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INVESTIGATIONS

Medical Facilities Under Fire

An investigation about attacking 8 Syrian hospitals in Idlib

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Introduction

In April 2017 25 hospitals or medical facilities in Syria were attacked: an average of one attack every 29 hours. 91% have been independently found to be carried out by Syrian government or Russian forces. Many of those targeted were located in Idlib, the largest remaining opposition controlled city after 2016’s siege in Aleppo left thousands displaced - the [majority went to Idlib or to the Aleppo countryside][5].

Information published in this joint report suggests that in April 2017 Syrian and Russian armed forces were responsible for the eight attacks on Syrian hospitals and healthcare centres - facilities serving a combined 1.3 million people (a beneficiary group larger than the population of Brussels), as reported in witness statements as well as by the managers of those medical facilities.

![Medical Facilities Under Fire][6]

The Syrian Archive and its partners (Syrians for Truth and Justice, Justice for Life) analysed and verified this pattern of attacks by cross referencing a combination of open-source visual content, flight observation data, and witness statements. Findings regarding these attacks were characterised by repeated bombardments, lack of warnings, and an absence of active military hostilities in the vicinity of the attack. Through collecting, verifying and reporting investigative findings from these incidents, the authors hopes to preserve critical information that may be used for advocacy purposes or as evidence in future proceedings seeking legal accountability.

This report complements and supports recent efforts by human rights organisations to report violations targeting medical facilities in Idlib in April 2017. Those efforts include:

The added value of this report to the efforts mentioned above includes damage identification, as well as cross referencing and contextualising visual content (75 verified videos) with witness statements (14 people) and with flight observation data (6343 observations) provided by a spotter organisation of aircraft in the immediate vicinity of hospitals at the time of attacks. Geolocation of visual content was done in collaboration with the Bellingcat Investigation Team.

Prior to publication, consent was acquired with those interviewed (e.g. medical workers, facility managers, and Civil Defense volunteers) regarding the public sharing of information regarding attacks.

This report is broken into the following sections: Ethics; Research Methodology; Specific attacks against hospitals and field clinics; Further research; Errors, corrections and feedback.

Syrian Archive

The Syrian Archive is a Syrian-led initiative striving to promote sustainable peace and respect for human rights within Syrian society through facilitating justice and accountability efforts. This includes evidence gathering and documentation of incidents; the acknowledgment that war crimes and human rights violations have been committed by all parties to the conflict; the identification of perpetrators to end the cycle of impunity; and the development of a process of justice and reconciliation. Through collecting, verifying, curating and investigating visual content, the Syrian Archive aims to preserve data as a digital memory to establish a database of human rights violations, and to act as a tool for legally implementing justice and accountability efforts as concept and practice in Syria.

Since its founding in 2014, the Syrian Archive have collaborated with organisations including Human Rights Watch (HRW), Amnesty International, Human Rights Center at UC Berkeley School of Law, and Essex University, Witness, Bellingcat and various agencies of the United Nations (UN), specifically the Independent International Commission of Inquiry on the Syrian Arab Republic.

Syrians for Truth and Justice

Syrians for Truth and Justice is an Syria-based independent, non-governmental organization whose members include Syrian human rights defenders, advocates and academics of different backgrounds and nationalities. The initiative strives for Syria, where all Syrian citizens (males and females) have dignity, equality, justice and equal human rights.

Justice for Life

Justice for Life is a Syria-based civil society and a non-governmental non-profit organization concerned with strengthening and promoting the culture of human rights in Syria. The organisation is based in Deir Ezzor province. Justice for Life aims to contribute to the implementation and promotion of human rights culture and to the supporting of activists in this area - informing citizens of their civil and political rights and emphasizing the concept of “the rule of law” and its role in community development. Justice for Life has successfully implemented research and advocacy investigations with the goal of building an evidence base of human rights violations. Since its founding in 2013, the group has grown to include a staff of 45 volunteers.

Bellingcat

Bellingcat is an award-winning investigative search network of using open source and social media content to investigate a variety of subjects, ranging from Mexican drug lords to conflicts being fought throughout the world. Bellingcat brings together contributors who specialise in open source and social media investigation, and creates guides and case studies so others may learn to do the same.

