The New York Review of Books - USA (2022-06-23)

56 The New York Review

Health Care Under Fire

Annie Sparrow

Perilous Medicine:

The Struggle to Protect Health Care

from the Violence of War

by Leonard Rubenstein.

Columbia University Press,

372 pp., $35.00

Necessary Risks:

Professional Humanitarianism and

Violence Against Aid Workers

by Abby Stoddard.

Palgrave Macmillan,

175 pp., $89.99

There is a new medical specialty in

Syria. Driven by deliberate attacks on

doctors, other medical personnel, aid

workers, hospitals, and ambulances,

this multidisciplinary field covers mass

casualties and severe malnutrition

caused by indiscriminate bombard-

ment and blockades of humanitarian

aid. Lack of electricity means that op-

erations are often done by the light of

an iPhone. Without routine lab tests,

pathology services, or imaging beyond

X- rays, diagnosis is challenging. Clini-

cal resources—fluids, antibiotics, insu-

lin—are scarce. Without blood banks,

transfusions must come directly from

donors, often the medical personnel

themselves. Triage is redefined as a

process of determining not when but

whether patients are treated—a calcu-

lation of their odds of survival against

the use of finite resources. This is siege

medicine.

Since the Syrian government’s bru-

tal repression began in 2011, hundreds

of physicians have been murdered.

Security forces have “disappeared”

hundreds more. By 2015, some 15,000

physicians had fled or emigrated. In

areas besieged by the government,

remaining doctors must practice far

outside their original fields. Pediatri-

cians double as emergency physicians,

general surgeons do vascular surgery,

and dentists handle anesthesia. Under

the expedited system of “see one,

do one, teach one,” specialists learn

from one another, medical residents

rapidly develop broad skills, and even

students perform amputations. Those

who survive the training end up with

expertise in war trauma, competence

in managing antimicrobial resistance,

and familiarity with infectious diseases

previously relegated to history books.

In late December 2017 doctors in

besieged Eastern Ghouta, a semirural

area of 400,000 people ten miles north-

east of Damascus, facing mounting

child casualties and intolerable life-

and- death decisions, issued an urgent

appeal to the World Health Organiza-

tion (WHO). The head of emergencies

withheld the letter from the director-

general and did not respond. A second

letter, to the United Nations secretary-

general, also went unanswered. By

April 2018 Russian air strikes had de-

stroyed Ghouta’s last hospitals and Syr-

ian troops overran the area, displacing

hundreds of thousands, including the

surviving doctors.

Systematic attacks on hospitals am-

plify the harm of war and increase suf-

fering. The effects reverberate widely,

spreading terror and driving people to

flee. This exemplifies the weaponiza-

tion of health care—the use of people’s

need for health care against them at a

moment when that need is particularly

acute. This military strategy isn’t lim-

ited to Syria—health care has been

heavily targeted in conflicts in Ethiopia

and Myanmar. Russian forces invading

Ukraine are doing it, too.

Attacks on medical personnel have

been forbidden since at least 1864,

when governments adopted the first

Geneva Convention. Since then, inter-

national humanitarian law (IHL) has

expanded to protect civilians in conflict

zones and to uphold the right to receive

humanitarian aid. Because attacking

health care flouts the core purpose of

IHL—to relieve suffering—it has be-

come a sign of broader atrocities.

The growing phenomenon of delib-

erate attacks on medical workers and

hospitals is the subject of Leonard

Rubenstein’s Perilous Medicine: The

S t r uggl e to P rot e c t He a l t h C a re f ro m t h e

Violence of War. Rubenstein, a human

rights lawyer and professor at the Johns

Hopkins Bloomberg School of Public

Health, traces the evolution of interna-

tional standards protecting health care

and examines assaults on them.

He begins with the origins of the

Red Cross. In 1859 Henri Dunant, a

Swiss banker, traveled to Castiglione

in northern Italy, hoping to meet with

Napoleon III, who was commanding

Franco- Sardinian troops in the Italian

war of independence against Austria.

Dunant, who desperately needed Na-

poleon’s help with a business problem,

arrived on the day of one of the blood-

iest battles of the nineteenth century.

