BMJ 2014;348:g83 doi: 10.1136/bmj.g83 (Published 9 January 2014)
Page 1 of 2
Observations
OBSERVATIONS HUMANITARIAN AID
The sideline or frontline: where should the UK medical profession stand in times of armed conflict overseas? Doctors can no longer afford to be apathetic in the face of violations against other doctors Faheem Ahmed medical student, King’s College London at Guy’s, King’s and St Thomas’ Medical School Only days before his proposed release date the British orthopaedic surgeon Abbas Khan was found dead in a government prison in Damascus. Arrested soon after his arrival in Syria, Khan had planned to stay for two weeks in support of the humanitarian relief effort. Instead, he was detained for over a year and was starved, subjected to physical abuse, and tortured.1 He was the second British doctor reported to have been killed in Syria last year, after the death of Isa Abdurrahman in June.2 These two men had a selfless desire to uphold their oath as doctors: “consecrating their lives to the service of humanity.”3 British doctors have often found themselves, intentionally and unintentionally, in the middle of wars in other countries. This leaves our medical community with two important options: we should either discourage doctors from putting their lives in danger or provide them with more protection and support.
There is a third, simpler option: indifference, for which most healthcare professionals have opted. However, when it becomes a military strategy to indiscriminately attack medical staff and services, perhaps it is time for us to reassess our position.4 A recent World Health Organization (WHO) report said that more than half of all public hospitals in Syria had been destroyed or were only partly functioning.5 One of the most alarming tactics the regime uses is the deliberate targeting of hospital staff, resulting in an unbearable strain on Syria’s healthcare system. At least 70% of health workers have been forced to flee regions affected by the war, making a dire situation worse for the exponentially rising number of casualties.6 The relentless assaults, torture, and imprisonment of healthcare professionals and their families are in direct contravention of international law.7
In accordance with the Geneva Conventions, governments have a duty not just to prevent armed forces from impeding physicians who provide care but also to protect them during conflict.8 The World Medical Association further states that these doctors have a right to treat their patients and must “never be prosecuted or punished” for doing so.9 But in the Syrian conflict the inclusion of hospitals in the battleground has resulted in severely wounded
civilians avoiding healthcare facilities.10 Patients rely heavily on underground makeshift clinics mostly funded by charities and external organisations, such as Human Aid and Hand in Hand for Syria, for which, respectively, Khan and Abdurrahman volunteered. More disturbingly, Amnesty International has reported incidents of doctors complicit in the abuse of patients and prisoners, out of pressure from the Syrian government or loyalty to it.10 Not only medical but also pharmaceutical facilities have been targeted, which has led to a dramatic decline in drug production.11 Low rates of vaccination coverage have already prompted the fear of a widespread outbreak of polio, with 17 reported cases so far and many more likely this winter owing to poor levels of hygiene and sanitation.12 However, political issues have prevented aid, including vaccines supplied by outside agencies such as Unicef, from reaching the most vulnerable regions.13 The Syrian government has criminalised the provision of medical support to rebel held areas; like Khan, many relief workers have been imprisoned for doing so. The United Nations has strongly condemned such actions, although calls to bring a stop to these war crimes have largely gone unanswered. As a public health crisis looms over Syria, neighbouring states have already begun to take precautionary measures, with major vaccination campaigns under way in Jordan, Egypt, Turkey, Iraq, and Lebanon.14
Modern day conflicts have distorted the principle of medical neutrality. Despite WHO’s efforts to restore the sanctity of hospitals in 2009, attacks on healthcare staff and facilities are now seen as a political endpoint, with devastating social consequences.15 The decline in respect for the medical profession is widespread: the number of assaults reported in the NHS is rising.16 Doctors can no longer afford to be apathetic while violations continue against our colleagues, whom we swore to acknowledge as “brothers and sisters.”3 Doctors should not have to fear for their own lives as a result of saving the lives of others, nor should they be forced into situations that may contradict the core principles of medical ethics.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2014;348:g83 doi: 10.1136/bmj.g83 (Published 9 January 2014)
Page 2 of 2
OBSERVATIONS
The influence of the British medical community should not be underestimated. We have seen its effects recently in other conflicts in the Arab spring, such as in the release of imprisoned British doctors in Bahrain.17 We should harness this pressure to support humanitarian corridors in Syria in honour of our fallen colleagues, ensuring that Khan and Abdurrahman’s sacrifices were not in vain. Competing interests: None declared. Provenance and peer review: Not commissioned, not peer reviewed.
