The blood forms pools on the floor of a whitewashed operating room. Two men pose for a photo with their table of metal instruments, unable to smile.

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It’s late at night after a long day of airstrikes on Syria’s northwestern Idlib province. The two doctors have been operating on the wounded for hours.

“This is from a day where we were working from early morning until late at night, treating injuries,” said Dr. Haitham Diab, who sent The New Humanitarian the August photograph via WhatsApp.

Diab is a surgeon in one of the few hospitals close to the front lines in Idlib that is still operational. He said it was hit by an airstrike in July, but the damage was minor.

In another photo, Diab can be seen crouched down in a corner of the hospital in a set of wrinkled green scrubs, exhausted. Packages of medicine, gauze, and other supplies lie stacked on metal shelves to his side. 

Diab is among the healthcare workers still doing their job in the midst of a four-month air, artillery, and land campaign waged by Syrian government and allied Russian forces in and around rebel-held Idlib – areas home to an estimated four million people

Despite the dangers, many doctors are working under fire with limited supplies, even as more patients need help.

At the peak of the bombing last month in the southern part of Idlib where he works, Diab said the hospital’s 20 doctors were performing some 40 emergency operations every day. (The New Humanitarian is not publishing the exact location of hospitals mentioned in this report, at the request of the staff still working in them.)

Civilians and civilian infrastructure, including hospitals and health clinics, have been hit hard by the offensive, which Syrian officials have said is a fight against “terrorists” in Idlib. Russia’s UN envoy, Vasily Nebenzya, has called many reports of bomb attacks on hospitals “fake”, according to Russian state news agency TASS. 

The UN says 400,000 people have had to flee since late April, either to escape violence or to “access services essential to survive”. As of early September, the UN’s human rights office said it had verified the killing of 1,089 civilians (among them 304 children) since 29 April – 94 percent of them killed by pro-government forces.  

The offensive, which has faced stiff resistance from rebels, marked the end of a Turkish-Russian deal reached last September that was meant to stave off an all-out assault by pro-government forces to retake Idlib, which is largely controlled by an extremist group defined as terrorist by the UN.

Reduced to rubble

Several doctors said the places where they work have been bombed, including the hospital where Diab operates alongside Shaker al-Hamido.

After an airstrike hit just outside their house several months ago, al-Hamido, a doctor from southern Idlib, said he sent his wife and toddler-aged children north to the Syrian-Turkish border so they could stay somewhere safer.

“Of course I’m afraid,” he said, but he continues to live and work in the area.

Among the bombed hospitals are those that voluntarily registered their coordinates with a UN-run no-strike list, which was shared with Russia, Turkey, and the United States as part of a deconfliction mechanism supposed to prevent such facilities from being targeted. 

Al-Hamido and Diab said their hospital had shared its location with the UN.

Read more → What is humanitarian deconfliction?

The UN says a total of 51 medical facilities – such as hospitals, ambulance points and clinics – have been damaged as a result of attacks since the offensive began.

At least 14 sites hit by the end of July had shared their coordinates as part of the UN mechanism, according to a tally provided by the Syrian American Medical Society, or SAMS, a US-based group that supports medical facilities in rebel-held areas in Syria.

Eleven of those sites match incidents recorded by the Armed Conflict and Location Event Data Project (ACLED), a group that monitors and maps conflict. 

The UN’s emergency aid coordination body, OCHA, which runs the deconfliction system, declined to verify the detailed listings, saying the parties to the conflict were responsible for their conduct under international humanitarian law (IHL) and investigating violations. 

Civilian infrastructure, and medical facilities in particular, enjoy special protection under IHL regardless of whether or not they were “deconflicted”.

Attacks on healthcare in northwestern Syria – April-September 2019

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HOW THE MAP WORKS: Medical sites damaged in the fighting since April 2019 – by any party to the conflict – are marked in green.

The source of the damage data is ACLED, which recently began including details of attacks on health facilities as part of its database on conflict in Syria.

