ON A wintry morning in February warplanes fighting on the side of Syria’s President Bashar al-Assad launched a series of missiles that slammed into a field hospital in northern Syria. Medics raced towards the thick cloud of grey dust that mushroomed above the building before clambering over breeze blocks and fallen trees to pull the wounded from the rubble.
About 40 minutes later, the jets—either Russian or Syrian, no one is sure—circled back and dropped another bomb on the medics as they worked. The air strikes killed 25 civilians, including eight medical workers, making it the single deadliest attack on medical personnel since the war in Syria began in 2011. Unsatisfied with the death toll, the jets tracked the ambulances carrying the wounded to another field hospital three miles north. They hit the hospital entrance with another missile and then, ten minutes later, dropped yet another bomb. “There’s no way on that day they didn’t know what they were doing,” says Dr Ahmed Tarakji, president of the Syrian American Medical Society, which funded the second hospital hit that day.
In the euphemistic lexicon of war, these attacks are known as “double tap” or “triple tap” strikes. This devastating tactic, used to hit schools, bakeries and marketplaces, has become a common feature of the Syrian government’s air campaign.
It has also turned Syria’s hospitals into death traps. Barrel bombs, artillery and air strikes have struck more than 265 medical facilities since the start of the war. Last month, possibly the deadliest since the war began, bombs and missiles hit a hospital or field clinic every 17 hours. Experts reckon that no previous war has witnessed such widespread, systematic targeting of hospitals and medical workers.
There is little doubt among human-rights groups and UN officials that many of these attacks are deliberate. There is also little doubt about who is responsible: those documenting attacks on medical facilities say Syria’s government and its Russian backers have launched more than 90% of the attacks. “It’s not that hospitals haven’t been bombed in Afghanistan, Yemen, Somalia and Sudan. It’s that the intent and strategy as a tool of war is on another level. The government of Assad has aimed its weapons at the delivery of health care,” says Susannah Sirkin of Physicians for Human Rights, a New York-based chronicler of the atrocities in Syria.
Kneel or starve
By laying siege to rebel-held areas and bombarding civilian buildings, the Syrian president has sought to make life unbearable for civilians trapped in rebel areas. It is a classic counter-insurgency technique, a chilling answer to Mao Zedong’s maxim that a guerrilla should move among the population as a fish swims in the sea. Mr Assad’s “kneel or starve” policy—so called for the graffiti scrawled on walls by government loyalists—is designed to deprive the rebels of the sea in which they swim.
The strategy is working. In the besieged east of Aleppo, once the country’s largest city, residents say they live inside a “circle of hell”. Less than one-quarter of its hospitals can operate. Fuel for the generators needed to power life-saving equipment is scarce. When air strikes hit blood banks and oxygen tanks, patients are simply left to die. Fewer than 35 doctors remain to treat a population of 300,000. The rest have fled or been killed, detained or tortured. In the rebel-held town of Madaya only two dentistry students and a veterinarian are left to treat a population of 40,000.
“The attacks are designed to terrify civilians. During sieges, people don’t want to give blood. They’d rather save it for themselves. Many are too scared to go to hospitals because they know they’ll be hit,” says Dr Hatem, one of the few remaining paediatricians in eastern Aleppo.
The rebels have clung on in Aleppo, despite the intensity of Russian and Syrian air raids. Elsewhere, however, Mr Assad’s strategy has proved too much. On August 26th, rebels in the Damascus suburb of Daraya surrendered to the government after enduring a siege that lasted four years and saw residents forced to eat grass to stay alive. A week before the surrender, Mr Assad’s air force bombed the last remaining hospital with incendiary weapons. Mr Assad once trained as a doctor.
The destruction of Syria’s once sophisticated health system has forced doctors and medical charities to come up with innovative ways to escape the daily bombardment. Western-funded aid agencies have built a handful of secret hospitals underground. Others have tunnelled into the side of a mountain to build wards inside caves. But the costs are prohibitive.
The legacy of the war and the regime’s unrelenting attacks on health facilities and medical workers have broader repercussions. The international community’s failure to stop the attacks has led to fears that the deliberate targeting of medical facilities will become the “new norm” in future wars. “The laws of war were drafted to protect civilians, to make war less hellish. These laws are being eroded in Syria,” says Widney Brown of Physicians for Human Rights. “When no one enforces these laws, when those who commit war crimes aren’t held to account, then what message does that send?”
Efforts to hold the Syrian regime and its foreign backers to account have failed. Russia and China blocked the country’s referral to the International Criminal Court in 2014. Governments in the West have begun to look at launching their own investigations into war crimes in the hope of prosecuting individuals under universal jurisdiction, but the creation of an independent body that investigates every alleged hospital attack is a dream.
“Without justice it will be impossible to get rid of this feeling of revenge,” says Dr Rami Kalazi, the only neurosurgeon working in eastern Aleppo. “Without justice people will lose their trust in the international community completely. They will lose their trust in everything except for weapons.”
