Hospital down: Attacks on medical neutrality

Hospital down: Attacks on medical neutrality
Comment: In Afghanistan, Yemen, Syria and elsewhere, targeting medical professionals has become a strategy for war, undermining the core beliefs espoused at Geneva, write Andrew Leber and Nicholas Morley.
7 min read
Salvaging international humanitarianism will require concrete action rather than blasé cynicism [Getty]

In 1859, Swiss businessman Henry Dunant came upon the carnage left by the Battle of Solferino in present-day Italy. His horror at the grim spectacle of the dead, dying and wounded led him to promote the idea that care for the wounded in the midst of battle be a priority above and beyond political aims and battle tactics.

In the ensuing decades, Dunant's initial zeal gave birth to a rickety yet expanding sense among the great powers of Europe and North America, that warring nations should subject themselves to some higher code of "honorable" conduct in war, at least when fighting each other.

The norms of war codified in the Geneva Conventions have enshrined the notion that medical personnel be exempt from the grim logic of conflict. No matter how much it might be to their battlefield advantage, signatory nations should not target clearly marked individuals and facilities concerned with care for the wounded rather than targeting the living.

More history than can be recounted here, demonstrates just how often such efforts to reconcile the violence of war and the ideals of humanitarianism have fallen short. No matter how much these conventions have served as a palatable veneer for violence, though, they at least provide a shared moral language for activists and statesmen alike, while forestalling a race to the bottom in terms of military brutality.

Yet at present, a constellation of internationalised conflicts threatens to expose just how flimsy the foundations of this code of conduct are. In Afghanistan, Yemen, Syria and elsewhere, powerful nations, their regional proxies, and their allies have openly targeted medical professionals, undermining the core beliefs espoused at Geneva some hundred and fifty years ago.


Few nations present themselves as guarantors of the present international order and the liberal humanitarianism more than the United States. Still, few countries maintain as strained a relationship between the ideals they claim to uphold and the implications of their foreign policies around the globe.

Few nations present themselves as guarantors of the present international order and the liberal humanitarianism more than the United States

Disputes over the Geneva Conventions are nothing new for US politicians - witness the ongoing saga of the "enemy combatants" held in Guantanamo Bay, unilaterally removed from the Conventions' jurisdiction over prisoners of war by the Bush Administration.

A sharper tragedy took place in Kunduz, Afghanistan last year. There, US Special Forces called in an airstrike ostensibly in support of local Afghan troops that ultimately killed 47 and wounded 30 within a trauma center operated by Medecins Sans Frontieres.

While President Obama issued an apology to MSF for the attack, there has been no independent investigation into the circumstances that led up to the airstrike. A Department of Defense probe cited human error and technical issues but unsurprisingly disagreed with MSF's claims.

Still, the pattern of running roughshod over respect for medical personnel in pursuit of the enemy - strongly suggested in a New York Times investigation of the attack, at least for local Afghan forces - seems all too commonplace. This and other public violations of the norms of war prompted the WHO to issue its first-ever report on attacks targeting health care providers for 2014 and 2015 - with Syria topping the list by a wide margin.

Syria's medical terrorism

The most blatant and appallingly systematic of these violations are those perpetrated by military forces loyal to the Assad regime in Syria.

Since the start of the civil war in 2011, the Assad regime has refused to allow impartial medical treatment of civilians, forcing medical professionals operating in regime-controlled territory to either become complicit in regime torture, retire quietly, or escape to rebel territory.

Once in rebel territory, medical professionals become targets. In 2012 the regime passed a law making it illegal to provide care for suspected "terrorists" and declaring that medical facilities operating in rebel territory were acceptable targets for military strikes.

According to Physicians for Human Rights, over the course of the war there have been 382 attacks on healthcare facilities, 344 of which were carried out by pro-Assad or Russian forces, and 757 healthcare workers killed, 703 of which were in those pro-Assad and Russian attacks.

