Destroyed Hospitals; Forgotten Responsibilities

The internationally recognized red moon of the Syrian Arab Red Crescent in Aleppo has been painted white. Ambulances across the city have been coated with mud to roam the streets incognito. The residents of one village begged doctors not to set up a hospital near their homes. ‘We’ll travel to another village,’ they said, ‘we don’t want our homes to be a target.’

Less than 40 doctors work quietly in underground operating theatres, surrounded by sandbags, across the city—sometimes three patients to a room. When a barrel bomb—a cylinder filled with explosives, shrapnel, nails and oil that is dropped from a helicopter and breaks into thousands of fragments upon impact—hits one of the only electric generators, surgeries continue under the hard glow of mobile flashlights and head lamps.

A destroyed Médecins Sans Frontières hospital in Idlib, Syria, one of three medical facilities attacked on Feb. 15, 2016
Credit: Dr. Abdulaziz

Sometimes the barrel bombs are the soundtrack to operations taking place in the corridors outside the theatre or the memories of near misses. Dr. Abdulaziz, a general surgeon who has been working in Aleppo since the Syrian conflict started in 2011, escaped death by 15 minutes one Tuesday morning. A barrel bomb exploded behind his hospital, forcing an evacuation of all personnel to lower ground. The third floor operating room they were working in was hit by another bomb 15 minutes later.

A hospital destroyed in the midst of intense fighting is, unfortunately, a frequent occurrence in past and present conflicts: patients and staff killed and wounded, the facility destroyed, a void of medical care ensued. It used to be an unintended, sometimes direct, casualty of war, says Executive Director of Médecins Sans Frontières-Canada, Stephen Cornish, often associated with forces outside the control of international humanitarian law. But Cornish says that’s changed “to something that’s frequent and increasingly brazen.”

Today, medical facilities are increasingly intended targets in countries like Syria, Yemen, South Sudan and Afghanistan, among others. In most cases, the perpetrators of these attacks are either permanent members of the United Nations (UN) Security Council, or local allies backed by one of those five countries. All are signatories of, or have ratified, the Geneva Convention, which makes clear in Article 18 that “Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.”

Yet US-led forces were accused of attacking a hospital in Kunduz, Afghanistan in October, 2015. Médecins Sans Frontières (MSF) has reported that, on average, one of its facilities in Syria was bombed or shelled every single week in 2015 and the first six weeks of 2016. Russian airstrikes (or Russian-backed airstrikes) have been found to be the perpetrators of these attacks. In Yemen, it was US- and UK-backed Saudi forces.

On February 15, 2016, three hospitals in Idlib, Syria, were attacked within 15 minutes of each other by airstrikes, killing 25 people. Abdulaziz calls it the “bloody day,” and notes that when the first hospital was attacked, all casualties were transferred to a hospital nine kilometres away. When that one was subsequently attacked, the hospital was evacuated 30 kilometres to a facility closer to the Turkish border, away from the zone of likely airstrikes.

Abdulaziz recalls similar attacks in northern Aleppo. One was a maternity hospital with 10 incubators in service. When a barrel bomb destroyed the only generator powering the medical facility, the critical newborns and their families had to be evacuated.
Such attacks contravene humanitarian law, says Cornish, indicating a loosening of respect for international law. One reason for this has been the blurred lines created by the War on Terror. The distinction between army efforts and humanitarian ones has been complicated by the construct of the three-block war, where the military can be a political peacekeeper in one block of the country, a fighting force in another block and a deliverer of aid and assistance in another. “They have undermined our ability to work in some of these conflict zones,” says Cornish. Casually-dressed military forces will drive the same white Land Cruisers used by NGOs, who have partnered with them in state-building initiatives.

The MSF has been putting pressure on countries and organizations to strongly reaffirm basic humanitarian laws, beginning with a social media campaign to raise awareness with #NotATarget. Last December, the UN General Assembly passed a resolution affirming protection from violence for medical personnel, patients and health facilities—it isn’t legally binding in the way a treaty is but rather a baseline statement condemning such attacks.

“There is a problem when it comes to holding violators to account,” says John Packer, associate professor of law and director of the Human Rights Research and Education Centre at the University of Ottawa. “It is typically only achieved as conflicts come to an end and, frankly, when victors hold to account the vanquished.”

Packer says that while the International Committee of the Red Cross is empowered, as a neutral actor, to observe and promote respect for international humanitarian law, they are not investigators or prosecutors. That can “only be done through substantial international cooperation amongst all states ready to commit their own behaviour and the needed resources.”

Caption: Physicians for Human Rights reports that 202 medical facilities have been attacked since the Syrian conflict began in 2011
Credit: Dr. Abdulaziz

But there is a notable lack of readiness to do this. Those who are supposed to uphold the rules of law aren’t doing so, perpetuating complicity for organizations and non-state actors. The International Humanitarian Fact-Finding Mission—a permanent international body whose main purpose is to investigate allegations of serious violations of international humanitarian law—has taken steps to investigate attacks on hospitals in Yemen and Syria. Its investigation in the Kunduz hospital attack was awaiting consent from the US (as per Article 90(2)(d) of the Geneva Convention), but ended when the Pentagon acknowledged that the clinic was targeted by mistake. No personnel faced criminal charges and the new commander of US-North Atlantic Treaty Organization forces in Afghanistan apologized six months after the attack.

“There is a basic sanctity of human life that has been understood by even the worst of the worst,” says Cornish. The rules for international humanitarian law were designed for the protection of soldiers at a time when the military had veterinarians to take care of their horses, but allowed their wounded veterans to die on the battlefields. Yet now, Cornish says, “The very fundamentals are slipping away.”

Today, medical workers like Abdulaziz are travelling eight-12 hours to work in conflict zones like Syria for 15-day sessions. Within that time he teaches 200 medical students in underground classrooms at Aleppo University, who also work part-time in the few facilities still standing. “Keeping hospitals safe shouldn’t be a problem,” says Abdulaziz. “It’s our right.”

On April 1, 2016, at 5.41 p.m. EST, two days after we talked, Dr. Abdulaziz sent me a message: “Just now one of our hospital in Aleppo targeted by airstrike killing one patient and others wounded. Hospital now out of service.”