A Paradigm Shift in the Historical Perception of Attacks on Healthcare?

Our starting point is that what counts as an attack on healthcare has a contested history. Historians have not asked the questions in those terms. Whereas recent advocates seek to quantify the impact of AoH, early proponents of international law and humanitarian practices did not use this terminology or discuss in much length what constituted an attack specifically, even though they referred to violent acts of various kinds.⁷ Significantly, the 1864 Geneva Convention detailed the objects to be protected by laws (medical personnel, structures of aid and patients) but did not specify what might be classified as an “attack on healthcare.”⁸ Not only is the term used far more widely today, but it has also taken on new meanings over the last fifteen years.⁹ Specifically, reference to “healthcare” has trumped restrictive legal definitions of “protected personnel” and broadened the range of violent situations in which protection was meant to apply, a trend recognizable in other definitions of international humanitarian law, as demonstrated by Amanda Alexander.¹⁰ Since the late 1980s, the concept of AoH had been primarily employed to describe violent incidents in healthcare setting, as either a descriptor of violence inflicted on healthcare workers by patients or their kin or as a way of talking about the structural violence of toxic medical environment.¹¹ In the 2010s, the notion became more widely associated with violations of human rights and IHL.¹² This shift was a result of a convergence of global health activists, including academics, many with a history of human rights activism, WHO-led reflection on violence and health dating back from 1996,¹³ and the International Committee of the Red Cross campaign and conferences.¹⁴ In this context, killings and violence against medical staff and structures were interpreted as assaults on healthcare [End Page 385] systems as well as on individuals’ health. Beyond the hurt and injuries inflicted on human beings, scholars and advocates against AoH attempted to evaluate their broader impacts in terms of loss of medical equipment and reduced availability and quality of healthcare. In 2011, for instance, Robin Coupland, who had directed a sixteen-country study for the International Committee of the Red Cross (ICRC), equated the emblematic bombing of a medical graduation ceremony in Mogadishu with 150,000 consultations lost per annum.¹⁵ The report denounced the senseless and absurd massacre, but interpreted the event as an assault on future medical provisions as well (including the suspension of health facilities, the changes in practices operated by healthcare workers, and the resurgence of chronic or vaccine preventable diseases). This framing borrowed its approach from the Land Mine Treaty campaigns and their “deployment of shame.”¹⁶ The report further argued that violence was not merely immediate and that the intent went beyond the desire to hurt an enemy community in the present.

This shift originated as much from rethinking risk and risk taking within international humanitarian organizations as from a greater awareness among them of the scale of attacks themselves.¹⁷ This transformation was manifested and fueled by the development of the International Committee of the Red Cross (ICRC) program “Health Care in Danger,” Médecins Sans Frontières‘ “Medical Care Under Fire,” the Safeguarding Health in Coalition (SHCC), and World Health Organization (WHO) media and research campaigns.¹⁸ They heightened reports of attacks on health structures in Afghanistan, Iraq, Libya, Syria, South Sudan, Ukraine, Yemen, (and elsewhere). This lobbying gathered pace and evidence, and subsequently led to the adoption of the Resolution 2286 by the UN Security Council on the protection of civilians in armed conflict in May 2016—at a time when two of its permanent members faced public outcry. The United States was condemned for its bombing of MSF’s hospital in Kunduz and Russia for that of Syrian hospitals in Aleppo. In this context, “attacks against healthcare” were no longer anecdotal forms of brutality: they gave broader meaning to conflicts and their calculated excesses over time. The recent COVID-19 pandemic brought to the fore that violence against healthcare is confined neither to the context of war nor to political repression. The pandemic also often aggravated pre-existing pressures and violence against healthcare workers, ensuring that earlier meanings of attacks on healthcare are subsumed in a more expansive definition.¹⁹

As practitioners, lawyers, and public health specialists embraced this approach to attacks on healthcare, many academics and policymakers alike have searched for “historical precedents” to better understand current debates about the definition(s) and impacts of “attacks” on healthcare and establish genealogies, with the implicit purpose of finding out whether, in this respect, war was worsening.²⁰ This approach ran the risk of taking a teleological or a normative approach. By contrast, this special issue builds on and contributes to growing historiographies and the scholarly literature on wartime medicine, gender, international humanitarian laws, caregiving, and humanitarianism to go beyond a history of norms making and law violations. It proposes a broad and flexible definition of “attacks,” encompassing both high-profile military attacks (bombings, explosions, shootings, gunfire, etc.) and more diffuse forms of violence, including interpersonal and psychological events.²¹ The multifaceted forms of violence studied in the five articles reveal that the nature and type of attacks has not necessarily changed over time and that it has often been difficult to distinguish between incidents of attacks (deliberately targeting or unintentionally impacting healthcare facilities)—another contemporary problem. [End Page 386]

