ICRC the Right to Medical Care - Perrin

The Right to Health in Armed Conflict

Te Rig Rig o o Heal in Armed Armed Conic Conic Pierre Perrin*

Introduction

Te eecs o war on eal are muliaceed and range rom sriking eecs suc as e wounded, e dead, e epidemics and amine, o less visible ones including e disorganizaion o eal services and, in some cases, eir oal anniilaion. Bo ypes o eecs may resul in umaniarian ragedies wic aec wole populaions. Heal services reac o ese siuaions, owever, e implemenaion o e response sraegies encouners consrains a limi eir eec, especially wen violence is esablised as a war sraegy agains e civilian populaion. Suc acics o osiliies run couner o e umaniarian logic. Heal proessionals are no only responsible or proposing ecnical soluions o resolve eal problems, bu ey also mus use legal means, in paricular roug inernaional umaniarian law (IHL) and inernaional uman rigs, o eecively proec e rig o eal. In is regard, e role and responsibiliies o eal proessionals in ideniying e eecs o weapons wi e view o applying IHL rules on means and meods o  warare is a elling example o suc a role, as well as o e complexiy o addressing eal issues in e conex o war.1 In imes o armed conic, bo inernaional umaniarian law and inernaional uman rigs law oer imporan proecions or e rig o eal. Given e various componens o is rig, e applicable legal ramework enails ineracion beween ose wo bodies o norms. Wen considering IHL, i is wor noing a proecion goes beyond specic

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The Right to Health in Emergencies

provisions relaed o eal and eal services. I also encompasses norms a indirecly conribue o proecing e rig o eal, suc as e principles and rules governing e means and meods o warare. Wile one may primarily ink o civilians as persons wose eal is aeced by war, combaans are aeced oo. Indeed, IHL rules rs developed by ocusing on ways o alleviae e suering o wounded combaans on e baleeld and o ensure access by eal services o ose persons. Tis caper rs seeks o look a e legal bases o e rig o eal in armed conic o sow a IHL provides or a broad proecion. Second i oers a brie overview o e proecion o is rig in pracice. Finally i gives elemens on e underlying umaniarian and poliical background o undersand e curren evoluion wi respec o e proecion o e rig o eal in armed conic.

Te legal bases o the right to health

Te rig o eal Te rig o eal is undersood as e rig o ave access o eal services. However, i is no an absolue rig, as suc, o be in good eal. Te WHO denes eal services as all aciviies inended o resore and mainain eal. One ereore as o include vaccinaions, medical care, bu also saniary services relaed o waer and ygiene, and a clean environmen under is eading, as well as all aciviies ensuring access o ood resources. Tose “underlying deerminans o eal”  imply consideraion o e rig o eal in a broader perspecive, wic is e basis o Aricle 25 o e Universal Declaraion o Human Rigs.5 Te corollary o is rig is e idea a saes are responsible or adoping appropriae saniary and social measures or e populaions o ave eecive access o eal services. 6 Suc obligaions are ound in several legal insrumens, including e Inernaional Covenan on Economic, Social and Culural Rigs (Aricles 12, 24), e Inernaional Convenion on e Eliminaion o All Forms o Racial Discriminaion (Aricle 5), e Convenion on e Eliminaion o All Forms o Discriminaion Agains Women (Aricles 10, 12, and 14), e Convenion on e Rigs o e Cild (Aricle 24). Wile all ese legal insrumens are applicable a all imes, including during armed conic, is caper will ocus primarily on e provisions o inernaional umaniarian law. Having dened e rig o eal as

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The Right to Health in Armed Conflict