Background

Hospitals have been forced into the frontlines of the Syrian conflict since it began six years ago. On 22 May 2011, two months after opposition protests against President Bashar al-Assad began, government forces stormed the hospital in Dara’a, kicked out non-essential medical staff, and placed snipers on the roof. The following day snipers began firing on demonstrators, marking the start of escalations that have continued to this day.

In 2012, in a widely condemned move in violation of International Humanitarian Law, President Bashar al-Assad introduced counter-terrorism legislation which declared illegal any medical facilities operating without government approval. Requests for government approval to operate medical facilities in opposition held territory were ignored, effectively making illegal the operation of any opposition held hospitals. The law also criminalised failing to report “anti-government activity,” which according to the UN, “effectively criminalised medical aid to the opposition.”

Since then, hospitals and medical facilities have repeatedly been bombed in attacks largely attributed by international human rights monitors to Syrian and Russian forces. For example, in 2013 the United Nations Independent Commission of Inquiry, the group responsible for investigating alleged war crimes in Syria, found that attacks on hospitals are used systemically as a weapon of war by the Assad regime. The Commission of Inquiry additionally found that deliberate attacks against medical staff and ambulances amount to war crimes of intentionally attacking medical personnel and transport, who are awarded special protection under International Humanitarian Law.

Medecins Sans Frontieres, an international humanitarian non-profit organisation that supports many facilities in Syria, stopped sharing data on medical facilities with Russian and Syrian forces because they feared the data they shared, such as geocoordinates, that was intended to protect civilians and humanitarian workers was being used to deliberately target them.

Under International Humanitarian Law, medical personnel enjoy a protected status. As part of their protected status, they cannot be targeted by any party to the armed conflict. The law defines medical personnel as, “Personnel assigned, by a party to the conflict, exclusively to the search for, collection, transportation, diagnosis or treatment, including first-aid treatment, of the wounded, sick and shipwrecked, and the prevention of disease, to the administration of medical units or to the operation or administration of medical transports.” Moreover, persons performing medical duties who do not fall within this legal definition but are attacked when providing similar medical services enjoy the same protection under International Humanitarian Law.

The principle of proportionality also prohibits parties to an armed conflict from launching attacks that might incidentally harm medical personnel, creating excessive harm in relation to any concrete military advantages gained. Article 3 of the Geneva Conventions further requires that the wounded and the sick be collected and cared for during armed conflict.

Data Ethics

The authors have strived to incorporate a “Do No Harm” ethical framework into its processes. Due to the repeated targeting of hospitals, medical facilities, and medical personnel since 2012 particularly by Syrian and Russian forces, additional precautions and ethical issues were raised.

As the Syrian Archive, it is important to be transparent in our findings and methodologies. We believe that visual documentation of human rights violations that is transparent, detailed, and reliable are critical towards providing accountability and can positively contribute to post-conflict reconstruction and stability. Such content can humanise victims, reduce the space for dispute over numbers killed, help societies understand the true human costs of war, and support truth and reconciliation efforts.

In order to prove that digital content has been verified, geolocation is needed. In the past the Syrian Archive has verified and published the locations of particular human rights violations; due to repeated targeting of hospitals and medical facilities, it was decided that publicly publishing the exact locations of facilities, even for those in longer in use, could potentially pose additional risks towards those working in such environments.

For this reason, two versions of this report have been written: a public version which provides summary findings, and a private version which includes additional information, such as coordinates, provided to those groups given the mandate to investigate human rights violations in the Syrian conflict. The private report and its data will also be prepared to be given to the International, Impartial and Independent Mechanism on Syria (IIIM), as well as to the UN Commission of Inquiry on Syria.

Prior to publication, consent was acquired with those interviewed (e.g. medical workers, facility managers, and Civil Defense volunteers) regarding the public sharing of information regarding attacks.

Errors, Corrections, and Feedback

The authors of this report have strived for accuracy and transparency of process in reporting and presentation, while balancing the need to protect the safety of those providing documentation in some instances. With these interests in mind, detailed methodologies for some information deemed sensitive have not been published.

