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Originally published on October 7 and December 3, 2014, in two parts. This version has been updated and footnotes have been added.

Warning from a Mass Grave: Hospitals Under Attack

by Emily Friedman

Armed attacks on hospitals are occurring more often around the world, resulting in death, injury and destroyed facilities. What can be done to stop this disturbing trend?

In human tradition, three types of institutions have been considered safe in times of violence and civil strife; that is, it is expected that they will be exempt from armed attack. These institutions are places of worship, schools and hospitals.

Unfortunately, this is more myth than fact. History is rife with examples of churches, synagogues, mosques and other sites of worship being violated, including a 2012 shooting in a Sikh temple in Wisconsin that killed six innocent victims; the killer took his own life. [1] Schools also have been subject to violence all over the world. [2]

But it has generally been assumed that hospitals are still off-limits in times of conflict because of the healing nature of their work and the vulnerability of their unarmed staff and patients. Until the second half of the 20th century, this was a largely valid belief, although there is evidence of some hospitals having been attacked earlier in wartime.

An Unwelcome Trend

Unfortunately, in today's angry environment, healing institutions are no longer sacrosanct. In recent years, hospitals in several countries have been invaded by armed parties who have terrorized, kidnapped or killed staff members and patients in Afghanistan; the Central African Republic; Kiev and Crimea, Ukraine; South Sudan; and Yemen, among other places. [3]

The Yemen attack, in which 52 people were killed and 167 wounded in December 2013, was filmed by a security camera; the video was posted on YouTube, sparking widespread protest and an apology from al-Qaida of the Arabian Peninsula, at least one of whose fighters was responsible. [4]

Hospitals reportedly also have been damaged recently by missiles or bombs in Syria and in Gaza; in the latter case, Israeli and Gaza representatives each have blamed the other side for the incidents.

This unwelcome trend began earlier, however. During the Biafran War in Nigeria in 1968, physician volunteers reported that Nigerian government troops intentionally targeted Biafran hospitals, according to Médecins Sans Frontières (MSF, or Doctors Without Borders). [5] Some of those physicians went on to form MSF in 1971.

There were also dreadful incidents of hospitals, staff members and patients being attacked in Cambodia in 1975-79, Croatia in 1991 and Rwanda in 1994, among others. [6] [7] [8] [9] [10] [11]

It is difficult to comprehend why the basic right of sick and injured human beings and their caregivers to be safe from harm increasingly is being ignored.

In order to do so — and, equally important, to try to stop this from happening — examining the lessons of documented situations from the recent past is helpful.

Cambodia, 1975-79

After six years of U.S. bombing and civil war, Cambodia's capital city, Phnom Penh, fell on April 17, 1975, to a shadowy radical Communist force commonly known as the Khmer Rouge (usually referred to in Cambodia as the KR). [12]

The group pursued a vision of a ruthless agrarian socialism, under which all people would live in the countryside, growing rice on collective farms. There would be no class distinctions, no intellectual superiority.

There are many ways to achieve such an end; the KR's approach was to empty the cities and murder most educated people, including health care professionals. Survivors were forced to work in rice-growing collectives that were, essentially, concentration camps. During the four years of KR rule, it is estimated that 1.5- 2 million Cambodians were murdered or died of starvation, exhaustion or untreated disease.

When Phnom Penh fell, hospitals were among the first targets. William Shawcross, who has chronicled the Cambodian tragedy, described the scene when Phnom Penh's hospitals were taken by the KR: "The soldiers marched through the wards, and then they ordered all those patients who could walk to get off their beds and push out through the doors those who could not move. And so, in the heat of the day, a most dreadful parade began. From hospitals all over the city crawled and hobbled the casualties of the war, the first victims of the 'peace.'" [13] None is known to have survived.

Haing Ngor, an obstetrician in Phnom Penh who was one of only a handful of Cambodian physicians to survive the KR period, was operating on a wounded soldier when an armed KR guerrilla burst into the hospital surgical area, demanding that the physicians identify themselves. He then left. "The patient was lying on the table behind me, unconscious. His intestines were back in place, but we hadn't finished sewing him up," Haing later wrote in his autobiography. Realizing that their lives were at risk and that they could not protect their patient, he and his colleagues abandoned the hospital. "We took a last look at the poor young soldier on the table with pale, waxen skin and the long open incision in his belly. He was going to die.

"All my illusions were gone. They had broken into the sanctuary of the operating room." [14]

(Haing eventually found his way to the United States, where, in 1984, he played Cambodian journalist and photographer Dith Pran in the film The Killing Fields, for which he won an Academy Award for best supporting actor in 1985. He was the first male Asian, and only the second nonprofessional actor, to be so honored. He was murdered near his home in Los Angeles in 1996; three members of an Asian street gang were convicted of his killing, which the police classified as a random street crime, although many people believe that he was murdered on the orders of surviving leaders of the KR.)

