A view of a damaged hospital as civilians continue to hide in a bomb shelter under the hospital amid Russian-Ukrainian conflict in the city of Volnovakha, Donetsk Oblast, Ukraine on March 12, 2022. Photo by Stringer/Anadolu Agency via Getty Images

Ending Violence Against Health Care in Conflict

Systematic attacks on health facilities and targeting of health workers have become a go-to strategy of modern warfare. What will it take to end these crimes?

By Anna Louie Sussman

Houssam Alnahhas was in his fifth year of medical school at Aleppo University when the Syrian uprising began.  

His whole life, he had dreamed of becoming a doctor, of being able to help people, of saving lives. For the first few months of the conflict, he focused on trying to finish his education so he could graduate on time, but he could not ignore the violence around him. Like many of his fellow medical students and health care practitioners, he joined an underground network of field hospitals and impromptu triage sites run out of homes, shops, farms, and, eventually, dedicated clinical sites. He had no illusions that this would help advance his dream of becoming a practicing doctor. In fact, he knew that President Bashar al-Assad’s government was specifically targeting health care workers. Three medical student volunteers he knew were detained and tortured for three weeks. Their burned bodies were sent back to their families.  

Shortly after their gruesome murder, in June 2012, Alnahhas, MD, MPH ’20, was picked up by government authorities. They found a list of medical supplies on him as well as supplies in his car. They knew he’d been providing unofficial health care. This directly implicated him as a supporter of protesters. In detention, he was known to guards as “the doctor” (although it wasn’t until 2018 that he finally finished his medical studies at Istanbul University, having fled Syria and taught himself Turkish). “They were inviting each other to torture me. Guards would come up to me during the interrogation session … and ask, ‘Is he the doctor? Can we beat the doctor? Can we slap the doctor in the face?’” recalls Alnahhas, now the Middle East and North Africa researcher at Physicians for Human Rights, which he joined after completing his MPH at the Bloomberg School as the recipient of the joint MPH Syrian Scholarship and Sommer Scholar award. 

Doctors were deemed even more detestable by the regime than opposition protesters because they were the ones keeping those protesters alive.  

Alnahhas’ experience is, unfortunately, all too common. In recent years, the health and human rights community has documented increasing numbers of attacks on health care—the arrest, detention, and killing of health care workers, the destruction of hospitals and clinics, and attacks on patients—in the context of civil and cross-border conflicts. In Syria alone, Physicians for Human Rights has documented 601 attacks on medical facilities. Russia’s invasion of Ukraine has to date included more than 600 attacks on health care. Following the bombing of a maternity hospital in Mariupol, a heartbreaking image of a pregnant woman on a stretcher circulated in the news (neither she nor her child survived). And the nonprofit Insecurity Insight documented more than 4,094 attacks worldwide from 2016 through 2020. But to date, despite long-standing international prohibitions on attacking health care workers and health facilities, there has been just a single international prosecution for this widespread crime, let alone convictions.  

“We should recognize that the problem has been serious for a long time, and no one paid attention,” says Len Rubenstein, JD, a professor of the practice and core faculty at the Center for Public Health and Human Rights, Center for Humanitarian Health, and the Berman Institute of Bioethics, and the founder and chair of the Safeguarding Health in Conflict Coalition.  

A Syrian girl holds an oxygen mask over the face of an infant at a makeshift hospital following a reported gas attack on the rebel-held besieged town of Douma, on the outskirts of Damascus on January 22, 2018. Photo by Hasan Mohamed/AFP via Getty Images
A Syrian girl holds an oxygen mask over the face of an infant at a makeshift hospital following a reported gas attack on the rebel-held besieged town of Douma, on the outskirts of Damascus on January 22, 2018. Photo by Hasan Mohamed/AFP via Getty Images

