The year 2022 set a grim record — 1,989 attacks on health-care facilities and their personnel, the worst total number in the decade since the Safeguarding Health in Conflict Coalition began its sobering count.

This year is on track to be even more devastating for the toll on health care. In many of the world's ongoing conflicts — like Sudan, Syria, Ukraine and now between Israel and Hamas — health care has been a target. The reasons for this may differ from conflict to conflict but the end result is an affront to international humanitarian law, written to protect health care in times of war.

Article 18 of the Fourth Geneva Convention states, "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." Article 19 continues, "The protection to which civilian hospitals are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy."

When attacks on health facilities or medical workers do happen — as they have repeatedly in these and other conflicts — the results are devastating. In addition, "part of [health workers'] mission is to provide a witness function," says Amy Hagopian, a public health researcher at the University of Washington, now retired. In her view, this is one reason why health professionals can pose a threat to a military or militia. They can "undermine the credibility of the fighting force [and hold] them accountable in ways that legal entities seem not to be able to do," she says.

Global health officials are concerned with the quickening pace and severity of attacks in multiple conflict zones. "The sanctity of health care is less and less respected," observes Margaret Harris, a spokesperson for the World Health Organization. "It seems the world has lost its moral compass."

Sam Zarifi, the executive director of Physicians for Human Rights, agrees. He says, "There's a norm that we have to protect health-care facilities. The temptation to violate that norm has always been very high. That's why the norm has to be really strengthened."

But the opposite has happened, Zarifi believes. He's worried that this norm has been eroding in conflicts all over the world. Before the Hamas attack on Israel on October 7, the year 2023 was already positioned to be the worst yet for attacks on health care. The ensuing war between Israel and Hamas has pushed that trend into overdrive.

A tragic past and present

Attacks on health care aren't new. "You can go to the Korean War and wars in El Salvador and Central America during the 1980s," says Len Rubenstein, director of the Program on Human Rights, Health and Conflict at Johns Hopkins University. "Health care was attacked — just didn't get reported as much."

However, "the last few years have been particularly awful," he says.

For instance, the internal power struggle and conflict in Sudan that began (again) in April has severely compromised the country's health care. According to a study published at the end of September by an international team including two faculty members based in Khartoum, only a third of the hospitals in the conflict zone are functioning, medical workers have fled, and essential health services have been disrupted.

In a news release from June, WHO and the United Nations Population Fund wrote, "There are reports of a military occupation of the National Medical Supply Funds warehouses in the capital, Khartoum, where medicines for the entire country, including malaria medicines, are kept, and where the national pharmacy for chronic diseases is located." They also describe hospitals running out of fuel, leading to the death of newborns.

Zarifi summarizes the situation in a word — "grim."

A couple thousand miles away, Russian forces have persistently battered Ukraine's health-care infrastructure. By late May, WHO had documented more than 1,000 attacks on health-care facilities, ambulances and personnel in Ukraine since the war began 15 months earlier. Last month, teams from the group Doctors Without Borders witnessed lethal attacks on two Ukrainian hospitals.

Now, a case study just published by several human rights organizations elaborates on Russia's previously documented strategy of "widespread and systematic attacks on Ukraine's health care system." They report that medical workers have been detained and threatened, that Russia has repurposed health facilities for military bases and other non-medical aims, and that in some cases, Ukrainians only receive health care if they change their nationality to Russian.

The conclusion of the report, says Zarifi, is that "contrary to international law, they are misusing access to health care as a tool for controlling the population."

It's a strategy that grew out of fighting alongside the Syrian government in their ongoing yearslong civil war. "The Russians had taken what they had learned in Syria," says Marc Garlasco who served as a U.N. war crimes investigator and specializes in civilian harm, "and they were applying it in Ukraine."

The Syrian Civil War

Garlasco has been working in this space for two decades, and he says he's never seen anything like what's taken place in Syria. "I've been in Iraq, in Afghanistan," he says, "and Syria was just something at a different level when it came to attacks on medical facilities."

Garlasco acknowledges that health care has long gotten caught up in conflict. But in the civil war in Syria, which broke out in 2011, attacks on hospitals have been wanton and intentional.

The Syria Justice and Accountability Centre (SJAC), a nongovernmental organization, has uncovered internal Syrian government documents of multiple attacks. In one grievous example, on Saturday, Oct. 12, 2013, government forces used artillery to attack a group of opposition fighters close to the city of Idlib at 1 p.m. The wounded were taken to a nearby field hospital.

The government "knew they were being treated in a hospital in the area, and they decided to follow them," says Mohammad Al Abdallah, the director of SJAC. He says the government wrote in those documents, "We located the coordinates of that building and we hit it with artillery one hour after the initial attack."

That is, when the government struck that second time, they purposely attacked the field hospital where those injured from the first strike were being treated. "There's no ambiguity," says Al Abdallah.

This technique has a name — the double-tap strike. And it refers to attacking an enemy twice in rapid succession. It doesn't have to involve a health care facility, but in Syria, that second hit often targeted medical infrastructure and personnel, says Al Abdallah. It became a regular part of the Syrian government's strategy.

Garlasco says things only got worse once Russia became involved in the conflict in 2015. "It was insidious," he says, "where instead of having a medical facility on a no strike list, the Syrian and Russian governments" seemed to put them on the strike list. "It was always very suspicious that the list of hospitals with exact locations would get struck."

