The international community is failing to protect healthcare in armed conflict
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2474 (Published 12 November 2024) Cite this as: BMJ 2024;387:q2474
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One of the most defining factors of paediatric health inequality in the Middle East and North Africa (MENA) region is geography, particularly for children born in conflict zones. With over 45 ongoing armed conflicts, the MENA region is the most war-affected globally [1]. Children face not only inequitable healthcare but also the deliberate destruction of medical infrastructure. Hospitals are bombed, supply chains are blocked, and medical staff are forced to evacuate, making healthcare a calculated weapon of war rather than collateral damage. As a result, neonatal mortality rises, preventable childhood illnesses become fatal, and an entire generation suffers from inaccessibility to basic medical care.
International humanitarian law mandates the protection of medical units during armed conflict, strongly condemning attacks on healthcare facilities and personnel [2]. Yet, in the past three years, the MENA region has witnessed a surge in targeted assaults on medical infrastructure, disproportionately harming children.
Between October 2023 and January 2024, the WHO reported nearly 600 attacks on healthcare facilities in Gaza and the West Bank, crippling paediatric services amid a worsening humanitarian crisis [3]. A UN report confirmed that 136 attacks damaged hospitals in Gaza, affecting 27 hospitals and 12 medical facilities, and killing approximately 500 healthcare workers [4]. Lebanon has recorded 139 verified attacks on healthcare, while Syria saw 22 health facilities destroyed in 2023 [5,6]. Sudan has endured over 100 attacks on healthcare facilities since April 2023, severely restricting maternal and paediatric care [7]. In Yemen, years of war have decimated access to essential health services, leaving children without necessary medical treatment [8].
Without functioning healthcare facilities, treatable childhood diseases like diarrhoea and respiratory infections become lethal. Neonatal care is particularly affected as premature babies require incubators, oxygen, and skilled neonatal teams and resources systematically stripped away when hospitals are bombed or lose power, further increasing neonatal mortality rates. These attacks have lasting consequences for paediatric health, as newborns and children with chronic illnesses suffer the most when hospitals are rendered inoperable.
Despite repeated UN resolutions condemning attacks on healthcare, enforcement mechanisms remain weak. Countries supplying arms to warring factions continue to do so with little accountability, indirectly facilitating the destruction of paediatric healthcare in the region. Global responses remain largely rhetorical, failing to translate condemnation into meaningful action.
This crisis demands urgent intervention from the medical community. Paediatric hospitals should be designated as protected, non-targeted zones, enforced by peacekeeping operations where necessary. The global medical community must go beyond issuing statements of condemnation and demand accountability through legal channels, documenting these violations and pushing for consequences under international law. Medical journals, associations, and institutions must amplify these violations, ensuring attacks on paediatric healthcare are not normalized. Additionally, sustained investment in mobile paediatric units, neonatal care, and frontline healthcare workers is critical.
Children are the most vulnerable primary victims of this strategic destruction of healthcare in MENA conflict zones. The deliberate targeting of hospitals is not just a violation of international humanitarian law; it is an attack on the very foundations of medical ethics. Without urgent action, conflict-affected children will continue to suffer, and healthcare will remain a weapon of war designed to strip them of their most fundamental right which is access to medical care.
References
1. Geneva Academy. Today's armed conflicts [Internet]. Geneva Academy. [cited 2025 Feb 11]. Available from: https://geneva-academy.ch/galleries/today-s-armed-conflicts#:~:text=This...
2. United Nations Security Council. Security Council adopts Resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations [Internet]. 2016 May 3 [cited 2025 Feb 11]. Available from: https://press.un.org/en/2016/sc12347.doc.htm
3. World Health Organization. WHO reported nearly 600 attacks on healthcare facilities in the Gaza Strip and West Bank since the onset of hostilities in October 2023 [Internet]. 2024 [cited 2025 Feb 11]. Available from: https://news.un.org/en/story/2024/01/1145317
4. Office of the High Commissioner for Human Rights. Pattern of Israeli attacks on Gaza hospitals raises grave concerns: Report [Internet]. United Nations; 2024 Dec [cited 2025 Feb 11]. Available from: https://www.ohchr.org/en/press-releases/2024/12/pattern-israeli-attacks-...
