BOOK REVIEW: How to Resuscitate an Ailing Norm

Abby Stoddard

Perilous Medicine: The Struggle to Protect Health Care from the Violence of War, by Leonard Rubenstein (Columbia University Press, 2021)

In the mid-19th century, a brief and little-known contretemps transpired between two icons of humanity and public health: Henri Dunant, founder of the Red Cross and progenitor of the Geneva Conventions, and Florence Nightingale, military nursing innovator and statistician. While both had experienced firsthand the ghastly aftermath of war, they each held different views on how to organize an effective and humane response for its victims. As recounted in Leonard Rubenstein’s Perilous Medicine: The Struggle to Protect Health Care from the Violence of War, Nightingale disagreed with Dunant’s vision for mobilizing societies of trained volunteers in each country to care for the wounded. This was essentially letting governments off the hook, she argued, for what was rightly their own militaries’ responsibility. Dunant, who had sent Nightingale his proposal presumably hoping for an endorsement from the famed figure, shook off her critique, reasoning that “voluntary societies were essential because reform of military medical services was impossible.” This question of the rightful locus of responsibility and target for reform recurs like a background drumbeat throughout Rubenstein’s book.

On its face, the norm of allowing and protecting health care amid war makes unimpeachable sense from the standpoint of both morality and practical incentives. Combatants have strong interests in ensuring that their own wounded receive care and humane treatment, and in avoiding public moral outrage if they should, say, bomb a hospital. Yet this norm continues to be routinely violated by all manner of military actors, from small rebel militias to global superpowers, in violent acts that they readily justify on the grounds of strategic necessity or mere expedience.

Rubenstein, who directs the Human Rights and Health in Conflict program at the Johns Hopkins Bloomberg School of Public Health and was formerly president of the organization Physicians for Human Rights, has devoted much of his long career to making governments and international institutions pay attention to attacks on health care in armed conflict and to advocating for policies to better protect the wounded, the sick, and the people who care for them. In Perilous Medicine, he alternately employs the various lenses of his mixed professional background—advocate, academic, human rights lawyer—and engages the topic from these various angles. For readers seeking an in-depth and comprehensive understanding of the issue, it is an effective approach.

The narrative accounts of the violence experienced by medical providers and patients woven through the book give one the sense of being shaken by the collar by someone who has seen too much of this and insists we wake up to the enormity of the problem. Rubenstein describes in unflinching detail a great many documented cases of attacks on health care workers and facilities by warring forces who strike them intentionally or inadvertently. While noting that the violence is not at all new, the author underscores that the toll extends far beyond the visible damage. The individual tragedies of a bombing of a hospital in Yemen, of a massacre in a maternity ward in Afghanistan, or of doctors arrested and tortured for treating Arab Spring protestors are always compounded by the indirect harms to lives and health stemming from the loss in health care capacity. Once Rubenstein points it out, it is easy to see how many multiples of the original victim counts will follow after facilities close, programs are halted, and potential health care workers choose not to take on these dangerous roles. One example particularly illustrates the vastness of the ripple effects: “Insecurity in Pakistan, where more than seventy attacks on vaccinators have been committed, pushed back by years, perhaps decades, the realization of the comprehensive global plan to eradicate polio from the planet.”

How can such things happen, and so distressingly frequently, despite what most would believe to be a universal moral consensus condemning it, backed up by international legal instruments and codes? To examine this “paradox of inaction,” Rubenstein uses historical and legal analyses to argue that it comes down to competing interests and opposing views of morality in war (jus in bello) and of war (jus ad bellum). To illustrate what he posits as the fundamental tension, Rubenstein contrasts proto-humanitarian Henri Dunant with yet another of his historical contemporaries—the lesser-known Francis Lieber, a German American political theorist writing during the American Civil War.

Just as Dunant’s writing and advocacy helped shape the Geneva Conventions, Lieber’s work resulted in a major and enduring contribution to “laws defining the moral boundaries of the conduct of war, including obligations of the combatants toward the wounded and the sick.” In Lieber’s case, however, the laws were US military codes, which for many years bore his name and still bear the stamp of his ideas. The two different contexts of war shaped both men’s thought. For Dunant, having witnessed the bloody results of the Battle of Solferino, the latest installment of centuries of European conflict, left the Swiss businessman with a sense of the senselessness, as well as the inevitability, of war. His project was to limit the worst excesses of brutality and bring some humanity to the battlefield. Lieber, in contrast, was faced with what he saw as the epitome of a just and urgent war—a fight against the evil of slavery. The moral ends of winning such a war trumped all other concerns and justified a wider range of means. His consequentialist moral reasoning can be summarized in the attitude that brutal acts “are moral if they quickly bring a just war to an end.”

The tension between the two views continues to play out in armed conflicts, with military decisions often defaulting to the consequentialist logic of Lieber to justify or excuse harms against health care, whether through direct targeting or recklessness, physical obstruction, or legal constraints. Despite the Geneva Conventions’ rejection of Lieber’s consequentialist approach, and most combatants today likely having never heard Lieber’s name, the logic he codified in an order for the Union Army in the American Civil War pervades much of military (and radical fundamentalist) thinking and moral intuitions, embodying what Hugo Slim termed the “ruthless pragmatism” of war. Even in today’s hybrid wars against terrorist insurgencies, fought more with special operations forces and drones than with infantry battalions, enabled what Rubenstein calls “a vast extension of the logic of denying health care to enemies and punishing their caregivers.”

Rubenstein, who has been documenting and reporting on these incidents since the early 1990s, does not hide his frustration with governments and international political bodies, including the World Health Organization, which has proceeded “gingerly” in holding its member states to account for misconduct. The US-enabled Saudi military campaign, whose airstrikes have indiscriminately battered Yemen without taking the slightest care to avoid medical facilities, receives especially strong condemnation: “At every turn, the leadership engaged in manipulation, dissembling, spin, and intimidation. It kept its arms suppliers at bay through rhetoric that would please them and accepting technical support that made little difference to their conduct.”

Perilous Medicine is a significant milestone for a body of work that spans decades, continents, and professional métiers. Approaching the subject from multiple ethical, legal, and historical angles as Rubenstein has done (and more than this review has space to describe adequately) does due justice to a complex, longstanding, and morally thorny subject. Like most studies of chronic and complex issues, however, the book is more satisfying in its diagnosis of the issue than in its prescription for treatment. The principal contribution of this book is in laying bare and dissecting the problem and providing coherent explanations for why it persists. In terms of what to do about it, the author calls on the global community to

reinforce norms that protect health care that have been chipped away, often without acknowledgement, [on] governments, state militaries, and armed groups … to follow through on commitments they have made to undertake the actions needed to prevent attacks on health care and end impunity, [and on] new sources of leadership and solidarity [to] demand action and support those dedicated to protecting health care in war and in circumstances of political violence.

These sensible and necessary (if broad) calls to action are undercut to some degree by the author’s account, immediately following, of a promising report and series of robust recommendations by the United Nations Secretary-General never meaningfully taken forward by the member states of the Security Council: “[I]n the years that followed, the Security Council annually discussed violence against health care but never acted on the recommendations.” The answer to the question of who is ultimately responsible and where is the leverage point for addressing the current state of impunity seems every bit as elusive as it was in the 1860s.

If Perilous Medicine sounds a less than hopeful note, it nonetheless serves as a needed alarm bell, alerting us to the fragility of this most vital of humanitarian norms.

Abby Stoddard is a founding partner of the international policy research group Humanitarian Outcomes and the author of Necessary Risks: Professional Humanitarianism and Violence against Aid Workers (Palgrave Macmillan, 2020).