Abstract
Health workers in conflict settings strive to provide impartial and consistent care to all parties to the conflict, as well as civilians caught in the crossfire. They are increasingly under attack for this work, despite the legal protections afforded to them by the Geneva Conventions and other international law. Attacks on health staff and facilities may be intentional or inadvertent and can take a range of forms, including sniper fire, abduction, and destruction of infrastructure. APHA recommends three strategies: (1) improving monitoring, tracking, investigation, and reporting of targeted violence against health workers; (2) improving compliance with international law via training and legal reform; and (3) holding perpetrators accountable while removing political and material support for their actions. APHA urges the World Health Organization to expand its monitoring of attacks on health workers and urges the United Nations (UN) and its member governments to investigate politically motivated assaults. With respect to compliance, APHA calls on all parties to conflicts to adhere to the Geneva Conventions, human rights law, and United Nations Security Council resolution 2286. The UN resolution calls for protections of health workers and investigations of all attacks on and interference with health workers. APHA further calls on all nation-states to ensure that their national laws, military doctrine, and training protect health workers attempting to provide impartial care. Finally, APHA urges all public health advocates and organizations to join an international condemnation of attacks on and interference with health services and health workers in conflict settings.
Relationship to Existing APHA Policy Statements
The following policy statements are relevant to the current statement:
- APHA Policy Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
- APHA Policy Statement 20094: Ensuring the Achievement of the Millennium Development Goals: Strengthening US Efforts to Reduce Global Poverty and Promote Public Health
- APHA Policy Statement 20188: Advancing the Health of Refugees and Displaced Persons
- APHA Policy Statement 200030: Preventing Genocide (to be archived)
- APHA Policy Statement 9122: The Impact of Political Violence on Health and Health Services in South Africa (to be archived)
Problem Statement
Health workers worldwide rise to the challenge of serving the injured in their communities (or traveling to serve other communities) when conflict breaks out. They work in settings where it is highly challenging to provide quality care and protect patients, which undermines morale and job longevity. Assaults on health facilities, health workers, and the patients they serve are increasingly common in conflict zones.[1–3] Illegal under well-established international law,[4,5] these attacks compromise the care of patients, obstruct efforts to rebuild health systems after war, and lead to the flight of health workers vitally needed in these settings. Health workers of all kinds (community health workers, vaccination workers, medics, midwives, support workers, nurses, physicians, and many other cadres) are at risk of torture, abuse, kidnapping, injury, and death. Operating under these extreme conditions has implications for their mental health as well.[6]
Monitoring — lack of a robust system to monitor violence against health workers: As in all areas of public health, data are essential to understand the problem, provide a sound basis for prevention strategies, and measure progress toward improvement. Research in this field is not robust, and there is no international research agenda, few standardized approaches, and no reliable funding source. This leaves concerned parties to rely on data primarily from sources outside the scientific community, including journalists, relief workers, and individuals publishing across social media or other informal platforms. Many factors inhibit systematic data collection on attacks targeting health workers: poor reporting by those in the field, bias, insufficient funding for such research, and a lack of developed methods. In addition, multidisciplinary, collaborative, long-term retrospective and prospective studies are absent. Better collaboration between relief organizations and academic researchers has been recommended.[7]
A research agenda would include developing a deeper understanding of the circumstances that lead to attacks, motivations of perpetrators, actions that have been most successful in changing combatants’ calculus in deciding to attack, what works to deter violence against health workers and facilities, and best practices to protect workers and facilities when deterrence is not successful. For example, public health has been advanced by research on similar issues pertaining to gun
access [8] and police violence.[9]
Despite shortfalls in terms of an international monitoring system, some information is available. Attacks on hospitals, health workers, transports, and patients have become a common feature of war.[1,6,7,10–12] Safeguarding Health in Conflict reported 973 total attacks, 167 health workers killed, and 710 injured across 23 countries in 2018.[13] These numbers are worse than previous reports, including reports from 2017,[14] 2016,[15] and 2015,[16] when fewer incidents were recorded; however, these differences may be a product of increased reporting. In addition to health workers, international humanitarian aid workers are targeted.[17]
In 2018, 40 health facilities were destroyed across 11 countries, and 180 attacks that damaged health facilities were reported in 17 countries.[13,18] Aerial attacks, surface-to-surface missile attacks, and armed entry occurred in a number of locations, and some facilities were struck several times.[13]
According to the 2018 Safeguarding Health in Conflict report, at least 93 ambulances or health transports were damaged in nine countries, 20 were stolen or hijacked, and 18 health transports were destroyed. In two countries, improvised explosive devices were placed inside ambulances; in one attack, a suicide bomber detonated a bomb that killed at least 95 bystanders. In 2016, 74 reported events impeded access to facilities or movement of ambulances. Obstruction of access included violence during, blockage of, denial of, or severe delays in passage of ambulances and patients; use of explosives around medical facilities that prevented patients from accessing the facilities; and denial of treatment to sick and wounded people.[15]
