Collective punishment and ‘conditions of life’ in dark times: tracking health consequences and accountability in contemporary conflicts

By 12th February the World Health Organization’s surveillance system for attacks on healthcare (WHO n.d.) had confirmed 135 attacks in the occupied Palestinian territories (oPt) in the first 43 days of 2024. As a result of these attacks, averaging three per day, there were 56 deaths and 89 injuries. The country with the second highest number of attacks for the same period was Ukraine with 33. At the time of writing, the Nasser Hospital in Gaza has been declared non-functional after a week of siege and an ongoing raid, and the WHO team were not allowed access (BBC News 2024). Meanwhile, the relentless ratcheting up of reported deaths passed 29,000 with no end in sight. These are the hard figures beneath which lie injury, sickness, hunger and trauma.

Speaking at an event organized by Harvard FXB Centre for Health & Human Rights (FXB Harvard 2024), Dr Tlaleng Mofokeng, the UN Special Rapporteur for the Right to Health, explained how present events in the oPt were ‘quite visceral’ for those who had grown up in apartheid South Africa. Dr Mofokeng described how the constant evacuations the residents of Gaza have been experiencing in a confined and insecure space are themselves a form of trauma and violence. Both physical and mental health consequences will be severe: a recent article in the British Medical Journal pointed out that: ‘The collective punishment of Gaza’s extremely young population amounts to a child health catastrophe, with lifelong and intergenerational consequences’ (Boukari et al. 2024).

Also, at the Harvard FXB event, the international lawyer Katherine Iliopoulos unpicked the links between ‘conditions of life’¹ referred to in Article II(c) of the Genocide Convention (OHCHR n.d.), and the normative development of the right to health. These links have precedents in discussions at the International Criminal Tribunals of Rwanda and the former Yugoslavia. Katherine Iliopoulos also talked about the obligation on the part of other states to prevent genocide, including by not becoming complicit in actions inflicting negative ‘conditions of life’ which violate the right to health and could ‘be expected’ to lead to large-scale death.

Knowing what is happening in Gaza does not have to depend on daily information and data – vital as that is. For years, now there has been research to show that the direct and indirect impacts on health from the use of explosive weapons in built-up areas are both predictable and unacceptable. A recent report by Action on Armed Violence (AOAV) showed that Operation Swords of Iron in Gaza in October 2023 resulted in a ‘spike in civilian deaths compared to previous Israeli air strikes, with an average of 10.1 civilian fatalities per casualty-causing strike’ (AOAV 2023). Talk of precise and targeted strikes in densely populated urban areas has little meaning, just as notification of air strikes is meaningless for patients on ventilators and others who are critically ill with nowhere to go.

Food security is dangerously precarious in Gaza given the ongoing blockade and severely limited humanitarian assistance. The Integrated Food Security Phase Classification (IPC) Famine Review Committee (FRC) was activated in relation to Gaza on 11 December 2023. In their detailed findings published on 21 December 2023 (IPC 2023), they found that the threshold for Catastrophe (IPC Phase 5) acute food insecurity had already been exceeded and reached a technical consensus that there was a Risk of Famine in the projection period to May 2024 if the current situation persisted or worsened. A pocket of famine next to Israel – a country with a GDP per capita of US$56,680 (IMF 2023) and the responsibilities of an occupier – is criminal.

Medicine Conflict & Survival has published many articles on the occupied Palestinian territories and Israel over the years. We plan to publish a collection of this writing to help ensure that the roots and historical context of the present conflict are remembered and given proper consideration. It is hoped that such a collection will contribute to conflict prevention and accountability as part of conflict resolution.

While the conflict in the Middle East dominates the media, other conflicts continue with devastating effect. This issue includes an article by Fayaz and Akash in which they assess the factors that lead to resilience among adults living in violence-affected areas of Kashmir, with the aim of helping to design effective interventions and support. Triangulating the opinions of victims, experts, and scholars, they identify the key factors in resilience formation and discuss implications for practice, policy, and future directions. A commentary by Konozy Sudan’s devastating war: unravelling its multifaceted impact describes the social, medical, educational and infrastructural dimensions of the devastating war that erupted in April 2023. They emphasize the importance of the ongoing peace talks, and advocate for the safety of civilians and the restoration of vital services to take precedence.

An article by Sasaki explores the use of avatars for storytelling to help evacuees express themselves and create a digital archive after the trauma of the Great East Japan Earthquake. Using the Memorytalk online platform, high school students who may usually be hesitant to talk about where they come from are provided with anonymity and can more freely express themselves through role distancing. This research offers great potential for a positive use of technology to address trauma, also in other situations.

The importance of medical professionals reporting human rights abuses in militarized zones is explored in a commentary by Uzman et al. Breaking silence in the shadows of conflict. While emphasizing the important role medical professionals can play in reporting and documenting human rights abuses, they also examine barriers and risks to reporting, and the ethical and legal dilemmas doctors can face.

The third commentary in this issue considers humanitarian security management using the earthquake relief operation in Syria as a case study; this follows a previous article by Hasenstab on pre-deployment training. Some organizations are found to have better security management capabilities than others, and investing more resources into robust pre-deployment security training is recommended.

IPPNW’s African region convened their first Congress, and IPPNW’s first hybrid congress, Disarmament, Climate Crisis and Health, on 26–30 April 2023 in Mombasa. In a comprehensive report, Khadka describes the impressive range of international speakers, including a Youth Panel, and sessions linking the climate crisis and nuclear weapons, nuclear famine, energy choices, nuclear brinkmanship, climate and conflict, and the Treaty on the Prohibition of Nuclear Weapons (TPNW). ‘We must prevent what we cannot cure’ was a strong Congress message, as was advocacy for a more peaceful and secure world, with freedom from the threats of nuclear annihilation and armed violence.

Three book reviews remind us that we have to learn from history, from Patterns of plague – changing ideas about plague in England and France, 1348–1750 (reviewed by Endicott), to Humanitarianism and Greater War 1914–1924 (reviewed by Bergen), and Florence Nightingale and the medical men – working together for health care reform (reviewed by Hallett). Five others cover more contemporary issues and analysis: Facilitating researchers in insecure zones. Towards a more equitable knowledge production (reviewed by Lewer), Humanitarian extractivism: the digital transformation of aid, humanitarianism: key debates and new approaches (reviewed by Birch), Unparalleled catastrophe: Life and death in the third nuclear age & Unmaking the bomb: environmental cleanup and the politics of impossibility (both reviewed by Loretz), and Understanding war and peace, 2nd edition (reviewed by Hagopian). The final review by Hutchins of The morality of the laws of war: war, law and murder is followed by an analytical, very thoughtful and personal reflection on applying the morality of the law of war to current conflicts, with a detailed consideration of the conflict in Gaza.

As always, we are very grateful to our authors and reviewers. We hope that readers of Medicine, Conflict & Survival will find the rich content of this issue provides a little illumination in dark times.

Notes

1. Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part.