Morality of convenience: the ongoing failure to protect hospitals and health workers in conflict zones

Tedros Adhanom Ghebreyesus, director general of the World Health Organization, is pleading for protection of health facilities, health professionals, and vulnerable people (doi:10.1136/bmj.p2656).1 He is being ignored, as are the many sensible voices supporting an urgent ceasefire and peace in Gaza. These include the pope and the archbishop of Canterbury (https://www.theguardian.com/world/2023/nov/13/british-palestinians-demand-meeting-rishi-sunak-gaza-ceasefirehttps://www.reuters.com/world/europe/pope-urges-stop-name-god-calls-gaza-humanitarian-aid-2023-11-05).23 They include Jews and Muslims, and people of all faiths, races, and nationalities (doi:10.1136/bmj.p2645).4

Very many people understand that a peaceful resolution respecting the rights of both Israelis and Palestinians is the best path. The US and the UK are belatedly lobbying Israel for restraint (https://www.theguardian.com/us-news/2023/nov/13/biden-lawsuit-alleged-failure-prevent-genocide-israel-palestine).5 Today’s wars and conflicts pay scant heed to the Geneva Conventions. They care little for deaths of civilians, attacks on humanitarian workers, or targeting of health facilities and health professionals. The political lobbies, propaganda machines, and misinformation campaigns are mobilised to obfuscate, manipulate, and justify. The means are seemingly justified by the goal. Civilian deaths are “collateral damage.” Hospitals are “legitimate targets.”

The world order has utterly failed civilians, health professionals, and humanitarian workers. These groups are protected by the fourth Geneva Convention, one of the universally agreed legal standards for humanitarian treatment in war (https://www.icrc.org/en/war-and-law/treaties-customary-law/geneva-conventions).6 The Geneva Conventions are an expression of our humanity and are arguably the most important agreements in our shared history. They demand fair treatment of injured and imprisoned combatants and non-combatants in a conflict. That is the demand, that is the binding agreement—the reality is very different.

As the death toll in Gaza rises to over 11 000, after at least 1200 terrorist killings in Israel, the United Nations and aid agencies are calling for an immediate end to the “collective punishment” of Palestinians in Gaza (doi:10.1136/bmj.p2383https://press.un.org/en/2023/sc15473.doc.htm),78 and the chief prosecutor at the International Criminal Court is investigating war crimes by Israel and Hamas (https://www.theguardian.com/commentisfree/2023/nov/10/law-israel-hamas-international-criminal-court-icc).9 Both Israel and Hamas must be held accountable.

Attacks on hospitals and their staff are now commonplace in conflict, an instrument of battle, conducted with impunity and invariably unpunished. Syria, Sudan, Ukraine, and Gaza are just the latest examples (doi:10.1136/bmj.p892 doi:10.1136/bmj.p451).1011 These attacks are an inhumane but constant accompaniment to war. Doctors and nurses, patients, babies in incubators (https://www.reuters.com/world/middle-east/biden-says-gaza-hospitals-must-be-protected-2023-11-14) are not responsible for armed forces seizing control of hospitals and hiding in catacombs.12

And here is where the international order has failed consistently—not just in Gaza. It has failed to prevent and limit conflicts. It has failed to safeguard vulnerable and protected people in conflict zones, partly because nations such as the US and UK have lost moral authority through their own wars, partly because other powerful nations such as China, India, and Russia are motivated by political advantage rather than global solidarity, partly because prosecuting war crimes has proved complex and near impossible—and partly, too, because many medical leaders of national medical associations and professional colleges and societies remain silent or hesitate to speak.

Bold, humane, and principled leadership is required to remake the international order, to strengthen humanitarian laws, to end targeting of health facilities and staff in vulnerable conflict zones, to force a global consensus, and, importantly, to hold political leaders and nations accountable (https://www.hhrjournal.org/2021/06/five-years-after-security-councils-resolution-to-protect-health-care-in-conflict-still-at-zerohttps://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2020/01/14/a-call-to-end-violent-attacks-on-health-workers-and-health-facilities).1314 Peace must be the vision and the ultimate goal.

Unfortunately, bold, humane, and principled political leaders are what the world is lacking, especially among the major powers that originally shaped the very humanitarian laws that are now too often ignored (bbc.co.uk/news/uk-politics-67432393).15 Political expediency comes before the lives of doctors, patients, and innocent civilians. It is, on the face of it, a morality of convenience. Our moral, non-negotiable, duty must be to support and ensure the protection of health facilities, health professionals, and vulnerable people in conflict zones.