e rig o access o eal care, i applies o all persons weer ey are wounded or no. As is caper covers siuaions o armed conic owever, i will address mainly e rig o eal or persons, be ey combaans or non-combaans, wo are injured. Te rig o eal in armed conic Wiin possible limis, medicine as always responded o e needs o in jured persons and ried o limi e means and meods o warare, including roug describing and providing experise o beer undersand e eecs o weapons. In is work ‘On Te Pysician’, Hippocraes reers o war injuries as an area o surgical specializaion. 7 Based on repors o e consequences on eal o e use o nuclear weapons, wo pysicians, a Russian and an American, launced e idea o an associaion o medical docors o preven a nuclear war. Tis idea was e origin o e creaion o e organizaion called Inernaional Pysicians or e Prevenion o Nuclear War in Geneva. In 1985, is associaion received e Nobel Peace Prize or making people aware o e caasropic consequences a nuclear conic would enail. Te developmen o IHL, in paricular roug e Firs Geneva Convenion,8 was aimed a proecing and caring or persons injured during armed conic, rsly combaans. Tis consiued a major urning poin in modern umaniarian inking and oered a legal ramework or providing assisance o e wounded in wars.9 In parallel, various legal insrumens were elaboraed wi a view o limiing e means o warare, and o orbid e use o cerain weapons. In 1863, during e American Civil War, e Lieber Code 10 was elaboraed, limiing e miliary’s means o warare. Several inernaional insrumens were laer adoped, proibiing e use o expanding bulles, 11 biological 1 and cemical weapons.1 Suc regulaions are relevan wen considering eal issues in armed conics. Aloug e Inernaional Cour o Jusice, ollowing a reques by e World Heal Organizaion on e legaliy o  e use o nuclear weapons, ruled in is 1996 advisory opinion a suc reques did no relae o a quesion wic arises wiin e scope o WHO aciviies,1 is nding was limied o e purpose o assessing e condiions o le a reques or an advisory opinion. I does no mean a IHL norms regarding means and meods o warare are no relevan rules oering a proecion o e rig o eal agains e eecs o cerain weapons.

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The Right to Health in Emergencies

Tis dual approach – to provide care and to prevent the eects o weapons – has been consistent throughout the development of the law of armed

conic.

Protecting the right to health through international humanitarian law

Numerous aspecs o inernaional umaniarian law address e proecion o e rig o eal in armed conic; ey concern e proecion o  e rig o be given care and e proecion o essenial services o mainain eal. Te 1977 Addiional Proocol I saes a: “… all the wounded, sick and shipwrecked, to whichever Party they belong, shall be respected and protected. In all circumstances they shall be treated

umanely and sall receive, o e ulles exen pracicable and wi e leas possible delay, e medical care and aenion required by eir condiion. Tere sall be no disincion among em ounded on any grounds oer an medical ones.” 15

Several aricles in e Geneva Convenions and eir Addiional Proocols proec medical srucures and medical personnel. I is orbidden o aack ospials, and medical sa mus be able o perorm eir work wiou any discriminaion wasoever.16 Proecion is also required or essenial services aimed a mainaining eal, namely ood, drinking waer, ygienic measures, and abia. o ensure suc proecion, i is orbidden o aack or desroy ese services, or o render em inoperable. Wi respec o access o ood, i is orbidden o aack ood socks, agriculural zones, arvess, cale, and irrigaion insallaions.17 Inernaional umaniarian law also conains rules regarding e responsibiliies o e paries o e conic. For insance, in case o occupied erriories, e occupying power as e duy o ensure and mainain e medical and ospial esablismens and services, public eal and ygiene in e occupied erriory in cooperaion wi e naional auoriies.18 Restrictions on the means and methods of warfare

Resricions on e means and meods o warare, be ey roug general principles or roug specic rules covering paricular weapons, are also relevan wen considering e proecion o e rig o eal in armed con-

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The Right to Health in Armed Conflict

ic. Tese resricions aec a range o aspecs, rom e eecs o weapons a may impac upon e eal o combaans, o e indirec eecs on civilians. I is or example orbidden o use amine as a weapon o war. 19 Pillaging, and poisoning o waer supplies, is also proibied. Te developmen and use o weapons is an area were e inerace beween e law and eal is paricularly imporan. In is regard, e eal impac o a weapon is used in order o assess e eecs o a weapon wen deermining weer i causes superuous injury or unnecessary suering. Tis rule also requires medical consideraions o be applied in order o ideniy e naure o e eecs o a means o warare. Moreover, e qualiy and availabiliy o ospials and eal services in e enemy area may be an elemen o ake ino accoun wen assessing e superuous or unnecessary caracer o e eecs o a weapon compared o is miliary uiliy, depending on e peculiariy o e eec. For example, i a pary o a conic as no means o rea a paricular ype o injury, i may be relevan in applying e proibiion o superuous injury or unnecessary suering rule. Recenly, several umaniarian organizaions 0 ave sown a civilian populaions are paricularly aeced by e use o cluser muniions. 1 “Cluster munitions are weapons that spread hundreds of tiny explosive

devices over wide areas and leave idden unexploded bombles a keep on killing or many years. In modern wars, civilians pay a ig price rom e use o suc weapons.” 

