Medical Facilities Under Fire: Idlib Central Hospital

Incident Summary

• Place of Attack: Idlib Governorate Center in Idlib city
• Location Hit: Idlib Central Hospital, which is supported by SAMS and serves the 700,000 residents in the city and surrounding areas.
• Date: 25 February 2020
• Time: Around 13:55, according to interviews conducted by Syrian Archive’s investigations team with hospital staff, open source media found online, and flight observation data.
• Killed or Wounded: 8 were wounded including 4 hospital staff.
• Type of Attack: Airstrike
• Munitions: N/A
• Potentially Responsible: Flight observation data, witness testimony, and open source information point towards the Syrian Air Force as responsible for the attack.

Introduction

On the afternoon of February 25, 2020, at 13:55, Idlib Central Hospital in Idlib city was hit by an airstrike suspending its operations and closing its speciality clinics. The attack on the hospital supported by SAMS killed 3 and wounded 12 others. The airstrike partially destroyed the hospital’s outpatient clinics, cancer treatment center, interior pavilion, and staff residence wing. The investigation below examines the attack on Idlib Central Hospital and the subsequent damage to the facility.

Methodology

Syrian Archive conducted an investigation into the incident, based on 4 steps:

(1) A local investigations team collected testimonies from hospital staff treating those injured in the attack; (2) Securing, analysing, and verifying of 40 videos and images uploaded to social media networks purportedly showing the incident; (3) Analysing flight observation data revealing the warplanes over the town at the purported time of the attack; (4) The combined analysis of these sources has culminated in the present investigation report. Complementing each other, they provide information regarding the attack’s date and time, location, casualties, extent of damage, and potential perpetrators. Examining all information available on the attack, the investigations team developed an understanding of the incident and all potential perpetrators.

For more details on Syrian Archive’s methodology, please see our site.

Hospital Background

An image taken by the investigations team of the hospital after the attack.

Idlib Central Hospital was established in April 2015 becoming a vital medical facility in an area suffering from a scarcity in medical facilities and services. In an interview with the investigations team, Dr. Muhammed Mustafa Al Salat, administrative director of the hospital, noted that Idlib Central Hospital is a surgical hospital with departmental specialties including: Orthopedic and Neurosurgery, General and Plastic surgery, as well as Urology and Vascular surgery. In addition to these departments, the hospital includes an ambulance and radiology department, an intensive care unit for adults and children, a pediatrics department, an endoscopy department, a pharmacy, a laboratory, and multiple wards for inpatient care.

In November 2018, The Syrian American Medical Association (SAMS) in cooperation with the Idlib Health Directorate opened a cancer treatment center in Idlib Central Hospital. This center is the only one in northern Syria that provides free medical services to those with breast cancer or Lymphoma.

Beneficiaries

Idlib Central Hospital provides free services to the 700,000 residents of Idlib city in addition to the residents of villages surrounding the city and around the governorate. According to a media representative from SAMS interviewed by the investigations team, the hospital serves around 15,000 patients a month completing around 40,000 medical services for those patients.

Director of the hospital’s oncology department, Dr. Ayham Jomaa, stated in an interview with the investigations team that around 400 patients visit his department every month. According to Jomaa, the department provides chemotherapy for breast, colon, and lymphoma cancers as well as free consultations and blood transfusions for patients.

An image taken by the investigations team showing the entrance to the hospital’s cancer treatment center.

According to a report by SAMS, the opening of the cancer treatment center has alleviated the suffering of cancer patients living in opposition held territories. With limited options for medical services, cancer patients were forced to face the heavy costs of treatment in government held areas or travel to Turkey which limited the number of patients allowed to enter the country as five per day, according to Bab Al Hawa border control.

In an interview posted by SAMS on May 21, 2020, Dr. Mohammed Jomaa Eid, a doctor in the oncology department, additionally said that since its inception the department has provided 1,400 doses for chemotherapy and provided around 4,000 medical consultations that serve an upwards of 230 patients. The center, according to Jomaa Eid, also provided free CT scans for more than 200 patients outside the Oncology department.

Location

While under control of the Syrian government, the Idlib Governorate Center building in Idlib’s city center consisted of the governorate department, police headquarters, and passport and immigrations department. In 2015, with the city under opposition control, part of the building was used for the Idlib Central Hospital (also known as the Governorate Hospital).

An image posted by eSyria showing the governorate building, police headquarters, and passports and immigration department in 2012.

