Physicians, nurses and patients are under assault by the Syrian and Russian air campaign and U.S.-backed Saudi war in Yemen.
The first Russian airstrike missed the Sarmin field hospital in Idlib, Syria, by more than 20 yards — delivering a strong enough punch to blow out some windows but sparing the lives of the rattled patients and doctors inside.
Their luck would prove fleeting.
Ten minutes later, the Russians returned and fired on the road adjoining the hospital, killing a physiotherapist, a security guard, and 10 other patients and visitors. The trauma room was transformed into a scene of broken glass, rubble, and bloodied bodies. Mohamed Tennari, a Syrian radiologist who survived the Oct. 20, 2015, attack, told Foreign Policy that staff now see the hospital — which has been attacked 15 times since 2011 — as a “a ticking time bomb.”
“We don’t know when a bomb will explode and kill us all,” he said.
Tennari and his colleagues are far from the only doctors, nurses, and ambulance drivers worrying about their safety. Attacks against hospitals and clinics from Afghanistan to South Sudan and Yemen have grown distressingly common in recent years, killing hundreds, forcing the shuttering of numerous medical facilities, and adding to the misery of already war-torn nations.
Their plight has burst into public view in recent months following a series of gruesome attacks on facilities supported by the Nobel Peace Prize-winning French medical relief organization Médecins Sans Frontières (MSF). On Oct. 3, 2015, a U.S. military gunship mistakenly struck a hospital in Kunduz, Afghanistan, killing 42 patients, staff, and caretakers while injuring 43 more. The relief agency has also taken hits in Syria and Yemen, where a U.S.- and British-backed coalition led by Saudi Arabia has fired on two hospitals and one mobile clinic supported by MSF. Scores of other medical facilities have been destroyed by the Saudi-led coalition or opposition Houthi fighters. In South Sudan, MSF facilities were recently looted in the town of Pibor after fighting in the town forced the agency’s doctors and staff to flee to a U.N. compound for safety.
In a sign of the mounting concern over the targeting of hospitals, U.N. Secretary-General Ban Ki-moon scolded Russia and Syria for “severely disrupting” humanitarian operations and damaging hospitals and schools. He also took a veiled swipe at U.S. and Saudi air operations in Afghanistan and Yemen, denouncing “so-called ‘surgical strikes’” that hit medical facilities last year as “assaults on our common humanity.”
The attacks have grown so numerous and alarming that several U.N. Security Council members have begun discussions on a draft resolution condemning such attacks and highlighting the need for combatants to observe long-standing legal obligations to leave them in peace. “We felt that by highlighting the issue it might bring some pressure to bear” on the perpetrators, said New Zealand’s U.N. ambassador, Gerard van Bohemen, who is spearheading the effort. He said that international law governing conduct in armed conflict is clear. “There is a requirement not to attack health care facilities, and it’s not being complied with.”
Attacks on medical workers have always been a part of the reality in conflict zones. Governments at war have long bridled at the constraints imposed by the laws of armed conflict, which provide legal protections to medical workers tending to civilians as well as to wounded fighters on both sides of the conflict. Those protections include aiding injured enemy combatants who may one day return to the battlefield. Medical workers are supposed to heal wounded patients whether they are insurgents, civilians, terrorists, or government soldiers.
On the ground, that has sometimes resulted in anger and violence. Israel, for example, has long faced harsh criticism from human rights advocates for targeting clinics and health workers in the course of military operations in Palestinian lands. But Israel has countered that Hamas and other terrorist groups have transported weapons in ambulances and staged rocket attacks from schools and medical facilities. The Shifa Hospital in Gaza City has been used as the de facto headquarters for Hamas’s leadership, according to a report in the Washington Post.
Laws designed to protect medical workers in time of war date back to 1864 with the adoption of the first Geneva Convention — or “Convention for the Amelioration of the Condition of the Wounded in Armies in the Field” — which obliges states to offer relief to the war-wounded. The convention was updated and replaced in 1906, 1929, and finally in 1949, following World War II. Its sanctity is not absolute. Armed groups are permitted to fire on a medical facility if they receive direct fire from within the premises. But the response must be targeted and proportional.
It is difficult to precisely quantify or compare whether medical workers are facing riskier conditions today than in previous conflicts, according to Jason Cone, the executive director of MSF’s U.S. branch. Medical workers have been targeted from Bosnia in the 1990s to Bahrain in 2011, where doctors tending to injured anti-government protesters were subject to arrest or violence in the early months of the so-called Arab Spring.
