In 1989, Serbian forces dissolved the government of the local Kosovars and absorbed the Kosovar health system into the Serbian administration. This move dramatically limited access to healthcare for the people of Kosovo. Three years later, the Kosovo Liberation Army’s (KLA) increasingly violent clashes with Serbian forces highlighted the need for a Kosovar field health system, serving both combatants and civilians.
The article “Field-Improvised War Surgery in Kosovo: Use of Kitchen Utensils as Surgical Instruments” [gated] in the journal Military Medicine tells the compelling story of a Kosovar field hospital hidden in the Molopolce mountain region:
The conflict in Kosovo left surgeons and medical personnel with limited supplies during a time of war. The field hospital, located in a three-story building in the Molopolce mountain range, consisted of one operating theater, one recovery room, one examination room, and a room where minor surgical procedures could be performed (Fig. 1). At the Nerodime field hospital, skilled surgeons had to resort to the use of simple kitchen utensils as tools in the operating theater. Utensils with handles of plastic were transformed into retractors and used during major abdominal operations (Fig. 2, 3). The concavity of tablespoons was taken advantage of, allowing these utensils to be employed as retractors during appendectomy procedures. A light used for theatrical stage shows was improvised and used to illuminate the surgical field during procedures at the field hospital.
In addition to the main field hospital, the Kosovars established several second-line clinics consisting of one physician and three nurses working out of a private home. These clinics treated postoperative and minor wounded patients, thus increasing bed avalilablity in the main field hospital.
The incredible story of this make-shift health system in the Molopolce includes an equally dramatic ending.
After a NATO air strike on Yugoslavia in March 1999, the Serbian campaign more aggressively bombarded the Molopolce mountain region. A Serbian operation was launched in the eastern and southern areas and advanced in the direction of the KLA-controlled area. Eventually, an emergency midnight evacuation of all medical staff, patients, and remaining medical equipment was necessary. This evacuation was accomplished on a footpath through the hills with doctors and other medical personnel carrying patients on hand stretchers to a previously established rendezvous point located in a cave.
Recently, I have been reading treaties on war to find out how hospitals and health systems were legally handled during wartime. So far as I can tell, Article 17 of the Brussels Declaration of 1874 is the earliest instance of the codification of military behavior towards hospitals:
In such cases all necessary steps must be taken to spare, as far as possible, buildings dedicated to art, science, or charitable purposes, hospitals, and places where the sick and wounded are collected provided they are not being used at the time for military purposes. It is the duty of the besieged to indicate the presence of such buildings by distinctive and visible signs to be communicated to the enemy beforehand.
I am a first generation American from Zimbabwean parents, and so the recent events in Zimbabwe have had a particular personal significance. On April 29th, the Times Online reported on the growing evidence Zimbabwean government officials, including the Minister of Health, are using the nation’s health system to facilitate violence against opposition supporters. Accusations include using hospital grounds for political rallies, threatening physicians treating opposition victims of violence, raiding medical wards, and seizing patient lists. Opposition members have reportedly resorted to seeking treatment at sympathetic private clinics.
As evidence of increasing government-sponsored violence against the Zimbabwean opposition mounts a pattern is emerging of deliberate attempts to obstruct medical treatment for its victims and to cover up the violence. The Zimbabwean Minister of Health and other doctors who are linked to the ruling party have been implicated in orchestrating the violence and using government medical facilities for their activities.
The US Ambassador to Zimbabwe James McGee (my new hero) experienced this first hand in May when himself and other diplomats were detained for 45 minutes after visiting hospitals outside the capital to document violence against opposition supporters.
The diplomats involved in the incident at a roadblock on the edge of the capital, Harare, had just completed a tour of hospitals and an alleged torture camp when police demanded they prove they had official permission to visit the sites.
At one point, a police officer threatened to beat one of Mr. McGee’s senior aides. The officer got into his car and lurched toward Mr. McGee after he had demanded the officer’s name. The car made contact with Mr. McGee’s shins, but he was not injured.
Mr. McGee climbed onto the hood of the car while his aide snatched the keys from the ignition, then the diplomats used their mobile phone cameras to take photographs of the officer.
Zimbabwe’s healthcare system is already in deep trouble and these reports do not make me hopeful for the country’s health prospects in the future.
