Targeting healthcare in war: a tragically tried and tested strategy that humanity must disown—an essay by Jonathan KaplanBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o884 (Published 12 April 2022) Cite this as: BMJ 2022;377:o884
It is difficult amid the horror of Russia’s attack on Ukraine to identify any political process as it can usually be understood: a series of actions calculated to achieve a definable outcome. Carl von Clausewitz, an enduring authority on the subject of war, famously described it as “politics by other means,”1 but Ukraine appears instead to be war in its most unmitigated form—von Clausewitz called this “total war”—with absolute conquest the goal and terror and destruction its key weapons.
In such a war, healthcare services acquire strategic significance. They may be targeted to prevent soldiers receiving treatment that could return them to the fight. Bombed hospitals destroy morale. The invading army may seize health facilities for its own use, or place weapons there so that the proximity of patients might dissuade counter-fire.
“He who uses force unsparingly, without reference to the bloodshed involved, must obtain a superiority if his adversary uses less vigour in its application,” said von Clausewitz.1 “If our opponent is to be made to comply with our will, we must place him in a situation which is more oppressive to him than the sacrifices we demand.… Every change in this position which is produced by a continuation of the war should therefore be a change for the worse.”
It is noticeable that each development in the Ukraine war has, for the invaders too, been a change for the worse, with Russian losses of personnel and weaponry forcing a media blackout at home. But the Russian army historically has paid scant regard to the welfare of its troops, most recently in Afghanistan and Chechnya. Medical care has often been abysmal.2 Soldiers treated callously by their high command become brutalised; brutalised men commit atrocities. Obligations to identify and safeguard civilians and health facilities are ignored.
After the second world war the body of international humanitarian law (IHL) known as the “laws of war” became enshrined in the Geneva Conventions of 1949 and its 1977 Protocol, aimed at protecting the wounded and sick, non-combatants, and prisoners of war. A key principle of this law states: “The civilian population… shall not be the object of attack. Acts or threats of violence the primary purpose of which is to spread terror among the civilian population are prohibited.”3
Residents of cities and users of hospitals, theatres, schools, and care homes are targets in Ukraine because they constitute the soul of its people. Civic institutions providing healthcare and education, sustaining community, are the networks that make a nation’s identity. Dead civilians highlight a government’s impotence to protect its people. Destroy hospitals, collapse the social order, displace and deport the populace, render powerless the rule of law, and faith in the state is lost.
On day 22 of the Russian invasion, World Health Organization’s director general, Tedros Adhanom Ghebreyesus, reported to the UN Security Council that there had been 43 verified attacks in Ukraine on healthcare facilities, targeting staff, infrastructure, patients, and ambulances.4 There have been many more since. Russian weaponry permits accurate strikes on military installations in westernmost Ukraine from submarines six hundred miles away in the Black Sea. Their missile strikes on civilian hospitals and shelters show similar precision.
“In a conflict, attacks on healthcare are a violation of international humanitarian law,” observed Tedros. Humanitarian and human rights law guarantee to all—wounded and sick combatants and civilians caught in armed conflict, regardless of their affiliation or beliefs—access to medical care, a bedrock principle of the Geneva Conventions.3 By what lapse does it now appear that humanitarian assets like health workers and medical facilities have become the enemy?
What is happening in Ukraine is what has failed to arouse the same degree of public revulsion in other conflicts whose victims are not so close to Western empathies. In the same way that the horrors of the first world war brought to European eyes a manifestation of the raw brutality of colonial war and imperial subjugation by their governments—Belgian rapine of the Congo, Britain’s wars in Africa and Asia, French conquests in Africa and Indochina, German genocide in south-west Africa—so the targeting of healthcare and atrocities against civilians in Ukraine are simply the tactics of those long running, under-protested wars in Afghanistan, Syria, Tigray, or Yemen, revealed to the horrified gaze of the West.
Strangely, this fraying of moral sensibilities followed what seemed an enlightened concept: “humanitarian war.”
The Bosnian war (1992-1995) with its besieged cities and ethnic massacres brought NATO intervention, armed protection for humanitarian convoys, and airstrikes on Serbian forces.3 But then a 1993 US and UN deployment to end the civil war and famine in Somalia—the so-called “shoot to feed” mission—saw the bodies of US servicemen dragged through the streets of Mogadishu.5 This televised horror coloured Western reluctance to intervene in the Rwandan genocide in 1994—until the attacks of 11 September 2001 again placed humanitarian principles in the line of fire.
“Non-governmental organisations are such a force multiplier for us,” declared US Secretary of State Colin Powell as America prepared to invade Afghanistan, “such an important part of our combat team.”6 Signing up to the US-led global war on terror, the UN Security Council passed anti-terrorism resolutions binding all member states. Some could now define their enemies, internal and external, as terrorists.
