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Target


Read our latest issue on the systematic bombing of hospitals in Syria.

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Assad and Putin’s criminal strategy

How to understand and counter it?

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


1. Yes, a target

Responding to attacks on hospitals in Afghanistan and Yemen, South Sudan and Syria, in November 2016 Médecins Sans Frontières launched the #NotATarget campaign. If this slogan could possibly be read as implying that those bombing hospitals were merely misidentifying them, in the context of Syria such an idea would be quite wrong.

Attacks on hospitals by regime and Russian forces are deliberate and systematic. Hospitals are hit repeatedly. Hospitals on the UN deconfliction list are hit repeatedly. For Assad and Putin, hospitals are a target.

The aim of the Assad regime’s strategy from 2011 on has been to regain control of Syria by eliminating resistance amongst the population in three ways: by killing, by displacing, and by instilling fear in those who remain.

All three ways are served by the use of hospital attacks, and by the other instruments of the Assad regime: by detention, torture, rape; by massacres of civilians at the hands of armed militias; by starvation sieges; by artillery and aerial bombardment of civilians; and by the use of chemical weapons.

All three ways are also served by the regime’s manipulation of law: by demonstrations of contempt for international law to instil hopelessness in the population; and by abusive control of domestic law to administer arbitrary detention and mass executions, and to enable seizure of land and property.

Since Putin’s direct intervention in 2015, his forces have been a full partner in the Assad regime’s strategy of waging war against the civilian population, including in the deliberate targeting of hospitals.

If advocacy by humanitarians and human rights activists is to be effective, then it needs to understand hospital attacks as part of this wider strategy.

Similarly, if any action by the UK Government, and its allies is to be effective, it needs to confront the strategy of mass murder, mass torture, and mass displacement, and not just respond to particular tactics, whether chemical attacks or hospital attacks.

Note that the international response to the Assad regime’s use of chemical weapons focused on a tactic rather than on the strategy behind it. This allowed the regime to shift from one tactic to another, allowed it to continue targeting civilians, and to continue achieving Assad and Putin’s strategic aims.


2. Ways and means

In the history of the regime, there is a continuity in manipulating access to healthcare that goes from before 2011, through the period of mass peaceful protest, and into the current period of territorial armed conflict.

Paediatrician and health campaigner Annie Sparrow has argued that prior to the popular uprising in 2011, the Assad regime systematically denied vaccinations to parts of the population considered unsupportive to the regime. (See Syria Notes no. 13.) According to Dr Sparrow:

‘… one reason behind the 2011 uprising in Syria was the years of the Assad regime withholding standard vaccinations of children—which protect them from diseases such as polio, pertussis and measles—in areas considered politically unsympathetic, such as the provinces of Idlib, western Aleppo, and Deir Ezzor, while pro-regime areas such as Damascus and Tartous received full coverage.’

Dr Sparrow argued that the reemergence of polio in Syria in 2013 was not so much an effect of war, but of the vulnerability of Syrian children living in areas that had been deliberately deprived under Assad rule.

‘Not a single case occurred in territory controlled by the government. In Deir Ezzor, where polio first reappeared in 2013, polio vaccination coverage had dropped to 36%. This was a man-made outbreak.’

From the start, the first protests against the Assad regime were met with deadly violence from security forces. The first protesters to be killed were shot on 18 March 2011 in Daraa, southern Syria.

Sustaining peaceful demonstrations in the face of this violence required medical support, but anyone providing that medical support to demonstrators soon became a target for regime forces.

In the first months of protests in Daraa, the Assad regime mounted a military siege against the town. On 29 April 2011, the New York Times reported, hundreds tried to march into town to break the siege, bringing food and medicine. As they came, holding olive branches and white sheets to signal peacefulness, security forces opened fire and killed at least sixteen people.

A June 2011 Human Rights Watch report said that ‘Syrian authorities routinely denied wounded protesters access to medical assistance’:

‘Witnesses told Human Rights Watch that security forces prevented ambulances from reaching the wounded, and on several occasions opened fire as medical personnel were trying to reach the injured, in one case killing a doctor and a nurse, an episode the authorities later blamed on “armed gangs.” Security forces took control of most of the Daraa hospitals and detained the wounded who were brought in. As a result, most of those wounded avoided the hospitals and were treated in makeshift clinics like the one set up inside al-Omari mosque or in private houses with no access to proper medical care.’


3. Widening the strategy

The targeting of medics and the blocking of medical supplies first seen in Daraa was systematically replicated as the Assad regime mounted sieges in other cities and towns in the years that followed. UN aid convoys, despite having a right of access under Security Council resolutions, depended on permission letters from regime security forces before they could deliver aid. Deliveries were infrequent and inadequate. Regime forces systematically removed medical supplies from any aid convoys allowed into besieged areas.

