Editor's note: This piece is the first of a two-part series. The second part will be posted in early December.

In human tradition, three types of institutions have been considered safe in times of violence and civil strife; that is, it is expected that they will be exempt from armed attack. These institutions are places of worship, schools and hospitals.

Unfortunately, this is more myth than fact. History is rife with examples of churches, synagogues, mosques and other sites of worship being violated, including a 2012 shooting in a Sikh temple in Wisconsin that killed six innocent victims; the killer took his own life. Schools also have been subject to violence all over the world.

But, it has generally been assumed that hospitals are still off-limits in times of conflict because of the healing nature of their work and the vulnerability of their unarmed staff and patients. Until the second half of the 20th century, this was a largely valid belief, although there is evidence of some hospitals having been attacked earlier in wartime.

An Unwelcome Trend

Unfortunately, in today's angry environment, healing institutions are no longer sacrosanct. In recent years, hospitals in several countries have been invaded by armed parties who have terrorized, kidnapped or killed staff members and patients in Afghanistan; the Central African Republic; Kiev and Crimea, Ukraine; South Sudan; and Yemen, among other places.

The Yemen attack, in which 52 people were killed and 167 wounded in December 2013, was filmed by a security camera; the video was posted on YouTube, sparking widespread protest and an apology from al-Qaida of the Arabian Peninsula, at least one of whose fighters was responsible.

Hospitals reportedly also have been damaged recently by missiles or bombs in Syria and in Gaza; in the latter case, Israeli and Gaza representatives each have blamed the other side for the incidents.

This unwelcome trend began earlier, however. During the Biafran War in Nigeria in 1968, physician volunteers reported that Nigerian government troops intentionally targeted Biafran hospitals, according to Médecins Sans Frontières (MSF, or Doctors Without Borders). Some of those physicians went on to form MSF in 1971.

There were also dreadful incidents of hospitals, staff members and patients being attacked in Cambodia in 1975–79, Croatia in 1991 and Rwanda in 1994, among others.

It is difficult to comprehend why the basic right of sick and injured human beings and their caregivers to be safe from harm increasingly is being ignored.

In order to do so — and, equally important, to try to stop this from happening — examining the lessons of documented situations from the recent past is helpful.

Cambodia, 1975–79

After six years of U.S. bombing and civil war, Cambodia's capital city, Phnom Penh, fell on April 17, 1975, to a shadowy radical Communist force commonly known as the Khmer Rouge. The KR pursued a vision of a ruthless agrarian socialism, under which all people would live in the countryside, growing rice on collective farms. There would be no class distinctions, no intellectual superiority.

There are many ways to achieve such an end; the KR's approach was to empty the cities and murder most educated people, including health care professionals. Survivors were forced to work in rice-growing collectives that were, essentially, concentration camps. During the four years of KR rule, it is estimated that 1.5– 2 million Cambodians were murdered or died of starvation, exhaustion or untreated disease.

When Phnom Penh fell, hospitals were among the first targets. William Shawcross, who has chronicled the Cambodian tragedy, described the scene when Phnom Penh's hospitals fell to the KR: "The soldiers marched through the wards, and then they ordered all those patients who could walk to get off their beds and push out through the doors those who could not move. And so, in the heat of the day, a most dreadful parade began. From hospitals all over the city crawled and hobbled the casualties of the war, the first victims of the ‘peace.'" None is known to have survived.

Haing Ngor, an obstetrician in Phnom Penh who was one of only a handful of Cambodian physicians to survive the KR period, was operating on a wounded soldier when an armed KR guerrilla burst into the hospital surgical area, demanding that the physicians identify themselves. He then left. "The patient was lying on the table behind me, unconscious. His intestines were back in place, but we hadn't finished sewing him up," Haing later wrote in his autobiography. Realizing that their lives were at risk and that they could not protect their patient, he and his colleagues abandoned the hospital. "We took a last look at the poor young soldier on the table with pale, waxen skin and the long open incision in his belly. He was going to die.

"All my illusions were gone. They had broken into the sanctuary of the operating room."

(Haing eventually found his way to the United States, where, in 1984, he played Cambodian journalist and photographer Dith Pran in the film The Killing Fields, for which he won an Academy Award for best supporting actor in 1985. He was the first male Asian, and only the second nonprofessional actor, to be so honored. He was murdered near his home in Los Angeles in 1996; three members of an Asian street gang were convicted of his killing, which the police classified as a random street crime, although many people believe that he was murdered on the orders of surviving leaders of the KR.)

