Medical neutrality: resetting the moral compass
Authors: Zoë Mullan
Journal: The Lancet Global Health (2016)

On Oct 3, 2015, US forces commenced an hour-long aerial bombardment of a volunteer-run hospital in northern Afghanistan. The airstrikes began on the intensive care unit, killing the medical staff on duty and the patients for whom they were caring, and continued in waves across the main hospital compound. Two patients were killed as they lay on the operating tables; terrified staff fled the building, only to be shot from above as they ran. In total, 42 civilians were killed, including 14 staff, 24 patients, and four relatives. Médecins Sans Frontières (MSF), whose flags were flying from the hospital roof on the night of the attack, and which recorded at least 12 attempts to inform the appropriate authorities of the hospital's plight, rightly sought an immediate explanation. The response from the US Army was an initial claim of self-defence, followed by a cursory apology and an altered account, citing a cry for help from besieged Afghan forces—whom US troops were providing with “training, advice, and assistance”—and blaming the Taliban for “knowingly putting civilians at significant risk of harm”. A subsequent internal inquiry revealed that the attack was “the direct result of human error, compounded by procedural and technical failures” and that the individuals who ordered and carried out the strike did not undertake the necessary checks to verify that the building targeted was the correct one. Some individuals were suspended from duties. MSF's International President Joanne Liu said that the inquiry and the suspensions that followed did not fill her with confidence that the sort of basic failings described would stop history from repeating, and called for an independent inquiry by the International Humanitarian Fact-Finding Commission. The Lancet supported this call. The Commission stands poised to act but can only do so on instruction by the US and Afghan Governments, neither of which are parties to Article 90 of the first additional protocol to the Geneva Conventions under which authority the Commission acts. Human Rights Watch went a step further in December and called on the US Pentagon to instigate an independent criminal inquiry. There has been no discernable response. In the meantime, Liu's concern about history repeating itself has been borne out. As MSF staffer Miguel Trelles and others point out in a Correspondence letter, attacks by various parties on its medical facilities have continued unabated since the Kunduz assault. Just weeks later, an MSF hospital in Haydan, Yemen, was attacked, as was another in Houban, on Dec 2, and one in Razeh on Jan 10. On Feb 15, a further MSF hospital in Ma'arat Al-Numan, Syria, was destroyed, leaving 25 dead and 40 000 local people without access to health care. The organisation, and others such as Human Rights Watch and Physicians for Human Rights, no longer accepts that the attacks merely represent collateral damage. It has recently stopped providing the GPS coordinates of its facilities to the parties involved in the Syrian conflict on the basis that they are probably being used to target the facilities rather than to avoid them. If this is the case, then these attacks, several of which are being carried out or at least supported by governments who claim to hold the moral high ground—including the USA, UK, and France—are indeed war crimes, as MSF has claimed ever since the Kunduz attack. Further support for this alarming turn of events emerged earlier this month, when Amnesty International released a report claiming that its researchers had uncovered evidence that hospital strikes are being used as a weapon of war in Syria in a calculated and illegal attempt to cut off civilian lifelines and gain military advantage. What can be done? Trelles and colleagues call on the international community to “engage with armed groups and affected populations to encourage compliance with the Geneva Conventions, and reconfirm the legitimacy of international humanitarian law”. And five nations within the UN Security Council are now putting together a draft resolution that “holds up international law, re-states respect for medical workers and sends a message about health care in armed conflict”. While civilians, and their health-care workers, wait for their aggressors to reset their moral compasses, it is perhaps the fragile “cessation of hostilities” in Syria that holds the best chance of a break in the destruction there. For our part, however, we must loudly condemn the morally empty act of attacking medical safe havens in times of war, and reiterate our admiration and respect for the individuals who devote their time—and their lives—to caring for those whom sovereign nations have chosen to abandon. Attacks on civilians and hospitals must stopOn Oct 3, 2015, a US airstrike hit Médecins Sans Frontières' (MSF's) Kunduz Trauma Centre in Afghanistan; 42 lives, including 14 MSF hospital staff, were lost.1 The 92-bed hospital was the only facility with essential trauma care capabilities for hundreds of thousands of people living in northern Afghanistan; those who continue to live amid conflict will critically miss it. The attack was a violation of international humanitarian law and the Geneva Conventions, a war crime, and an incursion on the sanctity of humanitarian action globally. Full-Text PDF Open AccessNeuraminidase inhibitors for influenza: a call for better researchOn Oct 8, the Academy of Medical Sciences and the Wellcome Trust (AMS/WT) published a timely report on the use of neuraminidase inhibitor (NAI) antiviral drugs in seasonal and pandemic influenza treatment and prophylaxis. As winter approaches in the UK, the debate about whether the benefit of routine use of NAIs outweighs the risks of side-effects, such as nausea and vomiting continues; a meta-analysis published in The Lancet in January explored this issue in oseltamivir use for seasonal influenza. Full-Text PDF