Dr. Yamen’s nightmares began in 2015, the second time a hospital he was working in was attacked. Every night for about a month after he would return in dreams to the moment he emerged in shock from a basement bomb shelter at the primary care facility in the northwest Syrian city of Jarjanaz. He would see his destroyed car outside and an ambulance on fire; people running and the wail of sirens through the dust; the rubble and the bodies.
A year earlier, when a bomb exploded near the entrance of Haas Hospital in northwest Syria, Dr. Yamen had remained in the operating theatre as his co-workers fled to safety. On the table in front of him, the abdomen of a boy he was performing intestinal surgery on was still open. Yamen carefully finished the operation as he heard the helicopter that he believed had dispatched the bomb still circling overhead. After he finished suturing the boy’s belly, trauma victims from the blast began to be brought in for treatment.
“I remember that I was afraid. But I just focused on my patient,” says Yamen, who requested a pseudonym to protect his identity. “I couldn’t leave him under anesthesia and make myself safe while he was not.”
Experiences like Yamen’s have become the norm for healthcare workers over the course of Syria’s decade-long war. He is among 74 health workers and 237 patients interviewed for a chilling new report by nonprofit the International Rescue Committee (IRC)—and six of its Syrian partner organizations—on the impact of the conflict on Syria’s medical sector. More than two-thirds of health workers interviewed reported having been inside a hospital or clinic when it was attacked, and 81% said a co-worker or patient had been injured or killed during such an attack. At a time when frontline medical workers are being lauded globally for their selfless efforts to respond to the COVID-19 pandemic, the IRC report published March 3 is a stark reminder of the extraordinary risks Syrian health workers face doing their jobs, and how the institutions designed to protect the most vulnerable are seen as fair game by belligerents.
“Syria has become the poster child for the ‘Age of Impunity’, where the rules of war are ignored, and attacks on healthcare in violation of international law continue without consequence,” said IRC’s CEO David Miliband in a statement accompanying the report’s release. Despite growing international recognition of the widespread and sometimes deliberate nature of attacks, Miliband adds, “action by the international community to hold those responsible to account has been absent.”
Ten years of war have gutted Syria’s medical infrastructure, leaving it woefully unprepared to respond to some 12 million Syrians now in need of healthcare assistance, IRC says. Less than half of Syria’s hospitals are fully functional, and an estimated 70% of the medical workforce has left the country. For every 10,000 civilians, only one Syrian doctor remains.
The deficit has hampered Syria’s ability to mitigate the impact of the COVID-19 pandemic, experts say. But it has also left patients and healthcare staff bereft of mental health resources that might help them process the trauma of war. In northwest Syria’s Idlib and Western Aleppo provinces, says Yeman, there is only one remaining psychiatrist for a population of about 4-million people.
When hospitals become targets
Syria’s war began in March 2011, after dictator Bashar al-Assad’s government cracked down on anti-government protesters amid the wave of popular uprisings that swept across the Middle East that year. The Gulf States, Iran, Turkey, the U.S., Europe, and Russia each funneled money and munitions to various state and non-state actors. Meanwhile, the influence of jihadist groups mushroomed in the chaos, with ISIS rising to control an area the size of Great Britain until the capital of its self-proclaimed caliphate fell in 2017. The war has killed hundreds of thousands of Syrians and more than half of the country’s population has either fled or become internally displaced.
It was the Russian Air Force’s 2015 entry into the war that turned the tide in favor of the Assad government. It also precipitated an uptick in airstrikes against medical facilities, in defiance of international law. Since 2011, New York-headquartered Physicians for Human Rights has documented almost 600 attacks on Syrian medical facilities.
Many have been captured on film. The Berlin-headquartered Syrian Archive has verified and preserved videos documenting 412 separate attacks against a total of 270 medical facilities between 2011 and 2020. For the attacks where it was possible to verify a perpetrator, at least 90% were allegedly carried out by Russian and/or Syrian government forces. Over 90% of attacks on medical facilities show indicators that they were intentionally attacked, the Syrian Archive will announce in an upcoming March 9 report, and for at least 194 of the attacks, the medical facility’s existence and exact location were known or should have been known to the parties to the conflict beforehand.
