Medical Facilities Under Fire: Al Zerbeh Primary Healthcare Center

Joint investigation: Syrian Archive and Focus Aleppo

Initial Summary:

• Location: Aleppo: Al Zerbeh
• Target: Al Zerbeh Primary Healthcare Center, which reopened in 2018 and is supported by the Syrian American Medical Association (SAMS). Although continually closed and reopened throughout the war, Al Zerbeh Primary Healthcare Center has been operating since 2009.
• Beneficiaries: As the only healthcare center in the Zerbeh region of the Aleppo countryside, the medical facility received ~2500 - 3000 patients per month since 2018.
• Date: Friday, August 30 2019
• Time: ~5:30 - 6:10 PM, according to interviews conducted by the Syrian Archive investigations team with the director of the facility and one of its nurses as well as the director of the Free Aleppo Health Directorate’s primary health care department. Statements and articles published by the Syrian American Medical Association and local news organizations like Step, and Sham all reported times in congruence with witness testimonies.
• Victims: The attack on the facility killed a 12 year old child, Nasrallah Mahmoud al Hadi who was displaced from his home village of Tel Alloush to Zerbeh. The airstrikes also wounded three civilians: Lina al-Rajab with her child Almaza and another 13 year old child named Jamil Mohammed Ali. This is according to interviews conducted by the investigative team including with Abdul Karim Al Yassin, director of the Free Aleppo Health Directorate’s primary health care department.
• Type of Attack: One airstrike targeting the facility and the town center with two missiles according to interviewed witnesses.
• Munitions Identified: N/A
• Potentially Responsible: A Sukhoi 22 aircraft according to flight observation data.

Background on the Hospital:

An image from before the attack provided by the investigations team.

The Al Zerbeh Primary Healthcare Center is a free healthcare provider operating since 2009 and reopened at the start of 2018 under the support of the Syrian American Medical Association. Activist Ahmad Al Hamoud claims that the center has existed since 1982 in the same building that was destroyed in the attack.

A map published in a 2010 study of health centers in the Jabal Samaan region. The map includes Al Zerbeh Primary Healthcare Center further corroborating its existence before the conflict.

Like other medical facilities in the countryside of Aleppo, the medical facility provides basic healthcare to those in Al Zerbeh and its neighboring villages/rural areas. The hospital houses an internal medicine clinic, a pediatric clinic, a women’s clinic, a dental treatment clinic, a vaccination center, a pharmacy, and a laboratory for medical analysis. The facility also has an ambulance service both 24/7 for emergencies as well as to transport patients to other hospitals. It was not the first time that the center was targeted.

A Previous Attack

On May 6 2019, the center was first targeted with its main building, gate, and outer wall damaged. The Civil Defense were the first to reach the facility and assess the damage for both attacks. As shown in the images below, the hospital suffered greater damage from the August 30th attack. The hospitals sheet metal cover for the courtyard and wall bordering the water tower, for example, were completely destroyed from the August 30th attack and were not damaged from the May 6th attack.

Both these images are stills from videos taken by the White Helmets of the May 6th (on the left) and August 30th (on the right) attacks. The sheet metal covering the hospital’s courtyard and the wall bordering the water tower were preserved in the May 6th 2019 attack but destroyed in the August 30th 2019 airstrike.

Alongside destruction, the pictures and videos from both attacks show an attempted reconstruction of the hospital after its first May 6th attack. For example, the outer wall parallel to the street, previously destroyed in the May 6th attack, was under reconstruction and was again damaged with the August 30th attack.

Videos from the May 6th 2019 (on the left) and August 30th 2019 (on the right) attacks show an attempt to rebuild the outer wall, standing parallel to the street, destroyed in the May 6th attack.

Repeated attacks on the facility, like the May 6th and August 30th attacks, indicate the direct and deliberate targeting of the medical facility. Although threatened by these direct attacks, the hospital, because of its location, was vital for those living in the southwestern countryside of Aleppo.

Hospital Location

The location of Al Zerbeh, Al Eis, and Al Atareb on Google Earth.

The hospital is located in the small village of Al Zerbeh, which lies in the southwestern rebel controlled countryside of Aleppo. When the hospital is attacked and subsequently out of service, the nearest medical facilities for those in and around Al Zerbeh are 15 km away in Al Eis and 30 km away in Al Atareb. As shown below, the hospital’s location, was corroborated utilizing open source online information as well as satellite imagery from Google Earth Pro.

The buildings shown in Google Earth satellite imagery match what is shown in images provided by the investigations team on the left and Zerbeh Media Center on the right.

What Happened and When?

An image taken by the investigations team of the destroyed outer wall and entrance gate to the center.

