It “rained hell” in Douma on April 6 and 7, according to Dr. Muhammed, who used an alias for fear of reprisals. A possible deal between Russian negotiators and Jaish al-Islam––the Islamist rebel group that controlled half of eastern Ghouta––fell apart, and a new wave of bombing began. In seven years of war, Douma’s residents had grown used to the violence. But not like this––1,309 attacks were recorded in Douma over the two days, according to the Syrian Civil Defense (known as the White Helmets).
In the confusion caused by the heavy bombing, medics found their work difficult. “The bombing was so bad they couldn’t move patients, they had to stay inside, underground,” said Dr. Muhammed. In the most documented war in modern history, the heavy bombing left scant evidence of the ferocity of the attacks across Douma, save the images of the now-infamous chemical attack that struck in the afternoon and evening of April 7.
Piecing together images was critical. Attacks on Arbin Surgical Hospital on March 20 and Hamdan Hospital on April 7 represented a new low in a conflict where targeting hospitals and medical workers had become a routine occurrence. These were attacks on hospitals whose locations had been “deconflicted” by being shared with the Russian government the month prior––information that was shared to protect the hospitals against attack, and to hold the attackers to account if the facilities were subsequently struck. While the events of April 7 left little evidence of the Hamdan Hospital attack, over six months since the Arbin Surgical Hospital incident, images and videos have been tracked down through both open sources and from now-displaced individuals, and show, for the first time, the violence against a hospital whose location was known to its attackers.
Hospitals, medical facilities, and medical workers, have been attacked throughout the conflict. There were 492 attacks on 330 facilities recorded between March 2011 and the end of December 2017 by Physicians for Human Rights––446 of these were committed by the Syrian government and its allies. Between January 1 and May 4, 2018, there were 92 attacks on 79 medical facilities, causing 89 deaths and 135 injuries, according to OCHA statistics. To date, nobody has been held to account for the attacks.
Targeting hospitals and medical facilities is a war crime, if the identity of the target was known to those responsible for the violence. Doctors and media reports have highlighted the phenomenon in Syria for years. Politicians and diplomats have expressed concern and outrage.
It is normal practice for humanitarian organizations to share the location of hospitals and other humanitarian structures with parties to conflicts to ensure they avoid them and comply with the Geneva Conventions, which state that “civilian hospitals… may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.” But the system works only if the warring parties play by the rules. With all parties—most notably the Syrian government itself—demonstrating casual disregard for the laws of war, Syria has changed the landscape of international law.
Humanitarians have long agonized over what should be done in the new landscape. Should they share the locations of humanitarian structures––known as “deconfliction”––and risk deliberate attacks on the projects and personnel? Or keep the locations hidden and hope that camouflage prevents the violence? For many, early attacks on buildings that had served as public, government-run medical facilities for years prior to the war made the decision not to deconflict easy. As the war went on, deconfliction was discussed time and again. An official working for one major international non-governmental organization (INGO) in the country, who spoke on the condition of anonymity because he was not authorized to speak publicly about the issue, said the subject had been discussed frequently, as far back as 2014 when United Nations (UN) Security Council Resolution 2165 was agreed to, allowing humanitarians to work in the country “by notification” rather than “by permission” of the government of Syria. For this INGO, though, the decision had always been easy––“we’ve never shared locations.” Another INGO official, speaking on condition of anonymity for fear of reprisals against their organization, stated that they have “never shared medical locations and never would.”
On March 12, 2018, eleven non-governmental organizations (NGOs), including the Syrian American Medical Society (SAMS), took the unprecedented decision to share the locations of sixty medical facilities, including some in eastern Ghouta. Later, some 680 humanitarian locations––including warehouses, schools, and bakeries––were shared with both Russia and the United States by a range of NGOs, with the United Nations (UN) acting as the umbrella for sharing the location details, as well as for investigating any attacks on deconflicted locations. Less than a month after the March deconfliction, there were two attacks on deconflicted hospitals in eastern Ghouta.