Sweeping definitions of terrorism permitted governments to criminalise the act of providing medical care to “terrorists” or to deny humanitarian aid to regions considered to contain terrorist elements, making health services an apparently justifiable target.7
Security forces in Bahrain, Egypt, Myanmar, and Turkey entered hospitals to arrest doctors for treating protesting citizens. Medical ethics demand the provision of impartial care to all patients—civilian or combatant, friend or enemy, even those labelled an insurgent or a terrorist—on clinical need alone. But human rights monitors have documented the targeting of ambulances, aid workers, and hospitals in Chechnya, Gaza, Tigray, Yemen, and, most notably, Syria, where some 600 facilities have been hit by bombs or missiles. Syrian hospitals in areas under government assault previously publicised their GPS coordinates as a “deconfliction” protocol to notify military forces of the location of civilian infrastructure that should be spared from attack, in order to reduce humanitarian suffering and conflict escalation. Many were then targeted, often by Russian airstrikes.8
On 3 October 2015, the Médecins sans Frontières trauma hospital in Kunduz, northern Afghanistan, suffered a sustained attack by a US Airforce gunship. Fighting nearby was filling the hospital with casualties—civilians as well as wounded combatants from both Taliban and government forces. Despite the hospital’s coordinates being known to the US Department of Defence and US Army headquarters in Kabul since 2011, with regular reminders (most recently six days before), the algorithms driving US strategy identified—on the basis of the traffic of people and vehicles—that this was a military target. The hospital was obliterated, killing 42 and injuring 37 patients and staff.9
Condemnation of the attack prompted UN Security Council Resolution 2286 on 3 May 2016, demanding reform of international laws guiding military intervention, codes of conduct, and operational guidance. Governments were ordered that violations must be investigated and perpetrators called to account.
But 70 UN member states—including Iran, Israel, Russia, Saudi Arabia, Syria, Turkey, and the US—refuse to recognise the jurisdiction of the International Criminal Court in The Hague, the body charged with investigating and trying individuals charged with genocide, war crimes, crimes against humanity, and the crime of aggression.10
Powerful states have continued to flout international humanitarian law with impunity. Motions to censure these violations have been vetoed in the Security Council. The Syrian conflict used tactics honed by the Russians in Chechnya: announcing humanitarian corridors through battle zones, then abruptly shutting them down or rendering them unsafe through shelling, followed by the claim that non-combatants had been given the chance to leave and whoever remained is a terrorist. Russia’s bulldozer assault on Ukraine—pounding cities to rubble; besieging populations; targeting breadlines, hospitals, and humanitarian escape routes—follows explicitly the methods it has used since 2015 in Syria, where its military deployed to help President Assad wrest back the country from rebel control.11
A global health problem
Leonard Rubenstein, author of Perilous Medicine: The Struggle to Protect Health Care from the Violence of War and chair of the Safeguarding Health in Conflict Coalition, observes that between 2016 and 2020 “there have been more than 4000 reported incidents of violence against healthcare in conflicts around the world… every other day a health facility is damaged or destroyed, and every third day a health worker is killed.”8 Apart from the wounds, disability, impoverishment, and death inflicted by these violations, Rubenstein identifies attacks on the provision of healthcare as a global health problem.
In Yemen, Saudi airstrikes on water treatment plants, sanitation services, and public health clinics (using weapons supplied by the US and UK) led directly to the world’s worst ever cholera outbreak.812 By November 2021 there had been more than 2.5 million cases reported and over 4000 people died. Attacks on polio vaccination programmes in Afghanistan and Pakistan13 in defiance of humanitarian law cast a long shadow of suffering, with regional eradication of the disease set back 20 years.8 The International Committee of the Red Cross in Geneva describes a recent cyberattack against their computer servers as showing “a shocking disregard for lives and suffering and the vital mission of this humanitarian organisation.” The attack, accessing sensitive personal data about family members separated by armed conflict, violence, or displacement, affected national Red Cross and Red Crescent societies in 60 countries.14
Bombed hospitals in Ukraine are reminding the world that a code of international humanitarian law exists against which nations and leaders will be judged. Forensic documentation of these violations is underway. The litigation of conflict, says international jurist Philippe Sands, “provides hope to people who are on the receiving end of horror… that they’re not alone.”15 It can only be hoped that this war may compel a renewed global consciousness—and collective action.
Jonathan Kaplan has experience as a war surgeon in northern Iraq during the Kurdish uprising at the end of the Gulf War, in Mozambique, in Myanmar’s Shan State, in Eritrea, in a besieged town in Angola, and in Baghdad during the insurgency that followed the 2003 US invasion. He has worked in post-conflict environments in Nepal and Kosovo, assessed victims of mercury poisoning in Brazil and South Africa, and been an air ambulance doctor and ship’s medical officer.
Teaching roles have included honorary lecturer and faculty of the Principles of War Surgery course of the Royal Centre for Defence Medicine, St George’s University Medical School’s intercalated BSc on Conflict and Catastrophe Medicine, and the Surgical Training for Austere Environments course at the Royal College of Surgeons.
He was a contributing author to Making Sense of Disaster Medicine: A Hands-on Guide for Medics and has written The Dressing Station and Contact Wounds, about his personal experiences of conflict zone surgery and other less conventional areas of medicine.
Commissioned, not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.