Hannah Arendt's "dark times" were times of political upheaval during which the mere acts of doing good and refraining from evil were nothing short of extraordinary manifestations of courage and heroism. A century after her birth in 1906, dark times had not lifted, at least not for medicine and public health. Many nurses and medical doctors are subject to attack or persecution, or are refused access to their patients. Worse, many others succumb to a "banality of evil" (Arendt again) that leads them to betray the oath, and break the law by engaging in medical offences. For medicine and public health, dark times mean that the neutrality and Hippocratic values of medical practice are under siege in many parts of the world and that sometimes it is the medical profession itself that holds the siege.
It is urgent to protect medical and public-health practice from harm or from perpetrating harm. This requires a critical examination of past and current events that bear witness to the extreme vulnerability of nurses and doctors particularly in times of conflict or political unrest. And this in turn begs for the means to contain the siege on medicine and public health, and to propose protective measures.
Two dates, forty-five years apart - 19 November 1991 and 9 December 1946 - epitomise this "dark times" victim/offender duality in the world of medicine and public health. The killing of dozens of doctors and nurses together with their patients in Vukovar, eastern Croatia at the start of the Yugoslav wars in 1991 constitutes one of the biggest assaults against medicine and public health to date; and the twenty Nazi medical doctors charged in 1946 "with murders, tortures, and other atrocities in the name of medical science" remains the most extreme case of medical perversion of all times. It is vital that both events are engraved in the world's collective memory, for they are the embodiment of medical and public health held captive by a predatory and enslaving "banality of evil".
Michel Thieren is a Belgian physician specialising in humanitarian affairs and human rights. He has spent more than a decade managing emergency operations in non-governmental organisations and the United Nations, and was head of office in northern Bosnia for the World Health Organisation in 1995-6. He works as a medical scientist at the statistical department of the World Health Organisation in Geneva
Michel Thieren writes here in his personal capacity only
Also by Michel Thieren in openDemocracy:
"There was genocide in Srebrenica
(11 July 2005)
"Katrina's triple failure" (7 September 2005)
"Kashmir: brothers in aid" (17 October 2005)
"Dayton plus ten: Europe interrogated" (24 November 2006) with Louise Lambrichs
"Deaths in Iraq: how many, and why it matters"
(18 October 2006)
Libyan justice: medicine on death row
(19 December 2006)
A profession besieged
Yet it seems that there are lessons still to be learned. For although the national leaders convened at the United Nations general assembly recognise that the Millennium Declaration and the subsequent Millennium Development Goals embody the pre-eminence of health, the undermining of medicine and public health has gained momentum.
Four examples suffice to make the point:
▪ in the early 2000s the Global Polio Eradication Programme fell victim to ideological propaganda against the safety of the OPV vaccine, resulting in year-long delays in the eradication
▪ in 2005, totalitarian ideology undertook an assault on the heart of medical practice when the then president of Turkmenistan, Saparmurat Niyazov, ordered all physicians to pledge allegiance to him instead of taking the Hippocratic oath
▪ on 9 April 2006, five health-ministry workers were killed in their clinic in the Afghan province of Badghis, gunned down by insurgents determined to stamp out any sign of stability
▪ on 19 December 2006, a supreme-court judge in Libya trumped scientific evidence and reconfirmed a death sentence by firing-squad for six foreign humanitarian health workers (five Bulgarians and a Palestinian) on allegations of deliberately infecting hundreds of children with HIV in a hospital in Benghazi. These imprisoned healthcare workers are pawns in a far larger strategic game (see here).
Moreover, while the siege against doctors and nurses continues, offences in the name of medicine and public health have also resurfaced. Since the declaration of the "war on terror" post 9/11, various sources have reported the active participation of US military health and medical professionals in a variety of serious offences in the prison of Abu Ghraib in Iraq (see SH Miles, "Abu Ghraib: its legacy for military medicine", Lancet. 2004) and the US detention centre at Guantànamo Bay in Cuba (see MG Bloche & JH Marks, "Doctors and Interrogators at Guantanamo Bay", The New England Journal of Medicine, 2005).
These violations notwithstanding, on 17 October 2006, the United States legalised the Military Commission Act 2006 (MTC) that allows the suspension of basic human rights and humanitarian-law provisions, including the protection from degrading treatment for prisoners. The MTC bodes ill for the creation of a jus in bello of medical and public-health systems in the future.
Len Rubenstein, executive director of Physicians for Human Rights (PHR), recalls that 28 April 2007 marks "the third anniversary of the disclosure of the detainee abuse that took place at Abu Ghraib". In a message to PHR members, Rubenstein raises the case of Mohammed al-Qahtani, the alleged "twentieth 9/11 hijacker" who experienced "intensive and protracted abusive interrogation that which resulted in abuse, a health emergency, and sleep deprivation while the detainee was under their care".
"If this doesn't show how doctors were involved in the machinery of torture, then nothing does", Rubenstein said in a panel discussion with Lieutenant-General Kevin C Kiley, army surgeon-general, in Chicago in May 2006. In its campaign against torture, PHR highlights these ambiguities in posting Kiley's memorandum which says, inter alia: "I hereby approve all the [relevant and named] findings and recommendations, except the recommendation that psychiatrists/ physicians not be used as members of a Behavioral Science Consultation Team (BSCT) and that all detained individuals be treated to the same care standards as U.S. patients in the theater of operation".
The struggle to be neutral
All these examples share a context of conflict or political instability. In conjunction with the reverberations of Vukovar and Nuremberg, they raise two critical questions:
▪ what, in these politically volatile situations, makes medical and public-health practice - in fact the whole health system - prone to dark times?
▪ what measures can insulate medical and public-health practice from breaches of neutrality?