SAMS said its aim was accountability––it was frustrated that there had been none for the hundreds of attacks on medical facilities throughout the war. In many cases, the hospitals had been attacked prior to their locations being shared; for example, according to SAMS, the al-Maghara Hospital in Kafr Zita was hit eight times before they agreed to location sharing. One motivator for the decision to share locations was the belief that the coordinates were already known to the Syrian government and Russia, coupled with the hope that taking part in deconfliction might provide protection, or, failing that, accountability––they wanted publicity when shared locations were attacked, and robust UN investigations into any incidents.
Open source investigations into many of the hospital attacks in Syria have benefited from the extensive range and quantity of photos, videos, and testimony available online and through NGOs of all stripes. Bellingcat, DFRLab, the Atlantic Council in its Breaking Aleppo report, the New York Times, and others, have used the technology and testimony to document atrocities such as chemical attacks, the September 2016 Syrian Arab Red Crescent convoy attack, bombing campaigns, and hospital attacks, in detail. Laying out the details of the two reported hospital attacks in Ghouta––on March 20 in Abrin and April 7 in Douma––ought not to have been any different.
However, the reported attack on the Hamdan Hospital in Douma on April 7, 2018, was impossible to prove using open source investigation techniques. No footage of the attack or its aftermath could be found online or in extensive requests to NGOs and organizations working on the ground. SAMS claimed the Hamdan Hospital was hit during the heavy bombardment of Douma on April 7. Local news reported that it was targeted by “heavy shelling of military aircraft and artillery.” The specialized hospital (المشفى التخصصي) and a medical point (النقطة الطبية) in Douma were reportedly also struck. The Douma Medical Office tweeted at 5:50 p.m. local time on April 7 that the “specialised hospital” was out of services due to “direct targeting of all kinds of weapons.” This tweet was referred to by some as being the Hamdan Hospital, but it was in fact a different hospital not included in the deconfliction agreement, according to a local medical source.
The lack of evidence can be explained by the sheer intensity of the bombardment. The White Helmets reported that “on April 7th, Syrian Civil Defence responded to 403 bombardment in Duma [sic] including 3 chemical attacks,165 airstrikes, 84 barrel bombs, 100 rocket artillery and 50 artillery bombardment. In such circumstances, teams were not able to document the targets of these attacks, as there wasn’t time.” Due to the absence of footage and photos, and the lack of specificity about the timing of the attack, it was impossible to double-check the flight path with groups that track flight data in Syria. The Violations Documentation Center referred back to SAMS testimonies.
The lack of available footage does not mean that the attack did not happen, only that it is impossible to verify externally using the information available. Due to the ferocity of the violence, the quest for accountability was compromised. In a statement to the UN Security Council in late May, the UN Under Secretary-General for Humanitarian Affairs, Mark Lowcock, highlighted the number of attacks on medical facilities, and Panos Moumtzis, the UN regional coordinator for Syria, mentioned the two Ghouta attacks. The UN was sent reporting information about the attacks that was not available to this investigation, though its detailed findings regarding attacks on deconflicted medical facilities have not been released.
The attack on the SAMS-supported Arbin Surgical Hospital, in the town of Arbin in eastern Ghouta, is clearer, and helps to highlight the difficult decision-making process and impossible choices faced by those managing the deconfliction process. Thanks to images shared by media and displaced survivors, it has been possible to piece together the facts of the strike, and confirm that it took place.
Prior to the March 20 attack, a bigger attack on February 20 hit the facility during a forty-eight-hour period when six hospitals were hit. On that day, the hospital itself and neighboring houses were targeted—using an unknown form of weapon. The building was heavily shelled and sustained severe damage, and there were a number of reported casualties, including a female nurse named Bousra Abied, who was killed inside the hospital. At the same time, her newborn twenty-day-old baby was killed in her house, which is near the hospital. The hospital’s Facebook account was not updated after this date.
A hospital worker described the February 20 attack in a testimony given to the authors of the report:
On 20 February, Arbin hospital was attacked, the ambulance department was targeted and the eastern part of the hospital was completely destroyed [the entrances], they were bunker buster missiles, the attack first targeted an area near the hospital, injuring 25 people, then followed ambulances movement to locate the hospital to attack it then, we moved to the second building to the west which was also targeted, so we moved to the third building. There were 300 people then in the third building – we were lucky that one wasn’t bombed.