The very first iteration of the Geneva Conventions, dating back to 1864, prohibits attacking wounded or sick soldiers or civilians, health care facilities such as hospitals or ambulances, and the people who provide medical care, as Rubenstein details in his 2021 book Perilous Medicine: The Struggle to Protect Health Care from the Violence of War. In the 158 years since, that fundamental principle of respect for humanity in wartime has been repeatedly affirmed, and the law protecting health care strengthened, but these rules are too often observed in the breach. Some military strategists argue, notwithstanding the law, that ending a war swiftly—even if it requires destruction of civilian infrastructure or the taking of civilian life—justifies such noncompliance. This debate remains a live one: The same logic, expediency over humanity, rationalized torture during the U.S. “war on terror” and criminalizes health care when it is provided to so-called terrorists (examples include the persecution of a Turkish gynecologist who provided care to Kurdish patients who were said to be married to “terrorists.”) 

Rubenstein first encountered attacks on health care as executive director of Physicians for Human Rights, which he joined in 1996, after a long career as a civil rights advocate in the U.S. Reading his colleagues’ reports on atrocities in the former Yugoslavia, and seeing the damage to hospitals for himself, he was shocked at how little diplomats, journalists, and global health organizations did to address attacks that included shelling and sniper fire on hospitals in Bosnia throughout the war in the early 1990s. But as Rubenstein notes, the conventions have often gone unheeded.  

Indeed, the targeting of civilian infrastructure, including hospitals and health care facilities, has been an explicit strategy of modern warfare. “In the last 50 to 70 years, the bulk of armed conflicts have been distinguished by—or notorious for—the fact that they have been largely wars against civilians, where the large percentage of the victims, rather than being soldiers, have been civilians,” says Susannah Sirkin, MEd, the former director of policy at Physicians for Human Rights. She also points out that the bombings of Nagasaki, Hiroshima, and Dresden could be seen as early indicators that “every target is legit” in the eyes of perpetrators. Given that history, it is difficult to say whether we have entered a new phase of history in which attacks on health care are, in the words of former WHO Director-General Margaret Chan, “the new normal.” 

Rubenstein disputes the idea that attacks on health care are increasing, calling it “a myth.” “What we really know is that health care, along with civilians, were attacked throughout the 20th century, but systematic data on attacks on health care only began in the last decade,” he says.  

Sirkin acknowledges that, but she sees evidence mounting that “especially in recent decades, the situation continues to be egregious,” she says. She points to Syria as a prime example. “We have rarely seen a conflict where such blatant, intentional, overt, and widespread and systematic attacks on health facilities and personnel have occurred as a strategy of war,” she says. 

Whatever the raw numbers show, it seems clear that the attacks have become more audacious, taking place in plain sight of news cameras, and certain types of incidents have become significantly more frequent, says Christina Wille, MPhil, director of Insecurity Insight, which collects and analyzes data on attacks on health care and aid workers. Wille cites the extent to which oppressive regimes such as Myanmar’s and Sudan’s have detained health workers who have treated injured demonstrators. “Never before have I seen as many health workers arrested” as in the past year, Wille says, though she cautions that could, again, be a function of better documentation. 

The explicit targeting of health care is increasingly difficult to ignore. In Myanmar alone, the Safeguarding Health in Conflict Coalition reported 500 health workers arrested in 2021. Other examples are even more clear-cut. In April 2018, medical humanitarian groups working in Syria shared the coordinates of 60 health facilities with Russia, hoping that the information might help avoid further attacks, a process called “deconfliction.” Russia had been denying they were intentionally attacking hospitals, recalls Mohammad Darwish, MD, MPH ’18, who worked as a doctor in Syria before attending the Bloomberg School. Instead, Russia used the coordinates to target attacks. By September, six locations on the list had been hit. The following spring, another nine hospitals on the list were attacked. “Everybody can tell these are systematic attacks,” says Darwish. 

