The following is an excerpt from an essay published in the Fall 2013 edition of the World Policy Journal. The entire article can be read here

Jason Cone, MSF-USA director of communications, recently conducted a risk assessment of MSF facilities in South Sudan. Françoise Duroch, Ph.D., is managing MSF’s Medical Care Under Fire initiative.

In an age of asymmetric warfare and increasingly complex internal conflicts involving fragmented armed groups, who hold a tenuous monopoly on violence and often have weak chains of command, negotiating even the most basic acceptance and protection of medical staff, patients, and facilities in these environments is a frighteningly difficult challenge. Many armed groups and national armies ignore international humanitarian law, which makes it even harder to create a safe space to deliver medical care.

In other conflicts, the hospital has become part of the battlefield, more as an afterthought than as the main theatre of war. Medical organizations often face a complete ignorance of humanitarian law by the groups posing the gravest threats. It is incumbent upon medical organizations to play a role in building an understanding among armed groups of these principles and the importance of accepting the provision of impartial health care to all sides. Often the scope of the problem—even the nature of the threat—is poorly understood, given the weak reporting of incidents at national and international levels. Yet organizations operating in these zones must learn the power dynamics in place and leverage social, cultural, or religious norms, which can vary widely from one town to the next, let alone country to country. Only by accumulating such a base of knowledge can health care providers be in a position to navigate and dampen potential dangers for their staff, facilities, and patients.

At the same time, it is the responsibility of all armed groups—state and non-state alike—to respect the safety of medical facilities and vehicles, health workers, and patients. Yet, many of today’s most devastating conflicts have illustrated that these fundamental principles of international humanitarian law are being systematically ignored, resulting in populations being largely cut off from access to health care. The threats and attacks are coming not only from armed groups like the Taliban, Al Qaeda, and Congolese rebels, but also NATO, UN, and U.S. forces. By negotiating, though, with all warring parties, health care providers can succeed in keeping weapons and violence out of their hospitals. Only then will people in need of medical assistance feel secure enough to enter the health facilities, transformed into neutral, conflict-free zones, free from attack by all sides.


Perhaps no contemporary conflict has featured such concerted and sustained attacks against health care facilities as the one continuing to unfold in Syria. The country experienced its first major protests on March 15, 2011, in the town of Damas. As the weeks wore on, the number of protesters multiplied, but they soon found themselves under fire as security forces attempted to quell the then-peaceful uprising. Injured activists assumed that they could seek care at public or private hospitals should they need it, as health structures had the technical means, expertise, and resources necessary to treat trauma. After all, Syria’s health care system had once functioned at a high standard. Yet health care has morphed from a system meant to heal to a central part of the government’s strategy to repress any opposition.

Accounts from doctors and patients reveal that hospitals are being scrutinized by the security forces, and that people are being arrested and tortured inside them. Doctors risk being labeled “enemies of the regime” for treating the injured, which could lead to their arrest, imprisonment, torture, or even death. People hurt at protests therefore have stopped going to public hospitals with similar fears of being tortured, arrested, or refused care, and are essentially forced to entrust their health to clandestine networks of medical workers.

In Deraa, Homs, Hama, and Damascus, medical care is still provided out of public view. Makeshift hospitals have been set up inside homes near protest sites. Health centers treating the injured provide false official diagnoses to hide the fact they are treating people wounded at demonstrations. The major concern for doctors working in these underground networks is their safety.

As fighting began and later intensified, a rising number of medical facilities have been affected. In July 2011, the Syrian army deployed tanks in the city of Homs. In February 2012, the city was under constant attack by snipers, shelling, and aerial bombing by the government’s air force. Aid efforts have continued clandestinely, however, with medics working to treat the injured even as bombs rain down around them. The authorities still refuse to allow international humanitarian aid into the country. A ceasefire to evacuate the wounded has also been rejected.

A handful of makeshift hospitals provide health care close to the conflict zones—set up in caves, individual homes, farms, and even in underground bunkers. Following initial treatment and stabilization, patients are transferred to hospitals in safer locations.

As the repression of peaceful protests became a clear government policy, the opposition took up arms, eventually beginning to take control of certain areas, which spurred the conflict into even more brutal territory. Again, the health sector has been gravely affected. Medical structures are still being targeted and destroyed while health care workers are threatened or killed. Providing medical care has been transformed into an act of resistance, a crime, as medical structures become military targets.

In July 2012, a new front opened in Aleppo. The economic capital of the country was ravaged by aerial bombardments and ground fighting. Buildings, including medical facilities, were decimated. The blood bank supplying the region’s hospitals was among the first to go up in smoke. Dar El Shifa, the largest private hospital in Aleppo, was situated in an opposition-controlled area in the east of the city. It provided care for victims of violence until it was bombed during an air raid that August. Although the operating theater was destroyed, the emergency ward continued to operate and saw about 200 people per day. But in late November, it, too, was demolished by bombing and rendered inoperable.

Opposition military bases have been established close to some makeshift hospitals—even, in some cases, in the same building. These hospitals are at serious risk of being caught in the middle of fighting, or even directly hit in an attack. According to Syrian authorities, of 91 public hospitals across the country, 55 have been affected, of which 20 have been damaged, and 35 are out of service, as of June 2013.


The collateral damage of attacks on patients, wounded, sick, personnel, ambulances, and medical structures extends far beyond those injured from these violent abuses. These incidents have the power to create “deserts” in terms of access to health care in many of today’s bloodiest conflicts.

While it is difficult to ascertain the scale of this phenomenon, the real challenge is to find ways to prevent these acts from happening. The primary responsibility to stop the targeting, obstruction, or abuse of medical services lies with states and parties engaged in conflict. Health workers must be supported in carrying out their medical duties. States must ensure that all possible measures are taken to protect medical action through national legislation and that these measures are implemented.

States and non-state actors alike must implement and respect weapons-free policies within health premises; abstain from using force against demilitarized health or humanitarian structures, vehicles, and premises; and commit not to arrest or seek information from patients during their stay in medical facilities.

When armed teams provide security or medical aid to win “hearts and minds,” or hospitals are militarized, the results can be potentially lethal for patients and health care workers. When some schools, health facilities, or aid convoys become militarized by one side, they all become potential targets for the other side. All belligerents must make a commitment to recognize health structures and ambulances as “demilitarized sanctuaries,” and thereby off-limits from combat, police, and intelligence operations. And such commitments must be implemented at the very outset of any conflict.

Rhetoric is also critical. It is essential that states and non-state actors in their public discourse and modes of military deployment maintain an explicit distinction between partisan deliverers of relief and impartial humanitarian actors. Mixing motives for providing aid is a slippery slope that undermines the acceptance of the entire spectrum of medical assistance. Furthermore, medical and humanitarian organizations have a responsibility to remain true to their principles and not allow the politicization of their services.

But attacks on medical care won’t always fall into neat categories. Medical aid organizations must continually analyze risks and threats to ensure, while adhering to the fundamentals of medical ethics, that they are aware of social, economic, and power dynamics afoot in the terrain where they are operational. Recent years have shown a propensity for states—even those that have served as the very architects of the laws of war—and non-state actors to ignore the need for even the most basic respect for the practice of medicine and right to medical care in conflict areas. 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 contemporary humanitarian and security issues. The medical act benefits everyone, and anyone in need should be able to access it unconditionally.

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