Medics cited by the Daily Telegraph suggested it may have been a bunker-buster bomb. Other media have also mentioned the use of this specific type of bomb. An Agence France-Presse photographer is said to have identified a warplane on the hospital in Arbin as a Russian Su-34 jet.
It was after this major February attack, which reduced the hospital’s operational capacity significantly, that the location was shared with the Russian and US militaries. The hospital worker said: “We wanted to move the hospital to a new location, but we couldn’t, mainly because civilians of a certain area didn’t allow us to move near them as it was known that hospitals are the regime’s favorite targets. The staff of the hospital fixed the ambulance/ICU [intensive care unit], since then only severe cases were brought to the hospital.” It was, perhaps, out of sheer desperation, and the fact that the hospital had been damaged and its efficacy impacted by previous strikes, that its location was added to the deconfliction list.
Eight days after the location was shared, on March 20, the Arbin Surgical Hospital was reportedly hit with an attack. The bomb went right through the hospital, which was partly built underground, and sheltered beneath a four-story building. “The hospital was hit. With a missile that went through the whole building of 5 floors and didn’t explode, killing one patient,” said the hospital worker.
The attack on March 20 killed one patient and damaged the facility, according to SAMS. In a tweet, the Union of Medical Care and Relief Organizations claimed that the hospital had been destroyed.
Two videos allegedly taken after the March 20 attack were shared on WhatsApp with the report authors. Based on those videos, combined with other open source information, it is possible to determine the exact location of the Arbin Surgical Hospital and make some cautious observations about the damage. By examining a satellite image taken on March 27 and comparing it with imagery taken on March 1, no new damage could be observed. Witnesses to the attack stated that the missile did not explode, which would be consistent with the lack of new damage in the satellite images. This is also supported by images of the unexploded bomb.
On the footage from within the hospital, a large hole can be observed in at least three floors and a wall of the building in which Arbin Surgical Hospital is situated. This may indicate that a bomb went through several roofs before hitting a wall inside the underground hospital. It appears that one of the holes has been closed, either due to a secondary effect of the impact or a deliberate act to ease the work and/or movement after the strike. A Getty Images/Anadolu Agency photographer visited the hospital after an attack on February 8, 2018, showing what appears to be an underground entrance big enough for an ambulance. There are in total seven pages of photos, many of which show the interior of the hospital, confirming that the video footage of SAMS was indeed taken in the same location.
Another video obtained from a different doctor who had been working at the hospital at the time of the attack, shows the remains of an unexploded munition that shares characteristics with the BETAB-500 concrete-piercing bomb, such as the shape of the nose of the bomb and the wedge-like shapes around the rear of the bomb, which the tail section would have been attached to. While the bomb is incomplete and partly covered, these characteristics make it highly likely to be a BETAB-500, a bomb used to penetrate reinforced concrete structures. The remains of these bombs have been documented throughout the conflict.
While BETAB-500s can penetrate concrete, and would logically be used when trying to penetrate a basement or through several floors of concrete, as a targeted attack on a basement hospital would require, they are also unguided missiles and the ability to hit precise targets depends entirely on pilot skill. Therefore, while the location was known to the pilot, and the munition used was appropriate for a targeted attack, it is not possible to say with certainty that the hospital was the intended target. However, the urban nature of the surrounding area would indicate that at a minimum a concrete-piercing weapon was directed at an urban area.
 Physicians for Human Rights, “Anatomy of a Crisis: A Map of Attacks on Health Care Is Syria,” https://s3.amazonaws.com/PHR_syria_map/web/index.html.
 “Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, Mark Lowcock, Briefing to the Security Council on the Humanitarian Situation in Syria,” ReliefWeb, May 29, 2018, https://reliefweb.int/report/syrian-arab-republic/under-secretary-general-humanitarian-affairs-and-emergency-relief-85.
