Health Care and War
Editor's Corner | There is a series of documents called the Geneva Conventions that recognizes that, even in war, there has to be a limit on violence. Thus, rules were established to provide some protection for the wounded, prisoners of war and non-participating civilians. Since August of 2014, the Geneva Conventions principles have been in existence for 150 years. Within the Geneva Conventions are such principles that medical workers are not considered combatants and have the right to provide care to the wounded on either side of a conflict. Thus, military hospital in a war theater will receive casualties from both sides and provide care, and that has been the case with American field hospitals in war.
Because I was an active member of the Navy Reserve in 1990, I was recalled to active duty to help staff a field hospital in Saudi Arabia south of Kuwait1. The hospital was mainly established to care for American military personnel participating in the first Gulf War, and we all reviewed the Geneva Convention to be sure we were providing proper care to our own military members, but also to others who were either allies or enemy combatants. We lived by the rule that, as medical personnel, we were protected from threat of combat. We were given the opportunity to carry a weapon when traveling out of our hospital compound, but generally refused since we could then be considered combatants. Besides, without proper training, I would be more likely to shoot myself than anyone else. The history of the world wars indicates that the Geneva Convention rules were not consistently followed, and one can find numerous stories (Unbroken2 comes to mind) in which war prisoners were tortured, starved, and killed.
Our use of nuclear weapons on two Japanese cities and the German bombing of London both could be considered violations because of civilian casualties. And in current wars, where many of the combatants are insurgents, there seems to be no regard at all for the Geneva Conventions. We see hospitals being attacked, civilians being bombed, torture and murder being publicly displayed with no regard to any sense of civility. We read many stories of physicians trying to provide care of civilians and the wounded in extremely adverse environments. Medical supplies are unavailable, so the usual medications we take for granted, dressing for wounds, and x-ray machines for diagnosis are unavailable, and patients die for lack of simple medical supplies and medications. In most wars, temporary field hospitals, either military or civilian, are an important means of providing on-site medical care to civilians as well as military personnel. These hospitals are often initially supplied with the needed medications and other supplies with operating rooms and x-ray machines so that a reasonable level of care can be provided.
When we set up our 500-bed field hospital in Saudi Arabia in 1991, we staffed it with 1,000 personnel that included physicians of various specialties, nurses, pharmacists, physicians assistants, corpsmen, food service and engineering personnel, so that a fully operational hospital could be located in an area of need. The challenge for any field hospital is to maintain a continuous flow of medical supplies, food, water, fuel, and whatever else is needed to maintain the hospital operation. Logistics for deploying a field hospital in a distant location to aid in a war or natural disaster, sometimes in a hostile environment, requires an enormous amount of preplanning, and most of these facilities are developed and operated by the military.
But if you are a civilian physician working in a city or village where you take for granted the hospital, clinic, and pharmacy for your patients, then suddenly in a course of a few days or weeks they are all gone, the challenge is enormous for providing any level of care for your patients. Insulin dependent diabetics will slip into diabetic coma, hypertensives being managed with medication will suddenly experience uncontrolled hypertension, and usual antibiotics for various infections being absent, the severity of these disorders will be magnified. Such is the case today in many Middle Eastern towns and villages.
Today we see non-government organizations (NGOs) trying to bring health care to areas ravaged by war. These workers brave death or capture but persist in their humanitarian mission. Because national governments have failed in some cases, and combatants are not interested in restoring civilian health care, the NGO contribution is substantial, but often impeded by the local hostilities and corrupt politics. The ultimate solution is to return to civility and denounce war and insurgency as tools of dominance. Established governments would then have some responsibility for developing the health care infrastructure that is so valuable to growth of a society. We can only hope that it will all end in the near future and civility is restored… and appreciate deeply the society we live in that values civility and a functional health care system.
Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
- Bove AA, Oxler SJ. Medical Department Operations in a Fleet Hospital During Operation Desert Storm. Mil. Med. 1995;160:391-5.
- Hillenbrand L. Unbroken: A World War II Story of Survival, Resilience, and Redemption. 2014. Random House, New York.
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