Enab Baladi – Ahmad Jamal, Haba Shehadeh, Zainab Masri | Only few moments separated the survival of the mother and her daughter from their suffocation to death, as a result of an airstrike on al-Rami village in the northwest of Jabal Zawiya in Idlib countryside, which targeted the family’s building and hit the basement where they were hiding.
Hussein al-Nasser, the stricken husband and father, hoped that his wife and daughter would come out alive from under the rubble, but the late intervention of paramedics and Civil Defense teams due to the double shelling, warplanes, and the targeting of rescue teams and medical staff prevented this.
Hussein recounted the details of the raid that hit his family’s house in the first week of November to Enab Baladi. “They were alive but the Civil Defense members arrived late and we couldn’t get them out of the rubble,” he said.
The Russian military campaign and the systematic targeting of medical facilities and centers, since the beginning of this year, have caused the death of the mother, her daughter and about 100 others. It also caused the displacement of nearly one million Syrians who flowed from the eastern countryside of Hama and Idlib and the southern countryside of Idlib to the northern countryside of Idlib, as documented by Response Coordinators team in northern Syria.
In addition, the lack of support for the medical sector has led to a decline in the work of hospitals and medical points in north-western Syria, reducing the access of a large number of residents and IDPs in the region to the necessary medical services.
In this file, Enab Baladi sheds the light on three crises threatening the medical sector in northwestern Syria, namely the Russian systematic targeting, lack of support, and the fuel crisis. The file tries to clarify options that would reduce the impact of a crisis sweeping one of the most vital sectors in the last stronghold of the Syrian opposition.
Oncology Hospital in Idlib – November 2019 (SAMS Facebook page)
40 out-of-service medical points
Systematic targeting burdens the medical sector in Idlib
The Civil Defense has documented the targeting of more than 40 hospitals, centers or medical points in the southern countryside of Idlib since April. All these points have become out of service after being completely destroyed by Russian, Syrian and helicopter warplanes.
As a result, the southern countryside of Idlib has become almost devoid of any medical point, according to the director of the Civil Defense sector in Idlib, Mustafa Haj Youssef, who stressed to Enab Baladi that all medical points, ambulance staff, Civil Defense centers and rescue teams are “pursued and targeted.”
This has made it difficult for rescuers to move, and prevented the Civil Defense in the region from working in fixed centers to avoid being monitored by warplanes and reconnaissance aircrafts.
The escalation of the Russian air attacks on the area, and their focus on systematically targeting residential neighborhoods and service sectors, have left the region empty of most of the population, who fled to safer areas near the Turkish border to escape the bombing, according to Haj Youssef.⁵
11,252 families have been displaced from the southern countryside of Idlib in November, meaning a total of 61,229 IDPs, according to the Response Coordinators.
The suffering of the remaining civilians in the southern countryside of Idlib is increasing, with the almost complete lack of medical centers and hospitals needed by the remaining population in that area, especially those with chronic diseases, who are forced, in this difficult situation, to travel long distances to other areas to obtain the necessary medical treatment.
This is also the case for those who are hit by aerial and missile shelling in the conflict areas, where the tragedy lies in the fact that in these areas are no hospitals and medical points and that the medical and ambulance staff are continuously pursued by the Russian air forces. This forced the injured people to move to the nearest medical point at distances of up to 30 or 40 kilometers, according to the Director of the Syria Response Coordinators, Mohammed Hallaj.
Russia intentionally targeting hospitals
Russian air force bears a large responsibility in its focus on targeting hospitals, medical centers and staff in the opposition-controlled areas, through the coordinates transmitted by reconnaissance aircrafts before the airstrikes, while the Syrian regime bears the least responsibility in this targeting, according to Mohammed Hallaj.
Speaking to Enab Baladi, Hallaj said: “We have noticed that usually 86 percent of the attacks on the medical sector in the opposition-controlled areas, especially in Idlib, are carried out by Russian warplanes, while 14 percent of the attacks are carried out by Syrian warplanes and helicopters,” which recently applies to the situation in the southern, western and eastern Idlib countryside in the currently ongoing military campaign.
