Attacks on civilians and hospitals must stop
Authors: Miguel Trelles, Barclay T Stewart, Adam L Kushner
Journal: The Lancet Global Health (2016)

On 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.1Liu J Médecins Sans Frontières (MSF) denounces blatant breach of International Humanitarian Law. Médecins Sans Frontières, Geneva2015Google Scholar 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.1Liu J Médecins Sans Frontières (MSF) denounces blatant breach of International Humanitarian Law. Médecins Sans Frontières, Geneva2015Google Scholar, 2International Committee of the Red CrossConvention (IV) relative to the protection of civilian persons in time of war.https://www.icrc.org/ihl/INTRO/380Google Scholar, 3International Committee of the Red CrossConvention (I) for the amelioration of the condition of the wounded and sick in armed forces in the field.https://www.icrc.org/ihl.nsf/0/fe20c3d903ce27e3c125641e004a92f3?OpenDocumentGoogle Scholar In Syria, since the start of the conflict in 2011, there have been 223 attacks on 175 health facilities; these attacks have killed 599 medical personnel.4Physicians for Human RightsAnatomy of a crisis: a map of attacks on health care in Syria.https://s3.amazonaws.com/PHR_syria_map/web/index.htmlGoogle Scholar In 2015 alone, more than 90 airstrikes and shelling attacks hit facilities supported by MSF in Syria.5Shaheen K MSF stops sharing Syria hospital locations after 'deliberate' attacks.http://www.theguardian.com/world/2016/feb/18/msf-will-not-share-syria-gps-locations-after-deliberate-attacksGoogle Scholar Despite the global attention directed towards the need for all parties of conflict to respect the Geneva Conventions after the Kunduz attack, MSF and other hospitals continue to be bombed or shelled in both Syria and Yemen.6Médecins Sans FrontièresMSF-supported hospital bombed in northern Yemen.http://www.doctorswithoutborders.org/article/msf-supported-hospital-bombed-northern-yemenGoogle Scholar, 7Médecins Sans FrontièresSyria: series of deadly bombings partially destroys MSF-supported hospital in Homs region.http://www.doctorswithoutborders.org/article/syria-series-deadly-bombings-partially-destroys-msf-supported-hospital-homs-regionGoogle Scholar Given these attacks, MSF has had to stop sharing the GPS coordinates of hospitals in Syria to protect the patients and humanitarians within them. In addition to the injuries, loss of lives, and destruction of facilities required to care for populations caught in war, these attacks have challenged the fundamental tenets of impartiality and neutrality of humanitarian actors in war zones.8WHOInternational humanitarian norms and principles. World Health Organization, Interagency Standing Committee, Geneva2010Google Scholar It is time for all parties involved in conflicts globally to renew their commitments to international humanitarian law and the protection of civilians and civilian objects (eg, schools, churches, mosques) and hospitals, medical units, and medical personnel operating in conflict. The First and Fourth Geneva Conventions provide for the protection of medical personnel and facilities to ensure that they are able to operate without military interference and care for patients based on need only.2International Committee of the Red CrossConvention (IV) relative to the protection of civilian persons in time of war.https://www.icrc.org/ihl/INTRO/380Google Scholar, 3International Committee of the Red CrossConvention (I) for the amelioration of the condition of the wounded and sick in armed forces in the field.https://www.icrc.org/ihl.nsf/0/fe20c3d903ce27e3c125641e004a92f3?OpenDocumentGoogle Scholar In 1970, the UN General Assembly adopted Resolution 2675, which states that a hospital zone or similar refuge should not be the object of military operations.9United Nations General AssemblyResolution 2675. United Nations, New York1970Google Scholar Operations may be directed only against military objectives and combatants; it is prohibited to target civilian objects or civilians. Hospitals, medical units, and medical personnel are afforded "special protection" under international humanitarian law; they shall be protected, respected, and may not be the object of attack. This obligation applies at all times, even when the medical unit or hospital is not being used to accommodate wounded or sick patients, provided that the medical unit is used exclusively for medical purposes. Parties are obligated to do "everything feasible" to "cancel or suspend an attack" if the party learns that the target is either: (i) not a military objective; or (ii) the attack would violate the principle of proportionality. Extremist organisations often embed themselves with non-combatants or near protected structures, objects, or personnel.10Polatty D In the wake of the Kunduz hospital bombing: where do civilian-military relations go from here?.http://www.atha.se/blog/wake-kunduz-hospital-bombing-where-do-civilian-military-relations-go-hereGoogle Scholar, 11George S As Iraqi troops advance in Ramadi, Islamic State militants have pulled back, leaving booby trapped homes and taking civilians with them as human shields.http://www.usnews.com/news/world/articles/2016-01-15/militants-use-of-human-shields-in-ramadi-slows-progressGoogle Scholar The fourth Geneva Convention states that the protection afforded to hospitals and medical personnel "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..."2International Committee of the Red CrossConvention (IV) relative to the protection of civilian persons in time of war.https://www.icrc.org/ihl/INTRO/380Google Scholar Therefore, indiscriminant or targeted attacks on hospitals, medical units, and medical personnel functioning in a humanitarian capacity are never admissible. Continuing conflicts globally require that all actors remain committed to upholding the Geneva Conventions and international humanitarian law irrespective of differences in military tactics, strategy, or rules of engagement. To safeguard civilians, civilian objects, hospitals, medical personnel, and humanitarian action more broadly, the international community and parties involved in conflict must denounce unlawful behaviour, engage with armed groups and affected populations to encourage compliance with the Geneva Conventions, and reconfirm the legitimacy of international humanitarian law.12International Committee of the Red CrossThe rule of law at the national and international levels: ICRC statement to the United Nations.https://www.icrc.org/en/document/rule-law-national-and-international-levels-icrc-statement-united-nations-2015Date: 2015Google Scholar By doing so, the sanctity of humanitarian action can be upheld and humanitarian actors and civilians can provide and receive care no matter the context. MT and BTS are co-first authors. We declare no competing interests.