Drone Attacks on Health in 2023: International Humanitarian Law and the Right to Health

Vol 26/1, 2024, pp. 143-146  PDF

VIEWPOINT

Joseph J. Amon and Leonard Rubenstein

In May, the Safeguarding Health in Conflict Coalition (SHCC) and Insecurity Insight issued their 2023 report on attacks on health.[1] The report identifies 2,562 incidents of violence against or obstruction of health care in conflicts in 2023, a 25% increase from 2022, and the highest ever since the coalition began reporting on attacks in 2014.

The incidents documented—arrests, kidnappings, and killings of health workers, damage to or destruction of health facilities, and targeting of ambulances—occurred in 30 countries or territories, with the most intense violence occurring in conflicts in Gaza, Sudan, Myanmar, Ukraine, and Haiti. Countries in the Sahel region of Africa also experienced ongoing attacks and insecurity.

Overall, more than 480 health workers—doctors, nurses, ambulance drivers, pharmacists, lab technicians, paramedics, and psychologists—were killed in 2023, almost double the number reported in 2022. Both government forces and nonstate armed groups were responsible for attacks. In addition, in violation of international humanitarian law, health facilities were frequently occupied or repurposed for military use.[2]

Drone attacks

As drones are increasingly used in conflict globally, they are increasingly being used to target health facilities. The 2023 SHCC report documents and describes drone attacks in eight countries: Burkina Faso, Ethiopia, Myanmar, the Occupied Palestinian Territory, Sudan, Syria, Ukraine, and Yemen.

In Burkina Faso, in April, the Sabouna Health and Social Promotion Center in Nord region was hit in a government military drone strike. The following month, an ambulance evacuating a pregnant woman was hit in another government drone strike on a JNIM checkpoint in Centre-Est, which killed her and three health workers. In both strikes, Turkish-made Bayraktar TB2 drones, which often use munitions with wide-area effects, were used, resulting in damage to health targets and neighboring structures, including homes, schools, and businesses.

In Ethiopia, in November, the Ethiopian National Defense Force carried out two drone strikes in the Amhara region. The first strike hit an ambulance transporting medicine, killing an ambulance driver and pharmacist, wounding the head administrator of a hospital, and destroying the ambulance. The second drone strike hit Goshiamba Kebele, not far from the scene of the first incident. These attacks followed five strikes conducted by the Ethiopian National Defense Force in Tigray between December 2021 and October 2022, which killed two health workers, injured seven, damaged one hospital, and destroyed another.

In Myanmar, 418 incidents of violence against or obstruction of health care were documented in 2023, resulting in 37 health worker deaths; 102 health worker arrests; 53 incidents where health facilities were occupied; and 133 damaged or destroyed health facilities. Included in these incidents were 26 drone attacks on health facilities. Unlike most other conflicts, in Myanmar, local resistance forces were identified using drones armed with explosive weapons to attack Myanmar armed forces occupying health facilities. For example, the Ye-U Traditional Medicine Hospital in Ye-U township, Sagaing region, which was occupied by the Myanmar armed forces, was damaged on seven separate occasions in July, September, October, and November, with all of these incidents attributed to armed resistance groups.

In the Occupied Palestinian Territory, in 2023, there were at least 309 incidents of violence against health care by the Israeli Defense Forces, including 61 involving ground-launched missiles, rockets, and shelling and four drone attacks occurring between November 6 and December 24, damaging Al-Shifa Hospital, Kamal Adwan Hospital, and the Palestine Red Crescent Society Al-Amal Hospital.

In Sudan, 257 incidents of violence against or obstruction of health care were documented in 2023, compared to 54 in 2022. In these incidents, 56 health workers were killed, medicines were looted, and health facilities were damaged, destroyed, and occupied. Nine cases were recorded of air-launched explosive weapons impacting health care in Khartoum. Seven involved Sudan Air Force military aircraft dropping explosive weapons in residential areas that damaged hospitals and medical centers, and two cases involved drones armed with explosives. Both drone attacks targeted hospitals and were attributed to the Rapid Support Forces, a Sudanese paramilitary group.

In Syria, incidents involving explosive weapons use affecting health care doubled in 2023 compared to 2022. Most incidents involved air-launched explosive weapons use, but Turkish forces also used drones armed with explosives, destroying and damaging health facilities, including Meshtanour Medical Centre and a pharmacy, and killing a doctor.

In Ukraine, 109 health workers were killed, health facilities were damaged or destroyed on at least 192 occasions, and Russian military forces occupied health facilities 36 times in 2023. Russian forces used drones armed with explosives in 17 documented incidents, compared to two in 2022, and attacks were recorded in Khersonska, Kyivska, Odeska, Zaporizka, and Kharkivska oblasts.

