It has been said that death strikes in threes. Such was the tragic lesson learned by Médecins Sans Frontières (MSF, known in the U.S. as Doctors without Borders) in Afghanistan, Yemen, and Syria. While MSF and other global aid organizations often face violence, three particularly atrocious attacks against MSF facilities have led many to question international law’s ability to protect humanitarian medical aid workers.

Attacks against hospitals cause more outrage than other types of violence because such attacks are considered war crimes. According to the International Committee of the Red Cross (ICRC), “The Geneva Conventions and their Additional Protocols are international treaties that contain the most important rules limiting the barbarity of war. They protect people who do not take part in the fighting (civilians, medics, and aid workers) and those who can no longer fight (wounded, sick troops, and prisoners of war).” The three attacks against MSF facilities, then, are particularly alarming, because they violate international law.

In October 2015, the U.S. launched airstrikes on a MSF trauma center in Kunduz, Afghanistan. Before sunrise, U.S. planes bombed the hospital, then circled back and shot those trying to run away. Thirty staff, patients, and physicians were killed.

In an interview with the Associated Press,  Anayatullah Nazari, a survivor of the attack, said, “It was like they were determined to kill us all and that nobody would survive. It was like doomsday, nothing I could ever imagine.” The U.S. took responsibility for the attacks, saying it was an accident. General John F. Campbell, commander of operations in Afghanistan, conceded in a Defense Department press conference that the attack forces had not been properly briefed.

“This was a tragic but avoidable accident caused primarily by human error,” said Campbell. No one is likely to face consequences for the attack.

Three weeks later, a Saudi coalition destroyed another MSF hospital in Yemen. While everyone escaped safely, a critical part of the Yemeni medical infrastructure was destroyed, leaving many without trauma care. The Saudis, too, claimed the bombing was an accident—the result of tired troops, poor briefing, and confusion about which buildings are protected and which are not.

Then, in February 2016, a hospital in the Idlib province in northern Syria was bombed, leaving 25 dead and 11 injured. The volatility in Northern Syria has made it difficult to identify those responsible for the attack. Many speculate Putin and Assad were behind the operation. Some even suggest the attack was intentional, which Putin vehemently denied.

In quick succession, these three attacks have left many wondering if the state of humanitarian aid is changing fundamentally and if the Geneva Conventions–international laws designed to clarify and govern the rules of war–are eroding.

The answer is not immediately clear. The medical aid community, for example, disagrees on the true scale of the violence. While the number of attacks on facilities is increasing, so are the number of aid workers operating in the field. Despite more attacks, the rate of attacks fluctuates. Removing outlier countries like Somalia, Syria, and Afghanistanregions so conflict-stricken that the risks are significantly higher than averageall but eliminates any increases in the rates of violence against aid workers.

The aid community does agree, however, that public perceptions about humanitarian aid safety have deteriorated; security has become an area of increasing concern for aid organizations. The perception of increased violence, founded or not, will notably affect medical aid in the future.

Augustin Augier, CEO of the Alliance for Medical Action International (ALIMA) – a group that works in seven sub-Saharan African countries – does not agree that the recent violence is exceptional.

In an interview with The Politic, Augier said there is no evidence that humanitarian aid has become more violent. He noted that, Geneva Conventions aside, hospitals have always been targets. “Insecurity is a growing issue in the humanitarian aid community,” he said, “but it has always been a problem.”

Unni Karunakara, the former president of MSF, had a different take on the prevalence of violence today, but came to a similar conclusion with its implications. In an interview with The Politic, he explained that delivering medical aid in conflict zones has always been risky, but, from his interpretation, the data reveals increased violence against aid workers. In other words, “it’s not just a perception.”

Karunakara also noted that recent attacks have shaped the practical relevance of the Geneva Conventions. “I don’t think, to my knowledge, there’s ever been a time when the Conventions were absolutely respected,” he said. “There’s always been violations of the Conventions in the past. Hospitals have been attacked. Health workers have been attacked in the past as well.”

Despite different opinions on whether violence has increased in the modern age, most of the humanitarian community agree that aid delivery is changing. As Karunakara said, “We are living in the age of security.” While violence has always been a concern for humanitarian aid groups, security seems to have only become a major issue for aid organizations during the last few years. Organizations today, then, are far more risk-averse.

The shift toward caution has two major consequences. First, aid organizations may not be able to reach those most in need of care. Medical workers are most exposed to violence where it already exists. As a result, Ca

It affects our ability to perhaps reach some of the most difficult humanitarian contexts of our times,” said Karunakara. “It is not possible today to provide impartial humanitarian assistance, for all the people who need it in Syria, in Somalia, in Afghanistan today. There are many more people going without help or assistance as a result of these conflicts.”

Augier concurred. “Usually medical aid is delivered on the periphery, but many organizations now have been forced or have chosen – like MSF – to work in active conflict zones.” For example, the trauma unit in Kunduz was shuttered after the attacks leaving victims of the bloody conflict without medical care. And in Somalia, MSF ceased operations after the Somalian government failed to carry out a reasonable sentence for the murder of MSF staff. Today, in MSF’s absence, Somalians lack the humanitarian assistance they so desperately need.

This inability to reach those most vulnerable populations is exactly the goal of the perpetrators, Karunakara noted. “That’s also what many of the people who perpetrate the violence want,” he claimed. “They want to deprive people of basic services, and top of that list is health.” The need to focus on security, instead of aid, drains humanitarian organizations of their time and resources.  When an organization has to focus more on security, they focus less on providing medical services.

To further complicate access, increasing security measures often becomes cyclic. Karunakara noted how much has changed since he volunteered as a physician. When Karunakara volunteered, people could go to the local bars after work, visit the market, and be a part of the communities they served. Now, many regions are too dangerous for volunteers to leave MSF facilities. And because they are less visible in the community, these volunteers become outsiders and command less respect in the community. So security measures require more security measures.