Tayseer Alkarim, MD, an international humanitarian worker also detained and tortured for providing health care to protesters in Syria, says this systematic targeting serves several purposes. Alkarim, who has been admitted to the MPH program next fall, says that such attacks on health facilities and personnel in Syria are intended to demoralize the population: If Syrians cannot access necessary health care, what hope do they have of a normal life? The provision of public services like health care to insurgent communities not only strengthened their resilience but served as “a powerful symbol of Syrians’ ability to lead their country to a better future,” he says. Alkarim also notes that the Syrian government specifically set out to torture and discredit activists with higher levels of education, such as doctors protesting for democracy because their presence invalidated the official narrative of external drivers that easily manipulated “poor and ignorant” Syrians to oppose the regime. 

Whatever the motivation for targeting health care, it is clear that as long as these attacks go unpunished, those intent on inflicting maximum harm on civilians have little incentive to alter their behavior. “In the last century, we don’t have any examples that, ‘Okay, if you are going to do this, you will get this kind of punishment,’” says Alkarim.

Children being treated at a pediatrics hospital have their beds placed in the hospital’s basement, which is being used as a bomb shelter, in Kyiv on February 28, 2022. Photo by Aris Messinis/AFP via Getty Images
Children being treated at a pediatrics hospital have their beds placed in the hospital’s basement, which is being used as a bomb shelter, in Kyiv on February 28, 2022. Photo by Aris Messinis/AFP via Getty Images

If attacking health care is a straightforward violation of the laws of war, why has there been so little accountability? “Until the last decade, attacks on hospitals and health care got very little attention,” Rubenstein notes. “There was little documentation and reporting.” What there was, he adds, “rarely reached the global attention that stimulates investigations and prosecutions.”  

That has begun to change. Physicians for Human Rights and Syrian-run NGOs such as the Syrian American Medical Association and the Syrian Archive have been painstakingly documenting attacks on health care in Syria in a way that makes the evidence admissible in court settings. The Human Rights Center Investigations Lab at University of California, Berkeley Law School, Insecurity Insight, the Safeguarding Health in Conflict Coalition, and others have built an infrastructure for tracking attacks around the world. And, since 2018, the WHO has operated a surveillance dashboard recording attacks on health care, although it has been widely criticized for not naming the perpetrators of its documented attacks. (WHO has responded by saying it is not an investigative organization.) 

Still, the barriers to justice are many. In less-publicized wars, such as in the Tigray region of Ethiopia, where 80% of the hospitals have been destroyed in a civil conflict, “It’s been like whistling in the wind because there hasn’t been a commitment by a powerful state for accountability,” says Rubenstein. For its part, the UN has structural impediments to seeking justice for specific member states. For example, Russia’s permanent seat on the Security Council makes it unlikely that Syria will be referred to an international tribunal. The WHO and UN have been reluctant to vocally criticize member states such as Saudi Arabia, which has bombed hospitals and other infrastructure in Yemen since 2015, resulting in epidemics of malnutrition and cholera. When Saudi Arabia was included in the UN Secretary-General’s annual report on violations of the rights of children in armed conflict, it threatened to rescind its substantial contributions to the UN’s humanitarian operations if it wasn’t removed. It got its way, Rubenstein says.  

While Rubenstein acknowledges the shortcomings of international bodies such as the UN, he points to promising developments within individual countries. In Germany, prosecutors have used the concept of universal jurisdiction for crimes against humanity to commence proceedings against war criminals residing in their country. In Koblenz, Germany, two former Syrian officers are on trial for the torture and death of prisoners in custody. But perhaps the biggest turning point is Russia’s ongoing war in Ukraine. In May, a Russian soldier was convicted in a Kyiv court for war crimes, after he shot and killed a Ukrainian civilian. Ukraine has asked for an ad hoc international tribunal to address the crime of aggression, and investigators from the International Criminal Court are already on the ground in Ukraine at the country’s request.  

