Medical neutrality in war-ravaged areas is the cornerstone of healthcare provision in conflict zones. However, weaponisation of healthcare – the deliberate destruction or removal of access to healthcare as a means of hamstringing opponents – has emerged as a concerning and common practice in modern military engagements. Medical neutrality was formalised in 1864 with the inception of the First Geneva Convention, which sought to establish a permanent ‘neutral’ agency that would deliver medical aid and services to sick and wounded combatants. There was consensus amongst governments that armed conflict, no matter how violent, must maintain some semblance of compassion and humanity. This recognition was at the core of the message the Geneva Convention sent; that a line must be drawn in war and conflict. Recent years have seen military forces and governments ignore this sentiment, with clear violations of the Geneva Convention, from deliberate bombings and executions of doctors, nurses, pharmacists, medical students, and pharmacy students in Syria and Somalia, for example. Indeed, it would appear that many countries are either implicated in, or turn a blind eye to, atrocities resulting from violations of the Geneva Convention.
Dr Kathleen Thomas has experienced this degeneration in the standard of warfare first-hand. Her story has become a landmark in this field. As an Australian doctor, she was responsible for an Intensive Care Unit at a Médecins Sans Frontières (MSF) hospital in Kunduz, Afghanistan, when it was bombed by an American AC130 gunship in October, 2015. MSF had released the GPS coordinates of their hospital to American forces in the region days prior; their location was known. Repeated air strikes resulted in 42 fatalities, including 12 staff, 24 patients and 4 caretakers, with dozens more wounded. MSF maintains that the attack was deliberate and has called for independent investigations by multiple bodies. One must question why American forces, or indeed any government, would condone the attack of healthcare facilities. Similarly, however, it is important to realise that from a military perspective, this weaponisation of healthcare makes sense: it removes a valuable resource to guerrilla forces, that of neutral healthcare.
Healthcare and conflict in Syria
Syria is now the most dangerous nation in the world according to the Global Peace Index. The Syrian civil war has left much of the country’s population displaced since beginning in 2011. As early as March that year, the country saw its first documented execution of a doctor. Subsequently, the attrition of healthcare in Syria has been the result of direct and violent attacks on health workers, as well as a mass exodus of health workers fleeing persecution. These direct attacks are mostly carried out by pro-government forces, and have manifested as “attacks on health facilities, executions, imprisonment or threat of imprisonment, unlawful disappearance (i.e. kidnapping), abduction, and torture sometimes leading to death” . Of these deaths, shelling and bombing accounted for just over half (55%), followed by shooting (23%), torture (13%), and execution (8%). In addition to health worker fatalities, military forces have also targeted health facilities. This escalated in late September 2015, when Russia intervened militarily to provide support for the Syrian government, with 2016 data showing an 89% increase in verified attacks on healthcare facilities. The Syrian Network for Human Rights documented “289 attacks on medical facilities, ambulances and Syrian Arab Red Crescent bases, 96% of which were by Syrian or Russian forces”. In contrast to the attacks in Afghanistan, such as that of the MSF Hospital in Kunduz, these documented attacks became so blatant that the United Nations (UN) Security Council condemned them in Resolution 2286 on May 2016.
In 2009, Syria had 29,927 doctors, a figure that has fallen by 15,000 due to persecution and war, as reported by Physicians for Human Rights in 2015. This vacuum of physicians has led to the development of gaps and deficits in the skills and numbers of healthcare personnel available to serve the civilian population, which is already under duress from open conflict and aerial bombings. However, a deeper look at this gap reveals a disparity between government controlled areas and non-government controlled areas. In 2015, the non-government controlled region of Eastern Aleppo had a doctor-to-patient ratio of 1:7000; just 5 years prior, the ratio was 1:800. Research from The Syrian Centre for Policy Research has demonstrated a gross disparity in healthcare cover, with 31% of Syrians living in areas with insufficient health workers and 27% living in areas with a complete absence of health workers.
Many medical students in Syria have abandoned their studies, either because there are no longer doctors to teach them, or because there is such an urgent need to replace missing health workers that students are required to provide care. This has amplified the potential for suboptimal outcomes, with inexperienced doctors and medical students forced to practice outside of their scope of proficiency, increasing the risk of complications for patients. Indeed, surgical complications and infections have become more common, potentially reflecting shortcomings in medical training.
