Editor's note: This is the second of a two-part series. The first part was posted on Oct. 7.

Why would anyone, combatants or not, attack a virtually defenseless hospital?

Hospitals, their staff members and patients were protected by the Geneva Conventions of 1949, which declared that innocent civilians were to be spared in time of war. The conventions' additional protocols of 1977 stated specifically that, "The civilian population and individual civilians shall enjoy general protection against the dangers arising from military operations."

Emma Daly, in an essay for the Crimes of War Education Project, adds, "The wounded, sick, or shipwrecked military personnel who are considered to be hors de combat [that is, not involved in fighting, such as field medics], are protected, as are prisoners of war. Hospitals, both fixed and mobile, ambulances, hospital ships, medical aircraft and medical personnel — whether civilian or military — are also entitled to protection from hostile fire under the Geneva Conventions, provided that structures are marked with a red cross or red crescent and not used improperly or near military objectives, and staff are properly protected. Staff include not only doctors, nurses and orderlies, but the drivers, cleaners, cooks and crews of hospital ships — in short, all those who help a medical unit to function. Some aid workers — for example, Red Cross volunteers treating the sick and wounded on the battlefield — are also covered, as are military chaplains."

Yet these prohibitions are regularly ignored.

Leonard Rubenstein, J.D., chairman of the Safeguarding Health in Conflict coalition, which seeks to protect hospitals, other health care facilities, ambulances, staff members and patients in times of strife, says that there are several major reasons and common themes involved in attacks on hospitals. These include:

  • Military forces and non-state armed groups sometimes see securing a military advantage or political objective as a higher priority than their legal responsibilities to refrain from interfering with health care facilities and personnel.
  • Despite their legal obligations to allow medical care without regard to the person's military or political affiliations, military forces and non-state armed groups sometimes seek to deny medical care and health care resources to opposing fighters and, in some cases, to civilians thought to be supportive of the enemy, by such tactics as arresting, harassing or punishing medical personnel who provide such care.
  • In some cases, health care facilities and personnel serving a population are attacked as part of a campaign of ethnic cleansing or other forced population movement or genocide.
  • In other cases, military forces or non-state armed groups are not aware of their legal obligations, which include restrictions on occupation of health facilities and allowing passage of ambulances through checkpoints.
  • Rubenstein adds that "respect for impartial medical care is often resisted by combatants because of the political or military advantage [that] interference with health care can provide." Indeed, combatants have been known to take advantage of medical facilities or symbols to gain such an advantage, as when the Serbian military painted red crosses on vehicles carrying armed troops to avoid NATO bombing during the fighting in Kosovo in 1999.
  • Also, sometimes combatants store weapons in hospitals; they also may use them as shelter for armed fighters or even as a base for missile or rocket-propelled grenade attacks. Indeed, in October of this year, Islamic State, or ISIS, fighters in Iraq took over a hospital that was under construction in the town of Rabia and used it as a base for sniper attacks. After days of combat and air strikes on the building, Kurdish troops took it; most of the ISIS fighters were killed. One Kurdish soldier said afterward, "We were about to get the hospital, but they had really good snipers there."

Hardly the kind of words one wants to hear about a healing institution. The hospital was destroyed during the battle, and will not be able to serve the people of Rabia.

Unique Circumstances

Trying to comprehend why these attacks occur is complicated by the fact that each instance is unique. In the Cambodian holocaust of 1975–79, educated staff members, not the hospitals, were the targets. The Khmer Rouge concept of a classless society did not allow for such people, nor did it allow for Western medicine — except, of course, in a stunning example of hypocrisy, for its own elite leaders and fighters. Most Cambodian hospitals were destroyed by abandonment and neglect, not as a matter of intent.

The situation in Vukovar, Croatia, in 1991, although rooted in genocide, could also well have involved pent-up anger. Serb forces had planned to conquer Vukovar and then move on to invade larger cities in the eastern Croatian region of Slavonia; as it was, they were stalled for three months at Vukovar and were unable to proceed further. They also lost a large number of troops and tanks and, thus, likely were both frustrated and enraged.

