In this paper, we propose the idea of weaponisation of health care to capture the phenomenon of large-scale use of violence to restrict or deny access to care as a weapon of war. Weaponisation is multi-dimensional and includes practices such as attacking health-care facilities, targeting health workers, obliterating medical neutrality, and besieging medicine. Through large-scale violations of international humanitarian laws, weaponisation of health care amounts to what has been called a “war-crime strategy”.Weaponisation of health care in the Syria conflict is manifested most notably in the targeting of health workers and facilities. The historical context is important to understand.

Findings from studieshave emphasised the need to better understand the plight of local and international health workers in conflict. The bulk of attacks occur in ongoing conflicts in Afghanistan, Somalia, South Sudan, Syria, and Yemen.National staff are the most exposed and the most common victims of attacks.When international organisations are forced out of an area, not only are local humanitarians the only groups that remain active, but the UN and other international non-governmental organisations also rely on them as implementation partners. Despite research efforts to document their plight, knowledge and evidence remains scarce.

The power of holding humanitarianism hostage and the myth of protective principles.

Violence against health care: insights from Afghanistan, Somalia, and the Democratic Republic of the Congo.

The ability of people in need to access health care depends on state and non-state armed groups respecting international humanitarian law provisions that protect health workers. Yet several of today's armed conflicts and resultant humanitarian crises are taking place in settings in which both state and non-state armed groups have shown disregard for the safety and lives of health workers, flagrantly violating applicable international humanitarian law with impunity.

The imperative for unobstructed humanitarian aid during armed conflicts is well established.The importance of allowing health workers to treat sick and wounded combatants led to the creation of the International Committee of the Red Cross (ICRC) in 1863 and drove the development of the humanitarian principles of impartiality, independence, and neutrality underlying the first international humanitarian law in 1864.The four Geneva Conventions, codified in 1949, define the obligations of nation states engaged in armed conflict.The Fourth Geneva Convention, which requires warring parties to refrain from hostile actions against civilian populations, established distinct protections for health and humanitarian workers who provide aid to wounded combatants of any side and to civilian populations.These protections under international humanitarian law confer treaty obligations on all signatory nations. Every country in the world has signed and ratified the 1949 Geneva Conventions; however, not all nation states have signed or ratified the Additional Protocols to the Geneva Conventions that expand and clarify the protections for medical and humanitarian personnel and civilian populations.These protections are recognised as a matter of customary international humanitarian law, which means even governments that have not ratified the relevant treaties are required to respect them.Finally, recognition by UN rights bodies that international human rights law and international humanitarian law provide for access to health care in wartime is increasing.

Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

WHO Committee on Economic Social and Cultural Rights. The right to the highest attainable standard of health.

Office of the UN High Commissioner for Human Rights International legal protection of human rights in armed conflict.

International Committee of the Red Cross Protocols additional to the Geneva Conventions of 12 August 1949.

International Committee of the Red Cross Convention (IV) relative to the protection of civilian persons in time of war. Geneva, 12 August 1949.

International Committee of the Red Cross Convention (I) for the amelioration of the condition of the wounded and sick in armed forces in the field. Geneva, 12 August 1949.

The Syria conflict has seen large-scale aerial bombing of civilian areas, committed by the government and its allies. The pattern of government attacks on civilian areas suggests that the government deems all civilians, including those providing medical care, living in opposition-controlled areas to be affiliated with terrorism, and hence as legitimate military targets. But, as international humanitarian law makes clear, even that designation is no justification for the Syrian Government's war crime of deliberately bombing civilian homes; attacking infrastructure vital to civilian life such as schools, bakeries, and markets; and forcing the displacement of over half the country's population. Nor does international humanitarian law permit the Government's attacks on health workers who provide care for civilians or injured fighters in these areas. Human Rights Watch and Amnesty International describe all of these practices by pro-government forces as war crimes.

Evolving practices in the weaponisation of health care

19 Human Rights Watch

Death from the skies. , 20 Amnesty International

Syrian government targets the wounded and healthcare workers. , 21 Sparrow A Syria's assaults on doctors. 22 Gulland A Doctors in Syria are being forced to treat patients in secret, charity says. , 23 Zarocostas J Hospitals in Syria have become instruments of suppression, says Amnesty. 24 al-Khalidi S Syrian forces shoot protesters, kill 6 in mosque. 24 al-Khalidi S Syrian forces shoot protesters, kill 6 in mosque. 21 Sparrow A Syria's assaults on doctors. 25 United Nations Human Rights Council

Assault on medical care in Syria. 26 Physicians for Human Rights

Perilous medicine: the legacy of oppression and conflict on health in Kosovo. 2009. Targeting of health workers by pro-government forces was identified as a problem early in the Syria conflict, well before any substantial militarisation.Doctors practicing in areas which witnessed protests were forced to treat patients injured in such protests in secret for fear of being arrested.The first documented execution of a doctor by pro-government forces occurred in March, 2011.In April 2011, Syrian forces began arresting doctors, patients, and paramedics in Douma and other areas of eastern Ghouta where protests took place.In September, 2011, the first intentional attack on a clearly-marked ambulance occurred in Homs.In July, 2012, the Syrian Government passed a counter-terrorism law effectively criminalising the provision of medical care to anyone injured by pro-government forces in protest marches against the government.The passing of this law was an effort to justify the arrests, detention, torture, and execution of health workers despite explicit and customary international humanitarian law protecting health workers from punishment for acts in accordance with medical ethics in international and non-international conflicts. Notably, Serbia enacted a similar law during the 1998–99 war in Kosovo.

