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

June 23, 2022 57

turning to combat was remote, medical neutrality didn’t pose a threat to military efforts. Yet the second half of the nineteenth century brought huge advances in medicine and public health. In 1853 John Snow’s suc c essf u l del iver y of Queen Vic - toria’s son Prince Leopold using chloro- form created confidence in its anesthetic powers. Nightingale’s approach to infec- tion control during the Crimean War— improved sewage, clean water, and handwashing—drove reform of British military medicine and public hospitals. In 1861 Louis Pasteur published his germ theory, and in 1864 its application by the Scottish physician Charles Lister transformed surgery. The development of orthopedic splints reduced the need for amputations and fostered advances in reconstructive surgery. Contrary to the requirements of the Geneva Convention, these improve- ments provided a military rationale for depriving enemy troops of treatment, and the incentive to use the Red Cross symbol as a bull’s- eye. For example, the German air force torpedoed several British hospital ships during World War I. In 1935–1936 Mussoli- ni’s military campaign in Ethiopia included seventeen air strikes on clearly marked hospitals and ambulances. In- ternational outrage forced the League of Nations to investigate, but it took no action. Hospitals in conflict zones removed their Red Cross flags. The more than 70 million dead in World War II included twice as many civilians as combatants, many of them victims of indiscriminate bombing. Global concern over the participation of Nazi doctors in eugenics and meth- ods of mass killing led to the creation of the World Medical Association. Its first act was to update the Hippocratic Oath to impose a humanitarian duty on doctors to provide care in any emergency. The International Health Organiza- tion of the League of Nations reinvented itself as the World Health Organization and took on health as a human right. In 1948 the Universal Declaration of Human Rights included the right to medical care. In 1949 the Fourth Ge- neva Convention expanded protection to civilians and redefined attacks targeting medical care as a war crime, not just a violation of humanitarian law. Despite these protections, violations continued. The Biafran war in Nigeria in the late 1960s was significant for the bombing of several ICRC hospitals and the founding of Doctors Without Bor- ders. American protests against the Vietnam War and civilian harm added impetus to the ICRC’s campaign for the 1977 Additional Protocols, which strengthened civilian protections and specifically prohibited punishing physicians who provided impartial care to perceived enemies. Throughout the civil war in El Sal- vador, between 1980 and 1992, doctors were arrested, abducted, and killed. In areas held by insurgent groups, the Salvadoran government withheld essential medicines, obstructed aid, and impeded vaccination campaigns. Yet it was not until the conflict in Bosnia that WHO displayed any awareness of this issue. Following an urgent request from the UN Refugee Agency, in September 1992 WHO sent a mission to Bosnia. By then, Serbian forces had destroyed 30 percent of Bosnia’s hospitals and killed some four hundred medics, and Sara- jevo was under siege. In 1993 a World

Health Assembly (WHA) resolution fi- nally condemned the attacks but took no further action.

Bosnia was Rubenstein’s first experi- ence of war. In 1996, when he became the director of the US group Physicians for Human Rights, his first duty was to travel to Sarajevo to release its report describing these atrocities. A dozen reporters showed up at the press con- ference, but the report received little international coverage. He recounts:

The lack of attention was my first lesson among many to follow, that assaults on health care in war were widespread, but... addressing them was not a global health, diplomatic, or human rights priority.

Attacks on hospitals and clinics in Rwanda, Burundi, Chechnya, and So- malia—all described in Rubenstein’s book—also provoked little response. He notes the paradoxical contrast over the next decade between the increasing investment in global health security, such as the 2005 International Health Regulations, and the international in- difference to the growing problem of violence against medical workers, aid workers, and UN personnel. The most extreme example is Syria. After the Syrian government vio- lently responded to peaceful protests on March 17, 2011, injured protesters could not seek treatment without facing arrest from security forces embedded in public hospitals. Ambulances at- tempting to respond to massacres were ambushed and doctors were murdered. Government forces also targeted the paramedics of the Syrian Arab Red Crescent, the country’s branch of the Red Cross. Checkpoints were set up to stop anyone from smuggling lifesaving medicines to clinics providing care to protesters. The Ministry of Defense confiscated blood bags. In 2012, after the violence escalated into fully fledged armed conflict, Syr- ian doctors adapted to the government air strikes targeting hospitals, clinics, medical laboratories, and blood banks by moving facilities into basements and caves, eventually building entire hospitals underground. Beginning in 2014, Syrian Ministry of Health officials “de- leted” critical medicines and surgical items from lists of approved aid from UN convoys to besieged areas, depriving millions of civilians of essential medical supplies. After Russia entered the war in Sep- tember 2015, attacks on medical facilities and personnel escalated, despite the UN Security Council resolution in May 2016 condemning them. In Sep- tember 2016 Russian forces bombed a thirty- one- truck humanitarian convoy just outside besieged eastern Aleppo. In April 2017 a carefully orchestrated attack on the town of Khan Sheikhoun illustrated this exceptionally cruel strategy. Conventional bombing designed to drive people into basements was fol- lowed by air strikes with chemical weap- ons, which tended to seep into those basements. When survivors sought medical care, the Russians tracked their movements to the carefully hidden Al Rahma hospital and then either gave its coordinates to the Syrian air force or bombed it themselves. In February 2018 the Russian air force began its campaign to break East-