Part of the KR's plan was a return to Cambodian folk medicine for everyone but the KR leaders, soldiers and elite cadres, who had the convenience of Western medicine at a few select hospitals. Haing quoted one cadre leader: "We don't need doctors anymore. If someone needs to have their intestines removed, I will do it. It is easy. There is no need to learn how to do it by going to school." [15]

Given that philosophy, it is not surprising that most of the physicians, nurses and other health care professionals in Cambodia died at the hands of the KR; although estimates vary, it is possible that as few as 25 physicians survived. One of them is Hun Chhunly, who was a civilian physician in the city of Battambang until he was required to join the army as a second lieutenant in 1973 and work in a military hospital.

That hospital was taken by the KR on April 20, 1975. In an interview with me in Phnom Penh in 2014, Hun reported that, upon arriving at the hospital the next day, he learned that all of his physician colleagues holding the rank of first lieutenant or higher had been taken away by the KR and murdered. [16]

From July 1975 to October 1976, Hun worked at that same facility (Military Hospital P2), treating the KR elite who had denied effective medical care to the rest of the population. Although the hospital was substandard and resources thin, decent care could still be delivered. In November 1976, Hun was transferred to Civilian Hospital P1, the former Battambang Hospital, which was in dreadful shape, without running water or electricity. Many patients died of treatable disease, and others died as the result of barbaric medical experiments reminiscent of the Nazi period, including the use of a Buddhist monastery crematorium to dispose of the subjects; some were still alive when incinerated.

Hun concludes, "In short, the military hospital was a facility for taking care of and for promoting the health of Angkar's [the KR's name for its organization] Khmer Rouge soldiers. The civilian hospital was merely an antechamber of death for the Cambodian people." [17]

Most hospitals were abandoned, intentionally damaged or looted and, according to attorney Laura Vilim, who has documented health care practices under the KR (such as they were), "In addition to hospitals, hubs of medical knowledge were destroyed. The Library of the Medical Faculty in Phnom Penh … was raided and its collection set on fire. The Phnom Penh Medical School was emptied of its students … and its laboratory equipment, which was thrown onto the sidewalks." [18]

The carnage ended with the Vietnamese victory over the KR in 1979 and the subsequent 10-year occupation of Cambodia by that country. In the years since, Cambodia has struggled to rebuild its health care delivery system and workforce — a process that has proven to be agonizingly slow and difficult. [19]

Vukovar, Croatia, 1991

One of many results of the dissolution of Yugoslavia in 1990-91 was the Croatian War for Independence, which set autonomy-minded Croatians against the forces of Serbian President Slobodan Miloševi?, who envisioned a "Greater Serbia" that would include most former Yugoslav entities — with most non-Serbs removed.

The Croatian city of Vukovar, located near the Serbian border, became an early target and was attacked in August 1991. It was subjected to siege and constant bombardment by the Yugoslav National Army (JNA in its Croatian acronym) and paramilitary forces, and became the first European city to be entirely destroyed by armed action since World War II.

The town's hospital was not spared. It was shelled and bombed constantly during the 87-day siege. It became obvious that the hospital's patients and staff would not survive above ground, so much of the operation was moved into the basement, where patients were stacked in bunks three high along the main corridor. The staff, led by the chief nurse, Binazija Kolesar, carried on, sometimes receiving 70 patients a day (most with shrapnel wounds) and operating an intensive care unit, a neonatal unit, a birthing unit, a surgical suite and a casting room, among other services. "The hospital was operational from Day 1 until the city fell, under these impossible conditions," Kolesar recalled in an interview with me in Vukovar in 2013. "But almost anything in health care can be improvised." [20]

MSF had evacuated 105 patients on Oct. 19, but the hospital was full, as it always was, when Vukovar fell to the Serbs on Nov. 18. Many civilians, and possibly armed Croatian soldiers (although the latter attestation has not been documented), had sought shelter there as well. Evacuation of patients and staff, negotiated by the International Committee of the Red Cross (ICRC), was scheduled for Nov. 20, but Serb forces attacked the hospital on Nov. 19.

Many of those who had sought refuge at the hospital were forced to leave; men and women were separated and most of the men were detained by the JNA and Serb paramilitary forces. On Nov. 20, medical staff members were called to a meeting, where they were required to listen to a speech by a JNA officer. At the same time, the hospital was being emptied of Croatian staff, ambulatory patients and any remaining civilians; the men among them, and at least one woman, were taken away.

Although statistics are not entirely reliable because the attackers removed almost all documentation from the hospital, it is believed that 267 patients and staff were transported to the warehouses of Ov?ara, a nearby pig farm, where they were beaten and tortured. They were then taken to a field on the farm and summarily shot to death. Some of their bodies were thrown into a pit partially filled with pig carcasses. The rest of the bodies have not been found.

