Written by Aiman Ibrahim, Final Year Medical Student at Kings College London
War and destruction are the symbiotic parasites that dissolve its host nation of resource and surplus. Its impact on healthcare safety and access is so strong that specific rulings have been made, by the Geneva Conventions and international humanitarian law (1), to protect sites, personnel and transportation responsible for providing medical care.
Furthermore, an increase of trauma-induced injuries in war-torn nations exponentially adds to the surgical burden of healthcare facilities especially in reconstructive and maxillofacial surgical specialties (2). Such surgeries are often long, complex and time-sensitive requiring further inputs from orthopaedic and vascular subspecialties. Therefore, many recipients are left with fatal or devastating long-term complications which could have been avoided under normal circumstances often due to damage to provision facilities(3).
Despite attempts to push ‘ethical’ warfare in order to preserve healthcare amenities, warring parties may not choose to listen and worse still political agendas may cause them to look the other way.
This has been seen in the past through attacks made by Russian groups on Syria and Ukraine alongside American groups in Afghanistan indiscriminately attacking hospital sites (4,5). Moreover, a “double tap” warfare technique has been used by the CIA (US intelligence agency) against the Taliban in Pakistan in the past where a second set of air strikes are placed upon the same site to target medical and other aid groups seeing to the wounded (6).
A similar situation is currently happening with attacks across numerous hospital sites in Gaza where patients and medical aid groups are being forced to evacuate from hospital premises which are no longer deemed safe (7). Professor Abu Sitta, a plastic surgeon seeing to the surgical injuries in Gaza and a previous speaker at the Incision conference 2023, was forced to evacuate on the 9th of December 2023 due to risk to personal safety despite being a protected personnel under the Geneva Conventions (8). Unfortunately, calling for peace has been deemed a political stance and the UN proclamations of suspected war crimes and ceasefire have been wholly ignored (9).
A speech made at the UN security council by a French representative in August 2019 (Figure 1), highlighted the need to reinforce international rules of war which were “too often violated” (10). Despite the recognition of failures in upholding these laws, nothing absolute seems to have been put into practice and the protection of hospitals alongside medical staff remain at the whim and agenda of powerful political allies.
There is need to give international coalition organisations more weight in the international regulations around war to protect surgical and medical staff alongside hospital sites. To perform safe and effective surgery in international conflict zones, the laws protecting surgeons and operation sites must not be an afterthought.
Figure 1:
“Today, the Conventions and their Protocols Additional, for which we call for universal ratification, are too often violated, whether in Syria, Libya, Yemen, Palestine, Afghanistan, the Central African Republic, the Democratic Republic of the Congo or South Sudan. Certain parties to conflict even go so far as to knowingly incorporate violations of those rules into their military strategy in order to deprive people of all assistance and obtain their surrender. Others violate international humanitarian law in the name of fighting terrorism”
Statement on ‘International humanitarian law’ given by Ms. Anne Gueguen, Deputy Permanent Representative of France to the United Nations Security Council - 13 August 2019
1. ADVISORY SERVICE Respecting and Protecting Health Care in Armed Conflicts and in Situations Not Covered by International Humanitarian Law [Internet]. 2021 May. Available from: https://www.icrc.org/en/doc/assets/files/2012/health-care-law-factsheet-icrc-eng.pdf
2. Favour Tope Adebusoye, Wireko Andrew Awuah, Yasir Alshareefy, Wellington J, Mani S, Ahmad AO, et al. Craniomaxillofacial trauma in war‐torn nations: Incidence, management gaps, and recommendations. Acute medicine & surgery. 2023 Jan 1;10(1).
3. Mock C. Injury in the developing world. Western Journal of Medicine [Internet]. 2001 Dec 1;175(6):372–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1275961/
4. Tin D, Barten DG, Granholm F, Kovtonyuk P, Burkle FM, Ciottone GR. Hybrid warfare and counter-terrorism medicine. European Journal of Trauma and Emergency Surgery. 2023 Feb 10;
5. Double Standards in International Law: Did the U.S. Get Away with War Crimes in Afghanistan? [Internet]. Columbia Undergraduate Law Review. 2022. Available from: https://www.culawreview.org/journal/double-standards-in-international-law-did-the-us-get-away-with-war-crimes-in-afghanistan#:~:text=Despite%20having%20ratified%20both%20conventions
6. Williams BG. New Light on CIA “Double Tap” Drone Strikes on Taliban “First Responders” in Pakistan’s Tribal Areas. Perspectives on Terrorism [Internet]. 2013;7(3):79–83. Available from: https://www.jstor.org/stable/26296941?seq=1
7. Gaza hospital: “The situation became so dangerous because of the constant threats of drones and snipers.” [Internet]. 無國界醫生（香港）. 2024 [cited 2024 Feb 1]. Available from: https://msf.hk/en/content/gaza-hospital-situation-became-so-dangerous-because-constant-threats-drones-and-snipers
8. A British Palestinian surgeon gave testimony to a UK war crimes unit after returning from Gaza [Internet]. AP News. 2023 [cited 2024 Feb 1]. Available from: https://apnews.com/article/ghassan-abu-sitta-gaza-war-crimes-testimony-c0a40d6edc02bb0b91c94eb39cd8110d
9. Aturan. UN calls for independent investigations into allegations of war crimes and crimes against humanity committed in Israel and the Occupied Palestinian Territory [Internet]. Committee for Justice. 2023 [cited 2024 Feb 1]. Available from: https://www.cfjustice.org/un-calls-for-independent-investigations-into-allegations-of-war-crimes-and-crimes-against-humanity-committed-in-israel-and-the-occupied-palestinian-territory/
10. The Geneva Conventions are too often violated [Internet]. France ONU. 2020. Available from: https://onu.delegfrance.org/The-Geneva-Conventions-are-too-often-violated
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