An image posted by the Facebook page Eye on the Revolution in 2013 showing the governorate building before it was partially changed into a hospital.

Syrian Archive identified the exact location of the hospital (35.9273423, 36.6330128) through photos of the building from before and after the attack matching it with satellite imagery from Google Earth.

*A geolocation of the facility using satellite imagery from Google Earth with a photo of the building from 2012 posted by eSyria (on the left) and a photo of the hospital after the attack posted by SAMS (on the right).

Previous Attacks on the Hospital

Despite its afforded protections as a medical facility, the February 2020 attack on Idlib Central Hospital is not the first of its kind. The hospital was targeted several times in the past the first of which was on March 4, 2018. According to a Facebook post from SAMS, a car bomb detonated in front of the hospital killing 4 and wounding 14 others in addition to severely damaging the hospital’s children’s ward.

Two months later in May 2018, according to a SAMS post, another car bomb was detonated outside the main hospital door killing 9 civlians and injuring 28 others. This attack severely damaged and suspended operations in the pediatric, internal medicine, and surgical departments.

An image posted by SAMS showing the damage from the car bomb detonated in front of the hospital on May 13, 2018.

Lastly, on July 12, 2019, a SAMS Facebook post reported of air strikes which damaged the facility. SAMS reported the strikes as a part of a government military operation on northern Syria.

What Happened (and When)?

Idlib Central Hospital from before and after the attack.

Idlib Central Hospital in Idlib city was attacked around 13:55 on February 25, 2020 wounding 8 civilians. According to witness statements and media posted online, the attack, which destroyed parts of the hospital, was an air strike by a fixed-wing aircraft.

In an interview conducted by the investigations team, administrative director of the hospital Dr. Mohammed Mustafa Salat confirmed that the hospital was hit at around 13:55 on February 25. Salat further confirmed that the strike injured medical staff and wounded civilians on the street in addition to damaging the hospital.

Dr. Ayham Jumaa, director of the cancer treatment center in the hospital, further confirmed in an interview with the investigations team that the air strike on the facility took place around 13:55. He additionally stated that the strike hit near the end of the hospital’s operation hours reducing the number of staff and patients wounded or killed.

Moreover, in an interview with the investigations team, Muawiya (a journalist with SAMS) and Rami Rahel (a receptionist at the hospital) further confirmed the time of the strike, the number wounded, and the damage to the hospital.

Initial posts on social media alerting of an attack further confirm the time of the air strike. At 14:27 on February 25, a post from the Facebook page Governorate and Border Observatory reported of a direct attack on Idlib Central Hospital. Minutes later at 14:33, Al Jazeera correspondent Milad Fadl posted claiming Russian planes targeted the hospital’s roundabout. THe first video showing the attack’s aftermath was posted at 14:25 by the Macro Media Center (MMC). The video shows an MMC reporter near the hospital with dust still in the air. Ambulances are shown arriving at the impact site and the body of a child is shown lying on the ground.

A still from a video posted by MMC of the moments directly after the attack. The hospital building can be seen behind the reporter.

Posts showing the devastation immediately after the attack were followed by photos and videos posted hours after the strike documenting the efforts to recover and rescue the injured. At 16:31, the Facebook page Eye of the North posted photos showing a crater from the strike near the hospital as well as the damage to the outside of the facility. Around 15:00, SAMS posted a statement onto Facebook confirming the attack. According to SAMS, the strike hit in front of the gate to the speciality clinics where hospital personnel were present. With images showing the damage to the facility, SAMS confirmed 4 hospital staff were injured in the attack. The organization additionally announced it is suspending operations at the hospital because of the “security situation in the city, the direct targeting of the hospital, and the damage to the facility.”

An image posted by SAMS showing the hospital after the attack

The Syrian Civil Defense posted a video on its Facebook page showing Civil Defense team members recovering those killed in the attack. Hours after the strike, Al Jazeera additionally published a video report on the attack. Correspondent Milad Fadl spoke in front of the hospital building about Russian airstrikes targeting schools and kindergartens in addition to Idlib Central Hospital. Fadl described that the attack came amid battles taking place east of Idlib city near Neirab and its surrounding areas.

Additionally on February 25, Orient News posted on YouTube a report on the attack showing the damage to the hospital and the surrounding area. Claiming that 4 warplanes were present over Idlib city at the time of the video’s recording, the correspondent in the report stated that the hospital was targeted by missiles with cluster munitions dropped by a Su-24 warplane.

