By Anne Barnard

New York Times

BEIRUT >> The hospital in the northern Syrian town of Maarat al-Noaman was not just grazed, or damaged, by the airstrikes last week. It was destroyed, taking a direct hit that pancaked its three stories into one, entombing and killing 25 people, including nine staff members.

It was struck at around 9:02 a.m., just as day-shift workers and patients were arriving; then again at around 9:05. As rescuers swarmed around, another explosion struck at 9:45, and another at 9:48. That same morning, two airstrikes hit the National Hospital on the other side of town, which was treating nurses injured in the attack on the first facility.

This detailed account, provided by the director of the hospital, which was supported by Doctors Without Borders, is one example of why many Syrian medical workers in insurgent-held areas and human rights groups believe medical facilities are not just being hit by stray bombs or indiscriminate attacks, but have long been deliberately targeted by the Syrian government and its Russian allies. It is a measure of the deep mistrust that gravely challenges prospects for a truce set to begin Saturday.

“I had the feeling they were trying to kill me,” said the director, Dr. Mazen al-Saoud, 55, in a telephone interview from Maarat al-Noaman, his hometown. “Wherever I went, there was bombing.”

According to Doctors Without Borders, there were 94 attacks last year alone on 67 hospitals and clinics the group supports in insurgent-held areas from northern to southern Syria, destroying 12 facilities and killing 23 staff members. In 2016, there have already been 17 attacks on health facilities, including six assisted by the group.

Russian and Syrian officials deny having ever deliberately targeted civilians.

But allegations over the targeting of medical workers go back much further. As early as 2011, Amnesty International was reporting detentions of health workers who treated injured protesters, arrests of patients inside hospitals, and other practices designed to keep clinicians from treating all patients regardless of what side they were on.

The group Physicians for Human Rights has counted 346 attacks on medical facilities, with 705 staff members killed, since the Syrian uprising began with largely peaceful protests in 2011. It says that more than 90 percent of the attacks were by Syrian government forces or their allies, but notes that insurgent groups, including some supported by the West, have also been responsible for such attacks.

At least 58 health facilities have been hit by ordnance multiple times — including major hospitals like Dar al-Shifa Hospital in insurgent-held Aleppo — several of which were eventually destroyed or forced to close. At least 45 facilities struck were “in isolated areas, far from any other buildings, providing additional evidence of the intentional nature of these attacks,” the Physicians for Human Rights report states.

It also notes a report from SANA, the state news agency, in which the government announced it had targeted a field hospital and killed a number of “terrorists,” including a doctor.

Doctors Without Borders emphasizes that it is not equipped or responsible for assigning blame for the strikes or determining their intention. But, taken together, the reports by a range of medical, aid and human rights groups have documented a pattern of attacks on medical workers and hospital facilities in insurgent-held areas — areas that are generally under attack by Syrian government forces and now by allied Russian forces.

Strikes on hospitals and other civilian facilities have also been documented in Islamic State-held areas that have come under attack by the forces of the U.S.-led coalition. And in recent months, in other theaters of war, U.S. forces have attacked a Doctors Without Borders hospital in Afghanistan and Saudi warplanes hit one in Yemen.

At the very least, Doctors Without Borders and other humanitarian officials say the attacks point to a gross failure of the international community to hold accountable the four out of five U.N. Security Council members — Russia, the United States, France and Britain — that are currently bombing locations in Syria.

At worst, other organizations, such as Syrian opposition groups and civilian advocacy groups, say that many of the attacks are part of a scorched-earth strategy in which the government and its allies are deliberately driving out civilians from insurgent-held areas by destroying hospitals, schools and homes.

The attacks have not only changed the way clinicians practice medicine — sending them to basements and makeshift field hospitals — but also the way Syrians use medical services. Saoud said it was common for patients to try to leave hospitals before they are medically ready, or to refuse to be taken there at all, because of a belief that hospitals are targets.

He recalled one departing patient saying, “I can feel death in this hospital.”

The Doctors Without Borders report tallied 155,000 war-wounded cared for in 70 hospitals it supports, covering only a fraction of Syria. Between 30 and 40 percent of the wounded were women and children, the report said. Since the entry of two more militaries in the fall — the Russians, backing the government, and the French, joining the U.S.-led coalition — the group has also documented a spike in civilian casualties being treated in its facilities.

Doctors Without Borders points out that it has little confidence that disclosing locations of hospitals would protect them, given a Syrian law issued in 2012 that made it illegal to give aid, including medical care, to opposition forces. That is why clinics went underground in the first place.

The mistrust built up during years of attacks on medical facilities has created a conundrum over whether to reveal the locations of hospitals. Russian officials said the Doctors Without Borders hospital may have been hit because it did not disclose its location. But Saoud said the charity had asked the staff members whether they wanted to pass their coordinates to Russia, and after a meeting, they decided against it.

“I am 100 percent sure that they know where we are,” he said. “They have their informants. Imagine if I gave the coordinates and then we were hit. I would be a traitor.”

© 2016 The New York Times Company