Introduction: Syrian regular forces and their allies continued their military escalation on Idlib countryside during April 2018; they not only shelled the residential neighborhoods and educational institutions, but also targeted several hospitals and medical facilities since the onset of the campaign. The most recent was on April 25, 2018, when the Syrian regime helicopter dropped four barrel bombs on the medical center in Kafr Sijnah town, one of which fell directly on the center, causing significant destruction and made it out of service completely.
According to STJ's field researcher, the attack deprived 27, 000 people from services and health care, especially since it was the only center in the town that used to provide its free services to the people. He also pointed out that those who are currently in charge of the center attempt to rehabilitate and reactivate it, and that a preparatory school located near the center was also heavily damaged as a result of shelling the medical center, but no casualties recorded.
The Syrian regime and its allies, through these attacks, deliberately deny all life access from the civilians in Idlib province in order to be a pressure sheet on civilians and on the opposition factions, He added.
Syrian regular forces had already attacked several medical centers and facilities during 2018, and STJ had prepared a report entitled "Attacking Medical Facilities in Rural Idlib Deprives Tens of Thousands Residents from Medical Services", a special report documenting the targeting of "Sham Hospital" in Hass and the 'Blood Bank" in Saraqib during February 2018.
STJ had also prepared a report along with the Syrian Archive and Bellingcat with the title "Six Months On, Medical Facilities in Syria Still Under Fire", the report documents the exposure of four hospitals in Idlib province to airstrikes from January 3, 2018 to February 5, 2018.
Details of the Incident
On May 17, 2015, the Medical Center in Kafr Sijnah was established by several doctors who gathered and decided to establish it in order to provide health care for the townspeople. This idea came after the population grew and estimated about 27, 000 people including the townspeople and the displaced persons. The center provided first-aid health care for the critical and the emergency conditions, and included a maternity section, a pediatric section, a pharmacy and a dental clinic.
Around 1:30 pm, April 25, 2018, helicopters of the Syrian regular forces bombed the center with four barrel bombs. Khalid Hamdawi, director of the medical center in Kafr Sijnah confirmed this to STJ and said,
"Since the beginning of our work in the medical center, we have encountered lots of difficulties because the center was not subsidized and everyone was working voluntarily. After that, we worked on a project to train young cadres who wish to involve in the medical field. However, Apr 25, 2018, a helicopter affiliated to the Syrian regime dropped four barrel bombs on the center and near it; one barrel bomb fell 2 meters away destroying large parts of the center's roof and walls as well as most of the medical equipment within the center, consequently, it went out of service completely. We valued the losses, which were approximately $25,000. Most of the sections were damaged, let alone construction of the building, water tanks and the generators. As a result, we decided to move the medical center to another place in the town temporarily, but actually, it lacked many conditions that should be available when treating patients. We have tried to communicate with many sponsoring and supporting organizations in order to reactivate the targeted center, but we have received no reply until this moment."
An image shows an aspect of the destruction of the medical center in Kafr Sijnah, following shelling it with barrel bombs on April 25, 2018. Photo credit: STJ
The exit of the medical staff for a break half an hour before the incident contributed greatly to the absence of any casualties, Qasim ad-Dukhan, one of the personnel at the medical center in Kafr Sijnah, told STJ and added:
"That day, after I worked uninterruptedly since the morning, I went home to take a break and have lunch; about half an hour after I got home, I heard the sound of a helicopter approaching the town's airspace preceded by an intense hovering, in particular hovering of the reconnaissance aircraft. When I switched on my phone to get information from the news rooms through the WhatsApp, I learned that the helicopter will target Kafr Sijnah. Instantly, I took my wife and children down to the cave "shelter", and only moments later, I heard the sound of consecutive explosions. When I headed to the center after the attack, I was shocked to find it highly destroyed; 90% of the center's walls had been cracked and destroyed, but thank God there were few of the medical staff and visitors at the moment of the attack because most of them had been out for a break. "
A video footage published by the "SY PLUS" network showed moments of bombardment of Kafr Sijnah by Syrian regular forces helicopters Apr 25, 2018.
