Sarajevo on the morning of 29 May1992. The Serbian forces have surrounded the city. A Bosnian field commander reassures Esma Zecevic, the city’s chief paediatrician that the hospital will likely be safe. Why bombard a hospital? To what end? But that afternoon, the hospital is targeted. Amid gunfire and shell bursts, obstetric staff fight to get seventeen pre-term babies into the basement. Minutes later the ward is destroyed. In the following days, without warmth, electricity, or incubators, nine of the babies died. 

Thus opens Perilous Medicine: The Struggle to Protect Healthcare from the Violence of War, a major new book on healthcare in armed conflict from Leonard Rubenstein, destined to become a landmark in its field. When I first met Len—I was a little wet behind the ears—he worked for Physicians for Human Rights US. Unbeknownst to him he became something of an inspiration for me, a gentle, witty, self-deprecating authority. He is now at Johns Hopkins, and Perilous Medicine reads like a summation of a lifetime’s experience, much of it hands on, at the interface between healthcare, human rights, and conflict. 

The backbone of this sobering, deeply humane book is a series of case studies—accounts of the targeting or politically motivated corruption and misuse of healthcare during times of conflict. Many of the places the book visits have become bywords for inhumanity, places of bitter, often enduring hostility or calamitous political failure. In Chechnya, a Russian Republic between the Black and Caspian seas, we see summary Russian executions of Chechnyan men in their hospital beds, of the Russian hunt for the “bandit doctor,” Kassan Baiev, whose “crime” was seeking to save the lives of the horrifically injured, Russian or Chechnyan. At one point, following the Chechnyan retreat from the Russian bombardment of Grozny, Baiev operated for three days solid. Twice he fainted from exhaustion. “I cut through so much bone,” he wrote, “that the teeth at the centre of my hacksaw blade became dull.” 

When the Islamic State of Iraq and the Levant, better known in the west as ISIS, began to accrue territory, it faced a challenge familiar to all “successful” insurrections: how do you provide services to the populations under your control? The approach to healthcare was brutal: ISIS demanded its own fighters were prioritised; civilian wounded were charged exorbitant fees; hospitals were emptied of the sick to make room for ISIS wounded; doctors were compelled to treat—and prioritise—ISIS fighters. Omar Amouri, an orthopaedic surgeon, was forced to treat ISIS fighters for two and a half years before escaping to Kurdistan.

At times in Perilous Medicine the entire science and enterprise of medicine feels under existential attack. In 2018-19, during an Ebola outbreak, the Democratic Republic of the Congo saw “the most sustained and dramatic instance in memory of violence directed against well-funded and globally coordinated efforts to control a major outbreak of a deadly infectious disease.” Before shooting Richard Valery Mouzoko Kiboung, a Cameroonian epidemiologist working in a hospital in Butembo, close to the Ugandan border, his killers told him that Ebola did not exist in the DRC. 

Perilous Medicine chooses its case studies carefully. Not only are they accounts of healthcare and its professionals under attack, each example reveals different dimensions of the contemporary threat to international humanitarian law (IHL). For each case study is also an account of a certain kind of failure—a failure by one or other combatant to show even residual respect for the laws hammered out in response to the limitless suffering of war waged without restraint. 

For as long as there have been recorded wars, there has been dispute about whether morality has any part in it. As Michael Walzer writes in Just and Unjust Wars, there have always been those who claim that warfare stands outside—or beneath—morality: inter arma silent leges: in times of war the law is silent. But as Walzer also argues, the language we use to talk about war is saturated with moral meaning. We talk of cowardice and bravery, savagery and restraint, necessity and atrocity. The words come naturally to us. 

Perilous Medicine opens with an account of a more recent version of this dispute. On the one hand, Henry Dunant, whose experience of slaughter at the battle of Solferino, Lombardy, sparked the development of the Geneva Conventions. On the other Prussian-born writer and soldier Francis Lieber, who thought war a form of moral energy essential to a country’s “moral progress.” While Dunant argued for restraint, Lieber believed the exigencies of war permitted far more. Although not amoral—Lieber supported some restraint—in his view whatever was “necessary” to the speediest conclusion of war was justified. Only acts unnecessary to that end were prohibited.

In theory, and on paper, Dunant’s view prevailed. The Geneva Conventions and their several Protocols are the core of IHL. But while Dunant prevailed morally, the merciless pursuit of military goals, irrespective of any constraining rule or injunction, continues to disfigure modern conflict. Perilous Medicine takes us to Syria and the deliberate targeting of health services and personnel by Assad’s regime and its Russian allies; to Yemen and the relentless Saudi assault on hospitals, clinics, and civilian sanitation networks, resulting in the largest Cholera outbreak on record; to Myanmar and the Tatmadaw—Myanmar’s military—attacks on health workers serving intensely vulnerable minority communities; to Israel/Palestine and the “obstruction” of vital health services to the Palestinian people by the Israel Defence Forces. All these violations of IHL in some way rationalised by security or “military necessity.”

Perilous Medicine is an important and necessary book. Partly this is to do with the precision and thoroughness of its account of violations of health-related IHL. But also because it deliberately asks an urgent question. Although it is unlikely that there was ever “a golden age” of warfare, where restraint prevailed in pursuit of just military goals, it can nonetheless feel as if we are sliding back into barbarism. The Balkan Wars, waged in the continent that first conceived of the Geneva Conventions—and spearheaded the contemporary human rights movement—felt like a watershed. Since then, particularly in the wars disfiguring the greater Middle East, conflict rages without apparent restraint. So how are we to respond? Perilous Medicine is clear that political will—the expenditure of political capital by major powers—is vital. So too is continued agitation by civil society—public opinion can matter, even to apparently hardened regimes. But for BMJ readers, a critical “untapped” resource is the medical community. “With some notable exceptions,” Len writes:

“…health worker constituencies have rarely made protection of health care a priority domestically, where it is most needed. They could lobby governments, tell the stories of the risks to health care, and solicit support from the public, organize their members, and express solidarity with those who practice in dangerous, overwhelming circumstances.”

Exceptions include the Turkish Medical Association, and, I would argue, the Norwegian Medical Association along with one of my employers, the British Medical Association. For those committed to the concept of just war, and to the constraints and protections laid out in the Geneva Conventions, these are clearly difficult times. As Len Rubenstein writes, the appeal of overwhelming and indiscriminate force is again in ascendance. But this is not the time to despair. As Len writes, although countering this brutality will take a supreme effort “the costs in suffering and death are too great not to try.”

Julian Sheather is a writer and ethicist

Competing interests: none declared.