Stills from a video posted by the Civil Defense showing the rescue efforts after the strike

A still from a video posted by Orient News on the attack.

Reports from Sham News Network and Radio Al Kul further corroborate that the Idlib Central Hospital was bombed by warplanes on February 25.

Further confirming the time of the attack, Syrian Archive used the SunCalc tool to analyze shadows shown in a video posted by MMC at 14:25 and taken directly after the attack. Shadows confirm that the video was taken around 14:00, close to the purported time of the strike.

A screenshot showing the position of the sun in Idlib city at the alleged date and time of the incident

A still from an MMC video taken directly after the attack

Calculated using the tool Suncalc, the direction of the shadows shown in a video posted by MMC match the direction of the sun at 14:00 on February 25, 2020 in Idlib city.

Destruction Analysis

Syrian Archive identified and analyzed the destruction to Idlib Central Hospital from the attack using open source media as well as videos, images, and interviews taken by the investigations team on the ground. Media captured by the team and the open source media found online further confirm and corroborate statements that the facility was directly targeted and severely damaged from the attack.

External Damage

A GIF from a video posted by Al Jazeera on Facebook showing the hospital after the attack.

Videos and photos posted on social media and captured by the investigations team show the damage to the hospital as a result of the attack. Although the hospital building is still standing, the attack destroyed important wards and departments of the facility preventing it from receiving any patients.

An image posted by the Eye of the North Facebook page showing the destruction to the eastern side of the hospital.

Corroborating interviews conducted by the investigations team with the hospital staff, videos and photos of the outside of the hospital show broken windows, uprooted portions of the hospital’s iron wall, and damage to the roof on the eastern side of the facility. Photos additionally show a crater from the air strike around 35 to 40 meters away from the speciality clinics’ gate.

An image posted by SAMS taken the day of the attack showing the crater caused by the missile

Photo of the crater taken by the investigations team days after the attack

Photo taken by the investigations team days after the attack showing the external damage to the hospital from the attack

Internal Damage

Although the Governorate building still stands, the attack severely damaged the hospital internally forcing it out of service. The attack damaged the outpatient clinic building and the cancer treatment center as well as the internal medicine and hospital staff residence wards.

A media representative for SAMS stated in an interview that the hospital’s oncology department (including the cancer treatment center), the hospital staff residence ward, and the inpatient ward were the most damaged by the air strike. In addition to breaking doors and windows, according to the representative, the strike destroyed the hospital’s eastern walls which stood around 35-40 meters away from the missile’s impact site.

Break room for hospital staff

Break room for nurses

Inpatient clinics

Pictures taken by the investigations team of the damage to various departments in the hospital.

Dr. Ayham Jomaa, director of the hospital’s oncology department, confirmed in an interview with the investigations team that the hospital was severely damaged citing a hole in the wall, removed doors and windows, and significant damage to the cancer treatment center.

An image published by SAMS in a 2018 report on the hospital showing the second floor corridor to the hospital staff's break room

The same corridor to the break room as shown after the attack in a photo taken by the investigations team

Images of the second floor corridor to the break room from before and after the attack.

An image posted by SAMS of an inpatient room after the attack

An image taken by the investigations team of the same hospital room several days after the attack when hospital staff attempted to repair the room

Pictures of a patient room after the attack and after attempts to repair it

The repeated targeting of the only hospital in northern Syria that treats cancer, in addition to providing other services, will increase the suffering of hundreds of thousands of civilians in Idlib and the surrounding areas.

Killed and Injured

The Syrian Archive’s investigations team interviewed hospital staff and personnel at SAMS as well as reviewed open source media to verify the number and identity of those injured in the attack. The team confirmed 8 injured, four of which were hospital staff, as reported by SAMS and the Civilian Observatory channel on Telegram. The 4 hospital staff injured were Dr.Fahad Mohiuddin (neurologist), Mohammed Al Sheikh (anesthesiologist), Fatima Al Muallim (nurse), Mohammed Jomaa (nurse).

SAMS provided the investigations team with a list of 41 civilians injured on February 25 and taken to Idlib Central Hospital. Listing their ailments, the list reveals and confirms 8 people at the hospital were injured by the air strike, while the rest were injured from air strikes around Idlib that same day.

The names of patients at Idlib Central Hospital the day of the attack.