The Response Coordinators team has documented that since the beginning of this year, Russian and Syrian warplanes have carried out 80 attacks against medical facilities and points, including ambulance staff in Idlib Governorate. Some of these facilities have been repeatedly bombed at different periods with varying levels of damage. The most recent of these attacks are those that have targeted six hospitals, three health centers and three ambulances in November, according to Hallaj.
War crimes
Military analyst Colonel Ahmad Hamadi says that the targeting of civilian hospitals and medical points of all kinds is a war crime under international law and custom, and the flags of Cross or Red Crescent humanitarian organizations are usually raised above the medical points in military units that provide treatment for the injured and stricken people, especially in case of war, in order to prevent the bombing of warplanes.
“In the Syrian case, we notice that all international rules and laws are completely not followed, in the sense that internationally prohibited weapons (napalm, phosphorus and concussion bombs) are used against civilians,” added Hamadi, noting that “it is forbidden to use these weapons against combat forces and military units, let alone their use against residential areas and civilians. This is a war crime under international custom and law, and this shows that Russia and the regime are considered war criminals for their targeting of vital centers and civilians.”
Through the policy of systematic destruction of vital, especially medical, facilities, Russia and its ally al-Assad aim to eliminate all the necessities of life in opposition areas and to deprive civilians of any hope of returning to their neighborhoods and homes and any stability in their land, through an intentional policy of displacement of the two allies, according to Hamadi.
Targeting of hospitals in Idlib – May 2019 (AFP)
Ongoing policy…
Who can deter the Russians?
In its military campaigns in support of the regime in the former opposition areas in Syria, Russia pursued a policy of systematically targeting vital and service centers, including hospitals, medical points, schools, bakeries, water stations, Civil Defense centers and rescue teams.
The features of these attacks are reflected in the eastern neighborhoods of Aleppo, Eastern Ghouta, Wadi Barada, Damascus countryside, Homs countryside, and other Syrian areas, as documented by media and human rights reports.
However, the evasion of Russia, the first ally of the Syrian regime, from penalization and international accountability encourages it to continue carrying out “war crimes”, by targeting vital facilities and medical centers and killing civilians, including children, in all areas where Russian military machines move, according to Colonel Ahmad Hamadi, who expresses this by saying, “impunity leads to power abuse.”
Is there any accountability?
International laws stemming from the Geneva and Hague Conventions provide for the protection of military and civilian medical facilities that provide treatment to soldiers from any party. They also prohibit the targeting of military sectors near medical points. These laws oblige the signatory parties, including Russia, to implement these conventions in return for accountability against law violation charges, according to the director of the Syrian Legal Development Program, Ibrahim Alabi,
“Providing treatment to hostile forces during the fighting does not protect these medical facilities from attacks. Targeting military sectors and points close to medical facilities brings damage which is disproportionate to military interest,” said Alabi in an interview with Enab Baladi.
However, “Russia is not committed to the application of international humanitarian law stemming from international conventions, even though it is obliged to implement it,” Alabi stated, notably that the Syrian Civil Defense, the World Health Organization, the United Nations and the Syria Response Coordination Team documented in all its reports the targeting of medical facilities, which are far from military areas and fronts.
According to Alabi, Russia resumption to targeting vital centers, services and residential neighborhoods in opposition areas, especially in northern Syria, proves the absence of international accountability against Russia for violating laws and conventions that prevent the bombing of medical facilities in all its forms. Alabi also stated “international law is the creation of states and therefore it moves according to its Political desire.
Furthermore, Alabi believes that the trial of Russia for these crimes and violations has to take the form of international condemnation as well as imposing international sanctions on them, and promoting the image of this state as violating international laws and treaties.