When troops clashed in nearby Sol-

ferino in the early hours of June 24, bad

p l a n n i n g m e a n t t h e y w e r e f o r c e d t o fi g h t

without food, water, or field hospitals.

For fifteen hours, a quarter of a mil-

lion soldiers slaughtered one another

across a front line several miles long.

By evening, Solferino was carpeted

with tens of thousands of corpses and

injured combatants from both sides.

Defeated, the Austrians withdrew,

leaving thousands of their wounded

to die on the battlefield. Thousands of

injured French and Italian combatants

were lying alongside them, their misery

exacerbated by thirst, hunger, and flies.

The French had few doctors and even

fewer ambulances. Crates of bandages,

water bottles, and tents had been left be-

hind on the docks in Genoa. With four

veterinarians per thousand horses but

just one doctor per battalion, Napoleon

had prioritized the well- being of horses

over that of soldiers. Austrian ambu-

lances, packed to capacity, had already

left, and the Austrian military physi-

cians who stayed behind to help were

locked up in Milan with other POWs.

Dunant’s business trip turned into a

humanitarian mission. For the next two

weeks he mobilized boys to fetch clean

water and bandages and organized

shifts of women volunteers to carry

the water to dehydrated soldiers and

to clean maggot- infested wounds. He

turned a large church into a temporary

field hospital and assembled French and

Italian surgeons to perform mass ampu-

tations. He persuaded local residents to

give shelter even to Austrians and car-

riage drivers to evacuate them, bought

clean shirts and food for countless men,

and distributed tobacco widely, cogni-

zant of the lack of painkillers. Unafraid

of blood and bodily fluids, he held sol-

diers in their last moments.

Back in Geneva, Dunant cam-

paigned for a voluntary society to

care for wounded soldiers and an in-

ternational treaty that would protect

such efforts. After friends encouraged

him to put his proposals in writing, he

self- published A Memory of Solferino,

describing in detail the battle and its

appalling aftermath. Positively re-

ceived in France, it was soon translated

into German, Dutch, and Italian.

In February 1863 Dunant and his

allies cofounded the first incarnation

of the International Committee of the

Red Cross (ICRC). Dunant’s propos-

als gathered momentum after Charles

Dickens published several excerpts of

A Memory of Solferino in his maga-

zine All the Year Round. That October

representatives from fourteen govern-

ments and other delegates attended the

Geneva International Conference to

Study Ways of Overcoming the Inade-

quacy of Army Medical Services in the

Field. One of them, Florence Nightin-

gale, who had worked in military hos-

pitals during the Crimean War, wasn’t

convinced, arguing that voluntary

humanitarian societies would only en-

courage governments to shirk their duty

to care for the wounded. Rubenstein

notes that her views were dismissed

with more than a hint of misogyny.

In 1864 the Geneva Convention for

the Amelioration of the Condition of

the Wounded in Armies in the Field

was signed by all major European pow-

ers. In 1865 Britain and Turkey, then

the Ottoman Empire, joined. The Ot-

tomans’ accession surprised the com-

mittee, which had assumed that only

Christian belief could be a motive for

relieving human suffering. In fact, Is-

lamic humanitarian law predated the

convention by a millennium. Efforts to

reduce the worst effects of war appear

across all religions and throughout his-

tory. Dunant’s contribution was to cod-

ify these doctrines into a single treaty

and persuade governments to adopt it.

In 1882, after strenuous lobbying by

Clara Barton, known as “the American

Florence Nightingale” for nursing sol-

diers during the Civil War, the US gov-

ernment finally ratified the convention.

The convention was adopted at a

time when medical intervention could

do little to change the course of war.

Most soldiers (and civilians) died from

cholera, typhus, pneumonia, and ma-

laria—infectious diseases that doctors

struggled to treat. If injured soldiers

survived the battlefield, they usually

succumbed to sepsis. Amputation was

the only treatment for gangrene. Since

the likelihood of injured soldiers re-

Men inspecting a hospital damaged by an air strike in a rebel-controlled town, Eastern Ghouta, Syria, May 2017

Sameer Al-Doumy/

AFP

/Getty Images

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