Physicians for Doctors in the Crosshairs: Human Rights Four Years of Attacks on March 2015 in

A Syrian man carries a wounded child at a makeshift clinic following reported air strikes by forces loyal to President Bashar al-Assad in the rebel-held area of Douma, north east of the capital of . Photo: Abd Doumany / AFP / Getty Images About Physicians for Human Rights

For more than 25 years, Physicians for Human Rights (PHR) has used medicine and science to document and call attention to mass atrocities and severe human rights violations.

PHR is a global organization that was founded on the idea that health professionals, with their specialized skills, ethical duties, and credible voices, are uniquely positioned to stop human rights violations.

PHR’s investigations and expertise are used to advocate for persecuted health workers, prevent torture, document mass atrocities, and hold those who violate human rights accountable.

Acknowledgments

This report was written by The findings and analysis contained Elise Baker, investigations in this report are drawn from program assistant, and Widney research by Physicians for Human Brown, director of programs. Rights, originally produced in Erin Gallagher, director of “Anatomy of a Crisis: A Map of investigations, Adrienne L. Fricke, Attacks on Health Care in Syria.” Syria advisor, DeDe Dunevant, For additional information, director of communications, and please visit www.phr.org/syria-map. Donna McKay, executive director, reviewed this report. Eliza B. Young, publications coordinator, edited and prepared this report for publication.

2 Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria Introduction

here was a sense of hope Since 2011, the Syrian government has These numbers are conservative given when took to systematically violated this principle and difficulties in reporting during a war. the streets in 2011 amid is using attacks on medical workers But one thing is certain, these attacks the waves of protests and facilities as a weapon of war. It are deliberate and have a cascading that swept across the began when the government interfered effect on the health of Syrians. Four Middle East and North with and compromised health care years and hundreds of attacks later, a TAfrica following the self-immolation services by arresting injured protesters single bombing on a today can of Mohamed Bouazizi, a Tunisian in emergency rooms, but quickly have catastrophic consequences. With man who was protesting a repressive escalated into bombing in dwindling numbers of medical facilities government, corruption, and lack opposition-held areas and detaining, and providers, an attack could demolish of economic opportunity. No one torturing, and executing doctors who the only hospital and kill the only doctor imagined that four years later the were adhering to medical ethics by serving an entire neighborhood. For world would be standing by as Syrians treating the wounded regardless of every additional doctor killed or hospital endure a protracted civil war that has their political beliefs. The doctors who destroyed, there are hundreds – even spilled across its borders and led to the have risked their lives to remain in thousands – of Syrians who have largest displacement of people since Syria and treat the injured have been nowhere to turn for health care. World War II. The consequences of decimated by Bashar al-Assad’s forces, the international community’s failure which consider it a crime punishable by Syrian doctors have shown bravery and to protect Syrians from systematic and death to provide medical treatment to resilience in the face of this generation’s repeated violations of both human “the other side.” worst humanitarian disaster. Over the rights and humanitarian law have been past four years, they have not only devastating. Yet, one in particular As we approach the fifth year of provided medical care in desperate stands out: the erosion of the long- the conflict, at least 610 medical conditions, but have also witnessed established principle that neither personnel have been killed, and colleagues, friends, family members, militaries nor armed groups can target there have been 233 deliberate or and thousands of civilians die from medical workers and the health care indiscriminate attacks on 183 medical unlawful attacks and lack of care due system for attacks. facilities. Physicians for Human Rights to the country’s decimated health has documented these killings and care system. Attacks on health in Syria attacks through its interactive online have intensified with each year of the map, which is updated monthly. The conflict, yet doctors have continued Syrian government is responsible for 88 risking everything to save lives. percent of the recorded hospital attacks and 97 percent of medical personnel killings, with 139 deaths directly attributed to torture or execution.

Remains of an opposition field hospital in al-Qusayr in Syria’s central Homs province. Photo: AFP / Getty Images