With that said, while all efforts have been made to present our best understanding of alleged incidents, it is recognised that the publicly available information for specific events can at times be limited.

If readers have new information about particular events; find an error in our work - or have concerns about the way we are reporting our data - please do engage with us. You can reach us at info@syrianarchive.org.

Further Research

While attacks on medical facilities in Idlib during April 2017 were the focus of this report, many other medical facilities were attacked in Hama during the same period, and throughout the country over the last six years. The investigation of attacks on other medical facilities is the subject of further research.

Through using a variety of sources to corroborate verified visual content, the Syrian Archive aims to additionally provide a resource and methodological framework for other human rights researchers and advocates on using open-source investigation techniques to conduct similar investigations. Should readers have interest in potential collaborations on further research or investigations, please do engage with us at info@syrianarchive.org.

Methodology

This report took an interdisciplinary approach towards investigating attacks on medical facilities in Idlib during April 2017. In the report, the authors have included a variety of sources for analysis and investigation, which each have their own respective methodologies. Specific methodologies are provided in the following pages:

Witness Statements

Following the hospital attacks in Idlib province during the month of April 2017, Syrians for Truth and Justice, along with the Justice for Life Organisation, established a field research team which was tasked with entering the city and inspecting the impact sites. These organisations were additionally tasked with collecting material evidence as well as accounts of the survivors, such as those injured and their families, as well as accounts of eyewitnesses (e.g. medical staff; managers of the hospitals; civil defense team members).

Interviews were conducted in person in Idlib by staff members of their respective organisations and recorded on audio devices and then later transcribed. Staff members conducted a total of 14 semi-structured interviews using a standardised questionnaire. Questions asked to respondents focused on the following themes:

  1. Details surrounding the attack (e.g. date, time, location)

  2. The number of patients each medical facility provided care to on a monthly basis

  3. The types of departments or procedures medical facilities conducted

  4. The geographic areas served by medical facilities

  5. Whether this medical facility had been previously subject to attack

  6. Information regarding casualties and those injured as a result of the attack

Flight Observation Data

To cross-reference with findings from visual content, flight observation data information was provided to the Syrian Archive by an organisation employing a well-developed network of spotters (flight observers) of aircrafts departing from military air fields primarily located in northwestern and central Syria.

Flight data and the visual content were analysed to identify whether flights were observed in the vicinity of locations attacked for locations in which aerial bombings were alleged.

Visual Content

The Syrian Archive employed its Digital Evidence Workflow, based off of the Electronic Discovery Reference Model developed by Duke University School of Law. This workflow consists of five components: A) Identification; B) Collection and secure preservation; C) Processing, verification and analysis; D) Review; and E) Publication. A “Do No Harm” ethical framework has been applied to all steps in the digital evidence workflow. Detailed methodologies of these components are analysed in the following subsections.

workflow

A. Identification

The Syrian Archive’s identification process has three steps: 1) Establish a database of credible sources for digital content; 2) Establish a database of credible sources for verification; 3) Establish a standardised metadata schema. These three processes are outlined in detail below:

1) Establish database of credible sources for content

Before any collection, archival, or verification of digital materials was possible, the Syrian Archive first established a database of credible sources for visual content. The Syrian Archive project worked to identify over 300 credible sources, a list consisting of individual journalists and field reporters, larger media houses (e.g. local and international news agencies), human rights organisations (e.g. Syria Institute for Justice), Syrian Civil Defense (White Helmets), and local field clinics and hospitals, and others. Many of the sources used by the Syrian Archive began publishing or providing visual content in late 2011-early 2012 and have also published work in other credible media outlets.

Credibility was determined by analysing whether the source is familiar to the Syrian Archive or to its existing professional network of Syrian journalists, media activists, human rights groups and humanitarian workers; whether the source’s content and reportage been reliable in the past. This is determined by evaluating how long the source has been reporting and how active they are. To determine where the source is based, social media channels are evaluated to determine whether videos uploaded are consistent and mostly from a specific location where the source is based, or if locations differ significantly. Channels are analysed to determine whether the video account uses a logo and whether this logo is consistently used across videos. Channels are additionally analysed for original content to determine whether the uploader aggregates videos from other news organisations and YouTube accounts or whether they upload mostly user-generated content.