ern Ghouta by bombing twenty- five hospitals in four days. Yet in Septem- ber of that year, ignoring the evidence of hundreds of intentional attacks on health care facilities, the UN Office for the Coordination of Humanitarian Affairs (OCHA) pursued a “deconflic- tion strategy” in the northwestern city of Idlib. Under heavy pressure, Syrian doctors provided OCHA with the coordinates of the facilities that they had carefully hidden underground, which OCHA then gave to Russia, convinced that this would deter its attacks. As Rubenstein describes, Russian forces then targeted them precisely. The Syrian and Russian governments also targeted public health measures: when polio reappeared in mid- 2013 after an eighteen- year absence, it was the consequence of withholding vaccines from areas deemed politically hostile. WHO and UNICEF explained the outbreak as the result of conflict, though neighboring Iraq remained free of polio over eight years of war, until it spread to Baghdad from Syria in 2014. In 2017, during an outbreak of vaccine- derived polio, a sign of long- standing undervaccination, a Russian missile attack on a vital vaccine hub in Deir Ezzor destroyed 150,000 vaccine doses. The two outbreaks crippled well over one hundred children. Along similar lines, the government withheld chlorine for water treatment, facilitat- ing the return of typhus, hepatitis A, and other waterborne diseases (including polio). These actions amounted to passive biological warfare.

Systematic attacks on health care also feature in contemporary conflicts in Ethiopia and Myanmar, both of which have unfolded since Rubenstein finished his book. Tigray, Ethiopia’s mountainous northernmost region, is home to around six million people. Conflict erupted there in November 2020 following simmering tensions between the Ethiopian government and the Tigrayan People’s Liberation Front (TPLF), the political party that effectively ruled the country from 1991 until 2018, when Prime Minister Abiy Ahmed took power. Abiy prom- ised a free press and free elections in 2020, and made peace with neighboring Eritrea, for which he was awarded the Nobel Peace Prize in 2019. In March 2020, citing twenty- five reported cases of Covid- 19, Abiy postponed the elections. Tigrayan officials rejected the indefinite delay and held their own regional elec- tion, winning overwhelming support. In response the Ethiopian government invited in the Eritrean military and closed access to the region. Ethio Telecom, the sole provider, shut down Internet and cell service across the whole country (a private network was maintained for governments and close allies). Homes, hospitals, schools, and other public infrastructure were bombed. Government and allied militia troops massacred hundreds of civilians, burned crops, destroyed food stores, and raped tens of thousands of women and girls. Following the capture of towns in Tigray, troops systematically looted hospitals, health care centers, and phar- macies, and destroyed medicines and essential equipment. Hospitals were oc- cupied and ambulances seized. These attacks appeared designed to deprive the civilian population of access to care.

Pregnant women and survivors of sexual assault are especially harmed by the destruction of health care. Be- cause of a lack of ambulances and tight restrictions on civilian movement, women with difficult labors cannot get medical help. The mass rape and violence committed by Eritrean and Ethiopian forces in Tigray have been exceptionally cruel—women have been sexually tortured and mutilated with the aim of not just humiliation but sterilization. The consequences are physically catastrophic as well as socially devastating. In June 2021 Tigrayan forces mounted a successful counteroffensive and retook part of the region. Federal authorities as well as regional governments in Afar and Amhara severely restricted humanitarian aid and per- mitted only a fraction of needed food aid. In August Tigrayan defense forces looted at least one hospital in Amhara. In northern Amhara in late August and early September, Tigrayan soldiers raped dozens of women at gunpoint. In September, the government approved an EU airdrop of food and nutrition supplements but removed all medicines. No trucks carrying humanitarian supplies were able to enter Tigray between December 15, 2021, and April 1, 2022. In Myanmar, a military coup in Feb- ruary 2021 set off protests across the country. As in Syria, the junta met peaceful demonstrators with brutal re- pression, detaining, shooting, and killing unarmed civilians. Physicians have been targeted both for their support of the antijunta movement, including join- ing prodemocracy protests and strikes, and for treating injured civilians. The junta has been responsible for 95 percent of attacks against health care workers and facilities. From the time of the coup to March 31, 2022, government forces arrested 564 health workers, killed thirty- six medics, and raided 126 hospitals, occupying at least fifty- six of them. In November, eighty medical personnel were detained. Eight of these arrests were of female medics as- sociated with the antijunta movement. Another medic was shot at close range, execution- style. On Christmas Eve, thirty- five civilians, including women and children, were burned to death when government troops set fire to ve- hicles, one of which was clearly marked Save the Children. The junta diverts Covid- 19 vaccines and treatment to military personnel and has been using them as bait. Med- ics are lured by the militia to respond to false Covid- 19 emergencies, only to be arrested. In June 2021 the junta arrested a forty- five- year- old surgical lecturer at Mandalay University of Medicine, accusing him of having ties to the shadow opposition described by the junta as a terrorist group. After contracting the virus in prison, he was denied timely treatment and died.^

In March 2011, at Rubenstein’s initia- tive, sixteen organizations asked WHO director- general Dr. Margaret Chan “to engage the agency in addressing problems of violence against health- care.” Chan was receptive, and in her opening speech at the World Health Assembly she condemned Bahrain’s attacks on dozens of doctors. By the fall, Rubenstein had put together a coalition of NGOs and universities to press WHO to collect data on attacks

Sparrow 56 58 .indd 57 5 / 26 / 22 5 : 26 PM

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

Get our desktop app

Company

Features

Documentation

Resources