Impunity Must End: Attacks on Health in 23 Countries in Conflict in 2016

Executive Summary

In 2016, attacks on—or interference with—health care occurred in 23 countries in conflict or experiencing political unrest around the world. The sheer number of countries and the intensity of attacks on health facilities, health workers, ambulances, and patients are staggering. International law requires hospitals, clinics, and ambulances to be places of safety, yet health facilities are too often among the most dangerous places in communities. Moreover, health workers, who are bound by ethical codes to provide care to all who need it, were arrested, punished, and even killed for fulflling their duty of impartial care.

The lack of a global data collection system, using common defnitions and methods to track attacks on health care, makes it impossible to quantify the exact number of these attacks and their resulting deaths and injuries, or to identify global trends. However, data are available from organizations that use their own methodologies to track and verify attacks in specifc countries, as well as from other sources of information used to compile this report (see Methodology section). Syria was by far the worst case, in terms of the intensity and impact of attacks. Physicians for Human Rights (PHR) reported 108 attacks on hospitals and other health facilities in Syria throughout 2016, most by Syrian government and Russian forces. These data also show that in other countries—including Afghanistan, Iraq, South Sudan, and Yemen—the level of violence inflicted on health facilities and health workers was remarkably high.

In Afghanistan, the UN Assistance Mission in Afghanistan (UNAMA) found that the number of reported attacks targeting health facilities and personnel rose from 63 in 2015 to 119 in 2016. On April 20 in Paktia province, armed opposition groups fred mortar rounds that landed on or around an NGO-run medical facility, damaging the building and causing the evacuation of patients. In Iraq, the Islamic State of Iraq and Syria (ISIS) shelled hospitals, used ambulances as car bombs, took over health facilities, and executed health workers; government and allied forces sometimes conducted airstrikes against ISIS-occupied health facilities. In South Sudan, a major humanitarian crisis, including aid blockages, that has left only 43% of health facilities functional has been exacerbated by attacks on clinics and health workers, including in UN Protection of Civilian (POC) sites. In Yemen, UNICEF verifed 93 attacks on hospitals from March 2015-December 2016.In 2016, attacks on health care took many forms, including:

In 2016, attacks on health care took many forms, including:

• Bombing, shelling, and looting of hospitals and clinics

• Killing of health workers, emergency medical personnel, and patients

• Intimidation, assault, arrest, and abduction of health workers and patients

• Obstruction of access to care including blockage of and attacks on ambulances

• Takeover and occupation of health facilities by police, military, or other armed actors

• Attacks on and blockage of humanitarian actors, supplies, and transports.

Bombing, shelling, and looting of hospitals and clinics

Hospitals and clinics were bombed in fve countries—Iraq, Libya, Sudan, Syria, and Yemen—and shelled, attacked by car bombs and improvised explosive devices (IEDs), or otherwise destroyed in six other countries—Afghanistan, Niger, Pakistan, Somalia, South Sudan, and Ukraine. In August, Syrian and Russian forces bombed one of the main trauma facilities in Aleppo four times in ten days and eventually completely destroyed it. In Libya, hospitals were targets of aerial bombardment, car bombs, suicide bombs, and IEDs. In Yemen, the Saudi-led coalition bombed hospitals even when MSF had provided the coordinates of facilities in an attempt to protect them.

In Pakistan, a suicide attack targeted a health facility, killing 74 civilians and wounding 112. In Niger, Boko Haram destroyed an MSF health post that served as the lone health facility for 20,000 people and averaged 400 consultations per week, killing six people and wounding eight. In Afghanistan, armed groups used rockets and mortars against several health facilities. In South Sudan, shelling hit the maternity wing of an International Medical Corps hospital within a POC site in Juba, interrupting the availability of medical services and humanitarian aid to the 50,000 people living there.

Even when they were not direct targets, fghting in proximity damaged, often severely, hospitals and other health facilities in Afghanistan, Iraq, South Sudan, Turkey, Ukraine, and Yemen. In Iraq, fghting in and around Mosul damaged or destroyed a maternity hospital and a pediatric hospital, as well as three primary health care centers— none of which are now functioning. In Ukraine, 152 hospitals have been damaged during the ongoing conflict and 30 of these are now completely nonfunctioning.

Looting of health facilities and destruction of equipment and supplies has been reported in at least 11 countries, including Afghanistan, the Central African Republic (CAR), the Democratic Republic of Congo (DRC), Egypt, Mali, Mozambique, Myanmar, Niger, Nigeria, Somalia, and South Sudan. Hospitals and health clinics in Mozambique were raided, with medical records burned, equipment and supplies destroyed, and medication stolen. In Afghanistan, a health facility was looted and set on fre in retaliation for male staff treating female patients. In the DRC, there were multiple reports of hospitals being looted, sometimes by armed assailants, with equipment, medications, and documents stolen.

Killing of health workers, emergency medical personnel, and patients Health workers were killed by government security forces and armed groups in eleven countries: Afghanistan, CAR, Iraq, Libya, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. In Syria, there were 91 documented cases of health workers killed by bombing or shelling, shooting, or torture. In Iraq, the Islamic State of Iraq and Syria (ISIS) executed doctors for refusing to abandon their patients, and in Libya, health workers were shot for upholding their ethical obligations and providing care for the national army. Elsewhere, health workers were shot on roads and killed in attacks on hospitals.

Emergency medical personnel were killed in Syria and Yemen in so-called “double-tap” attacks. After frst responders rushed to provide aid to people wounded in an attack, security forces or armed groups launched a second attack on the same location, targeting and killing the responders. Patients have been killed as well. In CAR, members of a rebel group took patients belonging to an ethnic minority group and killed them at the hospital entrance. In Libya, patients have been targeted and attacked while being admitted to the hospital.

KILLING AND ABDUCTION OF VACCINATORS AND THE SECURITY FORCES PROTECTING THEM

Community health workers often work tirelessly to deliver medications and vaccinations to ensure equitable access to health care and to protect groups from communicable diseases, especially polio. Their provision of services in communities often places them at high risk and they have been subject to targeted killings and abductions in Afghanistan, Nigeria, and Nigeria. In recent years, under pressure to eradicate polio, Pakistan has increased police protection for vaccinators. The increased security has saved the lives of many vaccinators and has enabled children to receive the vaccinations they need, but it has also resulted in the targeting and killing of police and armed forces charged with providing security for vaccinators.