Health Care Under Fire

There is a new medical specialty in Syria. Driven by deliberate attacks on doctors, other medical personnel, aid workers, hospitals, and ambulances, this multidisciplinary field covers mass casualties and severe malnutrition caused by indiscriminate bombardment and blockades of humanitarian aid. Lack of electricity means that operations are often done by the light of an iPhone. Without routine lab tests, pathology services, or imaging beyond X-rays, diagnosis is challenging. Clinical resources—fluids, antibiotics, insulin—are scarce. Without blood banks, transfusions must come directly from donors, often the medical personnel themselves. Triage is redefined as a process of determining not when but whether patients are treated—a calculation of their odds of survival against the use of finite resources. This is siege medicine.

Since the Syrian government’s brutal repression began in 2011, hundreds of physicians have been murdered. Security forces have “disappeared” hundreds more. By 2015, some 15,000 physicians had fled or emigrated. In areas besieged by the government, remaining doctors must practice far outside their original fields. Pediatricians double as emergency physicians, general surgeons do vascular surgery, and dentists handle anesthesia. Under the expedited system of “see one, do one, teach one,” specialists learn from one another, medical residents rapidly develop broad skills, and even students perform amputations. Those who survive the training end up with expertise in war trauma, competence in managing antimicrobial resistance, and familiarity with infectious diseases previously relegated to history books.

In late December 2017 doctors in besieged Eastern Ghouta, a semirural area of 400,000 people ten miles northeast of Damascus, facing mounting child casualties and intolerable life-and-death decisions, issued an urgent appeal to the World Health Organization (WHO). The head of emergencies withheld the letter from the director-general and did not respond. A second letter, to the United Nations secretary-general, also went unanswered. By April 2018 Russian air strikes had destroyed Ghouta’s last hospitals and Syrian troops overran the area, displacing hundreds of thousands, including the surviving doctors.

Systematic attacks on hospitals amplify the harm of war and increase suffering. The effects reverberate widely, spreading terror and driving people to flee. This exemplifies the weaponization of health care—the use of people’s need for health care against them at a moment when that need is particularly acute. This military strategy isn’t limited to Syria—health care has been heavily targeted in conflicts in Ethiopia and Myanmar. Russian forces invading Ukraine are doing it, too.

Attacks on medical personnel have been forbidden since at least 1864, when governments adopted the first Geneva Convention. Since then, international humanitarian law (IHL) has expanded to protect civilians in conflict zones and to uphold the right to receive humanitarian aid. Because attacking health care flouts the core purpose of IHL—to relieve suffering—it has become a sign of broader atrocities.

The growing phenomenon of deliberate attacks on medical workers and hospitals is the subject of Leonard Rubenstein’s Perilous Medicine: The Struggle to Protect Health Care from the Violence of War. Rubenstein, a human rights lawyer and professor at the Johns Hopkins Bloomberg School of Public Health, traces the evolution of international standards protecting health care and examines assaults on them.

He begins with the origins of the Red Cross. In 1859 Henri Dunant, a Swiss banker, traveled to Castiglione in northern Italy, hoping to meet with Napoleon III, who was commanding Franco-Sardinian troops in the Italian war of independence against Austria. Dunant, who desperately needed Napoleon’s help with a business problem, arrived on the day of one of the bloodiest battles of the nineteenth century.

When troops clashed in nearby Solferino in the early hours of June 24, bad planning meant they were forced to fight without food, water, or field hospitals. For fifteen hours, a quarter of a million soldiers slaughtered one another across a front line several miles long. By evening, Solferino was carpeted with tens of thousands of corpses and injured combatants from both sides. Defeated, the Austrians withdrew, leaving thousands of their wounded to die on the battlefield. Thousands of injured French and Italian combatants were lying alongside them, their misery exacerbated by thirst, hunger, and flies.

The French had few doctors and even fewer ambulances. Crates of bandages, water bottles, and tents had been left behind on the docks in Genoa. With four veterinarians per thousand horses but just one doctor per battalion, Napoleon had prioritized the well-being of horses over that of soldiers. Austrian ambulances, packed to capacity, had already left, and the Austrian military physicians who stayed behind to help were locked up in Milan with other POWs.

