Attacks on Health in Armed Conflict

 The latest annual report from the Safeguarding Health in Conflict Coalition identified more than 2,500 incidents of violence against, or obstruction of, health care in conflicts during 2023. 

Those incidents, which span from Myanmar to Mali, include attacks on health care workers and facilities, the use of drones to target hospitals and ambulances, and the occupation of hospitals to conduct military operations. And many attacks are carried out with impunity. 

Joining the show to unpack patterns of attacks on health care in armed conflicts is an expert team from the nonprofit organization Physicians for Human Rights (PHR) and their local partners. 

Dr. Houssam al-Nahhas is PHR’s Middle East and North Africa (MENA) researcher where he documents attacks on health care, including unlawful detention of health care workers, and advocates for access to health.  

Dr. Neema Rukunghu Nadine-Néné is a gynecologist at Panzi hospital in the eastern Democratic Republic of the Congo (DRC) and an expert trainer on the care of survivors of sexual violence for PHR and the Panzi Foundation.  

Uliana Poltavets is PHR’s Ukraine Emergency Response Coordinator where she focuses on documenting attacks on health care in Ukraine since the onset of Russia’s full-scale invasion of the country in February 2022. 

Dr. “B” Zemen is an Organizational Psychologist and board member of the Health Professionals Network for Tigray (HPN4Tigray).

Show Notes: 

• Dr. Houssam al-Nahhas (@h_alnahhas)
• Dr. Neema Rukunghu
• Uliana Poltavets
• Dr. "B" Zemen
• Paras Shah (@pshah518) 
• Uliana and Christian De Vos’ Just Security article “Russia’s Attacks on Ukraine’s Energy Infrastructure Imperil Healthcare Access” 
• Just Security’s International Humanitarian Law (IHL) coverage
• Just Security’s health coverage
• Just Security’s Civilian Harm coverage
• Just Security’s Gaza, Russia-Ukraine War, Syria, and Tigray coverage
• Music: “Broken” by David Bullard from Uppbeat: https://uppbeat.io/t/david-bullard/broken (License code: OSC7K3LCPSGXISVI)

Transcript

Paras Shah: On a Wednesday night in November 2022, surgeons at the Heart Institute in Kyiv were in the middle of an operation when the power went out. The backup generators kept live-saving equipment running as nurses held flashlights over the operating table. 

Russian attacks on Ukraine’s electrical grid and energy infrastructure, along with direct attacks on health care facilities and workers, are taking a massive toll on the country’s health care system. And Ukraine isn’t alone. The latest annual report from the Safeguarding Health in Conflict Coalition identified more than 2,500 incidents of violence against, or obstruction of, health care in conflicts during 2023, a 25 percent increase from 2022. 

Those incidents, which span from Myanmar to Mali, include violent attacks on health care workers and facilities, the use of drones to target hospitals and ambulances, and the occupation of hospitals to conduct military operations. At the same time, many attacks are carried out with impunity. 

How should the international community respond to these attacks? What can be done to prevent them and to promote accountability? 

This is the Just Security Podcast. I’m your host, Paras Shah. 

Joining the show to unpack patterns of attacks on health care in armed conflicts is an expert team from the nonprofit organization Physicians for Human Rights (PHR) and their local partners. PHR forensically documents human rights abuses, develops capacity in local communities, and advocates for justice around the world. 

Dr. Houssam al-Nahhas is PHR’s Middle East and North Africa (MENA) researcher where he documents attacks on health care, including unlawful detention of health care workers, and advocates for access to health.  

Dr. Neema Rukunghu Nadine-Néné is a gynecologist at Panzi hospital in the eastern Democratic Republic of the Congo (DRC) and an expert trainer on the care of survivors of sexual violence for PHR and the Panzi Foundation. 

Uliana Poltavets is PHR’s Ukraine Emergency Response Coordinator where she focuses on documenting attacks on health care in Ukraine since the onset of Russia’s full-scale invasion of the country in February 2022.  

Dr. “B” Zemen is an Organizational Psychologist and board member of the Health Professionals Network for Tigray (HPN4Tigray), a nonprofit, and non-partisan organization that is committed to improving access to health care. 

Hello, everyone. Welcome to the show. We're so excited to have you here. Attacks on health care appear to be at their highest levels. And Hussam, I wanted to get started by taking a step back and looking at some of the global trends that you all are tracking when it comes to attacks on health.

Dr. Houssam al-Nahhas: Thank you very much for having me here today. Unfortunately, numbers of attacks against healthcare are increasing. Actually, the safeguarding housing conflict Coalition, which is a coalition of a human rights and humanitarian organization, and PHR is part of this coalition, documented around 2500 attacks against health care and obstruction of health care in the last year. This is a 25% increase in numbers of attacks against healthcare and obstruction of healthcare compared to the year before, to 2022. The coalition documented around 500 attacks more than last year. Among these attacks, the coalition found that these attacks resulted in about 480 deaths among healthcare workers and included around 450 arrests and detention cases of health care providers and resulted in about 625 cases of damage and destruction within the healthcare facilities. These incidents of attacks against healthcare affected around 30 countries with the highest number reported in occupied Palestinian territories, Myanmar, Sudan and in Ukraine. The coalition also found that actually more than 50%, or half of these attacks, were perpetrated by state actors. And mainly the reason behind this, this massive increase in numbers of attacks against healthcare, is attributed to the surge in numbers of attacks against healthcare facilities in occupied Palestinian territory, and the WHO, through their surveillance system documented around 824 attacks against healthcare in the last year alone.

