Whether in times of peace or conflict, a set of medical ethics and principles guides the work of healthcare workers and hospitals – the commitment to save lives and reduce suffering.
In times of war, to maintain some humanity in armed conflict, certain rules and agreements have been made that mean targeting civilians and civilian buildings – including healthcare facilities – constitute a war crime.
In Russia’s invasion of Ukraine, there have already been reports of protected sites coming under attack.
On March 9, 2022, there were reports of devastation after Ukraine said Russian air strikes destroyed a maternity ward and children’s hospital in Mariupol. President Volodymyr Zelenskyy said there were children beneath the wreckage, and Ukrainian officials called the attack a “war crime“.
Mariupol. Direct strike of Russian troops at the maternity hospital. People, children are under the wreckage. Atrocity! How much longer will the world be an accomplice ignoring terror? Close the sky right now! Stop the killings! You have power but you seem to be losing humanity. pic.twitter.com/FoaNdbKH5k
— Володимир Зеленський (@ZelenskyyUa) March 9, 2022
Before that, on March 3, it was reported that Russian shelling had hit a maternity hospital in the city of Zhytomyr. That strike damaged the hospital, breaking the windows, and burned three nearby homes. It was reported that new mothers and their babies were evacuated to the basement.
According to Amnesty International, by carrying out indiscriminate attacks on civilian areas and strikes on protected objects such as hospitals, Russia’s actions may constitute war crimes. Amnesty’s Crisis Evidence Lab analysed digital evidence – including photos, videos and satellite imagery – of three attacks carried out in the early hours of the Russian invasion on February 24. In the deadliest strike it documented, at approximately 10.30am local time a ballistic missile struck near a hospital building in Vuhledar, in the Donetsk region, killing four people and wounding 10 more. According to a local source who spoke to Amnesty researchers, six healthcare workers were among the injured.
The charity also said Russia’s claims that it uses precision-guided weapons are patently false.
The World Health Organization (WHO) said healthcare facilities in Ukraine were being attacked; in a tweet on March 5, the WHO said that it had “published 6 verified reports of attacks on health care in Ukraine. More reports are being verified. WHO strongly condemns these attacks that caused 6 deaths & 11 injuries. Health facilities, staff & patients are #NotATarget.”
As of today, WHO has published 6 verified reports of attacks on health care in #Ukraine. More reports are being verified.
WHO strongly condemns these attacks that caused 6 deaths & 11 injuries.
— World Health Organization (WHO) (@WHO) March 5, 2022
People who practise modern medicine are governed by a set of ethical rules both at times of peace and times of war. We are to treat all our patients equally and without prejudice. A physician’s ethical responsibility during a time of war is identical to that during a time of peace.
Medical neutrality refers to a principle of non-interference with medical services in times of armed conflict and civil unrest: physicians must be allowed to care for the sick and wounded, and soldiers must receive care regardless of their political affiliations. It is a fragile thing to maintain, as it requires opposing sides of a conflict to uphold the agreed principles. Medical staff are not permitted to discriminate against patients based on factors like politics or race, and in exchange, conflicting parties allow medical care to continue unimpeded.
As Dr Joanne Liu, former president of Doctors Without Borders (Medecins Sans Frontieres, or MSF), stated in 2016 in reference to attacks in Aleppo, Syria on medical neutrality, “We say loud and clear: The doctor of your enemy is not your enemy.” These principles allow medical professionals to treat the sick and wounded from either side of a conflict, the idea being they, themselves, will not be targeted as a result while they do this. In times of war, medical care and field hospitals are essential and it is important that they remain safe.
International Humanitarian Law (IHL) is a set of rules that seek, for humanitarian reasons, to limit the effects of armed conflict. A major part of IHL is contained in the four Geneva Conventions of 1949 that have been adopted by all nations in the world. The conventions are described by the International Committee of the Red Cross (ICRC) as one of humanity’s most important accomplishments of the last century. The original conventions had additional protocols added in 1977 and 2005, but their main aim remains constant: they represent modern efforts to protect people in times of armed conflict.