Among hospital staff members who were killed were the barber, cook, electrician, chief of maintenance, plumber, at least one nurse and all but one ambulance driver, who was mistaken for a physician and removed from the bus that was taking the rest to be murdered. He is still driving an ambulance for the hospital, which was rebuilt over the years; repairs were completed in 2007. No physicians were killed, although most of them spent time in prison camps. The hospital dentist also was spared.

There were 54 patients left in the hospital, either because they were too sick to be moved by normal transport or because there was a shortage of vehicles. The Serbs loaded them into ambulances and buses and drove them on a circuitous route that included Bosnia before they were turned over to Croatian authorities, who hospitalized them in other parts of the country. The patients were accompanied by Kolesar and other hospital staff members who had refused to abandon them. [21] [22]

Eric Dachy, M.D., a Belgian physician who was MSF chief of mission in Belgrade at the time, arrived in Vukovar on Nov. 20. "I could see how the hospital had been shelled, and some of the patients appeared to be starving," he told me in a 2013 interview. "I understood that the Serbs took the men, even the wounded, and it was expected that they would be killed. There was nothing that I could say or do. Very quickly, the hospital was emptied. The building was completely devastated." [23]

Most surviving staff members were either sent to prison camps or "ethnically cleansed" and forced out of Vukovar; some volunteered to remain at the hospital, which the JNA attempted to operate. Others, who were in internal exile for years, have since returned.

On Dec. 9, 2013, Binazija Kolesar was awarded the Florence Nightingale Medal, the nursing profession's highest international honor, by the ICRC for showing "exceptional courage and devotion to the victims of armed conflict or natural disaster." [24]

Rwanda, 1994

The tragic, tangled history that led to the genocide in Rwanda in 1994 has been well-documented. In brief, for hundreds of years, the Tutsi tribe had ruled the country, subjugating the majority Hutus. After the death of the Tutsi king in 1959, Hutus seized power and, over the next 25 years, Hutus and Tutsis periodically fought for control of the country, with atrocities committed by both sides.

In 1973, the army chief of staff, Juvénal Habyarimana, a Hutu, seized power and became president, inaugurating a period of Hutu supremacy in many aspects of Rwandan life. Some radical Hutus, especially armed militia groups known as the Interahamwe, wanted to go further and exterminate the Tutsi minority, but there were only sporadic killings until April 6, 1994, when a plane carrying Habyarimana and Burundi president Cyprien Ntaryamira was shot down (no one has ever admitted responsibility).

The next day, led by the Interahamwe and others, thousands of Hutus, armed with machetes, clubs and sometimes firearms, began an organized campaign of genocide against Tutsis. The killers included farmers, small businessmen, politicians, physicians, attorneys and even humanitarian aid workers. [25]

At approximately the same time, an expatriate Tutsi army based in Uganda, the Rwandan Patriotic Front (RPF), invaded Rwanda, bent on reclaiming power for Tutsis, and was moving toward the capital of Kigali.

Rwandan hospitals were targeted. In the town of Nyamata, the Sainte-Marthe Maternity Hospital was attacked by Hutu soldiers and the Interahamwe. Valérie Nyirarudodo, a Hutu nurse, who had brought her children to the hospital for safety, told historian Jean Hatzfeld, "A soldier came to … the hospital. He told me quietly, 'Get out, run away, those who can.' At the door, some Interahamwe shouted, 'Those who are not targeted, leave … . I looked at the mama who had just given birth in front of me on a mattress, lying there with her two children. I prayed at top speed, My God, tell me the one I should take. Then I thought, if I take the newborn, I can't feed it since I have no milk. The older one will be easier. I put him in a cloth sling on my back and told the soldiers, 'He is mine, too.'

"They surrounded the maternity hospital. They ripped down the gates … . They killed the women with machetes and clubs … . When a mama had hidden a child underneath her, they picked her up first, then cut the child [with a machete], then cut its mother last. They didn't bother to cut the nursing infants properly. They slammed them against the walls to save time, or hurled them alive on the heaps of corpses.

"That morning, we were more than 300 women and children. That evening … there were only five women left, spared because they were lucky to be born Hutu." [26]

At the Mugonero Adventist Hospital, "Hundreds of children and adults were mercilessly slaughtered, including many of the hospital workers and their families," according to news reports at the time. [27]

The Rwamagana Hospital lost 16 staff members, mostly physicians and nurses. [28]

One of the worst incidents occurred at Butare University Teaching Hospital, near the border with Burundi. Rony Zachariah, M.D., Ph.D., was working with MSF at the hospital. He recalls, "On the 22nd and 23rd of April, we were caring for 170 civilian Tutsi patients and 140 wounded Hutu soldiers … . We were the last functioning hospital in southern Rwanda … . Forty Tutsi patients were taken behind the hospital by the Interahamwe and soldiers and beaten to death."