Alenka Mirkovic-Nad, former acting director of the Vukovar Homeland War Memorial Center, who as a journalist was covering the fall of Vukovar for the BBC, "Sky News" and other media outlets before she was forced to run for her life (several of her journalist colleagues were killed), told me in a 2013 interview in Vukovar that she attributes the slaughter of nearly 300 patients and staff members at the town's hospital to "pure rage."

Furthermore, the hospital was caring for wounded Croat soldiers as well as civilians, and the Serbs likely did not want them returning to the fight. It should be noted that the hospital also was treating Serbian patients.

Eric Dachy, M.D., who was head of Médecins Sans Frontières (MSF or Doctors Without Borders) in Belgrade at the time, told me, "They [the Serbs] were not going to let one enemy escape. I don't think they took many prisoners … . But there was nothing special in the way the JNA [the Yugoslav National Army, in its Croatian acronym] treated the Vukovar hospital; they did the same thing in Bosnia [in 1992–95]. They killed all the men older than a certain age. In Vukovar, as in Srebrenica in Bosnia, they felt they had to do this because so many of the hospital patients were soldiers who had been fighting against them."

He adds that he does not believe that the Serbs wanted to destroy the Vukovar hospital entirely, because "they were very skilled with artillery" and that if they had wanted to "flatten" the hospital, they easily could have done so. And, in fact, after Vukovar fell and was "ethnically cleansed," the JNA attempted to operate the hospital, which was eventually returned to Croatian control, reconstructed and reopened.

The Rwandan genocide of 1994 has confounded those who have tried to comprehend it. There were many factors at work: The majority Hutus resented the privileges of the Tutsi minority, the possibility of acquiring the property of dead Tutsis in a low-income society was very tempting, peer pressure was extremely powerful, those who would not kill were threatened, there was a constant drumbeat of encouragement to murder Tutsis from radio broadcasts and Interahamwe [radical Hutu militias], and there was widespread fear — reinforced by Hutu Power proponents at every turn — that Tutsis might be planning to kill Hutus.

History also likely played a role. Adam Hochschild, professor of journalism at the University of California, has theorized that the brutal colonial period in this part of Africa may have left, as part of its grim legacy, a tendency on the part of contemporary Africans to emulate the cruelty of their ancestors' European overseers.

Although colonialism is often cited, justifiably, as a factor by those seeking to comprehend ongoing violence in Africa, it is insufficient to explain a catastrophe as vast as the Rwandan genocide, during which as many as a million people may have been killed in less than four months. It also does not explain the participation of tens of thousands of educated Rwandans, including health care professionals, in the killing, especially when it occurred in hospitals.

Mahmood Mamdani, director of the Makerere Institute of Social Research in Uganda, has written, "That victims looking for a sanctuary should seek out churches, schools and hospitals as places for shelter is totally understandable. But that they should be killed without any let or hindrance — even lured to these places for that purpose — is not at all understandable. As places of shelter turned into slaughterhouses, those pledged to heal or nurture life set about extinguishing it, methodically and deliberately. That the professions most closely associated with valuing life — doctors and nurses, priests and teachers, human rights activists — got embroiled in taking it is probably the most troubling question of the Rwandan genocide."

Perhaps the best observation was offered by Cassius Niyonsaba, who was a small boy when his entire family was slaughtered, and who told historian Jean Hatzfeld, "The truth about the killing of Tutsis is beyond each and every one of us."

No Excuse

More recent incidents also challenge explanation. Perhaps the best-documented situation is the long-running conflict in Syria, in which both pro- and antigovernment forces have not only targeted hospitals and their staffs and patients, but also have added torture to the unhappy list of actions taken against providers. Last year, a United Nations report cited the Syrian government as the worst offender, alleging that "Government forces deny medical care to those from opposition-controlled and -affiliated areas as a matter of policy." Furthermore, the report states, "Government forces have strategically assaulted hospitals and medical units to deprive persons perceived to be affiliated with the opposition of medical care."

