Throughout the final months of 2016, dozens of attacks on hospitals and clinics in opposition-controlled parts of Aleppo were reported. Doctors and nurses, whose chief task during the siege was to care for the victims of bombings and shellings, all too often fell victim to bombs themselves.
As many as 172 verified attacks on medical facilities and personnel were reported across Syria between June and December 2016. According to figures from the Syrian American Medical Society (SAMS), seventy-three of those (42 percent) occurred in the city of Aleppo. The attacks were so frequent, and some key hospitals were struck so many times, that the incidents appear to constitute a systematic attempt to destroy the city’s medical support.
These attacks against medical facilities reflected a pattern seen across the country, and documented by groups such as the World Health Organization, Amnesty International, and Médecins Sans Frontières (MSF). Physicians for Human Rights documented 400 attacks on 276 medical facilities, with the deaths of 768 medical personnel, between the beginning of the conflict and the end of July 2016; by their count, 362 of the attacks and 713 of the deaths can be attributed to the Syrian government and allied forces.
Using the masses of information available about these attacks, it is possible to examine their number and scale in Aleppo, the anatomy of individual attacks, and the impact of multiple attacks on individual facilities.
Art. 18. Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.(…)
Art. 19. The protection to which civilian hospitals are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.
The fact that sick or wounded members of the armed forces are nursed in these hospitals, or the presence of small arms and ammunition taken from such combatants and not yet been handed to the proper service, shall not be considered to be acts harmful to the enemy.
Fourth Geneva Convention, Articles 18 and 19
A Pattern of Attacks
Human rights organizations and other NGOs have attempted to record the number of attacks against medical facilities across Syria. Their calculations, made independently and across different time frames, reveal a staggering level of violence against medical facilities: an average of more than one attack a week, every week, since the conflict began.
Between 2011 and July 2016, Physicians for Human Rights mapped 400 attacks across Syria, the vast majority being by Russian and Syrian government forces. This translates into roughly one hospital strike every four and a half days. A Syrian American Medical Society (SAMS) report identified over seventy attacks by pro-government forces on medical facilities in Aleppo city between June and December 2016, an average of one attack every three days.
The Russian government “categorically” rejected allegations of hospital bombings by Russian forces; Kremlin spokesperson Dmitry Peskov stated, “those who make such statements are not capable of backing them up with proof.”
Syria’s President Assad, meanwhile, is on the record as saying that deliberately bombing hospitals would constitute a war crime. When challenged with the claim that hospitals in Aleppo were being bombed, he retorted: “We don’t attack any hospital. We don’t have any interest in attacking hospitals.” Assad continued: “As a government, we don’t have a policy to destroy hospitals or schools or any such facility.”
These statements offer, in essence, two defenses. Peskov argued that there was no proof of hospital strikes; Assad, that there was no policy.
The proof, however, exists in many forms, including witness testimonies, news footage, videos shot from security cameras and by rescuers, and photographs. Taken together and verified, these form a compelling body of evidence to suggest that the Assad government and its allies, including Russia, did indeed have a policy of targeting Syria’s hospitals.
Hospital Attacks In Aleppo
According to the Syrian American Medical Society (SAMS), 172 verified attacks on hospitals or medical facilities were recorded across Syria between June and December 2016. Of those, 73 verified attacks — 42 percent of the total — were recorded in the besieged, opposition-held half of Aleppo. According to the report, the strikes used a wide range of weapons, including air-to-surface missiles, cluster munitions, barrel bombs and incendiaries.
This data set can be cross-referenced against other open source information to understand what really happened to Aleppo’s hospitals.
According to UN operational plans, in mid-August there were nine “hospitals” and fifteen clinics in east Aleppo. Of these, ten had no doctors or were closed. Of nine SAMS-supported facilities and clinics in Aleppo city, only three offered trauma or intensive care facilities—the hospitals known as M1, M2, and M10. Only one of these clinics, M2, also had a pediatric facility. Some of the clinics were “staffed only by nurses (providing first aid) or midwives.”