5. World Health Organization. WHO Lebanon crisis: Situation report #9 [Internet]. WHO Regional Office for the Eastern Mediterranean; 2024 [cited 2025 Feb 11]. Available from: https://www.emro.who.int/images/stories/lebanon/situation-report-9.pdf?ua=1
6. Insecurity Insight. Safeguarding health in conflict: Syria 2023 [Internet]. 2024 [cited 2025 Feb 11]. Available from: https://insecurityinsight.org/wp-content/uploads/2024/05/2023-SHCC-Syria...
7. World Health Organization. Sudan complex emergency: Situation report, 4 September 2024 [Internet]. 2024 [cited 2025 Feb 11]. Available from: https://cdn.who.int/media/docs/default-source/documents/emergencies/suda...
8. Alsabri MI, Alsakkaf LM, Alhadheri A, Cole J, Burkle FM Jr. Chronic health crises and emergency medicine in war-torn Yemen, exacerbated by the COVID-19 pandemic. West J Emerg Med. 2022;23(2):276–84. doi:10.5811/westjem.2021.10.51926
Competing interests: No competing interests
Medical professionalism and Gaza: Values, ethics, and healing
The current war between Israel and Hamas shows no clear signs of resolution, notwithstanding an unprecedented number of civilian deaths and casualties, including healthcare and aid workers. Despite this devastation, most influential US medical professional organizations and journals have not taken substantive stands.[1,2] This reticence has prompted responses from physicians internationally with some expressing outrage and accusations of complicity with mass casualty [1,2] and others highlighting the inconsistency in how journals respond to war, for example by citing the Russia-Ukraine war as a counterpoint.[3] Yet others are relieved, by if not grateful for, the reticence, given that any statements could be perceived as one-sided and, therefore, alienating.[4]
However, it is no secret that omission, apathy, and even complicity regarding human mass atrocities have historically enabled their occurrence, for example, during the Holocaust.[5] We therefore write neither to defend the status quo nor to advocate for a specific medical response to the Israel-Hamas war. Instead, this moment represents a critically important opportunity for the medical profession to promulgate clear criteria for when, where, and how medicine as a scientific and moral profession should and must take public stances to preserve and promote health and wellbeing. Even more, continued ambiguity regarding public expression of values is a failure of ethical leadership that has contributed to a deterioration in trust between the medical profession and the public, a lack of psychological safety for physicians regarding the contours of permissible expression of views, and moral distress in physicians fulfilling their calling as healers amid global uncertainty and violence.
As a profession, we must learn from our past errors of omission and failed leadership. Taking sides and promulgating affirmations devoid of action guidance will not move us forward. Instead, as a profession, we must begin with our bedrock of medical ethics to conduct a transparent assessment and engagement of how our professional values resonate with and are relevant to the challenges we face as a society. The result must be the creation of values-based principles for when and how the profession should speak – a necessity for rebuilding trust within and outside the profession and for fostering discourse on how to address world events that threaten health, wellbeing, and human rights now and in the future. If the medical profession is to lead in the healing of our divided country amidst global threats to humanity, we must begin by embracing our core values and healing ourselves.
References
1. Abi-Rached JM, Reinhart E. The Palestinian challenge to US medical ethics. The Lancet. 2024; 490: 2285.
2. Reinhart E, Bassett MT. The US medical establishment is making one of its worst mistakes – again. The Nation. https://www.thenation.com/article/society/new-england-journal-gaza-medic.... Date: May 21, 2024. Date Access: July 24, 2024.
3. Gostin LO, Goodwin MB. Wars in Gaza and beyond: Why protecting the sacredness of health matters. JAMA. 2023; 331: 191-192.
4. Greenland P, Lasker O, Lipschutz L. Reporting health consequences of war in medical journals: First, do no harm. JAMA. 2024; 331: 1361-1362.
5. Abi-Rached JM, Brandt AM. Nazism and the journal. N Engl J Med. 2024; 390: 1157-1161.
Competing interests: No competing interests