7 8 9 10 11 12 13
1 2 3 4 5 6
Arie S. Investigate death of British doctor in Syria, say campaigners. BMJ 2013;347:f7647. Ahmed F. Doctors in Syria: saving the lifesavers. Lancet 2013;382:1619. World Medical Association. 2013. WMA Declaration of Geneva. www.wma.net/en/ 30publications/10policies/g1. UN Office of the High Commissioner for Human Rights. 2013. Independent international commission of inquiry on the Syrian Arab Republic. www.ohchr.org/EN/HRBodies/HRC/ IICISyria/Pages/IndependentInternationalCommission.aspx. World Health Organization. Donor update: the Syrian Arab Republic. 9 Apr 2013. www. who.int/hac/donorinfo/syrian_arab_republic_donorupdate9april2013.pdf. Physicians for Human Rights. A dual assault on Syrian civilians: unlawful attacks on medical care. http://physiciansforhumanrights.org/blog/a-dual-assault-on-syrian-civiliansunlawful-attacks-on-medical-care.html.
For personal use only: See rights and reprints http://www.bmj.com/permissions
14 15 16 17
International Committee of the Red Cross. Convention (IV) relative to the protection of civilian persons in time of war. 12 Aug 1949. www.icrc.org/ihl.nsf/ 385ec082b509e76c41256739003e636d/6756482d86146898c125641e004aa3c5. International Committee of the Red Cross. Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I). 8 June 1977. www.icrc.org/ihl/INTRO/470. World Medical Association. WMA Regulations in Times of Armed Conflict. www.wma.net/ en/30publications/10policies/a20. Amnesty International. Climate of fear in Syria’s hospitals as patients and medics targeted. https://www.amnesty.org/en/news-and-updates/report/climate-fear-syrias-hospitals-patientsand-medics-targeted-2011-10-25. Pitts-Tucker T. Healthcare in Syria is close to collapse as drug shortages bite. BMJ 2012;345:e5410. Committee for Disease Control. 2013. Polio in Syria. http://wwwnc.cdc.gov/travel/notices/ alert/polio-syria. Médecins Sans Frontières. Syria: urgent need for cross-border aid for Syrians. www. doctorswithoutborders.org/press/release.cfm?id=7229&cat=press-release. World Health Organization. 2013. Syrian Arab Republic: put polio risk above all other interests. www.who.int/features/2013/syria-polio-vaccination/en. Dobri CS. World Health Day 2009: Save lives: Make hospitals safe in emergencies.Vojnosanitetski pregled 2009;66:63-263. NHS Protect. 2011-12 figures released for physical assaults against NHS staff. www. nhsbsa.nhs.uk/3784.aspx. Godlee F. Support Bahrain’s imprisoned doctors. BMJ 2001;343:d6417.
Cite this as: BMJ 2014;348:g83 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Observations
OBSERVATIONS HUMANITARIAN AID
The sideline or frontline: where should the UK medical profession stand in times of armed conflict overseas? Doctors can no longer afford to be apathetic in the face of violations against other doctors Faheem Ahmed medical student, King’s College London at Guy’s, King’s and St Thomas’ Medical School Only days before his proposed release date the British orthopaedic surgeon Abbas Khan was found dead in a government prison in Damascus. Arrested soon after his arrival in Syria, Khan had planned to stay for two weeks in support of the humanitarian relief effort. Instead, he was detained for over a year and was starved, subjected to physical abuse, and tortured.1 He was the second British doctor reported to have been killed in Syria last year, after the death of Isa Abdurrahman in June.2 These two men had a selfless desire to uphold their oath as doctors: “consecrating their lives to the service of humanity.”3 British doctors have often found themselves, intentionally and unintentionally, in the middle of wars in other countries. This leaves our medical community with two important options: we should either discourage doctors from putting their lives in danger or provide them with more protection and support.
