58 The New York Reviewon health care. With the support of the
US, in May 2012 the decision- making
body of WHO mandated the organi-
zation to survey attacks and report on
them.
The need for rigorous data collec-
tion is emphasized in Abby Stoddard’s
Necessary Risks: Professional Hu-
manitarianism and Violence Against
Aid Workers. An aid worker herself,
Stoddard begins with an account of a
lethal attack on her colleagues at the
international organization Médecins
du Monde in Ruhengeri, Rwanda, in- Heavily armed Hutus held them
at gunpoint and stripped the office of
laptops and other valuables. Minutes
later, the leader returned with an AK-
47 and opened fired on the unarmed
team, killing three and critically injur-
ing a fourth.
The lack of data on the dangers
faced by people working in the field
inspired Stoddard to develop the Aid
Worker Security Database (AW S D),
which collects data directly from non-
governmental organizations and field-
based security agencies. Since 1997 the
number of attacks on aid workers has
increased dramatically, especially in
settings of armed conflict, described
by Stoddard as the “oxymoronically-
termed ‘chronic emergencies.’” Strik-
ingly, international aid workers have
a higher rate of violent death than US
soldiers and police officers. In 2020
there were more attacks on aid workers
than in any previous year.
Like many aid workers, I used to
believe that traffic accidents were the
greatest risk I faced. Stoddard’s data-
base shows that humanitarian workers
have always died primarily from direct
attacks. Gunshot wounds are the most
common cause, followed by air strikes,
often targeting health facilities and aid
convoys, as well as double- tap strikes
aimed at those rushing in to aid the
wounded.
Stoddard’s risk- management strate-
gies include removing logos and brand-
ing, which appeal to donors but make
offices and convoys easy targets, and
addressing needs as the community
sees them rather than as headquarters
dictates. She emphasizes that persuad-
ing warring parties that a humanitarian
effort is neutral requires aid workers
to show up in affected communities,
communicate regularly, and build local
trust.
While the importance of trust is in-
disputable, Stoddard’s limited focus
on international aid workers doesn’t
address the growing problem of heav-
ily restricted access in contemporary
conflicts. In Damascus, the Syrian gov-
ernment controls the movements of all
UN and international agency staff, and
strongly recommends they stay at the
Four Seasons Hotel for security pur-
poses—and for ease of surveillance.
Areas not controlled by the government
have been too dangerous for interna-
tional workers for years. The prolifer-
ation of aid agencies in Damascus and
neighboring countries hides the lack of
humanitarian space inside. In 2012 a
British surgeon, Dr. Abbas Khan, trav-
eled to Aleppo to work in a hospital. He
was arrested at a checkpoint and impris-
oned, and his suspicious death a year
later—according to the Syrian foreign
minister, he hanged himself in his cell—
was widely reported.
Yet local health care providers shoul-
der the greatest financial and personal
risks. Stoddard states that in 2018, 80
percent of victims were workers from
the area, not expatriates, reflecting the
predominance of local staff in most
aid efforts.* By 2020, the figure was 95
percent.
The global “war on terror” has con-
tributed to the erosion of protection
for health care and aid workers. Gov-
ernments may decide that doctors and
aid agencies who provide health care
in areas controlled by insurgents are
terrorists by association. The AW S D
shows that the number and sophistica-
tion of attacks against aid workers in
the Middle East and Africa increased
after the US invasions of Afghanistan
and Iraq: local populations perceived
Western- dominated aid groups and
even the United Nations as extensions
of the US military effort.
For Rubenstein the elevation of
counterterrorism over respect for the
laws of armed conflict poses the great-
est threat to the protection of medi-
cal workers, hospitals, and patients.
Prosecuting doctors is done as much
to dehumanize as it is to punish. As a
pediatrician, I experienced a version
of this myself. Beginning in 2002 I did
several stints at the Woomera deten-
tion center in South Australia, where
asylum seekers, mostly from Afghan-
istan, were held for months or even
years while their claims for asylum
were processed. On any given day, I
might see strep throat, polio, and symp-
toms of post- traumatic stress disorder
like self- harm or somatization. I was
not allowed to provide the usual stan-
dards of care. For example, instead of
allowing medical therapy to manage
bed- wetting in (understandably) trau-
matized ten- year- olds, security guards
handed out diapers.