This trend goes beyond mere collateral damage. It is clear too, that targeting healthcare in rebel territory is now an accepted strategy of war for the regime and its supporters, but both the Syrian government and Russia steadfastly refuse to acknowledge their part in the attacks.

Targeting healthcare in rebel territory is now an accepted strategy of war for the regime and its supporters

In fact, Russia, a permanent member of the UN Security Council, joined a May 2016 resolution that condemned attacks on healthcare workers and reaffirmed that hospitals were sanctuaries from war. The barefaced hypocrisy of such a gesture, while not particularly out of character, is barbaric and a black mark upon international law.

Yemen: Bombs Without Borders

Russia is not alone in its hypocrisy for condemning attacks on healthcare, though, given that the United States, United Kingdom, and France each have a hand in enabling similar atrocities. Coming in a close second behind the Assad regime's campaign of medical terrorism is the Saudi Arabian-led coalition forces' targeting of medical facilities in Yemen since the start of the Houthi uprising in 2015.

Coalition forces are kept well-stocked by arms sales from the United Kingdom and France. The two countries have together sold billions of dollars of bombs, ammunition, and aircraft to the Saudi forces, in flagrant violation of international, EU, and even domestic law. On top of this, the United States provides the coalition with "logistical support", including targeting data and jet fuel.

Coalition forces are kept well-stocked by arms sales from the United Kingdom and France

The resulting haphazard bombardment has led MSF to pull its staff out of northern Yemen's hospitals due to the frequency and severity of attacks by the coalition. This, despite repeatedly meeting with coalition officials and sharing the GPS coordinates of their facilities, unlike in Syria, where hospitals have stopped sharing their coordinates out of fear of deliberate targeting.

A Saudi-led investigation absolved the coalition of responsibility, blaming opposing Houthi militia for making such airstrikes necessary in the first place. With analyses putting 80 percent of Yemen's population in need of immediate aid and the country on the brink of a famine, though, the coalition and its backers cannot afford to have hospitals and medical staff targeted if they ever hope to rebuild the country's shattered communities.

Naming and shaming

Salvaging international humanitarianism will require concrete action rather than blasé cynicism. There can be no better place to start than ensuring the sanctity of medical workers and facilities in the midst of conflict.

Admittedly, concrete action is hard to come by when neither nations with the capacity to project power, nor their ostensible allies seem concerned with international law.

NGOs play an important role in defining and reinforcing such norms. After all, it was the International Committee for the Red Cross which laid the groundwork for the first Geneva Convention in 1864.

We propose what MSF has already called for: an independent investigation into the Kunduz hospital airstrike, and other instances of attacks on healthcare, by the heretofore unused International Humanitarian Fact-Finding Commission.

The Commission is a relatively weak organisation based in Bern, Switzerland, with theoretical but untested powers of fact-finding into international conflicts (as well as internal conflicts, given a bit of shrewd lawyering).

Lobbying its international board of experts to take a more activist stance on key breaches of humanitarian law - beginning with the targeting of medical personnel - would lend a degree of official (and independent) heft to efforts aimed at naming and shaming those who cross the artificial boundaries of our wars, whether in a direct capacity or aiding and abetting others.

The MSF hospital in Kunduz forms a clear starting point. It is an isolated incident in a conflict contained enough that an investigation seems possible, given that journalists have been able to report on the attack and photograph its aftermath.

The US administration would find it difficult to reject a request from the Commission while failing to provide for an impartial investigation on its own, and would have considerable sway over the Afghan government's willingness to consent to an investigation.

Establishing such precedent is a worthwhile investment. Even if many of us live in an era of declining war and violence, credible means of safeguarding or at least exposing attacks on health care workers are unavoidable if we are to prevent what conflicts remain from providing ever-newer definitions of "hell on earth".

Andrew Leber is a PhD student in the department of government at Harvard University, and Nicholas Morley a researcher and graduate of Brown University. Follow Andrew on Twitter: @AndrewMLeber

Opinions expressed in this article remain those of the authors and do not necessarily represent those of The New Arab, al-Araby al-Jadeed, its editorial board or staff.