Violence against hospitals, patients, and healthcare workers is a disturbing but common feature of modern warfare.
The latest Safeguarding Health in Conflict report cites “806 incidents of violence against or obstruction of healthcare in 43 countries and territories in ongoing wars and violent conflicts in 2020, ranging from the bombing of hospitals in Yemen to the abduction of doctors in Nigeria”. At least 185 health workers were killed and 117 kidnapped.
Attacks continue with impunity, as several states fail to act on global commitments and frameworks intended to safeguard medical professionals dedicated to saving human life: UN Security Council Resolution 2286 condemns violence and threats against the wounded and sick, against medical and humanitarian personnel exclusively engaged in medical duties, and against healthcare resources.
The nature of conflict is changing to include more non-state armed groups, yet states remain central conflict actors and are often implicated in attacks on healthcare.
Leonard Rubenstein draws attention to these issues and offers some ways forward in his new book, Perilous Medicine: The Struggle to Protect Health Care from the Violence of War, released this September. With 13 case studies seen through the eyes of health workers, the book reveals the dangers they face during conflict and critically discusses the legal, political, and moral struggle to protect them.
Rubenstein, a human rights lawyer focused on the protection of health in armed conflict, sat down with The New Humanitarian to talk about his book, and about what needs to change to better protect those who work so hard to save life during conflict, often at the risk of their own.
This interview has been edited for length and clarity.
The New Humanitarian: What motivated you to write this book?
Leonard Rubenstein: I have been working on this problem for about 25 years, starting back in the 1990s. My first exposure was the war in Bosnia, where I heard stories of what it was like to be under siege and under attack. One story in particular struck me. It's a story of a paediatrician who was attending to babies in a neonatal ward who were in incubators. The staff had very little warning that they were about to be shelled, but they got out just in time before the unit was destroyed. They took all the babies out and went to the basement of an adjacent hospital, which was also shelled. There was no water, electricity, or heat. Overnight, nine of the babies died.
“There was no water, electricity, or heat. Overnight, nine of the babies died.”
While that story is, in some ways, uniquely wrenching, in subsequent years when I started looking at conflicts in Kosovo, Chechnya, and Palestine, I saw varying patterns but similar results: Healthcare was under attack, and the world wasn't doing anything about it. So I started engaging in advocacy and further documentation of the problem. I was really frustrated that the world wasn't paying attention. This book is both a review of what I learned, as well as research into what's driving these attacks and what should be done about them.
The New Humanitarian: Wartime violence against hospitals and medical staff has been going on for years, but it has only started receiving concerted international legal and policy attention in the last decade. Why do you think it took so long? And why the spike in interest?
Rubenstein: It's a great question. First of all, I think we have to recognise that there's a narrative out there that this is a new normal. In fact, it is not a new normal. It's not due to, as many people argue, the changing nature of warfare such as internal wars, urban warfare, asymmetrical warfare. It has been going on since the first Geneva Convention in 1864. The problem has been adherence [to the Conventions]. But there was no tracking, and very little attention, no documentation, and very little reporting of the problem for years. And those things only started in the last decade. Before that, attacks on healthcare were found in occasional human rights reports or other kinds of UN reports, but they hadn't gotten onto the global health or human rights agendas. To the extent that the topic was on the humanitarian agenda, it was focused on how humanitarians can improve their own security.
That's obviously important, but the burden of protection and security should not be on the victims, and I thought it was really important to change the discussion. About a decade ago, that started to happen, with the International Committee of the Red Cross’s Health Care in Danger initiative. The Safeguarding Health in Conflict Coalition, which I'm involved in, got underway, and the attack on the Médecins Sans Frontières hospital in Kunduz [in Afghanistan] in 2015 galvanised action at the UN level. It did take a huge amount of effort, and an enormous amount of time, to get it on the global agenda.
The New Humanitarian: Your book argues that the motivations behind attacking the wounded and dying and those who care for them are difficult to determine. How would you explain the logic behind these attacks, especially as they mock the laws of war, as you state in the book?
Rubenstein: What I concluded from my research is that while the Geneva Conventions and their norms are widely embraced and reaffirmed in various forms and resolutions, there's a competing set of norms that combatants often follow. They are very rarely expressed and kind of subterranean, but influence conduct and behaviour.
Paradoxically, these norms derive from thinking that took place the same time the first Geneva Conventions were adopted in 1864. Those competing norms say that while gratuitous cruelty in war against non-combatants is wrong and morally abhorrent, protections can be limited by the need to win a just war quickly. That was the product of the thinking of a man named Francis Lieber, who was extremely influential. At the same time as Henri Dunant was promoting the Convention in the 1860s, Lieber wrote a code for the Union Army in the American Civil War that reflected this view. While his views were not incorporated [into international law], they have, I believe, great influence over conduct.
So, for example, there may be tactical reasons to take over a hospital or store weapons in a hospital or steal supplies to treat wounded soldiers. There may be strategic reasons, such as in Syria, where it has to do with displacement of populations and severing allegiances to rebel forces. There are times, as in the Saudi conduct in Yemen and Israel's conduct in Palestine, where required precautions such as duties of proportionality and distinction, or passage of ambulances are either inconvenient to comply with or take a lot of work.
Of course, the most prominent example is the resistance to providing impartial care to enemies, one of the foundations of the Geneva Conventions and the principle of humanity on which they’re based. But combatants don't like it, and you see this play out in different ways: combatants being denied care or killed, health workers being arrested or punished for treating the wounded, or in counter-terrorism policy, which criminalises healthcare to alleged terrorists. So I think these competing norms help explain the pervasiveness of violence.
