IV. Attacks on Hospitals
Human Rights Watch documented repeated attacks on two hospitals in the areas visited. In Aleppo city, jets and helicopters launched at least eight attacks on a clearly marked hospital, Dar al-Shifa, in the course of four months, eventually destroying significant parts of the hospital building so that the hospital could not continue to function. In the town of Salma in Latakia governorate, helicopters repeatedly dropped improvised aerial bombs in the vicinity of a makeshift hospital, eventually destroying it on October 15, 2012.
Under the laws of war, hospitals and other medical facilities must be “respected and protected” in all circumstances. Protocol II to the Geneva Conventions, considered reflective of customary international law, specifically provides that all medical facilities “shall not be the object of attack.” They remain protected from attack unless they are “used to commit hostile acts” that are outside their humanitarian function. Even then, they are only subject to attack after a warning has been given setting a reasonable time limit, and after such warning has gone unheeded. The presence of injured combatants does not affect the civilian character of medical facilities. The Rome Statute of the International Criminal Court (ICC) considers it a war crime to intentionally attack “hospitals and places where the sick and the wounded are collected” during non-international armed conflicts.
The repeated attacks on the two hospitals, as well as documented attacks on hospitals and medical staff in other parts of Syria, suggests that government forces deliberately targeted these places because they were hospitals. Information about the presence of opposition fighters in or near the hospital in Aleppo city indicates the need for an inquiry into whether the hospital was being used by opposition for military operational purposes. In any event, no warning was given before the attack, and the attacks caused disproportionate civilian harm beyond any expected military gain, and thus violated the laws of war.
Dar al-Shifa Hospital in Aleppo City 
Between August 12 and November 21, aircraft struck on or in the immediate vicinity of the Dar al-Shifa hospital, the main emergency hospital in the opposition-controlled area in Aleppo city, at least eight times. In addition, government forces launched at least one artillery attack at or in the vicinity of the hospital.
On August 14, Human Rights Watch visited the hospital about one hour after a jet had struck the upper floors of the hospital with at least three rockets, and examined the destruction and remnants from rockets used in the attack. Human Rights Watch also documented a similar attack on the hospital on August 12.
During the August 14 visit to the hospital, doctors told Human Rights Watch that because aircraft had attacked the hospital in the past, they had limited the use of the upper floors to emergency surgery. One of the doctors told Human Rights Watch: “We had just finished surgery and moved to the second floor when the rockets hit. If they had hit just minutes before, we would have all been dead.” After the August 14 attack brought further destruction to the upper floors of the building, hospital staff were forced to receive the wounded and conduct emergency operations on only the two lower floors.
Upon return to the hospital on August 24, Human Rights Watch documented a similar attack on the hospital on August 21. The three attacks on the hospital documented by Human Rights Watch killed four civilians and injured five, including three nurses.
Around 3 p.m. on August 24, while two Human Rights Watch researchers were visiting the hospital, a jet struck a building 50 meters away on a parallel street to the hospital. The direction of the incoming bomb, as determined by the damage to the building, suggests that the jet was aiming at the hospital, but that the bomb fell short. As a result of the attack, the building collapsed, injuring several children. The Human Rights Watch researchers had walked past the house approximately five minutes before the strike. The only Free Syrian Army (FSA) presence they saw in the vicinity at the time of the attack was two armed persons in front of the hospital who appeared to be guarding the hospital. Human Rights Watch was present when rescuers brought several injured children, some as young as five years old, to the hospital after the attack. Human Rights Watch did not see any FSA fighters injured in the attack.
In addition to the four attacks documented by Human Rights Watch, international journalists working in Aleppo city as well as local activists reported that government forces struck the hospital or its immediate vicinity four more times. On November 21, in the last attack, a jet dropped a bomb that leveled a contiguous building, part of the hospital and rendered the rest unusable. According to witnesses, up to 40 people were killed, including a doctor, a nurse, and two security guards at the hospital.
The hospital is located in the al-Sha`ar area, a commercial and residential neighborhood in the northeastern part of Aleppo city. In August, when Human Rights Watch visited the hospital, government and opposition forces were fighting in the southwestern part of the city, about five kilometers away from the hospital.
The hospital is an established medical facility and clearly marked with a Red Crescent emblem on the front. Hospital doctors told Human Rights Watch that government forces had used Dar al-Shifa Hospital until opposition forces took control of the area in late July, so its location and purpose should have been known to the government.
Commenting on the November 21 attack, the Syrian government news agency, SANA, reported that Syrian “armed forces … carried out operations targeting terrorist hideouts in…Dar al-Shifa Hospital in al-Sha`ar area….[This and other] operations resulted in the death of tens of terrorists and the destruction of their weapons and equipment.” Human Rights Watch saw no signs of opposition military activity in or around the hospital building during several visits in August. However, one person with knowledge of the situation in the hospital interviewed in January 2013, told Human Rights Watch that he had seen what appeared to be opposition commanders meeting in the hospital on several occasions after August. Another person said that there was a small group of opposition fighters staying in the building that was destroyed in the November 21 attack, and that about 20 of them were killed in that attack.
The presence of opposition fighters in or in the immediate vicinity of the hospital—beyond those providing hospital security—endangered the hospital, medical staff, and patients and thus constitutes a violation of the laws of war. But this did not relieve the government of its responsibility not to attack a hospital without warning or to take all possible precautions to minimize harm to civilians in attacks. Even if the hospital was being used for military purposes at the time they were hit, which is not evident, the attacks were disproportionate.