Medical personnel in situations of conflict and political unrest interact with victims and appear as resources of information on the nature and magnitude of abuses or war crimes, particularly under the aegis of medical confidentiality. It is a difficult challenge to balance information from the victim and information about the aggressor with medical neutrality, exposing the vulnerability of health workers in times of instability.
Conversely, health workers can forfeit their standards of practice and abuse their knowledge and access to confidential information in different ways: by diverting medical supplies and human resources; disclosing medical information for "security" or "intelligence" purposes, thus exposing patients to retaliation or abuse; collaborating in the design of coercive interrogations; or falsifying death certificates to protect perpetrators of torture and war crimes. Medical offences may escalate towards direct participation in torture and degrading treatments, and at the very extreme, in perpetrating war crimes and crimes against humanity.
The constant targeting of health systems in times of unrest and the occurrence of medically assisted offences mean that in certain circumstances, law and medical ethics are violated. On the contrary, a corpus of important bioethical instruments has come into existence since the elaboration of the Nuremberg Code to offer a comprehensive framework to inform medical practice and research. These include the judgment of the Nazi doctors' trial; the declaration of Helsinki in 1964; the declaration of Tokyo in 1973; the Belmont report in 1979; and the updated ethical guidelines of the Council for International Organisations of Medical Sciences (Cioms).
On the legal side, binding treaties have enunciated very specific provisions to regulate public health and medical practice. In June 1977, for example, twenty-seven articles were added to the body of international humanitarian law specifically to "extend the protection of the Conventions to civilian medical personnel, equipment and supplies and to civilian units and transports and contains detailed provisions on medical transportation."
These articles, better known as the "principles of medical neutrality" in time of war, were subsequently reflected in the convention against torture and other cruel, inhuman or degrading treatment or punishment (1984); and in the Rome statute of the International Criminal Court (1998). Nonetheless, the continuing vulnerability of medical and health workers in conflicts and political unrest shows that this body of knowledge - and there are yet other items in it - may still not be enough.
Respond, remedy, prevent
Further protective measures are needed on three levels: responsive, remedial and preventive actions. On the responsive and remedial fronts, additional checks and balances could be developed - for example, by expanding the statutes to the International Criminal Court and establish a special tribunal prosecuting medical crimes (a permanent "Nuremberg" for doctor's trial); standing parliamentary commissions for offences perpetrated by or against the medical and public health establishment; strengthening coordination mechanisms between medical associations and the judiciary system; and establishing standing commissions for financial compensations for victims of medical crimes.
On the preventive front, measures could target nursing and medical education by adding to their curriculum a significant load of mandatory case-based classes in humanitarian and human-rights law, bioethics, and public-health law. In fact, a graduating nurse or medical doctor today knows very little about the vulnerability of their profession when the neutral space and Hippocratic values of medicine and public health are in jeopardy.
An immediate recommendation, symbolic but significant, is for all medical and paramedical practitioners alike to take the Hippocratic oath, currently mandated only for physicians, as well as a vow to uphold human rights, as encapsulated by the universal declaration of human rights or by one of the aforementioned instruments. Finally, an overall critical measure could be to develop improved funding mechanisms for non-governmental and civil-society initiatives committed to the monitoring, disclosure and denunciation of breaches in medical neutrality around the world.
Doctors pledge to put their training, skills and acquired knowledge to be healers in the true sense of the word. But, doctors are gens ordinaires and may sometime fail in fulfilling this commitment. When Clément Kayeshima, physician and prefect of Kibuye in Rwanda, visited the South Kivu office of the United Nations high commissioner for refugees (UNHCR) in August 1994 seeking employment as a "healer", his eyes were still glazed with both Akazu power and the death of hundreds of thousand Rwandan Tutsis.
As I was the UNHCR medical coordinator at that time, Kayeshima came to my office first. I recall that fleeting absurd connection, a surreal instance when he, the génocidaire, and I, the humanitaire, were simply two doctors. But, two doctors in absolute opposing observance of the Hippocratic oath, the medical ethics and the law. A few years later, the International Criminal Tribunal for Rwanda condemned Kayeshima to life-imprisonment on charges of genocide, stipulating that "he is an educated medical doctor who betrayed the ethical duty that he owned to his community". Doctors are ordinary people, not immune to "(shaking) hands with the devil", thus not immune of a mutation from healer to killer.
As evident also in Libya, they also are vulnerable prey in the hands of evil-doers. The strict obedience to existing oaths and ethical principles together with the fulfilment of legal obligations vis-à-vis medical neutrality are required and additional responsive, remedial and preventive measures of the kind listed here should be explored.
The Nuremberg Code at sixty
On 19 August 1947, the judges at Nuremberg in the case of USA vs Karl Brandt et al (the Nuremberg medical case) did more than render their verdict. They addressed the legal gap around the question of medical experiments Nazi doctors used in their defence, arguing about similar precedents in such experiments both in Germany and the United States prior to the second world war. That day, the Nuremberg Code was born as one of the most aggressive attempts of any court in history to make jurisprudence on medical crimes.
Although the code remains the founding document of medical ethics and a landmark legacy of the medical case, it has failed to become international customary law. Robert Jay Lifton, in his preface to the second edition of his masterly book The Nazi Doctors, makes the dismal point that medical perversion has remained one of the pandemics of our time - a sort of a chilling and prophetic realisation of the famous picture The Bad Doctors painted in 1892 by the Belgian expressionist James Ensor.
August 2007 sees the sixtieth anniversary of the Nuremberg Code. It is an opportunity to reflect that the victims of medicine at Abu Ghraib or the Benghazi six in Libya still have nowhere to go to claim recognition and reparation.