Zachariah and ICRC representatives met with hospital authorities and with a Hutu military officer who was in charge of the affairs of wounded soldiers in the hospital, and tried to explain their organizations' position of neutrality, saying that they cared for all sick and injured persons regardless of ethnicity or affiliation. Zachariah told me in an interview in 2014 that the officer's first response after the meeting was, "This hospital stinks of Tutsis; let's clean up." Soldiers and militia members then ripped sutures and intravenous lines from Tutsi patients and killed them.

"They took five of our nurses, all Tutsis except for a nurse named Sabine, who was Hutu," Zachariah remembers. "Two Tutsi nurses — Alexis and Jean-Marie — were killed. Sabine, a great colleague, was seven months pregnant. When they came to take her, I said to the soldier who was trying to drag her away, 'She is Hutu; this must be a mistake. Please leave her alone. Furthermore, it is she who has been taking care of your wounded soldiers.' I stood between the soldier and the commander, who pulled out a piece of paper, looked at it carefully, and said, 'Doctor, you are right. Sabine is indeed Hutu. But her husband is Tutsi, and this baby will thus be Tutsi.' Sabine was taken away and killed. There was nothing more I could do to stop it.

"On April 22nd and 23rd, between 150 and 170 civilian patients were taken out and killed, including children, and some of our staff; they were all beaten to death. Almost all of our [indigenous] staff were killed except for Hutus.

"I thought there was hope, and then there was none. We were the last safe haven." [29] [30]

Zachariah was able to save only five Tutsi staff members, who threw away their government identification badges stating their ethnicity, and, along with him and other expatriate staff, slipped over the border into Burundi on April 24.

He says of his harrowing experience, "I have come to realize that one cannot stop genocide with doctors and nurses. Neither can one heal the deep wounds of Rwanda with bandages and sutures. There was a need for justice." Zachariah has testified at numerous war crimes trials and tribunals in the years since. [31]

The genocide ended in July, when the RPF entered Kigali and took control of Rwanda. By then, between 800,000 and 2 million Tutsis and moderate Hutus were dead. Hundreds of thousands of Hutus, including some who had been involved in the killing, but many more who were simply seeking safety, fled the country to refugee camps in Zaire (now the Democratic Republic of Congo). Both in Rwanda and in the camps, Hutus were massacred by vengeful Tutsis. However, the international community, which had done little or nothing to help the Tutsis, intervened, possibly because of extensive news media coverage of the Hutus' plight.

"Where Is Considered Safe?"

"If hospitals aren't safe in Yemen, where is considered safe?" asked an anguished Yemeni man who lives near the hospital that was attacked in 2013. [32] The question that hangs like a malignant black cloud over all these experiences is indeed: Why attack a hospital, especially when its staff members are caring for all people equally? "Why kill physicians?" Hun asked me when I interviewed him in Phnom Penh in 2014. "We can be useful." [33] Kolesar told me during our 2013 interview in Vukovar that she "has no idea why anyone would do such a thing," because "hospitals are sacred places." [34]

So why would anyone, combatants or not, attack a virtually defenseless institution and those who work within it?

Hospitals, their staff members, and patients were protected by the Geneva Conventions of 1949, which declared that innocent civilians were to be spared in time of war. The conventions' additional protocols of 1977 stated specifically that, "The civilian population and individual civilians shall enjoy general protection against the dangers arising from military operations." [35]

Emma Daly, in an essay for the Crimes of War Education Project, adds, "The wounded, sick, or shipwrecked, [and] military personnel who are considered to be hors de combat [that is, not involved in fighting, such as field medics], are protected, as are prisoners of war. Hospitals, both fixed and mobile, ambulances, hospital ships, medical aircraft and medical personnel — whether civilian or military — are also entitled to protection from hostile fire under the Geneva Conventions, provided that structures are marked with a red cross or red crescent and not used improperly or near military objectives, and staff are properly protected. Staff include not only doctors, nurses and orderlies, but the drivers, cleaners, cooks and crews of hospital ships — in short, all those who help a medical unit to function. Some aid workers — for example, Red Cross volunteers treating the sick and wounded on the battlefield — are also covered, as are military chaplains." [36]

Yet these prohibitions are regularly ignored.

Leonard Rubenstein, J.D., chairman of the Safeguarding Health in Conflict coalition, which seeks to protect hospitals, other health care facilities, ambulances, staff members and patients in times of strife, says that there are several major reasons and common themes involved in attacks on hospitals. These include:

Indeed, in October 2014, Islamic State, or ISIS, fighters in Iraq took over a hospital that was under construction in the town of Rabia and used it as a base for sniper attacks. After days of combat and air strikes on the building, Kurdish troops took it; most of the ISIS fighters were killed. One Kurdish soldier said afterward, "We were about to get the hospital, but they had really good snipers there." [39]

Hardly the kind of words one wants to hear about a healing institution. The hospital was destroyed during the battle, and will not be able to serve the people of Rabia.