In May 2008, 107 saes adoped a dra Convenion on Cluser Muniions wic eecively proibis e use, producion and ranser o all exising ypes o cluser muniions. Te dra Convenion esablises imporan commimens regarding assisance o vicims, clearance o conaminaed areas and desrucion o sockpiles. Furer, e adopion o e Proocol on Explosive Remnans o War in 2003 obliges e paries o e conic o remove all explosive remnans. Tis is a sep orward in e proecion o  e populaions in e pos-conic pase, bu e essenial issue ere is o proec e civilian populaion during e conic. More and more, governmens and oer acors are commiing o proibiions on suc weapons, since eir use goes agains e principle o disincion beween miliary objecives and e civilian populaion/objecs.

161

The Right to Health in Emergencies

Te problem o landmines and explosive remnans o war sows e difculies encounered in e eors o ban weapons aving armul pos-conic eecs, paricularly wen ey are already being widely used. I is preerable o adop a sraegy o primary prevenion, wi a view o proibiing e developmen o cerain weapons rig rom e iniial concep, i eir poenial eecs violae e principles o inernaional umaniarian law. Tis approac ad been successully adoped or banning e use o blinding laser weapons. Inernaional umaniarian law and uman rigs law is expressed in a variey o legal insrumens a are applicable in armed conics. Tese siuaions are oen accompanied by displacemens o e populaions o a counry oer an a o eir origin. Tese populaions may be specically proeced by exra proecions under e 1951 Reugee Convenion and is Proocol o 1967, wic dene e responsibiliies o saes vis-à-vis reugees, and e Guiding Principles on Inernal Displacemen, wic ses ou e siuaion vis-à-vis inernally displaced persons (IDPs).5 Heal sa can also ave recourse o e recommendaions o e World Medical Associaion (WMA). Wile ese are no binding legal insrumens in e sric sense o e erm, ey ouline e posiion o e medical proession on difcul problems suc as orure, 6 or economic embargoes,7 wic are someimes encounered in armed conics. Moreover, a cerain number o recommendaions concern armed conic direcly.8 For insance, e WMA denes e posiion o eal personnel in e case o surgical riage,9 wic may resul in limied access o care or cerain groups o wounded. Tis eical ramework complemens e legal ramework, so as o elp eal sa “o work or e iges possible sandards o eical beaviour and care by pysicians, a all imes”.0

Tese examples give a general overview o e legal ramework a exiss o ensure e proecion o e rig o eal in armed conic. Te en joyment o this right depends on the willingness o the parties involved in

ese siuaions o carry ou eir responsibiliies in is regard.

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The Right to Health in Armed Conflict

In practice: Protection o the right to health in armed confict

For e rig o eal o be respeced, eal services mus uncion correcly and populaions mus ave access o em. Te responsibiliies wiin eal services Providing appropriae care o persons aeced by armed conic is e responsibiliy o naional (miliary and civilian) auoriies. Depending on e willingness and capaciy o e auoriies o ace is responsibiliy, umaniarian organizaions concerned wi eal care sould adop a sraegy a combines e ollowing various approaces: Reminding e auoriies o eir responsibiliy by reerring o e rules o inernaional umaniarian law and uman rigs law, in paricular wen e auoriies appear insufcienly concerned abou populaions a are aeced by e conic, specically e ones a e iges risk, suc as prisoners and deainees. Supporing naional eal services wi a view o assising em in responding o e needs o e civilian populaion. O course, e auoriies sill need o ave a minimum uncional capaciy and be willing o cooperae wi umaniarian organizaions. Providing direc care o e populaions concerned. Tis approac mus no conribue o relieving e auoriies rom eir responsibiliy. Te las approac is required wen e capaciy o e naional eal services is overaxed by e increase in demand or eal services (or example, roug massive displacemens o people), deerioraion due o srucural problems (dysuncional governmen or insufcien budge allocaions or eal services), eal personnel eeing or securiy reasons, or e reusal o auoriies o provide eal assisance o cerain groups o people based on enic, poliical, religious or oer crieria. “… i circumstances cause it to provide services to the aected populations,

e ICRC does no ave e vocaion o subsiue e responsibiliies o  e auoriies. I will coninue is eors owards e laer so a ey ake care o ese services and us ully ull eir obligaions.” 1

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The Right to Health in Emergencies

Te inerace beween e auoriies and umaniarian organizaions depends on e applicable legal rameworks; us, in non-inernaional armed conics, umaniarian organizaions may oer eir services o e auoriies based on e rig o iniiaive,  and on e poliical willingness o  e auoriies o give access o e people o umaniarian organizaions.

Te good uncioning o eal services is a rs, necessary sage or obaining respec or e rig o eal, bu eal services mus also be accessible o all persons wiou discriminaion.