A second result of the recent attacks is greater public awareness of international legal systems and their flaws. The Geneva Conventions protect anything that bears the symbol of the ICRC – a red cross, red crescent, or the symbol of medical organizations like MSF. But the Geneva Conventions are hard to enforce because the international institutions overseeing them are notoriously ineffective.

For example, an investigation into the bombing in Kunduz would require one of the governments involvedthe U.S. or Afghanistanto officially request such an investigation. That is unlikely, said Augier. “The attack in Kunduz is the first time MSF has ever had to use the fact-checking assurance of the Geneva Committee, but for the process to go to international court, one of the governments would have to ask the Committee for the investigation. That’s not in the interests of the U.S. or Afghanistan.”

Even in a case like this one where liability is clear, the necessary actors are unlikely to investigate, prosecute, or sanction. In cases where involvement is more tenuous, like the attacks in Yemen or Syria, the appropriate international processes are nearly impossible to activate. Politics get in the way.

“Today, four of five members of the UN Security Council are part of coalitions who have attacked hospitals,” Karunakara commented. “It’s that pervasive. There’s no one to really stand up and say, ‘This has to stop.’ The failure of international relations is the inability to hold violators accountable.”

Another complicating factor is that non-state actors are usually the ones committing violence. International bodies have a hard enough time sanctioning nations for violating international law; they are even less suited to force groups like the Islamic State (IS) or al-Shabaab to answer for war crimes. In many humanitarian contexts, the political climate is too complex to call on highly bureaucratic legal bodies to enforce the human decencies of the Geneva Conventions.

But Karunakara suggests international law is more deeply troubled than just specifically in a humanitarian context. “Once [national] security is invoked,” he said, “it takes more of a priority than other concerns like human rights or sovereignty, which are concerns we’ve had in the past.” He suggests that in international politics, humanitarianism may not be a priority for powerful states. In situations where national interests and international law are in conflict, national interests usually win.

This repainting may be what has led historically human-rights-focused nations to begin to violate international laws during the recent refugee crisis in Europe. Though international law guarantees the right to asylum, many countries have sent refugees back to unstable countries to protect their own national interests. While the Geneva Conventions seem particularly vulnerable in this age, international legal systems in general play second fiddle to national laws, making international laws difficult to enforce.

But in light of recent violence, many have called for reform. “The change mechanism for international bodies is slow, but there is momentum,” Augier commented. One benefit from this violence, he suggested, is a change to international legal processes.

Kris Torgeson, a colleague of Augier’s, concurred. She explained, “Campaigns for security by bodies like MSF and ICRC may bring about more debate and discussion about the protections under international law, and therefore increase protections for people running humanitarian aid operations, legally speaking.”

Some members of the aid community hope that public outcry over the violence could lead to improvements for investigating and punishing infractions. Amidst all this discussion and media coverage of violence against health workers, some members of the aid community also worry that the violence may become normalized.

Torgeson, who is launching the U.S. branch of ALIMA, voiced such a concern, explaining, “While an increase in incidence of security threats has not been proven, there has been an erosion of understanding of what is protected under international law. Because the events have been so publicized, it makes it seem as though it is acceptable to politicize health.”

Her point reflects widespread anxiety about the desensitization that may result from publication and debate about attacks on medical aid organizations. She was echoed by Karunakara, who fears that normalizing violence against medical workers may decrease outrage, and therefore limit advocacy.

Their concerns are well-founded. “Poverty porn” is a widely-studied phenomenon. The same goes for drowning donors and policy makers in images of violence at hospitals. Augier noted that though the “aid under attack” rhetoric may motivate public policy and donors in the short term, the publication of violent images may eventually lose power.  After all, there is only so much devastation that Western audiences can absorb before they become numb to it.

When supporters of these groups become numb to violence, the ability of these organizations to operate and provide aid seems less dire and more normal. This numbing effect could be highly significant, especially considering that MSF got nearly 90 percent of its income in 2014 from private donors.

MSF is not necessarily targeted more than other aid organizations. While the three most shocking attacks were all against MSF facilities, other aid organizations face violence at roughly the same rate, and have to make choices based on risk and security in the same way.

Karunakara thinks the incidence of violence against MSF, specifically, can be explained by two factors. First, “As an international organization, we can bring much more resources to bear on a particular incident. So, we have a loud voice and you hear about it.” Second, “As an organization, given our experience and capacity, we tend to be in highly insecure areas, more so than other organizations.” While it may seem as though MSF experiences are more at threat than other groups, in fact, violence against health workers is truly universally felt.

Amidst all these complex political and humanitarian concerns, organizations must find a balance between taking risks and making compromises. In this new age of security, it is clear that organizations are thinking more critically than in the past about risk, safety, and their ability to deliver aid to those who need it most. Each organization answers these questions differently; each is bound by institutional capacity and objectives. Therefore, while experts in the field feel that organizations are becoming increasingly risk-averse, they still do what they can to push geopolitical boundaries. At the end of the day, despite any dangers, medical humanitarian workers have one objective: to provide care. The stakes are high if they fail.

While a clear consensus has not been reached about whether the perceived increase in violence is historically exceptional, most agree that the aid community has entered an age of security. Whether exceptional or not, violence against aid workers is changing the significance of international legal bodies, limiting the populations that organizations can reach, and normalizing the politicization of health. The image of doctors and patients being shot from above as they ran from a burning hospital is not a forgettable one. It is crucial in the coming years, as medical humanitarian workers navigate complex and often violent political climates, that those who work in global health never forget the injustices that have occurred against humanitarian medical workers.


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