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UN inaction emboldens attacks on health care

By Lauren Vogel | CMAJ | Oct. 4, 2016

Burnt-out corridors, collapsed roofs and twisted metal are all that remain of many buildings at the trauma centre in Kunduz, northern Afghanistan. (Andrew Quilty/MSF)

One year after the United States bombed a hospital in Kunduz, Afghanistan run by the humanitarian group Médecins sans Frontières (MSF), targeted attacks on health care workers and facilities have escalated around the world.

The events in Kunduz were a shock and a turning point in violence against medical humanitarians, said MSF Canada Executive Director Stephen Cornish at a commemoration in Toronto. During 20 such events worldwide hosted Oct. 3, MSF urged United Nations members to hold perpetrators to account.

“What we’re seeing now is many attacks are going unclaimed, unacknowledged and even some members of the international community have been filmed having some chuckles over recent hospital attacks,” he said. “What we’re seeing is a pattern of disrespect, of targeting in some cases and in others, not paying full attention to the rules of war.”

 A sudden strike

Kunduz was unusually quiet on Oct. 3, 2015. The fighting between government forces and the Taliban had paused for the first time in days. Suddenly, an American warplane fired multiple missile strikes on the hospital’s intensive care unit and surgical suites. Forty-two people were killed, including 14 MSF staff.

“Patients were burned alive in their beds and people who rushed to assist the injured were caught up in the firestorm when the plane returned to bomb again,” said MSF Canada President Dr. Heather Culbert. Those who tried to flee were strafed with gunfire, she added. “It took weeks to identify all the victims because they were so badly burned.”

Culbert said the official explanation for the attack left MSF with more questions than answers. “We were told that the hospital was bombed because there were Taliban militants in the hospital compound. Then we were told that Afghan ground troops were taking fire from the hospital. Then we were told that the intended target was not the hospital, but nearby Taliban insurgents.”

An internal investigation by the United States military finally attributed the attack to human error and equipment failure. Despite a global outcry, there was no independent investigation.

MSF doesn’t accept this outcome, said Cornish. “Unless there are lessons learned, unless there are ways to guarantee this won’t happen again, then it might.”



Vancouver orthopedic surgeon Dr. Edgar Escalante volunteered at the MSF trauma centre in Kunduz three months before the United States military bombed the hospital. He shared his experience of the tragedy in an interview with CMAJ. (Photo courtesy of Dr. Escalante)



“We had people from all corners of the world. The best moments were seeing the international and national doctors working as a team. Even though there were language barriers, we had the universal language of trying to help.” (Photo credit: Victor J. Blue/MSF)



“We worked 24/7 with the very severely wounded. At the beginning, it was women and children because they step on mines, so we had to deal with a lot of amputated limbs. But after some time we started receiving not only [patients with wounds from] bomb blasts and mine blasts, but also a lot of high-velocity projectiles.” (Photo credit: Victor J. Blue/MSF)



“There were a lot of government troops coming from Kabul and in the week after I left they entered the hospital trying to find some people from the Taliban. You could feel it in the environment … you could tell something was coming.” (Photo credit: Dan Sermand/MSF)



“When I first heard the news, I got angry. For probably several hours I was really angry about what happened. And then I was sad and I couldn’t stop crying because most of the people working that night were my team. I was working with them and then suddenly they were no more.” (Photo credit: Andrew Quilty/MSF)



“Kunduz area is so isolated … We were the only hope for these people, so if we’re not there, nobody is there.” (Photo of hospital staff one month before the attack, courtesy of MSF)

Increasing violence

The hospital remains closed, leaving thousands of people in the region with limited health care. Meanwhile, warring parties emboldened by UN inaction have increasingly targeted health care workers in other conflicts, said Cornish.

Last year, MSF-supported health facilities in Syria were attacked in 63 separate events. This year, 43 hospital structures were attacked in July alone.

“These are no longer accidents or collateral damage,” Cornish explained. “Over the last week, we’ve seen almost the extinguishing of hospitals in Aleppo, with the remaining four hospitals having been directly targeted.”

The few doctors still alive in the city say their hospitals are “turning into morgues,” he said. “They have vowed to continue caring for their neighbors … no matter what the end.”

The trust that hospitals are safe spaces is rapidly eroding in many countries. Cornish told stories about families whisking away patients who have had surgery “only hours out of the operating theater because they’re too afraid that the structure might come under attack.” Communities are refusing to allow MSF to build hospitals or clinics “because they fear it will bring unwanted attention,” he said.

The United Kingdom, US, Russia and other members of the UN Security council, who are tasked with upholding international humanitarian law, have been complicit in the attacks on health care, either directly or through coalitions they support, said Cornish.

According to Stéphane Michaud, emergencies and recovery director for the Canadian Red Cross, these attacks will continue “until there is a political solution.”

“We collectively have to say something and hold our governments accountable so they can bring accountability to those who are breaking international humanitarian law on a regular basis,” he said.

Cornish made a case for lobbying local elected representatives, as well as top brass. Because of public outcry over attacks on health facilities in Yemen, 50 members of the US Senate called on congress last week to investigate weapons sales to Saudi Arabia, and a similar motion is before the UK parliament. “Silence and inaction are simply not options,” he said.

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