Healthcare in the crossfire

Despite the attempts of the United Nations to better protect healthcare staff and patients, attacks on medical facilities in conflict zones are of increasing concern. Bette Browne reports

Stop bombing hospitals. Stop bombing health workers. Stop bombing patients.” That was the plea to world leaders when the United Nations (UN) passed a resolution in 2016 to protect medical workers in conflict
zones. But five years on, brutal attacks are continuing almost unabated and often with impunity. “UN Resolution 2286 was prompted, in part, by the devastating US airstrikes on the Médecins Sans Frontières (MSF) trauma hospital in Kunduz, Afghanistan, in October 2015, which killed 42 people, and by subsequent aerial attacks in 2016 by states on hospitals in Syria and Yemen,” Ms Isabel Simpson, Executive Director of MSF Ireland, told the Medical Independent (MI).

“We saw the resolution as a political reassertion of the legitimacy and protected status of humanitarian medical
action at a time when MSF was under deadly aerial attack from states, including member states of the United Nations
Security Council or coalitions they backed.

“States were forced to publicly reassure the protection of medical activities and to stop the erosion of International Humanitarian Law (IHL). It further contributed to clarifying grey areas of IHL and acknowledging the legitimacy of our activities.” IHL, also known as the ‘laws of armed conflict’, regulate the conduct of war.

Impact

While world leaders were sufficiently shocked by the scale of attacks to support the passage of Resolution 2286, they
appear to have done little to effect change, according to data from humanitarian agencies. Attacks have continued to deprive communities of health services as well as placing the lives of patients and healthcare workers in danger.

The International Committee of the Red Cross recorded 3,780 attacks on healthcare providers and patients from 2016
to 2020. Of the 231 reported attacks to date in 2021, most have occurred in Syria, Afghanistan, Yemen, and Myanmar, according to World Health Organisation (WHO) data.

This summer has seen a litany of shocking attacks. On 24 May, the International Rescue Committee (IRC) announced
the death of Dr Louis Edward Saleh Ufew, an IRC staff member who died in Panyijiar County, South Sudan.

“We are deeply disturbed by these attacks and extremely saddened by the loss of our esteemed colleague. Following
the horrific and tragic death of Dr Louis, IRC has suspended all its humanitarian operations in Ganyliel Payam with
immediate effect because we are very concerned about the safety and wellbeing of our staff working on projects in the
area,” said Ms Caroline Sekyewa, IRC South Sudan Country Director in a statement after the attack.

“Attacks on humanitarian staff constitute a severe breach of international humanitarian law. We urge the local authorities to provide a guarantee of staff security so that we can continue to provide life-saving humanitarian services to host and displaced communities in South Sudan.”

Ethopia, Afghanistan, and Gaza

One month later, on 24 June, three MSF aid workers were killed in Ethiopia’s Tigray region. They were María Hernández, Yohannes Halefom Reda, and Tedros Gebremariam Gebremichael.

“No words can truly convey all our sadness, shock, and outrage over this horrific attack, nor can they soothe the
loss and suffering of their families and loved ones,” sai Ms Marta Cañas, MSF General Director, in a statement.
“We condemn this attack in the strongest possible terms and will be relentless in learning what happened. Maria, Yohannes, and Tedros were in Tigray providing assistance to people, and it is unthinkable that they paid for this work
with their lives.”

They are among at least 12 aid workers reported killed since fighting broke out last year between Ethiopia’s military and forces loyal to the region’s former ruling party, the Tigray People’s Liberation Front (TPLF). The conflict has resulted in the deaths of thousands of people and displaced more than two million

Reports of rights abuses have been widespread in Tigray and the warring parties have been accused by human rights
groups of occupying schools and attacking hospitals

UN Secretary-General Mr Antonio Guterres also denounced the killing and emphasised that those responsible
must be brought to justice. “This is totally unacceptable and an appalling violation of international humanitarian law.
The perpetrators must be found and severely punished.”