Dunant’s business trip turned into a humanitarian mission. For the next two weeks he mobilized boys to fetch clean water and bandages and organized shifts of women volunteers to carry the water to dehydrated soldiers and to clean maggot-infested wounds. He turned a large church into a temporary field hospital and assembled French and Italian surgeons to perform mass amputations. He persuaded local residents to give shelter even to Austrians and carriage drivers to evacuate them, bought clean shirts and food for countless men, and distributed tobacco widely, cognizant of the lack of painkillers. Unafraid of blood and bodily fluids, he held soldiers in their last moments.

Back in Geneva, Dunant campaigned for a voluntary society to care for wounded soldiers and an international treaty that would protect such efforts. After friends encouraged him to put his proposals in writing, he self-published A Memory of Solferino, describing in detail the battle and its appalling aftermath. Positively received in France, it was soon translated into German, Dutch, and Italian.

In February 1863 Dunant and his allies cofounded the first incarnation of the International Committee of the Red Cross (ICRC). Dunant’s proposals gathered momentum after Charles Dickens published several excerpts of A Memory of Solferino in his magazine All the Year Round. That October representatives from fourteen governments and other delegates attended the Geneva International Conference to Study Ways of Overcoming the Inadequacy of Army Medical Services in the Field. One of them, Florence Nightingale, who had worked in military hospitals during the Crimean War, wasn’t convinced, arguing that voluntary humanitarian societies would only encourage governments to shirk their duty to care for the wounded. Rubenstein notes that her views were dismissed with more than a hint of misogyny.

In 1864 the Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field was signed by all major European powers. In 1865 Britain and Turkey, then the Ottoman Empire, joined. The Ottomans’ accession surprised the committee, which had assumed that only Christian belief could be a motive for relieving human suffering. In fact, Islamic humanitarian law predated the convention by a millennium. Efforts to reduce the worst effects of war appear across all religions and throughout history. Dunant’s contribution was to codify these doctrines into a single treaty and persuade governments to adopt it. In 1882, after strenuous lobbying by Clara Barton, known as “the American Florence Nightingale” for nursing soldiers during the Civil War, the US government finally ratified the convention.

The convention was adopted at a time when medical intervention could do little to change the course of war. Most soldiers (and civilians) died from cholera, typhus, pneumonia, and malaria—infectious diseases that doctors struggled to treat. If injured soldiers survived the battlefield, they usually succumbed to sepsis. Amputation was the only treatment for gangrene. Since the likelihood of injured soldiers returning to combat was remote, medical neutrality didn’t pose a threat to military efforts.

Yet the second half of the nineteenth century brought huge advances in medicine and public health. In 1853 John Snow’s successful delivery of Queen Victoria’s son Prince Leopold using chloroform created confidence in its anesthetic powers. Nightingale’s approach to infection control during the Crimean War—improved sewage, clean water, and handwashing—drove reform of British military medicine and public hospitals. In 1861 Louis Pasteur published his germ theory, and in 1864 its application by the British physician Joseph Lister transformed surgery. The development of orthopedic splints reduced the need for amputations and fostered advances in reconstructive surgery.

Contrary to the requirements of the Geneva Convention, these improvements provided a military rationale for depriving enemy troops of treatment, and the incentive to use the Red Cross symbol as a bull’s-eye. For example, the German air force torpedoed several British hospital ships during World War I. In 1935–1936 Mussolini’s military campaign in Ethiopia included seventeen air strikes on clearly marked hospitals and ambulances. International outrage forced the League of Nations to investigate, but it took no action. Hospitals in conflict zones removed their Red Cross flags.

The more than 70 million dead in World War II included twice as many civilians as combatants, many of them victims of indiscriminate bombing. Global concern over the participation of Nazi doctors in eugenics and methods of mass killing led to the creation of the World Medical Association. Its first act was to update the Hippocratic Oath to impose a humanitarian duty on doctors to provide care in any emergency.