Iraqi forces swept unopposed into Baghdad’s Sadr City today after a compromise with firebrand cleric Moktada al-Sadr. Most commentary focused on the impressive showing of the Iraqi Army, which conducted the operation largely independently. However, I (and also Dr. iRack from Abu Muqawama) noticed something else:
By late Tuesday, Iraqi troops had pushed deep into the district and set up positions around hospitals and police stations, which the Iraqi government was seeking to bring under its control.
A primary target for Iraqi forces seems to have been the facilities providing health services in the area. In the recent weeks Al-Sadr’s militia has tried to use ownership of these services to gain support amongst the population. Now with Iraqi forces firmly in control of Sadr City’s hospitals, it is a race against time to expand and improve available health services to win the support and loyalty of local residents.
Dr. Irack put it well: “[counterinsurgency] is a contest to influence and control the population”. The provision of health services is a low cost, yet powerful, approach to winning that contest. Those providing health services have a significant advantage in winning hearts, minds, and legitimacy in the population. By providing services, the government is aligning itself with the population’s interest. From then on, insurgent attacks are not simply a strike by one side against another, but an attack against the providers of the population’s health. In turn, the population is more willing to cooperate with local security forces in routing out insurgents and sympathizers. If in counterinsurgency populations are the battlefields, then hospitals are part of the commanding heights.
At approximately 10:00am on May 3rd, the United States fired three precision-guided weapons at a small building next to Sadr General Hospital in the Sadr City slum of Baghdad. The building is alleged by coalition forces to be a “criminal element command and control center“. The first munition struck the small building, the second struck the hospital’s ambulance parking lot and broke the hospital’s water line, and the third hit a generator used by the neighborhood but not the hospital.
McClatchy’s Leila Fadel and Shashank Bengali described the damage:
Sadr Hospital, one of two main hospitals serving the massive Shiite Muslim slum, is operating on a backup water supply that wasn’t expected to last longer than 48 hours. On Sunday afternoon, a main street outside the hospital was flooded as workmen tried to repair a series of underground pipes that ruptured when the missiles targeted what U.S. military officials described as a militia outpost a few yards from the hospital.
“If there are no more attacks, we might be able to fix it. We don’t know,” said a hospital security official who gave his name as Abu Sajjad. “Otherwise, in two days we will run out of water and the hospital can’t go on.”
The official said that the U.S. strike also damaged 15 ambulances and forced many hospital staff to flee. Not everyone returned to work Sunday, leaving a Spartan emergency ward nearly empty of doctors.
The airstrike betrays an understandable ignorance in coalition forces towards the nature of health care delivery. While coalition forces avoid targeting hospitals directly, this does not protect the ability of the hospital to function. The rational for not striking hospitals is to keep them operating and providing health to the local population. However, any hospital’s functions are reliant on a large network of facilities and services. This network includes ambulance facilities and water lines. Most of these network nodes exist outside the hospital’s physical perimeter and whose presence is not calculated into airstrike planning. If policy makers truly want to maintain access to healthcare during armed conflict they must consider not only the hospital’s physical facilities but also key nodes in the area’s health care network, regardless of whether or not they fly the red cross.
Security at Iraqi hospitals is provided by the Facilities Protection Service (FPS), the security wing of the Ministry of Interior. Officially a 4,000 strong force created to free up coalition forces from static building protection duties after the looting in Baghdad, by 2006 it had reportedly bloated to over 145,000 men. Furthermore, around the same time, the FPS was connected to a number of sectarian death squads operating in Iraq. To rein in the FPS, the Iraqi Ministry of the Interior (MOI) has started incorporating all FPS units under a unified command.
Alive in Baghdad, a weekly video blog employing Iraqi journalists to produce videos on daily life in Iraq, has a piece on the FPS guards at the Ibn Al-Nafees Hospital in Bagdad’s Karrada neighborhood. Despite their negative portrayal in the media, the guards are shown to be dedicated civil servants. They protect hospital personnel, facilities, and ambulances, and sometimes even assist with medical treatments. But wait, how can the FPS be both a tool of militant death squads and the guardian angel of the Iraqi healthcare system?
The answer lies in the convoluted nature of the FPS. While FPS personnel are (atleast on paper) part of the Ministry of the Interior, most of the guards work for and are paid by the ministry whose facilities they protect. Thus, when Lt. Colonel Mu’ayad Abd Al-Hasssan Taqfiq, the FPS officer in charge of hospital security, speaks about working “in cooperation with the Ministry of Interior and the Army”, he shows that his hospital guards, while FPS, do not consider themselves part of the MOI but rather part of the Iraqi Ministry of Health.