In this dossier, two essays consider instances of violence in conflicts that took place even as the notion of attacks on healthcare became more commonplace. Adopting an interdisciplinary approach, Bertrand Taithe, Bhimsen Devkota, and Louis Lillywhite investigate how targeted, often constant but moderate, violence against health providers distorted medical provisions and made them specific grounds for political contest. While this increased duress initially had a beneficial impact in public health terms, it came at great personal cost for medical practitioners. This discussion of a situation in which both sides valued healthcare, if not healthcare providers, refers to the recent history of civil war in Nepal, precisely as AoH was being defined conceptually. Without minimizing the actual long-term impacts of violence on societies engaged in war, this essay presents a more nuanced perspective of how internecine conflicts can follow other paths than the extraordinary and calculated onslaught on healthcare witnessed in Syria. Second, by examining the drivers of violence against Ebola responders in the Democratic Republic of Congo (2018–20), Sauter paints a new picture of the role of local elites and politics in framing Ebola as a political tool of government. Despite the “local turn” in humanitarian studies and growing efforts to engage local communities, Sauter argues that international humanitarian organizations have neglected how Ebola was instrumentalized by the DRC government during the last presidential elections. Drawing on MSF’s historical work on the Ebola response in West Africa, she convincingly highlights how the focus on localizing aid and engaging communities paradoxically led to the neglect of local discontent.

As these articles demonstrate, the development of human rights frameworks (and later focus on quantification of war losses) has led to more attention on incidents (in relation to the provision of healthcare) as opposed to seeing attacks and violence as part of “normal life” in war.²² This special issue seeks to push this analysis further into history by exploring why past actors neither discuss these in terms of AoH nor consider in much length the broader impacts of instances of violence against healthcare actors.

History Writing and Attacks on Healthcare

Historical studies offer valuable insights into how the concept of attacks has shifted over time and how attacks are culturally constructed as breaches of morality or of the laws and customs of war in the international public sphere. In this respect, the concept of attacks on healthcare is firmly grounded in the literature of international humanitarian law (IHL) and of humanitarianism.²³ But much like international law and humanitarianism more broadly, setting AoH in a historical context tends to highlight differences and semantic and definitional divergences, putting into question the ontological nature of what is being observed. For instance, in the era of the First World War, bombings of hospitals and killings of Red Cross staff were often framed as “atrocities” rather than violations of the Geneva Convention, except in the Bulletin International des Sociétés de la Croix-Rouge.²⁴ As Alan Kramer and John Horne argue, “atrocities” were violations of the laws of war and “war crimes,” but the perspective was different: the term reflected their cultural construction and confirmed the moral justification of the Allied cause.²⁵ Furthermore, atrocity acts became a propaganda weapon to mobilize domestic and neutral opinion. As Davide Rodogno and others have shown, this instrumental concept of atrocities had a longer history rooted in late nineteenth-century civilizing mission discourses. It had been deployed in previous generations to denounce massacres, consolidate Orientalist alterities, and justify humanitarian military interventions.²⁶ [End Page 387]

In order to take stock of and outline future directions for the history of acts of violence against healthcare workers, we focus on three key sets of approaches and debates. The first is that of definition and origins of the legal framework around the protection of healthcare workers and facilities. This framework should not be seen as an uncontested or simply progressive endeavor. Instead, we ask: What were the main political, ideological, cultural, and economic factors that contributed to the codification of rules for the protection of medical staff and patients? Who were the key actors beyond the development of the Geneva and Hague models? Why were some medical workers and patients (and not others) granted legal subjectivity (and thus protected) in the first half of the twentieth century? In the past twenty years, new approaches have revitalized this debate in ways that merit closer attention here.²⁷

The second lens is that of the radicalization of violence and the powerlessness of law. Why did states, conventional armies, or nonstate armed groups commit violence against medical spaces and staff? How far were instances of violence against healthcare part of a broader radicalization? What were the key “drivers of violence” and who was to blame for the violence? How did violent actors then justify their actions? Despite clear cultural and contextual differences, historians have recently highlighted important continuities in the ways in which brutal acts were represented and “justified” in the international public sphere.²⁸ In particular, perpetrators have often legitimized attacks on hospitals by framing them as “shields,” presenting them as refuge for combatants (rather than neutral spaces) and thus as legitimate targets.²⁹

The third set of questions arises from the emergence of new historiographical themes and perspectives, such as gender, intersectionality, and intimacies in relation to our understanding of violence in wars.³⁰ In what ways did race, ethnicity, gender, and nationality impact on representations of AoH and on the emotional experiences of those working in medical settings? How far did gender influence the ways in which survivors narrate, silence, or remember their experiences, determining, in particular, how confident they were that their voice would be heard within public or official contexts? While the gender dynamics of AoH remains understudied today,³¹ this introduction concludes by highlighting how historical and interdisciplinary approaches can contribute to a better understanding of the ways in which the very act of bearing testimony of AoH and providing “data” for international organizations remains a challenge deeply fraught with social, gender, and cultural overtones.³²

Before Attacks on Healthcare: Who Defined Problems and Advocated Against Them?