The International Health Organization of the League of Nations reinvented itself as the World Health Organization and took on health as a human right. In 1948 the Universal Declaration of Human Rights included the right to medical care. In 1949 the Fourth Geneva Convention expanded protection to civilians and redefined attacks targeting medical care as a war crime, not just a violation of humanitarian law.

Despite these protections, violations continued. The Biafran war in Nigeria in the late 1960s was significant for the bombing of several ICRC hospitals and the founding of Doctors Without Borders. American protests against the Vietnam War and civilian harm added impetus to the ICRC’s campaign for the 1977 Additional Protocols, which strengthened civilian protections and specifically prohibited punishing physicians who provided impartial care to perceived enemies.

Throughout the civil war in El Salvador, between 1980 and 1992, doctors were arrested, abducted, and killed. In areas held by insurgent groups, the Salvadoran government withheld essential medicines, obstructed aid, and impeded vaccination campaigns. Yet it was not until the conflict in Bosnia that WHO displayed any awareness of this issue. Following an urgent request from the UN Refugee Agency, in September 1992 WHO sent a mission to Bosnia. By then, Serbian forces had destroyed 30 percent of Bosnia’s hospitals and killed some four hundred medics, and Sarajevo was under siege. In 1993 a World Health Assembly (WHA) resolution finally condemned the attacks but took no further action.

Bosnia was Rubenstein’s first experience of war. In 1996, when he became the director of the US group Physicians for Human Rights, his first duty was to travel to Sarajevo to release its report describing these atrocities. A dozen reporters showed up at the press conference, but the report received little international coverage. He recounts:

The lack of attention was my first lesson among many to follow, that assaults on health care in war were widespread, but…addressing them was not a global health, diplomatic, or human rights priority.

Attacks on hospitals and clinics in Rwanda, Burundi, Chechnya, and Somalia—all described in Rubenstein’s book—also provoked little response. He notes the paradoxical contrast over the next decade between the increasing investment in global health security, such as the 2005 International Health Regulations, and the international indifference to the growing problem of violence against medical workers, aid workers, and UN personnel.

The most extreme example is Syria. After the Syrian government violently responded to peaceful protests on March 17, 2011, injured protesters could not seek treatment without facing arrest from security forces embedded in public hospitals. Ambulances attempting to respond to massacres were ambushed and doctors were murdered. Government forces also targeted the paramedics of the Syrian Arab Red Crescent, the country’s branch of the Red Cross. Checkpoints were set up to stop anyone from smuggling lifesaving medicines to clinics providing care to protesters. The Ministry of Defense confiscated blood bags.

In 2012, after the violence escalated into fully fledged armed conflict, Syrian doctors adapted to the government air strikes targeting hospitals, clinics, medical laboratories, and blood banks by moving facilities into basements and caves, eventually building entire hospitals underground. Beginning in 2014, Syrian Ministry of Health officials “deleted” critical medicines and surgical items from lists of approved aid from UN convoys to besieged areas, depriving millions of civilians of essential medical supplies.

After Russia entered the war in September 2015, attacks on medical facilities and personnel escalated, despite the UN Security Council resolution in May 2016 condemning them. In September 2016 Russian forces bombed a thirty-one-truck humanitarian convoy just outside besieged eastern Aleppo. In April 2017 a carefully orchestrated attack on the town of Khan Sheikhoun illustrated this exceptionally cruel strategy. Conventional bombing designed to drive people into basements was followed by air strikes with chemical weapons, which tended to seep into those basements. When survivors sought medical care, the Russians tracked their movements to the carefully hidden Al Rahma hospital and then either gave its coordinates to the Syrian air force or bombed it themselves.

In February 2018 the Russian air force began its campaign to break Eastern Ghouta by bombing twenty-five hospitals in four days. Yet in September of that year, ignoring the evidence of hundreds of intentional attacks on health care facilities, the UN Office for the Coordination of Humanitarian Affairs (OCHA) pursued a “deconfliction strategy” in the northwestern city of Idlib. Under heavy pressure, Syrian doctors provided OCHA with the coordinates of the facilities that they had carefully hidden underground, which OCHA then gave to Russia, convinced that this would deter its attacks. As Rubenstein describes, Russian forces then targeted them precisely.