Unique Circumstances

Trying to comprehend why these attacks occur is complicated by the fact that each instance is unique. In the Cambodian holocaust of 1975-79, educated staff members, not the hospitals, were the targets. The KR concept of a classless society did not allow for such people, nor did it allow for Western medicine — except, of course, in a stunning example of hypocrisy, for its own elite leaders and fighters. Most Cambodian hospitals were destroyed by abandonment and neglect, not as a matter of intent.

The situation in Vukovar in 1991, although rooted in genocide, could also well have involved pent-up anger. Serb forces had planned to conquer the town and then move on to invade larger cities in the eastern Croatian region of Slavonia; as it was, they were stalled for three months at Vukovar and were unable to proceed further. They also lost a large number of troops and tanks and, thus, likely were both frustrated and enraged.

Alenka Mirkoviç-Nad, former acting director of the Vukovar Homeland War Memorial Center, who as a journalist was covering the fall of Vukovar for the BBC, "Sky News" and other media outlets before she was forced to run for her life (several of her journalist colleagues were killed), told me in a 2013 interview in Vukovar that she attributes the slaughter of patients and staff members at the hospital to "pure rage." [40]

Furthermore, the hospital was caring for wounded Croat soldiers as well as civilians, and the Serbs likely did not want them returning to the fight. It should be noted that the hospital also was treating Serbian patients.

Dachy told me in our 2013 interview, "They [the Serbs] were not going to let one enemy escape. I don't think they took many prisoners … . But there was nothing special in the way the JNA treated the Vukovar hospital; they did the same thing in Bosnia [in 1992-95]. They killed all the men older than a certain age. In Vukovar, as in Srebrenica in Bosnia, they felt they had to do this because so many of the hospital patients were soldiers who had been fighting against them."

He adds that he does not believe that the Serbs wanted to destroy the Vukovar hospital entirely, because "they were very skilled with artillery" and that if they had wanted to "flatten" the hospital, they easily could have done so. [41] And after Vukovar fell and was "ethnically cleansed," the JNA did attempt to operate the hospital.

The Rwandan genocide of 1994 has confounded those who have tried to comprehend it. There were many factors at work: The majority Hutus resented the privileges of the Tutsi minority, the possibility of acquiring the property of dead Tutsis in a low-income society was very tempting, peer pressure was extremely powerful, those who would not kill were threatened, there was a constant drumbeat of encouragement to murder Tutsis from radio broadcasts and Interahamwe, and there was widespread fear — reinforced by Hutu Power proponents at every turn — that Tutsis might be planning to kill Hutus.

History also likely played a role. Adam Hochschild, professor of journalism at the University of California, has theorized that the brutal colonial period in this part of Africa may have left, as part of its grim legacy, a tendency on the part of contemporary Africans to emulate the cruelty of their ancestors' European overseers. [42]

Although colonialism is often cited, justifiably, as a factor by those seeking to comprehend ongoing violence in Africa, it is insufficient to explain a catastrophe as vast as the Rwandan genocide. It also does not explain the participation of tens of thousands of educated Rwandans, including health care professionals, in the killing, especially when it occurred in hospitals.

Mahmood Mamdani, director of the Makerere Institute of Social Research in Uganda, has written, "That victims looking for a sanctuary should seek out churches, schools and hospitals as places for shelter is totally understandable. But that they should be killed without any let or hindrance — even lured to these places for that purpose — is not at all understandable. As places of shelter turned into slaughterhouses, those pledged to heal or nurture life set about extinguishing it, methodically and deliberately. That the professions most closely associated with valuing life — doctors and nurses, priests and teachers, human rights activists — got embroiled in taking it is probably the most troubling question of the Rwandan genocide." [43]

Perhaps the best observation was offered by Cassius Niyonsaba, who was a small boy when his entire family was slaughtered, and who told historian Jean Hatzfeld, "The truth about the killing of Tutsis is beyond each and every one of us." [44]

No Excuse

More recent incidents also challenge explanation. Perhaps the best-documented situation is the long-running conflict in Syria, in which both pro- and antigovernment forces have not only targeted hospitals and their staffs and patients, but also have added torture to the unhappy list of actions taken against providers. In 2013, a United Nations report cited the Syrian government as the worst offender, alleging that "Government forces deny medical care to those from opposition-controlled and -affiliated areas as a matter of policy." Furthermore, the report states, "Government forces have strategically assaulted hospitals and medical units to deprive persons perceived to be affiliated with the opposition of medical care."

The report adds that "government forces have engaged in agonizing cruelty against the sick and wounded," including using hospitals as sites of torture inflicted on staff and patients alike, even children, who have been "beaten, burned with cigarettes and subjected to torture that exploits pre-existing injuries." [45]

However, the report said, opposition forces are also guilty of attacks, including one on a government hospital in the city of Homs in 2012. Each side clearly wants to deprive the other of access to care for its combatants and sympathetic civilians.

