10 Rules of War: Protecting Healthcare Workers and Facilities in Conflict Zones

This article was exclusively written for The European Sting by Ms. Sadia Khalid,a dedicated professional with an extensive academic background, holding an MBBS and an MD degree. She is affiliated with the International Federation of Medical Students Associations (IFMSA), cordial partner of The Sting. The opinions expressed in this piece belong strictly to the writer and do not necessarily reflect IFMSA’s view on the topic, nor The European Sting’s one.

In armed conflicts worldwide, the principles of international humanitarian law (IHL) serve as a protective framework to safeguard those who are not actively engaged in combat, particularly civilians, medical workers, aid workers, and vulnerable populations such as the wounded and sick. This framework, encapsulated primarily in the Geneva Conventions, establishes the “rules of war” that prohibit targeting healthcare workers and facilities. Yet, in modern conflict zones, these protections are increasingly under threat as healthcare facilities become battlegrounds.

Rule 1: Protect Civilians

One of the most fundamental tenets of IHL is the protection of civilians who do not participate in hostilities. This rule prohibits any intentional harm against civilians and calls for combatants to minimize risks to civilian populations. However, recent conflicts have seen repeated violations of this principle, with civilians often caught in crossfire and healthcare settings increasingly exposed to danger.

Rule 2: Medical Personnel Are Off-Limits

Healthcare workers have a unique position in conflict: their role is solely to save lives and care for the injured. IHL strictly prohibits attacks on medical personnel. Despite this, violence against healthcare workers has surged in recent years. Since 2015, Médecins Sans Frontières (MSF) has lost 26 staff members in ten attacks across conflict zones, including Afghanistan, Syria, and Yemen. In 2015, a U.S. airstrike destroyed MSF’s trauma hospital in Kunduz, Afghanistan, killing 42 people, including 14 staff members. This attack exemplifies the severe impact of disregarding the protections for healthcare workers.

Rule 3: Protect Medical Facilities

Hospitals and clinics are designated as neutral grounds under IHL, meaning they should never be targeted. Yet, this rule is frequently ignored in practice. In 2020, a maternity wing in Kabul, Afghanistan, operated by MSF, was stormed by armed groups, killing 16 women and an MSF midwife. In Yemen, MSF-supported facilities have been bombed multiple times, with ambulances often stopped or attacked. These incidents show how medical facilities have become high-risk zones, despite the protections in place.

Rule 4: Avoid Indiscriminate Attacks

IHL prohibits indiscriminate attacks that do not distinguish between military targets and civilians. This includes any act that could harm non-combatants or civilian structures, particularly hospitals and clinics. Violations of this rule are increasingly common, leading to calls for stronger accountability for these indiscriminate acts of violence.

Rule 5: Safeguard the Wounded and Sick

Under IHL, the wounded and sick, regardless of their affiliation, should receive necessary care. Denial of medical assistance is considered a breach of this rule. For example, an MSF ambulance was detained by armed men in Mali in 2021, resulting in the death of a patient due to delayed care. In Gaza, where health facilities are already strained, 885 healthcare workers have reportedly died in recent conflicts, further exacerbating the humanitarian crisis.

Rule 6: Allow Access for Medical Aid

Parties to conflict must allow humanitarian organizations to provide medical aid and supplies. Restrictions on aid delivery or targeting of medical convoys violates this rule. MSF has reported multiple instances of their aid efforts obstructed by both state and non-state actors, putting more lives at risk.

Rule 7: No Criminalization of Medical Aid

Healthcare workers should not face criminal charges for providing medical care to individuals on either side of a conflict. However, counter-terrorism laws in various regions criminalize aid in territories controlled by groups labelled as terrorists. This restriction endangers healthcare providers who, in adherence to medical ethics, prioritize life-saving assistance over political affiliations.

Rule 8: Ensure Accountability for Violations

When violations of IHL occur, independent investigations and accountability are essential to prevent recurrence. For example, after the Kunduz hospital bombing, MSF sought accountability through the International Humanitarian Fact-Finding Commission, a Geneva Convention entity. However, the United States declined to participate in the investigation, reflecting the ongoing challenges in enforcing accountability.

Rule 9: Enable Humanitarian Access Without Bias

Medical neutrality requires that humanitarian aid be provided impartially, without bias towards any party in a conflict. MSF and other organizations routinely communicate with conflicting parties to uphold their neutral stance, marking their facilities clearly to avoid misunderstandings. This dialogue is essential but requires constant effort to remind all sides of the humanitarian objective.

Rule 10: Demand Compliance from All Parties

Even with resolutions like United Nations Security Council Resolution 2286, which reinforced protections for healthcare in conflict zones, the reality on the ground remains bleak. Five years after the resolution’s adoption, medical facilities and personnel are still frequently targeted. UN expert Tlaleng Mofokeng recently condemned the death of Dr. Ziad Eldalou, a Gaza physician who died in Israeli custody, marking a grim milestone in the ongoing disregard for healthcare protection in Gaza. Mofokeng called for the immediate release of 128 detained healthcare workers and urged independent investigations and accountability, asserting that these repeated attacks on healthcare facilities and personnel may constitute war crimes.

Healthcare workers are risking their lives daily in some of the world’s most volatile regions. Despite IHL’s 10 fundamental rules aimed at safeguarding medical neutrality, violations continue to mount. To ensure that healthcare providers can operate safely, states must reassert their commitment to IHL protections and hold violators accountable. Without concrete actions and adherence to these principles, the sanctity of healthcare in war zones remains under dire threat, leaving millions without access to essential, life-saving medical care.

About the author

Sadia Khalid is a dedicated professional with an extensive academic background, holding an MBBS and an MD degree. She is an Early-stage Researcher (ESR), accomplished Medical Writer, and Research Engineer based at Tallinn University of Technology (TalTech) in Estonia.
Sadia’s research interests span a wide spectrum within the realm of medical sciences, including Molecular Medicine, Cell Biology, Infectious Diseases, Bacteriology, Hepatology, and Gastroenterology. Her work is underpinned by a strong belief in the mission of promoting public health, safety, and awareness.