The concept of violation of restraints on conflicts implies a form of consensus on what constitutes a legitimate use of force. The historiography of laws of war underpinning this baseline understanding is rich, as is the legal historiography of humanitarian international law.³³ Historians have challenged any canonical progressive narrative and nuanced the significance of “enlightened” networks of activists. Scholars have also revised old assumptions about the significance of shifts in “humanitarian sensibilities” and the critical role of self-promoting visionaries, such as Henry Dunant and Florence Nightingale.³⁴ As Adam Roberts observes, legal scholars have often simplified the 1863 Lieber Code developed during the American Civil War and the 1864 Geneva Convention, focusing on their newness and the story of their creators.³⁵ Building on Geoffrey Best’s work,³⁶ new studies have shown that interstate codifications of the laws of war also served the political and financial interests of the great powers, which dreaded nationalist and revolutionary forces in the late nineteenthj century. [End Page 388] Looking at the American context, John F. Witt stresses the importance of domestic politics in shaping the laws of war and the Lieber Code.³⁷ Meanwhile, there is no consensus among historians regarding the Russian government’s motivation for initiating the 1899 Hague conference beyond noting the influence of the Saint Petersburg legal tradition epitomized by the lawyer Friedrich (Fyodor) Fromhold Von Martens.³⁸ This legal approach emphasized the primacy of customary international law beyond and before treaty law.³⁹ Whether driven by self-interest or set in the idealist tradition of earlier Romanovs, this imperial Russian genealogy of laws of war brought with it more pragmatic origins in droit des gens and deeper social and cultural grounding than that of international treaties seldom read by combatants.⁴⁰

This historiography of “common laws” (agreed cultural norms) complements that of international legal processes, encouraging us to think about international norms as a process of political compromise and debunking foundational myths about the Geneva and Hague conventions. This, in turn, has impacted greatly upon historians’ understanding of the emergence of rules for the protection of medical staff and patients. It has forced them to rethink the question of who “first” defined the problem and to examine the role of “norms entrepreneurs” who “galvanized atrocious events to place the issue of new legal rules on states’ agenda.”⁴¹ Norm entrepreneurs, as defined in international relations, may comprise individuals, societies, or even government. The early promoters of humanitarian causes were members of elite educated groups well integrated into international and transnational networks and with the financial means to travel.⁴² When it came to the protection of wounded and sick or the otherwise defenseless in war, these entrepreneurs relied on military medicine expert networks, philanthropic, and often religiously inspired groups that transcended national boundaries.

Recent studies on humanitarian norms entrepreneurs have revised old assumptions about the allegedly uniquely European and North American dynamics that led to the codification of the protection of medical workers and patients. Sho Konishi has highlighted the Tokugawa origins of Japanese engagement with humanitarian ideals, demonstrating that local belief systems provided the grounding for norm setting.⁴³ Nevertheless, Tokugawa and later Meiji norm setters in the Japanese context belonged to internationalized elite groups.⁴⁴ At a time of growing citizen-armies and mass mobilization across Europe, the Americas, and Asia, norm entrepreneurs reflected the ambivalence of a melioristic project in increasingly murderous conflicts. Building on critical studies of the laws of war, Eyal Benvenisti and Doreen Lustig argue that the Franco-Prussian Wars and Paris Commune hardened states’ attitudes toward civilians who challenged their authority. For them, the “turn to interstate codification of IHL … assisted governments in securing their authority as the sole regulators in the international terrain.”⁴⁵ The rise of francs-tireurs, irregular resisters to invasion, and later that of insurrectionist combatants, challenged the narrow definitions of legitimate combatants who might be covered under the terms of the Geneva Convention. Revolutionary medical practitioners were not always granted a neutral or protected status. In May 1871, repressive violence took place in and around hospitals.⁴⁶ The terms of the legal framework for humanitarian aid enabled—without reference to Martens’s clause of droit des gens—a stricter interpretation of illegality in combat and the denial of neutrality for wounded terrorists and insurrectionists. In this sense, the laws of war trumped medical interpretations of humanity.

Cultural historians of war medicine have also highlighted the role of military doctors in defining who and what should be protected. As Jean Guillermand underscored in 1989, [End Page 389] doctors (Louis Appia, Theodore Maunoir, Friedrich Löffler, Jan-Hendrick Basting) substantially shaped the Geneva Convention.⁴⁷ They emphasized continuities among ancient Greek medical traditions “above military passion,” medieval codes, and seventeenth-century treaties that contained clauses for the treatment of wounded and ill patients.⁴⁸ Guillermand insisted on the pioneering role of the British John Pringle, whose work focused on improving the health of the British soldiers in the mid-eighteenth century.⁴⁹ Pringle advocated that hospitals be recognized as “protected” sanctuaries. Yet, arguably, there was a key difference between these historical precedents and late nineteenth-century laws: while the Geneva Convention focused on the neutrality of medical staff, prior traditions emphasized the neutrality of the wounded.⁵⁰ In effect, the convention reflected the significant developments of what Christy Pichichero calls a “military medical revolution” in wars of mass mobilization. Pichichero argues that Dominique Larrey’s agile ambulance volante, which brought medical care and resource-based triage to battlefields of the Napoleonic Wars, were part of military humanitarianism as a new type of patriotism, marked by compassion and sensibilité. According to Pichichero, “in their efforts to prevent and alleviate suffering in the sensible human being, these thinkers advanced new standards of wellness and happiness in the space of war, and in doing so planted the seeds of a military culture of human rights.”⁵¹ In the late nineteenth century, many of these debates on humanitarianism took place against a background of public debate around the resourcing of military medicine. In France, for instance, as Claire Fredj points out, military figures such as Jean-Charles Chenu had campaigned since the Crimean War for more autonomy within the French military to promote medical status and more humane attitudes toward the suffering of soldiers.⁵²