Paras: So, zooming in on a conflict that listeners may not have heard of, which is the Tigray conflict in Ethiopia. Be what have you been observing there?

Dr. “B” Zemen: Thank you. Just to start off with a little bit of background, Ethiopia is comprised of 12 regional states which each have their own regional governments in addition to the Ethiopian federal government; and Tigray, one of these regions, is Ethiopia’s northern most and Tigrayans are a minority group in Ethiopia. In November of 2020, tensions between the federal government and the regional government of Tigray escalated into armed conflict. Ethiopian forces along with soldiers from a country above Ethiopia called Eritrea, in addition to forces from the regional state below Tigray called Amhara, ended up invading to grow from multiple directions. The conflict led to widespread violence, including conflict related sexual violence, drone attacks, indiscriminate killings of civilians, as well as attacks on the healthcare system, health care and aid workers. Health centers were occupied by armed soldiers, used as military bases, as well as purposefully looted and destroyed. For nearly two years, the Tigray region was also placed under what the United Nations called a de facto humanitarian aid blockade, where little to no aid was allowed in and basic services including phone, internet, electricity and banking were shut down. In 2022, the World Health Organization reported only 3% of healthcare facilities in Tigray were fully functional. 

And unfortunately, despite the signing of a cessation of hostilities agreement between the Ethiopian and Tigray governments in November of 2022, the majority of health care facilities are still not fully functional, and over a third of the Tigray region remains occupied by invading forces committing ongoing human rights abuses. An estimated 600 to 800,000 civilians have died due to direct killings, starvation and lack of health care. And experts estimate up to 50% of women in Tigray experienced gender-based violence. Healthcare and aid workers were targeted as well. At least 34 aid workers were killed in Tigray alone, including three Doctors Without Borders staff members, and although the guns have largely been silenced in Tigray, over the past year armed conflict erupted in the Amhara region. So, the Amara forces that had been allied with the Ethiopian government forces in Tigray are now fighting against each other, and civilians are caught in the middle. Aid workers have been killed and healthcare infrastructure has been attacked in the Amhara region as well. In Tigray the health care system attacks damaged and looted diagnostic equipment as well as a continued shortage of basic medical supplies have resulted in many people, including the over 1 million people that remain internally displaced in the region, lacking basic medical services. 

Paras: Uliana, you are in Ukraine, what have you been seeing as the conflict has raged on for the last few years?

Uliana Poltavets: So, the scale of violence against healthcare since the start of the Russian full scale invasion in Ukraine as has been unmatched. In 2022 alone, attacks in Ukraine accounted for almost 40% of global attacks on health. And up until mid-April 2024, we at PHR together with our partners have documented almost 1,500 attacks on health in Ukraine since the start of the full scale invasion, or about two attacks per day on average. These include attacks on hospitals, clinics, ambulances, other infrastructure, and health care workers. It is important to say that this these are not just separate incidents, but a pattern of violence. We have analyzed these patterns, and we have reasonable basis to believe that Russian attacks on health in Ukraine constitute war crimes and potential crimes against humanity. 

Paras: And Neema, what are you observing in the eastern DRC, where there are many armed conflicts that are currently ongoing?

Dr. Neema Rukunghu: Thank you, what I can say about the attack of such in DRC. A study that was published earlier this year show that in 2022, we had around 159 attacks on health in DRC. And there was essentially based on the eastern half of the country on Goma, Baden and Gemena of this type, and  some in other small sites in the country. Among these that we did attack we had over 14 centers was completely burned. We had 43 centers completely destroyed, and they stole everything in the centers. Since the last year, we've had, for 2022 and 2023, we had 10 medical people killed, who were in our country where there was all these attacks.

Paras: As each of you know, across these conflicts, there are some trends that emerge, attacks on health care workers, attacks on facilities, and attacks by both government forces and non-state armed groups. But there are also trends that might be less seen or under covered, what are some of those?

Houssam: So basically, what we have seen in terms of documenting attacks on healthcare is the documentation of the attacks themselves and the damage they caused on the facility itself, the death toll, and the injuries among healthcare providers and patients. But less and less is what we see on the documentation of them, the medium and long term impact of these attacks on the health system and the right to health. For example, Physician for Human Rights, worked on documenting attacks on health care in Syria. And most recently, in the last few years, we started documenting how these attacks and the systematic targeting of health system impacted people's ability to access health care and impacted the availability of health services as well as the accessibility to these services. So, for example, in one of the reports that Physician for Human Rights published two years ago, we found that healthcare services were clustered in areas that are near the Turkish-Syrian border to avoid being targeted during the conflict, which means that people who live in remote areas or around the frontlines or near the frontlines were unable to access health care. 