One of the most important citations of the conventions is to protect medical personnel, faculties and equipment. This includes hospitals and healthcare facilities. In 1970, the UN General Assembly adopted Resolution 2675, which states that a hospital zone or similar refuge should not be the object of military operations. Therefore, indiscriminate or targeted attacks on hospitals, medical units and medical personnel functioning in a humanitarian capacity are never admissible.
Recent wars and continuing conflicts have shown us that the rules of war are often broken even by those who claim to be protectors of those very rules.
Indeed, Russia’s own rulebook, The Russian Federation’s Regulations on the Application of IHL (2001), states: “Persons protected by international humanitarian law include medical and religious personnel. Attacks against such persons are prohibited.”
The Geneva Convention can only protect countries at war so much. Other recent wars and continuing conflicts have shown us that the rules of war are often broken even by those who claim to be protectors of those very rules.
On October 3, 2015, a US air strike hit MSF’s Kunduz Trauma Centre in Afghanistan, killing 42 people, including 14 hospital staff. The 92-bed hospital was the only facility with essential trauma care capabilities in that part of northern Afghanistan. In Syria, since the start of the conflict in 2011, there have been 223 attacks on 175 health facilities; these attacks have killed 599 medical personnel.
The latest Safeguarding Health in Conflict Coalition report (PDF) says there have been 806 incidents of violence against or obstruction of healthcare in 43 countries and territories in continuing wars and violent conflicts in 2020, ranging from the bombing of hospitals in Yemen to the abduction of doctors in Nigeria. At least 185 health workers were killed and 117 kidnapped.
A pattern of attacks?
In Ukraine, Russia denies it is targeting civilians and claims to be using targeted missiles aimed at military structures, though much of the evidence suggests otherwise. The Kremlin has also denied the use of cluster bombs.
However, we have seen from previous conflicts Russia has been involved in, that the use of indiscriminate attacks and cluster bombs is not a new tactic used by President Vladimir Putin. He presided over the second Chechen war in 1999. The Chechen capital, Grozny, which was already severely damaged by the first war in 1994, was left as a hole in a map, called the most destroyed city on the planet by the United Nations. Almost nothing was left standing, nearly no one spared.
Russia again reportedly used cluster bombs in Syria, a war it joined in 2015, and one it fought largely through the air, with Syrian President Bashar al-Assad’s troops providing ground forces. Cluster bombs are banned by international treaties due to the widespread damage they can do and the likelihood that they can result in civilian casualties; however, neither Russia nor the US have signed these treaties.
As several governments fail to uphold global commitments to keep medical professionals and facilities safe, the attacks continue with impunity.
We have seen what has become of Syria, and Aleppo in particular. What was once a cultural city with a bustling centre is now ruined in the wake of thousands of civilian deaths. According to Humans Right Watch, the bombardment of the city by Russian/Syrian forces in September and October 2016 significantly affected several hospitals in eastern Aleppo. The Syrian-American Medical Society recorded 16 incidents of aerial bombardment affecting hospitals in the period. In some cases, aircraft dropped indiscriminate weapons such as incendiary weapons and cluster munitions near hospitals, causing some damage. In other cases, attacks struck the hospitals directly causing much greater damage. HRW went on to say, “Those who ordered and carried out unlawful attacks should be tried for war crimes.”
There have been international sanctions imposed against the al-Assad regime in Syria after the attacks on civilians and medical facilities, but there have been no international efforts to try him for war crimes.
The truth is that only after conflicts are over, after the damage has been done, are people tried for war crimes. And many are not even tried at all, as diplomatic efforts to resolve the conflicts often result in protective deals for individuals and states. As several governments fail to uphold global commitments to keep medical professionals and facilities safe, the attacks continue with impunity.
In the current war in Ukraine, one of Russia’s aims – as it is when any country invades another – is to break the morale of the people, something that is proving difficult for Putin to do. But bombing hospitals and civilian infrastructure will make things difficult for people in Ukraine. Bombing hospitals clearly means fewer facilities for sick Ukrainians to receive medical treatment, leading to an increase in infections and worsening of chronic diseases. Destroying towns and cities will increase the difficulty in accessing medicines and safe maternity, paediatric and elderly care, resulting in further mortality.
The one thing that has been a small beacon of light through these dark days has been the spirit of the Ukrainian people, but as Russia becomes more erratic and unpredictable in its actions, how much longer before that spirit is broken?