In 2019, a total of 483 aid workers were killed, kidnapped, or wounded, according to data from the Humanitarian Outcomes organisation. This was the highest number in the 20 years since it started keeping records. Of the 483 aid workers, 125 were killed, 234 were wounded and 124 were kidnapped.

In a particularly horrific and deadly attack on 12 May 2020 at the Dasht-e-Barchi Hospital – a facility supported by MSF
in the Afghan capital Kabul – 24 people were killed when attackers killed mothers and pregnant women in their beds.
MSF said the attack on a maternity ward had no precedent in MSF’s 50-year history.

On 16 May 2021, in Gaza, Israeli airstrikes damaged a MSF trauma and burns care clinic and killed at least 42
people in the vicinity. The clinic, which treats over 1,000 children a year, had to close.

As recently as 5 August, the UN expressed its deep concern about the safety and protection of tens of thousands of
people in Afghanistan, including those depending on hospitals and medical facilities. “There are reported increased
civilian casualties, destruction or damage to civilian houses, as well as to critical infrastructure and hospitals,” UN
spokesperson Mr Stephane Dujarric told reporters.

To coincide with the fifth anniversary of UN Resolution 2286, the Safeguarding Health in Conflict Coalition released its eighth annual report, documenting the global incidence of attacks and threats against health workers,
facilities, and transport.

It cited 806 incidents of violence against, or obstruction of, healthcare in 43 countries and territories in wars and
conflicts in 2020, ranging from the bombing of hospitals in Yemen to the abduction of doctors in Nigeria. The attacks included killings, kidnappings, and sexual assaults, as well as destruction and damage of health facilities and transport.

“The findings reveal that on the fifth anniversary of the UN Security Council’s Resolution 2286 on protection of healthcare in conflict, acts of violence against healthcare have not been curbed and impunity for those who commit them has remains a constant,” the report emphasised.

The organisation’s Chairperson Mr Leonard Rubenstein said while the reasons for violence were sometimes complex,
the explanation for impunity was not. “States have failed to fulfil their commitments to take action – individually or as
part of an international effort – to prevent such violence or hold the perpetrators accountable.

Action required

Ms Simpson also emphasised that the UN resolution was only a first step. She said it must be backed up with more concrete action by nations. “Whilst the resolution was an important political assertion at the highest political level, it is nevertheless not sufficient or cannot be considered as a standalone solution. Our teams and patients continue to witness and face horrific and unacceptable attacks. There have been over 500 attacks on healthcare so far in 2021. This includes attacks on patients, medical staff, ambulances, hospitals, and supplies. “Since 2015, we have marked the loss of 26 MSF staff who were killed while providing medical assistance in 10 separate incidents in Afghanistan, South Sudan, Yemen, Central African Republic, Syria, and Ethiopia.

This figure doesn’t account for the deaths of patients and care givers in these attacks, nor does it account for casualties in other attacks that have not been fatal. “MSF has also witnessed numerous signals – from accusations and smear campaigns to intense harassment and arrests of staff – across varying contexts that demonstrate to
us that the medical mission is being less and less respected. Words are not transforming into actions. Political leaders need to realise that Resolution 2286, as a political reassertion, was only the first step.”

Humanitarian organisations, including MSF, have already indicated the precise nature of the actions that could be taken. Ms Simpson told MI the steps should include the systematic inclusion of humanitarian exemptions in UN resolutions calling on states to implement counterterrorism and sanctions measures and the systematic inclusion of humanitarian exemptions in domestic counter-terrorism legislation.

“In fact, securitisation and anti-terror legislation further threaten the medical mission by impeding the provision of
humanitarian relief, as protected and authorised by international humanitarian law. Political leaders need to call on
states to take precise and concrete action to reassert the protection of the medical mission and explicitly upholding the
rules of international humanitarian law.”

Another major concern for aid groups is the move by some countries to seek to criminalise humanitarian action
in anti-terrorism measures. This concern was highlighted by Irish Ambassador Mr Brian Flynn at the UN Security
Council in a speech on 16 July.

