Even in war, attacking medical facilities must remain off limits

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“All is fair in love and war.”

The well-known proverb, attributed to John Lyly in the 1578 book Euphues: Anatomy of Wit, is catchy, but not really true.

There are rules – in war at least. There are lines that should not be crossed.

In recent years, there has been an appalling increase in attacks on health care facilities, patients and medical staff in conflict zones.

In 2024 alone, there were 3,623 attacks on health care facilities, the highest number ever documented by the Safeguarding Health in Conflict Coalition.

This includes everything from the bombing of hospitals, to shooting at and looting ambulances, as well as the kidnapping and incarceration of medical personnel, and deliberate shutdowns of electricity and water to health facilities.

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The report catalogues attacks in countries such as Ukraine, Lebanon, Myanmar and Sudan. But by far the largest number of attacks on health care – more than 1,300 – took place in Gaza and the West Bank.

In an article published in the journal BMJ Global Health this month, Dr. Joelle Abi-Rached and colleagues at the American University of Beirut in Lebanon also focus on the seemingly endless attacks on health facilities in the Israel-Hamas war.

“What is becoming clear is that health care workers and facilities are no longer afforded the protection guaranteed by international humanitarian law,” they wrote.

Israel’s military operations in Gaza since Oct. 7, 2023, have resulted in the deaths of at least 986 medical workers, the authors write. The toll includes 165 doctors; 260 nurses; 184 health associates; 76 pharmacists; 300 management and support staff; and 85 civil defence workers. Another 300 health care workers have been detained since October, 2023, with many allegedly subjected to torture and inhumane treatment.

Dr. Abi-Rached and her co-authors coined the term “healthocide” to describe the situation. It is defined as the deliberate “destruction of health services and systems for ideological purposes.”

People have, for time immemorial, used violence to settle disputes. But in all cultures, there have been limits on what violence was acceptable.

In particular, there are customs and rules protecting non-participants, prisoners and the wounded, as well as those who care for them.

The policy of “medical neutrality” was well-established in earlier eras, but it was informal – a gentleman’s agreement, if you will. But in modern times, it has been formalized in treaties.

The first Geneva Convention was adopted in 1864, thanks to the efforts of Henry Dunant. The Swiss businessman happened upon the Battle of Solferino and was appalled by what he saw – 40,000 French and Austrian soldiers dead and wounded on the battlefield.

He rallied volunteers to help the wounded, regardless of what side they were fighting on – the beginnings of what would become the International Committee of the Red Cross.

The red cross, and later the red crescent, became symbols of neutrality. Where those flags flew, there could be no attacks.

These rules were further formalized after the Second World War, when the four modern Geneva Conventions were adopted in 1949. These treaties lay out conditions in which sick and wounded soldiers, mariners and prisoners of war are treated, and protections for civilians in times of war.

Several articles of the conventions require that medical establishments and personnel be protected.

“Any attack of health care facilities is a violation of international humanitarian laws,” said Dr. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization.

Unfortunately, it’s not that black-and-white. There are loopholes in the rules.

Hospitals can be bombed if they are considered “harmful to the enemy.” Attacks, when they occur, are supposed to be “proportional” and warnings should be issued so precautions can be taken, like evacuating patients.

There is no blanket ban because situations are not always cut-and-dried. Attacks are often justified by saying health facilities double as weapons depots or command centres.

Yet, in some attacks on medical facilities, there are questions – debated at the UN and elsewhere – as to whether international conventions are being flouted.

The principle of medical neutrality is all-important. We need to protect health workers doing dangerous work in war zones as best we can.

We can’t allow ‘healthocide’ to become the norm, in Gaza or elsewhere.

War is never pretty. And it’s getting more complicated and impersonal with the advent of drones, robotics and AI.

But we can’t totally abandon our humanity. If we can’t agree on some limits to the barbarity – like not bombing hospitals and not starving people to death – then what hope is there for humanity?