Last week saw global outrage over the bombing of two hospitals in Aleppo, Syria. Coming soon after the bombing of a civil defense centre, the destruction of al-Quds hospital and Al Marjeh Primary Health Care Centre within days of each other made headlines around the world. Sadly, these horrific and illegal bombings were not isolated incidents.

Over the last few years, Syria, Yemen, Afghanistan, South Sudan and too many other countries, have seen attacks on health care facilities. Although health care facilities and medical personnel are protected under International Humanitarian Law (IHL), making such attacks war crimes, 2015 witnessed an alarming increase in these illegal tactics. To be clear, these are not mistakes or accidental collateral damage but targeted attacks on those providing life-saving medical care in the midst of conflict. As a result, there has also been a rise in the number of unmarked ambulances and covert field hospitals established in conflict zones.  These field hospitals have even become the main source of health care in opposition controlled Syria.

With hospitals, ambulances and medical facilities under attack or destroyed, thousands of civilians are being denied a fundamental human right guaranteed by the 1946 Constitution of the World Health Organization and the 1948 Universal Declaration of Human Rights: the right to health.  This unacceptable war tactic is exacerbating already dire humanitarian crises around the world. The ongoing situation not only undermines the credibility of the international community, but also highlights one of the most damaging long term impacts of the use of explosive weapons in populated areas.  

The unseen impacts of attacks on health care facilities

Attacks against medical facilities impede access to health care and have disastrous impacts on long term health. Beyond the obvious death and injury caused by attacks on health care systems and the lack of emergency treatment for those injured in the conflict, targeting health care has wide-spread humanitarian impacts. The already overwhelmed health care systems of states in conflict are often unable to cope with the influx of patients caused by the destruction of medical facilities.  “Targeting the health system has compounded the crisis, caused many medical personnel to flee, and prevented countless civilians from getting treated’’ said Widney Brown, Physicians for Human Rights’s director of programs.  In addition to war-injured persons, thousands of people are dying of preventable causes because they unable to access proper health care across conflict zones.

Targeting medical facilities has also impeded vaccination campaigns. The outbreak of polio in Syria and Iraq which started in October 2013 was called “the most challenging outbreak in the history of polio eradication.” Before this outbreak, polio was last reported in Syria in 1999 and in Iraq in 2000.  Unusually large outbreaks of malaria and dengue fever were reported in Yemen by the WHO in 2015. Additionally, fighting forced the postponement of a polio and measles vaccination campaign endangering the lives of millions of children in Yemen. 

Case studies

Syria

Attacks on medical facilities and health care providers have been a feature of the conflict in Syria. A report from Physicians for Human Rights (PHR) identified that between March 2011 and December 2015, 346 attacks were conducted on 246 Syrian medical facilities, killing 705 medical personnel. Syrian government and Russian forces were found responsible for 315 attacks according to the NGO.  Hospitals were specifically targeted on at least 211 occasions. 

The scale of attacks on medical care in Syria is overwhelming, we will just look at attacks on hospitals in Aleppo, both the city and governorate. The city of Aleppo, Syria’s most populous city, saw its health care facilities attacked 45 times in the three years prior to October 2015. As a consequence of these attacks, less than a third of its hospitals were functioning in late 2015, and the ratio of doctors to residents is eight times less than before the conflict started, denying access to much needed medical services. “The Syrian government is using attacks on Aleppo’s health care system as a weapon of war” said Dr. Michele Heisler, of PHR.

A late January 2016 Russian air attack destroyed the last major hospital, the Andan Charitable Hospital, in northern Aleppo. The hospital was providing advanced medical services, including surgery, to residents of the Aleppo countryside. Residents are now forced to travel 50 km to clinics along the Turkish border to receive health care. The hospital was directly targeted by Russian airstrikes. A doctor and a 10 year old patient were killed, and 24 others were injured as a result of the attack.

The result of these attacks is most evident in a media story from 1 May 2016:

Amr al-Halaby, 32, said his teenage daughter, whose leg was severed by a government barrel bomb, had only been able to receive limited treatment from a local vet in the family’s home. “Her painkillers have run out and there is nowhere for us to take her,” said Mr Halaby. “She has reached hell and we can only watch her sink deeper.”

Yemen

The already fragile health care system in Yemen is coming under severe strain since the conflict erupted in March 2015. The WHO has estimated that almost a quarter of Yemen’s medical facilities are no longer operational due to the violence. “The health system is on the brink of collapse” declared Dr Ahmed Shadoul, WHO Representative for Yemen.  The situation is so dire that the president of the ICRC, Peter Maurer, said that “Yemen after five months looks like Syria after five years", warning the international community of the growing humanitarian catastrophe as medical facilities continue to be targeted. Two ICRC staff were killed by gunmen in September 2015 and the organization’s office was raided by gunmen in a separate incident.

