Medical neutrality is in danger, unless the international community acts, a 2015 report says. As violence has recently unfolded at hospitals in Aleppo, the results still ring true.
This week, the world watched in horror as a hospital in Aleppo, Syria, was destroyed by bombs, killing at least 50, including three children and six staff members. The World Health Organization issued a statement calling for all parties in the conflict to end attacks on health providers.
By coincidence, the Pentagon released its response to a 2015 bombing of a hospital in Afghanistan run by Doctors Without Borders, attributing it to accidental targeting by a U.S. air crew and announcing discipline for those responsible.
Even in war, hospitals have a kind of invisible bubble around them, making them neutral territory and off limits for aggression for the sake of medical teams and their patients. But is something changing about the vulnerability of medical teams and facilities in wartime?
In Syria, that bubble has burst dozens of times, according to a 2015 report from the group Physicians for Human Rights. The hospitals in just the eastern half of Aleppo have suffered 45 attacks in three years, and two-thirds have closed, the report stated at the time.
A complementary opinion piece in the New England Journal of Medicine by the report's authors, including a University of Michigan Medical School professor, called on the international community to react to these violations of international humanitarian law and of the principle of medical neutrality.
"Medical professionals around the world think of Syria as not affecting them, but the situation there is setting a terrifying precedent throughout the world," says Michele Heisler, M.D., MPH, who volunteers to do research for Physicians for Human Rights as part of her U-M faculty role. "For much of the 20th century, warring parties for the most part had respected medical neutrality and allowed doctors and nurses to provide health care in conflict — but once that starts to be eroded it could make even the basic provision of health care impossible."
The longer the international community fails to enforce humanitarian law, the greater the chance that these violations will become the 'new normal' in armed conflicts around the world.Michele Heisler, M.D., MPH
Investigating the situation in Aleppo
Heisler and her colleagues documented the plight of Aleppo hospitals by interviewing 25 Syrian physicians and other health care workers. Many had crossed the border into Turkey to attend a medical conference held last July by the Syrian American Medical Society. They returned to their posts afterward, despite knowing that more than 95 percent of Aleppo's doctors have fled the country or been detained or killed.
The report examines the impact of attacks on the medical infrastructure and personnel in the portion of Aleppo held by opposition forces and the health care status and needs of the civilians in eastern Aleppo.
In the NEJM piece, Heisler and her colleagues recount some of the report's major findings and the history of the Geneva Conventions dating back to 1864 that have protected hospitals and medical teams in wartime.
They describe the particular effects of the barrel bombs dropped on hospitals and other civilian spaces, and the strategies that Aleppo's health professionals use to treat the wounded despite shortages of human and material resources.
Filled with explosives, shrapnel, nails and oil and weighing 200 to 2,000 pounds, barrel bombs are dropped from helicopters and break into thousands of fragments upon impact. The numerous wounds they cause require trauma care, and the remaining hospitals and teams struggle to provide needed treatment. No working MRI or CT scanners remain in Aleppo, the report says.
Because of this targeting, hospitals have literally had to move underground. When possible, as many operations as possible have been moved into basements. Most hospitals still functioning in Aleppo have been attacked repeatedly. One has been hit seven times.
Syria's hospitals and medical teams aren't the first to suffer direct and even deliberate hits, Heisler and her colleagues note in NEJM. They note instances in Afghanistan, the Democratic Republic of Congo, Rwanda, Somalia, the former Yugoslavia, Iraq, Bahrain, Libya, Ukraine and Yemen.
But the attacks in Syria are the most egregious, they say, because there have been so many. They call the targeting of medical care particularly troubling because the leader of the Syrian government, Bashar Al-Assad, is a physician by training.
Stopping 'a standard weapon of war'
Just as the international community stood up to Syria's government over its use of chemical weapons, Heisler and her co-authors call for an international stance against violations of medical neutrality.
"The longer the international community fails to enforce humanitarian law, the greater the chance that these violations will become the 'new normal' in armed conflicts around the world, eroding the long-standing norm of medical neutrality," they write. "Left unchecked, such attacks on medical care will become a standard weapon of war."
Heisler expresses admiration for the medical professionals who have stood by their oath to provide care for patients, despite the risk to themselves. The report tries to bring the improvisation, ingenuity and persistence they have shown in Aleppo, keeping even dialysis units running without any nephrologists, to the attention of the international medical community.
"They are true heroes. All the doctors we interviewed expressed their determination to stay as long as there are still civilians living in Aleppo who need medical care," she says.
But the conditions under which they work must not become the norm, Heisler adds. "If this is not stopped in Syria we're going to see more direct attacks on what we've thought of as sacrosanct. The right to provide and receive medical care is also under siege."
Heisler, a member of the U-M Institute for Healthcare Policy and Innovation, is a professor in the Division of General Medicine in the Department of Internal Medicine at the U-M Medical School, and holds a joint appointment in the School of Public Health. She is an associate director of the Global Reach program at the Medical School.
Her co-authors on the NEJM piece are Elise Baker, B.A., and Donna McKay, M.S. of PHR. Heisler is a member of the PHR board.
Photo credit: Beha el Halebi/Anadolu Agency/Getty Images
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