The New Humanitarian: Have you observed any differences in the ways that combatants act out these competing norms with regard to women versus men? Are there any gender differences?
Rubenstein: Unfortunately, as I say in the book, there's so little research in this area and even less on the gender dimensions of the violence. You know, in many countries, [female] nurses are frontline health workers, and in many cases women make up the majority of health workers. We do know, for example, women are the predominant community health workers, and are often targeted for assassination during vaccination campaigns. We don't know the extent to which this is gender-related or just vaccination campaign-related. We really need to explore this issue in greater depth, because there's so little attention to the gender dimension.
The New Humanitarian: In the book, you give several examples of instances where available data didn’t lead to tangible action by authorities. Why, in your view, is there so little interest and concrete action in this problem, except when what you refer to in the book as “spectacular” violence is involved?
Rubenstein: This is a major political issue. Impunity has as much to do with the continuation of the violence as any other factor. And not only are there no consequences in terms of discipline and individual accountability, but there are no consequences on the global policy level, either. For example, the massive British and American arms sales to the Saudis for their bombing in Yemen – known to have killed mass numbers of civilians and described as war crimes – continued well after the information was available, because of political, economic, financial, diplomatic reasons. We see too that the Saudis succeeded in not renewing the Special Expert Committee of the Human Rights Council to continue to investigate violations of international law in the war.
So we have problems at both the military level and at the policy level. After Security Council Resolution 2286 in 2016, in which signatories made commitments to increase accountability to reform law and military practice, there has been very little, if any, implementation of the commitments.
The New Humanitarian: Out of 13 cases discussed in the book, you say that Syria stands out for the “sustained, ruthless, and relentlessly destructive campaign” by Bashar al-Assad’s government against hospitals and health workers since 2011. So, following on from what you just said about Yemen and the politics of this, why were these attacks allowed to go on for so long and with so little impunity?
Rubenstein: Well, there was major political paralysis on Syria, which was exacerbated by the structure of the UN. There have been many attempts to refer Syrian cases to the International Criminal Court, but because Russia and China have a veto over these referrals and the Security Council, there was no action taken. At the same time, there was unwillingness to take action on protection that might go beyond humanitarian aid, and that's controversial. The idea of safe zones or protection zones remains controversial because behind it is the threat of military intervention, which we know is quite problematic in many cases. But there was really no serious discussion of those kinds of steps. And while there were sanctions and other actions against al-Assad, as a whole, the international community utterly failed to take any action regarding Syria, and so the impunity has continued.
“The idea of safe zones or protection zones remains controversial because behind it is the threat of military intervention, which we know is quite problematic in many cases.”
The New Humanitarian: What informed your choice of the war cases covered in the book?
Rubenstein: The case studies are intended to illuminate different aspects of the drivers of violence. I chose cases to show those differences, and also the differences in response and what could be effective in changing the dynamic. For example, in 2002, during the Israeli-Palestinian conflict, after killing Palestinian medics, Israeli Defense Forces changed their practices to make ambulance evacuation safer. That dissipated over time as the politics changed. I wanted to show the different kinds of events, drivers, logic, and responses so that we could do better in responding to different cases.
The New Humanitarian: What can or should be done to step up action to prevent hospital attacks in conflict and to respond more comprehensively to them when they occur? What needs to change?
Rubenstein: The 2016 resolution that I mentioned provides a template that can be applied in many cases, but their recommendations have to be followed. Militaries have to change their operational practices in the field, whether it's targeting, or hospital searches, or checkpoint practices. And that would make a huge difference, because it’s the less visible events which are probably more likely to cause more deaths and injuries than the more spectacular attacks. Of course, there has to be training of troops to go along with the changes in practice in the doctrine.
“It’s the less visible events which are probably more likely to cause more deaths and injuries than the more spectacular attacks.”
There have to be both domestic and international investigations and accountability. That has been talked about, but is almost entirely absent. Critically, there has to be support for health workers who are at risk. They're out there alone and they get very little support… They suffer enormously both the trauma of the violence and also the moral distress from not being able to do their jobs. So we need to support local health workers – not just humanitarians – as they bear the greatest brunt of the violence.
The New Humanitarian: Where do you see things going from here if attacks on healthcare during war are allowed to continue with impunity?
Rubenstein: I think they will just go on and on because whenever we see a new flare-up in violence, for example this year in Tigray or Myanmar, or in Gaza, we see attacks on healthcare.
One of the problems has been the limited constituency for protection which has been limited to humanitarian, human rights, and peace groups. We have to enlarge the constituency to the entire global health community, because apart from the individual deaths and injuries from the violence, the violence destroys healthcare systems. That constituency, as well as medical nursing and public health organisations that haven't taken it up, could have some influence.
“We have opportunities to change the dynamic, but without those new sources of pressure, and engagement, I think it will just continue as it has.”
We need to see more engagement from ministries of health. There have been some wonderful examples: Health Minister Pierre Somse in the Central African Republic has literally put his life on the line to try to do more to protect healthcare in his country in its war. So we have opportunities to change the dynamic, but without those new sources of pressure, and engagement, I think it will just continue as it has.
The New Humanitarian: Any last words?
Rubenstein: There's a myth out there that health workers are martyrs, but they don't want to be martyrs. They're suffering enormously, and they deserve more than celebration for martyrdom. They deserve protection. And it’s a tremendous abdication of global responsibility not to provide it.
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