In early 2003, as asylum claims
were increasingly rejected on specious
grounds, protests were met with tear
gas and water cannons. I had to man-
age teenagers who went on hunger
strikes and attempted suicide—neither
of which had been part of my medical
school curriculum. Eventually, dozens
of asylum seekers sewed their lips to-
gether in protest. Their awful treatment
led me to speak out publicly against the
punitive conditions. Woomera was shut
down later that year, but a few years
after that, Australia expanded its coun-
terterrorism laws to criminalize criti-
cism of detention centers—exactly what
I had done.Russia’s invasion of Ukraine provides
the most recent example of violence
against health care. An attack on a ma-
ternity hospital in Mariupol on March 9
was the first to spark international con-
demnation. At least three people were
killed, and one mother- to- be sustained
severe injuries. She needed a C- section
in order to save her baby, but the at-
tack made the surgery impossible, andboth she and her baby died. Since the
invasion began on February 24, Rus-
sian forces have damaged, destroyed,
or occupied hundreds of hospitals. In
the Luhansk region, every hospital is
damaged. TB centers have been emp-
tied and patients deprived of treatment.
Hundreds of women have been raped.
These attacks, which are part of Rus-
sian forces’ broader attacks on heavily
populated civilian neighborhoods, are
a major driver of displacement. Four-
teen million people—one third of
Ukraine’s population—have fled their
homes in ten weeks. It is a new world
record for mass displacement in the
shortest amount of time.
A decade after the WHA mandate,
WHO’s S u r ve i l l a n c e S y s t e m o f A t t a c k s i s
a huge disappointment. In conflict zones
where it does count attacks, there is no
analysis of the public health impact—
services disrupted, people affected or
displaced. In Ethiopia, where the health
care system has been destroyed and tens
of thousands raped, although WHO’s
current director- general, Tedros Ad-
hanom Ghebreyesus, is a strong public
supporter of Tigray’s invisible crisis and
its victims, has not recorded a single at-
tack. In Syria, although Russia’s culpa-
bility in Idlib was proved beyond doubt,
WHO described the attacks as a tragedy.
It’s not just WHO—the UN Board of
Inquiry report on these events did not
name Russia.
As the foremost global health in-
stitution, WHO has authority. Yet its
euphemistic reporting has degraded
international norms and fostered a
sense of impunity on the part of the
Syrian and Russian governments, en-
couraging more attacks, as we see now
in Ukraine. Attacks are described only
as violations, not as war crimes—which
they clearly are.
Rubenstein’s and Stoddard’s books
show that the fight to protect medical
and humanitarian workers is not new,
but we are running out of time before
it becomes futile. While few are pros-
ecuted for these war crimes, the stigma
attached to them remains evident in
the effort put into denying them. But as
governments increasingly are not held
accountable for breaching international
law, the stigma is dissipating. Putin’s
attacks, should they be allowed to con-
tinue, let alone go unpunished, funda-
mentally undermine the significance
of international human law and the jus-
tification for the organizations charged
with its realization.
We could all take a page out of
Dunant’s book. One hundred and sixty
years after its publication, A Memory
of Solferino is still the most power-
ful human rights report ever written,
emotional but devoid of self- interest or
sensational claims of saving millions
of lives. His proposals were practical
and based on collaboration and shared
humanity.
Rubenstein identifies Dunant’s cen-
tral truth—that the real story of war
is suffering. This is the moment to
build the infrastructure to safeguard
the people who are trying to protect
the innocent. Attacks on health care
aren’t a niche concern—they are war
crimes. The global stakes are high.
Underpinning international human
rights and humanitarian norms is a
basic acknowledgment that these com-
mon standards of conduct protect us
all. If they are discarded, everyone,
not just those in war zones, suffers the
consequences. Q*A new book by Hugo Slim, Solferino
21 : Warfare , Civilians and Humanitari-
ans in the Twenty- First Century (Hurst,
2022), addresses the evolving nature of
humanitarian work in modern armed
conflicts, including the central part of
national aid workers alongside interna-
tional ones. Slim plays down the impor-
tance of the ICRC, which continues to
have a part Dunant didn’t envision—
as the central communicator. Since
Franco- Prussian War, Red Cross soci-
eties have refused to talk to one another
and communicate through the ICRC.New York Review Books
(including NYRB Classics, NYRB Poets,
The New York Review Children’s Collection,
NYRB Kids and NYR Comics)
Editor: Edwin Frank
Executive Editor: Sara Kramer
Senior Editors: Susan Barba, Michael Shae,
Lucas Adams
Associate Editor: Alex Andriesse
Linda Hollick, Publisher; Nicholas During,
Publicity Director; Abigail Dunn, Senior
Marketing and Publicity Manager;
Alex Ransom, Assistant Marketing Manager;
Evan Johnston, Production Manager;
Patrick Hederman and Alaina Taylor, Rights;
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