Open source media in corroboration with flight observation data and videos, images, and interviews taken by the Syrian Archive’s investigations team on the ground 36 hours after the attack confirm that the Zerbeh Primary Healthcare Center was targeted, attacked, and destroyed by an airstrike missile on August 30 2019 at around 5:30 to 6:10 PM. Two missiles were allegedly shot from one plane with the first hitting the town’s center near the hospital and the second directly hitting the medical facility itself. The attack destroyed the hospital’s main square and building causing fires that spread throughout the facility destroying the majority of the hospital’s rooms.

Satellite imagery from Digital Globe of the healthcare center on August 23rd 2019 (on the left) 7 days before the attack and on September 20th 2019 (on the right) 21 days after the attack. The damage shown on the satellite imagery corroborates both the direct targeting of the hospital and the date of the attack.

The airstrike forced the hospital out of service. The extensive damage caused by the attack and the impact points of the missiles, as recorded by our investigations team, further confirms that the healthcare center was deliberately and directly targeted.

The airstrike resulted in the death of a child and the injury of three other civilians. This is in addition to the internal and external destruction of the facility and the town’s public square. As described later, the hospital’s patient reception corridor and solar panels were destroyed alongside its medical equipment (including respiration machines, ultrasound devices, dental clinic chairs, laboratory equipments and medicines from the pharmacy). This is featured in reports done by local news organizations like Step, as well as an interview done with the healthcare center’s director Dr. Abdullah Hamidi.

An image showing the fire in the healthcare facility after the attack posted by SAMS.

The Syrian American Medical Association (SAMS), which supports the healthcare facility, published a statement and 25 photos of the damage in congruence with Dr. Hamidi’s statement confirming the targeting of facility.

The Syrian Civil Defense and the Al Zerbeh Media Center posted a video at 11:24 PM and a video at 10:19 PM, respectively, showing the targeting of town of Al Zerbeh. Both videos, from an analysis of the shadows, were most likely recorded in the late afternoon further confirming the time the hospital was attacked. In an interview with the investigations team, Fawaz Jowaid, the director of the Al Zerbeh Media Center confirmed the time of the strike at 5:35 PM.

Shadows shown in the Syrian Civil Defense’s video on YouTube match the position of the sun at around 6:30 PM the day of the attack. This was found using the SunCalc tool.

In a video interview with the investigations team, Dr. Abdullah Hamidi confirmed that the healthcare center was attacked by airstrike destroying a large part of the building and pushing it out of service at around 6:10 PM. This time, for the second missile, was confirmed by one of the hospital’s nurses, Khaled Adiwi, who witnessed the airstrike and was interviewed by the investigations team.

Witness Testimonies:

Supplementary interviews conducted by the investigations team confirm the time and extent of damage of the attack. As mentioned earlier, Fawaz Juwaid, director of the Al Zerbeh Media Center, reported to the investigations team that he spotted a Sukhoi 24 warplane at 5:35 first targeting civilian areas, as shown in a previously mentioned Civil Defense video, then hitting the healthcare center. Juwaid detailed that he quickly arrived at the scene and took a number of photos and videos minutes after the attack on the medical facility.

In congruence with Juwaid’s statement, Nurse Khalid Adiwi, who said was standing close to the point of impact, said he saw a strike first hit the center of the town with a later second airstrike directly hitting the healthcare center.

Local News Reports:

Corroborating witness and first responder testimony, local news media covered in detail the airstrike on the village and its only healthcare facility. First at 8:59 PM, SAMS published a statement on its Facebook page confirming the attack on the hospital and its subsequent push out of service. Shortly thereafter at 9:18 PM, the national news organization SMART published a report on the attack confirming claims of two airstrikes with one hitting the town center and the other hitting the healthcare facility. The report also confirmed that a child was killed in the attack and three others were injured.

At 1:55 AM that night, Al Zerbeh Media Center posted a video of first responders, and citizen journalists, witnessing an airstrike on the town (with the smoke visible in the video) and arriving at the site of the attack. This video confirms that the village center was attacked alongside the medical facility itself as first responders in the video first looked at the damage of the city center and then ran to the medical facility nearby.

The Free Aleppo Health Directorate additionally posted on Facebook confirming the attack.

As mentioned above, Step, Sham, and SMART news all confirmed the attack and its casualties in separate reports.

Analysis of the Damage:

Because the medical facility was directly targeted by air, the hospital suffered severe external and internal damage rendering it beyond repair and out of service. The investigations team documented the damage to the healthcare center through pictures, videos, and interviews ensuring congruence between their own documentation, open source media of the attack, and old photos of the facility.

External Damage:

This photo, posted by SAMS the afternoon after the attack, shows the extensive damage to the outside of the hospital.