Although the International Criminal Court (The Hague) does not have authority over Russia, there may be a domestic trial in the future. Alabi points out that legal and judicial accountability in the strict sense may be difficult in Russia’s situation, as it is not a party to the ICC and “there is no keenness on holding it accountable within international courts.”
International debate
The Russian attacks on medical and service sites in northern Syria are under investigation by the United Nations. This investigation comes at the request of ten members of the Security Council, based on a special investigation published in The New York Times on October 13, amid Russian pressure on the organization to obscure the results of the investigation.
UN Secretary General Spokesman Farhan Haq informed the newspaper that the UN was still studying how to deal with the results of the investigation, which is supposed to be completed by the end of the year.
The UN investigation, which began in early August, was limited to only seven sites, according to special documents seen by the US newspaper, after statements made by the head of the Office of the High Commissioner for Human Rights, Robert Colville, on November 8, that the number of medical facilities targeted reached 61.
In its investigation, the United States relied on contacts made by the Russian Air Force during the bombing of medical facilities in northern Syria by decoding thousands of radio waves of Russian troops after documenting Russian pilots’ activity within months.
The investigation reveals the bombardment of four hospitals in the Syrian opposition areas in Idlib by Russian aircraft, including the bombing of “Nabdh el Hayat” (Pulse of Life) medical center in Hass in the southern countryside of Idlib, on May 5. The investigation also shows a doctor documenting the damage to the hospital and medical equipment.
According to the newspaper, Russian airstrikes targeted four hospitals in just 12 hours, in May, saying it had obtained a large body of evidence to analyze the bombings of hospitals that took place on 5 and 6 of the same month, as well as audio proofs by Russian pilots bombing each hospital from the four hospitals.
The United Nations investigation points out that Russian aircraft repeatedly bombed hospitals in order to “crush the remaining opposition” and “support al-Assad regime.” The video attached to the investigation shows that Russian shelling was concentrated in northern Syria, especially in Idlib, some of which was distributed between Homs and Latakia.
The American newspaper used through the investigation the statements of eyewitnesses and workers in the observatories of air traffic, and audio recordings of the Russian Air Force, which it considered as “a proof of the involvement of Russian pilots in these raids.”
However, according to The New York Times Russia has pressed UN Secretary-General António Guterres not to publish the results of the investigation concerning the targeting of hospitals in opposition areas in Syria.
The newspaper mentioned that Russia refused to comment on the charges related to its pressure on the Secretary-General of the United Nations, to keep the UN investigation secret.
The Russian ambassador to the United Nations, Vasily Nebenzya, commented on September 16, on the reports on the Russian role in targeting Syrian hospitals, denying the charges against the military campaign launched by the Syrian regime and its ally Russia on the southern countryside of Idlib and northern Hama since last February.
The Russian ambassador also stated: “Nobody denies the presence of civilians in Idlib, and they are living in difficult conditions, some of them were displaced for the second or even third time, but there is no other way to end their suffering except by liberating this area from the jihadists, who use these civilians as a shield to protect their own sites.”
But the director of Physicians for Human Rights, Susanna Sirkin, in her answer to the reasons behind and bombing of civilian facilities and the identified perpetrators, described the UN investigation as “having no depth and scope.”
“The victims and their families and the whole world have the right to know the facts. Silence will only increase the boldness of those responsible for war crimes in Syria,” Louis Charbonneau, director of Human Rights Watch, told the newspaper.
The British newspaper Telegraph reported on May 30 that the United Nations provided the Syrian regime, Russia coordinates, and non-governmental organizations operating in Idlib with hospital equipments.
In its report, issued on June 30, Physicians for Human Rights Organization documented 566 separate attacks on 348 medical facilities in Syria from 2011 to 2019, and 900 medical workers killed during the attacks.
Targeting hospitals in Idlib – May 2019 (AFP)
Declining support threatens to close hospitals
The health facilities, which were not targeted by the shelling and missiles in Idlib, faced the threat of closure and limiting the scope of services due to lack of support and the absence of basic work equipment; thus creating additional crises for a large part of the population in the province.
