Indian Journal of Medical Ethics


Healthcare workers and patients as targets and casualties in warfare

Adriaan van Es

Published online first on May 18, 2021. DOI:10.20529/IJME.2019.040.

Leonard Rubenstein, Perilous medicine: The struggle to protect healthcare from the violence of war. New York: Columbia University Press, 2021, pages 416, $35 (Hardcover), ISBN 9780231192460 (Hardcover)

In December 2016, I witnessed the departure of the People’s Convoy from the Chelsea and Westminster Hospital in London. The CanDo campaign, organised by Syrian refugee doctors in the UK, departed with a truck full of hospital equipment and supplies for a 2600-mile journey — travelling through and campaigning in France, Belgium, Holland, Germany, Austria, Hungary, Romania and Bulgaria — to the Turkish border near Aleppo. The campaign, supported by crowdfunding, managed to construct and open the Hope Hospital in Aleppo, and was the response of Syrian doctors to the brutal targeted bombing and destruction of the children’s hospital in Aleppo. The resilient and determined doctors simply did not accept the destruction of the hospital.

This initiative of hope and determination drew attention to the dreadful reality of massive and repeated attacks on hospitals and clinics in Syria, and the systematic violation of the Geneva conventions and human rights standards. A sign of hope that took shape against the background reality of continuing destructive and mortal attacks on health facilities worldwide, a reality that is described in Leonard Rubenstein’s book Perilous Medicine: the struggle to protect health care from the violence of war. Rubenstein is a lawyer with a lifelong commitment to health and human rights. He is a former director of Physicians for Human Rights and is currently a professor at Johns Hopkins Bloomberg School of Public Health in Baltimore. In 2011, he was a founder (and is still Chair) of the Safeguarding Health in Conflict Coalition, an advocacy group that was successful in mobilising the World Health Organization (WHO) to put the issue of violence against healthcare on its agenda.

As the main theme in his book, he describes the principles designed and meant to safeguard medical practice in wartime, and the ongoing failure to respect them. Violent targeting of health workers has become a familiar fact of modern warfare, as the book documents in great detail, and this is an urgent call for policies that effectively defend the protected status of medical premises, personnel and transport.

Rubenstein begins his book with the history of international humanitarian law and the early efforts to establish standards of conduct for the treatment of medical personnel in conflict zones. He describes the approaches articulated in the 1860s — of the German–American Francis Lieber (from his experiences during the Franco–Prussian war, the battle of Waterloo and the American Civil War) and the Swiss Henri Dunant (from his experiences during the battle of Solferino). Both argued that doctors and nurses should be able to treat combatants and civilians regardless of their (political and military) affiliation. Lieber accepted “military necessity”, allowing military commanders to deny enemies access to healthcare in order to weaken them (but forbidding cruelty), while Dunant argued that military considerations should never affect the principle of humanity — the basis of the protection of medical personnel. Lieber and Dunant’s work would become the foundational principles of the Geneva Conventions and Protocols. Rubenstein notes that, unfortunately, Lieber’s “military necessity” would become a frequent feature (and excuse) in many wars to come.

Violence against healthcare in war regularly shocks health workers worldwide and indeed the general public. Images of destroyed hospitals and blown-up ambulances trigger the public conscience, as do movies such as For Sama and The Cave that bring home, in sober but frightening visual language, the despair but also the resilience of health workers in Syria.

However, scholarly research and documentation of abuses of health systems, facilities and personnel, has been scarce, given the huge scale of the problem. In-depth and systematic analysis of violence against healthcare staff and facilities in war is needed. Rubenstein’s book represents an important step towards addressing this gap. A remarkable and welcome feature of his writing is the way in which he includes the personal stories of his many interviewees, their fears, frustrations, ambitions, and their wish to be heard. These voices give Rubenstein’s book an injection of humanity and personality that results in a moving read that profoundly touches the reader.

The book’s central chapters are extensive case studies in which Rubenstein documents various instances of atrocities against health workers around the world. He describes a variety of cases illustrating the practice of denying care to persons regarded as enemies: a Chechnyan doctor trying to protect his “enemy” patient while endangering his own life; population displacements in Myanmar; patients wrongly viewed as part of an armed group and violent searches of hospital wards in Afghanistan.