Health workers were attacked in a minimum of 23 countries in 2018: Afghanistan, Burkina Faso, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Egypt, Ethiopia, Indonesia, Iraq, Israel/Palestine, Libya, Mali, Myanmar, Nigeria, Pakistan, the Philippines, Somalia, South Sudan, Sudan, Syria, Turkey, Ukraine, and Yemen.[13] In 2017, polio vaccinators were attacked and abducted in Afghanistan, Nigeria, Pakistan, and Somalia.[14] Health workers are abducted on the road, from health centers, and from their homes. It is not always possible to determine whether these abductions were politically motivated or criminal in nature.[19–31]
Compliance — national laws are not consistent with Geneva Conventions: Many countries, including the United States, have made it illegal to offer impartial care when a patient is deemed a terrorist[32]; this use of criminal law is inconsistent with the requirements of medical ethics, the Geneva Conventions, and human rights law. Professional ethics require health workers to provide care to the wounded and sick based on medical need alone, without regard to affiliation or prior acts; governments punishing health workers for adhering to ethical obligations are in violation of international law. As the Geneva Conventions have become customary international law, they apply to all combatants, whether or not they have agreed to follow them (e.g., armed groups such as ISIS).[33]
Accountability — impunity for attacks on health workers: Attacks on health workers generally escape accountability. With weak accountability or leadership from the international community, attacks on health facilities and deliberate obstructions to humanitarian aid persist. For example, a review of 25 attacks on health workers in 10 countries in which a total of 230 people died showed that accountability was frustrated by national or international inaction.[34]
From 2002 to 2016, the United States provided roughly $197 billion in weapons and related military support to 167 countries[35]; this increased to $226.6 billion in 2017, accounting for 57% of the top 100 arms sales agreement that year. An analysis of American arms sales since 2002 revealed that the United States has repeatedly sold weapons to nations engaged in deadly conflicts, and to those with poor human rights records, in cases in which it has been impossible to predict where the weapons would end up or how they would be used.[36] Other nations are also involved in the arms trade industry; the combined arms sales of Russian companies accounted for nearly 10% of the top 100 total in 2017, edging out the United Kingdom as the second largest arms producer over the previous 15 years.[37]
As required by Security Council resolution 2286, the United Nations (UN) and its member states are to conduct “prompt, full, impartial, and effective investigations” of attacks and other forms of interference with health care in conflict settings. While the Geneva Conventions of 1949 (and the Additional Protocols to the Conventions of 1977) mandate the protection of health personnel and their facilities and patients, the only international institution where these protections are processed is the International Criminal Court (ICC). Several key countries, including the United States, choose not to participate in the ICC, however. Furthermore, the Security Council has blocked referrals. Internal investigations within countries can lack both credibility and accountability at the highest levels.[38]
Evidence-Based Strategies to Address the Problem
Monitoring — collecting international data more systematically toward prevention: All organizations engaged in seeking a solution to the problem, including the World Health Organization (WHO), the International Committee of the Red Cross, Medecins Sans Frontieres (MSF), and others, recognize that good data are essential to understand the problem and devise solutions. In 2018, WHO began to implement a surveillance system for attacks on health care workers and facilities.[39] The system was developed using sound epidemiological methods and includes a verification process. However, it covered only eight countries in 2018 and needs to be expanded. Several studies have attempted data collection in individual countries, informing data collection methods while providing important depth and context; examples include the Democratic Republic of the Congo and Somalia,[40] Sudan,[41] and Turkey.[42]
Compliance — reforming law and military doctrine and training: The International Committee of the Red Cross has consulted extensively with militaries and demonstrated that reforming military training and doctrine is key to preventing attacks on health care workers and facilities.[43] The UN Security Council adopted resolution 2286 in May 2016, signifying a global commitment to preventing assaults on health services in conflict areas. The council condemned attacks, demanded compliance with international humanitarian law in armed conflict, and urged member states and the UN secretary-general to take proactive steps toward preventing attacks and holding perpetrators accountable.[44] The secretary-general advised that implementing the resolution would require reforming military doctrine and training, strengthening investigations, and ensuring accountability.[45] Encouragingly, after the 2015 Kunduz hospital attack by U.S. forces, the secretary of defense directed the combatant commanders and service chiefs to take specific actions to mitigate the potential for similar incidents in the future.[46]
Accountability — addressing impunity: Safeguarding Health in Conflict has offered a nongovernmental focal point for the collection, reporting, and analysis of data on an annual basis for several years.[13–16] The group’s reports, which APHA has supported, promote transparency and create visibility for this important problem. As in other areas of public health, there is evidence that building an international consensus among health workers and their professional associations is key to progress.[47]
As the secretary-general pointed out in his advice to the Security Council, arms sales fuel conflict and often lead to attacks on civilians and health facilities.[45] In South Sudan, heavy arms are enabling warring factions to inflict horrific harms on the civilian population. The United States has sought to restrict such arms sales as a means to protect civilians and health facilities but has not succeeded in gaining the necessary votes at the UN to do so.
