Preventing Attacks on Health and Humanitarian Workers in Global Conflict Zones
Summary of a Documentary Screening and Discussion
On December 18, 2017, the National Academy of Medicine (NAM) hosted a screening of The New Barbarianism, an original documentary feature from the Center for Strategic and International Studies (CSIS). The film explores the growing trend of attacks on health and humanitarian workers in global conflict zones through the lenses of the Syrian and Yemeni civil wars, as well as a mistaken U.S. airstrike on a Médecins Sans Frontières (MSF; Doctors Without Borders) facility in Afghanistan in 2015. The documentary also probes the efficacy of current efforts to reduce such violence, including United Nations (UN) Security Council Resolution 2286 (2016), which called for stronger condemnation of attacks on medical and humanitarian personnel in violation of the Geneva Conventions. The New Barbarianism is available in its entirety on the CSIS website (runtime: 1 hour) and can be viewed and streamed for educational purposes free of charge.
This event is part of the NAM’s Films for a Healthier Future documentary screening and discussion series.
The following is a summary of an expert panel discussion following the screening. The panel was moderated by Margaret Hamburg, NAM Foreign Secretary, and featured J. Stephen Morrison, Senior Vice President & Director, CSIS Global Health Policy Center, and Executive Producer/Director of The New Barbarianism; Leonard Rubenstein, Senior Scientist at the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health and Founder and Chair of the Safeguarding Health in Conflict Coalition; Alexandra Boivin, Head of the Regional Delegation for the U.S. and Canada of the International Committee of the Red Cross (ICRC); and Patricia Evers, Senior Program Officer, Committee on Human Rights, National Academies of Sciences, Engineering, and Medicine (NASEM).
Margaret Hamburg (NAM): I am struck by what David Miliband said at the end of the film – that those of us who live comfortable lives should never give up hope. I think we should go further than that. Those of us who live comfortable lives must commit to making a difference. Steve, thank you for your important work on this film. Tell us, out of all the important issues in global health, why did you choose to focus on this one?
Stephen Morrison (CSIS): The accumulation of my experience over the past several years, particularly as I saw what was happening in Syria and Yemen, convinced me that the world has really changed. This new strategy of warfare – this deliberate, targeted violence against health and humanitarian workers – has become embedded across multiple wars. There has been a major shift, and this is an important story to tell. We wanted the film to come as close as possible to the real experience of living and working in these conflict zones. We were very fortunate to have more than 30 people agree to be interviewed for this film. They trusted us to be fair in how we made use of what they said. We also benefited from the brilliant work of writer/director Justin Kenny, who was able to safely capture scenes from very challenging environments.
Hamburg: Len, tell us more about the Safeguarding Health in Conflict Coalition, which you founded. What are its goals, and how can we support them?
Leonard Rubenstein (Hopkins Bloomberg School of Public Health): We started the Coalition six years ago, before the Syrian war got hot and attacks on hospitals became routine. But I had seen attacks on health care in my own experience in the Balkans, Chechnya, Gaza, Burma, and many other places. Hospitals and health care workers were under assault – attached, prosecuted, terrorized – and nobody was paying attention. It wasn’t on the agenda of UN agencies; in fact, a colleague at the World Health Organization (WHO) told me it wasn’t part of their mandate because it was too controversial. There was no regular monitoring of this problem except for the occasional human rights report. So, the Coalition came together to learn how we could apply strategies used in countering other chronic human rights abuses – like rape in war, abuses of political prisoners, and the denial of free speech. We didn’t have the Pollyannaish view that this kind of violence would come to a complete stop, but believed that there are mechanisms that could limit the carnage. We have urged a lot of steps. We needed data, so we pushed for WHO to be the group to collect it. It took 5 years, but WHO is now developing approaches to monitor and report on these incidents. We needed the human rights institutions of the UN to be engaged and invested in stopping the attacks and to speak out – and they’re starting to do so now. For example, the UN Special Rapporteur on the Right to Health is going to issue a report on the criminalization of impartial health care under the guise of counterterrorism. We needed to strengthen accountability and stigmatize the perpetrators, so the Coalition issues an annual report of attacks on health care. There are all kinds of mechanisms to bring about change.
Hamburg: Alex, you work with ICRC, a group that’s on the ground every day responding to crisis situations. When it comes to recruiting and retaining your staff, how do you balance the necessity of putting lives at risk in order to protect the lives of others?
Alexandra Boivin (ICRC): Our environment has become more unpredictable and difficult to read. It’s more challenging to do risk assessments. We explain that we are neutral and impartial, but the reality is that the services we provide are politicized and used as instruments of warfare. Our humanitarian imperative tells us that we have to serve people in the cruellest of situations. So, we choose to remain. This radical commitment to being on the ground, to being close to people and appealing to all sides – it does indeed come at a price. That price is the dilemma we face every day when we put our staff at risk. When we face security incidents, we have to decide whether we continue to provide life-saving support to communities or whether we withdraw because of safety concerns. It’s never an easy decision. You have to consider the incredible impact on populations of not having doctors or humanitarian actors present. These decisions are made by the people closest to the ground – our colleagues who are living in these communities and able to read the environment better than anyone else in the organization. The powerful nature of our mission continues to attract tremendous, humbling interest in spite of the challenges we face.