Rawaa Hashash, from the eastern countryside of Ma’arra, explain to Enab Baladi her suffering and the journey to find a hospital that provides the appropriate treatment for her daughter Shifaa, who suffered a broken rib, causing her lung wound and severe bleeding.
According to the mother, the child complained of severe chest pain while the family was visiting the village of al-Mashrafiya, west of Salqin, about seven kilometers away. She was then taken to Ma’saran Dispensary, where the parents were told that the child needed a specialist doctor for thoracic surgery and from there they were transferred to Bab al-Hawa.
As the distance was long, the parents chose to go to Idlib, and after reviewing several medical centers, they were sent to the tuberculosis care center for tests that the parents could not afford, so they chose to go to a hospital in Darkush.
The family found the doctor and the child was successfully operated, but she was diagnosed with “pneumonia”, due to overcrowding in the hospital. The new disease posed a major challenge to the parents who had left their home in the eastern Ma’arra countryside, south of Idlib, and remained beside Shifaa with her infant sister who needed special care from her mother.
The parents were forced to take turns to care for the two children, one caring for the sick girl in the hospital while the other trying to care for the baby girl in the car parked next to the hospital, for about a month and a half, away from their area, which is devoid of hospitals and medical care centers.
Al-Marah Surgical Hospital – September 2019 (SAMS Facebook)
The shortage increased
Several factors have accumulated to complicate the healing journey of Shifaa, from shelling hospitals south of Idlib to the lack of medical services in the city due to the decline of organizations’ support, and the pollution caused by the overcrowding of Darkush Hospital.
The director of the Syrian American Medical Association (SAMS) office in Turkey, Dr. Mazen Kewara, told Enab Baladi that the support provided by donors in favor of the victims of the recent crisis, whose support for the health and medical sector has not been enough for years, and has “decreased even further.”
The increase in health needs caused by the military campaign, i.e. aid to treat injuries, as well as assist displaced people and ease difficult living conditions, was not matched by an increase in the level of financial support. Thus, the decline has led to the formation of a “critical” funding gap, amounting to $ 11.2 million, until 14 November.
No hospitals without fuel
The Idlib Health Directorate issued a statement on November 28, warning of the danger of disrupting hydrocarbons supplies, especially diesel for the operation of generators, on the continuation of the work of hospitals in Idlib province and its medical facilities.
The lack of hydrocarbons, and fuel “exorbitant prices”, if available, may cause a “humanitarian catastrophe,” due to shutting down life-saving departments and services, such as operation rooms, intensive care facilities, humidicribs, dialysis centers and the emergency system.
Mustafa Ido, deputy director of the Idlib Health Directorate, told Enab Baladi that the 53 hospitals in Idlib can be closed at any time if no urgent solution is found soon.
Ido pointed out that the citizen’s ability to obtain medical service has become “very difficult” compared to the previous period, due to the current circumstances, i.e. the ongoing military campaign and the absence of fuel.
Along with the dreadful situation in the hospitals south of Idlib due to the bombing, the northern hospitals are also additionally burdened by the pressure of increasing numbers displaced Syrians, who reached about one million since the beginning of the campaign according to the statistics of Response Coordinators’ Team. This crisis has trapped the Idlib Health Directorate in a “complex problem,” as Ido puts it.
He added that there is no option but to raise the awareness of the international community and the United Nations about the ordeal in order to urge them to pump more funds. Thus, the health sector needs about $10 million per month, which the Directorate cannot secure by itself.
Financing gap
Although the health sector donors actors have diverted resources, medicines and medical supplies to meet the needs arising from the ongoing fighting in the northwest, those needs have not been fully covered, according to a 14-November report by the UN Office for the Coordination of Humanitarian Affairs (OCHA).
The funding gap for the health sector in Syria was estimated at $ 354 million, after receiving 21 percent of donor contributions, i.e. a $ 300 million decrease compared to last year.