We also found that, actually, the destruction of health facilities and the interruption in health services resulted in the elimination of these services and limited the availability of the services, given that when attacks on health care become consistent and continue, donors would refrain from investing in the health system to rebuild destroyed facilities and restore services, as well as healthcare providers will flee the country with the aim to protect themselves. So, these are some of the trends that we have seen in our documentation. And we see a little bit of a less attention to document these types of long term impacts on the health system and the right to health.

Uliana: So, there has been a lot of discussion of destruction. And we've all seen horrible pictures of damaged healthcare facilities, there are different calculation of how much it would cost to rebuild all of these hospitals in Ukraine. However, we've also been noticing patterns of non-physical violence in healthcare, particularly in the occupied territories in Ukraine. We documented a series of coercive measures targeting patients and health care personnel in Russian occupied territories to enforce civilian control. Some of these violations might constitute war crimes, demand investigation, and contribute to the overall atmosphere of fear in the occupied territories. We identified three primary methods. 

These include reports of misuse of health facilities for non-medical purposes, like repurposing civilian hospitals into military bases — which is a violation of international humanitarian law, and both endangers civilians and limits their access to health care. Another method that we saw is forced passportization, which is when people cannot access critical medical services and get medicines like insulin unless they obtain a Russian passport and change their nationality from Ukrainian to Russian. And finally, another coercive of method that we saw is threatening and harassing healthcare personnel, including detentions, arrests, torture and killings.

B: I can jump in on this question as well. So, overall the conflict in Tigray and now Amhara, as well as ongoing conflict in another region of Ethiopia called Oromia. All haven't received as much coverage or international attention as warranted for the Tigray war being one of the deadliest conflicts in the 21st century. A think tank called the New Alliance Institute recently came out with a report and legal analysis where experts found reasonable basis to believe that genocide has occurred in Tigray. So, a concerning trend is the lack of accountability for these gross violations of human rights, including attacks on health care workers and health facilities. At the end of 2023, the United Nations Independent Investigative Mechanism for Ethiopia was disbanded. So now a domestic transitional justice process is being pursued in Ethiopia despite there being a lack of transition, and also enabling the perpetrators to essentially become the judge. 

I feel these steps have emboldened the Ethiopian government to continue to operate with disregard for civilian life and international humanitarian law. Another issue that hasn't received much coverage is the severe mental health crisis in Tigray ,where there's reportedly only three psychiatrists in the region. Our partners on the ground in Tigray report that even healthcare workers themselves have experienced and continue to experience burnout, depression and vicarious trauma. During the siege on Tigray, health care workers were not paid their salaries, so, they worked for no pay in really dire conditions where they saw many patients died due to lack of medical supplies. And, all of this has been leading to brain drain as healthcare workers have to make the tough choice to either stay and not have enough resources to support their families, especially with inflation, or leave the region to pursue better opportunities. Although these aren't direct attacks, the conditions for health care workers in Tigray and other parts of Ethiopia are still really difficult to work in, especially in facilities, that you know, lack sufficient supplies for them to be able to do their jobs.

Paras: Yeah, very difficult circumstances in all of these contexts. Another aspect of these attacks are the impact that they have on women and girls, especially for services related to survivors of sexual and gender based violence, and what are you seeing in that context? 

Houssam: So, Physician for Human Rights worked on documenting as I mentioned earlier, the impact of violence against health care on the availability of and accessibility to health services, with a specific focus on sexual and reproductive health. And we published a report last year, titled As She Pays the Highest Price, and we actually found that women and girls were among vulnerable populations who were left behind in medical planning when trying to rebuild the health system in areas affected by the systematic and deliberate targeting of health infrastructure. We found that actually, when, attacks against healthcare become part of a war strategy, people and more specifically women and girls, will be unable to access health care or refrain from seeking health care to protect themselves and avoid being present in a facility that will be targeted, putting themselves, their kids, their spouses at danger. 

We've talked to health care providers who described how dire the situation is for pregnant people in Syria, and they describe how they would attend a baby delivery where the mom is experiencing or suffering from severe anemia, unmonitored anemia, because she did not want to visit a healthcare facility to monitor her pregnancy, due to the fear of being targeted when in a healthcare facility. We also found that there was a shift in the health seeking behavior among this specific population with a with a preference toward undergoing C sections, cesarean sections, instead of vaginal delivery, because this, according to health care providers and community members we interviewed, give us more certainty to both the mother as well as the healthcare provider, knowing that it's a scheduled procedure that can be done in in a short period of time, the recovery period is shorter than going into a vaginal delivery, and the labor that can extend to several hours, putting the mother as risk of being in a facility when it's targeted. And that was connected, statistically with military campaigns, where there was a surge in numbers of attacks against healthcare that accompanied a surge in the rate of C-sections or in hospital C-sections versus vaginal delivery. So, these are some of the gendered impacts of attacks on health care. 