Hamburg: Patty, the NASEM Committee on Human Rights (CHR) shows the power of mobilizing the scientific community to speak out against human rights abuses of fellow scientists, including medical professionals. Tell us more about CHR’s work.
Patricia Evers (CHR): CHR’s main focus is advocacy on behalf of colleagues suffering serious human rights abuses worldwide. We work primarily through sustained, behind-the-scenes pressure – including private petitions signed by members of the National Academies, submissions to international and regional human rights bodies, and direct personal appeals to governments. Over the years, we have worked on many cases of health professionals who have been targeted for a variety of reasons. Some have been detained for providing medical care to injured protesters, others for speaking out against human rights violations perpetrated by government officials. The Syrian conflict in particular has been a major challenge for us. Through the UN’s Commission of Inquiry on Syria, we have documented hundreds of cases of Syrian health professionals who have been detained or executed. One such case was a well-respected Syrian doctor from Aleppo. He was picked up by the authorities and beaten, mutilated, and ultimately killed because he had signed a petition stating that health professionals should be able to provide care to anyone in need. The government used his case to warn other health professionals about what would happen to them if they provided medical care to individuals on the other side of the conflict.
Hamburg: A question for all panelists – do you agree with the film’s suggestion that adherence and respect for the Geneva Conventions may be eroding?
Morrison: I believe that the U.S. military and the militaries of other major powers remain very committed to the principles of international humanitarian law. But we’re in an era when aerial campaigns are expanding dramatically – and that brings an issue set that has to be addressed. Groups like ICRC and MSF are still struggling every day to find the operational space they need to do their work. What we need to do now is build high-level political engagement. We need to make military and civilian leaders aware of the reality of this problem and ask what more they can do.The U.S. Congress has the capacity, on a bipartisan basis, to elevate this issue and encourage the executive branch and others to pay more careful attention to how we go about warfare in this era.
Rubenstein: I don’t agree that we need to rethink the Geneva Conventions. Remember, the Conventions have been strengthened over time. It wasn’t until 1977 that indiscriminate attacks on civilians were outlawed. When civilian areas in Vietnam were bombed by the United States, it wasn’t a violation of the Geneva Conventions. Now it is. The Geneva Conventions are just fine – but we have to find ways of making them respected and enforceable.
Boivin: At ICRC, we’ve been battling the notion of erosion. Erosion implies that we started with something very solid. However, as Len mentioned, there was never a golden era of compliance with the law. We think it can be irresponsible to spread the notion that the law is irrelevant or that respect for it is eroding. Of course, we recognize problems with compliance, but any solution has to uphold the law and recognize its value. It’s true that the consensus that was necessary to come up with the 1949 Conventions may not be there anymore. Building that kind of consensus today may require more people at the table. So many influencers have a stake in how these wars are fought, including the people paying the bill when it’s time for reconstruction. We have to be pragmatic. We have to cost these things and look at how we can incentivize compliance – again, while maintaining a strong line about what is and is not acceptable. This law saves lives every day – there is no doubt about it. We cross front lines to save lives because this law is respected. At the end of the day, if we can rebuild consensus and incentivize parties to reclaim their interests, we believe it is possible to make progress. It may be baby steps. In French we say “géométrie variable” (variable geometry) – it may not be multilateral progress. But there are definitely positive developments on the ground, and we should build on them.
Hamburg: For all panelists, what is one step we could take immediately to help solve this crisis?
Morrison: Here in Washington, DC, the key entry points are current and past military leadership and the U.S. Congress. They are open to the kind of dialogue we’re calling for, and we should push them on it.
Rubenstein: As the film says, the United States can provide the leadership we need to enforce the Geneva Conventions. But there are also areas in which we need to get our own house in order. We need more discussion about how counterterrorism laws criminalize health care. We need discussion with the military about their rules of conduct for soldiers in the field – how they operate at checkpoints, how they search hospitals, etc. We have a tremendous opportunity now through the National Defense Authorization Act, which has a provision about how the United States should limit civilian casualties and encourage its allies to do the same. Something everyone can do right now is ask that this law be implemented.
Boivin: In 2011, ICRC launched a project called Health Care in Danger, which includes a community of interest and practice for those in the medical community. I would encourage you to go online and check out the practical resources generated by health professionals – resources that are applicable in conflict but also other emergency situations.
Evers: When we see a film like this, it’s easy to feel overwhelmed by the enormity of the challenge. I would encourage people to bring it down to an individual level – faces and names. We have information on the CHR website; Amnesty International and Physicians for Human Rights also have stories about individuals who are suffering as a result of these conflicts. There are many ways you can support these individuals, as well as their families.
About The New Barbarianism The film is a collaboration between the CSIS Global Health Policy Center and the CSIS Ideas Lab. Executive Producer/Director: J. Stephen Morrison (Senior Vice President & Director, CSIS Global Health Policy Center) Director/Writer: Justin Kenny (Small Footprint Films) Editor/Graphics: Paul Franz (Andreas C. Dracopoulos Chair, Innovation and Creativity, Director of Technology, Ideas Lab) Narrator: Ross Huguet