A health worker in Gaza continues with an inoculation campaign. The Safeguarding Health in Conflict Coalition has called for international action to end violence against or obstruction of health care in conflicts. Credit: UNWRA/Twitter

BRATISLAVA, May 22 2024 (IPS) – Governments and international agencies must do more to end impunity for violence against healthcare, campaigners have urged, as a new report shows that attacks on healthcare during conflicts reached a new high last year.

The from the Safeguarding Health in Conflict Coalition (SHCC), an umbrella organisation of health and human rights groups, documented 2,562 incidents of violence against or obstruction of health care in conflicts across 30 countries—over 500 more than in 2022.
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The group pointed out that the 25 percent rise on the previous year came as tens of millions of people in conflict-affected countries were already suffering from war, massive displacement, and staggering deprivation of food and other basic needs.

But beyond the inevitable suffering such violence against healthcare causes, the report’s authors highlighted that one consistent feature of the attacks was the continued impunity for those perpetrating them.

They say that despite repeated commitments, governments have failed to reform their military practices, cease arms transfers to perpetrators, and bring those responsible for crimes to justice.

And they have now called on national leaders and heads of international bodies, including UN agencies, to take strong action to ensure violence against healthcare is ended.

“There has to be a change in how we ensure accountability for violations of international humanitarian law when the protection of health care and health workers is not respected because current mechanisms do not provide adequate protection. We need to ask some hard questions,” Christina Wille, Director of the Insecurity Insight humanitarian association, who helped produce the report, told IPS.

Attacks on healthcare have become a prominent feature of recent conflicts—the SHCC report states that the rise in attacks in 2023 was in part a product of intense and persistent violence against health care in the occupied Palestinian territories (oPt), Myanmar, Sudan, and Ukraine.

And human rights groups have increasingly drawn attention to the deliberate targeting of healthcare facilities and medical staff by attacking forces.

Hospitals and other medical facilities are designated as protected civilian objects under international humanitarian law and it is illegal to attack them or obstruct their provision of care. Ambulances also have the same status. This designation does not apply if the hospital or facility is used by combatants for purposes deemed harmful to an enemy, but even then, an attacking force must give warning of its attack and allow for an evacuation.

But in many conflicts, forces seem to be increasingly ignoring this.

The SHCC report highlights that right from the start of two new wars in 2023, in Sudan and the conflict between Israel and Hamas, warring parties killed health workers, attacked facilities, and destroyed health care systems. Meanwhile, attacks on health care in Myanmar and Ukraine continued unabated, in each case exceeding 1,000 since the start of the conflicts in 2021 and 2022, respectively, while in many other chronic conflicts, fighting forces continued to kidnap and kill health workers and loot health facilities.

At the same time, the report identified a disturbing new trend of combatants violently entering hospitals or occupying them as sites from which to conduct military operations, leading to injuries to and the deaths of patients and staff.

SHCC Chair Len Rubenstein said that in many conflicts, the conduct of combatants revealed “open contempt for their duty to protect civilians and health care under international humanitarian law (IHL)” and specifically highlighted how Israel, “while purporting to abide by IHL, promoted a view of its obligations that, if accepted, would undermine the fundamental protections that IHL puts in place for civilians and health care in war.”

“The report highlighted a lot of disturbing trends—there seemed to be no restraint on attacking hospitals right from the start of conflicts, we also saw for instance, a rise in hospitals being taken for military use, and it was also very disturbing to see children’s medical facilities being deliberately targeted,” he told IPS.

“These trends highlight the need for leadership [on increasing accountability]. Accountability for attacks on healthcare is not a silver bullet—accountability for murder does not stop all murders, for instance – but no consequences are a guarantee of further violations,” he added.

Christian de Vos, Director of Research and Investigations at Physicians for Human Rights (PHR), which is a member of the SHCC, suggested a lack of accountability for attacks on healthcare in previous conflicts had emboldened certain forces to do the same in new wars.

“This goes back to the historical evolution of attacks on healthcare and the consequences of impunity. The patterns of attacks on healthcare that Russian forces, together with the Syrian government, perpetrated in the Syria conflict have a lot of links to how Russia has fought its full-scale invasion of Ukraine,” he told IPS.

In its report, the SHCC has made a number of recommendations to help end attacks on healthcare and hold those behind them accountable.

These include UN and national authorities and the International Criminal Court (ICC) taking new measures to end impunity, strengthening prevention of conflicts, improving data collection on attacks at global and national levels, bolstering global, regional, and domestic leadership—especially through the WHO and UN—on protecting healthcare, and supporting and safeguarding health workers.

Some of these plans would also see a key role played by local actors, including NGOs and other groups active in healthcare and human rights.

SHCC admits, though, that some of these are likely to be hard to implement.

“Our recommendations are aspirational and we accept that their implementation could be difficult in the context of the inherent difficulties of conflicts, but there are some areas where we think definite change could be achieved,” said Wille.

She explained that developing capacity for local health programmes to be more security and acceptance conscious could be strengthened.

“There is a need for training for the healthcare sector on how to understand, approach, and manage security and risk in conflict. Such support should be given to those responsible for overseeing plans for healthcare provision in conflicts so that services continue to be provided but with as much safety as possible,” she said.

She added that governments could also make a real difference by pushing to ensure ‘deconfliction —the process by which a health agency announces to all parties who they are, where they work and what they are doing, and how it can be recognized and which in return receive assurances that they will not be targeted is adhered to by all sides in a conflict.

“Such mechanisms exist, however, at the moment, far too often they are not respected or applied in several conflicts. Governments can insist on the implementation of de-confliction, and this would also be a great help,” she said.

However, if significant change is to be made in ensuring accountability for attacks on healthcare, experts agree that it can only be done with strong political commitment on the issue.

“We have seen over the years that there hasn’t been this commitment and what we need is a strong commitment that will go beyond just words and statements condemning these attacks to real concrete action,” Rubenstein said.

He stressed that the massive, targeted destruction of healthcare seen in some recent conflicts had changed the wider political perception of the effects of such attacks.

“What has changed is the knowledge of the magnitude of these attacks and the enormous suffering they bring, not just directly at the time of the attacks but long after as well. This knowledge can stimulate the kind of leadership we need on this,” he said.

De Vos said that especially the Israel-Hamas war and the prominence of attacks on healthcare in that conflict had “shown clearly the devastation and suffering such attacks cause.”

“This might bring about the change [in will to ensure accountability] that we would like to see,” he said.

But while there may be optimism among experts around the chance for such change, they are less positive about the prospects for any reduction in the volume of attacks on healthcare in the immediate future.

“Unfortunately, the trajectory is not a positive one—there’s no ceasefire in Gaza, the war continues in Ukraine, and conflict is ongoing in the places where we have seen the most of these attacks on healthcare. It’s a pretty grim state,” said De Vos.

IPS UN Bureau Report