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Doctors in the crosshairs: four years of attacks on health care in Syria. Table 1 Health workers killed in the Syria conflict, 2011–17 2011 2012 2013 2014 2015 2016 2017 Physicians for Human Rights 28 Physicians for Human Rights

Anatomy of a crisis: a map of attacks on health care in Syria. Findings as of July 2016. * * Excludes three deaths for which the year was impossible to ascertain. 48 190 180 177 107 77 † † January to September, 2016. .. Syrian Network for Human Rights 29 Syrian Network for Human Rights

Statistics from March 2011. ‡ ‡ Included medical and civil defence personnel. 34 87 110 118 § § May to December, 2014. 112 104 ¶ ¶ 31 Syrian network for Human Rights

Reports on vital facilities attacked August 2014 through December 2016. Excludes 63 health workers who were not deliberately killed. 12 Violations Documentation Center 30 Violations Documentation Center in Syria. 36 232 242 148 70 82 5 Targeting of health workers largely by pro-government forces has continued and takes many forms ( appendix ): attacks on health facilities, executions, imprisonment or threat of imprisonment, unlawful disappearance (ie, kidnapping), abduction, and torture sometimes leading to death. The perpetrators are primarily government forces. Abuses by non-government forces have also been reported.As a consequence of the targeting of health workers, hundreds of health workers have been killed. Whereas data from single sources are commonly reported, we have collated data from several sources including Physicians for Human Rights (PHR), Syrian American Medical Society (SAMS), Syrian Network for Human Rights (SNHR), and Violations Documentation Center in Syria (VDC) to minimise possible reporting bias ( table 1 ). Although all these sources confirm targeting and associated deaths of health works as a major problem, variations in reporting exist, reflecting different methods of classification and verification. This illustrates the difficulty of accurate documentation of attacks from within a conflict area.

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Anatomy of a crisis: a map of attacks on health care in Syria. Findings as of July 2016. Figure 1 Profile of a war-crime: health workers killed in the Syria conflict, 2011–16 Show full caption Adapted from Harvard Public Health magazine based on data from Physicians for Human Rights (updated March, 2017). From March, 2011, to September, 2016, at least 782 health workers have died in attacks on health-care facilities and in targeted attacks on individuals. *Veterinarians and veterinary students killed while treating people. PHR report that 782 health workers were killed, in violation of medical neutrality, from March, 2011, through to September, 2016 ( figure 1 ).Shelling and bombing accounted for 426 (55%) deaths, followed by shooting (180 deaths; 23%), torture (101 deaths; 13%), and execution (61 deaths; 8%). The Syrian Government and allied forces are responsible for 723 (92%) of these deaths. Doctors were the most targeted group of health workers, accounting for 247 (32%) of those killed. 176 (23%) nurses and 146 (19%) medics have been killed. Medical, dentistry, veterinary medicine, and pharmacy students were also targeted, accounting for 9% of those killed. Between Oct 1, 2016, and Feb 28, 2017, our review of data from SNHR, SAMS, and VDC indicate that at least an additional 32 health workers were killed, which brings the total number of health workers killed in acts of war crimes over the 6 years of the conflict to 814.

33 WHO

Attacks depriving people of urgently needed health care. 34 United Nations

Security Council adopts resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations. 31 Syrian network for Human Rights

Reports on vital facilities attacked August 2014 through December 2016. 32 Syrian American Medical Society

The failure of UN Security Council Resolution 2286 in preventing attacks on healthcare in Syria. Figure 2 Attacks on health facilities over the course of the crisis, 2012–16 Show full caption 28 Physicians for Human Rights

Anatomy of a crisis: a map of attacks on health care in Syria. Findings as of July 2016. 28 Physicians for Human Rights

Anatomy of a crisis: a map of attacks on health care in Syria. Findings as of July 2016. 32 Syrian American Medical Society

The failure of UN Security Council Resolution 2286 in preventing attacks on healthcare in Syria. Data for years 2012–15 were from PHR, findings as of July, 2016.Number of attacks in 2016 was calculated by summation of the 27 attacks reported by PHRfrom January to May, 2016, and 172 attacks reported by Syrian American Medical Societyfrom June to December, 2016. PHR=Physicians for Human Rights. Over time, targeting of health facilities emerged as a key feature in the weaponisation of health care and became more frequent ( figure 2 ), more conspicuous, and more widespread.This practice was so flagrant that it led the UN Security Council to condemn attacks on health workers and facilities in conflict in resolution 2286 on May, 2016.With the military surge that began in late September, 2015, when Russia joined Syrian Government forces, 2016 marked the worst year of the conflict to date in terms of attacks on medical facilities. SAMS documented 194 verified attacks, an 89% increase since 2015. SNHR reported 289 attacks on medical facilities, ambulances, and Syrian Arab Red Crescent bases, 96% of which were by Syrian or Russian forces.Notably, although PHR data for 2016 is only published up until July, and reporting only 54 attacks for 2016 (of a total of 400 attacks since March, 2011) PHR only reports on attacks against medical facilities that are protected in accordance with international humanitarian law, using a three-point corroboration methodology. PHR stresses that their numbers are highly conservative, that numbers are an underestimate as only those attacks and deaths with sufficient evidence to be considered are counted. SAMS declared UN Security Council resolution 2286, passed in May, 2016, a failure after reporting a minimum of 172 attacks from June to December, 2016, with the Syrian Government and its allies responsible for almost 98% of the attacks.

The pattern of attacks on health facilities suggests intention to target, which is a war crime. To the best of our knowledge, the frequency and extent of targeting of health care is not known to have occurred in any previous war.