Responsibiliies or proecing access o eal services In many armed conics, people no longer ave access o eal services or dieren reasons, suc as: Insecuriy wic limis e access o eal aciliies: “[Te] Mortality rate was higher in unstable eastern provinces, showing the

eec o insecuriy. Mos deas were rom easily prevenable and reaable illnesses raer an violence. Regression analysis suggesed a i  e eecs o violence were removed, all-cause moraliy could all o almos normal raes”. 

Discriminaion a e poin o access o eal aciliies, based on enic, religious, poliical, or oer acors: “… these conficts are oten characterized by rampant and gross disrespect

or e principle o medical neuraliy, wic guaranees e provision o  eal care wiou discriminaion o all injured and sick combaans and civilians in ime o conic”.

 Access o eal services depends on weer e paries o e conic ake all measures required o ensure ree access o eal aciliies. Te role o umaniarian organizaions is o assess weer people do ave access o eal services and, i necessary, o ideniy e obsacles wic inder

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The Right to Health in Armed Conflict

suc access. Based on is analysis, umaniarian organizaions sould iniiae e ollowing: Dialogue wi all paries concerned: Wi e paries o e conic, o remind em o eir responsibiliies and o reques a measures be aken wi a view o ensuring e securiy o e populaion. Respecing e principles o inernaional umaniarian law requires a all ose bearing arms be inormed o e applicable sandards. eacing e basic rules o inernaional umaniarian law is ereore a rs sep. Wi eal sa, o remind em o e rules o inernaional umaniarian law and o e eical recommendaions applicable o e medical proession. Mobilizing e inernaional communiy by means o declaraions, repors, inervenions wi muliple players (saes, media, non-governmenal organizaions …) wo ave inuence in a given conex, wi e ob jecive o exering pressure on e paries o e conic and o encourage em o guaranee access o eal services. Humaniarian organizaions can sidesep e prerogaives o auoriies and oer eal services wiou e approval o e laer. Tis approac as been a e origin o e “wiou borders” movemens.  As one observes a radicalizaion o violence in armed conics, 5 ere ollows a cerain “radicalizaion” in e proecion o e rig o eal, wic is inegraed ino e sraegies a include proecion by armed means o ensure e direc proecion o persons. For example, e “umaniarian inervenion” approac is used, or “le droit d’ingérence”, based on eical consideraions regarding e obligaion o provide care o people in emergency eal siuaions. Suc inervenions may serve o mainain peace or o resore peace. “Most United Nations multi-dimensional peacekeeping operations are

ereore mandaed o promoe and proec uman rigs by monioring and elping o invesigae uman rigs violaions and/or developing e capaciy o naional acors and insiuions o do so on eir own.” 6

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The Right to Health in Emergencies

Te decisions o esablis peacekeeping orces o proec populaions are based on poliical and umaniarian acors. Waever e sare o one or e oer may be, eal consideraions will play an imporan role. In a sudy on moraliy in e Democraic Republic o e Congo (DRC), e auors recommended an increase o e UN peacekeeping orces o g insecuriy, wic is e main acor a prevens populaions rom accessing eal services in imes o armed conic.7 Tis ype o epidemiological sudy as a posiive impac on poliical decisions, especially wen ey are conduced wi a ig degree o proessionalism. Following a sudy on moraliy in Iraq,8 e respecive poliical players ried o discredi e resuls o e sudy by criicizing e meod used o gaer daa. 9 Tere is a risk o ocusing e discussion on e meods, insead o on e recommendaions o overcome e problems encounered.

Tere is an ineracion beween umaniarian and poliical aciviies. In e sor erm, is endency may ave repercussions on e percepion o e responsibiliies o e players in armed conics.

Te protection o the right to health in armed confict: What is its evolution?

wo acors ave o be considered: Inegraion o e rig o eal in e general concep o “uman securiy”; and Te searc or some consisency beween e poliical and umaniarian managemen o armed conics. Te rig o eal and uman securiy Te rig o eal and oer undamenal uman rigs are inerrelaed. Te dieren violaions o e pysical and menal inegriy o persons (orure, ill reamen, sexual violence, muilaions, ec.), and aacks on e social inegriy o populaions (enic purges, orced reselemens, breaking up o amilies, ec.), all ave dramaic consequences or eal. In more

