International law dating back more than 150 years holds that in all armed conflicts, whether internal or international, parties must not attack or interfere with health workers, facilities, ambulances, and people who are wounded or sick. The Geneva Conventions and customary international humanitarian law provide that parties have a duty to distinguish between military and civilian objects and to take precautions to avoid harm to hospitals even when a military target is nearby; that hospitals and clinics may not be taken over for military or security purposes—and that even if they are, parties to a conflict have an obligation to minimize harm to civilians inside; that health professionals may not be subjected to punishment for adhering to obligations to provide care consistent with their ethical duties, including treating the sick and wounded without discrimination; and that access to health care may not be obstructed through such practices as unreasonably delaying or blocking passage of ambulances, supply transports, medical staff, and the wounded and sick. International human rights law imposes similar obligations.
This report reviews attacks on and interference with hospitals, health workers, ambulances, medical supply transports, and patients in armed conflict and times of political violence that violated these obligations in 2015 and during the first three months of 2016.
ATTACKS ON AND INTERFERENCE WITH HEALTH CARE
Attacks on health services take many forms but can be grouped into four major categories:
Bombing, shelling, and looting facilities or transports, in some cases as a result of targeting the facility or transport, and in other cases because of an indiscriminate attack that failed to take precautions to avoid harm to the facility.
Violence inflicted on health workers independent of an attack on a facility or transport.
Military takeover of hospitals, or fighting in and around hospitals.
Obstruction of access to health care, medicine, and essential supplies. Bombing, shelling, burning, looting, and other violence inflicted on health facilities and transports
Hospitals, ambulances, and medical supply transports have been attacked and looted in many countries, sometimes intentionally and sometimes due to attackers failing to take precautions to distinguish between military and civilian objects. These attacks have led to the deaths of health workers, medical staff, and others during initial attacks and during ongoing violence following the attacks.
In five countries—Afghanistan, Iraq, Libya, Syria, and Yemen—hospitals were subjected to aerial bombing, as well as to explosives launched from the ground. In Syria, where the most rigorous reporting has taken place, at least 122 attacks on hospitals were documented in 2015, with some facilities hit multiple times. Syrian government forces and their Russian allies engaged in vicious “double-tap” attacks, launching a second strike after rescuers came to the aid of those wounded in the first attack. In four such double-tap attacks, 31 people were killed and more than 150 wounded. In Yemen, health facilities were attacked at least 100 times; a Saudi-led coalition indiscriminately bombed many hospitals, including in one case unleashing a two-hour bombardment. Opposing Houthi and allied forces have committed violations as well, shelling hospitals from the ground.
In Afghanistan, at least 92 acts of violence against health facilities and health workers killed 55 people. Forty-two people, including 24 patients, 14 health workers and four caretakers, were killed as a result of a United States military air attack on the Kunduz Trauma Center, the only facility of its kind in northern Afghanistan (whose coordinates were known to all parties to the conflict). Médecins Sans Frontières (MSF), which operated the facility, phoned and texted US authorities during the strike seeking to stop the attack, to no avail. In Iraq, there were at least 61 attacks on health facilities and personnel. In one of them, Iraqi Security Forces bombed a maternity and children’s hospital, killing 31 people, including at least eight children, and wounding 39 others. In Libya, the kidney disease and internal medicine wards and staff dormitories of a hospital were bombed.
In Central African Republic, Democratic Republic of the Congo, Mali, Somalia, South Sudan, and Sudan, health facilities have been burned and/or looted, medical supply vehicles attacked on the road, and medical staff abducted; these attacks have often forced the suspension of medical activities in the affected areas. In Central African Republic, there were more than 200 attacks on and looting of humanitarian compounds and transports, many of which were providing health care to a population in desperate need; there were 30 such attacks in Mali, as well. In South Sudan, health programs and nongovernmental organization (NGO) compounds in the Upper Nile region were repeatedly attacked during 2015, and multiple health workers were killed in separate incidents.
Violence inflicted on health workers independent of attack on a facility or transport
Horrific violence has been inflicted on health workers, patients and their families, and staff independent of the impact of shelling, bombing, and burning. In Democratic Republic of the Congo, seven patients and a nurse were brutally murdered inside a clinic. In one atrocity in Sudan, security forces attacked and looted the town of Golo in West Darfur, encouraging civilians to seek protection in a hospital. The security forces subsequently detained the civilians in the hospital for weeks, raped at least 60 women, and executed at least three people.