phr.org 3 Year One Doctors Deliberately Targeted and Killed

n March 22, 2011, During the first year of conflict, A Broken System: The Struggle government forces government forces launched eight to Provide Care in Syria entered Daraa attacks on medical facilities and killed National Hospital, 75 medical personnel. The majority Given extreme levels of violence and cleared it of non- of the attacks and deaths took place the government’s direct targeting of essential staff, and in central and – Daraa, their profession, thousands of medical Opositioned snipers on the roof. The Hama, and Homs governorates – and personnel have fled the country in snipers remained for two years, firing were carried out with hand-held fear for their lives, leaving entire at the sick and wounded to ensure weapons and mortar fire. The majority cities without emergency medicine that only government supporters could of medical personnel died as a result of physicians, cardiologists, and other enter the hospital. On April 8, a nurse shooting, while others were executed, specialists. The personnel who trying to rescue an injured person was killed by shelling and bombings, or remain use pseudonyms to protect shot and killed by government forces in tortured to death. their identities and have built field Daraa city. This was just the beginning hospitals run by local councils and aid of the government’s deliberate attacks organizations. Doctors, nurses, medical on medical personnel and facilities as a students, veterinarians, and volunteers weapon of war. without formal training operate these makeshift facilities. Dozens of hospitals have closed due to lack of staff, funding, and supplies, leaving civilians wounded by their government’s aerial bombardments with no options for treatment. Hospitals consistently deal with shortages of gauze, blood bags, syringes, anesthetics, and body bags, as the government systematically obstructs the delivery of medical aid to opposition-controlled areas. Government forces have also consistently harassed and detained those traveling with medicine and materials as modest as gauze, in order to deprive pro-opposition populations of medical supplies. In one case in 2012, a nurse from Rif Dimashq was arrested for providing medicine to the opposition. He was tortured in detention, and his family was notified of his death in August 2014.

Syrians watch as bulldozers clean the debris outside Dar al-Shifa Hospital in , northern Syria, after government forces bombed the facility. Photo: Francisco Leong / AFP / Getty Images

4 Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria Year Two Attacks on Health Care Triple

etween August and only leaving when their hospital was Attacks on health care more than November 2012, decimated. Even then, they did not stop tripled in the second year, with government forces treating patients. Instead, they moved government forces responsible for repeatedly attacked Dar down the street to establish Dar al-Shifa 97 percent of the 90 facility attacks and al-Shifa Hospital, located field hospital, which treated anyone 99 percent of the 199 personnel deaths. in the densely populated in need and was eventually attacked Aleppo, Damascus, Deir ez-Zor, and Rif Bal-Shaar neighborhood in Aleppo. again. This campaign illustrates a trend Dimashq governorates were hit hardest. After at least three earlier attacks, seen throughout the war: repeated While the weapons used in hospital the hospital finally suspended service airstrikes on the same facility, designed attacks were similar to the previous year, following a missile strike on November to intimidate medical workers and deaths as a result of shooting decreased 21. A 23-year-old medical student patients and cripple health care in and deaths by execution, bombing, and working as a paramedic in the hospital opposition-controlled areas. shelling increased. died. Despite repeated targeting, Dar al-Shifa’s staff remained stalwart, The summer of 2012 was particularly devastating. PHR documented 28 attacks on medical facilities between July and August – the record high for the conflict. With 26 killings, July also represented the second deadliest month for medical personnel, after May 2014.

Year Two: Weapon Use in Attacks on Medical Facilities by Percentage

Mortar Fire Aerial Bombardment 4 Hand-Held Weapons 6 Bombardment with Unknown Weapons Missiles and Rockets 8 Unknown Weapons 40 11

21

phr.org 5 Year Three The Rise of Heavy Weaponry and Non-State Armed Groups

A doctor looks at the register of dead people, stained with blood, in a hospital in the eastern sector of the city of Aleppo. Photo: Miguel Medina / AFP / Getty Images

n June 20, 2013, In the third year of the conflict, During this time, non-state armed government forces attacks by government forces groups emerged as perpetrators, bombed Raqqa increased in brutality. More than half responsible for nine attacks on medical National Hospital, of the 53 medical facility attacks PHR facilities. The self-declared Islamic State located on a large, documented were caused by rockets, (IS) and various other opposition groups easily distinguishable missiles, and aerial bombardment. were responsible for these attacks – Ocompound in the city’s center. The In January 2014, government forces three of which were on Tishreen and attack injured three medical personnel began their barrel bomb campaign. A Harasta military hospitals. While there and destroyed the intensive care unit. crude, low-cost weapon made from a are allegations that the government On March 11, 2014, government forces cylinder filled with explosives, shrapnel, uses these military hospitals for torture again bombed the hospital, destroying and oil, a barrel bomb is ignited and and detention, they also provide the governorate’s only dialysis clinic, dropped from a helicopter or plane. ongoing medical services and are leaving its 200 patients without access These weapons weigh between therefore protected under international to this lifesaving treatment. 200 and 2,000 pounds and are humanitarian law. In November 2013, extremely destructive and imprecise, PHR documented the first two attacks as they break into thousands of on hospitals by car bombs, both by small fragments upon impact. The non-state armed groups. government carried out two barrel bomb attacks on medical facilities that In the third year, 171 medical personnel month, both in pro-opposition, densely were killed, all but two by government populated civilian areas. Government forces, who increasingly killed personnel forces launched six additional attacks through aerial bombardment or torture. on facilities in heavily populated areas In one such case, Dr. Osama Baroudi, and nine attacks on isolated medical a prominent gastroenterologist and facilities (providing additional evidence founder of the Union of Free Syrian of the intentional nature of the attacks). Doctors, was detained by security forces in his Damascus clinic in February 2012. He was tortured and died in custody in late July 2013.