In Yemen, five cases recorded the use of drones armed with explosives in attacks on health care in Al Dali, Al Hudaydah, Dhamar, Sanaa, and Ta’izz governorates in 2023. Previously, only one case, in Marib governorate in 2021, had been documented. Three cases recorded Houthi rebels using drones to drop mortar bombs that damaged two clinics and a Southern Transitional Council military ambulance.

Addressing attacks on health

Comprehensively documenting attacks on health is complicated by many challenges, including insecurity, limited access and communication in conflict settings, and lack of reporting. The numbers reported in the 2023 SHCC report are undoubtedly an undercount.

Some authors have suggested that the problem should be tackled like any other public health issue—by improving our understanding of the scale and scope of the problem, identifying those most vulnerable, and developing effective interventions to prevent the risks.[3] While undoubtedly each of these steps should be taken, other steps to strengthen respect for international humanitarian law and end impunity are critically important as well. The SHCC report includes several recommendations toward ending attacks on health, and impunity for attacks, including the following:

  • The International Criminal Court and national courts, through principles of universal jurisdiction, should initiate prosecutions for war crimes and crimes against humanity involving attacks on the wounded and sick and on health facilities.
  • Governments should cease arms transfers to parties to conflict that engage in grave breaches of international humanitarian law.
  • Ministers of health should engage with their own military and security forces and armed groups to protect health care from violence and strengthen mechanisms to mitigate the impacts of attacks on communities, health workers, and health systems.
  • Regional bodies and the United Nations humanitarian cluster system should expand initiatives to protect health care in conflict and mitigate the impact of violence against it.

In addition, prosecutors domestically and internationally should bring cases of war crimes and crimes against humanity against those who commit attacks on health, and special tribunals should be established to hear cases of attacks on health—and to circumvent United Nations Security Council members’ vetoes of referrals to the International Criminal Court.

Attacks on health facilities, personnel, and transport also have an impact on the right to health broadly, as the destruction of health facilities, the killing of health workers, and other impacts on health systems interrupt the ability of people to access care and prevention services and to realize the highest attainable standard of physical and mental health.[4] Equally important, as Katherine Footer and Leonard Rubenstein point out, attacks on health can occur in the absence of formally identified conflict settings, limiting the reach of international humanitarian law.[5] In these settings, and in the aftermath of conflict, health care workers may nonetheless face hostility and physical and psychological injury, which limits their ability to provide care, and individuals may avoid seeking care in health facilities because of the history or threat of violence.

International human rights law obligates states to respect, protect, and ensure the right to health for all, including in conflict settings. The Committee on Economic, Social and Cultural Rights, which provides authoritative interpretation of the International Covenant on Economic, Social and Cultural Rights, has recognized the impact of conflict and violence on health and thereby states’ obligations to take steps to address violence among other determinants of health, to protect health workers and patients from harm, and to ensure that health facilities are available and accessible to all.[6]

Acknowledgments

The authors would like to acknowledge and thank the efforts of all SHCC members and health workers in conflict settings worldwide for their efforts to protect workers, patients, and facilities.

Joseph J. Amon, PhD, MSPH, is director of the Office of Global Health and a clinical professor at Drexel University Dornsife School of Public Health, Philadelphia, United States; editor-in-chief of Health and Human Rights; and a member of the Safeguarding Health in Conflict Coalition’s Steering Committee.

Leonard Rubenstein, JD, LLM, is distinguished professor of the practice, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States, and chair of the Safeguarding Health in Conflict Coalition.

Please address correspondence to Joseph J. Amon. Email: jja88@drexel.edu.

Competing interests: None declared.

Copyright © 2024 Amon and Rubenstein. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

[1] Safeguarding Health in Conflict Coalition and Insecurity Insight, Critical Condition: Violence against Health Care in Conflict 2023 (Baltimore: Safeguarding Health in Conflict Coalition, 2024).

[2] International Committee of the Red Cross, “International Humanitarian Law Databases: Rule 28; Medical Units,” https://ihl-databases.icrc.org/en/customary-ihl/v1/rule28#.

[3] K. Blanchet, L. Rubenstein, B. Taithe, and L. Fast, “Have Attacks on Healthcare Become the New Normal? A Public Health Call to Action for Armed Conflicts before It Is Too Late,” Conflict and Health 17/1 (2023).

[4] K. H. Footer and L. S. Rubenstein, “A Human Rights Approach to Health Care in Conflict,” International Review of the Red Cross 95/889 (2013).

[5] Ibid.

[6] Committee on Economic, Social and Cultural Rights, General Comment No. 14, UN Doc. E/C.12/2000/4 (2000), para. 10.