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The Right to Health in Armed Conflict

general erms, eal proessionals eel a i would be uneical o care or people wiou also aking ino accoun e serious violaions o uman rigs and IHL, o wic ey could also be vicims. For some years now, is global approac o uman rigs as been ound in e concep o uman securiy, wic allows or e inegraion o  all dimensions o uman rigs.0 Te searc or coerence beween e poliical and umaniarian approaces o armed conic Te poliical managemen o armed conics, and eir umaniarian consequences, are increasingly considered o be an exercise a needs o be conduced in a coordinaed manner. Te curren rend is o searc or coerence beween e andling o  armed conic and is umaniarian consequences: “Te original concep o coerence envisioned a collecive rallying o military, political, economic and humanitarian assets to suppor t peace and security. It assumed a common understanding o the nature and dynamics o  confict between these dierent domains, and a shared vision o the means

o resolving suc conic and o e naure o peace.” 1

In pracice, is global sraegy designed o ensure e proecion o uman securiy will require inervenions rom several angles: “Civilians are the main casualties in conficts. Both norms and mech anisms

o proec civilians sould be srengened. Tis requires compreensive and integrated strategies, linking political, military, humanitarian, and de-

velopmen aspecs.” 

Tis inegraion as repercussions on e specic sraegies or proecing e rig o eal. For insance, prevening eal problems in e conex o massive populaion reselemens primarily ress on making e zones were ese populaions live sae, in order o preven em rom aving o move or reasons o insecuriy. I, in spie o everying, evacuaions are unavoidable and people nd emselves in camps, ensuring eir saey is an essenial elemen or e prevenion o violaions o eir undamenal rigs, and also o allow or e regular organizaion o medical assisance.

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The Right to Health in Emergencies

Inegraion also as repercussions or e saring o responsibiliies beween e paries involved in armed conic. o guaranee access o eal services, we nd ourselves in a wo-way ow o responsibiliies beween civilian organizaions (NGOs, specialized UN organizaions), and e miliary eier under a UN mandae (peacekeeping orces), or acing wiin e ramework o agreemens wi naional auoriies (or example, e Unied Saes in Iraq). Te inegraion o poliical and umaniarian aciviies wiin a common sraegy is no wiou risk. Humaniarian organizaions will ave difculy in disinguising emselves rom e poliical acors, wo are paries in is sraegy, and consequenly o comply wi e principle o neuraliy vis-à-vis e paries o e conic. Te nancing o umaniarian inervenions by donor counries runs e risk o being condiioned by e progress acieved in e poliical andling o e armed conic. A cerain conusion may arise in e minds o e populaion regarding e percepion o e mandaes. For insance, in Aganisan e Inernaional Securiy Assisance Force (ISAF) mission is o assis e Agan governmen and e inernaional communiy in mainaining securiy. In pracice, is means a ere will be join inervenions beween ISAF orces and e Agan police, and e Civil Miliary Cooperaion (CIMIC)  projecs concerning educaion, eal, and drinking waer.5 Tis mix o aciviies creaes some conusion relaing o e percepion o e mandaes, bo among e populaion and e auoriies. OXFAM noes: “As a resul o e U.S. engaging in ‘aid or inormaion’, Oxam was orced o close is program in Kandaar in 2003 … Communiies a we work wi ave become conused as e lines beween aid agencies and e miliary ave become blurred in Aganisan.”6 In an aemp o avoid is conusion, some coerence will ave o be soug, bo a e poliical and e umaniarian levels. In e poliical andling o armed conics, e Unied Naions Organizaion plays is role wi regard o bilaeral inervenions. In e andling o umaniarian maers a arise as a consequence o armed conic, e curren reorms o e UN sysem ave e objecive o acieving greaer coerence in e realm o umaniarian acion. In e more specic area o eal, e emergence o e World Heal Organizaion (WHO) as a player in emergency siuaions, including ose

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The Right to Health in Armed Conflict

arising rom armed conics, as given i a cerain ormalized credibiliy due o is saus as ead o e eal cluser. In 2008, e declaraion o e WHO concerning e siuaion in e Gaza srip no only indicaes a e WHO akes par in e analysis o  eal problems in siuaions o armed conic, bu also a i ries o acieve some coerence wi is poliical managemen: “WHO urges and requess: 1.

Access of all urgent patients to specialized medical care outside the

Gaza srip, wiou unnecessary delays wic reduce eir possibiliy o  surviving; 2. Free and unindered passage ino Gaza o all necessary medical equipmen, drugs, and consumables; 3. Provision o sufcien amouns o uel and elecriciy or e Gaza srip o ensure e ull uncioning o ospials, ambulances, generaors, waer and saniaion sysems, and oer vial inrasrucures; 4. Availabiliy o primary and secondary eal care, waer and ood or people living under curew wiin e Gaza srip. WHO advocaes or all paries concerned o bring o an immediae end all military operations and resume peace negotiations. Furthermore, WHO

calls all paries involved o abide by and conorm wi e Inernaional Humaniarian Laws and e Human Rigs reaies including e respec and ullmen o e rig o eal.” 7