Since the civil war began more than a decade ago, Physicians for Human Rights has confirmed 601 separate attacks on medical facilities in Syria (as of June 2022).

Garlasco says this strategy is a potent way of terrorizing a population and targeting skilled medical workers — who are a limited resource.

For instance, Houssam Alnahhas, who was in his fourth year of medical school when the civil war broke out, joined a clandestine medical team in Aleppo. "It was clear that the Syrian government was weaponizing health care," he says, "and using it against the Syrian people."

Over the next few years, Alnahhas saw the resolve and resilience of his neighbors, friends and colleagues disintegrate. This tactic of attacking medical infrastructure, he observed, "will break you. It's just like depriving [someone] of food and water."

Eventually, Alnahhas' fear of being apprehended became too great. "I cannot tolerate this anymore," he says. He joined millions of others and left his homeland.

Alnahhas hasn't been back to Syria since 2017. He now works as the Middle East and North Africa researcher at Physicians for Human Rights.

Israel and Hamas

In Israel's war with Hamas, hospitals have once again become flashpoints of military action and violence.

According to a paper published by the group Physicians for Human Rights-Israel, on October 7, Hamas attacked the Be'eri Emergency Clinic, killing an on-call paramedic and resident physician. Within a little more than a week, three rockets collided with the Barzilai Medical Center in Ashkelon.

Meanwhile, Israeli forces have long accused Hamas of using medical facilities across Gaza, including Al-Shifa — its largest hospital — as command centers, hideouts and cover for their underground operations. Hamas has rejected these assertions.

Since the start of the war, Israel has steadily attacked infrastructure in the enclave in an effort to pursue its goal of eliminating Hamas, including critical health-care facilities. Of the enclave's 36 hospitals, WHO reports only about a third are partially functional. And without adequate humanitarian aid, these beleaguered medical facilities lack the fuel and supplies they need to meet the basic needs of their patients.

"Atrocities by one side don't justify atrocities by the other," says Zarifi.

According to the Gaza Ministry of Health, Israel has rendered many of the strip's hospitals non-operational. Those facilities that are still open are "completely overwhelmed," according to WHO.

Global health advocates worry this conflict marks the latest erosion of international humanitarian protections afforded to health care during war.

"Just as we would never accept that Hamas could justify its massacre on October 7th by claiming that it's fighting decades of discrimination," Zarifi says, "that also applies to the IDF [Israel's military]. It cannot use the righteousness of its cause or the ferocity of its passion or the odiousness of its enemy to justify the disproportionate impact of this strategy on health-care facilities."

Assaults on health care in this part of the world aren't unique to the current conflict. In Gaza, for example, Al-Shifa hospital was attacked in 2014. Zarifi says the Palestinians blamed it on an Israeli strike, but the IDF said a misfire by Palestinian militants was responsible.

"The International Criminal Court has had multiple years to carry out this investigation and it hasn't," says Zarifi. "Hamas has blocked it. The Israelis have blocked it. But that lack of accountability has really fostered an environment in which different groups can think that they can attack these targets with impunity."

Rarely are leaders or armies prosecuted and imprisoned or required to pay appropriate damages for health-care facilities. And this sense of impunity, says Zarifi, has been gaining momentum in different parts of the world for years, leading to an acceleration in the pace of attacks on health care and an increase in their severity.

A fading standard

This trend is especially worrisome because international law prohibits attacks on health-care facilities and health workers. "One of the great things that made our last century a century of great hope," says Harris of WHO, "was one of the earliest agreements on protections in war was the protection of health care."

These agreements included the Geneva Conventions and the Universal Declaration of Human Rights, and were largely born from the ashes of the two World Wars. Under humanitarian law, hospitals and health professionals cannot be targeted. "Doctors, medical workers, ambulances, medical transport must be protected at all times and allowed to do their work," says Omar Shakir, the Israel and Palestine director at Human Rights Watch.

Otherwise, "every war will just descend into complete barbarism," says Rubenstein.

If, however, a health care facility becomes partly or wholly repurposed for military aims, it loses its special protection status. But the burden of proof is high. In the case of the current conflict between Israel and Hamas, Shakir says that even if the Israeli government had strong evidence that Al-Shifa or another hospital had been compromised, "attacking hospitals is only permitted if provision for safe evacuation and an effective warning is provided." Such evacuation orders, which the IDF has said it's issued, are complicated when patients are injured, weak or in need of urgent medical care. "We're obviously treading carefully when it comes to hospitals but we're also not going to give immunity to the terrorists," Israeli Prime Minister Benjamin Netanyahu said on CNN's State of the Union in mid-November.

Also, if the harm done to civilians, medical professionals and patients is disproportionate to the military goals of an attack, it's not allowed. In international humanitarian law, this is called proportionality. It's a tough formula to work out, but in principle it's intended to further constrain an army's action within various contexts, including health care. That's because "even a relatively minor military campaign can have life-altering consequences for patients in need of care," says Shakir.

Adherence to these prohibitions, however, has disintegrated in recent years. "That's why ensuring that there's accountability," says Zarifi, "that people who violate the laws of war face justice, and that the victims receive truth and a remedy is essential."

In large part, however, that hasn't happened. And with attacks on hospitals continuing to mount in different parts of the world, Zarifi says the International Criminal Court and global leaders must strive for accountability — or attackers will continue targeting health care with further impunity.

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