 Gro Harlem Brundtland et al., “Open Letter: Let Us Treat Patients in Syria,” The Lancet, September 16, 2013, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61938-8/fulltext?elsca1=TW&elsca2=socialmedia.
 Emma Beals, “Syria’s Government Targets Hospitals,” Daily Beast, October 1, 2013, https://www.thedailybeast.com/syrias-government-targets-hospitals.
 United Nations, Office of the United Nations High Commissioner for Human Rights, Human Rights Council Holds Urgent Debate on the Situation in Syria’s Eastern Ghouta. 02 March 2018, https://www.ohchr.org/FR/HRBodies/HRC/Pages/NewsDetail.aspx?NewsID=22750&LangID=E.
 Convention (IV) Relative to the Protection of Civilian Persons in Time of War, Geneva 12 August 1949, International Committee of the Red Cross, available from https://ihl-databases.icrc.org/ihl/3
c125641e004aa3c5. See more: Practice Relating to Rule 35. Hospital and Safety Zones and Neutralized Zones, Geneva 12 August 1949, International Committee of the Red Cross, available from https://ihl-databases.icrc.org/customary-ihl/eng/docs/v2_rul_rule35.
 ReliefWeb report “SAMS and 11 Other Humanitarian Organizations Share Hospital Coordinates,” April 04, 2018, https://reliefweb.int/report/syrian-arab-republic/sams-and-11-other-humanitarian-organizations-share-hospital-coordinates.
“كأنها القيامة .. دوما في مواجهة الموت 55 شهيداً خلال يومين والغازات السامة توقع عشرات الإصابات,” Shaam News Network, 07.04.2018, http://bit.ly/2xswB9k.
 المكتب الطبي دوما, Twitter, April 07, 2018, https://twitter.com/Doumamedical/status/982676907211808768.
 “UN Investigating Attacks on Syrian Hospitals after Locations Shared with Russia,” Radio Free Europe/Radio Liberty, May 29, 2018, https://www.rferl.org/a/un-investigating-attacks-syrian-hospitals-locations-russia/29257543.html.
 “Syria Regime, Russian Airstrikes Target Six Hospitals in Eastern Ghouta,” New Arab, February 20, 2018, https://www.alaraby.co.uk/english/news/2018/2/20/six-hospitals-bombed-in-eastern-ghouta-in-two-days.
 “’End This Senseless Human Suffering:’ UN Demands End to Eastern Ghouta Bombardment after 100 Killed,” New Arab, February 20, 2018, https://www.alaraby.co.uk/english/news/2018/2/20/un-condemns-senseless-suffering-as-100-killed-in-ghouta.
 Josie Ensor, “UN under Fire for Giving Russia Coordinates of Syrian Hospitals in ‘High-Risk’ Strategy to Stop Attacks,” Telegraph, March 24, 2018, https://www.telegraph.co.uk/news/2018/03/24/un-fire-giving-russia-coordinates-syrian-hospitals-high-risk/.
 Scott Lucas, “UN Gives Coordinates of Syria’s Hospitals to Russia – Russia Then Attacks Hospital?” EA WorldView, March 23, 2018, https://eaworldview.com/2018/03/un-gives-coordinates-of-syrias-hospitals-to-russia-assad-russia-bomb-hospitals/.
 “SAMS and 11 Humanitarian Organizations Share Hospital Coordinates,” SAMS, April 04, 2018, https://www.sams-usa.net/press_release/sams-11-humanitarian-organizations-share-hospital-coordinates.
 Union of Medical Care and Relief Organizations, Twitter, March 20, 2018, https://twitter.com/UOSSM/status/976193473270439936.
 Dia Al-Din, “Syrians Carry a Wounded Man to a Hospital after Assad Regime Carried Out Airstrikes over Arbin Town of the Eastern Ghouta Region of Damascus Which Is a De-escalation Zone in Syria,” February 08, 2018, Photograph, Getty Images, http://bit.ly/2QMWF78.
 Brown Moses, “New Bomb Identified in Syria – BETAB,” Brown Moses blog, September 16, 2012, http://brown-moses.blogspot.com/2012/09/new-bomb-identified-in-syria.html.