There is a third, simpler option: indifference, for which most healthcare professionals have opted. However, when it becomes a military strategy to indiscriminately attack medical staff and services, perhaps it is time for us to reassess our position.4 A recent World Health Organization (WHO) report said that more than half of all public hospitals in Syria had been destroyed or were only partly functioning.5 One of the most alarming tactics the regime uses is the deliberate targeting of hospital staff, resulting in an unbearable strain on Syria’s healthcare system. At least 70% of health workers have been forced to flee regions affected by the war, making a dire situation worse for the exponentially rising number of casualties.6 The relentless assaults, torture, and imprisonment of healthcare professionals and their families are in direct contravention of international law.7
In accordance with the Geneva Conventions, governments have a duty not just to prevent armed forces from impeding physicians who provide care but also to protect them during conflict.8 The World Medical Association further states that these doctors have a right to treat their patients and must “never be prosecuted or punished” for doing so.9 But in the Syrian conflict the inclusion of hospitals in the battleground has resulted in severely wounded
civilians avoiding healthcare facilities.10 Patients rely heavily on underground makeshift clinics mostly funded by charities and external organisations, such as Human Aid and Hand in Hand for Syria, for which, respectively, Khan and Abdurrahman volunteered. More disturbingly, Amnesty International has reported incidents of doctors complicit in the abuse of patients and prisoners, out of pressure from the Syrian government or loyalty to it.10 Not only medical but also pharmaceutical facilities have been targeted, which has led to a dramatic decline in drug production.11 Low rates of vaccination coverage have already prompted the fear of a widespread outbreak of polio, with 17 reported cases so far and many more likely this winter owing to poor levels of hygiene and sanitation.12 However, political issues have prevented aid, including vaccines supplied by outside agencies such as Unicef, from reaching the most vulnerable regions.13 The Syrian government has criminalised the provision of medical support to rebel held areas; like Khan, many relief workers have been imprisoned for doing so. The United Nations has strongly condemned such actions, although calls to bring a stop to these war crimes have largely gone unanswered. As a public health crisis looms over Syria, neighbouring states have already begun to take precautionary measures, with major vaccination campaigns under way in Jordan, Egypt, Turkey, Iraq, and Lebanon.14
Modern day conflicts have distorted the principle of medical neutrality. Despite WHO’s efforts to restore the sanctity of hospitals in 2009, attacks on healthcare staff and facilities are now seen as a political endpoint, with devastating social consequences.15 The decline in respect for the medical profession is widespread: the number of assaults reported in the NHS is rising.16 Doctors can no longer afford to be apathetic while violations continue against our colleagues, whom we swore to acknowledge as “brothers and sisters.”3 Doctors should not have to fear for their own lives as a result of saving the lives of others, nor should they be forced into situations that may contradict the core principles of medical ethics.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g83 doi: 10.1136/bmj.g83 (Published 9 January 2014)
Page 2 of 2
OBSERVATIONS
The influence of the British medical community should not be underestimated. We have seen its effects recently in other conflicts in the Arab spring, such as in the release of imprisoned British doctors in Bahrain.17 We should harness this pressure to support humanitarian corridors in Syria in honour of our fallen colleagues, ensuring that Khan and Abdurrahman’s sacrifices were not in vain. Competing interests: None declared. Provenance and peer review: Not commissioned, not peer reviewed.
7 8 9 10 11 12 13
1 2 3 4 5 6
Arie S. Investigate death of British doctor in Syria, say campaigners. BMJ 2013;347:f7647. Ahmed F. Doctors in Syria: saving the lifesavers. Lancet 2013;382:1619. World Medical Association. 2013. WMA Declaration of Geneva. www.wma.net/en/ 30publications/10policies/g1. UN Office of the High Commissioner for Human Rights. 2013. Independent international commission of inquiry on the Syrian Arab Republic. www.ohchr.org/EN/HRBodies/HRC/ IICISyria/Pages/IndependentInternationalCommission.aspx. World Health Organization. Donor update: the Syrian Arab Republic. 9 Apr 2013. www. who.int/hac/donorinfo/syrian_arab_republic_donorupdate9april2013.pdf. Physicians for Human Rights. A dual assault on Syrian civilians: unlawful attacks on medical care. http://physiciansforhumanrights.org/blog/a-dual-assault-on-syrian-civiliansunlawful-attacks-on-medical-care.html.
For personal use only: See rights and reprints http://www.bmj.com/permissions
14 15 16 17
International Committee of the Red Cross. Convention (IV) relative to the protection of civilian persons in time of war. 12 Aug 1949. www.icrc.org/ihl.nsf/ 385ec082b509e76c41256739003e636d/6756482d86146898c125641e004aa3c5. International Committee of the Red Cross. Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I). 8 June 1977. www.icrc.org/ihl/INTRO/470. World Medical Association. WMA Regulations in Times of Armed Conflict. www.wma.net/ en/30publications/10policies/a20. Amnesty International. Climate of fear in Syria’s hospitals as patients and medics targeted. https://www.amnesty.org/en/news-and-updates/report/climate-fear-syrias-hospitals-patientsand-medics-targeted-2011-10-25. Pitts-Tucker T. Healthcare in Syria is close to collapse as drug shortages bite. BMJ 2012;345:e5410. Committee for Disease Control. 2013. Polio in Syria. http://wwwnc.cdc.gov/travel/notices/ alert/polio-syria. Médecins Sans Frontières. Syria: urgent need for cross-border aid for Syrians. www. doctorswithoutborders.org/press/release.cfm?id=7229&cat=press-release. World Health Organization. 2013. Syrian Arab Republic: put polio risk above all other interests. www.who.int/features/2013/syria-polio-vaccination/en. Dobri CS. World Health Day 2009: Save lives: Make hospitals safe in emergencies.Vojnosanitetski pregled 2009;66:63-263. NHS Protect. 2011-12 figures released for physical assaults against NHS staff. www. nhsbsa.nhs.uk/3784.aspx. Godlee F. Support Bahrain’s imprisoned doctors. BMJ 2001;343:d6417.
Cite this as: BMJ 2014;348:g83 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
