Throughout the Syrian conflict, Syrian government forces and their allies have perpetrated the vast majority of the 566 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.
Location and background: Eastern Ghouta, a collection of rural towns and villages that envelops the northeastern edge of Damascus, has been at the center of the Syrian conflict since its inception. Eastern Ghouta’s population rapidly took up the anti-government cause and, by the end of 2012, the area had fallen under the control of various armed opposition groups. Its proximity to Damascus and the risk it posed to the capital made Eastern Ghouta the target of a particularly long and destructive regime military campaign.
In April of 2013, the Syrian government and its allies imposed a siege on Eastern Ghouta that would last a full five years and one week. Over the course of that period, the Syrian government and its allies systematically subjected the hundreds of thousands of civilians residing in the area to a suffocating siege, intentionally disrupting food supplies, fueling severe malnutrition, and cutting off access to water, fuel, and electricity. The Syrian government also routinely blocked humanitarian access in what was an apparent strategy to compound the misery inflicted by the siege. The blockade was accompanied by an endless barrage of shelling and aerial bombardment with conventional and banned weaponry [^1] that deliberately and repeatedly hit densely populated civilian areas. The Syrian government also systematically targeted hospitals, clinics, and other critical infrastructure protected under international law. Since 2011, PHR documented a total of 77 attacks on health facilities in Eastern Ghouta – over 13 percent of all documented attacks across Syria, concentrated in a suburb of the capital.
Eastern Ghouta is a microcosm of the wider conflict in Syria. It clearly encapsulates the Syrian government’s cruel and flagrantly unlawful approach to waging war in all its individual components, including the indiscriminate bombing of civilians, the sieges, the denial of humanitarian access, the destruction of health infrastructure, and the use of banned munitions. It’s the Syrian government’s deployment of every available tool to collectively punish populations into submission or forced displacement and subsequently recapture territory. It happened in Homs, in Aleppo, in Madaya, and in other locations that came into the crosshairs of the regime and its allies.
Between 2012 and 2018, Eastern Ghouta was subjected to a number of military offensives as part of the government’s campaign to regain control over the area. The latest offensive, ‘Operation Damascus Steel,’ occurred between February and April 2018 and culminated with the fall of Eastern Ghouta to the government and its allies. The operation was launched on February 18, with a sharp surge in aerial and artillery attacks. Within the first day of the offensive, five health facilities were reportedly attacked and either heavily damaged or destroyed. By the end of the second day, partners were reporting 13 attacks on health facilities. As the aerial offensive escalated, the number of civilian casualties rose, and the need for care became more pressing, more hospitals were targeted. After a week of relentless aerial bombardment – and less than 24 hours after the UN Security Council passed resolution 2401 calling, among other things, for an immediate nation-wide cessation of hostilities – the Syrian government and its allies intensified their ground campaign into Eastern Ghouta. By that time, humanitarian and civil society organizations on the ground had reported 31 attacks on 26 separate medical facilities since February 18.
As the ground offensive unfolded, reports of attacks on medical facilities kept coming in, albeit at a slower pace. Areas of Eastern Ghouta successively fell to government control as armed opposition groups capitulated after periods of particularly intense attacks on civilians and civilian structures. The last reported attack on a health facility in Eastern Ghouta came on April 7, coinciding with one of the deadliest chemical attacks perpetrated by the Syrian government throughout the conflict. On April 8, following the surrender of the armed opposition group in control of Douma, the government was effectively in full control of Eastern Ghouta.
Operation “Damascus Steel” claimed the lives of more than 1,700 civilians and injured over 5,000. In its aftermath, more than 65,000 civilians and fighters were forcibly transferred to the opposition-controlled north – primarily Idlib and northern Aleppo. Between the operation’s beginning on February 18 and its end on April 7, PHR received over 58 credible reports of attacks on health facilities – a staggering figure, even by the standards of the Syrian conflict.
Dates of Attacks: Of the 58 reported attacks on medical facilities, PHR was able to document 29 incidents. Of those, 22 took place between February 18 and February 25, as the aerial and artillery bombardment campaign was paving the way to the ground offensive. Five of the verified attacks were carried out between the March 6 and March 8, one on March 20, and a final attack on April 7.
Circumstances and Impact of the Attacks: The temporal and geographic concentration of attacks on medical facilities during operation “Damascus Steel” was unlike anything previously witnessed over the course of the conflict. During the first week of the operation, the Syrian government and its allies intentionally targeted and damaged or destroyed hospitals, primary health care centers, ambulance systems, and specialized facilities, including obstetric centers.
By the time the government and its allies launched their ground offensive on February 25, the health system in Eastern Ghouta, crippled by a protracted siege and relentless targeting, was in ruins. The impact on a civilian population already ailing from years of malnutrition, untreated wounds and illnesses, and unsanitary living conditions, would be immense. The ability of health structures to provide even the most basic emergency services to a rapidly growing number of injured was crushed. Doctors, nurses, and paramedics were forced underground, literally, into basements, garages, and any sub-surface enclosures that provided a measure of protection from air attacks. They worked under unimaginable pressure and with extremely limited access to necessary equipment and medication, often having to move along with their equipment from one location to another to avoid targeting.
Eyewitness Account: “During that last operation, we didn’t know which hospitals were still standing and which ones were in ruins. We didn’t know who was dead and who was alive. We were completely disoriented. Completely overwhelmed. Patients were streaming into the hospital non-stop. Everyone who was still able to was working non-stop for weeks. We had gotten used to a certain level of pressure, but nothing like that. A single medical worker taking a break could have meant the death of a patient. That pressure only rose as more hospitals and clinics were destroyed. By mid-March, a handful of facilities remained operational and were only providing a limited set of emergency services to the thousands of sick and injured.” Rami, a health care professional working at a prominent hospital during the last offensive on Eastern Ghouta
Analysis of Attacks and Responsibility: Throughout the year preceding the final offensive on Eastern Ghouta (2017), PHR documented eight attacks carried out by the Syrian government and its allies on health facilities in the area. Attacks on health facilities climbed dramatically during the first week of operation “Damascus Steel,” wound down as the ground offensive unfolded, and stopped once the government had recaptured the area. Many of the targeted facilities, like the Douma Central Hospital and the Tuberculosis Hospital in Kafr Batna, were public facilities whose locations were known to the Syrian government. Others, like the Erbin Hospital, had shared their coordinates with the belligerents through the UN’s deconfliction mechanism – and yet were still targeted.
Operation “Damascus Steel” is highly representative of the manner in which the Syrian government and its allies have prosecuted the war in Syria – with civilians as their core targets. The systematic obliteration of the health system in the first week of the offensive effectively denied all possible recourse to the injured. It dramatically amplified the impact of the indiscriminate bombing and shelling of population centers that ensued and contributed directly to the collapse of the population, the capitulation of armed groups, and the recapture of territory by the Syrian government and its allies.