Wars without limits will lead to battlefields without doctors 

This week Doctors Without Borders (MSF) remembered one of the darkest moments in our 45 year history. On 3 October 2015, U.S. airstrikes killed 42 people and destroyed the MSF trauma hospital in Kunduz, Afghanistan. As we grieve the loss of our colleagues and patients, we are left with the question: is it still possible to safely provide medical care on the frontline? In the past year, there have been a further 77 attacks on medical facilities run and supported by MSF in Syria and Yemen. Hospitals are being continually dragged onto the battlefield, and patients and their doctors and nurses are sacrificed in the process. 

Burnt building of the MSF Trauma Centre in Kunduz, northern Afghanistan, following the 03 October U.S. airstrike on the facility. Photo: Andrew Quilty. 

No one knows this more acutely than Jonine Lotter, a South African operating theatre nurse, who survived the attack on the Kunduz Trauma Centre (KTC). This week Jonine and our colleagues in Johannesburg spoke out about impunity and alarming regularity of these deadly attacks on health facilities in Syria and Yemen that led to UN Security Council Resolution 2286 being passed in May 2016. 

The resolution strongly condemns attacks on medical facilities and demands that all parties to armed conflict comply fully with their obligations under international law. Yet, five months later the hypocrisy of States and governments is very clear – particularly those involved in the wars in Syria and Yemen. On one hand States sign a resolution to protect health facilities, while on the other they continue to be directly involved or complicit in the ongoing onslaught against health workers and patients in conflict zones. 

With every attack on a health facility the chasm widens between the rhetoric from governments about their respect for International Humanitarian Law, and the way they wage wars in reality. No government has ever said it intentionally bombs hospitals, but hospitals are bombed nonetheless. More often than not, these attacks occur under the umbrella of the ever-expanding ‘war on terror’ – a label used with increasing frequency including today by all military coalitions in Syria. Attacks are either dismissed as tragic ‘mistakes’ – as the U.S. did with the Kunduz attack – or they are denied outright, or become political footballs as States desperately point fingers at each other. 

There have been no impartial investigations carried out by an independent international body into any of the attacks on hospitals that have occurred over the past year. This simply because there is zero political will among governments to have their military conduct examined by anyone but themselves. In the case of Kunduz, the U.S. carried out an internal military investigation and made a heavily redacted report available to the public in April. It is more than we have received from any other military force that has been involved in bombing an MSF facility. 

The investigation undertaken by the U.S. painted a deeply worrying picture. The ground troops in Kunduz falsely assumed that “all civilians had fled and only Taliban fighters remained in the city”. They made no effort to find out whether this was actually true and did not take the necessary precautions to avoid civilian casualties. The entire city of Kunduz was deemed hostile. While invoking ‘self-defence’ rules, U.S. forces in Kunduz were opening fire pre-emptively in a ‘shoot first, ask questions later’ military operation. No one in the chain of command consulted the existing no-strike list in the hours leading up to the attack. The report determines that our hospital was misidentified. This led to 211 artillery shells from an AC-130 plane being unleashed on our hospital. 

MSF continues to engage with the highest levels of U.S. and Afghan governments to gain assurances that this will not happen again.

The responsibility for the protection of hospitals – in whichever conflict they operate – does not lie with us moving healthcare away from the battlefield. At the core of the law of war is the responsibility that militaries have to distinguish legitimate targets from protected civilian sites. If there is no distinction made between a civilian and a combatant, then everyone becomes a potential target. 

As Jonine explains:  “Our objective was to treat all people with trauma, injuries and wounds – regardless of who they were. To us it did not matter if you were a civilian or an injured fighter – what mattered was that we save lives and limbs. No what side of the war you were fighting. No matter whether you were an adult or a child, a man or a woman. Our medical team only see a patient that needs medical treatment.” 

For more than 40 years MSF has negotiated the protection of its medical facilities in conflicts around the world. Our work in convincing warring parties to respect health facilities will continue. However, in the wake of these attacks in Afghanistan, Yemen and Syria we are left wondering: does adhering to medical ethics and treating everyone who needs health care, including the wounded, transform our hospitals into ‘enemy bases’? 

We cannot accept that we might be targeted for treating the wounded enemy. We will take our message to those with the fire-power in all of the places where we work. We will continue to demand of the most powerful and their allies that they turn their rhetoric into reality. And we will denounce those who seek to erode the laws of war.
A war without limits leads to a battlefield without doctors. We will not sit silently by and let this happen

Afghanistan, Yemen and Syria might be far away from South Africa, but as Jonine points out: “I’ve seen that people are the same all over. All over the world patients have the same need for medical care that doesn’t take sides. We need South Africans to stand with us and send a clear message to governments, militaries and armed opposition groups during conflict: Stop these attacks – medical facilities, patients and health workers are not targets.” 

Dan Sermand, the interim general director for MSF Southern Africa was in Kunduz immediately after the attack to assess the extent of the damage and was leading the crisis team on the ground.

Find out more about MSF's work in Afghanistan.