Together, these studies reveal that if there was an innovation in Dunant’s vision, it lay primarily in his carving out a legitimate space for civilians, especially a philanthropic elite with international networks, to enter the battlefield to complement sanitary services in delivering care to the wounded. States endorsed his claim, although the 1864 Geneva Convention made no explicit mention of volunteer societies. From the start, military doctors were thoroughly divided about this development. Critics, including Nightingale and, initially, Chenu, warned that undisciplined and ill-trained private societies would be more of a liability than an asset in improving care for the sick and wounded soldiers and risked giving states and military authorities an excuse to evade their responsibility.⁵³ The flurry of Red Cross–bearing private ambulances during the Franco-Prussian War—together with the widespread practice among French civilians to hang a Red Cross flag on their house to avoid requisitions by the Prussian troops—a case in point that Geneva rules could be instrumentalized by civilians, too—convinced the belligerents that discipline was indeed an issue and the “neutrality” of caregivers a source of confusion and suspicion.⁵⁴

In this vein, Lia Brazil sheds light on legal contestations in a conflict on the margins, the war in South Africa from 1899 to 1902. Using micro-historical approaches, she argues that Boer fighters held differing conceptions of what constituted medical “neutrality” and the meaning of the 1864 Geneva Convention to that of their British counterparts. In the Boer states, wartime citizenship dissolved the distinction between fighter and doctor. In the Boer mass mobilization for survival, medical provisions were only another resource to requisition. Her article clearly illustrates the tensions between legal norms and medical staff’s self-understanding of their role in conflict. A lack of available medical personnel drove those with limited medical experience to occupy medical roles and move between “combatant” and “non-combatant” positions, whether opportunistically or altruistically. [End Page 390] She paints a new picture of the legal contests over what constituted medical personnel, hospitals, and ambulances, and thus what and who should be considered protected. For the British, by failing to conform to the stipulation that medical workers must be “neutral,” Boer men had “broken” international law and could be “punished” through deportation or even trial. Crucially, she demonstrates that pre-existing medical cultures and portrayals of the Boers as “uncivilised” shaped in large part a British vision of professionality and standard of neutrality that were arbitrarily set on the ground.

The Boer War took place at a crucial juncture, when states sought to redefine the terms of their commitments to international treaties. When the Geneva Convention was revised in 1906, volunteer societies were explicitly mentioned but only to be placed firmly under state and army’s control. In 1906, the Geneva Convention stipulated that the condition for their personnel to benefit from “protection and respect”—the wording which from then on would replace “neutrality” in international law—was that they “be subject to military laws and regulations”; conditions were even more stringent for the societies of neutral nations, including the obligation to carry both the Red Cross flag and that of the belligerent to which they were “attached.”⁵⁵ The revision, which seems to confirm Eyal Benvenisti and Doreen Lustig’s argument that interstate codification served to assert the state’s authority over civilians, also reflected developments that had taken place over the past two decades, by which Red Cross societies increasingly conceived of their role as a patriotic one. Jurist Louis Renault, the head of the French delegation at the diplomatic conference, who successfully argued for the removal of “neutrality” from the letter of the Geneva Convention, was himself a member of the French Red Cross. As argued by Rebecca Gill, by the time of the First World War, this evolution was “ruling out the improvised relief ventures by concerned individuals that had been a feature of earlier conflicts.”⁵⁶

Studies of medical humanitarianism during the First World War have further sharpened our understanding of the “politics of wounding,” revealing that Red Cross societies were integrated into the overall effort to win the war and, at times, abandoned their impartiality.⁵⁷ As the Red Cross movement became a formidable organizer of mass volunteerism and arguably a mobilizer of social forces hitherto unconcerned with war, in particular wars abroad,⁵⁸ it followed logically that total wars brought about a greater level of confusion between mobilized civilian and military medicine and politicized both more explicitly. As Ana Carden-Coyne has argued, surgeons encountered new public pressures, complicated by the clash of civilian Hippocratic ideals and military pragmatism.⁵⁹ Widespread coverage of medical facilities, the diversity of ailments, and the range of treatments available to war wounded—particularly on the western front—made healthcare key to the social compact sustaining the war effort as well as to shared notions of humanity.⁶⁰ The mass training of first aiders, their uniforms, and the strongly militaristic ethos of the Nightingale ward culture of nursing participated in this convergence of cultures.⁶¹ Mass mobilization and the blurring of boundaries between civilian and military life brought health structures among the key assets of nations at war.

The Oldest War Crime in the Book? Barbarization, Condemnations, and Prosecutions

Historians have interpreted these shifts in behavior on the battlefield by analyzing the “barbarisation process”: the political deployment of violence to reinforce military coherence and the use of brutality to humiliate enemies.⁶² Clearly, how we understand instances [End Page 391] of violence against healthcare workers in the past has dramatically changed as a result of the “cultural turn” that took place in the historiography of war in the 1990s. While historical studies were prevailingly top-down, the historiographical focus has since been more “bottom-up,” nuancing the context of violence that targeted healthcare facilities, often inter alia. For instance, historians have debunked the myth that violence was confined spatially to the battlefield during the First World War, leaving civilians unaffected even if many in the West never experienced it first-hand.⁶³ Vast territories, including in northern France, Belgium, Poland, and the Balkans experienced long-term military occupation, which subjected civilians to different kind of hardships and torments.⁶⁴ Even second-hand violence reshaped perceptions of the war. As Heather Jones shows, the battlefield was seen as a site on which norms of war were violated and the notion that “the enemy was practicing forms of transgressive violence” was key in explaining why the population carried on fighting.⁶⁵ In terms of violence against the wounded, Annette Becker and Stéphane Audoin-Rouzeau wrote on the nettoyeurs des tranchées, who “mopped up” and killed wounded Germans left on the battlefield.⁶⁶ The transgressive and sometimes “intimate” nature of killing, to use Joanna Bourke’s notions, were at the heart of historical thinking around 2000, precisely at the time of the development of notions of attacks on healthcare.⁶⁷