An image taken from the previous video footage shows part of the bombardment of the Syrian regular forces helicopters on the town of Kafr Sijnah Apr 25, 2018.
An image shows some of the damage affected to the medical center in Kafr Sijnah following the April 25, 2018 bombardment. Photo credit: The Local Council in Kafr Sijnah.
STJ could obtain another testimony from Abdurrahman ar-Rahal, a doctor in the medical center of Kafr Sijnah, who was in the center at the moment of the attack, and in this regard he said:
"That day at 1:30 p.m. while I was at the center with some doctors, we heard the sound of a helicopter; immediately, we went out fearful of being targeted, and we headed to a cemetery near the center. Only a few minutes later, the helicopter cleared its load of barrel bombs on the center directly. After the helicopter left the town's skies, we went to the center and saw the aftermath of the devastation; it had been devastated completely, and the destruction rate exceeded 90 %. It was no longer suitable for treating the injured or the sick, besides many medical equipment have been damaged, such as the Echo device, the projector, the autoclave (hot-air oven), and the pharmacy. We tried to take out the rest of the equipment and devices that were partially damaged and we transported them to a safe place. It should be known that the center was never used for any military purposes, besides it provided professional treatment to the people without any discrimination or racism."
Ar-Rahal continued that the center was the only one of its kind in the town, as it contained a clinic for the treatment of leishmaniasis, a disease that had spread remarkably in Kafr Sijnah during the last period, noting that, following the attack on the center, the number of people affected by this disease increased day by day, particularly that the center was providing services to patients and reviewers for free.
Hamoud aj-Jaras, a native from Kafr Sijnah, told STJ, that when the medical center went out of service, it caused a medical crisis in the town, especially since it was providing good and free medical care to the patients. In this regard, he said:
"At noon on that day, while I was sitting with some friends at home, we heard through the Walkie talkie that a helicopter was approaching the middle of the town especially towards the medical center, which is about 100 meters away from my house. At once, we split up the crowd, and I took my children and my wife to a nearby shelter. After that, I started watching the helicopter approaching the impact site; I was sheltering behind a wall at the moment of dropping those barrel bombs. It was such a resounding sound that shook the town. News of targeting the center was so disturbing to all the residents due to its great importance in treating the injured and the sick, besides it was providing free treatment services, especially with the difficult living conditions that most of the townspeople were experiencing."
An image shows part of the devastation affected to the medical center in Kafr Sijnah after bombarding it with barrel bombs Apr 25, 2018. Photo credit: STJ
Analysis of visual evidence.
 This campaign has begun since October 2017, following Hayat Tahrir al-Sham/formerly al-Nusra Front controlled Abu Dali village in the north east countryside of Hama province on October 9, 2017. However, the Syrian regular forces, supported by warplanes affiliated to the Russian Air Force, were able to restore this village, as well as other villages in the northern countryside of Hama, on December 29, 2017. Furthermore, the Syrian regular forces and their allies could advance towards the south-east countryside of Idlib, and took control of several villages such as Atshan, Khwein and Sinjar on January 7, 2018, with the aim of arriving at the "Abu Duhur" military airbase in the south-eastern countryside of Idlib. According to STJ's researcher, the military operations led the Syrian government forces and allied militias to control the airbase on January 27, 2018.
 Hayat Tahrir al-ham/formerly al-Nusra Front controls Kafr Sijnah.
 Mainly, as a vector-borne disease through bite of infective female phlebotomines (sandflies). L. major is transmitted by Phlebotomus papatasi from the animal reservoir to humans. L. tropica is transmitted by P. sergenti from person to person.
Very rarely, L. tropica through transfusion. Cutaneous leishmaniasis factsheet- World Health Organization