And of course, as I mentioned earlier, there is this issue around the limited availability of specific services like tertiary care for more complicated medical issues, including cancer treatment, especially for types of cancers and malignancies that impact women. So, all these types of challenges — we found that actually — they are impacting the ability for women and kids more specifically to access the services they need during conflict, and specifically when attacks on healthcare become part of this wider war strategy and war tactics.

Uliana: I think that there are a lot of similarities between context, a lot of things that Houssam mentioned, and particularly because there is a perpetrator in Syria and Ukraine. But, I also wanted to say that in Ukraine, we know that the prosecutor general's office of Ukraine is interested in looking at the Russian invasion as bearing indication of genocidal violence, and we need to look at attacks on health in this context as well. And in our database, only, there were about 80 attacks that affected child health care, and at least about 80 attacks that affected maternal health care. For example, clinics, like IVF clinics, you know, that have been damaged. And attacks like this can have an effect on the survival of the group. And when we're looking at the Genocide Convention in relation to these attacks, it could be interesting to look at these attacks in the context of preventing birth. So, I think that this is something that international lawyers could be interested to look at. 

B: I can jump in as well. Conflict-related sexual violence and gender based violence was widespread in Tigray, and was also very systematic, with an estimated 200,000 survivors — and that's probably on the low end, since we know many of them do not come forward. And it’s also perpetrated in extreme forms, organizations like Physicians for Human Rights as well as the UN have detailed these attacks and their investigations. And conditions were inflicted upon women to prevent birth, and women and girls were also purposely infected with HIV. Many survivors still have not received health care or mental health support to this day, especially those living in occupied regions and internally displaced people, one of the regions including the Irob region, where the Irob people, who are a minority within a minority in Tigray, have really faced a lot of conflict-related sexual violence and have been unable to seek treatment. Survivors in some cases have to walk up to 12 hours just to get even basic treatment. There's also a huge concern regarding potential HIV crisis, as many facilities can't even do basic diagnostics and testing, let alone provide medication and treatment, and the follow up that's needed. Conflict-related sexual violence survivors have had to give birth to children that were a product of the violence. 

And there are also, as I mentioned, many survivors that are both internally displaced and starving due to lack of sufficient aid even in the present moment. It's hard to put in words just really how dire the conditions are for survivors of sexual and gender based violence due to there being so many and not enough resources to provide them with the care they need and just the level of brutality that was inflicted upon them. Overall, in Tigray, the mortality rate of mothers giving birth is estimated to be five times the prewar rate, as many women lack any form of obstetric care. UN High Commissioner for Human Rights also reported on incidents of sexual violence in the Amhara, and Oromia regions as well. So, very much a widespread issue, you know, not just in the Tigray region, and survivors, including internally displaced people, have difficulty accessing the resources that they need to heal.

Neema: The access to the healthcare was very, very limited and sometimes impossible for women, for girls, and for children essentially. And what we can say also is that we have a high number of deaths, that was really increased, especially in women giving birth when they wanted to give and in small children less than five years. There was an increase of the number of deaths in all those areas. And also when you see the attack of a health structure, the consequence is that the population also there with a displacement of the population, because the health structure most of the time is the structure that is the single structure that's most of the time in wartime, where we have conflict, this is the thing that seemed to be respected. That is the thing that sometimes stay there, it was it was not attack, and then when it is attacked, that means that then very terrible and the population they just displace an they need to displace. This is one another consequence that population is displaced. And we see also a huge number of vaginal deliveries, essentially at home — in the homes or in the roads or in the bushes without sometimes any assistance. 

And that means a huge also number of fistulas that are increased after the attacks. there is also another thing that we have had about after those attacks of structure, that's also much of the time with the attack of structure. And if they will, they kill people, medical personnel. So, now that means that when the displacement will be, there will be a long time before the population can be again there, can be back to try to rebuild something. This is another thing that we have about noticed, as a consequence of the effects of health structures. I think this is what I can say about the situation. 

Paras: So you've all provided a very helpful overview of these trends and the really devastating impacts that we're seeing with attacks on health care. I want to turn to the relevant legal framework, which is international humanitarian law, the law that governs armed conflict, and it has very strict protections for medical personnel and facilities like hospitals. They are protected, they must be respected, they can't be the objects of attacks. And yet in many instances around the world, we've seen both governments and non-state armed groups violate these rules. How can the international community better protect the system of rules and the norms that are existing and that should be enforced?