The Syrian and Russian governments also targeted public health measures: when polio reappeared in mid-2013 after an eighteen-year absence, it was the consequence of withholding vaccines from areas deemed politically hostile. WHO and UNICEF explained the outbreak as the result of conflict, though neighboring Iraq remained free of polio over eight years of war, until it spread to Baghdad from Syria in 2014. In 2017, during an outbreak of vaccine-derived polio, a sign of long-standing undervaccination, a Russian missile attack on a vital vaccine hub in Deir Ezzor destroyed 150,000 vaccine doses. The two outbreaks crippled well over one hundred children. Along similar lines, the government withheld chlorine for water treatment, facilitating the return of typhus, hepatitis A, and other waterborne diseases (including polio). These actions amounted to passive biological warfare.

Systematic attacks on health care also feature in contemporary conflicts in Ethiopia and Myanmar, both of which have unfolded since Rubenstein finished his book. Tigray, Ethiopia’s mountainous northernmost region, is home to around six million people. Conflict erupted there in November 2020 following simmering tensions between the Ethiopian government and the Tigrayan People’s Liberation Front (TPLF), the political party that effectively ruled the country from 1991 until 2018, when Prime Minister Abiy Ahmed took power. Abiy promised a free press and free elections in 2020, and made peace with neighboring Eritrea, for which he was awarded the Nobel Peace Prize in 2019. In March 2020, citing twenty-five reported cases of Covid-19, Abiy postponed the elections. Tigrayan officials rejected the indefinite delay and held their own regional election, winning overwhelming support.

In response the Ethiopian government invited in the Eritrean military and closed access to the region. Ethio Telecom, the sole provider, shut down Internet and cell service across the whole country (a private network was maintained for governments and close allies). Homes, hospitals, schools, and other public infrastructure were bombed. Government and allied militia troops massacred hundreds of civilians, burned crops, destroyed food stores, and raped tens of thousands of women and girls.

Following the capture of towns in Tigray, troops systematically looted hospitals, health care centers, and pharmacies, and destroyed medicines and essential equipment. Hospitals were occupied and ambulances seized. These attacks appeared designed to deprive the civilian population of access to care.

Pregnant women and survivors of sexual assault are especially harmed by the destruction of health care. Because of a lack of ambulances and tight restrictions on civilian movement, women with difficult labors cannot get medical help. The mass rape and violence committed by Eritrean and Ethiopian forces in Tigray have been exceptionally cruel—women have been sexually tortured and mutilated with the aim of not just humiliation but sterilization. The consequences are physically catastrophic as well as socially devastating.

In June 2021 Tigrayan forces mounted a successful counteroffensive and retook part of the region. Federal authorities as well as regional governments in Afar and Amhara severely restricted humanitarian aid and permitted only a fraction of needed food aid. In August Tigrayan defense forces looted at least one hospital in Amhara. In northern Amhara in late August and early September, Tigrayan soldiers raped dozens of women at gunpoint. In September, the government approved an EU airdrop of food and nutrition supplements but removed all medicines. No trucks carrying humanitarian supplies were able to enter Tigray between December 15, 2021, and April 1, 2022.

In Myanmar, a military coup in February 2021 set off protests across the country. As in Syria, the junta met peaceful demonstrators with brutal repression, detaining, shooting, and killing unarmed civilians. Physicians have been targeted both for their support of the antijunta movement, including joining prodemocracy protests and strikes, and for treating injured civilians.

The junta has been responsible for 95 percent of attacks against health care workers and facilities. From the time of the coup to March 31, 2022, government forces arrested 564 health workers, killed thirty-six medics, and raided 126 hospitals, occupying at least fifty-six of them. In November, eighty medical personnel were detained. Eight of these arrests were of female medics associated with the anti-junta movement. Another medic was shot at close range, execution-style. On Christmas Eve, thirty-five civilians, including women and children, were burned to death when government troops set fire to vehicles, one of which was clearly marked Save the Children.