That certainly seems to be the government's motivation: Its forces have detained, arrested and sometimes tortured physicians, nurses, ambulance drivers, humanitarian volunteers and others who provide care to rebels or civilians who are opposed to the government. Other health care workers simply have disappeared. The government apparently justifies this on the basis of "antiterrorism" laws issued in 2012 that "effectively criminalized medical aid to the opposition," according to the UN report. [46]

Burning sick and injured children with cigarettes in hospitals, however, defies any explanation. No military objective can justify it. There is simply no excuse for such behavior.

There are other current examples, including restrictions placed on hospitals in the city of Mosul, Iraq, by ISIS, which controls the area. These include not allowing women staff members to work at night, requiring women physicians to wear full-face veils, abolition of family planning and availability of contraceptives to married persons, and refusing to allow male physicians to attend births. At least five physicians have been executed, and one pharmacist was arrested and has disappeared, according to 2014 news reports. [47]

The Imperative to Protect Hospitals

Whether the reasons can be comprehended or not, attacks on hospitals must be prevented. Rubenstein suggests reinforcing and ensuring adherence to existing norms (such as are codified in the Geneva Conventions) and collecting data; there is not much information available in many instances. He also stresses the need for accountability, which would "raise the cost of an attack." And he advises that hospitals themselves must be better prepared, with stronger early-warning systems, better surveillance and more robust security arrangements. [48]

His organization also advocates commitment by governments and "non-state actors" to forbear from attacking or obstructing health care services, enhanced visibility for the issue and better understanding of the nature and extent of attacks, systematic documentation and reporting, "vigorous" action to ensure accountability when attacks occur, practical strategies to prevent violence against health care entities, and "repeal of laws that render the provision of impartial care a crime." [49]

MSF also has launched a project, Medical Care Under Fire, which seeks to learn more about violence against hospitals and health care activities and practitioners, and how to prevent it. Françoise Duroch, Ph.D., who is the project manager for the effort, told me in a 2014 interview, "In the middle of conflict, especially civil war, hospitals are in many cases not exempt from the general violence that the civilian population is faced with on a daily basis."

She concurs that the reasons for attacks are complex, ranging from a desire to acquire medications or other hospital supplies to unhappiness with care to an effort to deprive the enemy of a valued resource. "We've been faced with this issue since MSF was created, but we have mainly dealt with it in the field, and never analyzed the problem more globally. We [MSF] are now present in more countries, with more humanitarian workers on the ground, and are much more exposed to facing attacks than we were in the past. The reality is that we must have a better understanding of why these attacks occur. Although we cannot control our environment, we need to see if there are ways in which we can mitigate the risks and safeguard access to medical care for thousands of people in need." [50]

The ICRC and the Red Crescent are supporting a project, Health Care in Danger, which includes both "legal and practical initiatives." These include providing information about international humanitarian law to key stakeholders and encouraging incorporation of that law into domestic legislation, seeking to increase the knowledge of stakeholders about the rules governing both health care providers and combatants, appealing to all participants in conflict to not obstruct provision of care, and reporting allegations of violation of international law.

Health Care in Danger also provides on-the-ground services, such as negotiating safe passage for health care providers and patients, including those in need of vaccination, and "fast-track" permission for ambulances to get through checkpoints; bolstering protection of provider facilities through provision of sandbags and bomb-blast film for windows and creating bunkers; control of the use of Red Cross and Red Crescent symbols; collection of weapons at hospital entrances; providing global positioning system information on the location of health care facilities to all sides in conflict areas (which, needless to say, could be a double-edged sword); and conducting activities designed to make both access to and provision of care easier in troubled places. [51]

Governments also can provide direct assistance as well as honoring existing laws and conventions. Indeed, in Yemen on June 28, 2014, government troops repelled an attempted attack on a military hospital in the south of that country; four attackers and two soldiers were killed, but no one in the hospital was injured. [52]

Speaking Out

At least one more action is needed to stem this frightening tide, and that is for the world's health care community to recognize the problem and make it more visible. Rubenstein has written, "The medical community has a responsibility to speak out collectively to protect health workers in fulfillment of their ethical duties to the people in their care without risk of arrest or attack on themselves or medical facilities." [53]

Hospitals constitute a worldwide community of healing, and even if they are not all equally vulnerable, they have an obligation to support and protect each other.

As part of this commitment, hospitals must do their part. To the extent that they can — and this is not always possible — they should:

However, if armed combatants invade a hospital and insist on using it for cover or conducting their fight from its premises, the hospital may not be able to prevent them from doing so. And that endangers everyone there.

