What Assad and Putin are doing in Syria "is not counter-terrorism. It is barbarism.”

One of the most disturbing features of the war in Syria — and there are many, many disturbing features of the war in Syria — has been the repeated attacks on medical facilities and personnel by Russian and Syrian government forces.

"Instead of helping get lifesaving aid to civilians, Russia and Assad are bombing the humanitarian convoys, hospitals and first responders who are trying desperately to keep people alive," said Samantha Power, US ambassador to the United Nations, at an emergency meeting of the UN Security Council on Sunday. "What Russia is sponsoring and doing is not counter-terrorism. It is barbarism."

In the past few days, Syrian and Russian forces have launched an all-out assault on the city of Aleppo. According to the Washington Post, "Branches of at least three rescue teams have been hit by airstrikes, and firetrucks and ambulances have been damaged or destroyed."

Last Wednesday, four medical workers were reportedly killed and a nurse critically injured in an airstrike on a medical clinic in a village near the besieged Syrian city of Aleppo. The London-based Syrian Observatory for Human Rights claims the strike was carried out by either Syrian or Russian warplanes.

That attack followed on the heels of a massive bombing of a United Nations humanitarian aid convoy on Monday that killed one aid worker and approximately 20 civilians, and destroyed at least 18 of the 31 aid trucks. US intelligence officials believe Russian forces carried out that airstrike.

These attacks have been the rule, not the exception. There have been 382 attacks on medical facilities in Syria between March 2011, when the Syrian civil war began, and June 2016, according to data collected by Physicians for Human Rights. Of those strikes, at least 344 — or 90 percent — were conducted by Syrian government forces or Russian forces fighting on behalf of Syrian President Bashar al-Assad. These forces have also killed over 700 medical personnel in Syria, according to the group’s statistics.

"When you kill a doctor you don’t just kill them," Widney Brown, director of programs at Physicians for Human Rights, told Reuters’s Helen Coster. "You destroy the lives of people they could have saved."

Had there been just a few medical facilities bombed here and there over the course of the five-year war, one could perhaps be persuaded to believe those were just tragic accidents. But when you get into the triple digits, that excuse just doesn’t fly.

Numbers that large mean the only explanations are that the medical facilities are being inadvertently hit by the Syrian and Russian warplanes carpet bombing much of the country — or that they’re being deliberately targeted.

And, in fact, the UN independent inquiry commission on Syria stated in a report earlier this month that "[t]he pattern of attacks [by the Syrian regime], and in particular the repeated bombardments, strongly suggests that there has been deliberate and systematic targeting of hospitals and other medical facilities during this reporting period."

Targeting hospitals and medical facilities is prohibited under international humanitarian law. So why are these attacks still happening? The answer is twofold: The attacks are effective, and the Russian and Syrian governments know they can get away with them.

Killing the people who are providing aid to your enemies is effective

If you want to completely cripple your enemies and are not concerned with pesky things like basic human decency and morality, bombing hospitals and humanitarian aid convoys is a great idea. After all, they’re providing aid to your enemies. (Never mind the fact that they’re neutral and thus may also be providing aid to your own forces and innocent civilians caught up in the mix.)

How are you supposed to eliminate your enemies or force them to surrender if all those meddlesome doctors keep fixing them up so they can go back out on the battlefield and fight another day? And how can you lay siege to a city if those obnoxious do-gooder types keep bringing in food and medicine?

The more they’re bombed, the more the aid groups suspend their activities or leave entirely, so it’s also successful at making it harder for the outside world to get a real sense of the horrors on the ground. For instance, almost immediately after Monday’s airstrike on the humanitarian aid convoy, the UN announced that it was suspending all aid deliveries inside Syria.

And although many brave and deeply committed doctors and other aid workers continue to provide services despite the dangers, fewer and fewer are willing to risk their own lives to save those of others.

In August, 15 of the dwindling number of doctors left in Aleppo wrote a letter to President Barack Obama explaining how dire their situation is and pleading for him to take action to help them:

"Last month, there were 42 attacks on medical facilities in Syria, 15 of which were hospitals in which we work. Right now, there is an attack on a medical facility every 17 hours. At this rate, our medical services in Aleppo could be completely destroyed in a month, leaving 300,000 people to die," they wrote.

