Even wars have rules

Ketil Slagstad About the author

Attacks on healthcare personnel in situations of conflict are not a new phenomenon, but the brutality of the war in Syria has appalled the entire world. Healthcare workers have become targets in a carefully calculated strategy of terror

Photo: Sturlason

In Aleppo, the Syrian city that historically has been so central to various empires, shots are again fired through arrow slits in one of the world’s most ancient stone fortresses. For a long period the city was the largest in Syria, with more than 2.1 million inhabitants. Many have now left, and many have lost their lives in the war. The human suffering is hard to comprehend. At the end of last year, only one-quarter of the city’s original population remained. The health services lie in ruins. Two-thirds of the hospitals have been destroyed, and 95 % of the doctors have either been killed or have fled (1).

On 28 April this year, a rocket struck the city’s Al Quds hospital. The hospital is run by Syrian healthcare personnel, supported by Doctors Without Borders and the International Committee of the Red Cross. The rocket hit the entrance to the emergency department (2). A total of 27 people were killed, including three children and six healthcare workers. Among them was Dr Maaz, one of the region’s only remaining paediatricians (3), and several women in labour. Following the attack, only six doctors and 26 nurses remain at the hospital.

Physicians for Human Rights has documented that from the start of the war in Syria in 2011 until April this year, more than 700 healthcare workers have been killed, of whom at least 150 have been executed or tortured to death. More than 90 % of the attacks have been carried out by the Syrian and allied forces (4). Most of the attacks on medical units were of a targeted nature.

It is not the first time that healthcare personnel have been under attack in war. In the Second World War, hospitals on both sides were bombed (5). This paved the way for the Geneva Convention in 1949, ratified by 196 countries, including Syria (6). It constitutes a war crime to purposely attack a hospital or medical facilities, irrespective of whether they are civilian or military. In more recent times, attacks have been documented on healthcare personnel in Rwanda, Somalia, the former Yugoslavia, Libya, Iraq, Yemen and Afghanistan, among other countries – for example with the bombing of the Doctors without Borders hospital in Kunduz last year (6). But nowhere has it been as atrocious as in Syria. As the rules of war come under pressure, the principle of immunity for healthcare personnel is in danger of being eroded: in the Syrian war, it has become open season on healthcare workers.

This is part of the backdrop to the newly adopted Resolution 2286 by the UN Security Council, stating that targeted attacks on hospitals, patients and civilians are unacceptable (7). More than 80 of the UN’s 193 member states and the Security Council condemned the attacks on and threats to the sick and wounded, to hospitals and healthcare workers. The long-term consequences for the civilian population and the local community were emphasised – not only is the emergency health service affected, but when hospitals are destroyed, the consequences persist long after the war ends, and vulnerable groups such as children, the elderly, pregnant women and the chronically ill are most affected (8). «Even wars have rules», emphasised UN Secretary-General Ban Ki Moon (7).

The global community is to some extent powerless to act in the Syrian conflict, where many parties have blood on their hands. Bashar al-Assad, ophthalmologist and President of Syria, is not only blind to what is happening, he himself is an active administrator of terror. However, Russia and China have used their Security Council veto to block any attempt to bring Assad before the International Criminal Court (8). Nevertheless, the international judiciary has proved to be resourceful on previous occasions, for example in condemning Radovan Karadzic and Jean-Pierre Bemba Gombo for war crimes and crimes against humanity in the former Yugoslavia and the Democratic Republic of the Congo, respectively. Some hope therefore exists that those responsible will one day be brought before the court. Nevertheless, this is of little comfort to the civilian population in Aleppo.

Dr. L, who lives in Aleppo with his wife and son, is one of few doctors who remain (1). When asked how he survives the psychological strain of living and working under such conditions, he replies bravely: «When we are under attack, we laugh and sing Here we stay, here we stay.» Healthcare personnel in Syria display admirable courage and pride, but despite their bravery, the civilian population’s need for assistance can only be ensured through international agreement on healthcare workers’ absolute immunity in war.

1

Aleppo abandoned. A case study on health care in Syria. Physicians for Human Rights november 2015. http://reliefweb.int/sites/reliefweb.int/files/resources/aleppo-abandoned.pdf (22.5.2016).

2

Walsh D. On the ground in Aleppo: bloodshed, misery and hope. The New York Times 30. april 2016. http://nytimes.com/2016/05/01/world/middleeast/syrian-city-torn-by-war-shows-jarring-resolve-to-try-to-live-normally.html?_r=0 (22.5.2016).

3

Salloum R. Schwere Angriffe auf Aleppo: Eine Stadt blutet aus. Spiegel Online. http://spiegel.de/politik/ausland/syrien-aleppo-blutet-aus-a-1090534.html (22.5.2016).

4

Anatomy of a crisis. A map of attacks on health care in Syria. Physicians for Human Rights. https://s3.amazonaws.com/PHR_syria_map/findings.pdf (22.5.2016).

5

Coppieters B, Kashnikov B. Right intentions. Moral constraints on war: principles and cases. Oxford: Lexington books, 2002: 76.

6

Heisler M, Baker E, McKay D. Attacks on health care in Syria – normalizing violations of medical neutrality? N Engl J Med 2015; 373: 2489 – 91. [PubMed] [CrossRef]

7

Security Council Adopts Resolution 2286 (2016). Strongly condemning attacks against medical facilities, personnel in conflict situations. United Nations Press Release 3. mai 2016. http://un.org/press/en/2016/sc12347.doc.htm (22.5.2016).

8

Katari RS. Medical neutrality and solidarity in the Syrian armed conflict. The Journal of Global Health 1. november 2013. http://ghjournal.org/medical-neutrality-and-solidarity-in-the-syrian-armed-conflict/ (22.5.2016).

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