The report adds that "government forces have engaged in agonizing cruelty against the sick and wounded," including using hospitals as sites of torture inflicted on staff and patients alike, even children, who have been "beaten, burned with cigarettes and subjected to torture that exploits pre-existing injuries."

However, the report said, opposition forces are also guilty of attacks, including one on a government hospital in the city of Homs in 2012. Each side clearly wants to deprive the other of access to care for its combatants and sympathetic civilians.

That certainly seems to be the government's motivation: Its forces have detained, arrested and sometimes tortured physicians, nurses, ambulance drivers, humanitarian volunteers and others who provide care to rebels or civilians who are opposed to the government. Other health care workers simply have disappeared. The government apparently justifies this on the basis of "antiterrorism" laws issued in 2012 that "effectively criminalized medical aid to the opposition," according to the UN report.

Burning sick and injured children with cigarettes in hospitals, however, defies any explanation. No military objective can justify it. There is simply no excuse for such behavior.

The Imperative to Protect Hospitals

Whether the reasons can be comprehended or not, attacks on hospitals must be prevented. Rubenstein suggests reinforcing and ensuring adherence to existing norms (such as are codified in the Geneva Conventions) and collecting data; there is simply not much information available in many instances. He also stresses the need for accountability, which would "raise the cost of an attack." And he advises that hospitals themselves must be better prepared, with stronger early-warning systems, better surveillance and more robust security arrangements.

His organization also advocates commitment by governments and "non-state actors" to forbear from attacking or obstructing health care services, enhanced visibility for the issue and better understanding of the nature and extent of attacks, systematic documentation and reporting, "vigorous" action to ensure accountability when attacks occur, practical strategies to prevent violence against health care entities, and "repeal of laws that render the provision of impartial care a crime."

MSF also has launched a project, Medical Care Under Fire, which seeks to learn more about violence against hospitals and health care activities and practitioners, and how to prevent it. Françoise Duroch, Ph.D., who is the project manager for the effort, told me in a recent interview, "In the middle of conflict, especially civil war, hospitals are in many cases not exempt from the general violence that the civilian population is faced with on a daily basis."

She concurs that the reasons for attacks are complex, ranging from a desire to acquire medications or other hospital supplies to unhappiness with care to an effort to deprive the enemy of a valued resource. "We've been faced with this issue since MSF was created, but we have mainly dealt with it in the field, and never analyzed the problem more globally. We [MSF] are now present in more countries, with more humanitarian workers on the ground, and are much more exposed to facing attacks than we were in the past," Duroch says. "The reality is that we must have a better understanding of why these attacks occur. Although we cannot control our environment, we need to see if there are ways in which we can mitigate the risks and safeguard access to medical care for thousands of people in need."

The International Committee of the Red Cross and the Red Crescent are supporting a project, Health Care in Danger, which includes both "legal and practical initiatives." These include providing information about international humanitarian law to key stakeholders and encouraging incorporation of that law into domestic legislation, seeking to increase the knowledge of stakeholders about the rules governing both health care providers and combatants, appealing to all participants in conflict to not obstruct provision of care, and reporting allegations of violation of international law.

Health Care in Danger also provides on-the-ground services, such as negotiating safe passage for health care providers and patients, including those in need of vaccination, and "fast-track" permission for ambulances to get through checkpoints; bolstering protection of provider facilities through provision of sandbags and bomb-blast film for windows and creating bunkers; control of the use of Red Cross and Red Crescent symbols; collection of weapons at hospital entrances; providing global positioning system information on the location of health care facilities to all sides in conflict areas (which, needless to say, could be a double-edged sword); and conducting activities designed to make both access to and provision of care easier in troubled places.

Governments also can provide direct assistance as well as honoring existing laws and conventions. Indeed, in Yemen on June 28 of this year, government troops repelled an attempted attack on a military hospital in the south of that country; four attackers and two soldiers were killed, but no one in the hospital was injured.