As the UN report on the atrocities in Syria states, "Using hospitals, outside their humanitarian function, for acts harmful to the enemy, such as sheltering able-bodied combatants, storing arms or ammunition, as military observation posts or shield for military action, leads to a loss of their protection, exposing such hospitals to a risk of attack." [54]

Special Cases

There are also two special situations for which there are few answers. One is military hospitals, which in recent years have been attacked in both Yemen and Ukraine, among other places. Obviously, they are likely to be caring for the wounded combatants of one side or another, and thus are tempting targets for opposing forces. However, the patients are still wounded, and a hospital is still a hospital. These facilities are at enhanced risk, and a solution for their predicament is sorely needed.

Also, as occurred in most of the situations described here, civilians often seek shelter in hospitals in times of strife, because they still believe that hospitals will not be attacked. Their presence is a problem in numerous ways: They need to be fed, must use toilet facilities and have other needs. They also take up space that may be critically needed. Often, they also wish to be of assistance, which is usually more hindrance than help. And, unfortunately, combatants or terrorists could masquerade as innocent civilians and use the hospital for cover.

Nonetheless, hospitals are not in the habit of turning away neighbors in need, whether in the aftermath of Hurricane Katrina, where providing shelter to healthy non-patients and, sometimes, their pets was a common practice even among badly stressed providers, or in times of violent conflict. What civilians seeking sanctuary must understand is that if hospitals cannot protect themselves, they cannot protect their uninvited visitors either.

In issuing a call to action on this issue, Jason Cone and Duroch of MSF wrote, "The protection of the sick and wounded lies at the heart of the Geneva Conventions. It is incumbent upon medical aid organizations to find a means of negotiating safe space for their staff and patients. Violence in all its forms — against health facilities and personnel — represents one of the most serious, complicated, and neglected humanitarian and security issues. The medical act benefits everyone, and anyone in need should be able to access it unconditionally." [55]

Everyone's Problem

There are those who would dismiss this issue as relevant only to the Third World or a few violent "hot spots," not developed nations. It is a fallacious belief.

First, every year thousands of physicians, nurses and other health care professionals go overseas on humanitarian missions; they understand that their safety may be at risk, but they are determined to serve anyway. To not protect these people to the utmost extent possible is to threaten one of the greatest and most admirable outpourings of clinical service anywhere, and could discourage what many clinicians report is one of the most valuable experiences of their professional and personal lives.

Furthermore, when a health care humanitarian organization is forced to withdraw its services from a country — as MSF has felt obliged to do in the Central African Republic, Somalia and South Sudan — the heaviest price is paid by thousands of innocent civilians who are thereby deprived of access to care.

Second, the damage caused by these attacks does not cease when the crisis is over. The trauma inflicted on survivors — patients, caregivers and witnesses alike — can last for decades. Even seasoned medical volunteers who have survived report that they have not fully recovered from what they experienced and, based on my research on post-traumatic stress among survivors of the Cambodian holocaust, I fear that they may never do so.

Third, most developed nations have a somewhat naïve belief that "it can't happen here." Although there have been incidents at American hospitals, almost all the result of personal domestic conflicts involving a staff member, there is still a pervasive belief that no one would attack a North American or European or North Asian hospital and kill patients or staff members for ideological or military reasons- even though it already has occurred in Ukraine.

The problem with the "it can't happen here" mindset is that prior to September 2001, no one conceived of anyone ramming commercial jets into the World Trade Center or the Pentagon. Prior to December 2012 in Connecticut, it was inconceivable that someone would attack first-graders with a semiautomatic rifle. The town of Dunblane, Scotland, hardly expected a gunman to kill 17 people in its primary school in 1996. Norwegians did not anticipate a disturbed man slaughtering 77 people in an antigovernment frenzy in 1991.

Tourists in Tasmania could not possible think that 35 people would be fatally shot by an assailant in the national park at Port Arthur in 1996. Residents of Tokyo in 1995 and London in 2005 did not foresee that their subways would be assaulted. All these incidents occurred in developed countries.

An insufficiently protected hospital can be attacked at any time.

Furthermore, recent violence at medical facilities in El Paso, Texas, and Boston, Massachusetts, even though the violations were conducted by "lone wolf" attackers, has resulted in deaths and disruption of hospital activities. If one person can wreak such havoc on a hospital, it is obvious that an armed, organized group could do much worse. [56] [57]

For example, on July 10, 2014, perhaps coincidentally shortly after the outbreak of renewed violence in Gaza, a major urban U.S. Jewish teaching hospital received a threatening phone call. Heavily armed police responded quickly and the hospital went into lockdown for approximately four hours. Although the police response was speedy, the hospital likely could not have defended itself if the call had been followed by an immediate attack. [58]

The Hospital as a Sanctuary

Finally, the idea of a hospital as a sanctuary is a concept worth honoring. It would be a much kinder world if all putative sanctuaries — places of worship, schools and hospitals — were considered sacrosanct in terms of armed attack. But that has never been true of places of worship, and has long since ceased being true of schools. Hospitals are the only remaining sanctuary acknowledged by most of the world.

