Tempers on the Turkish and Russian sides in Syria have frayed once again as warplanes targeted opposition-held areas on Sunday in a country already engulfed by a civil war.
In a conflict that is yet to see face to face confrontation between the pair, Syrians on the ground in the rebel-held northwest usually take the brunt of the proxy battles.
In Sunday's attacks, a woman and a child were among seven civilians killed when mortar rounds hit a hospital in the city of Atareb.
Footage published by the Syrian Civil Defence on social media shows a ward damaged and civil defence rescuers carrying bloodstained patients outside.
"This is systematic aggression by the regime and the Russians. They target civilians and intimidate them into fleeing to refugee camps to depopulate the remaining pockets of resistance," Firas Al Khalifa, spokesman for the Syrian Civil Defence, also known as the White Helmets, told The National.
Ankara blamed Russian-backed Syrian government forces for the attack. But Syria and Russia say they only target militant groups and deny any indiscriminate shelling of civilian areas, or deliberate attacks on hospitals and infrastructure.
Despite the Covid-19 pandemic, government and Russian air strikes continued in 2020, driving almost a million civilians from their homes in Idlib province since December of the previous year.
The UN says this is the biggest single displacement of Syria’s 10-year war and has warned that a full-scale battle – promised by the regime to recapture Idlib – could result in a new “bloodbath”.
Those who have stayed cower in basements to avoid the shelling. Fearing infection with coronavirus in the dilapidated internally displacement camps, some families risk their lives to return home.
“They will eventually escape their neighbourhoods once again. It’s a vicious circle and years of exile,” said Mr Al Khalifa.
The White Helmets was formed in 2014 to help in medical evacuation, urban search and rescue in response to airstrikes and barrel bombs against civilians.
In another attack on Sunday, Russian jets targeted the Bab Al Hawa area, which is located at the Syrian-Turkish border.
The attack damaged a gas facility near Samada city, in Idlib province, cement factory, and several towns and cities near Syria's border with Turkey. Eyewitnesses say one air strike came close to hitting the densely populated refugee camps in the area.
It's the latest attack on fuel facilities that are an economic lifeline for a region home to more than four million people.
Syrian activists have blamed Russia for a missile strike earlier this month that set dozens of local oil refineries ablaze. Verified footage of the attack was widely shared on social media.
The hospital in Al Atareb was targeted on Sunday even though its operator, a partner of the International Rescue Committee (IRC), said it had shared the locations and co-ordinates with the Russians through a UN system to protect its relief efforts.
The medical facility was so severely damaged that it can no longer be used. The strike was the fifth attack on health care infrastructure recorded so far this year, and brings the total number of attacks on health care facilities to 118 since January 2019, according to IRC estimates.
“Health facilities are protected under international law and should be safe havens in times of crisis, but after 10 years of war this is not the case in Syria. Past experience shows that any sharp rise in attacks on health care in the northwest can foreshadow a new escalation in violence,” the IRC said in a statement.
Such incidents in northern Syria ramp up tension between Turkey and Russia, which back opposing sides in the war.
Moscow intervened in the civil war in 2015 and has a vital military base in the port of Tartus. It controls the airspace with the Syrian army and is determined to keep President Bashar Al Assad in power.
Turkey, which backs the rebel groups that opposed Mr Al Assad, also has vested interests in the conflict. Were Idlib to fall back under Syrian government control, thousands of Syrians would flood into Turkey, which has already taken nearly four million refugees since the start of the war a decade ago.
Ankara is also concerned about a homeland for the Kurds on its borders as Kurdish groups have already declared the establishment of a federal system in territory they had captured from ISIS.
There have been several ceasefires over Idlib in the past. In September 2018, Russian President Vladimir Putin and Turkey’s Recep Tayyip Erdogan agreed to establish a "de-escalation zone."
And in March of last year, another ceasefire agreement was signed by Mr Putin and Mr Erdogan in Moscow on Idlib. Both agreements have not lasted long, while Mr Al Assad in Damascus renewed his vow to recapture “every inch” of Syrian territory.