Yet this historiography of violence, which considers its intimate, cultural, and gendered dimensions, is often neglected by historians of international legal developments, international organizations, or judicial processes. In this respect, the recent historiography on perpetrators of violence on healthcare reveals three emerging, interrelated trends: first, a renewed emphasis upon military necessity, in both the motivations and justifications of acts of violence against healthcare workers. Second, a debunking of the role of the ICRC in condemning perpetrators’ actions, which highlights the ways in which it supported anti-revolutionary and racist norms of sovereignty prevailing in Europe. Third, a questioning of what enabled prosecutions and the “utopia of universal tribunal.” Regarding the first trend, historians have highlighted the enduring legacies of the legal scholar Francis Lieber and the eponym code in shaping a distinct notion of military necessity. This code influenced jurists, numerous European and non-European field manuals, and the laws of war (Geneva and Hague conventions) at the end of the nineteenth and early twentieth century.⁶⁸ The code defined brutal acts as morally justifiable if they enabled a party to end a war quickly, which could include brutal acts against the wounded or the hospitals in which they were housed. As Len Rubenstein argues, obligations toward wounded and sick were contingent upon what was seen as necessary from a military-strategist point of view.⁶⁹ Frances Houghton demonstrates how, during the Second World War, British military authorities justified the capture of the Italian hospital ship Ramb IV as both a form of reprisal against attacks on their own hospital ships and by military necessity.

New historical research has improved understanding of how laws of war impacted decision-making within military headquarters.⁷⁰ Building on a rich historiography on “Belgian atrocities” during the First World War, Isabell Hull has provided some ground for a key reassessment of the central, though forgotten, role of laws of war during the conflict. Hull demonstrates that while the French and British military incorporated The Hague and Geneva rules into their military manuals prior to the war, German armies did not, even though they had distributed the Geneva Convention among their troops in 1870.⁷¹ She drew on her previous work Absolute Destruction to offer important views about German military culture and the importance of the concept of “military necessity” to explain this [End Page 392] difference.⁷² Hull demonstrates that the submarine war “shows Imperial Germany at its most sensitive toward International law,” particularly at the start.⁷³ Nevertheless Germany changed its public position toward the sinking of hospital ships in January 1917, and justified doing so by claiming that the British had misused hospital ships to carry troops and ammunitions. This decision was widely condemned, including by the ICRC in its Bulletin.⁷⁴ According to Hull, the British were less eager to violate the conventions signed before the war. There was a deep-seated belief in the importance of law among British elites and concerns about damaging diplomatic relations with the United States.⁷⁵ According to Nicholas Lambert, by contrast, violation of international laws was a necessary step to reinforce her maritime strength.⁷⁶ Focusing on mines, Richard Dunley shows that that conception of military necessity was more powerful in the Royal Navy than Hull might suggest and that many were ready to flout legal and international norms.⁷⁷ Focusing on the Ottoman archives and the battles of the Dardanelle, Emre Öktem and Alexandre Toumarkine also argue that Germans and Turks reported British attacks on medical facilities. The Allies expressed their regret via the United States embassy in Constantinople, presenting the attacks as accidents and accusing the Ottomans of having placed their hospitals too near the frontline.⁷⁸

Frances Houghton draws on this historiography of British attitudes toward international law to reassesses common tropes and myths about British compliance. She demonstrates that the issue of protecting British medical care during the Second World War at sea was integrated into national mythmaking. At the level of the state, she suggests that enemy attacks on British medical care afloat fed into state production of “reassurance” propaganda, which positioned Britain as innately more compliant with the laws of war than Axis nations. She also identifies a major shift in the ways in which attacks were represented. During the First World War, the British government used “atrocity” propaganda to whip up public passions and present the sinking of vessels as evidence of German depravity in the press. During the Second World War, by contrast, the government pursued politics of “reassurance,” avoiding sensationalized atrocity propaganda in the press while publicly denouncing attacks through diplomatic channels, notably via the United States.