Dr. Ahmed al-Dabais, Director of Safety at the Union of Medical Care and Relief Organizations (USSOM), attributed the decline in funding to the general policy of international organizations, which opt for providing a significant amount of aid during the first five years of war, and then move to support stability if it occurs. In case the conflict was not settled down, these organizations resort to suspending their activities and move to other areas.
Speaking to Enab Baladi, al-Dabais added that donations for the health sector are still taking place, with a significant decrease in the percentage of donors, including EU countries, the United Nations as well as international and Arab organizations.
One of the reasons behind the departure of donors, according to al-Dabais, was the ongoing violence and repeated targeting of health facilities despite being repeatedly relocated and the protection measures undertaken by the officials, prompting some desperate support organizations to shut down their medical centers.
The presence of various armed factions, their intervention in the course of humanitarian action, and the classification of other organizations as terrorist have prompted many donors to suspend their activities or definitively leave the region.
Losses and shortages
What kind of medical care is available in Idlib?
Idlib has the majority of medical specialties to provide medical care. However, the hospitals in Idlib are lacking a number of services, in addition to hiring inexperienced doctors, due to the shortage of cardiovascular surgeons, and cancer treatment centers, and both chemical and radiological therapy. Hence, there are only two doctors specializing in the endocrine system, and about four neurosurgeons.
Al-Dabais indicated that the shortage of medical staff exerts more on doctors and delays the treatment of patients who have to wait a month or two, due to the increasing number of injuries. This also applies to MRI services, as only one or two devices are available, at an affordable cost to all patients.
Dr. Kewara highlighted that the remaining hospitals in the southern countryside of Idlib, such as the Maarra Central Hospital, which is the sole operating health facility in the region, are overburdened, despite the fact that the population remaining in the region is limited.
He added that specialized surgeries in general are missing in Idlib, as only one tumor centre is still providing services in the area. However, not all types of tumors are treated in this centre and there is a general lack of medicines and equipments.
Where is the treatment?
The lack of medical facilities and financial support has led to a decrease in the quantity and quality of services, which is reflected in the worsening condition of patients and the increase of death tolls, due to unsuccessful injury treatment.
Patients have only two options when they do not manage to secure the medical services they need in Syria, said Dr. Kewara, either to head to Turkey, which requires special conditions for life-threatened cases, left untreated in Idlib, or head to areas controlled by the regime. This solution can be accessible only to those, who are not intimidated by the regime security measures.
According to a report issued by REACH Initiative published in August, which surveyed the availability of health facilities and medications in 922 districts in north-western Syria, 55 percent of the inhabitants of 696 districts have problems accessing medical services, due to the unavailability of medical centers in their areas, while 39 percent cannot receive treatment due to the lack of transportation, and the other 38 percent cannot go to medical facilities because of high transportation costs.
Residents of 81 districts said they were using private means to deal with the lack of medical services. Hence, 43 percent of these individuals re-used medical materials, 43 percent resorted to low-quality medicines and 42 percent made use of non-medical materials for treatment.
Al-Dabais suggested a solution to the situation of the hospitals in northern Idlib, which consisted of working to reintegrate health care personnel, who are dispersed and displaced from the southern areas, whether due to the destruction or closure of the health facilities they were working in; while benefiting from the infrastructure of medical facilities, which have been suspended or relocated to increase the operational capacity of the hospitals already in service.
He asserted that the directorates of health in Idlib, Hama, Aleppo countryside and Latakia are studying the idea of employing charitable methods to re-operate medical facilities, i.e. the hospitals will be auto-financed by charging symbolic fees from the beneficiaries of medical services, such as radiographs, CT scans, MRI, and laboratory analysis or consultancy services, taking into account the physical condition of patients.
Al-Dabais considered that this method can ensure the survival of health facilities in order to continue providing services and fill the funding gap.
Ambulance offered from USSOM to the Idlib Health Directorate – September 2019 (USSOM-Facebook)