The junta diverts Covid-19 vaccines and treatment to military personnel and has been using them as bait. Medics are lured by the militia to respond to false Covid-19 emergencies, only to be arrested. In June 2021 the junta arrested a forty-five-year-old surgical lecturer at Mandalay University of Medicine, accusing him of having ties to the shadow opposition described by the junta as a terrorist group. After contracting the virus in prison, he was denied timely treatment and died.

In March 2011, at Rubenstein’s initiative, sixteen organizations asked WHO director-general Dr. Margaret Chan “to engage the agency in addressing problems of violence against healthcare.” Chan was receptive, and in her opening speech at the World Health Assembly she condemned Bahrain’s attacks on dozens of doctors. By the fall, Rubenstein had put together a coalition of NGOs and universities to press WHO to collect data on attacks on health care. With the support of the US, in May 2012 the decision-making body of WHO mandated the organization to survey attacks and report on them.

The need for rigorous data collection is emphasized in Abby Stoddard’s Necessary Risks: Professional Humanitarianism and Violence Against Aid Workers. An aid worker herself, Stoddard begins with an account of a lethal attack on her colleagues at the international organization Médecins du Monde in Ruhengeri, Rwanda, in 1997. Heavily armed Hutus held them at gunpoint and stripped the office of laptops and other valuables. Minutes later, the leader returned with an AK-47 and opened fired on the unarmed team, killing three and critically injuring a fourth.

The lack of data on the dangers faced by people working in the field inspired Stoddard to develop the Aid Worker Security Database (AWSD), which collects data directly from nongovernmental organizations and field-based security agencies. Since 1997 the number of attacks on aid workers has increased dramatically, especially in settings of armed conflict, described by Stoddard as the “oxymoronically-termed ‘chronic emergencies.’” Strikingly, international aid workers have a higher rate of violent death than US soldiers and police officers. In 2020 there were more attacks on aid workers than in any previous year.

Like many aid workers, I used to believe that traffic accidents were the greatest risk I faced. Stoddard’s database shows that humanitarian workers have always died primarily from direct attacks. Gunshot wounds are the most common cause, followed by air strikes, often targeting health facilities and aid convoys, as well as double-tap strikes aimed at those rushing in to aid the wounded.

Stoddard’s risk-management strategies include removing logos and branding, which appeal to donors but make offices and convoys easy targets, and addressing needs as the community sees them rather than as headquarters dictates. She emphasizes that persuading warring parties that a humanitarian effort is neutral requires aid workers to show up in affected communities, communicate regularly, and build local trust.

While the importance of trust is indisputable, Stoddard’s limited focus on international aid workers doesn’t address the growing problem of heavily restricted access in contemporary conflicts. In Damascus, the Syrian government controls the movements of all UN and international agency staff, and strongly recommends they stay at the Four Seasons Hotel for security purposes—and for ease of surveillance. Areas not controlled by the government have been too dangerous for international workers for years. The proliferation of aid agencies in Damascus and neighboring countries hides the lack of humanitarian space inside. In 2012 a British surgeon, Dr. Abbas Khan, traveled to Aleppo to work in a hospital. He was arrested at a checkpoint and imprisoned, and his suspicious death a year later—according to the Syrian foreign minister, he hanged himself in his cell—was widely reported.

Yet local health care providers shoulder the greatest financial and personal risks. Stoddard states that in 2018, 80 percent of victims were workers from the area, not expatriates, reflecting the predominance of local staff in most aid efforts.^* By 2020, the figure was 95 percent.

The global “war on terror” has contributed to the erosion of protection for health care and aid workers. Governments may decide that doctors and aid agencies who provide health care in areas controlled by insurgents are terrorists by association. The AWSD shows that the number and sophistication of attacks against aid workers in the Middle East and Africa increased after the US invasions of Afghanistan and Iraq: local populations perceived Western-dominated aid groups and even the United Nations as extensions of the US military effort.