By March 2015, the Syrian American Medical Society reported that 640,200 people in 49 communities were besieged in Syria. Hundreds had died of causes such as malnutrition and lack of medical care.

Medical centres in besieged areas were run by local medical councils, understaffed and under­supplied. By 2015, most medical professionals in besieged areas had been killed, arrested, or had fled, according to SAMS. About fifty-five specialised physicians were left in the Eastern Ghouta suburbs around Damascus, and only about four hundred health sector workers in all, including medical students, nurses, technicians, janitors, and administrative staff. These had to serve for a population of half a million people.

Manipulating aid brought benefits to the regime even as it hurt people in besieged areas. Annie Sparrow argued (Syria Notes no. 13) that World Health Organisation support for Syria’s National Blood Bank, controlled by the Ministry of Defence, made the WHO complicit in the regime’s abuses:

‘The effect is not simply to place control of these essential life-saving goods in the hands of an institution that has a long history of ignoring humanitarian principles, and withholding safe blood transfusion not just from wounded opposition soldiers, but also from the tens of thousands of civilians injured each month in eastern Aleppo, Ghouta, and other rebel-held areas.

‘These subsidies also free up defence ministry funds that would have been spent on these blood-related needs, enabling them to be used to finance the targeting of hospitals and civilian infrastructure, and the incarceration and torture of doctors—in short, the undermining of WHO’s ostensible public-health priorities.’

As well as blocking medical aid from entering besieged areas, the Assad regime blocked patients in need of medical evacuation from leaving. Patients became bargaining chips in negotiations. By the end of 2015, people were dying of malnutrition in besieged Madaya. Twenty-three died from 1 December 2015 to 8 January 2016. Hundreds were suffering severe malnutrition. Ten patients needed immediate evacuation and hospitalisation.

After international pressure, and a quid pro quo deal involving two towns besieged by anti-Assad forces in Idlib, a UN aid convoy received regime permission to enter Madaya on 11 January 2016. But despite the entry of some aid, more deaths came in the following months due to medical evacuations being denied. Three children died from injuries sustained when playing with an unexploded bomb in March 2017. They had been denied medical evacuation, the UN Special Advisor Jan Egeland said. Siege Watch reported two further deaths from malnutrition in April 2016: a 65-year old man named Abdallah al-Darsani, and a boy named Mohamad Shabaan. Again, medical evacuation had been refused.

As the regime pressed one besieged area after another into surrender, attacks on hospitals were key. The Damascus suburb of Daraya suffered massacre, siege, starvation and bombardment from 2012 to 2016. The breaking point came on 19 August 2016 with an incendiary attack on the only hospital, after which the remaining community of 8,300 surrendered, and all were forcibly displaced.

The 2016 final regime assault on besieged east Aleppo city followed the same strategy on a larger scale, with scores of attacks on medical facilities, before the same end of surrender and forced displacement. In besieged Eastern Ghouta, smuggling tunnels had been used to bring medical supplies in, and to get severely ill patients out, but when Assad regime forces tightened the siege in 2017, these were cut off. For months, the regime refused to allow medical evacuations. In December 2017, the Jaish al-Islam armed opposition group agreed to release 29 prisoners, and in return the Assad regime allowed the evacuation of 29 of the most critical cases, in a deal facilitated by the International Committee of the Red Cross. But the total number in need of medical evacuation was 641, according to SAMS. Seventeen patients had already died waiting for evacuation.

The 2018 final assault on besieged eastern Ghouta again saw a massive assault on all civilian life, including hospitals, two of which had been put on the UN’s deconfliction list just a short while earlier. The end brought the forced displacement of 158,000 people, approximately 66,000 of whom were evacuated to opposition-held areas in Idlib and Aleppo provinces.


4. Torture

Since 2011, medics have been targeted with arrest, torture, and killing in detention. In July 2012, the Assad government passed a counter-terrorism law which, according to an inquiry published by the Lancet, effectively criminalised the provision of medical care to anyone injured by pro-government forces in protest marches against the government.

One of those killed in Assad’s prisons was a British doctor, Abbas Khan. A specialist registrar in orthopaedic surgery at the Royal National Orthopaedic Hospital in London, in 2012 Dr Khan left for Aleppo to work in a hospital there. He was detained by Assad’s forces on 22 November 2012.