Conclusion

Te proecion o e rig o eal in armed conic requires reliance on a legal ramework a recognizes e many aces o is rig. Wile IHL inegraes specic consideraions, sriking a balance beween umaniarian consideraions and miliary necessiy, uman rigs law remains relevan o complemen IHL in order o ll e poenial gaps. Considering e curren and uure evoluion o armed conics and eir impac on eal, i is no longer a maer o inking in erms o managing e umaniarian consequences o war, bu raer o aving o coose beween war or eal, because e consequences o war on e rig o eal will no longer be manageable or e medical corps.

169

170

The Right to Health in Emergencies

Heal proessionals are also responsible or paricipaing in e elaboraion o a rue sraegy or e prevenion o conics. In pracice, ey can conribue o is goal by: Raionally using e epidemiological ools o promoe eal concerns in e conex o curren and uure armed conics. Exercising eir abiliy o inuence poliical players. Conrolling researc and bioecnological work, or example roug eical commiees, o ensure suc researc will no be applied owards developing new weapons. Paradoxically, one major risk may derive rom medical researc: Te use o geneically engineered germs, or even germs produced by nanoecnology, would ave eecs on e populaion, wic would exend beyond any erapeuic capaciy. Only a sraegy o prevening armed conics will allow us o saeguard e rig o eal or uure generaions.

*

1

2

is caper was originally wrien by e auor in Frenc and ranslaed ino Englis by Salomé Hangarner. e auor would like o acknowledge wi graiude eo Bouruce or is conribuion o is caper. See, or example, Robin Coupland, ‘e eecs o  weapons and e Solerino cycle’ 319(7214)  British  Medical Journal (1999), a 864–865. Commiee on Economic, Social and Culural Rigs (CESCR), General Commen No. 14 on e

3

4 5

rig o e iges aainable sandard o eal, 11 Augus 2000, UN Doc. E/C.12/2000/4, a paras. 9 and 11. See urer p://www.wo.in/opics/eal_ services/en/. CESCR, supra noe 2.  Aricle 25 o e Universal Declaraion o Human Rigs reads: 1. Everyone as e rig o a sandard o living adequae or e eal and well-being o imsel 

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The Right to Health in Armed Conflict

6

7

8

9

10

11

12

and o is amily, including ood, cloing, ousing, and medical care and necessary social services, and e rig o securiy in e even o unemploymen, sickness, disabiliy, widowood, old age or oer lack o liveliood in circumsances beyond is conrol. 2. Moerood and cildood are eniled o special care and assisance. All cildren, weer born in or ou o wedlock, sall enjoy e same social proecion. Preamble o e Consiuion o e World Heal Organizaion (WHO) (1946), available a p:// www.wo.in/gb/bd/PDF/bd46/e-bd46_p2.pd. Hippocraes, On The Physician, 14: “Surgery concerning e injuries by war weapons is relaed o our opic, insoar as i as o do wi e exracion o arrows.” Firs Geneva Convenion or e Amelioraion o  e Condiion o e Wounded in Armies in e Field (1864). Te IHL rules or proecing non-combaans in armed conics are conained in e our Geneva Convenions o 1949 and eir wo Addiional Proocols o 1977. IHL depends on classiying a conic as eier an inernaional armed conic or a non-inernaional conic. Inernaional armed conics are ose in wic a leas wo saes are opposing eac oer. Tese conics are ruled by a vas range o rules, among em e ones saed in e Geneva Convenions o 1949 and e addiional Proocol I o 1977. In non-inernaional armed conics, dissiden armed orces are conroning eac oer on e erriory o a single sae, or armed groups are ging eac oer. More limied rules, overall, are applicable o is ype o conic. Insrucions or e Governmen o Armies o e Unied Saes in e Field (1863). Declaraion (IV, 3) concerning Expanding Bulles (1899), available a p://www.icrc.org/il.ns/ FULL/170?OpenDocumen. Convenion on e Proibiion o e Developmen, Producion and Sockpiling o Baceriological (Biological) and oxin Weapons and on eir Desrucion (1972), available a p://www.icrc. org/il.ns/FULL/450?OpenDocumen.

13

Convenion on e proibiion o e developmen, producion, sockpiling and use o cemical weapons and on eir desrucion (1993), available a p://www.icrc.org/il.ns/INRO/ 553?OpenDocumen.

14

Legality of the Use by a State of Nuclear Weapons in  Armed Conflicts, I. C. J. Repors (1996), para. 31.

