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Over the last two decades, medical facilities and staff have become casualties of war more frequently, in violation of international law.
The explosion at the Ahli Arab Hospital in Gaza City on Tuesday was the latest in a growing series of violent incidents involving medical facilities in conflict zones, which together have taken an enormous toll on vital health care infrastructure and staff in violation of what was once a bedrock aspect of international law.
Over last two decades, as the principle of sparing health care workers and facilities has continually eroded, the most dangerous incidents have been carried out by state actors, said Michiel Hofman, who is an operational coordinator for Doctors Without Borders in Sudan and a veteran of medical aid delivery in Afghanistan, Yemen and Syria.
Yet Article 18 of the First Geneva Convention, ratified by United Nations member states after World War II, says that civilian hospitals “may in no circumstances be the object of attack, but shall at all times be respected and protected by the parties to the conflict.”
Article 20 of the convention says that health care workers similarly must be protected by all sides.
“The willingness of states to push the boundaries of international humanitarian law seems to have accelerated,” Mr. Hofman said. “It’s the states that have explicitly signed the Geneva Conventions, and states usually have far greater military power and especially air power.”
In Ukraine, Russia has carried out more than 1,100 attacks on health care facilities and personnel since it began its invasion 21 months ago, a staggering number for so short a period, said Leonard Rubenstein, an expert in health and human rights at Johns Hopkins University.
Mr. Rubenstein chairs the Safeguarding Health in Conflict Coalition, which is made up of more than three dozen human rights and humanitarian organizations working in conflict zones, tracking attacks on health care around the world.
Mr. Rubenstein said the pattern of Russian attacks showed that Moscow has in some cases intentionally targeted hospitals and in others indiscriminately attacked areas where hospitals were located; both are war crimes. “They’re unaccountable, with complete impunity,” he said. “And they don’t care.”
Neither Russian soldiers or commanders nor any other state or paramilitary actor that has attacked medical sites, with one exception, has ever faced prosecution by international bodies, he added: “There is wide agreement in the international community that attacks on health care are unacceptable — protection of health care is like motherhood and apple pie. But there’s no real commitment by governments to do what you need to do to stop it.”
He added: “There has been no accountability, instead complete impunity — no prosecution and political interference with U.N. entities that seek even mild condemnation of states responsible for attacks.”
The only time a deliberate attack on a hospital was ever referred for prosecution in an international court involved the war in Bosnia. The charge was one of seven against a Serbian military commander considered by the tribunal investigating war crimes in the former Yugoslavia.
The International Criminal Court, a tribunal set up by the United Nations 21 years ago to prosecute crimes against humanity, has never issued an indictment for an attack on medical personnel or infrastructure.
Attacks on medical facilities jeopardize health care not only for those injured by fighting, but also for all those with routine medical needs. On Thursday, Doctors Without Borders (also known as M.S.F., an abbreviation for its French name, Médecins Sans Frontières) withdrew a surgical team from a hospital in Sudan after military authorities blocked all delivery of supplies to the facility. The team had been providing lifesaving trauma surgeries and cesarean sections from one of the last functioning hospitals in the capital, Khartoum.
“It’s so painful, because of the moral distress of the medics,” Mr. Hofman said. They were unable to function without basic supplies, but also profoundly disturbed to cut off one of the last sources of care in a city where fighting has not let up since rival factions of the military government went to war in April.
In Ukraine, Russian attacks have destroyed 10 to 15 percent of medical facilities. The damage is even more far-reaching than it might seem, said Pavlo Kovtoniuk, a former deputy minister of health in Ukraine who now works with a think tank called the Ukrainian Health Center.
“Hospitals symbolize respect for civilian life, and when people see that disregarded they say, ‘We have to get out,’” he said. “We have a huge loss of human capital, with more than six million people now living outside the borders.”
Among those who remain, there is a growing population in need of rehabilitation and psychosocial support, from a steadily shrinking health system.