Houssam: I can jump in first. So in terms of ending impunity, and the international community's response to this issue of attacks on healthcare. I think we need to first remember that actually, as I mentioned earlier, around half of the attacks against healthcare were perpetrated by state actors, meaning governments are involved in these types of attacks. As I said earlier, for example, in Syria, attacks on healthcare were perpetrated in more than 90% of the time by the Syrian government and Russian government. So, meaning that actually there might be a lack of political will to protect health care, or prosecute attacks on health care or end impunity for attacks on health care. But this is this is a must, unless we see actual persecution for perpetrators of attacks on healthcare on a global level, I don't think it's possible to end this increasing trends of attacks against healthcare, healthcare facilities, and healthcare services. So, when it comes to how this can be done, as I said earlier, ending impunity is one of the top priorities and this falls on the ICC, governments in general, the UN Security Council, the Secretary General of the United Nations, as well as individual countries utilizing the universal jurisdiction abilities. 

There's also of course, enhancing and strengthening prevention. And this is also something that falls on states, as well as militaries, and armies. When we talk about states responsibilities, of course, arms embargo and arms trades is one of the ways that can be used to put more pressure on armies or parties involved in in armed conflict to stop attacks on health care and ensure compliance with IHL and the international human rights law. On the military's level, there should be more education, more enforcement for policies that ensure protection of health care in conflict, and compliance with IHL and HRL. We still lack an actual leadership that would actually push the agenda of protection of health care in conflict. And currently, we see a limited role for the WHO for example, to protect health care in conflict. the WHO, the World Health Organization, collects data and documents attacks on healthcare, but this data has never been used for accountability purposes and was never used for prosecuting perpetrators of attacks against healthcare. There is a need for an actual leader to lead this initiative of protecting health in conflict. And of course, there's also the diplomatic way of engaging with those who perpetrate attacks on health care in general, as well as naming and shaming. 

Simply, sometimes this is an effective way to actually highlight countries and governments and armed actors and non-state actors who are involved in attacking healthcare and are targeting health infrastructure and violating the right to health. These all are different types in which we can actually move forward with an agenda that actually protect healthcare in conflict.

Uliana: I can add to that. Though, we welcomed the recent arrest warrants put out by the International Criminal Court against the two Russian commanders for alleged war crimes and crimes against humanity during the campaign of attacks on Ukraine's energy infrastructure. The arrest warrants noted that the alleged strikes were directed against civilian objects and that the expected incidental civil and civilian harm and damage would have been clearly excessive to the anticipated military advantage. And as much as we'd like a big case on attacks on health as a pattern, we realize that these are the routes that are taking right now. And we will try to help prosecutors at all levels internationally, locally, nationally, to assess how attacks on energy, for example, might have impacted access to health care. In Ukraine, blackouts attacks on energy do have an impact. 

Right now, we in Ukraine are in the midst of a horrible Russian campaign for attacks energy and blackouts due to Russian attacks. Where I live blackouts last 20 hours a day, and the energy system and healthcare system are so interdependent. When there's no electricity, hospitals have to run on power generators, which is very expensive, unsustainable and eliminates functionality of a hospital. In some cases, doctors are forced to perform surgeries in the dark. There could be no heating, when there's no electricity, patients could be seen with no heating. Culture and supply for medications could be at risk, it means that there could be a disruption of transit or storage of medication. Surgeries or medical procedures could be postponed because of these blackouts. So right now, we would like to tie these existing investigations with these attacks and put pressure on these mechanisms and tie them in the investigations for attacks on energy infrastructure, for example, and attacks on health and access to health care.

Neema: Look, I can think for the DRC conflict, we have some government attacks. The normal government, the army groups, that attack but we have our example, as I said, for 159, you had only, five were with government army group. The other was perceived by the report group. And this is a huge challenge, because we have a challenge in the local level, in the national level, but also in the international level. And we don't have any law since now, that has, that is really strong to help to put a stop to put an end on this phenomenon. But so this phenomenon now more and more is used as a strategy. Because beginning of the war, we can take 20 years before, yes, we have attacks against health structures. But it's also very few compared to today. The last five years, multiply by 10. So, what we can say, yes, you can educate it. All these are improved. Our national average, we can do this, but we don't have any impact on the rebel groups. And so, this can be only done in the international level, to say that we need to put, to have really to take concrete action, and to have some global, international neighbor, that really put the concrete action against all the groups or the army that can do the attack of our health centers. We need really to have concrete and strong decisive action to see what we can do, and to not only say that we are not okay with this. We are against this, because this is a political way to say that we don't agree, but we need to really to have also strong action that can help to discourage bad practice that is now increasing more and more. We don't have the lack of the political will yet. Because also in our centers, our army groups, after all that we call of further diplomatic way how they talk about one to another. In some time, they begin, they become in the place of the government, they have now the power. 

They don't just develop this will to continue to fight against this, or they can even say that we can do this, we can continue to follow these attacks, because now they are the one who have the power. And they are also the one who were perpetrators in the past times. That means they will not wish for this to come up. And then I think it's really a challenge, and maybe trying to reflect concretely. But I think the international law can try to be stronger on these topics, essentially. 