Dr Khan’s family in the UK campaigned for his release. His mother Fatima Khan travelled to Syria in July 2013 to try and free him. She later told the coroner’s inquest how she found him in a Syrian court. ‘I hugged him, he was a skeleton,’ she told the inquest, according to the Guardian’s report. Her son was missing a fingernail and his feet were completely burnt. He told her, ‘This is nothing, I have suffered more than this.’ Dr Abbas Khan was unlawfully killed on 16 December 2013 in an ‘unknown prison or place of detention’ in Damascus, the coroner’s court jury found. ‘Dr Khan was deliberately and intentionally killed without any legal justification,’ the jury forewoman said.

Despite the verdict, the Metropolitan Police have reported little progress. Speaking at an Amnesty event last year (Syria Notes Autumn 2018), human rights lawyer Toby Cadman said that a number of individuals who bore criminal responsibility for Dr Khan’s killing could be identified:

‘We have made it very clear to the Metropolitan Police exactly where he was killed, and in any event it doesn’t matter if he was killed in facility one, two, or three, because the command structure is the same for all of these facilities, so it makes no difference.

‘And there are no rogue elements operating within these facilities. This is a policy, and there is a credible basis for bringing an investigation.’


Photos: Chlorine attack on Latamneh Surgical Hospital, 25 March 2017. Via Syria Civil Defence.


5. Chemical weapons

We have seen that attacks on health services are an integral part of regime repression, linked to the violent suppression of protests, to sieges, to forced displacement, to detention, torture, and murder. Hospital attacks are also linked to the regime tactic that has received most attention from Western powers: chemical attacks.

While only a few of Assad’s chemical attacks have drawn wider notice, a study by Tobias Schneider and Theresa Lütkefend for the Global Public Policy Institute in Berlin counted 336 confirmed attacks during the course of the war in Syria, 98% attributed to the Assad regime, and the rest to ISIS.

The three chemical weapons attacks which have brought most international attention are the 21 August 2013 Ghouta attack where between 1,400 and 1,700 people were killed by Sarin nerve agent, the 4 April 2017 Khan Sheikhoun attack where 89 people were killed by Sarin nerve agent, and the 7 April 2018 Douma attack where 43 people were killed by chlorine. Each of these events was followed by attacks on hospitals, apparently intended to target the treatment of chemical attack victims.

In the case of the 21 August 2013 attack, a report by the Violations Documentation Centre, titled The Medical Situation in Eastern Ghouta, gave details of three hospital attacks, before, during, and after the chemical attack.

Eight days before the chemical attack, Douma National Hospital had been hit with a Grad missile. Fateh hospital in Kafarbatna was bombed during the chemical attack, ‘to prevent people from using it.’ Medical Point 1 in Douma was bombed two days after the chemical attack.

For the staff at Medical Point 1, the 21 August 2013 attack was their sixth experience of treating victims of a chemical attack. The attack began at 3am. Dr Saif Eddin told the VDC what happened next:

‘At first we received four casualties with slight injuries. Then, suddenly, the number started to increase on a larger scale as they were being transferred by buses. At that day we received 600 casualties in batches, although our medical point can only accommodate twenty cases. Most of those casualties were completely unconscious, and the medical staff at the time consisted of eight people, only a doctor and a number of Medicine students, in addition to two nurses and two paramedics.

‘Of the 600 hundred casualties, we received 98 sufferers that were in need of intensive care. Our ICU was equipped to receive only thirteen patients. This made us put some of them on beds and the necessary apparatuses, while the rest were put on the ground because of the severe shortage of beds. Unfortunately, the number of the martyrs in the first five minutes was twenty martyrs, which made it a historic catastrophe.’

Tens of casualities could have been saved if the necessary medical supplies had been available. Dr Majed Abu Ali of the Unified Medical Office in Eastern Gouta said that doctors had to resort to picking patients depending on their degree of response to the assigned treatment:

‘For example, we could not pick patients with neuro disorders, because that might have meant missing the opportunity to save another patient. So, we can say that our doctors not only are doing their jobs but also making the most difficult decisions of their lives—the selection of patients among casualties. At some of our ICUs, we regretfully do not receive patients with infarcts hoping that they will get better depending only on the prescribed drugs. In short, all the above is a result of the acute shortness of the medical equipment and drugs which is caused by the prolonged siege imposed by the Syrian regime forces.’

In the case of the 4 April 2017 Khan Sheikhoun attack, a munition containing Sarin nerve agent was dropped on the town at around 6.30am local time by an Assad regime jet. Victims suffering the effects of nerve agent were taken to a number of local medical centres.

Victims couldn’t be sent to Al Ma’arra National Hospital in Ma’arat al-Nu’man, the main hospital in the region, as it had been bombed two days days earlier. The Syrian Network for Human Rights reported that a Russian jet had been responsible for the Al Ma’arra National Hospital bombing.

