Attacks on Healthcare are Beyond the Limits of War

In the spring of 2016, the 15 members of the United Nations Security Council adopted Resolution 2286, which had been cosponsored by more than 80 Member States. The issue behind the Resolution, which brought such overwhelming support from a sometimes fractious body, was the increase in attacks on medical staff and facilities in conflict zones. The Resolution was broad, covering attacks or threats against patients, personnel, transportation mechanisms, and medical facilities. It emphasized that such attacks are not only detrimental to those immediately affected, but for the long-term consequences on already fragile health outcomes and systems. Of course, these protections are not new, codified by the Geneva Conventions in 1949 and the Additional Protocols from 1977 and 2005. However, an unprecedented number of attacks on health, many of which were occurring in the same few countries, led to this new push to pressure antagonists to cease their attacks and provide medical and humanitarian personnel with their due protections under humanitarian and human rights law. “Even wars have rules,” said then-UN Secretary-General Ban Ki-moon.

Despite the strong words from the UN and organizations like Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC), little action was prompted by the newfound interest in health-related attacks. As a result, attacks have only increased since the year before the resolution was passed; while there were 256 attacks in 2015, there were 302 recorded attacks in 2016, 322 in 2017, and 149 attacks in the first quarter of 2018 alone. Not surprisingly, attacks in Syria propel the bulk of these numbers, with the Central African Republic, Pakistan, Libya, and Nigeria rounding out the top five countries featuring attacks in 2017. Of course, with the imperfect methods of collecting data in these fragile countries, as well as fears of witnesses or survivors to speak out about perpetrators, it is likely that more threats and attacks exist than can be captured by these data. In fact, as attacks continue and even proliferate, medical workers who risk their lives documenting attacks and their outcomes have questioned whether their work is worthwhile.

In these fragile countries, where access to health care is vital in maintaining a civilian population’s ability to stay, fifty-six health programs were closed due to increased insecurity to the facilities and staff in 2017. Ambulances are destroyed or hijacked. Health workers are arrested or kidnapped. Some countries have attacks that are more specific to the nature of their conflict- for example, the occupied Palestinian Territories, where movement restrictions are common, reported the highest numbers for obstruction to the provision of healthcare. In countries affected by polio, such as Nigeria, vaccination efforts are common targets of attacks. Countries where terrorist groups such as the Islamic State reside see reports of fighters disguised as medical personnel to attack or occupy hospitals. While the mechanism of attack differs, the outcomes are the same: terrorized civilians, diminished health infrastructure, demoralized health workers, prolonged conflict, and a frustrated but ultimately immobilized international community.

Despite these grim reports, there are still actions that can be taken by stakeholders of all levels that can hope to at least minimize these attacks. A two-pronged approach is required: one focusing on investigation and the other on penalties. First, a robust investigation and data collection mechanism must be developed and, most importantly, implemented where needed. MSF president Joanne Liu urged the UN Security Council to conduct robust, independent, and impartial investigations of such attacks, noting that previous calls for such initiatives have been disregarded. In almost all cases where investigations are conducted, they are led and settled by the perpetrator themselves. Independent, well-funded, and rigorous investigations, coupled with new methods of surveying and interviewing witnesses and survivors, should be supported by the UN and civil society in such nations. Additionally, it is apparent that such attacks persist due to the lack of consequences on offenders. Perpetrators on or allied with members of the UN Security Council would be tasked with condemning or punishing themselves and each other, unlikely in the current environment of norms in the international order. While a strengthening of the commitment of states to international humanitarian law is long overdue, in the meantime, action is not necessarily limited to the walls of the UN. Some humanitarian organizations, such as Oxfam, are taking a more direct approach, petitioning states to stop selling arms to countries that have used these weapons to attack civilian infrastructure like hospitals.

Addressing the World Humanitarian Summit in 2015, ICRC President Peter Maurer said “Wars without limits are wars without end. Limiting wars is an intrinsic test of our civilization, and probably of all civilized worlds.” Public health advocates must insist that the international community draws a line on protecting those serving the world’s most vulnerable in the most challenging environments imaginable. While war may be inevitable, the erasure of the human rights of those involved is entirely preventable through collective advocacy and action. Much of the needed action lies at the institutional level, but individuals concerned with these issues can follow social media campaigns like #NotATarget, started by the UN and the theme of World Humanitarian Day 2017, or support NGOs tasked with delivering healthcare in conflict environments, either on the local level or with international organizations such as the ICRC and MSF. Lastly, organizations like Safeguarding Health in Conflict, Insecurity Insight, and Physicians for Human Rights produce data and reports about these issues that can be used to direct advocacy or propel research efforts.