From the attack, the hospital suffered significant damage to its outer courtyard with the parts of the fence surrounding the center either damaged or completely destroyed. The sheer power of the airstrikes destroyed the main gate and paved floors of the facility. Parts of the healthcare center’s courtyard cover and roof, made from sheet metal, were destroyed from the attack with remnants found on an elevated piece of transformer equipment as well as in a tree, which again indicates the strength of the attack and explosion.

An image of the hospital courtyard cover before the attack provided by the investigations team.

Images taken by the investigations team show the previous cover of the hospital courtyard now destroyed.

Moreover, infrastructures necessary for the function of the hospital were destroyed. The facility’s solar panels, which supply a significant amount of electricity to the center, were damaged and ruined by shrapnel along with the hospital’s water tanks which were punctured and displaced from the attack.

The hospital’s solar panels were severely damaged by shrapnel as shown in this image provided by SAMS.

Photos and videos show the extensive damage to the fundamental structure of the hospital as well. The collapse of the concrete columns in the front of the building and on its outer wall as well as the uprooting of the outer cement and paint layers from the inner building indicate the high pressure of the attack and its subsequent damage.

An image taken by the investigations team showing the outer destruction of the center.

The intensity of the attack is also seen in the iron “sheets” or “grilles” originally placed over the windows which are now only pieces strewn along the external and internal grounds of the hospital. Additionally, in congruence with interviews and reports, the outside of the facility features combustion burns, a black residue on the concrete, which confirms images and reports of a fire in the facility after the attack. The indications of fire and extensive external damage further confirms the facility’s status as out of service.

Internal Damage:

With the hospital pushed out of service as a result of the attack, the entirety of the healthcare center’s interior walls, including the lobby, show large cracks and openings with fallen parts of the ceiling and walls covering the floor of the lobby and pharmacy.

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

Additionally, images and videos show broken wooden benches in the waiting rooms, a damaged patient and dental treatment chair as well as the complete destruction of the pharmacy and its inventory of medicines. Moreover, blacks walls in the lobby of the hospital match the previously mentioned burn marks outside the facility.

An image posted by SAMS of the dentistry clinic after the attack.

Additional internal damage to the facility documented by the investigations team.

Noting the extent of the fire’s reach and the holes in the ceiling, Civil Engineer Ahmed Ali Al Khalaf reviewed the videos and photos from the center and reported the facility as more than 80% damaged and impossible to repair without building anew.

Flight Data Analysis:

To provide a further layer of verification, the Syrian Archive cross referenced findings from the open source media above and the media from the investigations team with flight observation data from a spotter organization. Data for flights occurring before and after 5:35 PM around Aleppo, Idlib, and, more specifically, Al Zerbeh was closely analyzed.

Beginning outside of Aleppo and Idlib in the province of Homs, a Su-22 (or Sukhoi 22) was spotted taking off north from Shayrat Airbase at 5:18 PM. A Su-22 was then spotted flying north at 5:26 PM over Taman’a, a town in the Idlib province around 70 kilometers south of Al Zerbeh. At 5:04 PM and then later at 5:34 PM, a Su-22 was spotted above the International Agricultural Research Center in the Dry Areas (ICARDA), which lies just 6 kilometers southwest of Al Zerbeh. Lastly at 5:35 PM, a Su-22 was spotted circling over Al Zerbeh. With the common practice of circling by warzone aircrafts indicating a target acquisition and/or preparation for an imminent attack, the circling by a Su-22 over Al Zerbeh corroborates the estimated time of the attack as reported in interviews conducted by the investigations team.

This data however does not fully match reports, such as Fawaz Juwaid’s from the Al Zerbeh Media Center, of a Sukhoi 24 warplane targeting the hospital and town. Although possibly a simple misidentification, there is no direct evidence available that one of the observed aircraft was involved in the attack on Al Zerbeh. However, the presence of aircrafts above Al Zerbeh and neighboring towns increases the likelihood that an air attack occurred on the town and hospital during the times shown and corroborated in open source media and reported on by the Syrian Archive’s investigations team.

Conclusion:

Based on open source media posted online, documentation and interviews conducted by the Syrian Archive’s investigations team, and flight observation data, it is confirmed that Al Zerbeh Primary Healthcare Center, as well as the town itself, was attacked by two missiles at around 5:30 - 6:10 PM on August 30 2019. It is also confirmed that the hospital, supported by the Syrian American Medical Association, was destroyed and pushed out of service because of the attack. However, given the limitations of the investigation, the Syrian Archive is unable to confirm the perpetrators of the attack although statements by hospital staff in interviews and by local human rights organizations claim the airstrike was conducted by the Syrian Air Force.