Evidence of that was provided by al-Qaida of the Arabian Peninsula — an organization not known for expressing regret over its actions — which felt compelled to apologize for the attack on the hospital in Yemen. [59]

Furthermore, the situation of those within hospitals is unique, in that most of them, even though they are adults, cannot protect themselves. That is the frailty, the innocence and the importance of a sanctuary. As a former patient who volunteers at the Hadassah University Hospital in Jerusalem — which treats both Jewish and Muslim patients — told a reporter, "A hospital is not a battleground." [60]

Marco Baldan, M.D., chief war surgeon for the ICRC, has said, "One of the first victims of war is the health care system itself." [61] If we cannot or will not protect these most vulnerable of places and people, then we will not only have failed as a health care sector and as professionals engaged in healing work; we will have failed ourselves as a human community. As Dr. Zachariah, who barely survived the Rwandan genocide, says, "When humanity fails, we all fail."

Logo of the memorial in the new hospital in Vukovar, Croatia

Logo of the memorial in the new hospital in Vukovar, Croatia
Representing a red cross riddled with bullet holes, it was designed by Ivica Propadalo and Zeljko Kovacic. In English, the words mean "Place of Remembrance, Vukovar Hospital, 1991."


This article is the result of more than a year of research, including site visits to Cambodia and Croatia and extensive telephone interviews. All activities were funded by the author; there was no outside financial support.

Participation in interviews with the author, provision of logistical support, language interpretation, review of the manuscript and other assistance were provided by: George Annas, J.D., M.P.H., chairman, Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health; Maureen Bisognano, president and CEO, Institute for Healthcare Improvement, Cambridge, Mass.; Eric Dachy, M.D., Linkebeek, Belgium; Françoise Duroch, Ph.D., Medical Care Under Fire project manager, Médecins Sans Frontières International Office, Geneva; Renée Fox, Ph.D., Philadelphia; Maria Friedman, D.B.A., Silver Spring, Md.; Hun Chhunly, M.D., Phnom Penh, Cambodia; Rudolf Klein, emeritus professor of social policy, University of Bath, England, and visiting professor at the London School of Economics and the London School of Hygiene, London; Binazija Kolesar, R.N., adviser to the director, Vukovar General Hospital, Vukovar, Croatia; John C. Lewin, M.D., president and CEO, Cardiovascular Research Foundation, New York; Alenka Mirkoviç-Nad, former acting director, Vukovar Homeland War Memorial Center, Vukovar, Croatia; Ksenija Mitrovic, assistant professor, Wake Technical Community College, Raleigh, N.C.; Jasna Rogic-Namacinski, specialist, clinical chemistry and laboratory medicine, Vukovar General Hospital, Vukovar, Croatia; Leonard S. Rubenstein, J.D., senior scholar, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore; Alan Sager, Ph.D., professor of health management, Boston University School of Public Health, Boston; Marjorie Smelstor, Ph.D., Overland Park, Kan.; Tim Shenk, press officer, Doctors Without Borders-USA, New York; Judith Swazey, Ph.D., Bar Harbor, Maine; Maurits van Pelt, executive director, MoPoTsyo, Phnom Penh, Cambodia; Michelle Vachon, Phnom Penh, Cambodia; Kam Vuthy, Phnom Penh, Cambodia; Rony Zachariah, M.D., coordinator, operational research and strategic adviser (DG-Luxembourg), Médecins Sans Frontières — Brussels Operational Center, Luxembourg.


This article is dedicated to the dead and survivors of all hospital attacks, and especially to those physicians, nurses and other health care personnel who risked their lives, and sometimes lost them, while seeking to protect their patients.

Recommended Readings

Online Resources


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[13] Ibid.
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[30] Zachariah R. Interview with the author, op. cit.
[31] Zachariah R. Interview with the author, op. cit.
[32] Knickmeyer E, Habib MA, Almasmari H, op. cit.
[33] Hun C. Interview with the author, op. cit.
[34] Kolesar B, Mirković-Nad A, op. cit.
[35] American Red Cross. Summary of the Geneva Conventions of 1949 and Their Additional Protocols. April 2011.
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[39] Krohn J. Kurds seize Iraqi town from militants. USA Today, October 3, 2014, p. 3A.
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[41] Dachy E, op. cit.
[42] Hochschild A, op. cit.
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[44] Hatzfeld J. Into the Quick of Life, op. cit.
[45] United Nations Human Rights Council. Report of the independent international commission of inquiry on the Syrian Arab Republic. August 13, 2014.
[46] Ibid.
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[50] Duroch F. Interview with the author, March 17, 2014.
[51] International Committee of the Red Cross. Health Care in Danger: Making the Case. August 2011. Accessed April 15, 2014.
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Copyright © 2014 by Emily Friedman. This article may be copied, distributed and posted on the Internet at no cost as long as proper attribution is included.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. Her website is