From 27 April to 15 September 2019, ACLED’s latest information, shared with TNH ahead of public release this week, records 69 incidents affecting health workers and patients in northwestern Syria, mainly aerial bombing and shelling by Syrian government and allied Russian forces. 

The Syrian American Medical Society has provided a partial list of strikes on sites whose coordinates were on the UN’s no-strike (or “deconfliction”) list through the end of July.

TNH has found 11 incidents that match the two listings. These are in the locations marked with red dots. Hover or click on the dots to read details.

Among the hospitals bombed out of service this year was one situated outside Ma’arat al-Nu’man, a town in southern Idlib province. Wassel Aljork, a general surgeon, treated patients there until an airstrike hit it several months ago. 

The hospital, which once served more than 100,000 residents of the surrounding countryside, according to Aljork, is now a pile of rubble. 

When he and other doctors went to survey the wreckage, they found that none of their equipment could be salvaged.

After the bombing, Aljork left his nearby hometown, where he ran a makeshift clinic out of his house, and headed north. He now works in a hospital near the border with Turkey, where hundreds of thousands of people have fled in search of safety. 

The UN announced earlier this month that it would launch an investigation into attacks on hospitals and other civilian sites, although some doubt how effective it can be. 

“An investigation won’t stop the attacks, but at least it might put some pressure,” says Mohamad Katoub, a doctor and spokesperson for SAMS. The organisation supports some 43 healthcare facilities in Idlib province, according to its website. “We have many concerns about the safety of our medical staff,” he added.

Some facilities have been built to survive bombardment. Dr. Ahmad al-Bayoush, who specialises in internal medicine, spoke with TNH earlier this month as missiles flew overhead. His hospital was moved underground, he explained, to protect it from the bombs. 

Still, the hospital has been hit once already and al-Bayoush worries it could happen again: “The missiles are still flying over us,” he said.

‘The psychological pressure is going to kill us’

Those who fled north leave behind dozens of ghost towns in their wake, according to a report published in May by REACH, an organisation that analyses humanitarian data. 

But civilians are still living in southern Idlib; mostly people too poor to afford the cost of transportation out of the area.

And doctors are running low on supplies to treat them, including some basic medicines like antibiotic creams. “There’s a lot we’re running out of, for surgeries [and] for medical exams,” said Diab. “We’re just working with what we’ve got.”

The shortages can be deadly. Last month, a man arrived in the operating room having lost his legs in an airstrike. His stomach had been torn open by the blast.

“We didn’t have enough blood on hand to give him,” said Diab, recalling how the patient died while his wife and children were outside the room. “They were waiting to hear any good news,” he said.

Al-Hamido said the scale of patients’ injuries is so severe there is often little he can do to save them, even when supplies are on hand.

One patient sticks in his mind in particular: a pregnant mother who arrived in the operating room in May, after a bomb left her head riddled with shrapnel. The wounds were too deep to save the mother, so al-Hamido and other staff performed a Caesarean section on her in an attempt to save the baby. Despite their efforts, both the mother and child died soon after. 

“I couldn’t save anyone,” al-Hamido said. “I sat down and cried like a child.” 

“This psychological pressure – it’s going to kill us,” he said. 

As pro-government forces continue bombing the area, he and others say they fear what could be in store for southern Idlib, where they work.

Last month, the Syrian army took the city of Khan Sheikhoun, along a key highway in to the south in Idlib, and doctors worry about their fate if there is a further advance northwards.

They fear further bombs on their hospitals, but also possible government arrest.

Late one night, after a shift at the hospital, Diab told TNH he was determined to stay, regardless.

“What else can we do? There is a lot of bombing still happening,” he said. “We’re staying here. As long as there are still people [getting injured], we’ll continue working.”

(TOP PHOTO: A health centre at al-Zerbeh in southern Aleppo after an airstrike on 30 August 2019.)

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