This nuancing of approach to violations of international law was seemingly not uniquely state business. Recently, the literature on the bombing of hospitals and sinking of hospital ships has begun to explore the ambivalent attitudes of the ICRC.⁷⁹ Notably, Lindsey Cameron asks whether the attitudes of the ICRC or its mandate in defending treaty laws translated into an “unwavering belief in the power of law.”⁸⁰ For instance, during the First World War and its immediate aftermath, the ICRC received around eighty protestations of violations of the Geneva and Hague Conventions of 1906 and 1907, mostly related to military attacks on hospitals and bad treatment of medical staff.⁸¹ The ICRC published these complaints in its Bulletin, though the marquis Charles-Jean de Vogüé, president of the French Red Cross (Société de secours au Blessés), believed they risked compromising the international position of the ICRC in doing so.⁸² Among others, Paul des Gouttes, vice president of the ICRC, was implicated in research on the issue of intentional torpedoing of hospital ships.⁸³ It was, however, difficult to establish what happened at sea. As Duncan McLean observes, until recently there remains a considerable lack of research on the matter.⁸⁴ What is certain is that the ICRC was more lenient toward some perpetrators than others. The first recorded attack took place in February 1915, when a German submarine torpedoed the British ship Asturias. The German embassy in Washington apologized [End Page 393] for mistaking the vessel for a military ship transporting troops.⁸⁵ Cedric Cotter, who has examined the ICRC archives, has shown that, after 1916 and the bombing of a hospital by the Germans in Dunkirk, the ICRC showed double standards in its condemnation of these attacks. Lenient toward the entente, it was much more condemnatory toward the central powers.⁸⁶

Historians have also commented on the conservatism of ICRC, revealing that the committee supported anti-revolutionary and racist norms of sovereignty prevailing in Europe at the time.⁸⁷ Many scholars have insisted on the links between the Red Cross Movement and aggressive militarism in the early twentieth century.⁸⁸ For instance, they have demonstrated that Genevan norms traveled better to some geographical areas. Considered “semi-barbarians,” the Balkans were excluded from the nations subjected to international law, seen as an attribute of civilisation.⁸⁹ On the whole, laws of war were exclusionary and colonial actors were granted little legal subjectivity. Imperial powers took advantage of this double standard, a prime example of which was the second Italo-Ethiopian War of 1935–37.⁹⁰ According to Rainer Baudendistel, Mussolini and his generals had no use for international law and force prevailed over law even if McLean notes that “there was at least some awareness in the Italian leadership that attacking the Red Cross hospitals could be counterproductive.”⁹¹ As a League of Nations member, Haile Selassie knew it was in his interest to uphold international law, though the practice was not so easy for the military of “a country just emerging from feudal rule.”⁹² This conflict brought about major change in the role of ICRC including the dispatch of a delegation to Ethiopia seeking information through delegates who were the eyes and ears of the organisation. Arguably, the Genevan organization was no longer above the parties but directly involved—albeit often passively so. According to Baudendistel, ICRC lacked realism during this conflict: “By taking for granted that the belligerents wanted the application of Article 30—despite indications that this was not the case—the ICRC adopted a passive attitude and trusted blindly that a process of law had been set into motion.”⁹³

The political expediency one could attach to the respect of rules of war and international law is nowhere better demonstrated than in the shift in practices of the Japanese military. During the widely covered 1905 Russo-Japanese war, the Japanese military cultivated a well-curated image of martial humanitarianism.⁹⁴ In contrast, the rapes of nurses in the Far East during World War II and the Japanese attacks on hospitals in Hong Kong and Singapore violated The Hague Conventions of 1899 and 1907 and the Geneva Convention of 1929. While much of the commentary on these atrocities in the Allied press has tended to treat them as instances of the Japanese deliberately singling out medical institutions, or medical personnel in general and nurses, in particular, for rape and murder, Charles Roland argues, by contrast, that medical personnel were not particularly singled out in either instance.⁹⁵ There is no denying that the historiography on Japanese medical war crimes reveals a general crumbling of medical ethics,⁹⁶ but recent histories demonstrate that Japanese occupation forces also provided medical care to the Chinese population in order to legitimize their power. As Reut Harari has argued, “Curing the bodies of the populace in China served as a tool for emotional mobilization, by cultivating a willingness among the occupied to cooperate with the occupier.”⁹⁷

Overall, the historiography of international military tribunals does not single out the issue of violence against healthcare workers. Although the issue of war crimes rose to prominence after the German attacks in Liege in August 1914, historians have demonstrated [End Page 394] that the aftermath of the First World War was marked by a sense of failure in international justice.⁹⁸ The trials in 1921 satisfied no one: “If Leipzig was victor’s justice, it was on the terms of the vanquished, satisfying no one except of the British government, which had decided to move beyond the whole business.”⁹⁹ Despite this sense of failure, some historians insist on the “relevance” of international discussion around the punishment of attacks on healthcare. Veronique Harouel and Daniel Marc Segesser have examined Gustave Moynier’s early efforts at creating an International Judicial Institution to judge the violation of the Geneva Conventions, while also promoting national measures to sanction the violators of the conventions.¹⁰⁰ The project of the 1864 Geneva Convention included Article 10 to punish misuse of the Red Cross armbands for spy activities. In 1872, Moynier suggested a more ambitious project of international court and, through the 1873 Institut de droit International and the International Red Cross Movement, kept on arguing for the punishment of the violations.¹⁰¹ Medical evidence established whether a crime was committed and what the intent was, from the trial of the Andersonville major Henry Wirz, hanged in 1865 for his treatment of captives,¹⁰² to more recent international tribunal hearings.¹⁰³ Yet, the history of war crime tribunals challenges any neat demarcation of violence in relation to health provisions. Medical crimes against humanity and acts of violence within a medical setting were a feature of World War II trials and of subsequent attempts to bring acts of violence in war to light.¹⁰⁴ The ensuing Nuremberg code reframed medical ethics within this context and codified consent but it did not put an end to the use of medicine in contexts of torture or experimentation.¹⁰⁵