While the United States urges restrictions on arms sales to regimes it opposes, it is not always consistent with its own policy. Despite the unfolding public health disaster in Yemen, the United States and the United Kingdom have provided billions of dollars in arms sales to the Saudi-led coalition perpetrating attacks on civilians and health workers. It is likely that U.S. weapons were used in an air attack that led to the deaths of 40 children in an attack on a school bus.[48] An evidence-based strategy to slow such arms sales is the 1976 Arms Export Control Act, which created the framework and authority for Congress to cancel arms deals. Furthermore, section 502(B) of the U.S. Foreign Assistance Act prohibits security assistance to states that have shown a “consistent pattern of gross violation of internationally recognized human rights.” As evidence of the capacity of Congress to act, both chambers have voted to end American military assistance for the war in Yemen, consistent with the 1973 War Powers Resolution.[49]
Since the Nuremburg trials after World War II, an end to impunity is one of the most well-accepted strategies to stop violations of international humanitarian law. Prosecutions of war criminals in Bosnia, Rwanda, Sierra Leone, and elsewhere have sent a strong signal that accountability is part of the solution.[50] The ICC, formally established in 2002 with 123 member states, was created to prosecute war crimes, crimes against humanity, and genocide, including assaults on hospitals and health workers. As such, it is a key internationally recognized vehicle to hold accountable violators of international law requiring the protection of health workers.
Nonmembers can refer cases to the ICC, but other UN Security Council members can block referrals for political reasons. Although the United States has never joined the ICC, it has voted for UN Security Council referral of cases involving perpetrators of attacks on hospitals and health workers to the ICC. Unfortunately, these referrals have routinely been blocked at the UN Security Council by China or Russia.[50] For example, Russia blocked a referral of Syria to the ICC, and there has been no accountability for the Saudi-led coalition’s bombing of health facilities and other civilian structures in Yemen. In 2015, an editorial in the New England Journal of Medicine stated that the ICC should hear more cases concerning attacks on health workers.[51] Domestic investigations and prosecutions are also needed and are called for by Security Council resolution 2286. Other mechanisms can be effective as well, such as the listing of persistent perpetrators of grave violations against children (including attacks on schools and hospitals) by the secretary-general’s special representative on children in armed conflict.[52] The “naming and shaming” dimension of this mechanism is considered so powerful that Saudi Arabia threatened to withhold funding for UN humanitarian efforts if it was listed for its bombing of hospitals and schools in Yemen.[53]
Opposing Arguments/Evidence
Some argue that gathering more data, reforming military practice, and holding perpetrators accountable will make no difference in preventing future attacks (although they have not offered alternative solutions). Those who attack hospitals, health workers, ambulances, and other health infrastructure sometimes offer the explanations or aims described below. These excuses are not valid, however, as the law is clear that both intentional and indiscriminate attacks are unlawful.
Acting to protect the country’s interests: According to Physicians for Human Rights, perpetrators of attacks on health workers or facilities sometimes assert that they take these actions because of the notion that a physician who treats my enemy must be my enemy. Treating wounded enemies enables them to return to battle. Sometimes attackers will claim that facilities are occupied by enemy combatants who are either operating or have hijacked the facilities. Others argue that because one side of a conflict does not adhere to international law, the other side is not obligated to abide by it.