B: Just one thing to add, I think that others covered really well and echo a lot of the points made. But especially when it comes to attacks on the energy infrastructure, as I mentioned in Tigray, the region was under siege for nearly two years. So, for almost two years straight — including attacks on the electricity infrastructure — there was pretty much no electricity, no phone, no internet; some record as one of the longest internet blackouts in the world. All of that made it extremely, extremely difficult for people to be able to access health care. As Uliana mentioned, you know, when there's no electricity, the hospitals have to run on generators, because the region was under siege, there wasn't much gas as well, so it also made it difficult to run generators. In addition to that, there was a fleet of over 270 ambulances integrated at the beginning of the war, which really helped people from more rural areas access health care and come to larger health facilities. 

That was reduced down to 30 at the height of the war due to those ambulances being stolen. So, all of this and the lack of, as mentioned, accountability, a lot of this being perpetrated by both state and non-state actors and then being able to kind of continue to act with impunity just led to more and more emboldening of the perpetrators. Now you see a little, not to the same scale, but you see some of the same crimes that were being perpetrated in Tigray and in other regions of Ethiopia as well. 

Paras: Civil society organizations also have a really important role to play in documentation and advocacy work. And I'm wondering how states can best support the efforts of civil society organizations and of local partners? 

B: States and others can best support the efforts of civil society organizations and local partners by providing funding and resources, including for mental health and psychosocial support for both survivors and local data collectors, as well as training and capacity building and really just funding investigations. The UN investigators were never even allowed into Ethiopia during the Tigray conflict to do their work. So, they had to do all of it remotely. So many areas where human rights abuses occurred and continue to occur have yet to be physically investigated, so a lot of evidence is degrading. It's also important to provide funding for the humanitarian aid response and the rebuilding of the health care system. A combination of conflict and drought has led to really, really dire need in Ethiopia. 

Currently, the country needs $3.2 billion to meet the humanitarian needs of its civilians, and only 13% of that is funded. So, documentation and advocacy and investigation is important. But, when people are still dying due to lack of aid and lack of health care services, survivors of sexual violence still haven't, you know, received psychological and physical health care, it's critical not to lose sight of this and for states and individuals to continue to support and provide funding and resources for civil society and local partners who tend to do the bulk of the response. There was a recent UN interagency committee report on the humanitarian response in Tigray and how it was a complete system failure and how a lot of local partners had to step in and uncovered the gaps. That continues to be a pattern that we see now. So, it's really critical to support local civil society organizations. 

Houssam: Echoing what B said, I think it's important to remember that there is actually a UN Security Council resolution that aims toward protecting health care and conflict, which is resolution 2286. And 2286 is unique in its nature, given that it requests that governments and states investigate and prosecute attacks against healthcare. And what B said is very important. But there is also one additional component, when actually the state itself is the one that is attacking healthcare. And here there is a need for civil society organizations, nongovernmental organizations, as well as even UN agencies to be able to access these areas where attacks against healthcare are taking place to investigate independently these attacks, collect data transparently, and share it between agencies with justice and accountability mechanisms as well as with the public, again, to enforce this the end of impunity agenda. 

Of course, these organizations and civil society organizations and nongovernmental organizations will need support from different states, the states they are working in, as well as the international community to ensure that they are allowed to do their job in terms of collecting data, systematically developing their methods, sharing their data, and developing also security protocols to ensure that this data is being used for justice and accountability and not used to cause more harm on the health infrastructure in these areas and in these conflicts.

Neema: I can also jump in this question. This is really important role that civil society organizations are playing and should normally play because they are the one who can do the documentation and all the investigation, like free, without any influence of rebel or government. So, it should be really clean, they are free. And it seems really helps to support a concrete and a true investigation. That's why I think that all these civil societies are going to do organization they need the need the support not for the government, not for the rebel because they need to be really freed from that. But probably the support all the international organization with support from the UN for them, to really make the good documentation to really make a good recommendation, but also, they need to be protected. Because if they are not ensured of their own security in our different conflicts. Because it is difficult, they're also targeted, when they are doing all the documentation, doing all the investigation, normally by all those who are perpetrators. That means they don't want them to continue and to fulfill this. Another thing that will be helpful, be even taken as a a huge support for all the civilian societies and organizations, is that each person can come in when we are talking ending impunity. It's not only documenting, it's not only investigated, but it's also using this documentation, using all this data and litigate in the courts, and to help centers use because they can help to be really pedagogic. We can help to discourage all those who can do after during even thinking, during planning, during the other attacks. But even just for example, in DRC, we have had 20 years, we had more than 30 years since we had the first attack of the health centers. 

But we know nothing was done in the courts, we have documenting, we have all this civil society organization that met all the documentation, but nothing will be done. It can be really discouraged but also dangerous for all those civil society members. So, it's very important to have the resolution, its good, but also to apply concretely the resolution as to respond, to change this concrete thing. Because we have many notes, we have writing, we have every documentation. But concretely it is what is done on the ground.