As there were only a limited number of medical facilities in east Aleppo, the seventy-three verified attacks often hit the same hospitals repeatedly. This led to a situation where medical facilities were temporarily disabled while repairs took place and staff and equipment were replaced, leading to confusion and the spread of false information about the situation at the hospitals.
For example, the SAMS-supported M2 hospital in al-Maadi district was reportedly damaged in at least twelve attacks between June and December 2016. By examining open source videos and images, as well as satellite images of the area around the hospital, it is possible to confirm that many of those attacks occurred. Damage to structures around the hospital are consistent with attacks from above and would strongly indicate the use of air-dropped bombs and artillery, in line with reports from the hospital.
On June 14, the hospital reported it had been hit by an aerial attack, with the moment of the attack being caught by the hospital’s CCTV system.
Video footage and photographs from inside the hospital showed structural damage to the building and damage to equipment.
More attacks followed. One strike was reported on July 14; on July 16, another attack was reported, again with CCTV footage showing the moment of the attack from multiple angles. In this incident, photographs and videos from the attack allowed locations in the photographs to be firmly identified; allowing analysts to confirm that the locations featured were indeed M2 Hospital. To begin this process, a photograph taken outside the hospital after the attack, showing debris and damaged vehicles, was geolocated:
A video published by the Aleppo Media Center (AMC) showed the aftermath of the attack, with patients being evacuated to another medical center. During the video, a sequence showed one patient being transported through the building into an ambulance waiting outside the building. It was possible to match the balcony visible in the geolocated photograph to a balcony in the background of the exterior shot in the Aleppo Media Center video:
By following the journey of the patient in the AMC video back to its starting point inside the hospital building, it was then possible to match the route to CCTV footage showing the moment of the attack, also posted on YouTube by AMC.
This CCTV footage, from the same cameras that captured the June 24 bombing, clearly shows that the building was damaged on July 16; parts of the video show the explosion throwing debris through the air with civilians, staff, and patients caught in the attack. The image below shows the moment a civilian is hit by a large piece of material flung through the air by the explosive force of the attack:
Footage published online from the July 16 attack included many more CCTV camera videos than the June attack, as well as footage filmed by local activists showing different areas of the hospital and confirming that the building was damaged on several floors. Reports from the Syrian American Medical Society, who were supporting the hospital at the time, stated that six medical staff were injured, along with seven patients and civilians in and around the hospital.
Further attacks were reported at the start of August, the most significant of which resulted in the total destruction of a large multi-story building less than 20 meters (m) west of the hospital building, clearly visible in satellite imagery of the area.
Elsewhere, photographs from the August attacks showed further damage to the hospital building and the destruction of an ambulance used by the hospital that was featured in earlier photographs.
September 28 brought familiar scenes as CCTV cameras, their locations and angles now mapped out by examining footage of previous attacks, yet again caught the moment of an attack in footage broadcast on Britain’s Channel 4 News:
As the location of the cameras had been established by examining footage from the earlier attacks, it was possible to find footage from an earlier attack from the same camera showing the same part of the hospital, confirming that September footage broadcast by Channel 4 News was recorded at M2 hospital, and showed yet another attack:
Reports from SAMS stated that this attack resulted in significant damage to the hospital, damaging its generators and fuel tanks, as well as killing five people and injuring twenty civilians, staff, and patients.
Taken together, these images from multiple sources over a period of several months confirm that the M2 hospital was repeatedly struck between June and December 2016. Multiple vehicles used by the hospital were damaged and destroyed, equipment in the hospital was damaged and destroyed, and the attacks, while not destroying the hospital, severely reduced its ability to serve the local population.
