Violence against healthcare in conflict settings: a msf perspective

Exposure to violence is nothing new for MSF. Violence has been present in the places where MSF has worked since the organization was founded more than 45 years ago. In many instances, that violence was the reason MSF was there in the first place. Although the phenomenon is not new, we feel there is a worrying recent trend of systematic and deliberate targeting of medical facilities and personnel in some conflict settings.

The most emblematic attack occurred on October 03, 2015 when 13 MSF staff and 10 patients lost their lives as an American air force plane bombed the MSF emergency trauma hospital in Kunduz, Afghanistan. For over an hour, the U.S. plane raided the hospital’s main building, containing the operating theatre and intensive care unit. While the Kunduz event was unprecedented for MSF, it was not the first time the medical-humanitarian organization was affected by the bombing of a hospital it was running or supporting. In October 2015, 12 hospitals in Syria – including 6 supported by MSF – were hit, and in Yemen the MSF-supported health centre in Haydan was hit and destroyed in a number of airstrikes by the Saudi Arabia led coalition. Outside the Middle East, a hospital operated by MSF in the South Kordofan region of Sudan was directly targeted in an aerial bombing by the Sudanese Air Force on 20 January, 2015. Other shocking events have included the killing of 58 people, including 25 patients, on MSF hospital grounds between December 2013 and June 2014 in South Sudan.

Most of these incidents have both direct and indirect consequences for MSF’s operational capacities and its ability to access and treat patients. Although difficult to quantify, the consequences for patients are dramatic and disturbing as well. Some are too frightened to even attempt to get to a hospital. Others are unable to reach the hospital when they do try to go. In the most extreme cases, patients have been assaulted or, in certain instances, killed in their hospital beds. And when MSF (and other organizations) are forced to suspend or withdraw from their projects, civilians lose what little access to medical care they had.

The specifics of incidents vary but the end result follows a familiar dynamic. The ‘working space’ that MSF seeks to establish in order to undertake its medical-humanitarian work is encroached upon and compromised while the ability of would-be patients to access necessary medical care is impeded, if not completely cut off, often at great cost. The withdrawal of MSF teams and services means local populations cannot access the medical care that many of them urgently need, adding to their suffering, and leading, we believe, to many deaths that might well be avoided.

Protecting medical care in conflict settings

In situations of conflict, international humanitarian law (IHL) grants a special status and specific protection to medical services – medical units, transportation and personnel. Facilities – including hospitals, clinics, pharmacies, and laboratories – are protected from destruction, attacks, and requisitions under the IHL framework first developed more than 150 years ago with the drafting of the first Geneva Convention (1864). Civilian hospitals that are organized to provide care for the wounded and the sick may in no circumstances be the object of attacks. They must be respected and protected, at all times, by the parties to the conflict. Medical personnel must have access to any place where their services are essential to collect and care for the wounded and sick. IHL is based on the agreed notion that civilians and wounded combatants are not part of the conflict. As such, legal frameworks and customary practices protect the most vulnerable (sick and wounded) and the medical personnel taking care of them.

A multitude of provisions aim to protect members of medical personnel in the exercise of their functions. They must be respected and protected at all times and in all circumstances, and no one may demand that they give priority to any person or group of persons, except on medical grounds. Medical personnel may not be punished for their activities, no matter what the circumstances may have been and regardless of the person benefiting from their actions, as long as these actions are compatible with medical ethics. Medical personnel may not be compelled to carry out acts contrary to the rules of medical ethics or to breach doctor-patient privileged confidentiality.

It would, however, be naïve for MSF as well as for other IHL promoters to not acutely realize that war results in brutality towards civilians and providers of essential services. This has been the norm, and it is an undeniable fact backed by the history of humankind and warfare. In many ways, IHL is meant as a mitigating factor against the worst outcomes of armed conflict. Within this pragmatic approach, what MSF does is to try and negotiate a ‘working space’ in which to operate safely in conflict zones. In these negotiations MSF will use every argument conceivable to obtain access to the victims of violence, from IHL to appealing to human values shared across cultures and to the benefits for local populations afforded by the presence and medical assistance MSF would offer. Under this rationale, IHL is thus rather an agreed standard that can be useful as a tool to achieve humanitarian access to populations in crisis and in dire need of healthcare in conflict zones.

Current approaches to tackling the challenge of protecting healthcare in conflict settings should highlight the impact such attacks on facilities and practitioners have on civilians living in conflict zones. International advocacy efforts should not be limited to arguments based on the absence of a hospital for the victims of war, but should also focus on the interruption of routine services such as basic vaccination for children and the availability of maternity services or the drugs required to treat non-communicable diseases. What all attacks have in common is that they deprive vulnerable people and communities of access to medical care and, in so doing, increase their risk of suffering greater harm or even death. They also put organizations like MSF on the defensive, forcing them to react to a situation that is being dictated by others who do not share similar humanitarian objectives.

What to do

Since 2012, MSF has engaged with this issue by undertaking in-depth research and targeted advocacy in order to limit attacks on healthcare in conflict settings and their repercussions on civilian populations. By documenting attacks and speaking publicly about them, MSF’s awareness raising and advocacy efforts complemented that of other actors such as the ICRC, and ultimately led to a resolution by the UN Security Council (Resolution 2286) in May 2016. However, this is only a small step in a long process and there clearly remains a lack of commitment from political and military leaders to respect medical missions, as other attacks in Syria and Yemen have shown since UNSC Resolution 2286 was passed in New York almost 9 months ago.

MSF and other actors cannot successfully tackle this challenge on their own. There is a role for and a clear need for doctors and medical associations to get involved within their own societies, adding their voice and their weight to demand accountability and respect for the basic laws of war. It is only by applying increased political pressure on governments engaged in conflict zones (as the Netherlands is in Iraq), by mobilizing across numerous countries and constituencies, and by raising the political price paid for such attacks that civil society organizations will favourably impact the respect given to providers of healthcare services in war zones. Only by reaffirming that doctors should never be targets can the ability of MSF and others to provide life-saving medical assistance in conflict zones be protected and preserved, thereby offering some semblance of ‘humanity’ in the heart of chaos and destruction.

Further reading

• Abu Sa’da, Caroline Duroch, Françoise and Taithe, Bertrand, Attacks on medical missions: overview of a polymorphous reality: the case of Médecins Sans Frontières, International Review of the Red Cross, Volume 95, Number 890, Summer 2013.
• Cone, Jason and Duroch, Françoise. Don’t Shoot the Ambulance: Medicine in the Crossfire. World Policy Journal, Fall 2013, available at: http://www.worldpolicy.org/journal/fall2013/Medicine-in-Crossfire
• Human Rights Watch “Civilians Struggle to Get Medical Care”, March 2015 available at: http://www.hrw.org/news/2015/03/13/ukraine-civilians-struggle-get-medical-care
• Physicians for Human Rights “Turkey Passes Bill that Criminalizes Emergency Medical Care”, March 2014, available at: http://physiciansforhumanrights.org/press/press-releases/turkey-passes-bill-that-criminalizes-emergency-medical-care.html
• Rubenstein, Leonard and Bittle, Melanie Responsibility for protection of medical workers and facilities in armed conflict, The Lancet 2010; 375: 329-40

PHOTO AYE PYAE SONE / MSF