Speaking Out

At least one more action is needed to stem this frightening tide, and that is for the world's health care community to recognize the problem and make it more visible. Rubenstein has written, "The medical community has a responsibility to speak out collectively to protect health workers in fulfillment of their ethical duties to the people in their care without risk of arrest or attack on themselves or medical facilities."

Hospitals constitute a worldwide community of healing, and even if they are not all equally vulnerable, they have an obligation to support and protect each other.

As part of this commitment, hospitals must do their part. To the extent that they can — and this is not always possible — they should:

  • refuse to serve as a haven for active combatants;
  • not allow weapons on the premises (MSF insists on this as a condition of its working in a hospital);
  • not allow attacks to be launched from their premises.

However, if armed combatants invade a hospital and insist on using it for cover or conducting their fight from its premises, the hospital may not be able to prevent them from doing so. And that endangers everyone there.

As the UN report on the atrocities in Syria states, "Using hospitals, outside their humanitarian function, for acts harmful to the enemy, such as sheltering able-bodied combatants, storing arms or ammunition, as military observation posts or shield for military action, leads to a loss of their protection, exposing such hospitals to a risk of attack."

Special Cases

There are also two special situations for which there are few answers. One is military hospitals, which recently have been attacked in both Yemen and Ukraine, among other places. Obviously, they are likely to be caring for the wounded combatants of one side or another, and thus are tempting targets for opposing forces. However, the patients are still wounded, and a hospital is still a hospital. These facilities are at enhanced risk, and a solution for their predicament is sorely needed.

Also, as occurred in most of the situations described here, civilians often seek shelter in hospitals in times of strife, because they still believe that hospitals will not be attacked. Their presence is a problem in numerous ways: They need to be fed, must use toilet facilities and have other needs. They also take up space that may be critically needed. Often, they also wish to be of assistance, which is usually more hindrance than help. And, unfortunately, combatants or terrorists could masquerade as innocent civilians and use the hospital for cover.

Nonetheless, hospitals are not in the habit of turning away neighbors in need, whether in the aftermath of Hurricane Katrina, where providing shelter to healthy non-patients and, sometimes, their pets was a common practice even among badly stressed providers, or in times of violent conflict. What civilians seeking sanctuary must understand is that if hospitals cannot protect themselves, they cannot protect their uninvited visitors either.

In issuing a call to action on this issue, Jason Cone and Duroch of MSF wrote, "The protection of the sick and wounded lies at the heart of the Geneva Conventions. It is incumbent upon medical aid organizations to find a means of negotiating safe space for their staff and patients. Violence in all its forms — against health facilities and personnel — represents one of the most serious, complicated, and neglected humanitarian and security issues. The medical act benefits everyone, and anyone in need should be able to access it unconditionally."

Everyone's Problem

There are those who would dismiss this issue as relevant only to the Third World or a few violent "hot spots," not developed nations. It is a fallacious belief.

First, every year thousands of physicians, nurses and other health care professionals go overseas on humanitarian missions; they understand that their safety may be at risk, but they are determined to serve anyway. To not protect these people to the utmost extent possible is to threaten one of the greatest and most admirable outpourings of clinical service anywhere, and could discourage what many clinicians report is one of the most valuable experiences of their professional and personal lives.

Furthermore, when a health care humanitarian organization is forced to withdraw its services from a country — as MSF has felt obliged to do in the Central African Republic, Somalia and South Sudan — the heaviest price is paid by thousands of innocent civilians who are thereby deprived of access to care.

Second, the damage caused by these attacks does not cease when the crisis is over. The trauma inflicted on survivors — patients, caregivers and witnesses alike — can last for decades. Even seasoned medical volunteers who have survived report that they have not fully recovered from what they experienced and, based on my research on post-traumatic stress among survivors of the Cambodian holocaust, I fear that they may never do so.

Third, most developed nations have a somewhat naïve belief that "it can't happen here." Although there have been incidents at American hospitals, almost all the result of personal domestic conflicts involving a staff member, there is still a pervasive belief that no one would really attack a North American or European or North Asian hospital and kill patients or staff members — even though it already has occurred in Ukraine.