Part of the KR's plan was a return to Cambodian folk medicine for everyone but the KR leaders, soldiers and elite cadres, who had the convenience of Western medicine at a few select hospitals. Haing quoted one cadre leader: "We don't need doctors anymore. If someone needs to have their intestines removed, I will do it. It is easy. There is no need to learn how to do it by going to school."

Given that philosophy, it is not surprising that most of the physicians, nurses and other health care professionals in Cambodia died at the hands of the KR; although estimates vary, it is possible that as few as 25 physicians survived. One of them is Hun Chhunly, who was a civilian physician in the city of Battambang until he was required to join the army as a second lieutenant in 1973 and work in a military hospital.

That hospital was taken by the KR on April 20, 1975. In an interview with me in Phnom Penh earlier this year, Hun reported that, arriving at the hospital the next day, he learned that all of his physician colleagues holding the rank of first lieutenant or higher had been taken away by the KR and murdered.

From July 1975 to October 1976, Hun worked at that same facility (Military Hospital P2), treating the KR elite who had denied effective medical care to the rest of the population. Although the hospital was substandard and resources thin, decent care could still be delivered. In November 1976, Hun was transferred to Civilian Hospital P1, the former Battambang Hospital, which was in dreadful shape, without running water or electricity. Many patients died of treatable disease, and others died as the result of barbaric medical experiments reminiscent of the Nazi period, including the use of a Buddhist monastery crematorium to dispose of the subjects; some were still alive when incinerated.

Hun concludes, "In short, the military hospital was a facility for taking care of and for promoting the health of Angkar's [the KR's name for its organization] Khmer Rouge soldiers. The civilian hospital was merely an antechamber of death for the Cambodian people."

Most hospitals were abandoned, intentionally damaged or looted and, according to attorney Laura Vilim, who has documented health care practices under the KR (such as they were), "in addition to hospitals, hubs of medical knowledge were destroyed. The Library of the Medical Faculty in Phnom Penh … was raided and its collection set on fire. The Phnom Penh Medical School was emptied of its students … and its laboratory equipment, which was thrown onto the sidewalks."

The carnage ended with the Vietnamese victory over the KR in 1979 and the subsequent 10-year occupation of Cambodia by that country. In the years since, Cambodia has struggled to rebuild its health care delivery system and workforce — a process that has proven to be agonizingly slow and difficult. (See the two-part article "Starting from Scratch," published in June and August of 2009.)

Vukovar, Croatia, 1991

One of many results of the dissolution of Yugoslavia in 1990–91 was the Croatian War for Independence, which set autonomy-minded Croatians against the forces of Serbian President Slobodan Miloševic, who envisioned a "Greater Serbia" that would include most former Yugoslav entities — with most non-Serbs removed. The Croatian city of Vukovar, located near the Serbian border, became an early target and was attacked in August 1991. It was subjected to siege and constant bombardment by the Yugoslav National Army (JNA in its Croatian acronym) and paramilitary forces, and became the first European city to be entirely destroyed by armed action since World War II.

The town's hospital was not spared. It was shelled and bombed constantly during the 87-day siege. It became obvious that the hospital's patients and staff would not survive above ground, so much of the operation was moved into the basement, where patients were stacked in bunks three high along the main corridor. The staff, led by the chief nurse, Binazija Kolesar, carried on, sometimes receiving 70 patients a day (most with shrapnel wounds) and operating an intensive care unit, a neonatal unit, a birthing unit, a surgical suite and a casting room, among other services. "The hospital was operational from Day 1 until the city fell, under these impossible conditions," Kolesar recalled in an interview with me in Vukovar in 2013. "But almost anything in health care can be improvised."

MSF had evacuated 105 patients on Oct. 19, but the hospital was full, as it always was, when Vukovar fell to the Serbs on Nov. 18. Many civilians, and possibly armed Croatian soldiers (although the latter attestation has not been documented), had sought shelter there as well. Evacuation of patients and staff, negotiated by the International Committee of the Red Cross, was scheduled for Nov. 20, but Serb forces attacked the hospital on Nov. 19.