"Unless a permanent lifeline to Aleppo is opened it will be only a matter of time until we are again surrounded by regime troops, hunger takes hold and hospitals’ supplies run completely dry. Death has seemed increasingly inescapable."

So not only does attacking medical facilities and personnel hamper the ability of that one facility and those personnel to provide aid to the regime’s enemies, it also deters people in other areas of Syria from providing aid.

As documented in the UN independent inquiry commission report:

Medical workers, including doctors, dentists, nurses, paramedics, ambulance drivers and laboratory technicians, have been attacked for attending to the wounded. Many have been killed and injured. Others have fled with their families across the Syrian borders, seeking refuge. Hospitals, clinics and ambulances have been destroyed. As a consequence, there has been a severe weakening of health-care infrastructure, particularly in areas of the country not under government control.

"For the regime, withholding access and preventing aid from reaching rebel-held areas is a deliberate strategy to punish and weaken opposition groups and to prevent the creation of an alternative political order," writes Benedetta Berti, a fellow at the Institute for National Security Studies.

"Regulating and distributing basic public goods, from food to electricity, is also used to reward loyalty and further civilian dependency on the regime."

Historically, with a few exceptions, hospitals and medical facilities (and their staffs) have been largely viewed as neutral — and untouchable — by parties involved in conflict. As such, standard practice is for these facilities to provide precise coordinates of their locations to the warring parties to ensure they are not attacked.

In Syria, however, this standard operating procedure has become a liability. Indeed, as Foreign Policy’s Siobhán O’Grady reported, the humanitarian organization Doctors Without Borders (MSF) deliberately tried to hide one of its hospitals in Syria by refusing to give its location to the Syrian government. It didn’t work: The hospital was destroyed in February.

Assad, of course, completely denies any of this is even happening at all.

They know they can get away with it

That’s because Assad believes (correctly) that the world will essentially look the other way even though targeting medical facilities is prohibited under international humanitarian law. As MSF explains:

A targeted attack on a medical facility … can constitute a war crime if it was A) intentional, B) due to negligence stemming from a failure to properly verify the military or civilian nature of the target, C) a disproportionate response to the identified military threat, or D) undertaken without advance warning of an imminent attack.

UN Secretary General Ban Ki-moon denounced Monday’s strike on the aid convoy as a "sickening, savage and apparently deliberate attack." He called for accountability for the perpetrators, describing them as "cowards."

In reality, though, there are very few ways the world can actually hold Assad and his Russian backers accountable for their gross violations of international law. The UN Security Council could, if it wanted to, refer Assad to the International Criminal Court.

The problem is that Russia is a veto-wielding permanent member of the UN Security Council, and since it’s the one helping Assad commit all these humanitarian violations, it’s highly unlikely the country would let such a referral happen. Indeed, Russia has already blocked a draft resolution that would have allowed the UN to refer the case to the ICC.

Strange bedfellows, Syria edition

The Obama administration spent years arguing that Assad had to go, and had to go quickly. The continued rise of ISIS has changed that calculus, though, with Washington making clear that defeating the terror group is its top priority, even though that means forging a de facto alliance with Assad.

The White House would dispute that characterization, but the grim reality is that US warplanes are bombing ISIS targets in Syria, not ones linked to the Assad regime, and funneling weaponry and ammunition to the rebels fighting ISIS, not the ones fighting to unseat the strongman.

Secretary of State John Kerry said that the US would look to closely coordinate its air campaign against ISIS with Russia, which is also bombing the group. Kerry even held out the prospect of the two countries opening up a joint operations center where US and Russian troops could theoretically sit side by side to exchange information.

Left unsaid is that Russia’s primary mission in Syria is ensuring that Assad stays in power — not destroying ISIS. Moscow has already carried out significant numbers of attacks on US-backed rebels opposed to the regime, leaving many in the Pentagon skeptical that Russia will suddenly redouble its efforts against the ISIS. Even if it does, teaming with Russia means at least temporarily accepting that Assad won’t be going anywhere. And that means the strikes on medical facilities are almost certain to continue.

Last Tuesday, Staffan de Mistura, the UN’s special envoy to Syria, said he was "profoundly outraged" by Monday's attack on the aid convoy. The problem is that profound outrage is not going to stop Assad or his Russian backers from continuing their scorched-earth tactics. And so the suffering continues.