Medical Facilities Under Fire: Al Ikhlas hospital

Joint investigation: Syrian Archive and Focus Aleppo

Initial Summary:

• Location: Idlib: Shanan
• Target: Al Ikhlas Hospital for Women and Children, which was first supported by Syria Relief and World Vision until November 2018 and is now supported by the Union of Medical Care and Relief Organizations (UOSSM).
• Beneficiaries: The hospital serves around 4500 to 5000 patients per month according to an interview with the hospital’s director Dr. Zuhair Karat. As the only specialized hospital for over 15 villages, it services about 100,000 women and children in the surrounding areas.
• Date: 6 November 2019
• Time: The attack occurred around 1:00 - 1:30 AM, according to interviews conducted by the Syrian Archive’s investigations team with hospital staff and civilian witnesses nine hours after the attack. Reports and open source media uploaded online by the local media, the Health Directorate of Idlib, SAMS, the UOSSM as well as flight observation data corroborates this estimated time.
• Victims: Three members of the hospital staff sustained minor injuries from the attack including lab technician Ahmad Al Saeed according to interviews conducted by the investigations team with the director of the hospital. The number injured is also corroborated and documented by press reports from the Syrian Civil Defense Directorate, Health Directorate of Idlib, and Halab Today.
• Type of Attack: Four missiles shot between two airstrikes.
• Munitions Used: Unknown
• Potentially Responsible: The Russian Air Force. The Idlib Health Directorate reports that the shelling came from a Russian aircraft that fired Missiles at the hospital. This matches analyzed flight observation data.

Background of the Hospital:

Image of Al Ikhlas hospital from before the attack published by Baladi News.

Founded in 2017, Al Ikhlas Hospital for Women and Children is a two story hospital with both a children’s and women’s department. The children’s department houses six incubators and six patient beds. The women’s department has an operating room as well as a women’s clinic where normal and Caesarean deliveries are performed.

An image published by Al Arabi of the hospital’s incubator room after the attack.

An image taken by the investigation’s team of a patient’s room after the attack.

In addition to the women’s and children’s department, the hospital hosts an internal medicine clinic 2 days a week, a vaccine center for kids one day to five years old, a laboratory for all major medical tests, and a pharmacy that provides medicines and supplies for the facility. The hospital has 50 staff total composed of doctors, nurses, technicians and administrators. All services at the hospital are free.

Beneficiaries

Given its remote location, as described below, the medical facility serves a large population in the surrounding areas. The hospital, according to an interview with its director Dr. Zuhair Karat, serves in total around 100,000 women and children in the surrounding areas with around 4500 to 5000 patients treated each month.

Location

Image from Google Earth Pro of Shanan and it surrounding cities and villages.

The Al Ikhlas hospital is located in the village of Shanan, which lies in a rugged mountainous region around 22 km south of the city of Idlib and 11 km north of Ma’arat Al Nu’man. As shown in videos taken by the investigations team, houses are more than 2 km away from the facility and no military bases are nearby. This further corroborates the direct and deliberate targeting of the hospital by warplanes.

A still from a video taken by the investigations team of the hospital’s surrounding areas.

The location of the hospital was corroborated by the Syrian Archive (as well as independently by the Syrian Network for Human Rights) using media taken by the investigations team and satellite imagery.

A geolocation of the facility with satellite imagery taken from Google Earth Pro compared with images taken by the investigations team.

Previous attacks on the Facility:

An image released by the Syrian Civil Defense of the hospital after its April 17 2017 attack on the left and an image of the hospital after its November 6 2019 attack on the right. The hospital suffered much more extensive damage externally and internally after the latest November 6 attack.

Alongside its deliberate targeting on November 6 2019, the hospital was bombed with three missiles on April 17 2017. The air raid on the hospital occurred 3 months after its establishment. The Syrian Archive investigation team published a detailed report about it in 2017 that verified videos and photos about the attack as well as the location of the hospital and analysed flight data about the incident.

This attack, according to a report by the UOSSM, injured at least 5 hospital staff as well as a member of the Civil Defense. Posts from the Civil Defense’s Facebook page show the injured Civil Defense team member as well as the external damage to the medical facility. Additional sources show the damage to the inside of the facility. The hospital was repaired quickly after the attack and served its communities until November 6 2019 when it was forced out of service.

What Happened and When?

An image of the hospital taken 9 hours after the attack by the Syrian Archive’s investigations team.

According to interviews, photos, and videos taken by the Syrian Archive’s investigations team nine hours after the attack as well as open source media from the attack, Al Ikhlas Hospital for Women and Children was directly targeted on November 6 2019 by 4 high explosive missiles. Two of the rockets fell about 20 meters southeast of the hospital at around 1:00 AM. The other two fell about one meter away from the women’s operating room at 1:20 AM.