Some of the victims of the Sarin attack were taken to the medical point of Khan Sheikhoun, known as Al Rahma Hospital. At around 11am local time, as victims were being treated, that medical point was bombed. According to the Syrian Archive, Al Rahma Hospital was hit by as many as five S-5M air to ground rockets. The aircraft most likely responsible for firing the missiles were identified as Russian by early warning spotters.

In the case of the 7 April 2018 Douma attack, two chlorine canisters were dropped on a residential building, and 43 people were killed.

According to the Syrian NGO Alliance, the chemical attack was followed by several air strikes targeting Douma’s Specialised Hospital and its surrounding area. According to a Syrian Network for Human Rights report, warplanes fired a number of missiles on the hospital. The missile attack on the hospital came in parallel with a barrel bomb attack by Assad regime helicopters and bombardment by regime rocket launchers.

Chemical weapons have also been used to attack hospitals directly. The Telegraph reported on a chemical attack next to al Wisam Hospital in Kafr Zita, Hama, on 18 April 2014. It had been the fourth in a series of chlorine attacks on the town that had begun a few days earlier. The bomb on 18 April landed close to the hospital, and doctors and nurses became casualties.

Forensic samples were collected by a doctor, one of a group of Syrian medics that had been trained in evidence collection by western chemical weapons experts, including by Hamish De Bretton-Gordon. ‘In each of the samples we have found evidence of chlorine,’ Mr de Bretton-Gordon told The Telegraph.

On 8 June 2015, Kansafra Hospital in Idlib was hit by a chlorine bomb, according to oral evidence given by Dr Annie Sparrow to the United States Congress House Foreign Affairs Committee.

The Global Public Policy Institute study lists hospital attacks in Eastern Aleppo city using chemicals on 10 January 2016 and on 1 October 2016.

Physicians for Human Rights published a case study of a chemical attack against an underground hospital in Latamenah on 25 March 2017. The hospital was hit by multiple barrel bombs. Structural damage was minor, but at least one bomb which landed inside the hospital contained a chemical agent. The hospital’s coordinator said that chemical exposure led to the death of one of the medical staff, Dr Ali Ahmed Darwish.

Medics have also been targeted as part of the Assad regime’s attempts to obscure evidence of chemical attacks. The Atlantic Council report, Breaking Ghouta, says that after the regime recaptured Eastern Ghouta in 2018, regime officials ‘intimidated medical personnel and locals who witnessed the deadly attack into remaining silent’ about the Douma chemical attack.

This took place in the context of the Assad regime’s wider continued repression of medics and health services. Its forces were reported to have arrested and tortured to death medical workers who chose to remain in eastern Ghouta. The regime also continued to severely restrict access to healthcare for the remaining population, even blocking access to necessary cancer treatments.

In interviews with the Guardian and Washington Post, medics reported intimidation by regime security services and Russian military police to keep silent about what they had witnessed, to not cooperate with investigations into the Douma chemical attack, to hand over samples they had collected from victims, and to appear on state television to deny the attack had happened.


6. A red line for hospital attacks?

In their report for the Global Public Policy Institute, Tobias Schneider and Theresa Lütkefend draw lessons on responses to Assad’s chemical weapons use that may also be applicable in considering responses to hospital attacks.

They write that ‘the Syrian regime’s persistent and widespread use of chemical weapons is best understood as part of its overall war strategy of collective punishment of populations in opposition-held areas.’ The same can be said of attacks on medical services.

Schneider and Lütkefend recommend that countries willing to uphold the ‘red line’ over chemical weapons should maintain their public position that any use of chemical weapons by the Assad regime will trigger an immediate military response. They argue that stopping the strategy of chemical attacks requires halting the regime’s overall machinery of violence. In particular they suggest that Assad’s helicopter fleet, responsible for delivery of conventional and chemical barrel bombs, should be a primary target.

If we judge that attacks on healthcare are equally central, or even more central, to this same war strategy, should we also consider enforcing such a red line for hospital attacks?

Schneider and Lütkefend further recommend that governments should continue to support civilian mitigation efforts, through funding and training first responders, medical personnel, and early warning systems. They recommend continued support for efforts to bring accountability for war crimes and crimes against humanity.

They write that Europe in particular must reckon with the effects of mass violence or population warfare on regional stability and refugee flows.

The red line on chemical weapons use has not wholly ended the Assad regime’s use of chemical weapons. It has reduced their use while allowing other deadly violence targeting civilians to continue. A red line to deter hospital attacks might also only displace violence.

To be properly effective, a red line on hospital attacks would need to be joined with a commitment to end the Assad regime’s entire strategy of waging war against the civilian population. For that, protection of civilians would need to become the centre point in all aspects of policy towards Syria for the UK and its allies.


Next: Birth under bombing I — An interview with a mother in Idlib.




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