There have been more than 100 attacks on hospitals and health care workers in Ukraine since the Russian invasion began.

This is based on World Health Organization data as of April 11, which also reports 73 deaths and 51 injuries resulting from the attacks.

These attacks include a maternity hospital in Mariupol, which wounded at least 17, as well as medical facilities in at least eight other cities.

Providing health care to the wounded has been a part of war since time immemorial. Medical workers have risked their own lives in order to care for allies, enemies and civilians in all major world conflicts.

Any type of service in an active combat zone comes with significant risk, but countless brave men and women have always answered this dangerous call.

It has been illegal to deliberately attack health care facilities during international conflict for over 150 years. Health care workers have been granted medical neutrality – a moral principle which argues that health care professionals should be afforded access to treating the sick and wounded during armed conflict without the threat of reprisal.

Ethicists think of it as a social contract between nations designed to protect health care resources during war, which are needed by both sides and by combatants and civilians alike.

Medical neutrality was codified in the Geneva Convention Article 19 which states, “The protection of which civilian hospitals are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given, naming, in all appropriate cases, a reasonable time limit, and after such warning has remained unheeded.”

The article goes on to provide provisions for injured combatants arguing, “The fact that sick or wounded members of the armed forces are nursed in these hospitals, or the presence of small arms and ammunition taken from such combatants which have not yet been handed to the proper service, shall not be considered to be acts harmful to the enemy.”

The Geneva Convention clearly protects hospitals, health care professionals, medical transport, patients and medical supply depots. The intention is to ensure that medical resources and facilities needed for injured combatants and civilians will be available.

This is as much an altruistic principle as it is egotistical necessity. Any rational society wants to protect health care resources that they may need in the event that they experience an excessive number of casualties themselves.

To facilitate the protection of health care resources and personnel, buildings and vehicles are marked with a red cross, red crescent or red crystal. Combat medics wear patches signifying their role and non-military humanitarian volunteers will wear vests in an agreed upon color.

The problem is that health care workers are operating in an active war zone. Misfires, accidents, poor line of sight and bad intelligence can lead to unintentional destruction of medical facilities and the death of personnel.

No nation has been immune to this problem, and there are many examples of times when medical neutrality has been violated. A June 2021 report found more than 800 instances worldwide of such violence during conflict in 2020 alone, and more than 4,000 since 2016.

In 2001, the U.S. mistakenly bombed a Red Cross facility in Kabul, Afghanistan, which the Pentagon attributed to “a human error in the targeting process.” On Oct. 3, 2015, U.S. forces inadvertently killed 42 people and destroyed a Doctors Without Borders facility in Kunduz, Afghanistan. A similar event occurred in May 2021, when Israeli airstrikes in Gaza damaged a Doctors Without Borders facility.

While dozens of such attacks have taken place in recent years, the nature of urban warfare makes it difficult to determine if the attacks were intentional or the result of poor intelligence.

Russia is not without blame prior to the current incidents being reported in Ukraine.

During the First Chechen War, Russian forces openly attacked Municipal Hospital No. 9 in Grozny in 1996, taking around 500 civilians as hostages. Later, forces attacked the International Committee of the Red Cross Hospital of Novye Atagi, killing six staff members.

Such attacks force us to ask about intentionality and carelessness. Neither are acceptable.

Russian-sponsored attacks on medical facilities are not isolated to Chechnya or Ukraine. They became a hallmark of the recent war in Syria.

The non-profit Physicians for Human Rights have compiled an interactive map detailing hundreds of attacks on medical facilities by Russian and Syrian forces from 2011-2021. The volume of attacks against health care facilities cannot be ignored or simply explained away by the “fog of war.”

The bombing of the Mariupol Maternity Hospital illustrates the problem, with Russian officials seeking to justify the attack by claiming the facility was not used by patients but was hiding extremists and ammunition.

While this claim should be investigated, there is no indication that the Russian allegations are true, and it does not explain the volume of Russian attacks on health care facilities throughout Ukraine.

Violations of medical neutrality have historically been difficult to prosecute, and it has been difficult to hold bad actors accountable. The only successful International Court case dates to the Croatian War.

In 1991, the Yugoslavian People’s Army attacked the hospital in Vukovar, capturing around 250 health care workers and civilians, mostly non-Serbian. Ultimately, the hostages were transported over 30 miles outside of town, murdered and buried in mass graves. The case was not successfully prosecuted until 2007.

The international community has watched health care professionals bravely put themselves in harm’s way and allow themselves to become targets.

This is not just a Russian crime. It has been happening globally for decades, either intentionally or due to mistakes or bad intelligence gathering.

It is time for the civilized world to say, “enough!” and stand up for these brave souls by demanding accountability and consequences for any nation, group or individual who violates the principle of medical neutrality.

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