Aware of the limitations of these trials, European military doctors and concerned jurists mobilized in the 1950s and 1960s for the protection and control of medicine in wartime, a movement little studied by historians to date. Driven by the revelations of medical crimes in the postwar trials and by their direct experiences of Nazi occupation, which had seen caregivers arrested, deported, or executed as part of the repression of partisan movements, these military doctors were frustrated by the 1949 Geneva Conventions.¹⁰⁶ In their eyes, diplomatic compromises had not extended legal protection to all civilian medical practitioners or reaffirmed medical exemption from captivity prevalent since 1864. Military doctors concluded that it was for the profession itself to define a world status for medicine and have it recognized by states. This definition would be the basis for a new body of law, International Medical Law, that would remedy the gaps in the Geneva Conventions. Their goal led them to lobby, like Gustave Moynier had done in his time, for an international penal court that would sanction violators. They also asserted the absolute neutrality, impartiality, and independence of medicine, years before the Red Cross Movement gave these notions central place among its fundamental principles.¹⁰⁷ Their ambitious vision of the role that doctors, irrespective of nationality, should play in offering care and controlling the application of the laws of war made for an uneasy partnership with the ICRC. Most significantly, it was a vision fitting with an idealized conception of conventional wars, not with the “subversive wars” of decolonization and the Cold War. In these settings, following counterinsurgency tactics, doctors ministering to the “rebel” side were arrested and abused, and medical personnel were assigned to “hearts and minds” campaigns and often took part in torture. During the Algerian War, the president of the Comité International pour la Neutralité de la Médecine, Pr. Charles Richet, a deported resistant and a figurehead of the military doctors’ movement, stood by the French Army rather than admit to this fact.¹⁰⁸ [End Page 395]

The historiography shows that medical providers in conflict zones were thus not exempt from being enrolled in the violence that may affect them or their patients. During the Second World War, for instance, the distinction between combatant and non-combatant in occupied Europe collapsed, as the Nazis considered resistance caregivers and patients to be terrorists. In April 1944, German authorities declared that anyone in occupied France who took care of a person injured by firearms or explosives was compelled to report their patient, thereby breaking doctor-patient confidentiality, a legal obligation since 1810.¹⁰⁹ Medical doctors frequently refused to follow the rules and joined the French Resistance.¹¹⁰ As this example suggests, the political nature of conflicts implies that medical and health-care facilities are often central targets. In Nepal, for example, medical practitioners’ role as providers and potential informers made them the object of particular attention, as demonstrated in Taithe et al.’s article devoted to the civil war, during which they were the object of constant surveillance and low-level violence.

Historical evidence demonstrates that medical practitioners have often been only too aware of the vicarious nature of legal protection in practice or of its limited and often tactical uses. Pouget explores the situations of extreme vulnerability experienced by French military doctors in Africa and Southeast Asia, torn between the duty to serve the army and fear for their lives. In these former colonial territories in the 1970s, these doctors had to pursue conflicting missions of public health and the defense of France’s external interests. For these doctors, who were deployed as humanitarian aid, full impartiality in the delivery of aid was not attainable: they were torn between having to obey their military commanders while maintaining their non-combatant status in armed conflicts. In this context, they were not protected by law. The law, according to Israeli legal historian Neve Gordon, is thus no shield for health practitioners. In his view, any naïve understanding of IHL has to be mitigated by counter arguments and practices that emphasize exceptions, justifications, and strategic considerations that allow militaries to attack medical staff and sites. If Gordon’s view remains highly debated among health practitioners in the field today, historical evidence shows that medical practitioners have often been very aware of their vulnerability and the limitations of legal protection in practice.¹¹¹

Reading Past Violence Through A Gendered Lens

Clearly, cultural, comparative, and interdisciplinary approaches have enabled scholars to provide new answers to key questions about the ways in which acts of violence were framed in particular historical contexts and the ways in which they were interpreted, if not exploited, to justify interventions and actions by states and interstate organizations, but also volunteer groups and individual caregivers. In many cases, such as Brazil in Houghton and Pouget’s case studies in this dossier, there could not be neutrality in its “diplomatic” sense; in other words, in the ways some of the creators of the 1864 Geneva Convention understood it. What is also evident is the extent to which new methodologies emerging in the fields of the history of masculinities, femininities, and emotions could be fruitfully applied to current studies about AoH and help contextualize violence against health providers. While not making these methodologies central, the authors of this special issue nevertheless raise important questions about the ways in which race, ethnicity, gender, and nationality impact on representations of AoH and on the emotional experiences of those working in medical settings. For instance, Brazil considers the gendered [End Page 396] view of male medical volunteers as potential military threats, a view that does not extend to women, who are almost entirely absent from the British Military Police records. Houghton points to the emotional significance of sharing the same danger for wartime British medical officers and male nursing staff at sea, contributing to the sense of belonging to a ship’s company and a sense of masculine self-worth. She demonstrates how male naval doctors attached acute emotional significance to wearing military uniform, associating it with “doing one’s bit” and constructing naval medical dress as a badge of desirable masculinity and good citizenship.

