Protecting medical care in armed conflict

The wreckage of ambulances in Aleppo The wreckage of ambulances in Aleppo © George Ourfallan/AFP

This article is a brief presentation of the report of CNA on protecting medical care in conflict

The report presents possible solutions, identified by CNA, for better safeguarding medical facilities and health care workers from attacks in armed conflict. CNA is a nonprofit research and analysis organization based in the United States (US) that deals with national defense, security and air traffic management.

The report is based on analysis carried out by CNA on military operations over the past two decades and examination of nearly 1,000 real-world incidents where civilians were harmed in conflict.

Hospitals and health care workers have been victims of a tragic number of attacks over the past few years even if these aggressions are prohibited under international humanitarian law (IHL). Indeed, all parties to armed conflict, whether States or non-state armed groups, are bound by a strict obligation under IHL to respect and protect medical workers and facilities, as well as the wounded and sick. Medical facilities are generally included in a No-Strike List (NLS) defined as a “list of objects or entities characterized as protected from the effects of military operations under international law/or rules of engagement”.

In 2016, the United Nations Security Council unanimously adopted Resolution 2286 (UNSCR 2286), Healthcare in Armed Conflict, which calls for strongest actions to better protect health care, in response to its deep concern about the acts of violence, attacks and threats against medical care in armed conflict. Together, IHL, Resolution 2286 and the Secretary General’s recommendations on measures to operationalize the resolution form a solid framework for preventing attacks on medical care, enhancing its protection and improving accountability for violations. Despite this framework, there is little indication that the levels of violence are reducing and in some corners of the world they appear to be increasing. Indeed, the protection of medical care in conflict still faces challenges and gaps and unlawful attacks on health care have continued or intensified in many conflicts, notably in Syria. According to Physicians for Human Rights, which has systematically collected information on this since 2011, the period that followed the adoption of the resolution was the most dangerous to health workers in Syria. Meanwhile, South Sudan experienced a particularly high level of violence against health facilities during May-September 2016 and in the Democratic Republic of Congo health workers and facilities have continued to be attacked.

The international community can and need to take better actions in order to protect health care in conflict and in this regard the report of CNA states that this is a problem with possible solutions. The report says that analysis of military operations of the past two decades (including in Iraq, Afghanistan, Syria and in Yemen) has led to the identification of practical steps for military forces to reduce risks to civilians. According to CNA if the root causes of tragic events through analysis of actual incidents are analyzed, more effective ways to avoid them can be identified; this data-based approach has shown different matters.

First of all, analysis of historical attacks and real-world operations has led to the discussion of practical measures such as: improving deconfliction measures, finding additional options for identification of medical facilities, taking a comprehensive, life-cycle approach to protect civilians, developing awareness of the location of medical facilities in conflict.

As far as it concerns deconfliction, determining what is and what is not a lawful target is a vital part of the responsible use of force. From a legal perspective, protected entities on the NSL can, under certain circumstances, become lawful military targets, but they are still subject to the IHL principle of proportionality. When a proposed military target is found to be on the NSL or is found to be in proximity to an entity on the NSL, there are a number of best practices that can guide targeting decisions and guard against inadvertently attacking these entities. These practices include: provide effective advance warning that allows evacuations before the facility is attacked; show tactical patience, that includes waiting until enemy forces move to another location that is free of collateral concerns; consider tactical alternatives such as the use of ground forces instead of airstrikes. In fact, ground forces can sometimes better determine if there are noncombatants along with combatants. 

Regarding the search for additional options for identification of medical facilities, CNA has documented ways for a positive use of Artificial Intelligence (AI). Nowadays, a red cross or red crescent emblem indicating medical facilities will not necessarily be a discriminating feature for a pilot conducting an air strike using an infrared sensor. Militaries could use AI to improve the identification of hospitals using machine learning techniques. Technology could improve not only identification but also situational awareness and communications to facilitate safe passage for medical evacuations or to facilitate time-sensitive transfers of patients to medical care.

Another way to help improve the protection of medical and other protected facilities is to follow best practices in order to reduce risks to civilians overall. A so-called “civilian harm mitigation life cycle” includes considering the civilians at all points in the planning and use of military force and foresees learning loops so that militaries can adapt and improve to overcome challenges.

Medical care in conflict needs and deserves protection. Attacks on medical facilities results in an immediate loss of life, injury, destruction and the deprivation of essential healthcare. It also has catastrophic longer-term consequences as medical facilities close and medical workers are forced to flee, depriving entire communities of vital care. According to CNA this tragic problem can be a solvable one if militaries, as mentioned before, act on the basis of real-word observations through better training, education and doctrinal development. In the meantime, States should take practical steps in this sense. The United States has already demonstrated global leadership over the past decade in its commitment to comply with international law and concrete actions for the protection of civilians. This effort is an opportunity for the United States to disseminate good practice and contribute to an evolution in the protection of health care services in conflict.



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Author: Leyla El Matouni


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