Makeshift Hospital in Salma, Latakia
On October 15, 2012, a helicopter struck a makeshift hospital in the town of Salma in Latakia governorate using an improvised aerial bomb, causing significant destruction to the building and forcing the hospital to close and move to a new location.
During a visit to the site, Human Rights Watch documented two other attacks in the immediate vicinity, indicating that the hospital might have been deliberately targeted. One bomb exploded right behind the hospital, hitting a building under construction. Another bomb exploded right in front of the hospital, killing one civilian and injuring seven.
A worker at the hospital told Human Rights Watch:
They had been attacking this area a lot of times because of the hospital, but they were not able to hit it. Finally, on October 5, a helicopter dropped several bombs, one of which hit the hospital. Most of the bombs dropped in Salma land around the square in the center or in the area around the hospital.
Local residents and hospital staff told Human Rights Watch that they were convinced that the government knew about the hospital from informers in the area. Human Rights Watch has not been able to establish, however, whether the government knew that the building was used as a hospital. This should be investigated further.
Local residents told Human Rights Watch that although the FSA sometimes passed through, they were stationed outside the town. The government separately had targeted a police station located about 200 meters from the hospital, according to local residents, who said that it was easy to determine when the helicopters were trying to hit the hospital and when they were trying to hit the police station based on where the bombs landed.
 The Geneva Conventions make use of the term “medical units,” which refers to military or civilian establishments used for medical purposes, such as hospitals and other healthcare centers. See: Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field (First Geneva Convention), art. 18, adopted August 12, 1949, 75 U.N.T.S. 31, entered into force October 121, 1950; Protocol I, art. 8(e).
 Hospital and other medical facilities remain protected objects even if it “is guarded by a picket or by sentries or by an escort” or “the personnel of the unit are equipped with light individual weapons for their own defence or for that of the wounded and sick in their charge.” Protocol I, art. 13 (2)(a & b).
 Protocol II, art. 11; see also ICRC, Customary International Law, rule 28.
 Rome Statute of the International Criminal Court, UN Doc. A/CONF.183/9 of 17 July 1998, corrected by procès-verbaux of 10 November 1998, 12 July 1999, 30 November 1999, 8 May 2000, 17 January 2001 and 16 January 2002, Part 2, Jurisdiction, Admissibility and Applicable Law, http://untreaty.un.org/cod/icc/statute/romefra.htm (accessed December 13, 2011), art. 8(2)(e)(ii) and (iv).
 In December 2012, government forces also struck the National Hospital in Azaz. There were no casualties. Human Rights Watch phone interview, January 15, 2015; see also: “Syria: Air Strike on Market Kills and Injures Scores,” Doctors Without Borders news, January 14, 2013, http://www.doctorswithoutborders.org/press/release (accessed January 30, 2013). For reports about other attacks on hospitals and medical staff, see also: Human Rights Watch, “We’ve Never Seen Such Horror,” pp. 30-34, http://www.hrw.org/sites/default/files/reports/syria0611webwcover.pdf; Human Rights Watch, “We Live as In War,” November 2011, http://www.hrw.org/sites/default/files/reports/syria1111webwcover_0.pdf; “Syria: Security Forces Remove Wounded From Hospital,” Human Rights watch news release, September 8, 2011, http://www.hrw.org/news/2011/09/08/syria-security-forces-remove-wounded-hospital. See also: “Syria: Detained medics tortured and killed amid Aleppo crackdown,” Amnesty International news release, June 26, 2012, http://www.amnesty.org/en/news/syria-detained-medics-killed-brutal-bid-silence-dissent-2012-06-26 (accessed January 30, 2013); “Climate of fear in Syria's hospitals as patients and medics targeted,” Amnesty International news release, October 25, 2011, http://www.amnesty.org/en/news-and-updates/report/climate-fear-syrias-hospitals-patients-and-medics-targeted-2011-10-25 (accessed January 30, 2013).
 For more information about the August 12 and 14 attacks on the Dar al-Shifa hospital, see “Syria: Fighter Planes Strike Aleppo Hospital,” Human Rights Watch news release, August 15, 2012, http://www.hrw.org/news/2012/08/15/syria-fighter-planes-strike-aleppo-hospital.
 Human Rights Watch interview, Aleppo city, August 14, 2012.
 Human Rights Watch interview with hospital staff, Aleppo city, August 24, 2012.
 Footage of the aftermath: [The massacre caused by the shelling of MiG on civilians], video clip, YouTube, August 22, 2012, http://www.youtube.com/watch?v=_yS5SEyOP_Y&feature=plcp (accessed Feb 1, 2013).
 Nick Paton Walsh, “Heart-rending choices in Syrian warzone hospital,” CNN, September 8, 2012, http://www.cnn.com/2012/09/07/world/meast/syria-aleppo-hospital/index.html (accessed January 30, 2013).
 [Aleppo al-Sha`ar neighborhood: building completely collapsed by the shelling of barrels], video clip, YouTube, November 21, 2012, http://www.youtube.com/watch?v=A3XG2YbxLy4&feature=youtu.be (accessed January 30, 2013).
Human Rights Watch phone interview, January 29, 2013.
 Human Rights Watch interview with hospital staff, Aleppo, August 14, 2012.
 Daily Newscast of Syrian TV (video), November 21, 2012, https://syria360.wordpress.com/2012/11/21/sana-headlines-november-21-22-2012/ (accessed January 30, 2013).
 Human Rights Watch phone interview, January 29, 2013.
 Human Rights Watch written electronic communication, January 29-30, 2013.
 Human Rights Watch site visit, Salma, December 16, 2012.
 Human Rights Watch interview, Salma, December 16, 2012.