15

16

17

18 19

20

21

22

23

24

 Aricle 10, Firs Addiional Proocol o e Geneva Convenions (1977).  Aricle 12, paragrap 1, and Aricle 15, paragrap 1 o e Firs Addiional Proocol o e Geneva Convenions; Aricle 19 o e Four Geneva Convenion, Aricle 15 o e Firs Addiional Proocol and  Aricle 11 o e Second Addiional Proocol. “Sarvaion o civilians as a meod o comba is proibied. I is ereore proibied o aack, desroy, remove or render useless, or a purpose, objecs indispensable o e survival o  e civilian populaion, suc as oodsus, agriculural areas or e producion o oodsus, crops, livesock, drinking waer insallaions and supplies and irrigaion works”: Aricle 14, Second  Addiional Proocol o e Geneva Convenions.  Aricle 56 o e Four Geneva Convenion.  Aricle 14, Second Addiional Proocol o e Geneva Convenions. Inernaional Commiee o e Red Cross (ICRC), Handicap Inernaional, Human Rigs Wac, Unied Naions Mine Acion Service. Cluser muniions are deined as “all ammuniions or explosive carges designed o blow up a a speciic momen aer aving been launced or ejeced rom a paren cluser muniion”: 10th Ses sion o e Group o Governmen Expers o e Paries o e 1980 Convenion on Cerain Classical Weapons, 8 Marc 2005. Human Rigs Wac, Cluster Weapons: Scourge of  Civilians, 23 Sepember 2008. ICRC, Cluster Munitions: Decades of Failure, Decades of Civilian Suffering  (Geneva: ICRC, 2008), available a p://www.icrc.org/web/eng/sieen g0.ns/ml/p0946. Proocol on Blinding Laser Weapons, Proocol IV o e 1980 Convenion on Cerain Convenional Weapons (1995).

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The Right to Health in Emergencies

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See urer p://www.uncr.c/ml/menu2/ 7/b/principles.m. okyo Declaraion o e World Medical Associaion Direcives or pysicians concerning orure and oer punismens or cruel, inumane or debasing reamens in e conex o deenion or imprisonmen. World Medical Associaion Resoluion on Economic Embargoes and Heal (1997). World Medical Associaion Regulaions in imes o Armed Conlic (1956). World Medical Associaion Saemen on Medical Eics in e Even o Disasers (2006). World Medical Associaion Mission Saemen, available a p://www.wma.ne/e/abou/index. m#mission. ICRC, ‘Assisance Policy’, reproduced in 855  International Review of the Red C ross (2004), a 677–693. Common Aricle 3 o e our Geneva Convenions. Benjamin Coglan, Ricard J. Brennan e al. ‘Moraliy in e Democraic Republic o e Congo: A Naionwide Survey’ 367 The Lancet (2006), a 44–51. World Heal Organizaion (WHO), 25 Questions on Health and Human Rights (Geneva: WHO, 2002), available a p://www.wo.in/eniy/ r/NEW37871OMSOK.pd. Repor o e Secreary-General o e Unied Naions on e Proecion o Civilians in  Armed Conlic, 28 November 2005, UN Doc. No. s/2007/643. Jean-Marie Guéenno, Under-Secreary-General or Peacekeeping Operaions, Unied Naions Peace Keeping Operaions: Principles and Guidelines, Marc 2008. Coglan, supra noe 33. Gilber Burnam, Riyad Laa, Sannon Doocy, Les Robers, ‘Moraliy aer e 2003 invasion o Iraq: A cross-secional cluser sample survey’, 368(9546) The Lancet (2006), a 1421–1428. U.S. Presiden George Bus dismissed e meodology as “prey well discredied”: CNN,

