Playing By the Rules: How to Address Attacks on Healthcare in Combat

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The last decade has seen a rise in attacks on healthcare workers in areas of conflict. Alongside increasing attacks on civilians, ambulance drivers, doctors, and healthcare support staff also find themselves unwilling targets of modern warfare. Such attacks are a clear violation of International Humanitarian Law as stated by the Geneva Conventions and threaten to destroy our concept of human rights and civility.

As the nature of warfare changes, strategies to enforce the protection of civilians and healthcare workers must be adjusted. Ensuring that innocents are protected and access to health is not hindered must always be a priority.

In May of this year the UN Security Council took the first necessary step in protecting the lives of healthcare workers by adopting Resolution 2286 condemning attacks on medical personnel and facilities. However, until the perpetrators of these heinous acts are held accountable for their actions these measures amount to nothing more than empty words.

The Unites States has an opportunity to set an example of how attacks like these should be addressed. On October 3, 2015 an airstrike hit the MSF-run Kunduz Hospital in Afghanistan killing 42 and injuring more than 30. It has since been discovered that the attack was conducted in error by a US Airforce gunship. While the US government has conducted investigations, acknowledged errors and punished those who were involved, they have been rightly criticized by many for the inherent bias in such investigations and the reluctance to call these attacks crimes against humanity.

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Medical staff after the attack on Kunduz Hospital – photo courtesy of MSF

If “even wars have rules,” as stated by Secretary Ban Ki-moon, then it should follow that all member states should abide by them. Until the US attack on Kunduz Hospital is treated as a crime against humanity and a transparent and independent investigation is conducted there will be no hope for rogue nations, terrorist organizations and other actors to respect these foundations of international law. The United States needs to recognize this challenge and play by the same rules it would readily enforce upon others.

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8 Responses to “Playing By the Rules: How to Address Attacks on Healthcare in Combat”

  1. schan78 Says:

    A very interesting and relevant post. Thank you. Humanity in war is indeed what should be demanded. It seems that the harm done when healthcare workers are attacked is not just limited to the attack itself, but also a knock-on-effect that can occur which deprives patients of their treatment. In war-torn countries, if medical infrastructure is damaged, this isn’t just a loss in life to healthcare workers in such facilities, but the impact is that patients are denied access to life-saving equipment and essential medicines. Particularly in urban areas where people live closely together, there is a very deep connection between infrastructure, public services and communities. Thus, any attacks here have the potential to cause extremely devastating consequences.

    With all the media coverage on this topic e.g. in Syria, Afghanistan, South Sudan and in Yemen, that we see and hear from the news, it seems evident that the working environment can be poor. Resultantly, I wonder at what point do healthcare workers pull out, i.e. migrant and leave? How do organizations such as MSF continually recruit and attract personnel to such dangerous areas? Keeping healthcare workers safe and their facilities protected should be of critical importance. Furthermore, in such war-torn countries, will there be a “brain drain” of educated and professional personnel? Doctors and nurses are much in need and a shortage of talent and of the workforce will only further overburden the healthcare system.

    Today I can certainly see a need for alignment of legislation with obligations under international law, as you have mentioned, along with ethical principles of the medical sector. Thanks again!

  2. atfoxblog Says:

    As a former military medical provider, this topic is near to my heart. Although I never served in a conflict environment, I have friends who provided health care on various levels in Iraq and Afghanistan. Conflict/war zones are always brutal, chaotic, complex and continually stressful environments. Ever changing technology (unmanned drones, long range weapons) brings a degree of inaccuracy, increases the risk of unintended casualties, and makes certain aspects of war ‘impersonal’ due to the ability to attack from a distance. In addition, like in Vietnam, recent conflicts in Iraq and Afghanistan are the antithesis of ‘traditional’ warfare. The enemy is nebulous, widely dispersed, not easily identified and they use unconventional tactics (IEDs, suicide bombers). When you place non-combatants including healthcare providers into this volatile mix, it is a recipe for disaster.

    Constant feelings of fear and fighting for survival (on both sides of the conflict) elevate opportunities for human and mechanical error which can result in the unintentional loss of innocent civilian lives. While the consequences are devastating, the lack of intent removes criminality from these actions. However, intentional attacks on healthcare facilities violate established treaties, protocols, and procedures. As such, they constitute war crimes and need to be addressed through the appropriate international tribunals. Crimes against humanity require that the government is engaging in widespread, systematic attack on a given civilian population and based on this, the attack on Kunduz Hospital is not a crime against humanity. However, if the attack was intentional in any way, then it would be a war crime and the U.S. should be held as accountable as any other country.

    The larger, global issue is how to prevent future attacks on healthcare facilities in conflict ares. We can no longer completely rely on compliance with the Geneva Convention as currently written. Given the changes in how war is fought, perhaps we need to update the international laws regulating protection of patients, providers, and facilities. Improved coordination between the UN, governments involved in the conflict, and aid organizations is vital to protect civilians. Lastly, monitoring and investigating attacks on health care facilities is vital to assess intent, determine accountability, and develop preventive measures.