The Khmer Rouge in Cambodia murdered doctors and other professionals or put them in labor camps in the 1970s. In the 1980s, Soviet aircraft frequently bombed hospitals in Afghanistan, including MSF-assisted clinics, during the Soviet Union’s struggle to defeat U.S.-backed mujahideen fighters, Cone said.
But he said one of the more disturbing recent developments is that at least three of the five major powers on the U.N. Security Council — which share responsibility for the maintenance of international peace and security — have either participated in attacks on medical facilities themselves or are supporting armed forces like the Saudi-led air coalition in Yemen that have hit medical facilities. The involvement of those governments — Russia, the United States, and the United Kingdom — risks sending a signal to other countries that striking out at medical facilities is not beyond the pale.
“If you have the majority of permanent members of the Security Council actively involved in major conflicts in Syria and Yemen, where you see the largest concentration of attacks on medical facilities and medical workers, it creates an environment conducive to the commission of these kinds of attacks in the future,” Cone said.
The environment for attacks on medical workers has been perversely favorable in recent years.
In Syria, the deadliest place in the world for doctors and nurses, more than 700 medical workers have been killed since the start of the conflict in 2011, according to figures produced by Physicians for Human Rights, a New York-based medical NGO. The vast majority — 659 — were killed by Syrian government forces, according to the NGO.
In Yemen, nearly 100 medical facilities have been attacked by the Saudi-led coalition and their Houthi opponents since March 2015, according the International Committee of the Red Cross. Six volunteers with the Yemen Red Crescent Society have been slain.
Afghanistan, South Sudan, Israel, Palestine, Somalia, and other conflict zones have also seen their share of attacks on health workers.
Alarmed by the strikes, the International Red Cross and Red Crescent Movement launched its “Health Care in Danger” project in 2011 to monitor attacks against health care workers and facilities. In April, the project documented 2,398 incidents of attacks against medical workers in 11 countries between January 2012 and December 2014.
“In total, at least 4,275 people were victims of violence against health care, 1,633 of whom were patients,” according to a background report published in December. The report also stated that more than half of the attacks took place inside or near a clinic, hospital, or other health care facilities. Nearly 600 health care workers were killed.
Those figures are far from a complete global tally of attacks on medical workers and likely reflect only the “tip of the iceberg,” according to the ICRC findings.
The perpetrators of attacks on health care workers include government security forces from South Sudan to Saudi Arabia and Syria, as well as rebel insurgents and terrorist organizations, including the Taliban and the Islamic State. This includes the big powers: Russia, which targeted hospitals in Syria, and the United States.
The United States has acknowledged responsibility for the attack on the MSF hospital in Kunduz and has called on its Saudi ally to comply with its obligations under international humanitarian law, which upholds the inviolability of medical facilities, in Yemen. But Washington has resisted calls from MSF and the U.N. to permit an independent investigation into the Kunduz attack, which is instead the subject of an internal probe by the Pentagon. And it has shown little enthusiasm for pressing the Saudis to hold those responsible for attacks on hospitals accountable for their crimes.
Russia, meanwhile, has steadily denied charges that it has targeted medical facilities in Syria.
Following the strike on the Sarmin field hospital, Moscow issued a statement denying it had inflicted any damage on the hospital. It released overhead imagery showing that the hospital had suffered no damage. The independent reporting group Bellingcat challenged the Russian account, saying the overhead pictures were likely taken before the attack occurred.
Tennari provided FP with video and photos documenting the destruction, including before and after pictures of the slain physiotherapist, Hassan Taj al-Din. The attack on the Sarmin hospital, according to Tennari, is part of a campaign by the Syrian government and its allies to make the city of Idlib and other rebel-controlled cities uninhabitable.
For much of the past year, the United Kingdom — which advises the Saudi-led coalition on targeting — has pushed back on claims that the air campaign has intentionally targeted civilians in violation of the laws of war. In January, Britain’s then-Foreign Secretary Philip Hammond said there was “no evidence of deliberate breach of international humanitarian law.”
But a report by a U.N. panel of experts released last month documented “widespread violations of international humanitarian law,” including 22 airstrikes against hospitals and the repeated shelling of hospitals and attacks on health workers by opposition Houthi forces in Taiz and Aden.
Medical workers say the violations of international law are obvious to those on the ground.
“When I first came to Sa’ada city in May, [it] was being hit by airstrikes every day,” Mariela Carrara, an emergency physician who was until recently based there, wrote in a blog post on her experiences in Yemen. “We were living in the basement of the hospital because of the bombing, which was very close by. With each blast, you could feel the windows and doors shaking. Two months later, the city had been almost completely destroyed and was empty of people.”