In Syria, 27% of the health workers killed in 2015 were shot, executed, or tortured to death. In Iraq and Libya, the self-proclaimed Islamic State of Iraq and the Levant (ISIL) has forced health workers, under threat of death, to give its fighters priority in treatment, including moving from their places of work at civilian hospitals to ISIL facilities housing injured fighters. ISIL executed at least 12 health workers in 2015. Health workers have been ambushed, abducted, and killed—often while in marked medical vehicles—in Afghanistan, Central African Republic, Iraq, Mali, Nigeria, Pakistan, Somalia, South Sudan, and Yemen.
Globally, health workers who participate in vaccination programs, as well as police and other security personnel charged with protecting them, are especially vulnerable to attack, particularly those involved in polio prevention (table 1). Their necessary travel to remote and dangerous areas puts them at a high risk of murder and abduction.
Military takeover of health facilities and fighting around hospitals
In some cases, fighting took place directly on hospital grounds. In Iraq, there were at least two instances of firing directly at a hospital; in one of them, combatants were fighting from the roof while the opposing forces shelled the hospital. Also in Iraq, ISIL forces have taken over civilian hospitals for their own use, sometimes evicting all civilian patients. In Thailand, armed insurgents took over a hospital to stage an attack on a nearby government security post.
Military forces have entered hospitals to remove enemy fighters, often severely disrupting care and assaulting patients or staff. On one occasion, 300 fighters in Yemen entered a hospital and forced staff to reveal the location of two Houthi fighters, who were then removed and executed outside the hospital; Houthi forces retaliated by firing repeatedly at the hospital. In Afghanistan, Afghan National Security Forces took control of clinics five times to search for medical supplies or wounded enemies, disrupting care and intimidating patients and staff. In one case, two patients were removed from the hospital and health workers were arrested and beaten. Israeli security forces entered Palestinian hospitals on at least eight occasions to conduct investigations, during which they interfered with patient care and, on some occasions, assaulted patients and/or health workers.
Obstruction of access to health care, medicine, and essential supplies
Obstruction of access to health care took place in many of the countries included in this report. This was carried out through blocking, unreasonably delaying, or threatening medical supply and aid transports, ambulances, health workers, and patients and their families.
Parties to each conflict have frequently restricted passage of health and other humanitarian aid, often in dire health situations. In Syria, the Assad government has continued to block humanitarian aid to besieged and hard-to-reach populations who are at risk of starvation. In South Sudan, parties to the conflict have periodically suspended or obstructed the flow of aid to people in desperate need, who have been displaced and are living in precarious settings. Sudan has severely restricted NGO access to areas of great need for health care aid in Darfur. The government of Iraq has prevented the delivery of health supplies to ISIL-controlled areas, including Mosul, Fallujah, and Anbar.
And in the wake of violence in September 2015, medical teams in the Central African Republic were unable to reach many people in urgent need of medical care because of threats of violence or blockades.
Medical aid has been obstructed in low-intensity conflicts as well. The Turkish government, which is engaged in military action against armed Kurdish separatists, imposed a weeks-long curfew preventing all civilian movement in and out of the city of Cizre and other towns in the southeast. As part of the curfew, security forces prevented the evacuation of wounded and sick civilians, some of whom died as a result. In Ukraine, armed groups suspended MSF humanitarian medical programs for two months in 2015. Throughout the year, restrictions imposed by both sides on individuals crossing conflict lines severely curtailed civilian access to medical care and the delivery of medical supplies, including much-needed medication for HIV, tuberculosis, and drug addiction. In Jerusalem and the Occupied Palestinian Territories, Israeli security forces created new checkpoints and refused to allow priority of passage to Palestinian ambulances until receiving authorization through bureaucratic channels, thereby delaying the transport of patients who were in the midst of emergencies by up to an hour.
THE AFTEREFFECTS OF ATTACKS
In some cases, in addition to the deaths and injuries inflicted during attacks, the assaults have negatively affected the health of people in the area who need urgent care. In South Sudan, for example, shortly after an attack on Kodok Hospital, 11 people in need of surgery died. In Yemen, infants in a pediatric hospital died when ventilators cut out as a result of an airstrike. In Syria, local security forces would not approve the inclusion of surgical kits and intravenous fluids on a convoy to eastern Aleppo city, depriving more than 33,000 people of these vital medical supplies. The far-reaching effects of these attacks and strategies can be assessed in different ways:
Loss or lack of access to health facilities.
Flight of health workers.
People deprived of health care.
Increased mortality or morbidity risk.
Loss or lack of access to health facilities
In Afghanistan, 23 health clinics in six provinces were closed in early 2016 as a result of violence and insecurity.