The problem with this mindset is that prior to September 2001, no one conceived of anyone ramming commercial jets into the World Trade Center or the Pentagon. Prior to December 2012 in Connecticut, it was inconceivable that someone would attack first-graders with a semiautomatic rifle. The town of Dunblane, Scotland, hardly expected a gunman to kill 17 people in its primary school in 1996. Norwegians did not anticipate a gunman slaughtering 77 people in an antigovernment frenzy in 1991.

Tourists in Tasmania could not possible anticipate that 35 people would be fatally shot by an assailant in the national park at Port Arthur in 1996. Residents of Tokyo in 1995 and London in 2005 did not foresee that their subways would be assaulted. All these incidents occurred in developed countries.

An unprotected hospital can be attacked anywhere, at any time.

For example, on July 10, 2014, perhaps coincidentally shortly after the outbreak of renewed violence in Gaza, a major urban U.S. Jewish teaching hospital received a threatening phone call. Heavily armed police responded quickly and the hospital went into lockdown for approximately four hours. Although the police response was speedy, the hospital likely could not have defended itself if the call had been followed by an immediate attack.

The Hospital as a Sanctuary

Finally, the idea of a hospital as a sanctuary is a concept worth honoring. It would be a much kinder world if all putative sanctuaries — places of worship, schools and hospitals — were considered sacrosanct in terms of armed attack. But that has never been true of places of worship, and has long since ceased being true of schools. Hospitals are the only remaining sanctuary acknowledged by most of the world.

Evidence of that was provided by al-Qaida of the Arabian Peninsula — an organization not known for expressing regret over its actions — which felt compelled to apologize for the attack on the hospital in Yemen.

Furthermore, the situation of those within hospitals is unique, in that most of them, even though they are adults, cannot protect themselves. That is the frailty, the innocence and the importance of a sanctuary.

Marco Baldan, M.D., chief war surgeon for the ICRC, has said, "One of the first victims of war is the health care system itself." If we cannot or will not protect these most vulnerable of places and people, then we will not only have failed as a health care sector and as professionals engaged in healing work; we will have failed ourselves as a human community. As Rony Zachariah, M.D., who survived the Rwandan genocide, says, "When humanity fails, we all fail."

Logo of the memorial in the new hospital in Vukovar, Croatia.
 Representing a red cross riddled with bullet holes, it was designed by Ivica Propadalo and Zeljko Kovacic. In English, the words mean "Place of Remembrance, Vukovar Hospital, 1991."

Acknowledgements

This article is the result of more than a year of research, including site visits to Cambodia and Croatia and extensive telephone interviews. All activities were funded by the author; there was no outside financial support.

Participation in interviews with the author, provision of logistical support, language interpretation, review of the manuscript and other assistance were provided by: George Annas, J.D., M.P.H., chairman, Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health; Maureen Bisognano, president and CEO, Institute for Healthcare Improvement, Cambridge, Mass.; Eric Dachy, M.D., Linkebeek, Belgium; Françoise Duroch, Ph.D., Medical Care Under Fire project manager, Médecins Sans Frontières International Office, Geneva; Renée Fox, Ph.D., Philadelphia; Maria Friedman, D.B.A., Silver Spring, Md.; Hun Chhunly, M.D., Phnom Penh, Cambodia; Rudolf Klen, emeritus professor of social policy, University of Bath, England, and visiting professor at the London School of Economics and the London School of Hygiene, London; Binazija Kolesar, R.N., adviser to the director, Vukovar General Hospital, Vukovar, Croatia; John C. Lewin, M.D., president and CEO, Cardiovascular Research Foundation, New York; Alenka Mirkovic-Nad, acting director, Vukovar Homeland War Memorial Center, Vukovar, Croatia; Ksenija Mitrovic, assistant professor, Wake Technical Community College, Raleigh, N.C.; Jasna Rogic-Namacinski, specialist, clinical chemistry and laboratory medicine, Vukovar General Hospital, Vukovar, Croatia; Leonard S. Rubenstein, J.D., senior scholar, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore; Alan Sager, Ph.D., professor of health management, Boston University School of Public Health, Boston; Marjorie Smelstor, Ph.D., Overland Park, Kan.; Tim Shenk, press officer, Doctors Without Borders-USA, New York; Judith Swazey, Ph.D., Bar Harbor, Maine; Maurits van Pelt, executive director, MoPoTsyo, Phnom Penh, Cambodia; Michelle Vachon, Phnom Penh, Cambodia; Kam Vuthy, Phnom Penh, Cambodia; Rony Zachariah, M.D., coordinator, operational research and strategic adviser (DG-Luxembourg), Médecins Sans Frontières — Brussels Operational Center, Luxembourg.

