 on. As Mathieu Boulegue of Chatham House explained to Syria Notes, for the first two years, high intensity bombing operations were placed directly under the responsibility of the commander in chief of the Russian VKS (Aerospace forces) Colonel-General Viktor Bondarev. He was succeeded in 2017 first by interim chief Lieutenant-General Pavel Kurachenko and then by Colonel-General Sergei Surovikin.

The VKS is made up of three branches under one command: the Air Force, Aerospace/Missile Defence Force, and Space Command. The chief of the Air Force of the VKS is Lieutenant-General Andrey Yudin, who took office in August 2015 right before the start of the Syrian operation.

The head of the Russian group of forces in Syria at the start of Putin’s intervention was General Aleksandr Dvornikov, from September 2015 to July 2016. The post was held by by Lieutenant General Alexander Zhuravlev to December 2016, by Colonel-General Andrey Kartapolov to March 2017, and by Colonel-General Sergei Surovikin to Autumn 2017. Surovikin went on to be commander in chief of the VKS. Zhuravlev held the post for a second time until September 2018. Since April 2019, Colonel-General Andrey Serdyukov has held the position, journalist Pierre Vaux told Syria Notes.

Kartapolov is subject to EU sanctions for his role in Putin’s war in Ukraine. Dvornikov, Kartapolov and Serdyukov are subject to sanctions by Australia for their role in military actions in Ukraine.

Ibrahim Olabi of the Syrian Legal Development Programme said to Syria Notes that the responsibility of commanders under international law, which is binding on Russia, is ‘beyond debate.’ It is an established rule under customary international humanitarian law and has been applied in various international criminal courts. He cited the articulation of this fundamental concept given by the International Committee of the Red Cross:

‘Commanders and other superiors are criminally responsible for war crimes committed by their subordinates if they knew, or had reason to know, that the subordinates were about to commit or were committing such crimes and did not take all necessary and reasonable measures in their power to prevent their commission, or if such crimes had been committed, to punish the persons responsible.’

In short, Ibrahim Olabi said, ‘Russian commanders are criminally responsible,’ and ‘they need to live up to that responsibility, or be held to account by states that have a duty to uphold the international order, the UK included.’

Next: Case files — Hospital attacks from 28 April to 10 July 2019.

Case files
Hospital attacks, 28 April–10 July 2019.

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.


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:

Amnesty International report:

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:

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:

Physicians for Human Rights case study on Kafranbel Hospital:

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.

Next: Assad and Putin’s criminal strategy — How to understand and counter it?