Perilous Medicine: The Struggle to Protect Health Care from the Violence of War by Leonard S. Rubenstein

Abstract

Reviewed by: Perilous Medicine: The Struggle to Protect Health Care from the Violence of War by Leonard S. Rubenstein David P. Forsythe (bio) Leonard S. Rubenstein, Perilous Medicine: The Struggle to Protect Health Care from the Violence of War ( Columbia University Press, 2022), ISBN 9780231192460, 392 pages. Leonard Rubenstein is well qualified to address the subject of health care in situations of violence. He is past president of Physicians for Human Rights, a respected NGO, and directs the program on Human Rights and Health in Conflict at Johns Hopkins University. His book is nicely framed. On the one hand, there is Francis Lieber, who during the American civil war, authored a set of rules for the Union Army addressing limits on violence in the name of humanitarian concern. Lieber's approach gave expansive scope to the idea of military necessity. If acts of violence by the Union side shortened the war and helped get rid of slavery, then the violence was justified. Thus, the sacking of Atlanta by General Sherman, for example, fell within the bounds of permissible action. It was not gratuitous violence, under Lieber's code, but rather part of a just cause and had the effect of helping end the war. On the other hand, there is Henry Dunant, who, at about the same time as Lieber, popularized the idea of limits on war in the name of a common humanity, taking as his focus the notion of neutral aid to all war-wounded. For Dunant, the justness of the cause and whether or not a battle shortened or prolonged a war did not enter into calculations. From 1864 and the first Geneva Convention on the subject of victims of war, inspired by Dunant but drafted by his Genevan colleagues Gustave Moynier and Guillaume Dufour, a prohibition on attacking the wounded and those that tended them was general and absolute. Modern international law follows the Swiss Dunant and not the Prussian-American Lieber. In both human rights law and the laws of war (or international humanitarian law, or the international law of armed conflict), the official norms prohibit explicitly or by implication attacks on medical installations and medical personnel. Unfortunately, much practice tends to follow Lieber (even by those who never heard of him) in that that there is great scope given today to military necessity, seen by political actors as being part of their just cause. In a way, clearly enough, Rubenstein's book is depressing. He documents, thoroughly and without question, the extent of the violations of norms designed to protect medical installations and personnel. In general, "We know that, from 2006–2020, more than four thousand [End Page 648] acts of violence in conflict against health care led to a health care worker killed every three days and a facility damaged or destroyed every other day."1 He backs up the disturbing generalizations by going into the weeds on health care in conflicts with attention to Chechnya, Myanmar, Turkey, Kosovo, Syria, Afghanistan, Palestine, Liberia, Central African Republic, and elsewhere. One is perhaps not surprised to read about attacks on health care in conflict situations by the likes of the Afghanistan Taliban or the Islamic State Group. He also shows that Israel has blocked ambulances and interfered with medical relief in Palestinian areas, while refusing to hold Israelis legally accountable for their misdeeds. He reminds readers that when the United States used a supposed vaccination worker to track down Osama bin Laden in Pakistan, the results included a suspension of vaccination programs in that area with serious negative effects on children, and even fatal attacks on some other vaccination personnel. In all these cases, political authorities gave broad scope to military necessity and saw their cause as just. Lieber lived, in spirit at least, and Dunant was eclipsed. In another way, however, Rubenstein's book is inspiring. Faced with the broadly negative record on protecting health care in conflict situations, whether officially recognized as armed conflict (where IHL applies) or something similar short of armed conflict (where human rights law applies), he shows that individuals and organizations continue to struggle against dominant trends. There are creative endeavors that show some success, whether by MSF (Doctors...