Crater southeast of the hospital	Crater one meter away from the hospital

The image on the left shows the crater from two rockets falling 20 meters southeast of the hospital at 1:00 AM. The image on the right shows the crater from two rockets falling about one meter away from the hospital’s women’s operating room at 1:20 AM. Both images were taken by the investigations team.

Image showing the locations of the craters on the hospital’s southern side.

Shortly after the first two missiles fell at 1:00 AM, the Syrian Civil Defense evacuated the medical staff and patients from the facility, according to Dr. Zuhair Karat the director of the hospital. An interview with two other hospital staff confirms that the hospital was operating normally before the first missiles, and that it had 16 people, including 12 hospital staff and two children with their mothers. They said the initial attack caused panic among patients and staff and prompted the evacuation of the site before another attack. A second attack occurred after ten to twenty minutes at around 1:20 AM, according to the interviewed staff. Dr. Karat claimed that it was two Russian planes that targeted the facility on November 6 2019.

A still from a video report uploaded by the Syrian Civil Defense of the hospital directly after the attack. This still shows a fire in the facility shortly after the missiles hit.

The attack on the hospital, which sits inside the de-escalation zone, injured three medical personnel and comes after a ceasefire agreement made in August 2019 by the Russians that halted air attacks in the region for two months. Nevertheless as a result of the attack, according to Dr Karat, about 80% of the equipment and infrastructure of the hospital were completely destroyed with incubators and the women’s operating room under rubble. Additionally, pharmaceuticals and laboratory equipment were severely damaged from the attack. Al Karat stressed that the hospital was damaged beyond repair and, further, out of service.

Organizations and Local News Reports:

Videos uploaded by STEP TV and the Syrian Civil Defense in Idlib, posted the morning after the attack, show the moment of the raid in the middle of the night. The video uploaded by the Civil Defense additionally shows first responders approaching the burning hospital and assessing the damage of the hospital’s interior. The Syrian Archive’s investigations team verified the location of the hospital (as featured above) and matched the photos and videos from the scene with satellite imagery of the location. The Civil Defense’s video, SAMS and Idlib Health Directorate reports confirm that the hospital was targeted by a Russian raid at 1:30 AM on November 6 2019.

A video uploaded onto YouTube by the Idlib Health Directorate shows the damage to the hospital hours after the attack. Staff from the hospital confirm that airstrikes occurred between 1:00 - 1:30 AM. According to a staff member in the video, the hospital was targeted by four missiles. Additionally, an interview with the director of the hospital in this video confirms both the time of the attack as well as the number of staff injured.

A hospital staff member, interviewed by the Idlib Health Directorate, holding a piece of metal he asserts is a remnant of a missile that hit the facility.

Alongside the videos mentioned above, the UOSSM published a statement on the attack saying it occurred at 1:30 AM, injuring three members of the medical staff. The report detailed the hospital as severely damaged with its infrastructure destroyed. The statement called the direct and deliberate targeting of the facility a war crime.

Additional media reporting on the attack was first posted by media activist Mohammed Fathallah who reported on his facebook page at 1:32 AM, shortly after the attack, the news that Shanan Hospital was hit by missiles. Shortly thereafter, Al-Jazeera Syria posted on Facebook at 1:59 AM about the attack citing claims by local flight observatories that the attack was conducted by a Russian aircraft. A Facebook page named Shanan Today posted a video on Facebook at 2:29 AM supposedly showing the moment the hospital was targeted.

An image posted by the Idlib Health Directorate showing the damage to the hospital after the attack.

These posts from the night of the attack were followed by posts that morning from the Idlib Health Directorate at 8:49 AM with images showing the magnitude of the damage as well as a statement corroborating the time of the strike.

The media outlets Halab Today and Orient TV published video reports about the attack at 10:44 AM and 12:08 PM respectively. Their correspondents in the videos detail, while reviewing the damage to the facility, confirmed the attack on the hospital. Director of the hospital, Dr. Zuhair Karat, again confirmed the attack and its time in an interview with Radio All broadcasted and uploaded online at around 12:00 PM.

A video posted on Facebook by Orient TV of its correspondent at the hospital the day after the attack.

Lastly The Syrian Civil Defense and SAMS published statements, pictures, and reports on the attack further confirming its time of occurrence and number of injuries.

Analysis of the Damage:

A still from a video taken by the investigations team of the hospital’s internal damage.