2) Establish database of credible sources for verification

Secondly, the Syrian Archive project worked to establish a database of credible sources for verification. These sources provide additional information used for verification of content originating on social media platforms or sent from sources directly. Those verifying content are made up of citizen journalists, human rights defenders and humanitarian workers based in Syria and abroad. To preserve data integrity, sources used for content did not comprise part of the database for verification.

3) Establish standardised metadata scheme

Third, the Syrian Archive recognised the need for a standardised metadata scheme for organising content, but also that any metadata scheme used would be a highly political choice. Given that there are no universally accepted legally admissible metadata standards as of the date of this publication, efforts were made to develop a framework in consultation with a variety of international investigative bodies. Among these include consultations with members of the International Criminal Court, with members of the United Nations Office for High Commissioner of Human Rights, with members of the International, Impartial and Independent Mechanism on international crimes committed in Syria (IIIM), with archival institutes like the NIOD Institute for War, Holocaust and Genocide Studies, with international human rights organisations like Amnesty International, Human Rights Watch, and Witness, and with research institutes like the Human Rights Center at UC Berkeley School of Law.

Establishing a standardised metadata schema is necessary in order to assist users in identifying and understanding when, where, and what happened in a specific incident. A review of practices by other war archival institutes, such as those of NIOD, found that additional information is helpful for contextualising raw visual content (e.g. location of video recording; date of video recording and upload; and the origin of the video). Metadata collected by the Syrian Archive project includes description of the visual object as given (e.g. YouTube title); the source of the visual content; the original link where footage was first published; specific landmarks able to be identified; weather (which may be useful for geolocation or time identification); specific languages or regional dialects spoken; clothes or uniforms able to be identified; weapons or munitions used; device used to record the footage; and media content type. The metadata is populated automatically and manually depending on how it was collected from e.g open source or closed source. A detailed description and full list of metadata field types are provided on the Syrian Archive website.

In categorising violations, the Syrian Archive has decided to use the violations categories used by the Office of United Nations High Commissioner for Human Rights (OHCHR). This was done because OHCHR is one of the groups in the unique position of being able to investigate incidents of human rights violations and war crimes. These categories consist of many often overlapping categories. Categories identified by the UN OHCHR Inquiry on Syria and used by the Syrian Archive project include:

Violations: treatment of civilians & hors de combat fighters

  • Massacres and other unlawful killing;
  • Arbitrary arrest and unlawful detention;
  • Hostage-taking;
  • Enforced disappearance;
  • Torture and ill-treatment of detainees;
  • Sexual and gender-based violence;
  • Violations of children’s rights;

Violations: conduct of hostilities

  • Unlawful attacks;
  • Violations against specifically protected persons and objects;
  • Use of illegal weapons;
  • Sieges and violations of economic, social and cultural rights;
  • Arbitrary and forcible displacement.

Should potential investigations by international bodies not be pursued by the UN OHCHR and rather by another investigative body, it is anticipated that the Syrian Archive will modify violations categories to meet the needs of those investigating.

B. Collection and secure preservation

The collection and secure preservation of the digital evidence workflow ensures that the original content is not lost due to removal on corporate platforms. This is done by collecting and securely storing digital content on external backend servers before it goes through basic verification. It is then backed up securely on servers throughout the world. Videos are hashed with (SHA-256) and (Md5) consistent with current best practices and timestamped to ensure they are not tampered with after being collected from social media platforms (open source) or taken directly from sources (closed source). Simultaneously it is hashed and timestamped by an independent and impartial third party for reference and integrity purposes. Once verified, content is centrally published on the Syrian Archive website in an open-source format. The Syrian Archive uses the Littlefork software for this process, a free and open source software developed for use in human rights investigations using online-based user generated content research.

C. Processing, verification, and analysis

After content has been collected and stored securely, the next stage of the digital evidence workflow refers to the processing, verification, and analysis of digital materials. Detailed descriptions of these three components of the digital evidence workflow are outlined below:

1) Processing

Metadata from visual content collected from social media platforms is parsed and aggregated automatically using a predefined and standardised metadata scheme, as described above. Metadata from visual content sent to the Syrian Archive directory is created manually using the standardised metadata scheme.

