Doctors working in government hospitals and field clinics have, in recent years, been increasingly targeted in armed conflict zones in the Arab region - particularly in Syria, Iraq, Libya and, to a lesser extent, in Yemen. Killings, assaults, arrests, forced disappearances and extra-judicial detentions are cited among tools used by governments, terrorist organizations, militias, criminal gangs and violent sectarian groups to target doctors. This phenomenon can be explained by several drivers, including attempts to weaken political opponents, cover up crimes committed by government authorities, the growing influence of criminal gangs, the dominance of tribalism as well as driving highly qualified scientists and physicians out of their countries.
Certain incidents reflect the grim reality facing doctors and other medical staff in Arab conflict zones, in Iraq in particular. In July 2017, woman dentist Shaza al-Samarrai was murdered by unknown people using knives when they broke in her home in al-Iskan district in western Baghdad and stole all her personal belongings and furniture. The crime took place only two days after a doctor named Salim Abdul Hamza, was stabbed to death by unknown attackers in his clinic in al-Maamel district in eastern Baghdad. Reports had it that the motive was revenge.
Soon after that, on July 18, the Iraqi Medical Association announced that an armed group kidnapped Dr. Ali Mohammed Zayer, head of Surgery at the Al-Hakeem General Hospital, while he was heading from his house to his clinic. The next day, the surgeon was found alive and handcuffed in a Baghdad alley. Eight days later, on July 26, the Association decided to stage a sit-in for all doctors across the country (except for emergency and ICU doctors and anesthesiologists) to protest against failure to provide needed security measures to protect doctors. Banners held up by protesters read: “Enough with your complacency concerning the rights and safety of doctors”, “Protect doctors”, and “doctors’ dignity is the country’s dignity".
There are no accurate statistics to indicate the real extent of the phenomenon, although the international health institutions reveal its upward trend and increasing violations against respecting and protecting medical units. Literature indicates that there are a number of factors that explain the increasing targeting of doctors in Arab conflict zones, as follows:
Military Superiority
1- Weakening political opponent’s resistance. Just like fighters, medical workers have become targets in ongoing conflicts. In Syria, warring parties used doctors and hospitals as part of its war strategies. Last year, Syria became the most dangerous place on earth for healthcare providers, according to the World Health Organization. The US-based Physicians for Human Rights also announced that Syria was the most dangerous place for doctors.
Doctors are no longer the sole target of assaults. Nurses, pharmacists, volunteer healthcare professionals, medical transport companies, ambulance drivers and just anyone who can provide healthcare services, have all been targeted by attacks aimed at ensuring that the regime of Bashar al-Assad gains military advantage over armed opposition groups and depriving their supporters from any medical aid.
Chief of the UN Commission of Inquiry on Syria, Paulo Pinheiro, told the UN Human Rights Council in Geneva on June 21, 2016, that widespread, targeted aerial attacks on hospitals and clinics across Syria have resulted in scores of civilian deaths, including much-needed medical workers. Pinheiro added that 'as civilian casualties mount, the number of medical facilities and staff decreases, limiting even further access to medical care'.
For instance, Syrian government forces target medical workers and facilities in areas controlled by armed opposition factions after besieging these areas, blocking the injured who are not among the regime’s loyalists from receiving medical aid at government hospitals, as was the case in the provinces of Aleppo and Idlib. The measures poses a serious threat to the lives of thousands of citizens. Moreover, a sufficient reason for the Assad regime to arrest Syrian doctors living in areas under its control would be that they belong to the Sunni majority, according to identical accounts from residents.
In a news conference held in August 2016, Tawfik Shujaa’, the president of the Union of Medical Care and Relief Organizations (UOSSM), a non-profit organization of Syrian doctors, warned that the situation of healthcare in Aleppo City was deteriorating. This is primarily due to a decline in the numbers of doctors, a severe shortfall of medical equipment, supplies, a lack of operating rooms, sufficient sterilization and anesthetic drugs as well as power outages, all coupled with the regime’s surveillance and crackdown on activist doctors who treat injured people at field hospitals.
Yemen’s rebel Houthi group followed a similar approach targeting some doctors in the country. This prompted Meinie Nicolai, the president of Doctors Without Borders/Médecins Sans Frontières (MSF), to state, on October 3, 2016, that "Over the past year, we recorded 77 attacks against medical facilities operated or supported by MSF in Syria and Yemen. This is unprecedented.”
Uncovering the Crimes
2- Covering up the crimes of authoritarian regimes. This became evident in the case of al-Assad regime which carried out targeted attacks on activist doctors in the early days of the
Syrian Revolution. In 2011, a group of revolutionaries working in secret formed what became known as “Doctors Coordinate of Damascus” (or Damascus Doctors) and created their own Facebook page. The aim of the network of health care workers was not only to save lives but also to expose al-Assad regime’s crimes and its exercise of intimidation, assassination and violation of the neutrality of the medical profession enshrined in International human rights law.
