IHSA Conference – History of attacks on healthcare

Xavier Crombé (Médecins Sans Frontières, CRASH) opened the panel with his presentation on “Attacks on Healthcare: Attempting a Genealogy of the Present”, in which he analyzed the short and longer-term factors behind the international mobilization against attacks on healthcare over the last fifteen years. He argued that campaigning on this theme represented an attempt by primarily Western medical and public health actors to escape the polarizing logics of the War and Terror, much like the language of human rights had allowed new grassroots activists to challenge Cold War politics in the 1970s.

The ‘Arab Spring’ added momentum to the mobilization: images and testimonies of local doctors caring for demonstrators confronted with state repression gave a non-Western voice to the issue of attacks on healthcare and prompted medical outsiders to lay claim for transnational solidarity on professional grounds. Re-occurring across the Middle-East, counterinsurgency violence affecting medical practitioners and facilities also seemed to confirm early campaigners’ description of the phenomenon of attacks as a ‘new’ and ‘dangerous trend’ at global level. Yet, the mobilization’s language and modes of action reflect pre-existing repertoires formulated in the past, thus belying the understanding of current forms of violence as unprecedented.

‘Medical human rights’, embodied by organizations such as Physicians for Human Rights, developed in the late 1970’s and 80’s in the name of transnational professional solidarity grew out of concern with issues of torture and counterinsurgency tactics that have returned to the fore after 9/11. Present insistence on International Humanitarian Law (IHL) norms have likewise revived issues and debates left pending since the Two Additional Protocols to the Geneva Conventions were adopted in 1977, the last formal attempt at IHL development. Yet, it is in the 1990s that the understanding of violence as a global public health issue, prominent in the new paradigm, was conceptualized by the WHO, at a time when the organization’s relevance was being questioned.  This notion has since grown in connection with the global health security concept, a framework which, it may be argued, institutionalized a sanitary fault-line between the ‘West and the rest.’ As such, Xavier concluded, if public health-inspired statistical recording of attacks now supports long-time HR groups’ calls ‘to end impunity’, it still largely leaves unaccounted for the no-less real violence of distant policies of neglect and disruption on whole healthcare systems.

In “Wounded and caregivers of the Resistance in occupied France: an experience of violence during WW2”, Raphaële Balu presented her research on the history of Nazi repression against French resistance forces, which directly targeted their wounded and their caregivers as well as their fighters.

For a long time, historians of the Nazi occupation in Europe have opposed an Eastern front subjected to extreme violence, to a Western front where laws of war had been broadly respected. However, recent studies have shown that while violence against civilian populations was widespread in the East, it was not absent from the theaters of occupation in the West. By refusing to apply the law of war to Resistance fighters, the forces of repression considered caregivers and patients as terrorists. In April 1944, the German authorities even declared that anyone who took care of a person injured by firearms or explosives was compelled to denounce their patient – silence could be punished by death. Despite this threat, Anne Simonin has shown that doctors massively refused to follow this rule since reporting their own patients was unethical[1].

Even before that date, massacres of Resistance fighters identified in hospitals, attacks on clandestine hospitals, murder or deportation of caregivers were common. For all these reasons, Raphaële focused on the experience of “irregular” war for caregivers who were denied the protection of international laws as well as the way in which they faced the extreme violence directed against them and their patients. She drew on personal narratives produced during or after the war. Overall, such sources show that most actors do not refer to international laws when describing these instances of violence and analyzed this repression as one more proof of the enemy’s barbarity. These sources shed important lights on medical staff’s emotional responses to the death of comrades and on the psychological impacts of permanent fear, rather than on the various breaches of Geneva conventions. From an ethical point of view, it seems that even when caregivers of the resistance treated the enemy’s wounded, this was more about respecting their Hippocratic oath than about implementing a “medical neutrality” which stayed very theorical in such circumstances.

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Building on Raphaële’s paper, Laure Humbert’s paper entitled “Medical Care under Fire: Violence, Gender and the ethos of stoicism in the international Hadfield-Spears hospital, 1941-1945” explored how military attacks impacted on the psychological and physical health of those attending the wounded within this specific medical unit. This hospital provides a highly unusual case study, since it was made up of French surgeons and doctors belonging to the French Resistance, volunteers in the British Friends’ Ambulance Unit (FAU), British female high-society ambulance drivers, nurses and colonial orderlies from Cameroon and what was then French Equatorial Africa.  Thus, it offers a fascinating microcosm to observe how people with various trajectories react to air attacks and to the loss of staff members. Like in Raphaële’s case, military attacks were often described as part of the normal life of the hospital:  the Geneva Conventions were rarely used when describing the violence that the personnel faced.

Drawing on military records, the hospital logbooks and personal narratives, Laure considered the ways in which race, ethnicity, gender and nationality impacted on the emotional experiences of those working in the hospital. She asked: How did this shared ‘ethos of stoicism’ emerge and manifest itself in the hospital, despite important tensions between the various groups?  How did trained and untrained medical workers respond to instances of violence, negotiate contradictory obligations, and face ethical dilemmas? How far did this ethos shape, in memory at least, the emotional dynamics of medical care under fire? And, to what extent, did it make it difficult to openly voice distress, grief and discomfort?

Laure showed that read closely, personal narratives of the hospital provide a fascinating window into how Hadfield Spears men and women, who were not combatants but often identified with them, ‘composed’ their masculine and feminine selves. Through a focus on official military records, oral testimonies, diaries and memoirs, she unveiled how Spears staff negotiated the duality of the spatial environment of the Hadfield Spears as both a space of danger and a ‘home’, a site of extreme violence but also festive and deeply compassionate encounters. Crucially, she argued that an ethos of stoicism was essential to the maintenance of the emotional community of the hospital.

Finally, Bertrand Taithe gave his paper “Like Yam Between Two Stones”: Remembering Healthcare at War in Nepal (1996-2006)”. The Nepal civil war, 1996-2006, opposed a rural Maoist insurrection and a succession of monarchical regimes and governments backed by the West. Despite a shift in perception of the conflict post 9/11, the conflict remained largely internal to Nepal with limited international contributions. Over that same period, health indicators in most domains recorded significant growth including in the most affected areas of the country. Building on human rights datasets of incidents and systematic oral history among three regions affected to varying degrees by the conflict, he argued that the political nature of the conflict ensured health care facilities were instrumentalized by both sides of the conflict, while medical practitioners had to manage the demands of insurgents and security forces. Through 80 interviews conducted in 2020-2021 in situ, this paper engaged with the health paradox of a conflict which did not follow usual patterns, while it considers how the war, violence and mental health consequences of a decade of terror are now recalled and made sense of. With the new republic now run with former insurgents, militants now remember the war in sometimes nostalgic ways when it comes to their centrality in the Maoist project. The healthcare provisions arising from the war fail to match promises or even some of the wartime resources deployed by insurgents keen to demonstrate their commitment to health provisions as a common good which needed to be made more accessible.

Finally, this paper reflects on the absence of the concept of attacks on healthcare in contemporary analyses, at a time when the concept was gathering support internationally. In this sense it charters a paradox and a pre-paradigm shift analysis of a seemingly outmoded political insurgency.

This panel led to a fruitful discussion on the reasons why the concepts of Attacks on Healthcare has been used as a mobilizing tool and analytical category to understand specific acts of violence since 2011 and whether this shift is a ‘mere parenthesis’ with little tangible impacts.

[1] Anne Simonin « Le Comité Médical de la Résistance: un succès différé » dans Le Mouvement social, No. 180, Pour Une Histoire Sociale de la Résistance (Jul. -Sep., 1997), pp. 159-178