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The Internationalist

Medical care is now a tool of war

Modern conflicts have destroyed the old protections around health care—and we’re only just beginning to assess the damage.

BEIRUT — The medical students disappeared on a run to the Aleppo suburbs. It was 2011, the first year of the Syrian uprising, and they were taking bandages and medicine to communities that had rebelled against the brutal Assad regime. A few days later, the students’ bodies, bruised and broken, were dumped on their parents’ doorsteps.

Dr. Fouad M. Fouad, a surgeon and prominent figure in Syrian public health, knew some of the students who had been killed. And he knew what their deaths meant. The laws of war—in which medical personnel are allowed to treat everybody equally, combatants and civilians from any side—no longer applied in Syria.

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“The message was clear: Even taking medicine to civilians in opposition areas was a crime,” he recalled.

As the war accelerated, Syria’s medical system was dragged further into the conflict. Government officials ordered Fouad and his colleagues to withhold treatment from people who supported the opposition, even if they weren’t combatants. The regime canceled polio vaccinations in opposition areas, allowing a preventable disease to take hold. And it wasn’t just the regime: Opposition fighters found doctors and their families a soft target for kidnapping; doctors always had some cash and tended not to have special protection like other wealthy Syrians.

Doctors began to flee Syria, Fouad among them. He left for Beirut in 2012. By last year, according to a United Nations working group, the number of doctors in Aleppo, Syria’s largest city, had plummeted from more than 5,000 to just 36.

Since then, Fouad has joined a small but growing group of doctors trying to persuade global policy makers—starting with the world’s public health community—to pay more urgent attention to how profoundly new types of war are transforming medicine and public health. In a recent article in the medical journal The Lancet, Fouad and a team of researchers looked closely at the conflicts in Iraq and Syria and found that the impact of what they call the “militarization of health care” in modern wars goes far beyond the safety of combat zone doctors, ensnaring even uninvolved civilians, with effects that can persist for years.

Other groups have begun focusing on the change as well. The International Committee of the Red Cross and Doctors Without Borders have documented and condemned disruptions of medical care by combatants. The entirety of the most recent issue of the journal Public Health is dedicated to a critical assessment of the failure of the World Health Organization to adapt to the new realities of conflict.

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Fouad and his Lancet coauthors say—reasonably—that any new global policy norms for wartime health care ultimately need to be hashed out in the security and political realms, not by doctors. But doctors, especially public-health specialists, have a crucial role to play: They gather the data and define the issues that drive much of global health policy. And as war has become a free-for-all, dissolving the rules that long protected medical care, Fouad and his coauthors suggest that their own field has been slow to awaken to the importance of that change.

“To be honest, we are stuck in this problem, and we don’t know what to do,” said Omar Al-Dewachi, a physician and anthropologist at the American University of Beirut, and the lead author of the Lancet paper. “The first thing is to start a conversation, and come up with new tools.”

What will replace the current system is far from clear, they say, but it’s time to start figuring it out: Right now, war has a quarter-century headstart.

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Until recently, medical care was something of a bright spot in the history of conflict. Major European powers, shocked by the suffering and grisly deaths of their soldiers in the Crimean War, agreed in 1864 to the First Geneva Convention. It granted medical workers a special neutral status on the battlefield, and upheld the right of all wounded to medical care regardless of nationality.

It was the first article of international humanitarian law and became the cornerstone of all subsequent Geneva Conventions. When we talk about “crimes against humanity” and “war crimes,” we’re usually referring to the body of law that arose over the next century and half, built on the narrow foundation of neutral, universal medical care for combatants in the battle zone. There were always breakdowns and violations, but the laws of war were remarkably effective at limiting abuse, establishing taboos, and shaming the worst offenders.

That relative comity disappeared with the end of the Cold War. When the rival superpowers were locked in combat, they had an incentive to promote the laws of war; they didn’t want their own fighters mistreated if there were another world war. But with the United States and Soviet Union no longer in direct armed confrontation, small wars across the globe flared with new ferocity and fewer scruples.

The wars of the 1990s spread in shocking new ways, with widespread torture, starvation, and genocidal murder campaigns. Rather than fighting other soldiers, armed groups often concentrated on battling civilians. The Geneva Conventions barely figured for the combatants in the former Yugoslavia, Somalia, Rwanda, the Congo, and Afghanistan. The United States contributed to that decline after 9/11 when it suspended Geneva Convention protections for prisoners in the “war on terror,” and normalized drone strikes against targets in civilian areas.

The protections around medical care started to collapse as well. Dr. Jennifer Leaning, director of Harvard University’s FXB Center for Health and Human Rights, has worked in conflict zones for decades and has surveyed the eroding conditions of medical care. Increasingly, she found, the biggest victims in armed conflicts weren’t the combatants but the civilian populations suffering in scorched-earth or ethnic cleansing campaigns in which doctors and hospitals became explicit, rather than incidental, targets.