As public awareness of the plight of Aleppo’s hospitals grew, so did official denials. Between September 28 and October 3, 2016, the SAMS-supported al-Sakhour hospital (also known as the M10 hospital), was hit in three separate incidents, damaging the hospital buildings and killing staff and patients. The Russian Ministry of Defense (MoD) gave a press conference that included a denial that attacks on the facility had taken place. The MoD briefer, Lieutenant-General Sergei Rudskoy, presented satellite imagery, which he claimed was taken between September 24 and October 11, stating “no changes to the facility can be observed” and that “this fact proves that all accusations of indiscriminate strikes voiced by some alleged eyewitnesses turn out to be mere fakes.”
However, open source images and satellite imagery proved that this was not the case, and the Russian MoD’s imagery was deceptive. Due to the frequency of the attacks in that one-week period, photographs and videos taken by local media and activists are available showing different levels of damage to the hospital area after each attack. For example, a massive crater in the road just east of the hospital appeared after the October 3 bombing, as well as previously unseen damage to the east side of the building:
This crater and the damage to the hospital building are also clearly visible in satellite imagery of the area taken on September 25 and October 13:
CCTV cameras at the hospital also recorded the moment of impact, showing damage inside and outside of the hospital buildings, with footage verified against other imagery of the hospital shared after previous attacks.
The Russian MoD’s satellite images of the same location were taken between September 24 and October 11, very close to the dates of the above images, yet they claim no damage is visible. On commercially available imagery the damage is clearly visible. It is unclear whether the error stems from a Russian satellite, a Russian analyst, or the Russian MoD’s spokesman; what is clear is that Rudskoy’s claim that “no changes to the facility can be observed” was false.
This misinterpretation of satellite and aerial imagery by the Russian MoD has been a frequent occurrence, both in the conflict in Syria and previously, in response to the downing of flight MH17 in Ukraine. It is fair to say that the MoD’s use of such imagery has revealed so many inaccuracies that it should be considered unreliable unless supported by corroborating independent evidence.
Targeting Hospitals: A Deliberate Strategy?
The evidence that many hospitals were hit, and that individual hospitals were hit repeatedly, is extremely strong. Nonetheless, throughout the conflict, the response from the Syrian and Russian governments was to deny any and all accusations of deliberately targeting hospitals.
Lacking direct documentary or eyewitness evidence of orders given by the government and its allies to target hospitals, those denials are difficult to disprove. However, several strands of circumstantial evidence point toward hospital strikes as a deliberate policy.
The first circumstantial thread is the sheer volume of strikes on medical facilities recorded during the conflict: over 400 across Syria, according to Physicians for Human Rights; over 70 in Aleppo in the second half of 2016, according to SAMS. It is very unlikely that such a high rate of strikes on facilities covered under the Geneva Convention was accidental.
Second is the Assad government’s intimate knowledge of the terrain. It has ruled the country for decades; most, if not all, of the hospitals destroyed were built under its aegis. It would therefore be illogical to argue that the government and its allies did not know where the hospitals were. They did know; but somehow, they failed to protect them, not once or twice, but hundreds of times. At best, this is a systemic failure of the duty to protect medical facilities; at worst, it suggests a deliberate policy of targeting hospitals.
A third indicator is the repeated confiscation by pro-government forces of medical supplies from humanitarian aid convoys to opposition-controlled areas across Syria. While trauma and surgical equipment was most frequently removed, antibiotics, anesthetic and antibacterial medicines, obstetric kits for midwives, burn kits, and other medicines were all extracted. In one convoy to besieged al-Waer in 2016, 5.3 tons of medical aid was removed from a convoy, allowing only 440 kg to get through. This apparent attempt to deprive doctors and hospitals in areas under opposition control of medicines and supplies suggests a consistent strategy, implemented whenever and however possible.
The final indicator is the strategic context of the strikes, and their application in the broader pattern of siege warfare. The bombing of Darayya’s last hospital on August 18, 2016, precipitated the agreement of the community to accept an evacuation deal. Darayya had endured four years of siege; the loss of the hospital was a decisive factor in the civilian population’s decision to vacate the area.
Taken together, this evidence strongly suggests that the Assad government and its allies targeted hospitals deliberately, as part of a strategy intended to break the will and infrastructure of the resistance.