Many of those who had sought refuge there were forced to leave; men and women were separated and most of the men were taken away by the JNA and Serb paramilitary forces. On Nov. 20, medical staff members were called to a meeting, where they had to listen to a speech by a JNA officer. At the same time, the hospital was being emptied of Croatian staff, ambulatory patients and any remaining civilians; the men among them, and at least one woman, were taken away.

Although statistics are not entirely reliable because the attackers removed almost all documentation from the hospital, it is believed that 267 patients and staff were transported to the warehouses of Ovcara, a nearby pig farm, where they were beaten and tortured. They were then taken to a field on the farm and summarily shot to death. Some of their bodies were thrown into a pit partially filled with pig carcasses. The rest of the bodies have not been found.

Among hospital staff members who were killed were the barber, cook, electrician, chief of maintenance, plumber, at least one nurse and all but one ambulance driver, who was mistaken for a physician and removed from the bus that was taking the rest to be murdered. He is still driving an ambulance for the hospital, which was rebuilt over the years; repairs were completed in 2007. No physicians were killed, although most of them spent time in prison camps. The hospital dentist also was spared.

There were 54 patients left in the hospital, either because they were too sick to be moved by normal transport or because there was a shortage of vehicles. The Serbs loaded them into ambulances and buses and drove them on a circuitous route that included Bosnia before they were turned over to Croatian authorities, who hospitalized them in other parts of the country. The patients were accompanied by Kolesar and other hospital staff members who had refused to abandon them.

Eric Dachy, a Belgian physician who was MSF chief of mission in Belgrade at the time, arrived in Vukovar on Nov. 20. "I could see how the hospital had been shelled, and some of the patients appeared to be starving," he told me in a recent interview. "I understood that the Serbs took the men, even the wounded, and it was expected that they would be killed. There was nothing that I could say or do. Very quickly, the hospital was emptied. The building was completely devastated."

Most surviving staff members were either sent to prison camps or "ethnically cleansed" and forced out of Vukovar; some volunteered to remain at the hospital, which the JNA attempted to operate. Others, who were in internal exile for years, have since returned.

On Dec. 9, 2013, Binazija Kolesar was awarded the Florence Nightingale Medal, the nursing profession's highest international honor, by the ICRC for showing "exceptional courage and devotion to the victims of armed conflict or natural disaster."

Rwanda, 1994

The tragic, tangled history that led to the genocide in Rwanda in 1994 has been well-documented. In brief, for hundreds of years, the Tutsi tribe had ruled the country, subjugating the majority Hutus. After the death of the Tutsi king in 1959, Hutus seized power and, over the next 25 years, Hutus and Tutsis periodically fought for control of the country, with atrocities committed by both sides.

In 1973, the army chief of staff, Juvénal Habyarimana, a Hutu, seized power and became president, inaugurating a period of Hutu supremacy in many aspects of Rwandan life. Some radical Hutus, especially armed militia groups known as the Interahamwe, wanted to go further and exterminate the Tutsi minority, but there were only sporadic killings until April 6, 1994, when a plane carrying Habyarimana and Burundi president Cyprien Ntaryamira was shot down (no one has ever admitted responsibility).

The next day, led by the Interahamwe and others, thousands of Hutus, armed with machetes, clubs and sometimes firearms, began an organized campaign of genocide against Tutsis. The killers included farmers, small businessmen, politicians, physicians, attorneys and even humanitarian aid workers.

At approximately the same time, an expatriate Tutsi army based in Uganda, the Rwandan Patriotic Front (RPF), invaded Rwanda, bent on reclaiming power for Tutsis, and was moving toward the capital of Kigali.

Rwandan hospitals were targeted. In the town of Nyamata, the Sainte-Marthe Maternity Hospital was attacked by Hutu soldiers and the Interahamwe. Valérie Nyirarudodo, a Hutu nurse, who had brought her children to the hospital for safety, told historian Jean Hatzfeld, "A soldier came to … the hospital. He told me quietly, ‘Get out, run away, those who can.' At the door, some interahamwe shouted, ‘Those who are not targeted, leave … . I looked at the mama who had just given birth in front of me on a mattress, lying there with her two children. I prayed at top speed, My God, tell me the one I should take. Then I thought, if I take the newborn, I can't feed it since I have no milk. The older one will be easier. I put him in a cloth sling on my back and told the soldiers, ‘He is mine, too.'