Dedication

This article is dedicated to the dead and survivors of all hospital attacks, and especially to those physicians, nurses and other health care personnel who risked their lives, and sometimes lost them, while seeking to protect their patients.

Recommended Readings

Abdulrazzaq al-Saedi and Richard Sollom. Syria: Attacks on Doctors, Patients, and Hospitals. Physicians for Human Rights, December 2011.
Hun Chhunly, M.D. The Life of a Physician under the Khmer Rouge Regime. Self-published in Khmer, Phnom Penh, Cambodia, 2010. English-language version pending.
Jason Cone and Francoise Duroch. "Don't shoot the ambulance: Medicine in the crossfire." World Policy Journal, fall 2013.
Nick Cumming-Bruce. U.N. reports Syria uses hospital attacks as a "weapon of war." New York Times, Sept. 13, 2013.
Roméo Dallaire. Shake Hands with the Devil: The Failure of Humanity in Rwanda. Da Capo Press, Philadelphia, 2003.
Emma Daly. Immunity from attack. Crimes of War Education Project. http://www.crimesofwar.org/a-z-guide/immunity-from-attack.
Renée C. Fox. Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières. Johns Hopkins University Press, Baltimore, 2014.
Philip Gourevitch. We Wish to Inform You That Tomorrow We Will Be Killed with Our Families. Farrar, Straus and Giroux, New York, 1998.
Jean Hatzfeld. Into the Quick of Life — The Rwandan Genocide: The Survivors Speak. Serpent's Tail Books, London, 2008.
Jean Hatzfeld. Machete Season: The Killers in Rwanda Speak. Picador Books, New York, 2005.
Adam Hochschild. King Leopold's Ghost. Mariner Books, New York, 1999.
International Committee of the Red Cross. Health Care in Danger: Making the Case. August 2011. http://www.icrc.org/eng/resources/documents/publication/p4072.htm.
Mahmood Mamdani. When Victims Become Killers. Princeton University Press, Princeton, N.J., 2001.
Haing Ngor and Roger Warner. Survival in the Killing Fields. Constable & Robinson Ltd., London, 2003.
Office of the United Nations High Commissioner for Human Rights. Assault on Medical Care in Syria. Sept. 13, 2013. www.ohchr.org/EN/HRBodies/HRC/RegularSessions/Session24/Documents/A-HRC-24-CRP-2.doc
Leonard Rubenstein. Responsibility for protection of medical workers and facilities in armed conflict. Lancet, vol. 375, Jan. 23, 2010.
William Shawcross. Sideshow: Kissinger, Nixon, and the Destruction of Cambodia. Cooper Square Books, New York, 2002.
William Shawcross. The Quality of Mercy: Cambodia, Holocaust and Modern Conscience Simon & Schuster, New York, 1985.
William Shawcross. Deliver Us from Evil: Peacekeepers, Warlords and a World of Endless Conflict. Touchstone (subsidiary of Simon & Schuster), New York, 2000.

Online Resources

Center for Health Care Emergency Readiness. www.chcer.net
Crimes of War. www.crimesofwar.org
Doctors Without Borders/Médecins Sans Frontières. www.doctorswithoutborders.org/our-work/humanitarian-issues/armed-conflict
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