“There is now a greater awareness of the extent to which these measures can limit humanitarian access, criminalise the delivery of assistance, or curtail the ability of NGOs to finance humanitarian operations in areas under the
control of sanctioned individuals and entities, including designated terrorist groups.”

He said Ireland, which now holds a seat at the Security Council, supports efforts to promote dialogue between
donors, regulators, banks, and international NGOs. He also emphasised that UN bodies working on countering
terrorism should engage systematically with humanitarian organisations.

“The Security Council also has a role to play in improving the protections for humanitarian actors in UN counter-terrorism and sanctions regimes, by including designation criteria sanctioning those that obstruct or harm humanitarian activity and actors, and providing for appropriate exemptions in sanctions regimes for humanitarian work.”

The Safeguarding Health in Conflict Coalition called on the UN Secretary-General to report on the actions and inactions of member states with respect to the commitments made five years ago. It recommended the appointment of a special rapporteur or representative to report on countries and themes as a step towards accountability.

While the direct loss of lives is tragic, the indirect impact of the loss of a medical facility to a given population
is also devastating. Each attack on health facilities means that thousands of people are deprived of urgent access to
medical care. The attacks can also affect the numbers volunteering with aid agencies.

Mr Jan Egeland, Secretary-General of the Norwegian Refugee Council, which employs some 15,000 aid staff globally,
said the international community needed to do far more to protect medical staff including volunteer workers.
“I’m really worried that there will be even fewer aid workers able and willing to stay and deliver in the worst hit conflict
areas in the future,” he told The Guardian last year.

“Already, we see fewer groups being able to stay and deliver in the worst areas and I fear it will be even thinner in the
future. We need governments, donors, diplomats, military leaders, and politicians to do more to protect our humanitarian workers. There must be a higher price for those who can now attack with apparent impunity.”

With Ireland a member of the Security Council until 2022, it could play a constructive role in ensuring UN members live up to their responsibilities in enforcing Resolution 2286 and advocate for measures to reinforce the protection
of medical workers “Since the Security Council adopted 2286 five years ago, we have seen increased recognition of the need to protect medical workers and facilities,” Ambassador Flynn, told a webinar in May. The webinar was organised by MSF Ireland, the Irish Red Cross, and DSA Ireland’s Humanitarian Action Study Group.

“Ireland has a long record of supporting the humanitarian and healthcare efforts around the world. And as members of
the Security Council, we are deeply conscious of the need to protect those doing such vital work.

“Since the Security Council adopted 2286 five years ago, we have seen increased recognition of the need to protect medical workers and facilities. Notwithstanding this, we’ve also seen a continuation of horrific attacks on healthcare facilities and workers and violations (of the Resolution).

“These attacks have a devastating impact on populations of those already in extremely fragile situations. In the first
five months of this year alone we’ve seen multiple attacks on medical workers, humanitarian staff, and health facilities.
“As a member of the Security Council, we have consistently highlighted (the need) to address these attacks. And,
of course, we highlighted the violations in Gaza or damage to clinics and hospitals from airstrikes. Unfortunately, this is
just to name a few instances.” However, as Ambassador Flynn also stated, words and good intentions were not enough.

“We need to find ways of making a real difference on the ground. This begins with speaking out where attacks take
place. We’ve also endorsed a call for humanitarian action made by France and Germany this year, an initiative that
aims to better fight impunity for attackers.” He said the concerns of humanitarian workers must be
included in drafting sanctions and anti-terror legislation. He acknowledged, however, that measures to hold those
responsible for violations are often blocked by one or more UN members.

“It comes back to having to political will to take the steps necessary, we cannot simply look the other way.”
The Irish Ambassador emphasised this point by quoting the words of former MSF International President Mr James
Orbinski: “We are not sure that words can always save lives, but we know that silence can certainly kill.”

Indeed, when Resolution 2286 was passed back in 2016, then MSF President Ms Joanne Liu charged that while the
Security Council was responsible for maintaining peace and security, four of its five permanent members had been associated with coalitions responsible for attacks on health structures over the previous year.