A UNICEF report stated that at least 63 health facilities have been attacked since the start of fighting in March 2015 and almost 600 facilities have ceased operations due to damage or lack of supplies, electricity and staff. The report goes on to estimate that “nearly 10,000 children under the age of five may have died in the past year from preventable diseases as a result of the decline in key health services such as immunization against vaccine preventable diseases and the treatment of diarrhoea and pneumonia.”

Afghanistan

An attack on a medical facility in Afghanistan in October 2015, brought the issue of attacks on health care to the general public’s attention. The MSF hospital in Kunduz province, the only trauma centre in northern Afghanistan, was repeatedly attacked and eventually destroyed by U.S airstrikes, killing 42, including 14 staff and 24 patients and 4 caretakers.  Now, residents in the Kunduz province have to either go to expensive private clinics, or attempt the long and dangerous journey to Kabul or Pakistan to receive treatment. On 29 April 2016, the United States Department of Defence released their long, jargon filled and partially redacted report on the incident and said the incident was not a war crime.

The hospital in Kunduz has not yet reopened.

Response

In December 2011, during the 31^st International Conference of the International Red Cross and Red Crescent Movement, the international community adopted a resolution mandating the ICRC to initiate consultations with subject matter experts to formulate practical recommendations for improving safe access to health care services.  The “Health Care in Danger” project was created to achieve this objective.  The ICRC published its first recommendations in 2013. 

In conjunction with those 2013 recommendations, the United Nation (UN) adopted four resolutions for the protection of health care services during armed conflict in December 2014.  This reinforced the principles in four Geneva Conventions and two additional Protocols already providing for the protection of health care facilities. These resolutions asserted to warring parties that attacks against medical facilities constitute a war crime. 

However, governments and rebel groups appear to be ignoring the warnings of the international community, as more and more hospitals and medical clinics become the targets of attacks.

Civil society has not been silent in the face of these unacceptable and illegal attacks. MSF launched a social media campaign to raise 

awareness on the fact that its hospitals have been bombed every week in 2015 and 2016 in Syria and have been targeted countless times worldwide. The #NotATarget campaign demands that medical facilities stop being treated as military targets in conflict zones.  The longer these attacks are tolerated by the international community, the more likely they will become a new norm in armed conflicts. The usually reserved ICRC is speaking out more on this issue, most recently in collaboration with MSF, and the ICRC President Peter Maurer has been uncharacteristically blunt.

In our humanitarian disarmament work, we advocate strongly for effective assistance to victims of landmines, cluster munitions, explosive remnants of war and explosive weapons used in populated areas. The targeting of health care facilities and medical personnel prevents victims from getting the emergency and long term care they need.  

The international community has a chance this month to reverse course and reaffirm international prohibitions on attacking medical facilities.  Tomorrow, 3 May 2016, the United Nations Security Council is scheduled to vote on a resolution designed to stop future attacks against hospitals, patients and civilians in war zones. Update: We're pleased to see that Canada will be co-sponsoring this resolution. Later this month, states will gather in Turkey for the World Humanitarian Summit where they will make core commitments in regards to humanitarian issues. One of the High-Level Leaders’ Roundtables is on “Upholding the norms that safeguard humanity” where states will have the opportunity to speak out on the targeting of civilian objects like medical facilities. In both these discussions, states have the responsibility to speak out against the targeting of medical facilities and personnel and to take action to protect those who risk everything to save lives in conflict. 

Jean-Philippe Lambert Ste Marie is an undergraduate student at the University of Ottawa and a Mines Action Canada research assistant and Erin Hunt is the Program Coordinator at Mines Action Canada.

This week something incredibly important is happening in Vienna. The Government of Austria and UNOCHA have invited some states, international organizations and civil society to a two day meeting aimed at addressing harm from the use of explosive weapons in populated areas. Our colleagues at the International Network on Explosive Weapons have the details in the Network's most recent bulletin and press release.

Although Mines Action Canada couldn't be in Vienna, we have released a new paper to contribute to the discussion. Our paper Hidden Victims: Additional Humanitarian Consequences of Explosive Weapons Use explores the less obvious humanitarian impacts of explosive weapons used in populated areas. We go beyond the initial casualty count to look for long term humanitarian harm.

Read the paper here.