He notes that in circumstances of armed conflict, health workers were facing medical and political crises. “The motivations of the health workers didn’t matter to the armies or regimes that oppressed them, contemptuous as they were of the obligation they owed to protect and respect healthcare and alleviate the suffering. On the contrary, the forces wanted to increase the suffering of all the people under health workers’ care, whether members of an indigenous ethnic group or members of a political movement, and punish those who got in their way. This attitude would become even more pronounced in the global campaign against terrorism.” (p 91)

Counterterrorism became a global priority at the end of the previous century and produced policies and laws denying healthcare to “enemies” and prosecuting, arresting, intimidating and applying violence against their caregivers. Doctors offering care to alleged terrorists in Kosovo and Turkey were prosecuted. While these practices were initially criticised as violations of human rights, the mood changed, and regimes worldwide, including Western countries, created legislation that criminalised healthcare in the name of counterterrorism. Rubenstein highlights the case of Turkish doctors, who refused to remain silent when witnessing torture and who have been arrested many times and prosecuted on charges of terrorist activity or support, accusations that were systematically levelled against the Turkish Medical Association, and the medical profession as a whole.

Counterterrorist forces are known to have abused medical facilities and personnel in setting out to achieve their goals. A notorious example is the search for Osama bin Laden by the United States’ Central Intelligence Agency in Pakistan. A fake door-to-door vaccination campaign was undertaken to provide cover for the search of bin Laden. This failed but, when exposed, resulted in serious blocking of the previously successful polio vaccination in Pakistan, and in attacks on health workers.

For me, the most depressing chapter in the book is on Syria: ‘Health care as a strategic target’. The chapter describes the disastrous strategies of Assad’s regime, supported by Russian military forces, to attack, kill and maim the civilian population, with airstrikes, cluster bombs and chemical weapons. In the midst of this warfare against civilians is the specific targeting of hospitals and health workers, leaving city quarters without medical aid, traumatising health personnel, creating medical shortages, and impeding vaccination programmes. Rubenstein’s Safeguarding Health in Conflict Coalition and Physicians for Human Rights have documented with painstaking accuracy all these war crimes, crimes against humanity and related human rights violations.

The chapter “Recklessness” points out how “enablers” are guilty in warfare and violence against healthcare. In these proxy wars, suppliers of weapons play a crucial role, as for instance, the war in Yemen and Syria prove.

Obstruction of healthcare, in violation of the Geneva Conventions, is illustrated by many cases in the Israel-Palestine conflict. Checkpoints, barriers and the permit system systematically threaten effective and quick passage of ambulances despite attempts to regulate them. Communication between the Palestinian Red Crescent and the Israeli Defence Force, and agreements between them have more often failed than worked.

A special chapter is dedicated to the threats and violence by non-state actors, from generalised violence against civilians (Liberia) to the difficulties faced by the International Committee of the Red Cross/Crescent (ICRC) in its attempt to create safe havens of healthcare in coordination with the Taliban in Afghanistan, and healthcare in a “caliphate” (Iraq and Syria). Describing how difficult upholding international humanitarian law can be, the book quotes a 2007 al-Qaeda propaganda video that said that “the amount of respect we hold for your international law is even less than you show for our defined Islamic Shariah” and cited “international infidel law” (p 254).

While concluding his book, Rubenstein calls for more and coordinated health activism. He rejects a cynical acceptance of the seemingly “new normal” with its lack of respect for international standards. He highlights signs of hope, such as political mobilisation against arms sales in many countries including in producer countries such as the UK and USA, and the response of Israel, during the second Intifada, to “pressure from monitoring and human rights groups, the media, and its own military officers to enable safe medical evacuation” (p 303).

He calls for more effective and coordinated mobilisation of health activism, domestically as well as globally. Recalling violence against Turkish and Syrian doctors as examples, he reminds the reader that solidarity at a national and international level can work and contribute to wider initiatives to end such violence.

The book does not contain Indian cases of violence against healthcare workers and facilities, but the reader in India will not find it difficult to identify parallels.

Perilous Medicine is a guiding and foundational book that should appear on the obligatory reading list for students and scholars working on conflict and peace studies, human rights, international humanitarian law, but also those in law school and medical or nursing school. The book provides a solid ground and source of information for human rights advocates and NGOs, and challenges governments and international organisations to adhere to standards and policies to protect healthcare from the violence of war. In addition, the book also reaches out to the general (lay) public, and should be read by journalists and media editors.