Issue No. 846

Hospitals in Armed Conflict

Hospitals and health clinics are generally not targeted deliberately in armed conflict because a belligerent could lose international credibility immediately and be liable for prosecution under the International Humanitarian Law. In recent years, as armed conflicts have surged and the fog of war rendered any reporting hard to verify, hospitals are increasingly becoming targets in themselves.

In Somalia, there is no hard evidence of an armed group targeting hospitals, but in July 2023 during the Laas Anood conflict, a hospital came under indirect fire and was partially destroyed. The SSC-Khatumo rebels claimed the Somaliland army was deliberating shelling the hospital. Activists cited the shelling of the hospital as evidence of ‘war crimes’ and demanded the Muse Bihi administration be taken to the International Court of Justice at The Hague. The authorities in Hargeisa denied the claims. The Somaliland Army’s use of imprecise artillery and the SSC-Khatumo rebels’ use of areas near the hospitals to launch mortar attacks certainly played a big role in transforming the hospital and its surrounding areas into an active combat zone.

Protection of medical facilities, patients and staff is a value enshrined in guidelines for conduct of war – a binding blueprint that has been signed by almost every state in the world: the Geneva Conventions. Put simply it states that all people have the right to medical treatment: civilians, children and combatants from all sides. Not only should the clinic or hospital be considered neutral and outside of the conflict, but ambulances, staff and those seeking medical care have access to the hospitals/clinics. Even your enemy should receive medical care. The principle of medical neutrality dictates that medical personnel and facilities must be allowed to care for all sick and wounded people and ensure access to care for all, regardless of their affiliation or involvement in the conflict. Sadly, we are witnessing a steady rollback of such universal values in many countries and Somalia is no exception. Many Somali doctors and nurses have fled over the past decades to more safe environments abroad. Insecurity in the health environment has forced many closures of services in Somalia since the fall of the Siyad Barre regime in 1991. They can broadly be categorised into basic groups. Failure in the aftermath of state collapse in the early 1990s led to government closure of a robust health care system. The myriads of governments since then have categorically failed to resurrect governmental health care despite billions in assistance. Therefore, the initial conflict led to a state breakdown of healthcare that almost completely was not filled by ensuing government institutions.  

Into this gap, stepped NGOs (both international and local) and private health care providers.  The insecurities they faced were different. Many security incidents were not headline driven massive military assaults. For 25 years, they fell broadly into two categories: people that had grievances about the perceived quality of care for a loved one and issues relating to internal structure (i.e. hiring of local staff). In both of these categories, international organizations and staff and local Somalis abilities to both understand their respective cultures added an accelerant to disagreements.  

Over time, Somalia’s insecurity has turned medical professionals - both foreign and local - into high-value targets. Skilled health workers have been abducted or held for ransom, transforming them into bargaining chips in a wider web of political and criminal violence. Most infamously, in April 2019, Al-Shabaab militants abducted two Cuban doctors who had been deployed to Kenya as part of a bilateral healthcare agreement. These doctors were held captive for ransom for approximately 18  months, during which the militants are believed to have exploited their medical skills to treat injured fighters and local communities in areas under their control. Fear of abduction and lack of protection have made both local and international medical personnel increasingly unwilling to work in Somalia. The international NGO footprint in the Somali medical realm is but a shadow of what it was even during the difficult contextual times in the 2000s.

Hundreds if not thousands of trained staff have left the country. The attack at the medical graduation ceremony  in December 2009,  put a generational chill in aspiring medical personnel training. A suicide bomber targeted the graduation ceremony for medical students at the Shaamo Hotel in Mogadishu. The attack  killed at least 19 people - mostly students - including the minister of Health, and injured dozens more. Government malaise has not re-invigorated the situation. Kidnapping and security incidents have crippled international medical response. But Somalia and the world continues to evolve with regards to attacks on healthcare. 

When it comes to security for medical personnel and structures, Somalia can be thankful that it has not had targeted airstrikes on medical facilities or ambulances. As the country works toward a more stable and resilient health system, past incidents should be treated not as anomalies, but as warnings. Strengthening protections for medical staff, reinforcing the neutrality of healthcare spaces, and building contingency protocols must form part of any sustainable healthcare strategy. In a context where health workers have so often been forced to operate under threat, ensuring their safety is a humanitarian imperative and is essential in rebuilding public trust in the system.

The Somali Wire Team