Responses to healthcare weaponisation
In the face of these atrocities, what is there to do? In keeping with observations regarding healthcare in conflict zones, particularly in the context of healthcare weaponisation, health policy released by The Lancet and American University of Beirut (AUB) Commission has explored priorities for maintaining and promoting healthcare despite the challenges of conflict. Strengthening accountability with respect to the protection of health workers has been noted as the key priority in combating the surge in violence towards health workers and facilities. Multiple nations and key advocates, such as the UN Secretary General and the UN High Commissioner of Human Rights, have supported and referred numerous war crimes from the Syrian conflict to the International Criminal Court. These attempts have been obstructed by Russia and China, two of the five permanent members of the UN Security Council. Indeed, the UN Security Council has issued multiple resolutions demanding humanitarian access and condemning chemical warfare, the latter of which is particularly pertinent given recent chemical attacks in Syria. However, these resolutions have resounded emptily due to political and diplomatic obstruction. Fouad et al., publishing under the Lancet/AUB Commission, suggest that responsibility falls to the civic society and medical community to bring governments and warring factions to account, and to end war crimes against both health workers and civilians. Groups in the Netherlands, Belgium, Spain, France, and Sweden have already had some success in bringing the agenda of health workers in conflict zones to peace negotiations.
Other recommendations include supporting health workers in conflict zones with resources, and reinforcing their capacity to deliver a wide range of services beyond trauma management. The Syrian conflict has highlighted the short- and long-term complexities of healthcare in conflict zones, and it is not feasible to allow other domains of care, such as maternal and neonatal care, to suffer as a consequence of conflict, or to allow vaccine-preventable endemics to resurge, as has happened in Nigeria.
Institutions, including military organisations, should actively encourage and promote the concept of medical neutrality, and work to minimise disruption to healthcare services. It must also be realised that promoting global solidarity with health workers will help to develop an environment within which protection in times of conflict is more readily achieved. Initiatives such as the Safeguarding Health in Conflict Coalition and the Red Cross’ Health Care in Danger Project should be developed further to prevent targeting of health workers, or at least to facilitate early mobilisation and response to violence against health workers and facilities.
Finally, but perhaps most importantly, more research on health workers in conflict is required, with an emphasis on developing understanding across multiple nations and conflict zones, given the heterogeneity in warfare and its effects on healthcare. Such data will allow governments and organisations to draw precedence for future conflicts, and will lend weight to arguments advocating for the protection of health workers and the civilian populations they serve.
Fighting against this paradigm shift away from medical neutrality is an arduous and daunting task. Even with strong backing from top UN position holders and many governments, offending parties still roam free of retribution and accountability. Despite feeling like a David vs. Goliath battle, the fate of healthcare in conflict relies upon the empathic and moral consideration of medical neutrality, a responsibility which belongs to every health worker, medical student, and civilian.
“The standard you walk past is the standard that you accept” – General David John Hurley (AC).
Michael Wu graduated with a B.Pharm from the University of Sydney in 2012 with a major from the Clinical Excellence Commission focusing on IV to Oral Switch Therapy. Since then, my passions have grown from Infectious Diseases to just about everything. It’s a problem. I’d like to work all over the world at some stage, whether in Trauma or Ophthalmology.
Conflict of Interest
- Shaw M. Geneva Conventions. In: Encyclopaedia Britannica [Internet]. Chicago: Encyclopaedia Britannica Inc; 2004. Available from: https://www.britannica.com/event/Geneva-Conventions. (Accessed March 30th 2017)
- Thomas K. What was lost in the Kunduz Hospital Attack [Internet]. Medecins Sans Frontieres; 2016. Available from: https://www.msf.org.au/article/stories-patients-staff/what-was-lost-kunduz-hospital-attack. (Accessed March 30th 2017)
- Institute for Economics & Peace. Global Peace Index 2016 Report. IEP Report 39. 2016. Available from: http://visionofhumanity.org/app/uploads/2017/02/GPI-2016-Report_2.pdf. (Accessed March 30th 2017)
- Fouad F, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts A, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet –American University of Beirut Commission on Syria. Lancet. 2017. DOI: http://dx.doi.org/10.1016/ S0140-6736(17)30741-9
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- Reports on vital facilities attacked August 2014 through December 2016 [Internet]. Syrian Network for Human Rights. Available from: http://sn4hr.org/blog/category/report/monthly-reports/vital-facilities-monthly-reports/ (Accessed 30th March 2017)
- United Nations. Security Council adopts resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations [Internet]. 2016. Available from: https://www.un.org/press/en/2016/sc12347.doc.htm (Accessed 30th March 2017)
- Annual Report, 2009. Ministry of Health Syria; 2009. Available from: http://www.gov.sy/Default.aspx?tabid=251&language=en-US (Accessed 30th March, 2017)
- Kupferman S. Syria’s neighbors must let doctors practice [Internet]. Physicians for Human Rights. 2016. Available from: http://physiciansforhumanrights.org/press/press-releases/syrias-neighbors-must-let-doctors-practice.html (Accessed 30th March 6, 2017)