In addition to bringing aircraft and missile systems not previously available to Syrian government forces, Russia also contributed “disinformation about those attacks to make confusion around them,” says the Syrian Archive’s co-founder Hadi Al-Khatib.
On several occasions, he says, Russia has disseminated doctored satellite imagery or videos intended to falsely show that hospitals it has attacked in Idlib and Aleppo remain intact. On March 1, the Russian military bombed the Al Maghara cave hospital in Kafr Zita, Hama province—territory the Russian-allied Syrian government controls. Al-Khatib says the bombing was an attempt to erase evidence of the damage wrought by previous attacks when the area was rebel-held.
“There is no evidence if you go there right now physically that this hospital even existed. This might be the future of all hospitals, and all other civilian infrastructure in Syria that was attacked,” he tells TIME. “That’s why preparing these cases now is really important: because the evidence is being destroyed in Syria.”
The Syrian Archive joined other humanitarian groups in filing a criminal case in Germany against the Syrian government in October for two of the worst sarin-gas attacks it carried out in 2013 and 2017. The documentation center and two international NGOs filed a similar complaint in France on March 1 that seeks a criminal investigation of Assad and other Syrian government and military officials over the use of chemical weapons. France and Germany’s legal codes permit a form of universal jurisdiction, which allows their national courts to prosecute individuals accused of heinous offenses committed in any county.
‘They didn’t know the ghost of death was chasing them.’
The testimonies collected by the IRC make for harrowing reading. A social support worker who identifies herself as Muna speaks of how her pregnant friend was killed in a strike on a hospital where she had gone for treatment, along with one of her children who had accompanied her on the hospital visit. The strike also obliterated the neonatal ward at the hospital—the region’s largest—destroying its incubators and killing the babies inside. “There was a complete paralysis in health service provision and this greatly impacted the people who needed health care, because they could no longer get it,” Muna says in a testimony translated from Arabic. “For women who will give birth, there are no longer incubators for premature babies.”
In another testimony, a nurse in Idlib—who at one point worked from a tent due to being displaced multiple times—describes how a clinic where he was administering a routine vaccination campaign for infants came under attack. He and his colleagues rushed the infants to a basement bomb shelter. The nurse, who identifies himself as Ghaith, laments trying to inoculate babies against childhood diseases when they might not even have a childhood: “they didn’t know that the ghost of death was chasing them while they were receiving their most basic rights.”
Dr. Yamen says he no longer has such frequent nightmares. One reason they ended, he believes, was the support he received from his family and friends; another was that he became so used to witnessing atrocities that he no longer went into shock. Later, he would witness an airstrike that killed another doctor and 30 children at a school some 500 meters from Haas hospital. Seeing bombs on parachutes fall outside the school, he says, was “like watching death coming to the ground.”
Yemen’s son—now aged four—was born the year after the Jarjanaz attack. In the latter months of his wife’s pregnancy, airstrikes frequently targeted civilian houses in the area where they lived. In part because of the stress, his wife kept feeling as if she was going into labor. Knowing that airstrikes would target any light on the road, Yamen would drive around 6 miles to the hospital with the car’s headlights off. They made the journey several times before deciding that his wife would take medicine to induce labor.
Today, Yamen works for the nonprofit Syria Relief and Development. But he is also taking a remote university course on legal documentation so that he can effectively collect evidence of the atrocities to which he bears witness. He says he believes that eventually the perpetrators of the attacks on medical facilities will be held to account: “We are waiting for this moment, that justice will take place inside Syria.”
Correction, March 3
The original version of this story cited outdated figures on the number of attacks on medical facilities that the Syrian Archive has verified and preserved. It documented 412 separate attacks against 270 medical facilities, not 411 against 269.