The Damascus Doctors group also set up secret clinics in neighborhoods witnessing protests, but they had to keep changing their places so that even doctors providing medical equipment and care would not know where the clinic would be set up the next day. The aim is to spare doctors from crackdown by al-Assad regime forces which succeeded in capturing a number of them while others either joined militias or fled the country.
In one of the accounts, a physician working for MSF once said, “Syrian doctors say that catching a doctor in the company of a patient is like being caught with a gun.” A highly famous Yemeni doctor from Taiz who heads the Yemeni Center for Transitional Justice (YCTJ), was arrested in June 2013 for supporting the Yemeni youth revolting against the regime of the now-ousted president Ali Abdullah Saleh.
Fragile Rule of Law
3- Flourishing criminal gangs taking advantage of weak rule of law in conflict zones in certain states kidnap doctors of high income to extort ransoms. In both Syria and Iraq, although kidnappings, extortion and assaults against healthcare facilities and workers are increasing on daily basis, no deterrent measures have been taken against perpetrators who remain and escape justice for their actions. The failure makes doctors and other medical staff feel more unsafe.
Despite increasing demands in Iraq for enforcing Law No. 26 of 2013 on Doctors - which provides for the punishment for anyone threatening or assaulting a doctor with a three-year jail term and a fine of 10 million Iraqi dinars- Iraqi security authorities have not been responsive because they prioritize confrontations with ISIS in Mosul. For instance, on September 29, 2013, a tribe from Basra threatened a surgeon named Kazim Hussein, after one of his patients died during surgery. Kazim was forced to pay 20000 dinars as a compensation. Generally, this situation shows that insecurity blocks doctors from practicing the profession.
Tribal Law
4- Prevalent tribalism, obviously, affects doctors across Iraq, where they fall victims to frequent targeted assaults, according to local media reporting and social media. Pictures of deserted homes published by the media show writings on the walls and doors that read “The owner of this house is wanted for blood (fued)”, a marking indicating that the owner is vulnerable to killing or has to pay a ransom to those threatening him.
Tribes in Iraq enforce their own laws when a failed surgery or a wrong prescription leads to the death of, or causes a permanent disability for a member of the tribe, and even when he cannot afford to pay financial compensation. The situation reveals weak social awareness of the crucial role of doctors and the medical profession as a whole.
Eliminating Qualified People.
5- Driving highly-educated people out of Iraq. Available literature highlights the issue of rampant gangs driven by political agendas that target doctors in Iraq for instance, where the goal is to empty Iraq of its highly-educated people, academics and scientists.
Ayad Allawi, Iraqi Vice President and leader of the National Coalition, made a statement to the press on July 24, 2017, saying “evil agendas are behind the targeting of doctors across the country. What doctors are exposed to is a security setback that requires urgent security plans.” The next day, the Iraqi Medical Association issued a statement saying “these assassinations are recurring unabated and the perpetrators escape due to a lack of effective governmental or legal measures against their crimes, which are the result of increasing incitement in the media against doctors. The goal is to empty the country of its qualified people and undermine its health and national security.”
The situation plays into the hands of Western countries of which Germany is home to the largest community of expatriate Syrian doctors. While thousands of Syrian doctors leave their country each year for work abroad, Germany estimates that it will need 111 thousand doctors by 2030 to serve its citizens. According to Foreign Policy, the number of foreign doctors in Germany increased 60% between 2010 and 2014, with Syrian doctors competing with Romanians on the top spot of the list of Germany’s largest community of foreign doctors.
Politicization of the healthcare sector.
Healthcare has been militarized due to several factors including escalating internal conflicts in the Arab region, interference of warring parties to employ it to serve their own military and strategic goals, increasing primitive loyalty to traditional social environments, receding rule of law as well as under performance of the government security establishment. This situation imposes several obstacles for development of plans to provide a safe environment in Syria, Iraq, Yemen and Libya, a demand driven by the growing power of terrorist organizations and other militias, the use of hospitals for non-medical purposes and taking actions to undermine opponents. That is, hospitals are increasingly being used to harbor militants, stash arms and ammunition and are even turned into military checkpoints and installations for military operations.
Such actions prevents the provision of “neutral” medical treatment, endangering the lives of patients and medical workers as well as threatening the humanitarian use of medical facilities. International human rights law does state that under no circumstances a person shall be punished for carrying out medical activities compatible with medical ethics regardless of the person benefiting therefrom, or shall be compelled to perform acts or to carry out work in contravention of medical ethics, regardless of religion, race and political affiliations. However, when hospitals are used for non-medical and non-humanitarian purposes, their protection may not be removed before an appropriate warning is issued, and a reasonable deadline is set, in all cases, even after these hospitals ignore warnings.