Juan Prieto, the general coordinator for MSF projects in Yemen, which are based out of the Al-Jamhouri hospital, said the situation has improved somewhat in the city. But he added that most of the medical facilities beyond the city, and closer to the Saudi border, have either been destroyed or shuttered because health care workers are too terrified to come into work. Saada, he said, is far from safe, recalling that an ambulance driver was killed by an airstrike there in the past month. “We feel sometimes overwhelmed,” Prieto told FP.
In Afghanistan, the shift of the U.S.-led coalition from a combat mission to an advisory role has dramatically reduced the number of civilian casualties by NATO forces.
However, unidentified military trainers from the U.S.-led Resolute Support Mission participated in a joint operation this month with Afghan special forces that raided a government clinic in the country’s Wardak province.
During the mission, Afghan forces seized three suspected Taliban militants — two patients and a 15-year-old boy — from the clinic who “were taken to a nearby shop and summarily executed,” according to a statement issued by the U.N. Assistance Mission in Afghanistan (UNAMA).
The U.N. did not release the nationality of the coalition personnel involved in the strike.
And there was no evidence that foreign advisors entered the hospital or witnessed the execution of the suspected Taliban militants.
A spokesman for the Swedish Committee for Afghanistan, which supported the hospital, said eyewitnesses claimed two soldiers in foreign military uniforms, including one who spoke English, were present on the ground when the forces prepared for their evacuation. The raid, according to the relief agency, was a “gross violation” of the Geneva Conventions, which uphold the sanctity of medical facilities.
“[The Afghan forces] behaved very badly. They detained and beat some of our staff,” Bjorn Lindh, a Kabul-based spokesman for the Swedish relief agency, told FP. “One group took three people and went off and killed them, while another group continued their search in the village for more Taliban or whatever they were searching for.”
Anti-government forces have behaved even worse.
According to UNAMA’s 2015 annual report, the Taliban, the Islamic State, and other anti-government forces targeted hospitals and medical workers 63 times in 2015 — a 47 percent increase compared with the 34 attacks in 2014. More than half of the attacks were carried out by the Taliban, which has abducted several health care workers in an effort to shut down an international polio vaccination drive, part of a broader campaign of intimidation.
The Islamic State, which has made inroads into Afghanistan during the past year, has directed one-third of its attacks in 2015 at health and education facilities. On Sept. 12, the Islamic State entered two health clinics in the Kot district of Nangarhar province, looting all the medicine and equipment. The group has also targeted polio vaccination operations, under “the belief that vaccination is ‘anti-Islamic,’” according to the UNAMA report.
But nowhere has the assault on health workers been as ferocious as it has been in Syria, where the Russian attack on the hospital in Sarmin simply marked the latest stage in an attempt to deny civilians and war-wounded in opposition areas access to medical relief.
The Syrian government has systematically blocked the delivery of life-saving medical supplies to opposition-controlled areas. On Feb. 17, the U.N. chief told the Security Council that the Syrian government had yet to approve medicines or medical supplies to more than 2.5 million people in besieged or hard-to-reach areas in Syria. Syrian officials have also routinely removed medical equipment — surgical supplies in particular — from U.N. aid trucks.
Osama Abo el-Ezz, a surgeon in Aleppo and representative for the Syrian American Medical Society, told FP that all of his hospital’s supplies have to be trucked into Aleppo from Turkey. But he said many doctors have fled the area. Abo el-Ezz said the risks of tending to the wounded are so dangerous that he was forced to move his family to Turkey. He spends two weeks a month with them and two weeks in Syria to perform surgeries. “The situation in Aleppo is very dangerous,” he said.
Outside observers agree.
“We have determined Syria is by far the worst, most egregious assault on health care we have ever seen,” said Elise Baker, who tracks Syria with Physicians for Human Rights. “We have never seen anything this widespread or long-lasting anywhere else in the world.”
She said her organization’s concern is that the failure to hold perpetrators of crimes against health care workers accountable will encourage others to follow suit. “It threatens to become the new norm,” she said.
One of the grisly bright signs is that the number of health care workers killed in Syria fell in 2015 to 107, 70 fewer than in 2014, according to Physicians for Human Rights. The reason for the decline may be attributed to the implementation of more efficient security precautions. But it also may be the result of a shrinking population of medical experts that can be targeted.
Photo credit: Damien Meyer/AFP/Getty Images