This prepares the visual content for initial verification. As much additional metadata and chain of custody information as possible is recorded. This is done to assist users in identifying and understanding when, where, and what happened in a specific incident.

2) Verification

Verification is comprises of three components: 1) Verify the source of the video uploader; 2) Verify the location where the video was filmed; 3) Verify the dates in which the video was filmed and uploaded. Detailed descriptions of these three processes are outlined below:

  • Verify the source of the video uploader

Establish that the source of the video on the Syrian Archive’s verified list of credible sources. If the source is not an existing trusted source, determine the new source’s credibility by going through the procedure highlighted above.

In some cases, near-duplicate content may be published. For example, if one video is 30 seconds and a second video is 10 minutes but includes all or portions of the first video, both videos would be published as long as it is possible to verify both videos. Similarly videos from news organisations or media houses featuring all or parts of content from other videos are also preserved, as long verification is possible. The Syrian Archive also preserves duplications if they are from different sources and the original uploader is unable to be determined (for example if two identical videos are uploaded simultaneously).

The video uploader source may not necessarily be the same as the source who originally filmed content. In most of the video footage verified by the Syrian Archive, only the video uploader and not the video filmer is known. Advanced verification in the analysis phase includes the source of filming, a process done in cases deemed priority.

  • Verify the location where the video was filmed

Each video goes through basic geolocation to verify that it has been captured in Syria. More in-depth geolocation is conducted for priority visual content in order to verify that it has been captured in a specific location. This has been done by comparing reference points (e.g. buildings, mountains ranges, trees, minarets) with Google Earth satellite imagery, Microsoft Bing, and Digital Globe, as well as OpenStreetMap imagery and geolocated photographs from Google Maps. In addition to this, the Syrian Archive has referenced the Arabic spoken in videos against known regional accents and dialects within Syria to further verify location of videos. When possible, the Syrian Archive has contacted the source directly in order to confirm the location, and cross-reference video content by consulting existing networks of journalists operating inside and outside Syria to confirm the locations of specific incidents.

  • Verify the dates in which the video was filmed and uploaded

The Syrian Archive verifies the date of capturing the video by cross referencing the publishing date of visual content collected from social media platforms (e.g YouTube, Twitter, Facebook and Telegram) with dates from reports concerning the same incident. Visual content collected directly from sources is also cross referenced with reports concerning the same incident featured in the video.

  • News reports from international and local media outlets, including Reuters, Smart News Agency, Aleppo Media Center, Qasioun News Agency, LCC;
  • Human rights reports published by international and local organisations, including Human Rights Watch, Amnesty International, Syrian Human Rights Network, Violations Documentation Center in Syria, Syrian American Medical Society, and Physicians for Human Rights;
  • Reports shared by the Syrian Archive’s network of citizen reporters on Twitter, Facebook and Telegram about the incidents.

Additional tools are used to check the date of the visual content such as Google reverse imagery and Sun Calc.

3) Analysis

In some cases, the Syrian Archive is able to conduct in-depth open source investigations. Time and capacity limitations means not all incidents are able to be analysed in-depth, however by developing a replicable workflow it is hoped that others can assist in these efforts of investigate other incidents using similar methods. A detailed overview of in-depth incident analysis is provided in the investigations section of the Syrian Archive website.

D) Review

Once digital materials have been processed, verified, and analysed, it is then reviewed for accuracy. In the event of a discrepancy, content is fed back into the digital evidence workflow for further verification. If content is deemed accurate it moves to the publishing stage of the digital evidence workflow.

E) Publication

Once the visual content is verified and reviewed, it’s then published on the Syrian Archive database where they are made publicly available in a free and open source format. Regular reports on verified visual content ensure that the feedback loop between the Syrian Archive and sources who filmed the videos is closed. This allows the Syrian Archive to add value to the visual content being preserved, verified and analysed immediately for advocacy purposes and later on for accountability and justice purposes.

The Syrian Archive is fully independent and accepts no money from governments directly involved in the Syrian conflict. We are seeking individual donations to carry out our work. Please consider supporting our work through our Patreon page.

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