An ambulance was destroyed in Novyi Bykiv, Ukraine.

Opinion: We Must End Attacks on Hospitals in Conflict Zones

International laws meant to shield hospitals and health workers from belligerents are rarely, if ever, enforced.

Since Russia launched its invasion of Ukraine in February, Ukrainian hospitals and health care facilities have been barraged by more than 200 verified attacks, resulting in at least 76 deaths. Sadly, these kinds of attacks are not unique to Ukraine; health workers around the world who care for patients in conflict zones are increasingly subject to violence.

In the year 2021 alone, a group of nongovernmental organizations known as the Safeguarding Health in Conflict Coalition, or SHCC, documented more than 1,000 attacks on health care globally. Collectively, these attacks killed 161 health workers, and health facilities were destroyed or damaged in close to 200 incidents. Health care systems in Myanmar and the Tigray region of Ethiopia were almost wholly destroyed. Even in countries free of conflict, the Covid-19 pandemic has elicited an unprecedented assault on health workers.

The attacks in conflict zones are particularly egregious because hospitals have long represented a sort of sacred space. Since at least the First Geneva Convention of 1864, health workers have been recognized as a protected class on the battlefield. In 1977, amendments expanded these protections to include injured civilians as well as civilian ambulances. Importantly, combatants were also forbidden from punishing medical professionals for treating patients, even if these patients were enemies.

As an analyst at Insecurity Insight, a nongovernmental organization that documents attacks on health care and which contributed to the SHCC report, I worry that this protected status is eroding before our eyes. As an emergency medicine resident physician, I fear that my colleagues will remain at risk so long as the world remains silent. The consequences to society will be severe.

Across the world, attacks on hospitals and health workers have become a tool of war for governments and militaries. In countries like Myanmar and Sudan, where doctors have led pro-democracy protests against ruling regimes, targeting physicians can often be an act of political retaliation. In the aftermath of a military coup in Sudan, emergency rooms became battlegrounds as security forces stormed hospitals, firing tear gas, to arrest injured pro-democracy protestors.

In Syria, which has been embroiled in civil war for more than a decade, Physicians for Human Rights has documented 601 attacks on 400 medical facilities, which killed close to 1,000 health workers between March 2011 and February 2022. In a remarkable investigation in 2019, The New York Times obtained audio of Russian pilots that — combined with video evidence and witness accounts — provided overwhelming evidence that they were either intentionally or recklessly targeting Syrian hospitals with airstrikes in “order to crush the last pockets of resistance to President Bashar al-Assad.” It is reasonable to expect that Russia is targeting hospitals in Ukraine in the same manner.

The problem is exacerbated by the fact that we have only an incomplete picture of the extent of the threats faced by health care workers.

Almost certainly, the targeting of hospitals is intended to crush the will of the civilian population — to demonstrate that nowhere is safe and that there is nowhere for civilians to run if they need medical care. The destruction of health systems in these countries will have a cascading series of effects that will take decades to fix. And as care is disrupted and medication supply chains break down, mothers and children often face the most severe consequences. In the war-torn Tigray region of Ethiopia, for instance, reported maternal deaths in childbirth have more than doubled, compared with pre-conflict figures.

Up to this point, the international community has done little to hold perpetrators accountable, and powerful American medical organizations have remained embarrassingly silent. Outside of an April statement concerning the attacks in Ukraine, the American Medical Association, one of the largest lobbying organizations in the U.S., appears to have said little as health workers are maimed and killed across the globe.

The problem is exacerbated by the fact that we have only an incomplete picture of the extent of the threats faced by health care workers. The World Health Organization has been tasked with documenting attacks on health care in countries with complex humanitarian emergencies, but so far their efforts have been paltry. The WHO’s platform, the Surveillance System for Attacks on Health Care, is nearly useless for researchers, advocates, and health workers in the field. It doesn’t release information on perpetrators, the exact location of attacks, or detailed descriptions of incidents. The surveillance system laughably documented no attacks in Ethiopia in 2021, a country that health officials estimate saw hundreds, if not thousands, of health facilities damaged or destroyed during the war in northern Ethiopia. Non-governmental organizations including my own, Insecurity Insight, have stepped up to fill in the gaps. But organizations like the AMA should be lobbying for increased investment in research on these attacks.

The longer these attacks continue with impunity, the greater the risk that they become normalized.

The international community must also come together to hold offenders accountable. Attacks on hospitals or health workers that could constitute war crimes are rarely investigated, and it is even rarer for an investigation to lead to a war crimes trial. According to a recent article in the journal the BMJ, only one attack against a hospital has been successfully prosecuted in an international tribunal. The longer these attacks continue with impunity, the greater the risk that they become normalized. To end this cycle, there must be rigorous, in-depth investigations and documentation of incidents that are likely to qualify as war crimes. And governments that target health workers should be subject to sanctions, like those sought by Burmese activists in their effort to stem indiscriminate attacks by military junta in Myanmar — arguably the most dangerous place to be a health worker in 2021.

For many physicians and health workers in the U.S., this is personal: Some of the health workers under attack are people we have trained with, who we have done research collaborations with, and who we call friends. They swear the same oaths that we do. It is time that we stand up in defense of our colleagues under threat. And it is time that the AMA and other medical advocacy groups push the WHO to fulfill its mandate to protect health workers.

One can never underestimate the power of solidarity. While researching attacks on health care in Myanmar, I recently corresponded with Burmese medical students who had been targets of regime violence. I was struck by their idealism. They believed in the power of international institutions and western democracies. They believed that if only their colleagues abroad knew about their plight, those colleagues would be compelled to take action on their behalf. On their official Twitter account, Myanmar’s pro-democracy Civil Disobedience Movement wrote that the lack of outrage from the global medical community was “disheartening,” adding, “Perhaps they have no idea.”

Powerful medical organizations can no longer give their members and the public the excuse of not knowing. These organizations, including the AMA, should engage in a campaign to educate society on the threats facing health workers abroad. Health workers across the world are dying. We owe it to them, and to their innumerable patients, to speak out.

Brian Elmore is a researcher and analyst for Insecurity Insight, an organization that documents attacks on aid and health care in conflict. He is also an emergency medicine resident physician.