  3. petertwyugmailcom Says:

    Difficult read, excellent post. Thank you for bringing to light these terrible events. I think that posts such as yours, the formal condemnation of such events by the UN, and global media attention are the first steps towards improving the problem. Once public awareness–and outrage–is aroused, there is a better chance for effective intervention to occur. Regardless of political views, religion, and culture, it is safe to say that the vast majority of humanity will stand unified in opposition to attacks on healthcare workers and their sick and injured patients.

    I really appreciate atfoxblog’s comments as well, for they provide the valuable insight of a former military medical provider. It is easy to see how fear and the drive to survive will increase human and mechanical error leading to the loss of human life (in this case, the loss of the lives of healthcare workers and their patients). I also agree with atfoxblog’s comments that lack of intent removes criminality from these actions…to an extent. There is no question that the job of the military is incredibly difficult; additionally, there is no doubt that great measures are taken to ensure that mistakes are avoided. However, we as a global society need to demand higher and higher standards such that these unintentional deadly events ultimately approach zero. We cannot accept these errors as the unintentional cost of doing business in warfare.

    In the same light, as a proud American, I was saddened to hear about our nation’s role in the deaths at Kunduz Hospital in Afghanistan. Some may disagree, but I would like to believe that every precaution was taken by our own forces to avoid this tragic outcome. I have no doubt that those responsible feel the highest degree of remorse. That said, the world looks to our country to lead; we have a great responsibility to avoid failures like this not only because of the real cost of human life, but also because of the example that we must set for all other nations who engage in war. Furthermore, no matter the truth, rogue nations will twist accidental events such as this in order to justify bloody and violent means. Because of this, I think one part of the solution to this problem is for the U.S. to lead by adopting standards that are even more strict that those provided by the Geneva Convention and to hold itself accountable with complete transparency. Only by being above reproach can we institute true, meaningful change.

    • ynemazee Says:

      Thank you all for your comments – this is an area that I have grown more and more interested in and hearing all of your comments helps me refine my thoughts further. And atfoxblog is correct regarding crimes against humanity and war crimes – thank you for clarifying that error.

  4. mvessblog Says:

    This is an important topic and it is helpful to have open dialogue and to understand different vantage points. I, too, am impressed that MSF continues to have volunteers despite the terrible conditions and now the fear of “friendly fire” on top of intentional attacks. There is clearly no easy solution to this problem. Also, I think atfoxblog’s distinction about intention is important to note. I was horrified to hear of the attack and would certainly like to understand the circumstances better, but I can’t imagine that the Kunduz hospital attack was intentional. However, numerous other examples of intentional attacks on hospitals and physicians in Syria1 and other locations warrant more attention to this problem. The UN Security Council Resolution 2286 is at least a step in the right direction. A broader topic to consider is the escalating attacks on medical and other aid workers and volunteers in general.

    1 http://physiciansforhumanrights.org/press/press-releases/aleppo-region-suffers-worst-week-of-hospital-attacks-since-syrian-conflict-began.html?referrer=https://www.google.com/

  5. atfoxblog Says:

    Thank you all for the additional posts. I really appreciate all the different perspectives and thoughts. I completely agree with petertwyugmailcom that ‘we as a global society need to demand higher and higher standards such that these unintentional deadly events ultimately approach zero. We cannot accept these errors as the unintentional cost of doing business in warfare.’ Well said and a goal we should strive to reach.

    As others have said, the attack on Kunduz was terrible and devastating. I applaud those with MSF and other organizations who put themselves in harms way on a daily basis. From what I have read about the Kunduz Hospital situation, in the days prior to the attack, Guilhem Molinie(MSF head, Afghanistan), made the effort to reach out to his contacts with the US Military, Afghan National Forces, US Embassy, USAID, various ministries within the government, and within the insurgency. He provided GPS coordinates for the hospital and confirmed the hospitals neutrality and protected status.

    Given the effort by MSF to ensure their safety, how did the situation go so wrong? Where did communication breakdown? Why did those involved in the attack not receive the GPS coordinate information? Where, when and why did mistakes happen. Only with an intense step by step investigation, similar to that done by the airline industry after an accident, can we begin to understand the Kunduz attack and prevent it from happening again.

    Thanks for the interesting link to hospital attacks in Aleppo. here is one about Kunduz.

    https://theintercept.com/2016/04/28/searching-for-ground-truth-in-the-kunduz-hospital-bombing/

  6. ynemazee Says:

    That is a very good link, thank you for sharing. Harrowing.

  7. aguzmangva Says:

    I appreciate all the excellent point of views presented here. As the geopolitical landscape continues to radically change, it will be interesting to see how international recruitments in the field will keep up with the demand for need. I currently live and work in Geneva, Switzerland, where a large number of international agencies are headquartered. Even in the past 12 months, there has been quite a solemn vibe due to the devastating losses of staff and volunteers who sacrifice everything.

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