"They surrounded the maternity hospital. They ripped down the gates … . They killed the women with machetes and clubs … . When a mama had hidden a child underneath her, they picked her up first, then cut the child [with a machete], then cut its mother last. They didn't bother to cut the nursing infants properly. They slammed them against the walls to save time, or hurled them alive on the heaps of corpses.

"That morning, we were more than 300 women and children. That evening … there were only five women left, spared because they were lucky to be born Hutu."

At the Mugonero Adventist Hospital, "Hundreds of children and adults were mercilessly slaughtered, including many of the hospital workers and their families," according to news reports at the time.

The Rwamagana Hospital lost 16 staff members, mostly physicians and nurses.

One of the worst incidents occurred at Butare University Teaching Hospital, near the border with Burundi. Rony Zachariah, M.D., Ph.D., was working with MSF at the hospital. He recalls, "On the 22nd and 23rd of April, we were caring for 170 civilian Tutsi patients and 140 wounded Hutu soldiers … . We were the last functioning hospital in southern Rwanda … . Forty Tutsi patients were taken behind the hospital by the Interahamweand soldiers and beaten to death."

Zachariah and ICRC representatives met with hospital authorities and with a Hutu military officer who was in charge of the affairs of wounded soldiers in the hospital, and tried to explain their organizations' position of neutrality, saying that they cared for all sick and injured persons regardless of ethnicity or affiliation. Zachariah told me in an interview earlier this year that the officer's first response after the meeting was, "This hospital stinks of Tutsis; let's clean up." Soldiers and militia members then ripped sutures and intravenous lines from Tutsi patients and killed them.

"They took five of our nurses, all Tutsis except for a nurse named Sabine, who was Hutu," Zachariah remembers. "Two Tutsi nurses — Alexis and Jean-Marie — were killed. Sabine, a great colleague, was seven months pregnant. When they came to take her, I said to the soldier who was trying to drag her away, ‘She is Hutu; this must be a mistake. Please leave her alone. Furthermore, it is she who has been taking care of your wounded soldiers.' I stood between the soldier and the commander, who pulled out a piece of paper, looked at it carefully, and said, ‘Doctor, you are right. Sabine is indeed Hutu. But her husband is Tutsi, and this baby will thus be Tutsi.' Sabine was taken away and killed. There was nothing more I could do to stop it.

"On April 22nd and 23rd, between 150 and 170 civilian patients were taken out and killed, including children, and some of our staff; they were all beaten to death. Almost all of our [indigenous] staff were killed except for Hutus.

"I thought there was hope, and then there was none. We were the last safe haven."

Zachariah was able to save only five Tutsi staff members, who threw away their government identification badges stating their ethnicity, and, along with him and other expatriate staff, slipped over the border into Burundi on April 24.

He says of his harrowing experience, "I have come to realize that one cannot stop genocide with doctors and nurses. Neither can one heal the deep wounds of Rwanda with bandages and sutures. There was a need for justice." Zachariah has testified at numerous war crimes trials and tribunals in the years since.

The genocide ended in July, when the RPF entered Kigali and took control of Rwanda. By then, between 800,000 and 2 million Tutsis and moderate Hutus were dead. Hundreds of thousands of Hutus, including some who had been involved in the killing, but many more who were simply seeking safety, fled the country to refugee camps in Zaire (now the Democratic Republic of Congo). Both in Rwanda and in the camps, Hutus were massacred by vengeful Tutsis. However, the international community, which had done little or nothing to help the Tutsis, intervened, possibly because of extensive news media coverage of the Hutus' plight.

"Where Is Considered Safe?"

"If hospitals aren't safe in Yemen, where is considered safe?" asked an anguished Yemeni man who lives near the hospital that was attacked last year. The question that hangs like a malignant black cloud over all these experiences is indeed: Why attack a hospital, especially when its staff members are caring for all people equally? "Why kill physicians?" Hun asked me when I interviewed him in Phnom Penh earlier this year. "We can be useful." Kolesar told me during our interview in Vukovar last year that she "has no idea why anyone would do such a thing," because "hospitals are sacred places."


This article is the result of more than a year of research, including site visits to Cambodia and Croatia and extensive telephone interviews. All research 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, 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., advisor 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 advisor (DG-Luxembourg), Médecins Sans Frontières — Brussels Operational Center, Luxembourg.

Copyright © 2014 by Emily Friedman. This article may be copied, distributed and posted on the Internet at no cost as long as proper attribution is included.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express.