In addition to opening research questions around humanitarian and medical masculinities, this dossier points to how attacks on healthcare were repeatedly narrativized through a highly gendered lens. While historians have demonstrated that representation of women as passive, “vulnerable” victims were frequent in European humanitarian imagery and discourses, historical analysis of instances of violence reveals that in press reports of attacked hospital ships, female nurses were shown to be as brave and capable of overcoming pain as men, and their deaths were equated with combatant sacrifice.¹¹² As Nicoletta Gullace argues, British atrocity narratives were central in creating a “gendered international language of ‘just war’ indispensable in addressing Western public opinion ever since” during the First World War.¹¹³ According to Gullace, alleged violations of international law—such as the execution of nurse Edith Cavell—carried a particular potency when depicted in terms of women, children, and the safety of the home. Historians have also demonstrated how military surgeons belonged to a hypermasculine culture that stressed toughness and the ability to remain in control at all times.¹¹⁴ For all this, as Michael Brown suggests, we still know too little about the role that emotions played in the practice of emergency medicine and the ways in which medical workers negotiated “their identity as emotional beings” in various environments under fire.¹¹⁵ Using the lenses of intersectionality, emotions, and intimacy, our research on wartime medical care during the Second World War evinces the need to consider the gender dynamics of medical experiences and narratives of violence.¹¹⁶

In a study of a mobile international hospital, Laure Humbert explores how military attacks and instances of violence impacted the psychological, emotional, and physical health of those attending the wounded within an international mobile unit that moved across three continents during the Second World War. Drawing on a diverse sources, including archival records, private diaries and correspondence, published memoirs, and oral interviews conducted between 1987 and 1993 by the Imperial War Museum, Humbert unearths a shared moral expectation emphasizing self-control, abnegation, and psychological detachment when looking after the wounded and sick in the face of events that could trigger fear, isolation, and physical and mental trauma. This shared ethos (an “ethos of stoicism”) was central to forming a successful (though not inclusive) transnational community (which stretched gender and professional boundaries), to individuals’ coping mechanisms, and to the ways in which they later remembered and narrated their wartime experiences. In this dossier, Taithe et al. also examine the emotional and affective impacts on attacks on healthcare, drawing on oral testimonies. They discuss that Maoist rule frowned on alcohol abuse, domestic violence, and gambling while promoting gender and caste equality within the confines of their ideology. While this might have had a beneficial impact on under-privileged groups, such as the people of Rolpa, the war itself had dramatic mental health consequences as a whole. [End Page 397]

Violating medical neutrality thus takes a different meaning depending on the gender, semantic, and broader understanding of legitimate violence. In this sense, and to return to our initial questioning of the existence of a “paradigm shift” at the turn of the millennium, historians add nuance and perhaps complexity to the under-researched history of medical neutrality and advocacy against violence toward healthcare. Certainly, the end of the Cold War generated great expectations that new links of solidarity would be formed within the international community in the quest for global development and global health. Scholars, global health experts, and activists placed renewed hopes in ambitious infectious disease eradication campaigns and believed that residual, depoliticized violence could be treated like a “global public health problem,” as asserted in a 1996 WHO resolution. These dreams have largely foundered in the first decade of the twenty-first century under the polarizing logics of the “War on Terror.” Arguably, campaigners against AoH, primarily found among Western public health and medical actors, have tried to reaffirm the relevance of their action at a time of hindered access to their fields of intervention.

While the quantification method of recent AoH discussions and their insistence on the global as a relevant site of policymaking can be traced back to the 1990s, we argue that the rhetoric of AoH is reminiscent of earlier campaigns and mobilizations. In particular, during the civil war in El Salvador (1979–92), transnational human rights doctors claimed solidarity with Salvadoran health practitioners’ victims of abuses, torture, and summary execution by state forces. They defined these instances of violence as “violations of medical neutrality”—a nod to IHL norms. At the same time, they denounced the effects of the Salvadoran regime’s scorched-earth policy in the rural areas with reference to the WHO Alma Ata Declaration, which premised social and equitable development on community primary healthcare programs. The ultimate aim of the activist caregivers was to pressure the American administration for change by exposing US direct backing of these counterinsurgency tactics. The return to the fore of counterinsurgency violence and torture, first in the context of the US-led War on Terror in the first decade of the twenty-first century, then in many settings of the so-called Arab Spring in the 2010s, help explain the revival of this past mobilization repertoire: AoH connects once again the assaults on health practitioners and patients to their impact on the health and social development of the society at large to pressure for policy change. There is thus no doubt that the paradigm shift at play is marked by continuity and change, innovations, and reconfigured practices and language, or, in the words of Samuel Moyn, “long-term preconditions and medium-term novelties as well as short term triggers.”¹¹⁷ New interpretations of laws of war or even more recent notions of attacks on healthcare, historians show, do not supplant heroic war representations but run alongside them, reinforcing some of their tropes. The ennobling of suffering and the sacred body of the wounded were and remain crucial in war imageries and in the mobilization for war. Recurrent calls for a judicial process did not end exactions or the sense of impunity that perpetrators often displayed and continue to demonstrate. Whether new understandings of the disabling implications of this violence for the future will become the hegemonic interpretative framework of violence in war, reframing tactical use of violence and defining afresh the legal redress against perpetrators, remains to be seen.