Pavlo Kovtoniuk, a former Ukraine deputy minister of health who cofounded a health policy think tank in 2021, quickly began documenting attacks on health shortly after the war began. Seven of his colleagues work from news reports, social media, eyewitness interviews, and, when possible, site visits to document the damage. A key part of their work is attempting to reconstruct the attack itself, with the help of military experts: What sorts of weapons were used? How far away were they fired from? Which was the likely battalion that committed the attack? Which grade of officer is cleared to use such weapons? With those details, they hope to identify who was responsible for specific attacks, describe specific patterns of attacks, and ultimately establish the systematic nature of Russia’s targeting of health facilities.  

Kovtoniuk says it is especially incumbent on countries that proclaim to uphold human rights values to step up to the plate and ensure international justice that reinforces global norms. “It is very important to prosecute internationally, because I think that this war is not about Russia and Ukraine. This war is about the world order,” he says. “Russia is actually challenging, not Ukraine, it’s challenging the West, it’s challenging the world order. And that means that the result should be internationally reflected.” 

Alkarim highlighted several additional reasons why Ukraine, rather than Syria, was a likely candidate for prosecutions. First, he notes, war was happening on Europe’s doorstep, and to a largely white and Christian population (“We need to be very honest about this,” he says). Plus, Ukraine is a resource-rich country, a major source of the world’s maize, wheat, and sunflower oil, which gives many countries a stake in its well-being. He contrasted the relative novelty of a war on European soil with the situation in the Middle East, where conflicts have been ongoing for so many decades that they have come to feel routine. 

The U.S. has sent several positive signals that it will play a role in this fight for justice, says Stephen Morrison, PhD, senior vice president at the Center for Strategic and International Studies. He cites public statements by U.S. Secretary of State Anthony Blinken, the establishment of a Conflict Observatory that will use satellite imagery and other tools to document evidence for accountability, and the visit by U.S. Attorney General Merrick Garland to Ukraine in June. Garland has since announced the creation of a war crimes accountability team that would collaborate with Ukrainian and international groups. “The United States is leaning way far forward; it has never leaned this far forward, and that is terrific,” Morrison says.  

Rubenstein would like to see the public health, medical, and nursing communities prioritize this issue, given how it affects their colleagues around the world. He also envisions a crucial role for academics as these efforts get underway. First, to continue to build the evidence base on the harms of attacks on health care, particularly in the medium and long term. What happens to maternal and infant mortality? To people with chronic illness? Although evidence of indirect harm is not necessary to prove a war crime, it is critically important when thinking about who suffers as a result of these attacks. Second, for the health community to press for protection and accountability. If both the International Criminal Court and the Ukrainian judiciary can hold Russia accountable for attacks on health care, it could be a tipping point for the future. “We’re hoping that if there is justice in Ukraine for this form of violence, it won’t be a one-off,” he says.  

Alnahhas has been able to use the skills developed during his studies to hone his documentation and epidemiological reporting in his work at Physicians for Human Rights. For example, he used data on length and outcome of detention incidents to confirm his hunch that health care workers were singled out for especially harsh treatment if they were suspected to be providing care to an injured protester, rather than engaging in political activity themselves. He found that health workers who cared for protesters were 91% less likely to be released, and 550% more likely to be forcibly disappeared, compared with health care workers detained for political reasons.  

To survivors such as Alkarim, justice is critical, but it will not rewind the clock on what happened to him in detention. “No one will erase these memories from my mind, no one,” he says. “All of us—Syrians, Ukrainians, Iraqis, Yemenis, Afghanis—we are suffering. … We are not going to forget. We are not going to see inner peace.” But, he hopes, with accountability comes the chance that in the future, fewer people will have to suffer. “At least we will gain some good feelings if we feel like, Okay, less people will go through this torture, this humiliation, this maltreatment,” he says.  

Alnahhas, for his part, also thinks of the future as he does his work. He is teaching his 6-year-old daughter that one day, the family will visit Syria again. Now she asks him often, “Did Bashar al-Assad leave?” so they can return. “That’s why every day I wake up at PHR I feel motivated to continue documenting these crimes,” Alnahhas says. “So we can hope that we can one day witness Bashar al-Assad being brought to justice.” 

From Public Health On Call Podcast