{"id":51101,"date":"2021-10-08T13:43:29","date_gmt":"2021-10-08T12:43:29","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=51101"},"modified":"2021-10-08T13:43:29","modified_gmt":"2021-10-08T12:43:29","slug":"julian-sheather-perilous-medicine","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/10\/08\/julian-sheather-perilous-medicine\/","title":{"rendered":"Julian Sheather: Perilous medicine"},"content":{"rendered":"<p><span style=\"font-weight: 400\">Sarajevo on the morning of 29 May1992. The Serbian forces have surrounded the city. A Bosnian field commander reassures <\/span><span style=\"font-weight: 400\">Esma Zecevic, the city\u2019s 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.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Thus opens <\/span><i><span style=\"font-weight: 400\">Perilous Medicine: The Struggle to Protect Healthcare from the Violence of War<\/span><\/i><span style=\"font-weight: 400\">, <\/span><span style=\"font-weight: 400\">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\u2014I was a little wet behind the ears\u2014he 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 <\/span><i><span style=\"font-weight: 400\">Perilous Medicine <\/span><\/i><span style=\"font-weight: 400\">reads like a summation of a lifetime\u2019s experience, much of it hands on, at the interface between healthcare, human rights, and conflict.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The backbone of this sobering, deeply humane book is a series of case studies\u2014accounts 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 &#8220;bandit doctor,&#8221; Kassan Baiev, whose &#8220;crime&#8221; 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. &#8220;I cut through so much bone,&#8221; he <\/span><a href=\"https:\/\/fivebooks.com\/book\/oath-by-khassan-baiev\/\"><span style=\"font-weight: 400\">wrote<\/span><\/a><span style=\"font-weight: 400\">, &#8220;that the teeth at the centre of my hacksaw blade became dull.&#8221;\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">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 &#8220;successful&#8221; insurrections: how do you provide services to the populations under your control? T<\/span><span style=\"font-weight: 400\">he 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\u2014and prioritise\u2014ISIS fighters. Omar Amouri, an orthopaedic surgeon, was forced to treat ISIS fighters for two and a half years before escaping to Kurdistan.<\/span><\/p>\n<p><span style=\"font-weight: 400\">At times in<\/span><i><span style=\"font-weight: 400\"> Perilous Medicine<\/span><\/i><span style=\"font-weight: 400\"> 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 &#8220;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.&#8221; 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.\u00a0<\/span><\/p>\n<p><i><span style=\"font-weight: 400\">Perilous Medicine<\/span><\/i><span style=\"font-weight: 400\"> 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 <\/span><span style=\"font-weight: 400\">an account of a certain kind of failure\u2014a 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.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">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 <\/span><i><span style=\"font-weight: 400\">Just and Unjust Wars<\/span><\/i><span style=\"font-weight: 400\">, there have always been those who claim that warfare stands outside\u2014or beneath\u2014morality: <\/span><i><span style=\"font-weight: 400\">inter arma silent leges<\/span><\/i><span style=\"font-weight: 400\">: 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.\u00a0<\/span><\/p>\n<p><i><span style=\"font-weight: 400\">Perilous Medicine <\/span><\/i><span style=\"font-weight: 400\">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\u2019s &#8220;moral progress.&#8221; While Dunant argued for restraint, Lieber believed the exigencies of war permitted far more. Although not amoral\u2014Lieber supported some restraint\u2014in his view whatever was &#8220;necessary&#8221; to the speediest conclusion of war was justified. Only acts unnecessary to that end were prohibited.<\/span><\/p>\n<p><span style=\"font-weight: 400\">In theory, and on paper, Dunant\u2019s view prevailed. The <\/span><a href=\"https:\/\/www.icrc.org\/en\/war-and-law\/treaties-customary-law\/geneva-conventions\"><span style=\"font-weight: 400\">Geneva Conventions<\/span><\/a><span style=\"font-weight: 400\"> 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. <\/span><i><span style=\"font-weight: 400\">Perilous Medicine<\/span><\/i><span style=\"font-weight: 400\"> takes us to Syria and the deliberate targeting of health services and personnel by Assad\u2019s regime and its Russian allies; to Yemen and the relentless Saudi assault on hospitals, clinics, and civilian sanitation networks, resulting in the largest <\/span><a href=\"https:\/\/www.outbreakobservatory.org\/outbreakthursday-1\/1\/16\/2020\/large-cholera-outbreak-on-record-continues-in-yemen\"><span style=\"font-weight: 400\">Cholera outbreak<\/span><\/a><span style=\"font-weight: 400\"> on record; to Myanmar and the Tatmadaw\u2014Myanmar\u2019s military\u2014attacks on health workers serving intensely vulnerable minority communities; to Israel\/Palestine and the &#8220;obstruction&#8221; 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 &#8220;military necessity.&#8221;<\/span><\/p>\n<p><i><span style=\"font-weight: 400\">Perilous Medicine<\/span><\/i><span style=\"font-weight: 400\"> 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 &#8220;a golden age&#8221; 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\u2014and spearheaded the contemporary human rights movement\u2014felt 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? <\/span><i><span style=\"font-weight: 400\">Perilous Medicine<\/span><\/i><span style=\"font-weight: 400\"> is clear that political will\u2014the expenditure of political capital by major powers\u2014is vital. So too is continued agitation by civil society\u2014public opinion can matter, even to apparently hardened regimes. But for <\/span><i><span style=\"font-weight: 400\">BMJ<\/span><\/i><span style=\"font-weight: 400\"> readers, a critical &#8220;untapped&#8221; resource is the medical community. &#8220;With some notable exceptions,&#8221; Len writes:<\/span><\/p>\n<p><i><span style=\"font-weight: 400\">&#8220;\u2026health 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.&#8221;<\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\">Exceptions include the Turkish Medical Association, and, I would argue, the Norwegian Medical Association along with one of my employers, the <\/span><a href=\"https:\/\/www.bma.org.uk\/what-we-do\/working-internationally\/our-international-work\/human-rights\"><span style=\"font-weight: 400\">British Medical Association<\/span><\/a><span style=\"font-weight: 400\">. 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 &#8220;<\/span><span style=\"font-weight: 400\">the costs in suffering and death are too great not to try.&#8221;<\/span><\/p>\n<p><em><strong><span class=\"il\">Julian<\/span>\u00a0<span class=\"il\">Sheather<\/span><\/strong>\u00a0is a writer and ethicist<\/em><\/p>\n<p><em><strong>Competing interests<\/strong>: none declared.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Sarajevo on the morning of 29 May1992. The Serbian forces have surrounded the city. A Bosnian field commander reassures Esma Zecevic, the city\u2019s chief paediatrician that the hospital will likely [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2021\/10\/08\/julian-sheather-perilous-medicine\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":66,"featured_media":51102,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[954],"tags":[],"class_list":["post-51101","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-julian-sheather"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Julian Sheather: Perilous medicine - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2021\/10\/08\/julian-sheather-perilous-medicine\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Julian Sheather: Perilous medicine - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Sarajevo on the morning of 29 May1992. 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