BEIRUT — Only one health facility remains operational in the Islamic State-held part of Raqqa, serving thousands of civilians trapped in the Syrian city with virtually no emergency services or rescue personnel as the intense U.S.-backed campaign to liberate the city continues, Physicians for Human Rights said Friday.

The New York-based group described as “nightmarish” conditions in the ever-shrinking area controlled by IS militants amid an incessant bombing campaign. The wounded civilians are left under the rubble because civilians fear being struck by further airstrikes. The lone operating hospital is using salt water to sanitize wounds and treatment of traumatic injuries is limited to stopping the bleeding, the group said based on interviews it carried out with survivors, physicians and aid workers from the city.

The U.S.-led campaign, which began in earnest in June, left only the national hospital functioning at reduced capacity, as others were either bombed or closed, the group said according to witnesses it interviewed.

One doctor who escaped in mid-August told PHR he operated out of his home because civilians feared going to the hospital in case it was shelled, or to avoid extortion by IS. Militants from the extremist group administer the hospital, which has been divided in two sections, one for civilians and another for the group’s fighters. Amid the campaign, the last of the hospital’s remaining services were forced underground, providing very basic medical care, PHR said.

In recent weeks, medical supplies dwindled and pharmacies were closed. The doctor finally left Raqqa after two of his colleagues were killed in airstrikes that struck their homes. As he fled, his daughter was killed in a land mine explosion.

“Raqqa is a deathtrap where civilians who have already suffered for years under (IS) rule now also suffer the deadly consequences of the fight against (IS),” said Racha Mouawieh, Syria researcher for PHR.

The U.N. has estimated that up to 25,000 civilians remain trapped in the city, unable to leave either because IS holds them to use as human shields, or because of land mines along the roads and the heavy bombing.

For those who survived escaping the city, the closest health facility is 50 miles away, in Tal Abyad, or 90 miles away in Kobane for a specialized trauma unit. A new private hospital opened in Tabqa, about 25 miles from Raqqa, last week, PHR said.

The group called on parties to the conflict to ensure civilian access to medical care and safe evacuation.

The U.S-led coalition described reports of the violence and destruction around the area’s health facilities as “abhorrent”. It reiterated that “the avoidance of civilian casualties is our highest priority when conducting strikes against legitimate military targets,” but noted that casualties are inevitable in street-by-street battles with militants.

Since the campaign began in June, U.S.-backed Syrian fighters have seized more than 60 percent of the city, tightening the noose on hundreds of IS militants who are fighting to the death for the city, and trapping thousands of civilians with them. The U.N. and rights groups have expressed concern for civilian safety, with one official urging a “humanitarian pause.”

Meanwhile, Russia’s Ministry of Defense said Friday it has killed four IS leaders, including one it described as the group’s war minister, in an airstrike outside the eastern Syria city of Deir el-Zour, south of Raqqa.

Russia has been providing air cover for Syrian President Bashar Assad’s offensive on IS since 2015.

The defense ministry said its airstrike killed 40 militants, including four prominent warlords who gathered for a meeting of IS commanders in an underground bunker outside Deir el-Zour.

Heavy clashes are taking place between Syrian government forces and IS around Deir el-Zour as militants fight to reinstate a years-long siege of the city.

Assad’s troops on Tuesday broke the nearly three-year militant blockade of parts of the city, marking a significant advance against the extremists.

The Russian military named Abu Muhammad al-Shimali and Gulmurod Khalimov as two of the four IS leaders killed in the airstrike. The other two were not named in the statement.

Al-Shimali reportedly headed the movement of foreign fighters into Syria and processed the group’s new recruits.

Khalimov, a colonel who received U.S. training while heading the riot police force in his native Tajikistan, has often been described as the IS’ minister of war. The United States last year placed a $3 million bounty on his head.


Associated Press writer Nataliya Vasilyeva in Moscow contributed to this report.