“This is not a situation of waging war according to the laws of war and the Geneva Convention — this is a completely different philosophy of war where civilian lives are disregarded entirely,” Mr. Kovtoniuk said.
He added: “We are revisiting the rules we thought were a given on regard for civilian life, and Russia has contributed to this feeling, ‘OK, we can do this. We can attack civilian infrastructure as a weapon of war.’”
Ukrainian officials are working with the International Criminal Court to compile evidence from the attacks, Mr. Kovtoniuk said. At least some top Russian officials must be indicted in order to re-establish the principle of protecting health care workers and facilities, he said. Russia has often either said that the facilities it hit were harboring Ukrainian fighters or dismissed the accusations as fake.
In Sudan, M.S.F. says that fatalities caused by neglected medical needs are as great as those caused by violent injuries. According to the World Health Organization, 70 percent of Sudan’s medical facilities are no longer functioning. More than seven million people are now internally displaced and face a cascade of disease outbreaks.
There are epidemics of cholera, malaria, dengue fever and measles in Sudan. The W.H.O. says measles and malnutrition have killed 1,200 children since the war began in April, and vaccine delivery is impossible in many parts of the country.
“Health care was terrible to begin with, and any specialized care we had was overwhelmingly centered in Khartoum and it’s no longer functioning,” said Dr. Yasir Yousif Elamin, president of the Sudanese American Physicians Association. “The places able to do cardiac surgery, neurosurgery, cancer care, dialysis — all of these are out of service now.”
People who need these services are scattering to areas far from the capital; patients who need dialysis three times a week are receiving it once in a 10-day stretch, while cancer patients might manage to find chemotherapy treatment every few months, he said.
The physicians’ association is tracking attacks on health care facilities in hopes of supporting eventual prosecution.
Last month, in the city of Wad Madani, Dr. Elamin met a 5-year-old child who had been shot in the abdomen in Khartoum. His mother had taken him hundreds of miles in search of help.
“Imagine you don’t have something as basic as this, for a boy hit accidentally,” Dr. Elamin said.
Researchers began tracking attacks on health care facilities in conflict zones in an organized fashion only in the early 2000s, so it is difficult to speak with much certainty about the trend, Mr. Rubenstein said.
But in an analysis of the figures for 2022, Safeguarding Health in Conflict said that the 1,989 incidents that were tabulated represented “by far the highest number” documented since the coalition began reporting a decade ago.
After Ukraine, which accounted for nearly half the incidents, the most-affected country was Myanmar. More than 800 health care workers have been arrested there since a military coup in 2021.
Between 2014 and 2016, there was a series of horrific bombings of medical facilities in Afghanistan, Syria and Yemen — including a U.S. airstrike on an M.S.F.-run trauma center in Kunduz, Afghanistan, in 2015 that killed 42 people. (The Pentagon called it “unintentional.”)
The violence prompted the U.N. Security Council to unanimously adopt a resolution calling for greater protection of health care workers and facilities in armed conflict, which brought “a bit of a breather,” Mr. Hofman said. Those kinds of airstrikes continued in Syria, however.
“But now with four major wars erupting in the last few years — Ethiopia, then Ukraine, Sudan, and now Gaza — we are at a peak again,” he said.
There have been more than 115 attacks on health care facilities and personnel in the West Bank and Gaza Strip since the Oct. 7 Hamas attacks. Israel has warned 20 hospitals in the north of Gaza to evacuate their patients in anticipation of a ground invasion but Palestinian doctors say it is impossible to move them.
In 2009, a suicide bomber infiltrated a graduation ceremony for medical students in Mogadishu, the Somali capital, and killed three cabinet ministers who were in attendance, plus the dean of the medical school, a dozen students and two journalists.
In addition to the terrible loss of life, the International Committee of the Red Cross calculated that an indirect effect of those deaths was as many as 150,000 missed physician consultations per year, in a country where the medical system was already in tatters because of a decades-long civil war.