6 Doctors in the Crosshairs: Four Years of Attacks on Health Care in Syria Year Four The Onslaught of Barrel Bombs

n April 18, 2014, According to data collected by PHR More than 64 percent of medical government forces between March 15, 2014 and February personnel killed in the past year dropped a barrel 28, 2015, 162 medical personnel were were targeted for their lifesaving bomb filled with killed and there were 82 attacks on work or killed in the line of duty – chlorine gas near medical facilities. Of the 70 facility the highest proportion seen during Wisam Hospital in attacks committed by government the war. Many medical personnel OKafr Zita. Patients and medical staff forces, rockets and missiles were used have lost their lives in “double tap” evacuated the hospital to escape 50 percent of the time and barrel strikes, whereby government forces the toxic fumes, and medical service bombs 40 percent. Government attack a location, wait for first stopped temporarily. On June 23, forces used barrel bombs at least responders to arrive, and attack the government forces again barrel 12 times to attack medical facilities location again. On October 2, 2014, bombed the hospital from helicopters, in eastern Aleppo city between April a doctor and ambulance worker this time destroying it. A newborn, a and July 2014. Throughout the whole responded to a barrel bomb attack three-month-old child, and a nurse conflict, government forces have used in the al-Haydariya neighborhood were killed, and several medical barrel bombs in at least 32 attacks on of Aleppo city. While the two were personnel were injured. 24 medical facilities. They have not treating those injured in the attack, used barrel bombs near frontlines government forces barrel bombed or pro-government populations (for the area again, killing them both. fear of hitting and decimating their own supporters); instead, they use rockets and missiles, which can target specific locations.

Many medical personnel have Government forces were responsible lost their lives in “double tap” for 93 percent of the 162 medical strikes, whereby government personnel killed in the last year. While forces attack a location, wait the number of deaths caused by for first responders to arrive, shooting has decreased, deaths as a and attack the location again. result of shelling and bombing have increased significantly. Throughout the war, Aleppo governorate reported the highest percentage of deaths caused by shelling and bombing.

Cause of Medical Personnel Deaths over Time by Percentage

100

80

60

40

20

0 Year One Year Two Year Three Year Four

Shooting Shelling and Bombing Execution Torture Unknown and Other

phr.org 7 Conclusion

he Syrian government has targeted health care and increasingly used it as a weapon of war to destroy its opponents by preventing care, killing Tthousands of civilians along the way. Medical personnel and facilities have been attacked for putting the needs of patients first and providing care to all sides of the conflict. Non-state armed groups noted the international community’s indifference to these repeated violations of international law and emulated government tactics. PHR has seen these same tactics spread around the world: parties to the conflicts in Ukraine, Gaza, and Message from a Syrian doctor working in a field hospital in an opposition-held area: the Central African Republic have “I am a doctor not soldier.” attacked medical personnel and facilities in dozens, if not hundreds, The symbols of the Red Cross and It is not clear how much longer the of attacks throughout 2014. Red Crescent have been turned from under-staffed, overwhelmed, and a shield of protection into crosshairs fractured health care system in Syria on the backs of those who knowingly can survive. However, another year of risk their lives to save others. The barrel bombs and executed doctors international community must act will cause exponential devastation for strongly and collectively to reclaim the the millions of Syrians caught in the The symbols of the Red Cross and norm establishing the protected status crossfire, dying from war wounds and Red Crescent have been turned of medical personnel and facilities. It is treatable diseases. from a shield of protection into already too late for so many Syrians – crosshairs on the backs of those medical personnel who were targeted who knowingly risk their lives to and civilians who had nowhere to turn save others. for lifesaving treatment – but concerted action could reverse this trend before it The full report can be found at: becomes the new normal in conflict. phr.org/syria-doctors

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