plos PLoS Currents: Disasters 2157-3999 Public Library of Science San Francisco, USA 10.1371/currents.dis.1a1e352febd595087cbeb83753d93a4c Brief Report The Solidarity and Health Neutrality of Physicians in War & Peace Burkle Frederick M. Jr. Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, USA; The Woodrow Wilson International Center for Scholars, Washington, DC, USA

Professor Burkle, MD, MPH, DTM, PhD(Hon.), is a Senior Fellow with the Harvard Humanitarian Initiative, Harvard University, and Visiting Scientist at the Harvard School of Public Health. He is a Senior International Public Policy Scholar at the Woodrow Wilson Center for International Scholars in Washington DC, and Senior Associate Faculty, Department of International Health and the Center for Refugee & Disaster Response, Johns Hopkins University Medical Institutes. He holds Adjunct Professorships at Monash University School of Medicine and James Cook University in Australia and is Adjunct Professor of Surgery, Division of Military and Emergency Medicine, the Uniformed Services University of the Health Sciences in Bethesda, MD. He is the recipient of the prestigious William Crawford Gorgas Medal for "distinguished work in preventive medicine, groundbreaking work in disaster management and humanitarian assistance and the training of an entire generation of U.S. and international personnel. ”In 2007 he was elected to the Institute of Medicine of the National Academies of Sciences. In 2012 he was selected by the National Institutes of Health to give the Joseph Leiter Award lecture recognizing the “best and brightest” in science and medicine. Dr. Burkle has published over 200 scientific articles, 53 book chapters, four books, three on disaster management including Disaster Medicine (1984). He has worked in and consulted on numerous humanitarian emergencies and large-scale international disasters in Asia, Africa, the Middle East, and Eastern Europe. From 2002-03, Dr. Burkle served as Deputy Assistant Administrator for the Bureau of Global Health at the U.S. Agency for International Development and as the Interim Minister of Health in Iraq. A 1961 Saint Michael’s College and 1965 University of Vermont College of Medicine graduate, Dr. Burkle holds post-graduate degrees from Yale, Harvard, Dartmouth, the University of California at Berkeley, University of Geneva, and the Royal College of Surgeons in Ireland. He is qualified in Emergency Medicine, Pediatrics, Pediatric Emergency Medicine, Psychiatry, and holds a Master's Degree in Public Health and Diploma in Tropical Medicine. He is a combat decorated and now retired Naval Reserve Captain, who served with the Marines in Viet Nam, Somalia, the Persian Gulf War, and Iraq. He is a current member of the Board of Directors and Overseer of the International Rescue Committee, the world’s largest refugee organization, the Science Advisory Board of the American Red Cross, and served as Chair of the National Disaster Life Support Consortium of the American Medical Association for 4 years.

Erickson Timothy ChiefBrigham and Women's Hospital, Harvard Medical School, Harvard Humanitarian Initiative, Harvard University von Schreeb Johan Centre for Research on Health Care in Disasters, Health System and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

MD. PhD. Associate professor, Specialist in general surgery Centre for reserach on health care in disasters Department of Public Health Karolinska Institutet Stockholm, Sweden
Kayden Stephanie ChiefBrigham and Women's Hospital, Harvard medical School Redmond Anthony Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK

Professor of International Emergency Medicine Head, WHO Collaborating Centre for Emergency Medical Teams and Emergency Capacity Building Deputy Director Humanitarian and Conflict Response Institute University of Manchester +44(0)161 275 0464 Chairman, UK-Med

Chan Emily YY Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong S.A.R., China, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom, FXB Centre of Health and Human Rights, Harvard University, Cambridge, Massachusetts, USA Della Corte Francesco Research Center in Emergency and Disaster Medicine and Computer Science applied to Medicine (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy Cranmer Hilarie Director, Global Disaster ResponseMassachusetts General Hospital Otomo Yasuhiro Professor and ChairmanTokyo Medical and Dental University Johnson Kirsten McGill University