One of the Victims

With the prolonged duration of the conflict and subsequent increase of human rights violations in Syria, human suffering throughout Syrian conflict is often diluted by the media and expressed only through statistics of those killed and wounded. Syrian Archive’s investigations team followed the story of one of the attack victims on February 25 who were sent to the Governorate Hospital. A nurse at the hospital Abdel Monneim Okkeh’s daughter was injured in an attack. Alongside the rest of their family, they were forced to move from Sarmin in late January 2020 due to heavy attacks on the town. They moved to Idlib city where Abdel Moneim began working as a nurse in the Idlib Central Hospital.

Right before the Idlib Central Hospital was attacked, Abdel Monneim was working inside receiving patients injured from various strikes around the city. He was shocked to see his daughter Nada (5 years old) amongst those brought into the hospital. Abdel Moneim fainted upon seeing Nada. Videos show Abdel Moneim falling with Nada screaming “Oh my eyes, my eyes” in the background. She was hit with shrapnel in the head as well as throughout her body. After Abdel Moneim stood up and regained his balance, he carried his daughter washing her the blood off her face with warm water. With Abdel Moneim fairly disoriented, hospital staff had to tell him who was present and where he was going. Carrying Nada who was crying at her father, Abdel Moneim buried his face in her body and took her outside the hospital.

A picture posted by SAMS’ Facebook page showing Nurse Abdel Moneim carrying his daughter while she was treated.

Nurse Abdel Moneim Okkeh was mentioned and quoted in a report published by SAMS: “After we were displaced from the city of Sarmin due to the recent escalation, my family and I sought refuge in Idlib City. I’ve been working here at the Central Hospital for the past 25 days non-stop, responding to the overflowing number of injured civilians. Today, I was surprised to see my 5-year-old daughter Nada among them. I was devastated.”

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 briefly before, during, and briefly after the time of the attack (13:00-14:30) on February 25, 2020 around Idlib, Hama, and Homs was closely analyzed.

At 13:22 and 13:35 observers spotted Su-24 warplanes taking off northwest towards Idlib from the T4 West Airbase in Homs. At 13:32, a Su-24 was also seen circling above Sarmin (9 km from Idlib). At 13:33 and 13:41, Su-24 warplanes were spotted flying northeast over Ariha (13 km from Idlib) towards Idlib. Additionally at 13:48, a MiG-23 warplane was spotted taking off north towards Idlib from the Hama Military Airbase. Shortly before the attack, at 13:40 and 13:55, Su-24 and MiG-23 warplanes were spotted circling above Idlib city. Previous research has found that warplanes circling over a location indicates target acquisition and/or preparation for an imminent attack. Furthermore, the circling by a MiG-23 over Idlib further corroborates local news reports and interviews conducted by the investigations team estimating time of the attack as around 13:55.

Screenshots from the Idlib Syrian Civil Defense and Idlib Governorate Observatory confirm that an MiG-23 warplanes is most likely responsible for the attack.

In addition to the provided flight observation data, the Idlib Governorate’s Observatory channel on Telegram warned of the departure of a MiG-23 warplane flying north from the Hama Military Airbase at 13:48. Spotters on the channel noted that it could reach Idlib within six minutes. The Civil Defense observatory additionally confirmed on Telegram the targeting of the hospital at 13:54 by a MiG-23.

Although this data matches allegations made by posts on social media which point towards an MiG-23 plane as responsible for the attack, no evidence available shows the direct involvement of the MiG-23 in the attack on Idlib Central Hospital. Nevertheless, the presence of this aircraft circling above Idlib city at the time that the attack occurred further confirms that the hospital was attacked by an air strike. Given that the MiG-23 spotted over Idlib at the time of the attack is frequently used by the Syrian Air Force, it is likely that the Syrian government is responsible for the attack.

Conclusion

At approximately 13:55 on February 25, 2020, the Idlib Central Hospital (Governorate Hospital), supported by SAMS, in Idlib city was targeted. The attack damaged several of the hospital’s departments including the oncology department and outpatient clinics that provided health services for the area’s residents. The investigations team verified the time of the attack and its subsequent destruction using open source media posted online, media and interviews taken by the investigations team at the site of the attack, and flight observation data. Although witness statements, open source media, and flight observation data suggest the Syrian Air Force as responsible for the attack, Syrian Archive is unable to definitively identify and confirm a perpetrator of the attack given the limited information in open source investigations.