Throughout the Syrian conflict, Syrian government forces and their allies have perpetrated the vast majority of the 578 verified attacks on medical facilities in Syria. These attacks have effectively transformed medical facilities into deadly spaces, both for medical professionals and their patients, and left the Syrian medical sector in tatters. Physicians for Human Rights has painstakingly documented attacks on medical care in Syria throughout the eight-year conflict. This is the third in a series of brief case studies that underscore the intentional nature of many of these attacks and highlight the glaring violations of international humanitarian law and international human right law these cases represent.
Name of facility: The Kafr Nabl Surgical Hospital, previously known as the Kafr Nabl Orient Hospital
Location and background: The Kafr Nabl Surgical Hospital is located in the town of Kafr Nabl in southern Idlib. In July 2012, a group of local activists, concerned about the lack of medical services and the growing needs of the community, established a medical point and pharmacy. Over the next year, the medical point expanded the types of services it was providing and the number of people it was covering, and, in June 2013, it was turned into a hospital under the name of Orient Hospital. In November 2016, the British NGO Hand in Hand took control of the hospital and has operated it ever since. The hospital has a staff of about 100 medical personnel and provides services to an average of 14,000 beneficiaries every month. While constantly operating at less than full capacity due to shortages in medical professionals and supplies, the hospital still provides a variety of services, from orthopedic care to specialized surgery and dialysis, and caters to the entire region of southern Idlib with an estimated population of 400,000.
Dates of Attacks: Since the hospital’s establishment, PHR has verified 12 attacks on the facility that caused significant damage and repeatedly disrupted medical activities. All 12 attacks were perpetrated by the Syrian government or its allies between June 2014 and May 2019. The series of attacks began with a Syrian government airstrike on June 29, 2014. The incident resulted in major damage to the facility and killed a newborn baby and two members of the medical staff – a doctor and an anesthesia technician. The hospital suffered another attack less than two months later. At the end of the year, Syrian government forces bombed the hospital again, killing 15 people and injuring scores more. The hospital was attacked four times in 2015, twice in 2017, once in 2018, and twice in 2019- once in May and most recently in July 2019.
Circumstances of the Attacks: The Kafr Nabl Surgical Hospital is not located near any apparent military targets. In fact, the hospital is situated in a populated civilian area. Furthermore, there is no evidence that its status as a medical facility was compromised at any point during the conflict. The hospital’s administrators shared the facility’s coordinates with UN OCHA and the facility’s humanitarian status was verified by the UN. Within the UN’s deconfliction mechanism, the exact location of the facility and its status were then shared with parties to the conflict. It was nevertheless attacked multiple times after its coordinates were shared.
Impact of the Attacks on Facility’s Operations: Each of the attacks caused serious and costly material damage to the hospital. The damages from the September 22, 2015 attack, for instance, were estimated at over $140,000, according to Hand in Hand. Because of the local population’s dependence on the services provided at the facility, its staff scrambled to make repairs after each attack. After an attack on April 20, 2015 that killed three civilians and wounded dozens, the hospital’s staff was able to bring the facility back online in the span of a day. It was not as easy to recover from other attacks. On February 5, 2018, Syrian government or Russian fighter jets carried out four airstrikes against the hospital. The munitions used caused a very high level of destruction. The bombs pierced through three concrete floors, destroying the intensive care unit with all its equipment on the ground floor. The facility’s doors and windows were blown out and the generators were irreparably damaged. The attack put the main hospital building out of service for nearly 25 days. While a single section continued to discreetly operate out of the basement, many of the medical staff members refused to return to work for fear of being attacked again.
Eyewitness Account: A hospital staffer and survivor of several attacks described the February 5, 2018 attack, saying:
“At the time of the attack, there were at least 100 people in and around the hospital waiting to receive medical attention. I was in the middle of the courtyard. All the medical personnel were doing their jobs. The first bomb fell in the courtyard, 20 meters away from where I was standing. Everyone tried to move the patients out of harm’s way as quickly as possible, but it was very difficult to do. The doors were all blocked by debris or broken and everything in front of our eyes was destroyed. There was not just one bomb but at least four or five. The second bomb hit the intensive care unit directly, destroying it completely.”
A dialysis technician present at the time of attack added:
“There was dust everywhere, you couldn’t see anyone, even if they were standing right in front of you. We couldn’t even breathe from the thickness of the dust. The patients were terrified. I kept trying to calm them – I was saying ‘keep moving, everything will be ok.’ Since I couldn’t see them, we all held hands and just moved together. They were the biggest explosions I had ever experienced. The walls caved in on us. I finally got the patients to the door of the basement, but I was so disoriented that instead of following them down to safety I started walking up the stairs toward the wreckage. It was as if I was sleepwalking. It was very hard. I thought I was going to die. I lost all control of my emotions.”
Analysis of Attacks and Responsibility: Multiple attacks on known health facilities and sequenced attacks on multiple health facilities in the same geographical location point to intentionality. Both patterns apply in the case of the Kafr Nabl Surgical Hospital.
The fact that the hospital was struck multiple times, even after its coordinates had been shared with the UN de-confliction mechanism, suggests that the aerial attacks by the Syrian government forces and their allies were deliberate in nature. At the very least, Syrian government and Russian forces are in no position to deny knowledge of the nature and status of the Kafr Nabl Surgical Hospital. One of the medical professionals working at the hospital pointed to a broader trend in the attacks he witnessed:
“We quickly learned that when a nearby hospital is hit, we are likely to be hit as well. On May 5 2019, the Nabd al-Hayat Hospital in Hass was attacked, and we were certain we were going to be hit next. We are used to this type of campaign now. As soon as Nabd al-Hayat was hit, we started preparing for the expected attack. We moved the ambulances, we moved the medical staff to a safe place, and fully evacuated the hospital. Within an hour the first bomb fell, hitting the hospital’s main entrance, and killing a civilian who was still in the area as we were evacuating. The hospital was struck with four more bombs, three of which struck the main door and one of which hit the roof of the building. Thank God all our staff members were safe, but a number of patients and visitors were injured.”
PHR documented attacks on four separate facilities within the same area of southern Idlib, all carried out on May 5, 2019. On that day, Syrian government or Russian forces struck the Kafr Nabl Surgical Hospital, the Nabd al-Hayat Hospital, the Kafr Zita Surgical Hospital also known as the Cave Hospital, and the Termala Women and Children’s Hospital. These types of sequenced attacks by the Syrian government and its allies against health facilities in the same geographical locations are an indicator of the targeting not only of those individual facilities, but of local health networks and referral systems. This theory is further supported by examining the Maarat al-Nu’man Hospital, located 30 km from the Kafr Nabl Hospital. When the Kafr Nabl Hospital was attacked and put out of service, many locals in need of medical attention were forced to go to Maarat al-Nu’man Hospital. However, both hospitals were often attacked within a close time frame. In an example of the use of this tactic by the Syrian government and its allies, the Maarat al-Nu’man Hospital was attacked on February 4, 2018, just one day before the February 5 attack on Kafr Nabl Hospital. In two other instances, attacks on both hospitals occurred less than a month apart. This strategy effectively deprives the local civilian population of access to medical care at particularly sensitive moments when surges in violence are accompanied by surges in casualties.