Dr. Kirsten Johnson practices Emergency Medicine at McGill University's Health Centres and she is an Assistant Professor in the Department of Family Medicine at McGill University in Montreal, Canada. Her research has focused on genocide, child combatants, sexual gender-based violence and conflict-related mental health and psychosocial support. As CEO of Humanitarian U, she is involved in humanitarian professionalization, working on the development of competencies and standards for the training, education and certification of humanitarian responders globally. In 2010, Dr. Johnson was awarded the Segal Centre’s Januscz Korczak award for her work on protecting the rights of children in conflict and the Award of Excellence for her work in global health by the College of Family Physicians of Canada. She was recognized as one of Canada’s Top 40 Under 40 in 2011.
Roy Nobhojit Dr. Centre for Research on Health Care in DisastersKarolinska Institutet
20 1 2017 ecurrents.dis.1a1e352febd595087cbeb83753d93a4c 2019 Burkle, Erickson, von Schreeb, Kayden, Redmond, Chan, Della Corte, Cranmer, Otomo, Johnson, Roy, et al This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The wars in the Middle East have led to unprecedented threats and attacks on patients, healthcare workers, and purposeful targeting of hospitals and medical facilities. It is crucial that every healthcare provider, both civilian and military, on either side of the conflict become aware of the unique and inherent protections afforded to them under International Humanitarian Law. However, these protections come with obligations. Whereas Governments must guarantee these protections, when violated, medical providers have equal duty and obligations under the Law to ensure that they will neither commit nor assist in these violations nor take part in any act of hostility. Healthcare providers must not allow any inhuman or degrading treatment of which they are aware and must report such actions to the appropriate authorities. Failure to do so leads to risks of moral, ethical and legal consequences as well as penalties for their actions and inactions. There must be immediate recognition by all parties of the neutrality of health care workers and their rights and responsibilities to care for any sick and injured patient, regardless of their nationality, race, religion, or political point of view.

The authors received no specific funding for this article.

As physicians, we are reminded of Sir William Osler’s 1906 speech to graduating medical students when he asserted that: “Medicine is the only world-wide profession, following everywhere the same methods, actuated by the same ambitions, and pursuing the same end. This homogeneity, its most characteristic feature, is not shared by the law or religion”, nor the “extraordinary solidarity which makes the physician at home in any country.”1

In the century that followed, no other profession has exhibited the influential number of international associations, societies and collaborative efforts as has medicine. The end of the Cold War brought multiple humanitarian crises and the development of international academic and educational training programs designed to prepare humanitarian workers for these complex global tasks. The rigorous curriculum includes the unique roles and responsibilities that healthcare providers have under the Post-World War II Geneva Convention (GC) and International Humanitarian Law (IHL) which ensures their right to international health neutrality.

Historically, war has caused the loss of countless lives and has ravaged the most vulnerable populations, especially women, children, the elderly and disabled. The humanitarian crises that wars create, and the manner in which the world responds, have changed with every generation.2 Present-day healthcare workers in public hospitals and non-governmental organizations in conflict zones have never faced greater risks. In fact, deaths among all humanitarian workers have outnumbered those of UN Peacekeepers in recent years.3

The cross-border territorial wars that dominated the 20th Century have been replaced by endless religious, ethnic and tribal conflicts that produce neither winners nor losers. The war in Afghanistan has raged on since 1979, in Somalia since 1991, and the recent Yemeni civil war since 2015. Yet, there is something especially abhorrent about the current war in Syria that should gain the attention of every healthcare provider and health policy maker. These alarming statistics are reminders of the egregiously barbaric quest of ancient wars, designed to ensure that no survivor would remain to take revenge:

As of June 2016, 757 healthcare personnel have been killed and 382 premeditated attacks have occurred on 269 separate medical facilities across Syria. One-hundred and twenty-two hospitals have been targeted multiple times.4 In the midst of this misery one cannot forget the US targeted aerial bombing of Médecins Sans Frontières hospital in Kunduz Afghanistan in October 2015 that killed 42 people, including 14 MSF staff members, and wounded dozens more.5

We must take notice and stand in solidarity with our healthcare colleagues in Syria where patients, healthcare workers, and hospitals are under constant threat and attack. We have the obligation to ensure that every health care provider, both civilian and military, on either side of the current conflict in Syria, be made aware of the inherent protections provided them under IHL, including the four GCs of 1949, as well as the principles and rules of IHL applicable to the conduct of hostilities, which include the targeting of hospitals and medical facilities. These principles and rules must be upheld.

Healthcare providers of the militaries involved on both sides of the conflict are granted provisions and protections under international laws clearly referenced in The Hague Statement on Respect for Humanitarian Principles (1991), UN Security Council Resolution 2286 on attacks against medical workers (2016) and military manuals of many States. As an example, the Russian Federation’s Military Manual (1990) states that attack against medical personnel constitute a prohibited method of warfare. The Russian Federation’s Regulations on the Application of IHL (2001) states: “Persons protected by international humanitarian law include medical and religious personnel. Attacks against such persons are prohibited.”

As such, healthcare providers, both civilian and military, including the Assad Government and the Russian Federation, must equally recognize that under IHL, their own medical military personnel, activities, units, transports, and hospitals are guaranteed protection against direct attack themselves (see rules 25 to 30 of the ICRC’s customary IHL study, as well as protections in the Geneva Conventions and their Additional Protocols). IHL requires Parties to ensure respect for IHL, including under common Article 1 to the four GCs. Failure to do so leads to risks of moral, ethical and legal consequences as well as penalties for their actions and inactions.

