Attacks in Syria | Case Study

Repeated attacks on underground medical facility demonstrate deliberate targeting

Throughout the Syrian conflict, Syrian government forces and their allies have perpetrated the vast majority of the 553 verified attacks on medical facilities in Syria. Those 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 first 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: Martyr Hassan al-Araj Hospital, also known as “the Cave Hospital”

Location and background: Martyr Hassan al-Araj Cave Hospital is located in Kfar Zeita, a town in northern Hama within close proximity of the southern borders of Idlib. The Cave Hospital was established in response to the many attacks on the nearby Kfar Zeita Specialty Hospital, the main medical facility catering to the needs of the surrounding population. The Kfar Zeita Specialty Hospital faced a large number of targeted attacks –13 of which were verified by PHR – that caused structural and material damages, casualties among patients and medical workers, and repeated disruption and suspension of services. As has been the case in many other areas of Syria, the targeting of medical facilities in Hama was a fundamental component of a broader strategy aimed at rendering opposition-held areas uninhabitable, driving out their populations, and eventually allowing the regime to recapture the territory. Heavily contested areas, like Kfar Zeita, were particularly affected by this type of scorched-earth approach to warfare. In an attempt to provide a safer space for medical personnel and their patients, Dr. al-Araj and a number of other medical providers took advantage of the geographic terrain of Kfar Zeita and established a hospital 55 feet – about 17 meters – deep into a mountain, expanding on a natural cave previously used by shepherds to shelter their flocks. The Cave Hospital began providing services that complemented those offered at the Kfar Zeita Specialty Hospital. When Kfar Zeita Specialty Hospital was bombed out of service (which occurred repeatedly), the Cave Hospital became the primary care provider in the area. Either in tandem or individually, the two hospitals were catering to an estimated population of 50,000 individuals.

Dates of Attacks: Not long after the Cave Hospital was established toward the end of 2015, the Syrian government and its allies began targeting the facility from the air. Between 2016 and 2018, the hospital was reportedly subjected to dozens of direct attacks. PHR was able to verify six of those attacks, which took place in October 2016, December 2017, January 2018, February 2018, and September 2018.

Circumstances of the Attacks: The Cave Hospital was built underground in an isolated area, far from any obvious military target, but was still subjected to multiple direct attacks. These circumstances point to the intentionality of the attacks and the clear targeting of this medical facility.

Impact of the Attacks on Facility’s Operations: Each of the attacks on the hospital verified by PHR caused damage that resulted in temporary closure and the disruption of services. Due to the large number of people who needed access to medical care, every effort was made to reopen the hospital as soon as possible, even if some parts were still damaged. The latest attack, in September 2018, severely damaged the hospital’s emergency ward and caused heavy damage to other parts of the facility, resulting in the hospital’s closure for three days. The emergency ward has since been rebuilt.

A field contact who was present during many of the attacks on the hospital recently told PHR that attacks on health facilities have been so common that Syrians have taken to saying that hospitals bring only detriment to the areas in which they operate. Noting the absurdity of the situation, the same contact told PHR that even military outposts moved away from the vicinity of health facilities, finding that those tend to compromise their security.

Eyewitness Account: “I was there several times when the hospital was hit. At the beginning, the hospital was protected from damage because of its location and the strength of its structure. After some time, the regime and its allies started using more powerful weapons that were able to penetrate through layers of rock and sand and damage the hospital. I have lost many colleagues in the process. Dr. Hassan himself – the hospital’s founder – was killed 30-40 meters away from the hospital, after finishing one of his shifts. A guided missile struck his vehicle. These attacks are clearly meant to target the hospital.” Ahmad Dbeis, a Syrian pharmacist who help found Martyr Hassan al-Araj Hospital and oversees local documentation of attacks on Syrian medical facilities and personnel

Analysis of Attacks and Responsibility: Significant evidence indicates that the Cave Hospital was subjected to repeated deliberate aerial attacks by Syrian government forces and their allies. The Cave Hospital was established in an isolated location, away from civilian structures, away from military structures, away from any structures that could be construed as legitimate targets. It was known to the people of the area, and very likely known to the Syrian government and its allies, to be a hospital. It was never occupied by a military actor or used for a military purpose.

Due to the fear and danger associated with the provision of medical care in Syria, the Cave Hospital’s administrators did not initially share its coordinates with the Syrian government or its allies, opting instead to try to stay hidden. The hospital’s founders state that the Syrian government was well aware of the type of structure it was targeting and that the location of the facility was likely pointed out by government informants in the area shortly after its establishment. After repeated attacks on the hospital, the administrators decided to share its coordinates publicly, not in order to avoid being targeted, but in order to highlight the intentionality of the attacks. By this logic, when the facility was attacked again after the coordinates had been shared, the perpetrators would not be able to claim that they were unaware of the facility’s purpose or location. Even after the Cave Hospital was listed as a “de-conflicted humanitarian site,” the site continued to be targeted, further highlighting the intentional nature of the attacks.

These facts clearly demonstrate that Syrian government forces and their allies deliberately and systematically targeted the Cave Hospital with repeated attacks to inflict maximum damage and loss of life on a clearly-marked civilian medical facility operating in an opposition-held area.

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