War crimes

In the intervening years, that situation has changed little. In a briefing to the UN Security Council regarding attacks
on health facilities and personnel in Syria in July 2019, Ms Susannah Sirkin, Director of Policy with the US-based group
Physicians for Human Rights, commented: “When hospitals are destroyed, the loss is far greater than the buildings. When medical workers are killed, the human toll is not just their lives, but also the exponential number of people who suffer and die without medical treatment.” Physicians for Human Rights branded such attacks as potential war crimes

“International humanitarian law requires special protections for medical personnel and facilities to ensure the functioning of healthcare throughout a conflict. International humanitarian law also prohibits the targeting of civilians, including wounded combatants receiving care. Any attack that deliberately targets healthcare facilities, or that does not take appropriate measures to avoid the destruction of healthcare facilities, is potentially a war crime.”
Ireland made its position clear at the UN Security Council meeting in July 2021 that when the Council fails to call for accountability for violations of international humanitarian law, a culture of impunity pervades from one conflict to the next.

“From Yemen to Syria to the Democratic Republic of the Congo, we continue to tolerate such impunity,” said Ambassador Flynn, urging the Council to ensure that clear measures should be in place to protect civilians and humanitarian missions.

He also pointed out that local medical and humanitarian staff – and notably women – were often at the forefront
of humanitarian responses and they could face greater pressure than their international colleagues from local authorities, community members, and security forces. Such challenges must be factored into planning for the security
of all staff, he stressed.

Ms Amina Mohammed, Deputy Secretary-General of the UN, told the meeting that attacks were making it ever more
difficult to provide humanitarian aid.

“Since late June, just one convoy of aid has been able to enter Tigray, where an estimated two million people are displaced and 5.2 million are in need of humanitarian assistance.
“In Afghanistan, aid workers, particularly women, face increased attacks, harassment and interference in their work.
And in Yemen, there were over 350 incidents involving restrictions on humanitarian organisations, personnel, and
goods in just two months earlier this year.”

She reiterated the Secretary-General’s calls for the Security Council to take strong and immediate action to support its
resolutions. To that end, she pointed out that the Council had access to an array of practical tools designed to foster greater respect for international humanitarian law.

These tools include facilitating the training of national militaries, applying diplomatic pressure and imposing sanctions
when no other remedies remained viable. She also stressed that clear lines should be drawn between military operations, political objectives and humanitarian efforts, and that counterterrorism measures must explicitly ensure that humanitarian workers are not punished for doing their jobs.

Irish role

Ms Simpson told MI that “at this critical juncture, the UN Security Council must not be content to sit on their laurels” and she emphasised the role Ireland could play on the Council. “As an elected member of the UN Security Council, Ireland now has the opportunity to highlight this as a priority issue and one that is necessary for the survival of impartial humanitarian and medical assistance. States must uphold the obligations that they have themselves undertaken to be bound by in order to protect fundamental humanitarian principles, including humanitarian and medical assistance for all.”

But attacks on the medical mission must be viewed more broadly than the string of aerial attacks on health facilities
that triggered the adoption of Resolution 2286 in the first place, she said.

“Whilst this still constitutes a threat to humanitarian and medical assistance, today the medical mission is also menaced in less internationally visible ways. In situations where violence and conflict are permeated with a counter-terrorism
element, or where states of emergency are declared, there is no longer any space for impartial humanitarian and medical assistance to all populations in need.

“Relief to populations in need present in areas controlled by non-state armed groups, designated as criminals or terrorists, is considered as financing or material support to terrorists or criminal groups.
“Simply put, anti-terrorism laws tacitly criminalise humanitarian action. As long as states do not clearly and unequivocally exempt humanitarian actors under these laws when they provide exclusively medical and humanitarian relief, then humanitarian and medical facilities and personnel will be endangered.
“International Humanitarian Law protection of medical care is intended to allow doctors, medical and humanitarian personnel to provide necessary medical treatment to all persons. Without this protection and with the constant fear
of being attacked, pressured or harassed for the sole reason of providing medical care, doctors can simply not work.”