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‘Sudy: War Blamed or 665 000 Iraqi Deas’, 11 Ocober 2006. Ausralian Prime Miniser Jon Howard said: “I’s no plausible, i’s no based on anying oer an a ouse-o-ouse survey …”:   Ausralian Broadcasing corporaion, ‘Repor reignies debae over uman cos o Iraq war ’, The World Today, uesday, 27 Marc 2007. Perrin Pierre, ‘Sané publique e sécurié dans les urgences complexes’ 25 Refugee Survey Quarterly (2006), a 35–41. Humaniarian Policy Group, ‘e Poliics o Coerence: Humaniarianism and Foreign Policy in e Pos-Cold War Era’, Brieing Paper 1, July 2000, available a www.odi.org.uk/pg/papers/ pgbrie1.pd. Commission on Human Securiy, Human Security  Now (New York: Commission on Human Securiy, 2003), available a p://www.umansecuriycs.org/inalrepor/index.ml. e Inernaional Securiy Assisance Force (ISAF) is NAO’s irs mission ouside e Euro Alanic area. ISAF operaes in Aganisan under a UN mandae and will coninue o operae according o curren and uure UN Securiy Council resoluions. Civil Miliary Cooperaion (CIMIC) Projecs are developed by NAO o reinorce cooperaion beween NAO and e civilian auoriies o e populaion. NAO, ‘NAO in Aganisan: Facsee’, July 2007, available a p://www.nao.in/issues/ aganisan/040628-acsee.m. Caroline Green, OXFAM spokesperson, commens repored by Inernaional Iner Press Service, Augus 2004. WHO, ‘Saemen on e siuaion in Gaza’, 3 Marc 2008, available a www.wo.in/eniy/ ac/crises/inernaional/middle_eas/WHO%20 saemen%20on%20siuaion%20in%20Gaza. pd.

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 Autho r s

viously she has worked as human rights offic-

Pierre Perrin, MD, MPH, is an Associate Professor

er with the UN Human Rights Field Operation in

at the University Medical Centre,

Rwanda (1995–1996), and with the international

Geneva, Switzerland. He has been

commissions of inquiry on Darfur (2004) and on

an Associate Professor at the Insti-

Lebanon (2006). Lisa holds degrees in criminolo-

tut de Médecine Sociale et Préven-

gy (1992) and in law (1995) from the University of 

tive since 1998. Dr. Perrin is a grad-

  Alberta, Canada, and has been a member of the

uate of the Medical Faculty of 

Law Society of Alberta since 1997. She received

Rennes. He obtained a Master of Public Health

her Diplôme d’Etudes Supérieures in Interna-

from Johns Hopkins University (Baltimore,

tional Law from the Graduate Institute of Inter-

USA). From 1975 to 1979, he carried out several

national Studies in Geneva in 1999.

missions on behalf of Médecins Sans Frontières in refugee camps in Africa and Asia. In 1980, he

Francis Omaswa is the Executive Director of the Af-

  joined the staff of the International Committee

rican Centre for Global Health and

of the Red Cross, working in the field and in Ge-

Social Transformation (CHEST), an

neva. In 1996, he was nominated Physician in

independent “think-tank and net-

Chief of the ICRC, a position he held until leaving

work” initiative promoted by a net-

the ICRC at the end of 2006. In 1986, on behalf of 

work of African and International

the ICRC and in cooperation with the WHO and

leaders in health and development.

the University of Geneva, he created the course

Until May 2008, he was the founding Executive

HELP (Health Emergencies in L arge Populations)

Director of the Global Health Workforce Alliance

to train health professionals for missions. In -

(GHWA). This work culminated in the first ever

itially, the course was given annually in Geneva,

global forum on human resources for health and

in English, but currently the three week training

the Kampala Declaration and Agenda for Global

course is offered seven times per year: In Switzer-

  Action that now guides the global response on

land, the USA (2×), Japan, Benin (French), South

health workforce development. Before joining

 Africa, and Mexico (Spanish). He holds numerous

GHWA, he was the Director General for Health

academic positions: Associate at the Johns Hop-

Services in the Ministry of Health in Uganda, dur-

kins School of Public Health; Associate Professor

ing which time he was responsible for coordinat-

at the Faculty of Law and Political Sciences of Aix-

ing major reforms in the health sector in Uganda.

Marseille; Guest Professor at the Université Libre

  At the global level he was Vice-Chairman of the

of Brussels (2007–2008). He has been granted

Global Stop TB Partnership, Chair of the Portfolio

The Distinguished Alumnus Award 2004 from the

and Procurement Committee of the Global Fund

 Alumni Association of Johns Hopkins University.

Board and a member of the steering committee of the High L evel Forum on health-related MDGs

Helen de Pinho is from South Africa where she

and has served as an adviser to governments in

trained as a physician, specialized

developing and developed countries. Dr. Omaswa

in public health, and completed an

is a graduate of Makerere Medical School, Kam-

MBA focusing on management edu-

pala, Uganda, a Fellow of the Royal College of 

cation and systems thinking. She

Surgeons of Edinburgh, founding President of the

has worked as a health service man-

College of Surgeons of East, Central and South-

ager in the areas of reproductive

ern Africa and is a Senior Associate at the Johns

health, HIV/AIDS and health service delivery in

Hopkins Bloomberg School of Public Health.

both rural and urban areas of South Africa. In addition, she was a senior lecturer in the School of