Unhealthy Practice

A Pakistani nurse administers polio vaccines in Peshawar, November 2001. (Courtesy Reuters)

For the second time in less than six months, polio vaccine workers in Pakistan have come under fire. In early April, an unidentified armed group attacked a team of Pakistani health workers administering vaccines and killed one of the police officers guarding them. The program suffered a tragic loss last December, when gunmen killed nine polio workers. Since then, the government has suspended the vaccination campaign in Pakistan’s tribal region -- a major setback to public health in a country where polio remains endemic. By the end of March, almost a quarter of a million children scheduled for polio vaccinations had not received them in that region. Meanwhile, in northern Nigeria, where polio is also endemic, vaccination efforts are strained. Last February, nine vaccine workers there were killed by gunmen associated with Boko Haram, a militant Islamist group that claims polio vaccinations are part of a Western plot against Islam.

Some observers, such as the Council on Foreign Relations Senior Fellow Laurie Garrett, persuasively argue that the CIA is partially to blame for turning health workers abroad into targets. In 2011, the CIA employed a Pakistani doctor to conduct a fake vaccination campaign in an effort to track down Osama bin Laden. News of the scheme reinforced the population’s worst suspicions about the motives behind immunization campaigns. Earlier this year, deans of a dozen of the United States’ most prestigious public health schools wrote a letter to President Barack Obama demanding that public health programs never again be used as a cover for intelligence gathering operations.

The Pakistan and Nigeria killings and the CIA’s activities illustrate the disturbing and widespread erosion of the norm of health care as an intrinsic good that must be respected and protected in conflict zones. For the CIA, the faux vaccine campaign was justified as part of the war on terror. For the gunmen, killing health care workers was rationalized inasmuch as they saw vaccinating children as an illegitimate extension of Western power. But health care should not be an instrument for achieving political, intelligence, or military goals.

The principle of respecting health workers and their patients is one of the oldest norms of international law. In the industrial era, it dates to the Lieber Code, which was drafted in 1863 under the direction of Abraham Lincoln to establish ground rules for the treatment of prisoners, civilians, and the wounded during the Civil War. The next year, the first Geneva Convention established international law stating that volunteers could collect and attend to battlefield wounded without interference. Over time, international legal requirements for respecting health in armed conflict have become progressively stronger and broadly accepted. Today, warring parties are obliged to make care available to all who need it -- regardless of their affiliation. Health care workers are ethically bound to provide care impartially and cannot be punished for doing so. Last year, the World Medical Association strongly reaffirmed this rule, making clear that doctors must provide effective care to the wounded and sick, even if they are enemies.

Of course, securing adherence to international requirements has been a struggle; the rules are often set aside in favor of military objectives. Combatants often seek out and occupy hospitals in strategic locations. They deny individuals access to health care for security reasons, unreasonably delay ambulances at checkpoints, and in some cases heedlessly damage hospitals during fighting. These violations are serious enough. But there is another category of conduct that not only goes against norms but also undermines them. Actions such as targeting health workers and facilities or deeming the provision of medical services to be a hostile act are worthy of reprisal or prosecution. 

Under the auspices of the United Nations, the Independent International Commission of Inquiry on the Syrian Arab Republic recently found that, in the second half of 2012 alone, hospitals in Aleppo, Damascus, Dayr az Zawr, Idlib, and Homs were shelled or bombed by Syrian forces, often repeatedly. The World Health Organization (WHO) reports that half the hospitals in Syria are damaged and a third are not functional. According to the commission, government-affiliated forces have shot at, arrested, and tortured emergency medical workers wearing medical insignias, and have targeted ambulances marked with the Red Crescent logo. In March, the commission concluded that “Medical personnel and hospitals have been deliberately targeted and are treated by parties to the conflict as military objectives” and that medical personnel “have a well-founded fear of punishment if they provide treatment to members of anti-Government armed groups.”

