As the Syrian conflict moves into its eighth year, what was already one of the world’s largest humanitarian crises has only grown worse. As of December 2017, the UN estimated that more than half of Syria’s prewar population had been displaced—6.1 million people internally and 5.5 million registered as refugees in neighboring countries.  In addition, an estimated 13.1 million people were in need of humanitarian assistance, and 2.98 million were in hard-to-reach and besieged areas. Though the UN stopped tracking deaths in Syria years ago due to an inability to keep up with the rapid pace, in February 2016, the Syrian Center for Policy Research estimated the death toll to be 470,000.
Despite multiple attempts at ceasefires and peace talks mediated by the UN, the Syrian conflict continued to be characterized by a disregard for civilian welfare throughout 2017. The combination of attacks on health facilities and personnel, displacement of millions, siege and blockade of humanitarian aid, and the constant threat of injury and death have taken a catastrophic toll on the health and well-being of the Syrian population.
During 2017, PHR verified 38 individual attacks on medical facilities in Syria. Out of these 38 attacks, 34 were perpetrated by Syrian government forces and/or their Russian allies; one by Jaish al-Islam, an opposition coalition based primarily in eastern Ghouta; and three by unidentified actors. PHR also received reports of attacks on medical infrastructure perpetrated by ISIS and international coalition forces but was unable to confirm the reports due to the difficulty of gathering information from ISIS-controlled areas.
The majority of attacks verified by PHR were air assaults: 31 were carried out by air-to-surface missiles and three involved barrel bombs, including one incident in which suspected Syrian government forces dropped a barrel bomb containing chlorine gas on a surgical hospital in northern rural Hama. Russian forces also used high-capacity missiles, such as bunker buster bombs, to break through hospital fortifications and caves built to protect medical spaces. In addition, PHR documented two mortar attacks, one raid, and one additional incident using an unknown weapon type.
Attacks on medical infrastructure in 2017 often occurred in clusters, during which multiple facilities in close proximity to each other were bombed repeatedly within a short time period. At the end of September, for example, PHR documented five aerial attacks on four of the main hospitals in Idlib province over the course of seven days. In one of these attacks, SAMS reported that the hospital was hit by five air-to-surface missiles, severely damaging the facility and rendering it completely out of service.
Attacks occurred most frequently in areas under opposition control. Eastern Ghouta, northern Hama, and southern Idlib were particularly affected, with 31 of the 38 attacks or roughly 81% occurring in these regions. PHR also confirmed incidents in Aleppo, Damascus, Deir Ezzor, and Homs.
While PHR could not verify any facility attacks in Raqqa due to the difficulty in accessing independent field sources, the offensive to release the city from ISIS control devastated its health care system. In September, the city was left with only one semi-operational hospital, which was severely under-equipped after years of humanitarian aid obstructions. Residents were often unable to receive care there due to the intensity of the airstrikes. Those who tried to flee to seek care elsewhere were at high risk of injury from ISIS landmines and snipers.
According to data collected by SAMS in 2017, 41 health facilities in Syria were forced to close permanently or temporarily due to damage sustained in attacks. SAMS data show that at least 20 medical personnel, four administrative staff, and 19 civilians—including seven children—were killed in these attacks and that 45 medical personnel, ten administrative staff, and 127 civilians were injured.
PHR recorded 20 deaths resulting from the 38 individual attacks that the organization verified. The two incidents with the highest fatality counts both killed at least four people. In one case, a high-impact missile suspected to be Russian hit Hama Central Hospital, causing the cave structure that housed the hospital to partially collapse. A mother, father, and daughter who were seeking treatment at the hospital were killed, and some sources reported the death toll to be over seven. In another incident, four medical staff members were killed in a double-tap strike on Shamona Medical Point conducted by Russian or Syrian aircraft.
PHR also documented the deaths of 51 civilian health professionals, including those not killed in facility attacks, throughout 2017: 31 were killed by airstrikes, ten by artillery shelling, three by detention and torture, three by explosions, two by sniper fire, one by chemical attack, and one by kidnapping and execution.
With the absence of accountability or leadership from the international community, attacks on health facilities and deliberate obstructions to humanitarian aid persist in Syria with impunity. Ongoing aerial attacks and the Syrian government’s tightening of the siege on eastern Ghouta have severely restricted access to health care for ~400,000 residents. The approximately 100 remaining doctors face an ever-decreasing supply of medication and equipment, as these items continue to be routinely removed from aid convoys entering the area. SAMS doctors in eastern Ghouta have reported outbreaks of contagious diseases, including salmonella, typhoid fever, measles, tuberculosis, and inflammatory liver due to the continued use of contaminated water sources.
In addition, the end of 2017 was marked by a devastating, dramatic intensification of attacks on medical infrastructure in the so-called “de-escalation zones.” In the first week of January 2018, PHR verified at least six separate attacks on medical facilities in southern Idlib and northern Hama. In one case, Al- Salam Maternity Hospital, the only specialized maternal health facility in Ma’arat al-Nu’man city, which serves a population of 500,000 residents, was bombed by Syrian government or Russian forces. One missile hit the back wall of the delivery and labor section of the hospital, killing a newborn and father and forcing staff to remove premature infants from their incubators.
Given the continued attacks on health facilities into 2018, there is an urgent need for an effective cessation of hostilities and for accountability for these documented war crimes.
 United Nations High Commissioner for Refugees (UNHCR). Syria emergency. Accessed February 12, 2018.http://www.unhcr.org/en-us/syria-emergency.html.
 United Nations High Commissioner for Refugees (UNHCR). Updated February 8, 2018. Syria regional refugee response: Operational portal. http://data.unhcr.org/syrianrefugees/regional.php#_ga=2.75857047.3434193....
 United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA). November 2017. Humanitarian needs overview 2018: Syrian Arab Republic. https://hno-syria.org/#severity-of-needs.
 United Nations High Commissioner for Refugees (UNHCR). Syria emergency. Accessed February 12, 2018. http://www.unhcr.org/en-us/syria-emergency.html.
 Syrian Centre for Policy Research (SCPR). February 2016. Confronting fragmentation! Impact of Syrian crisis report. http://scpr-syria.org/publications/policy-reports/confronting-fragmentat....
 Physicians for Human Rights. December 2017. Anatomy of a crisis: A map of attacks on health care in Syria. http://s3.amazonaws.com/PHR_syria_map/web/index.html.
 Syrian American Medical Society (SAMS). May 2017. Saving lives underground: the case for underground hospitals in Syria. https://foundation.sams-usa.net/wp-content/uploads/2017/05/Saving-Lives-....