Afghanistan Accuses Pakistan of Hospital Airstrike; Pakistan Denies Targeting Health Facility
Afghanistan has accused Pakistan of an airstrike on a drug rehabilitation hospital in Kabul on Monday night, reporting at least 400 people killed and potentially hundreds more wounded. Pakistan denied deliberately targeting the health facility, stating its strikes precisely targeted military installations and terrorist support infrastructure of the Afghan Taliban.
Surging Attacks on Healthcare
Attacks on healthcare facilities are increasing globally. An Israeli airstrike in Lebanon on March 14 reportedly killed 12 healthcare workers, contributing to a total of 31 healthcare worker deaths in Lebanon recently.
The World Health Organization (WHO) verified 27 attacks on healthcare facilities in Lebanon alone since early March amidst intensified Israeli strikes in Lebanon and joint US–Israeli operations in Iran. The Office of the High Commissioner for Human Rights (OHCHR) and the WHO condemned these actions as violations of international law.
Protections Under International Humanitarian Law
International humanitarian law (IHL), also known as the “laws of war,” contains detailed rules to protect medical personnel, facilities, and the sick and wounded during armed conflict.
These rules ensure critical safeguards:
- Medical personnel, including doctors, nurses, and paramedics, must be respected and protected while performing their duties.
- Ambulances and transport exclusively used for medical purposes have special protections.
- These protections extend to the wounded and sick, including enemy combatants no longer participating in hostilities.
- Impartial humanitarian organizations must be allowed to provide medical assistance.
- Medical facilities must display distinctive protective emblems (Red Cross, Red Crescent, or Red Crystal), and medical personnel must carry corresponding identification.
- Misusing these symbols to shield military operations is prohibited and may constitute perfidy, a war crime.
- Deliberately attacking medical personnel or facilities displaying these emblems can also be a war crime.
These rules originated from 19th and 20th-century conflicts, with the first Geneva Convention adopted in 1864. Today, the 1949 Geneva Conventions and their Additional Protocols form a near-universal legal framework binding all parties to a conflict, including non-state armed groups.
Reasons for Increased Attacks
Médecins Sans Frontières (MSF) has reported that attacks on medical facilities and personnel have reached unprecedented levels globally. The legal framework remains unchanged, but warfare has evolved, often occurring in densely populated urban environments, as seen in conflicts in South Sudan, Ukraine, Gaza, Iran, and Lebanon.
Armed groups frequently operate within complex civilian settings, often near hospitals. Some warring parties now justify attacks on grounds of military necessity, claiming insurgents exploit hospitals or ambulances. For example, Israel has accused Hezbollah and Hamas of using medical infrastructure for military purposes.
Conditions for Loss of Protection
Hospitals can lose their special protection if they are used, outside their humanitarian role, to harm the enemy. However, IHL sets a very high threshold for this.
The presence of medical personnel carrying light weapons for self-defense, armed guards, or wounded fighters receiving treatment does not remove protection.
Protection may be lost only if hospitals are used for activities such as:
- Launching attacks
- Serving as an observation post
- Storing weapons
- Acting as a command or liaison center
- Sheltering able-bodied combatants
Even in cases of doubt, hospitals must be presumed protected. If a hospital is verified as being misused, international humanitarian law requires a warning to be issued, allowing reasonable time for the misuse to stop.
If the warning is ignored, the attacking party must still comply with core principles:
- Proportionality: The expected military advantage must be weighed against the humanitarian consequences. Attacks must be canceled if civilian harm would be excessive.
- Precautions: All feasible precautions must be taken to minimize harm to patients and staff, which may include facilitating evacuations.
Even when a facility loses protection, the wounded and sick within must still be respected and protected.
Normalization and Accountability
The UN Security Council, WHO, MSF, and OHCHR have expressed concern that attacks on medical personnel and facilities, along with a lack of accountability, are becoming dangerously normalized.
The existing legal framework requires states and armed groups to disseminate the law and train their forces. National legal systems are expected to investigate and prosecute war crimes against medical personnel, facilities, and the wounded.
However, investigating attacks during active conflict is challenging, and territorial states may be unwilling or unable to pursue prosecutions. Open-source investigative groups are increasingly playing a role in preserving evidence for independent fact-finding missions to pursue accountability where states cannot or will not.