Syria is hardly the only example. During the 1999 war in Kosovo, Serbian forces destroyed more than 100 medical clinics, and arrested and prosecuted Kosovar Albanian doctors who provided treatment to individuals alleged to be fighting for the Kosovo Liberation Army. Similarly, during Russian military action in Chechnya in 1999-2000, doctors who provided treatment to fighters on one side were often targeted by the other. And for decades, indigenous health workers in eastern Burma have been subject to arrest, kidnapping, robbery, and threats by the Burmese Army if they offer health care to rebellious populations.

Even governments that are not embroiled in violent conflict often treat the provision of health care as subversive. In the 1990s in Turkey, doctors were prosecuted for providing rehabilitation services to victims of government torture. During Egypt’s Arab Spring revolution, police and allies of the Hosni Mubarak regime assaulted doctors and nurses who set up medical tents to treat wounded demonstrators. During Bahrain’s 2011 uprising, doctors and nurses treating protesters at the country’s main hospital were arrested, tortured, tried, and convicted on trumped-up charges of crimes against the state.

The United States is not immune from this kind of conduct. The Pentagon takes pride in adhering to rules requiring medical personnel to provide impartial care in conflicts. Yet in recent years, the Department of Justice has broadly interpreted statutes prohibiting material support for terrorism as reason to prosecute doctors who have offered medical care under the direction or control of a terrorist organization -- even though U.S. law does not specify medical care as a form of material support. 

Washington’s use of health care programs to advance counter-terrorism goals further diminishes the respect and protection of health services in conflict zones. To be sure, security and health objectives align in some cases; for example, the U.S. Department of Defense has engaged in research around the world on tropical diseases and has supported laboratories that track the development of new infections. But the United States has also employed health-related interventions instrumentally in cases in which medical objectives were secondary or nonexistent. The CIA’s vaccination ploy to find bin Laden had no legitimate health motive at all. In other places, such as in Iraq, Afghanistan, and Kenya, Washington has initiated health programs to seek to entice populations away from terrorist groups and militants rather than to sustainably improve people’s health.

It is time to restore the integrity of medical work in conflict zones by decoupling health from political and military objectives. Governments must explicitly reject the idea that health care providers who act in accordance with ethical obligations and medical facilities that are properly used are legitimate military targets, and train their forces accordingly. National security considerations do not justify interference in or manipulation of health services. And laws that permit prosecuting those who provide health care to enemies must be repealed.

In addition, protection for medical activities must be ratcheted up. Pakistan has finally started taking steps to increase security for vaccination workers. It has also encouraged local leaders and the Islamic community there to help plan and carry out vaccinations. The International Committee of the Red Cross has launched a campaign to improve protection of health care in conflict situations, and governments and armed groups should participate in advancing these protection strategies.

The safety and effectiveness of health campaigns is improved when governments commit to providing impartial care. By making such a commitment, the Afghan government has, with the help of an intermediary, secured the Taliban’s support of polio vaccination campaigns in some areas of the country. Mullah Omar, the Taliban’s leader, even signed a letter urging his commanders to cooperate with the effort 

There is still much to do, of course, including ending impunity for attackers. Reporting of violations of health-protection provisions of international humanitarian and human rights law is spotty. To help address such problems, the Obama administration shepherded a resolution through the World Health Assembly in 2012, which requires the WHO to be a global leader in developing methods for documenting and reporting attacks on health workers, facilities, patients, and ambulances in complex emergencies. In 2011, the UN Security Council extended its accountability mechanisms for perpetrators of abuses against children in armed conflict to attacks on hospitals and health personnel. These steps, if implemented properly, will create a good foundation for the effort to ensure the safety of health services.

Those who attack medical personnel in conflicts should be prosecuted under international law for war crimes. As a start, the Security Council should refer the Syrian government’s killing, arrest, and torture of medical personnel for investigation by the International Criminal Court. Russia and China will no doubt resist, but their opposition is no excuse for refusing to demand criminal accountability.

The international community must recognize the fragility of health care in conflict, reaffirm the norms of protection and respect, and take vigorous action toward assuring adherence to legal obligations. Otherwise, health workers who provide care will remain at high risk and people who need care the most will be abandoned.