The World Medical Association (WMA) Regulations in Times of Armed Conflict and Other Situations of Violence6 assert that under IHL, healthcare providers can neither commit nor assist violations of IHL, nor take part in any act of hostility; must advocate and provide effective and impartial care to the wounded and sick (without reference to any ground of unfair discrimination, including whether they are the "enemy"); must remind their authorities of their obligation to search for the wounded and sick and to ensure access to health care without unfair discrimination; must not allow any inhuman or degrading treatment of which physicians are aware; must report to a commander or to other appropriate authorities if health care needs are not met; and must give consideration to how health care personnel might shorten or mitigate the effects of the violence in question, for example by reacting to violations of international humanitarian law or human rights law.

WMA summarizes the ethical obligations of physicians as follows:6

During times of armed conflict and other situations of violence, standard ethical norms apply, not only in regard to treatment but also to all other interventions. The medical duty to treat people with humanity and respect applies to all patients. Governments, armed forces and others in positions of power should comply with the GC to ensure that physicians and other health care professionals can provide care to everyone in need in situations of armed conflict and other situations of violence. This obligation includes a requirement to protect health care personnel and facilities. Privileges and facilities afforded to physicians and other health care professionals in times of armed conflict and other situations of violence must never be used other than for health care purposes.

Physicians should recognize the special vulnerability of some groups, including women and children. Provision of such care should not be impeded or regarded as any kind of offence, nor must they ever prosecuted or punished for complying with any of their ethical obligations. Physicians have a duty to press governments and other authorities to ensure they are planning for the protection of the public health infrastructure and for any necessary repair in the immediate post-conflict period. Necessary assistance, including unimpeded passage and complete professional independence, must be granted.

Healthcare Parties must be Identified and protected by internationally recognized symbols such as the Red Cross, Red Crescent or Red Crystal. Hospitals and health care facilities situated in areas where there is either armed conflict or other situations of violence must be respected by all combatants. Physicians must be aware that, during armed conflict or other situations of violence, health care becomes increasingly susceptible to unscrupulous practice and the distribution of poor quality / counterfeit materials and medicines, and must attempt to take action on such practices. As such, the WMA supports the collection and dissemination of data related to assaults on physicians, other health care personnel and medical facilities, by an international body. Assaults against medical personnel must be investigated and those responsible must be brought to justice.

In Syria, Yemen, and Afghanistan as well as in many other nations in conflict around the world, the following remedies must be implemented immediately:

1. The establishment of healthcare safe zones in conflict regions to ensure the integrity of hospitals, clinics, and medical centers.

2. Allowing safe and unfettered passage of medical supplies, equipment, and personnel.

3. Cessation of all attacks on patients, pre-hospital personnel, and hospital medical staff.

4. Recognition by all parties of the neutrality of health care workers and their rights and responsibilities to care for any sick and injured patient, regardless of their nationality, race, religion, or political point of view.

The authors are representatives of academic training centers worldwide that provide global health professionals with education and training in humanitarian assistance where every healthcare provider, both civilian and military, is made aware of the inherent protections accorded to them under international law.7 In the same Oslerian spirit of over a century past, we condemn absolutely these deplorable actions in Syria and demand their immediate cessation; and we ask healthcare providers globally to do the same.

Competing Interests

The opinions expressed in this article are the authors's own and do not reflect the view of their affiliated institutions.

Corresponding Author

Frederick M. Burkle, Jr.:

References Osler W. Aequanimitas, With other Addresses to Medical Students, Nurses and Practitioners of Medicine. P. Blakiston’s Son & Co., Philadelphia. 1925. Burkle FM, Jr, Martone G, Greenough PG. The Changing Face of Humanitarian Crises. Brown Journal of World Affairs, Brown University, Providence RI. Spring Issue: May 2014: 29-42. "UN: More aid workers killed than peacekeepers," Breaking News, August 19, 2009; Aid Worker Security Database, Project of Humanitarian Outcomes (2012). Physicians for Human Rights. Anatomy of a Crisis, a Map of Attacks on Health Care in Syria: Findings as of June 2016. Available at: Accessed 1 October 2016. Médecins Sans Frontières. Key MSF Articles, Statements, and Reports on Kunduz. April 28, 2016. Available at: Accessed 23 October 2016. World Medical Association. Regulations in Times of Armed Conflict and Other Situations of Violence. Available at: Accessed 10 October 2016. Heisler M, Baker E, McKay D: Attacks on Health Care in Syria — Normalizing Violations of Medical Neutrality? N Engl J Med 2015; 373:2489-2491.