In Syria, 57% of public hospitals are not functioning or are only partially functioning; that percentage does not include the informal field hospitals established in opposition-controlled areas that have been subjected to relentless bombing. In Yemen, after a single year of war, 600 health facilities—representing 25% of the country’s overall capacity to deliver health care—were not functioning because of destruction or a lack of staff and/ or supplies. In Libya, 40% of all health facilities are closed because of damage, lack of supplies and staff, or insecurity.
In South Sudan, a scorched-earth war has closed 55% of health facilities in the Upper Nile region, leaving one hospital to serve one million people.
Most health facilities are no longer functioning in Central African Republic. In Sudan, since 2011, the Sudanese Air Force has bombed 26 health facilities, including hospitals, clinics, and health units, leaving only two hospitals to serve 1.2 million people. In Mali, from August through September 2015, security incidents shut down all access to health care in the Mopti, Timbuktu, Kidal, and Gao regions. Additionally, targeted attacks forced Mali’s main international health partner in the region to suspend its activities and relocate staff, resulting in a complete ack of health assistance and the closure of all referral health centers in the districts of Tenekou and Youwaro.
In Thailand, health workers have had to cut back evening hours to avoid being exposed to attacks by insurgent groups.
Flight of health workers
Attacks often lead to the flight of health workers and consequent loss of health services capacity. Half of the health workers who practiced in Syria prior to 2011 and 95% of physicians living in Syria’s major city of Aleppo before the war have left the country. In Iraq, 45% of health professionals have emigrated since 2014. In Libya, 80% of the foreign nurses, who were the backbone of the country’s medical staff before 2011, have been evacuated.
In northern Nigeria, almost all health workers have fled areas controlled by Boko Haram, resulting in the closure of 450 health facilities.
People deprived of health care
One way of assessing the consequences of lost facilities and medical staff is to estimate the number of people who need access to health services but do not have it. Even single events or the loss of a single facility can lead to a dramatic decline in access for large numbers of people.
In Democratic Republic of the Congo, for instance, an armed group looted a town and brutally murdered seven patients and a nurse in a clinic, leading to the closure of the only health facility that served 35,000 people. In another case, two MSF staff were robbed and kidnapped between Kitchanga and Mweso, Masisi Territory in North Kivu, temporarily suspending medical programs that had conducted 185,000 outpatient visits and 6,000 hospitalizations in the prior 10 months. In South Sudan, violence against a health clinic in Pibor forced movement of key health functions to a more distant location, depriving 170,000 people of access to secondary health care. The destruction of a single hospital in Yemen led to deprivation of services for 200,000 people.
More broadly, UN agencies report a staggering number of people in need of health care in emergencies. Several factors contribute to the need, including civilian injuries, population displacement, and lack of available resources for humanitarian aid. But attacks on and interference with health care are major contributors to this enormous problem. In conflicts with some of the most pervasive attacks on health services, UN reports show the following figures for people deprived of health care:
• Iraq: 8.5 million people
• Libya: 1.9 million people
• Mali: 2.25 million people
• Somalia: 3.2 million people
• Syria: 11.5 million people
• Yemen: 14.1 million people.
Increased mortality and morbidity risk
Another way of measuring the impact of lost medical staff and facilities is by examining the increased risk of mortality and morbidity. Beyond attacks on health facilities and health workers, factors such as lack of food and clean water as a result of armed conflict are often highly significant. Yet diminished health capacity may well exacerbate the impacts of these and related factors.
For example, in Yemen, apart from death from traumatic injuries, lack of access to health care and lack of immunizations have resulted in the deaths of nearly 10,000 children under the age of five. UNICEF estimates that 2.5 million Yemeni children are at high risk of diarrheal diseases, 1.3 million are at risk of acute respiratory tract infections, 2.6 million are at risk of measles, and more than 320,000 are at risk of severe acute malnutrition. In Syria, lack of safe drinking water, sanitation, electricity, and fuel has made Syrians more vulnerable to outbreaks of diarrheal diseases, typhoid, hepatitis A, and other vaccine-preventable diseases. Inadequate or nonexistent treatment of chronic diseases—including diabetes, asthma, kidney disease, and cardiovascular disease—has increased the risk of death from these diseases. Shortages of skilled birth attendants and obstetricians have increased maternal and neonatal morbidity and mortality. In South Sudan, attacks on health clinics, humanitarian compounds, and aid workers led to a major decrease in health capacity at a time when there was an unprecedented outbreak of nearly 2.28 million cases of malaria.