As documented by the Syrian Archive’s investigations team and corroborated using open source media, Al Ikhlas hospital suffered extensive damage both internally and externally as a result of 4 total missiles directly targeting the facility. Because of the severe damage to the hospital and its infrastructure, the facility was pushed out of service.

External Damage:

As documented by the investigations team nine hours after the attack, Al Ikhlas hospital was severely damaged externally with 4 missiles hitting 1 meter and 20 meters away from the medical facility. The missiles hitting 1 meter away from the facility damaged the south eastern side of the hospital severely. The stone walls and cement of the facility were completely destroyed from the attack fully exposing hospital rooms. Moreover, the damage from these missiles pushed portions of the hospital to near collapse.

A still from a video taken by the investigations team of the crater from the second airstrike at around 1:00 AM. This crater was 1 meter away from the hospital.

An image posted by Zaitun Agency showing the southern side of the hospital after the attack.

On the opposite, the northern side of the hospital, a parked car is destroyed with massive holes in the walls between the sides of the facility.

A still from a video taken by the investigations team of a destroyed car parked on the northern side of the hospital.

The eastern portion of the hospital is best preserved yet still with crumbling walls and machinery falling out from the wall openings. Matching the internal destruction of the facility, the irreparable damage to the exterior of the hospital eliminated any potential for future hospital operations.

Internal Damage:

Inside the hospital, the majority of the rooms on the first and second floor were destroyed or severely damaged. This includes the pharmacy. Images and videos taken by the investigations team show the majority of the pharmacy’s medicine and equipment ruined and under rubble with one of the office’s walls collapsed. In addition to the pharmacy, patient rooms were incinerated as a result of fires. Videos and images feature wide cracks in the walls, burnt tools, and walls black from smoke and flames in hospital rooms affected by the fires. As in the first floor, the second floor of the hospital was filled with rubble from the attack with gapes in the wall and collapsed walls in multiple rooms. Destroyed medicine and equipment as well as collapsed walls leaves the hospital out of service for it surrounding communities.

hospital’s pharmacy 1	hospital’s pharmacy 2

Images taken by the investigations team of a portion of the hospital’s pharmacy. The attack ruined the hospital’s supply of medicine and broke one of its walls.

An image of a staircase in the hospital taken by the investigations team.

A still from a video taken by the investigations team of a destroyed hospital room on the first floor.

A still from a video taken by the investigations team of room destroyed first by the impact of the airstrikes and then burned by subsequent fires.

Flight Data Analysis

To provide a further layer of verification, the Syrian Archive cross referenced findings from open source media and images/videos taken by the investigations team with flight observation data from a spotter organization. Data for flights occurring before and after 1:00 - 1:30 AM on November 6, 2019 around Idlib and Aleppo was closely analyzed.

Beginning at around 1:00 AM and 1:11 AM, a Russian fixed-wing aircraft was seen flying west from the village of Jarjnaz, which is around 20 km south of Shanan. A Russian fixed-wing aircraft was then seen flying over Kafranbel, around 14 km southwest at 1:13 AM. Shortly thereafter from 1:17 to 1:28 AM, a Russian fixed-wing aircraft was seen circling over the neighboring town of Ma’arat Al Nu’man. After the missile attacks from 1:00-1:30 AM, a drone was observed circling at 1:44 AM over Jabal Al Zawye, a village around 9 km west of Shanan. With the common practice of circling by warzone aircrafts indicating a target acquisition and/or preparation for an imminent attack, the circling by a Fixed Wing Russian Aircraft over Shanan’s neighboring villages corroborates the estimated time of the attack as reported by local news organizations and in interviews conducted by the Syrian Archive’s investigations team.

Although this data matches claims by human rights organizations that the attack was committed by the Russian Air Force, there is no direct evidence available that one of the observed aircraft was involved in the attack on Shanan. Nevertheless, the presence of aircrafts above the neighboring villages and towns increases the likelihood that an air attack occurred on the hospital during the times shown and corroborated by open source media and reported on by the Syrian Archive’s investigations team.

Conclusion:

As documented and reported by the Syrian Archive’s investigations team through videos, images, and interviews as well as shown in open source media and flight observation data, it is confirmed that Al Ikhlas hospital in Shanan, Idlib was attacked between 1:00 - 1:30 AM on November 6 2019. 4 missiles, in 2 airstrikes, hit 1 meter and 30 meters away from the facility. The attack destroyed the hospital and pushed it out of service as well as injured 3 members of the hospital staff. Given the natural limitations of the investigation, the Syrian Archive was unable to confirm the perpetrators of the attack although statements by local organizations and interviewed witnesses attribute the attack to the Russian Air Force.