For Rubenstein the elevation of counterterrorism over respect for the laws of armed conflict poses the greatest threat to the protection of medical workers, hospitals, and patients. Prosecuting doctors is done as much to dehumanize as it is to punish. As a pediatrician, I experienced a version of this myself. Beginning in 2002 I did several stints at the Woomera detention center in South Australia, where asylum seekers, mostly from Afghanistan, were held for months or even years while their claims for asylum were processed. On any given day, I might see strep throat, polio, and symptoms of post-traumatic stress disorder like self-harm or somatization. I was not allowed to provide the usual standards of care. For example, instead of allowing medical therapy to manage bed-wetting in (understandably) traumatized ten-year-olds, security guards handed out diapers.

In early 2003, as asylum claims were increasingly rejected on specious grounds, protests were met with tear gas and water cannons. I had to manage teenagers who went on hunger strikes and attempted suicide—neither of which had been part of my medical school curriculum. Eventually, dozens of asylum seekers sewed their lips together in protest. Their awful treatment led me to speak out publicly against the punitive conditions. Woomera was shut down later that year, but a few years after that, Australia expanded its counterterrorism laws to criminalize criticism of detention centers—exactly what I had done.

Russia’s invasion of Ukraine provides the most recent example of violence against health care. An attack on a maternity hospital in Mariupol on March 9 was the first to spark international condemnation. At least three people were killed, and one mother-to-be sustained severe injuries. She needed a C-section in order to save her baby, but the attack made the surgery impossible, and both she and her baby died. Since the invasion began on February 24, Russian forces have damaged, destroyed, or occupied hundreds of hospitals. In the Luhansk region, every hospital is damaged. TB centers have been emptied and patients deprived of treatment. Hundreds of women have been raped.

These attacks, which are part of Russian forces’ broader attacks on heavily populated civilian neighborhoods, are a major driver of displacement. Fourteen million people—one third of Ukraine’s population—have fled their homes in ten weeks. It is a new world record for mass displacement in the shortest amount of time.

A decade after the WHA mandate, WHO’s Surveillance System of Attacks is a huge disappointment. In conflict zones where it does count attacks, there is no analysis of the public health impact—services disrupted, people affected or displaced. In Ethiopia, where the health care system has been destroyed and tens of thousands raped, although WHO’s current director-general, Tedros Adhanom Ghebreyesus, is a strong public supporter of Tigray’s invisible crisis and its victims, it has not recorded a single attack. In Syria, although Russia’s culpability in Idlib was proved beyond doubt, WHO described the attacks as a tragedy. It’s not just WHO—the UN Board of Inquiry report on these events did not name Russia.

As the foremost global health institution, WHO has authority. Yet its euphemistic reporting has degraded international norms and fostered a sense of impunity on the part of the Syrian and Russian governments, encouraging more attacks, as we see now in Ukraine. Attacks are described only as violations, not as war crimes—which they clearly are.

Rubenstein’s and Stoddard’s books show that the fight to protect medical and humanitarian workers is not new, but we are running out of time before it becomes futile. While few are prosecuted for these war crimes, the stigma attached to them remains evident in the effort put into denying them. But as governments increasingly are not held accountable for breaching international law, the stigma is dissipating. Putin’s attacks, should they be allowed to continue, let alone go unpunished, fundamentally undermine the significance of international human law and the justification for the organizations charged with its realization.

We could all take a page out of Dunant’s book. One hundred and sixty years after its publication, A Memory of Solferino is still the most powerful human rights report ever written, emotional but devoid of self-interest or sensational claims of saving millions of lives. His proposals were practical and based on collaboration and shared humanity.

Rubenstein identifies Dunant’s central truth—that the real story of war is suffering. This is the moment to build the infrastructure to safeguard the people who are trying to protect the innocent. Attacks on health care aren’t a niche concern—they are war crimes. The global stakes are high. Underpinning international human rights and humanitarian norms is a basic acknowledgment that these common standards of conduct protect us all. If they are discarded, everyone, not just those in war zones, suffers the consequences.