Uliana: Just briefly, because others have talked about this a lot, and I agree with everything that's been said. I think the level of cooperation with civil society documenters in Ukraine is unprecedented. And some say it's the most documented war ever. But at the same time, there is a lot of miscoordination here, which is why a lot of crimes tend to be looked at in silence as these separate things. But when you start seeing patterns, and really go beyond this, one particular attack in this one particular community attack. Attacks on health are not incidental. They are part of Russia's war strategy in Ukraine, they have been part of their strategy in Syria. So it would be great if they would be investigated as such, and this is where I think civil society could be very helpful. Referencing the resolution that Houssam and others mentioned in the oversight that should provide. The resolution 2286, strongly condemning attacks on medical facilities and personnel in conflict situations, was helpful to at the time, but it would be good to have a stronger enforcement, perhaps there should be a new position like the one we have for sexual violence, Special Representative of the UN Secretary General on Health or Health and Conflict, who would be reporting on the implementation of the resolution to give some teeth to it. So, in addition to seeking verdicts for perpetrators and courts, we also should think of accountability as redress for victims. 

And in this sense, I think mechanisms like a register of damage that was recently launched, under the Council of Europe for Ukraine could be a good tool. We would like to take a look at it a bit closer, what damage means for attacks on health? Is it only damaged walls and it facility? Bricks and Mortar? Or is it also loss of skills for a doctor could not practice for two years because of the occupation of the region? Or is it damage to the environment of the community because of the debris from the destroyed hospital? Or is it diminished the mental health of patients? All of this needs to be thought out in the framework of the attacks on health and addressed. 

Paras: Thanks, it’s so important that the international community bolsters the efforts of civil society organizations and local partners. We’re halfway through 2024, and I wanted to wrap up by asking each of you what you'll be looking for in the second half of the year. What trends will you be watching?

B: I'm keeping an eye out for our progress on the implementation of the cessation of hostilities agreement that I mentioned, was signed between the Tigrayan and Ethiopian forces in November of 2022. It was supposed to include unfettered humanitarian aid access, withdrawal of invading forces, among other things, but not enough progress has been made. And I feel this has contributed to ongoing attacks on health care and lack of access to health care, not just in Tigray but across Ethiopia and other regions as well. I'm also keeping an eye out for a much needed ramp up in humanitarian response, as well as sufficient funding allocation for rebuilding civilian infrastructure, including the health care system in Tigray, Amhara and other regions. And I'm also tracking and hoping for an end to the ongoing conflicts in Amhara and Oromia regions where many human rights abuses and attacks on health care systems occur under internet and communications blackouts, making it really difficult to get a clearer picture of what's happening overall. 

I'm also hoping as well as tracking for a more credible justice and accountability process for Ethiopia. They recently have started implementing the domestic transitional justice process, but surveys in the past have indicated that many survivors do not support or trust this process. This is also a process which cannot hold Eritrean perpetrators accountable because that is another country. So, support from the international community is still very much needed here. So those are the things that I've been keeping an eye on and will continue to over the next few months and rested here.

Houssam: I can go next. On my side and from what PHR has been doing and as I mentioned earlier, the issue of attacks on health care has both the chronic impact as well as the acute impact, and at PHR we will continue to monitor both of them again. As I said earlier about the conflict in Syria and the issue of attacks on health care as well as health care providers, for example, we have hundreds if not thousands of health care providers who are still missing. 

At PHR, we will continue to monitor and advocate toward revealing the fate and whereabouts of those missing healthcare providers. Of course, we will continue to monitor attacks on healthcare more generally, document these attacks, and collect evidence that can be admissible to courts and support justice and accountability, understanding that these processes can take time — meaning that it's always frustrating to see how slow justice and accountability moves. But it's also important for us as a human rights organization to continue to collect our data systematically and make sure that we have this evidence whenever there is a political will to prosecute these types of attacks.
 
And of course, we will continue and even beyond this year, we will continue to study and enhance our understanding on how the systematic targeting of health infrastructure, healthcare facilities, and health care providers are impacting the right to health and the availability and accessibility to health services and conflict areas.

Neema: But for me, I think that for the next coming months, if nothing concrete is done, if no action is taken completely, I am very scared about the increase of those attacks of health centers. As soon as now they have more and more taken as a strategy to push populations to leave the places, to leave their villages, to leave their homes. The goal is to take the place of actual occupation, this is a good, I think I can tell you a good strategy that they are using. And if nothing is really done, and I am really scared that they'll be an increase of this. 

But I hope we'll get that as we are talking about this. We are trying now with all the documentation that people will continue to raise awareness and trying to talk about these specific topics. As we meet, many focus on the one the gender background aspects. I hope to read that before the end of the year or the month ahead that we could even have built the red line and then say what we can do completely to all those army groups or governmental armies that are doing attack again. And this can be something that can discourage and try to reduce the number of attacks.  