The final strike against medical neutrality, Leaning says, came in the last decade during America’s wars in Iraq and Afghanistan. Insurgents targeted anyone connected to the “Western” side of the conflict, even local health care workers treating patients in public hospitals. The CIA used a polio inoculation campaign to gather information in its hunt for Osama bin Laden; ever since, Pakistani mullahs have condemned vaccination workers. By the time civil war broke out in Syria, the equal right to medical care in combat zones existed only on paper.

“What is now happening is the violation of deeply held legal norms that have taken 150 years of work,” Leaning said in an interview. “That is what is appalling.”

It’s been commonplace in the last decade in Iraq and Syria for militias to enter hospitals with guns drawn, and order doctors to treat their comrades instead of civilians. In the early 1990s in Mogadishu, such behavior was an oddity. In Baghdad in 2006, Shia death squads took over entire hospitals and infiltrated the health ministry, denying health care to Sunnis and even hunting down rivals in their sickbeds.

Doctors are also starting to document how a war-torn region’s health problems can continue even when dramatic violence subsides. Once a functioning health care system is destroyed, it can take years or decades to rebuild. Al-Dewachi worked as a physician in Iraq after the 1991 Gulf War, and has had a close view of how a war’s medical impact can persist and spread. With Iraq’s hospital system in shambles and doctors constantly emigrating to safer places, patients have flowed over borders, often seeking medical treatment at great cost in the relatively stable hospitals of Beirut. Even when Iraq is supposedly calm, the stream of patients never abates, he said. “It’s an invisible story of the war,” Al-Dewachi said. “The long-term effects continue even when the fighting stops.”

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With the old system broken, what should replace it? This is where it gets hard. Stateless rebels and insurgent groups, by definition, aren’t signatories to any international agreements. And the entire shape of modern warfare looks nothing like the formal battlefields that gave rise to the Geneva Conventions.

“We have to build new tools, new concepts, new institutions, that adapt to this concept of conflict,” Fouad said.

On the ground, under fire, health workers have improvised solutions. One common response has been to withdraw completely, only returning if combatants agree to respect the neutrality of clinics. At various times, groups as tough as Doctors Without Borders and the Red Cross have temporarily shut down operations when they were targeted in vicious conflict zones. Some aid groups have used private diplomacy to negotiate protected, equal access to government and rebel areas.

Leaning notes that some medical-aid groups have resorted to armed guards for clinics and vaccine workers, while other health care workers have evolved to function like military medics, embedded with combat forces and providing care on the run.

As for the longer-term effects, the recent Lancet paper suggests some ways for the public health community to rethink its approach to medical care in war zones—starting with its definition of what counts as a war zone.

Health care is normally a massive undertaking that operates through fixed channels—governments, national budgets, and clinics, with clear borders and supply chains. The paper suggests it’s time to scrap this notion when it comes to war zones: One facet of modern conflict is that it obeys no geographical limits. The researchers suggest that the global health community adopt a notion of shifting “therapeutic geographies” that acknowledges people caught in modern conflicts may change where they live—and where they get health care—from day to day, week to week.

That concept, abstract as it sounds, would mark a significant departure in global public health. The World Health Organization, the single most important international body dealing with health matters, still operates almost entirely through diplomatic channels, dealing only with the sovereign government even in complex, multisided conflicts like Syria’s. That means that when the regime wants to isolate a rebel province, WHO can’t vaccinate people there and other UN agencies might not be allowed to deliver emergency food aid. Health organizations and other humanitarian agencies will have to work with nonstate actors and militias, as well as governments, if they want to be able to operate throughout a war-affected area.

Public health research can also put more energy into measuring the human toll of war beyond the battlefield. Part of the recent Lancet paper is a strong call for doctors to start quantifying the effects of modern war on health, looking broadly at its full impact. “At this point, we need to just pay attention and describe what’s going on,” said Al-Dewachi.

The effects of better data could be political as well as medical, the authors suggest: A clear picture of the full health impact of war might well change the justification for future “humanitarian interventions.”

Today, Fouad’s former home of Aleppo is largely a ghost town, its population displaced to safer parts of Syria or across the border to Turkey and Lebanon. The city’s former residents carry the medical consequences of war to their new homes, Fouad said—not just injuries, but effects as varied as smoking rates, untreated cancer, and scabies. Wars like those in Syria and Iraq don’t follow the old rules, and their effects don’t stop at the border.

The researchers are energized by their quest to reorient the public health field, but they betray a certain world weariness when asked what might replace the current order, and provide better care for the millions harmed by today’s boundary-less wars.

“If I knew,” Al-Dewachi said, “I would be involved with it.”

Thanassis Cambanis, a fellow at The Century Foundation, is the author of “A Privilege to Die: Inside Hezbollah’s Legions and Their Endless War Against Israel.” He is an Ideas columnist and blogs at thanassiscambanis.com.

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