But these arguments are directly contrary to the requirements of the Geneva Conventions and the principle of humanity on which they are based. The fourth Geneva Convention protects hospitals and medical personnel unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Furthermore, the Additional Protocols to the Conventions, adopted in 1977, specifically prohibit punishing health workers who are acting in accordance with their ethical obligations, no matter the recipients of their services. Finally, the obligation to obey international humanitarian law exists even when one’s adversary does not do so. To safeguard civilians, civilian facilities, hospitals, and medical personnel, the international community and parties involved in conflicts must denounce unlawful acts, engage with armed groups and affected populations to encourage compliance with the Geneva Conventions, and reconfirm the legitimacy of international humanitarian law.[54]
Error or negligence: Sometimes perpetrators simply claim human error, as in the October 2015 U.S. bombing of the MSF hospital in Kunduz, Afghanistan. An internal investigation by the United States military attributed the attack to human error and equipment failure, and 16 lower-level individuals were disciplined (but not criminally charged), showing that even negligent attacks can be subjected to accountability.[55] Despite global outcry, however, there was no independent investigation. A panel of experts appointed by the UN found abundant evidence that the Saudis failed to consult a “no-strike list” of health and other civilian facilities in Yemen, which may or may not have been human error but certainly represented negligence and a failure to take precautions to avoid civilian harm as required by the Geneva Conventions.[56] MSF subsequently announced that there are times it withholds information from combatants about the location of its facilities because experience is showing that, rather than being protective, such information may invite attack.[57]
Cultural insensitivity or lack of knowledge of the law: Attacks also result from violations of complex social and cultural norms perpetrated by health workers, however unintentionally. This occurred, for example, in Liberia during the Ebola virus outbreak. Health workers there, ignorant of the depth of feeling remaining from violations of burial practices during the civil war, reignited old wounds and in so doing unnecessarily provoked attacks.[58] Similarly, attacks on mental health hospitals in Syria may reflect a view that imposition of Western psychiatry reflects a form of cultural imperialism that is unwanted.[59] Such acts, however, still violate the law and do not excuse the conduct. Attention to international humanitarian law and the Geneva Conventions can ensure the safety of global health care workers, especially nurses.[60]
Arms sales to violators of international law: The current U.S. policy favoring arms sales rests on three planks. First, advocates argue that arms sales enhance American security by bolstering the military capabilities of allies, enabling them to deter and contain their adversaries, and helping promote stability in critical areas such as the Middle East and Southeast Asia. Second, they argue that arms sales help the United States exert influence over the behavior and foreign policies of client nations. Finally, advocates argue that arms sales provide a boon to the U.S. economy and fiscal benefits in the form of lower unit costs to the Pentagon while helping ensure the health of the American defense industrial base.[61]
Opponents, however, argue that the benefits tend to be oversold and that the downsides are ignored. The defense industry and its champions, in particular, have long exaggerated the economic boon of arms sales. And even if they were greater, the economic benefits do not justify the use of arms in assaulting health workers.[62]
Referring to international tribunals: Some critics argue that war crimes and crimes against humanity will not end by holding some perpetrators to account. They point out that even after prosecutions, other people commit similar crimes. The most obvious international tribunal is the ICC, but some nations, including the United States, declined to join on the grounds that there are insufficient checks and balances on the authority of the ICC prosecutor and judges, believing that “accountability is obtainable by primarily relying on national judicial systems and international tribunals established where appropriate by the Security Council within the framework of the UN Charter.”[63]
Regardless of whether the United States joins the ICC, international tribunals offer an opportunity to reinforce norms and deterrence. No system of justice, whether for prosecuting murderers or robbers or for addressing international crimes, will prevent all future violations. American University’s ICC Legal Analysis and Education Project suggests that the ICC and its predecessor tribunals have been largely effective, while broader participation could improve operations.[64]
Action Steps
To improve monitoring of this problem, APHA urges:
- WHO to continue to develop its data collection and dissemination system to monitor attacks on health care, with the goal of providing a foundation for determinations of appropriate actions to prevent attacks in particular circumstances.
- Governments and the United Nations Security Council to carry out full, prompt, impartial, and independent investigations into uses of force that interfere with the safe delivery of health care.
To improve compliance in relation to the problem, all parties of conflict should adhere to and implement the requirements of the Geneva Conventions, human rights law, and Security Council resolution 2286, which calls for protections of health care workers and investigations of all attacks on and interference with health workers. APHA urges:
- Governments to reform their military doctrine and training to ensure protection of health care facilities and personnel in armed conflicts. Also, personnel should be trained on the Geneva Conventions and the Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies, adopted by the World Medical Association.[65]
- Governments to reform laws, military doctrine, and training to protect health workers attempting to provide impartial care.[66] Counterterrorism and related laws are particularly of concern, as health professionals should not be at legal risk for providing impartial care, no matter the beneficiary of such care.
To improve accountability, APHA urges:
- WHO and other bodies concerned with public health to raise visibility and accountability by condemning attacks on health workers and facilities, as WHO did in a 2015 statement on Yemen.[67]
- Governments to end arms sales to parties that use such weapons consistently to attack health care facilities or personnel. The United States should end such sales in compliance with the Foreign Assistance Act.
- The UN Security Council to refer alleged perpetrators of war crimes against health facilities and personnel to authorized tribunals such as the ICC.
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