Uliana: Of course, we are eager to see some more attention paid to attacks on health, cases being opened, and actual accountability at the international level. Our own research takes us to the impact of attacks on energy, infrastructure, and access to health. We would like to evaluate what damage means in the framework of attacks on health so that victims could get access to reparations. But I would also like the international legal community to break new ground in thinking about things like genocide with attacks on health in mind and not to be afraid to explore this concept. We are also asked a lot about impacts of these conflicts on the populations health. With the attacks growing each year globally, it is very timely probably to have a comprehensive overview of global impact of conflict on health from many sources, or many countries with recent data, which is now available, thanks to a lot of monitoring.

Paras: Yeah, those are all very important steps and very important trends to keep an eye on. Is there anything that we haven't touched on or any parting words or messages that you'd like to convey to our listeners?

Houssam: I think what I would like to end with is a positive note, just realizing that even though we have seen, and we are continuously seeing, increases in numbers of attacks on health care, there is more and more awareness on an international level, even among global population around this issue and how illegal it is and its impact on people's health. I think this level of awareness that we are seeing right now is very important towards providing justice for these attacks and putting more and more pressure on warring parties, state actors, non-state actors to end this this trend of attacks on health care. 

On a different note, I think, even though we were talking about this lack of accountability and continuous impunity for attacks on health care, it's important for me to always remember as a health care provider who experienced attacks on health care firsthand as a survival of detention, and as someone who worked in a hospital that was targeted by the same government, to recognize the fact that actually just few weeks ago, PHR, with other partners, submitted a complaint against Russia for an attack on a healthcare facility. And Physician for Human Rights brought an independent expert report that actually showed the impact of these attacks, or this attack specifically and more broadly the Russia strategy in Syria, on attacks on healthcare and its impact on the health system. I think this is a first good step. Not enough for sure, but at least there should be a first step. And I think we are moving forward in this direction. With all the technology that is evolving right now, documentation, data collection, and data reporting is improving, which means that when the time comes in terms of justice and accountability, and where there is a political will, there's enough public pressure for prosecution of attacks on healthcare — I think we will be ready for this.

B: That's one more point I wanted to add was just how interconnected a lot of these conflicts are, whether it be, some of the same governments involved, either directly or indirectly, via sending weapons to other countries, etc. But also, you know, allowing governments to continue to commit these acts, attacks on health care and other human rights abuses with impunity, not only further emboldened them to commit them in their own countries, but it also emboldens other governments and state actors. So, it really has like a ripple effect, and maybe contributing to just have so many conflicts right now across the world.

Neema: Yeah, thank you. So maybe we need to be really positive. Even though in some points, it's really discouraging, sorry to have negative last words.. But I think that's when I talk about 20 years now, it's been after the first big attacks of endless destruction, documenting, and nothing even we would have documented this, we have investigated, but nothing is done. We in the ground, you know, it's very important that we have all the steps that helps to continue with health now, we have good way of documentation. Now, we're more than 15 years in working with PHR on the ground. But we need also at some point to see something which is really concrete. Yet what I can say no, something that help us to say that is has begun. Now, we see that the small light in this darkness, and the when we see that the when the years are passing, the increase of number, and now it's become like normal strategy because of this impunity. We think that it's time more what we can pay back, now it's more than ever, it's time to say no to put a name on this and to say okay, we have collected data, we have also had all the litigation.
 
But we need to stop this thing of attacking the population through attacking the health structures, because this is the only one thing that is normally stable in a country, in a village, where there was conflict. But the structure that helps structure is where everyone can be not regarding any religion, not regarding you are from the government or you are a rebel, — everyone can be there and can seek for help. But if this you know, targeting more and more, we need to say stop. 

Uliana: We've talked about a lot already, and I feel like we spoke in this very high level manner, attacks on health this and attacks on health that, but I'd like to finish by narrowing our conversation back to what it means to attack health. First and foremost, in the center of the attack is a healthcare worker, or it could be a patient. In Ukraine, currently, we estimate that there are hundreds of healthcare workers held captive by the Russian Federation. Most of them are tortured or ill-treated. his is a direct violation of international humanitarian law. These are real people who have had lives before this war, who have had patients in their communities, and whose patients are now deprived of medical care because of this war, and because of the aggressor. We need to get this people home and to do everything in our power to stop these attacks.  

Paras: Very powerful messages. Thank you so much to each of you for joining the show. We'll be following all of these issues and attacks on health care and health at Just Security. Thanks, again.

Houssam: Thank you very much for having me today. It was pleasure to be part of this conversation. 

Neema: Thank you for having me. It was important for me to be a part of the conversation and these topics. Thank you.

B: Thanks so much. It was a pleasure.

Uliana: Thank you so much, Paras.

Paras: This episode was hosted and produced by me, Paras Shah, with help from Audrey Balliette and Harrison Blank. 

Special thanks to Dr. Houssam al-Nahhas, Dr. Neema Rukunghu, Uliana Poltavets, and Dr. “B” Zemen. 

You can read all of Just Security’s coverage of armed conflict, International Humanitarian Law, and accountability, including Uliana’s analysis, on our website. If you enjoyed this episode, please give us a five-star rating on Apple Podcasts or wherever you listen.