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The Right to Health in Armed Conflict

Pierre Perrin*

Introduction The effects of war on health are multifaceted and range from striking ef fects such as the wounded, the dead, the epidemics and famine, to less visible ones including the disorganization of health services and, in some cases, their total annihilation. Both types of effects may result in humani tarian tragedies which affect whole populations. Health services react to these situations, however, the implementation of the response strategies encounters constraints that limit their effect, espe cially when violence is established as a war strategy against the civilian popu lation. Such tactics of hostilities run counter to the humanitarian logic. Health professionals are not only responsible for proposing technical solutions to resolve health problems, but they also must use legal means, in particular through international humanitarian law (IHL) and international human rights, to effectively protect the right to health. In this regard, the role and responsibilities of health professionals in identifying the effects of weapons with the view to applying IHL rules on means and methods of warfare is a telling example of such a role, as well as of the complexity of ad dressing health issues in the context of war.1 In times of armed conflict, both international humanitarian law and international human rights law offer important protections for the right to health. Given the various components of this right, the applicable legal framework entails interaction between those two bodies of norms. When considering IHL, it is worth noting that protection goes beyond specific

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provisions related to health and health services. It also encompasses norms that indirectly contribute to protecting the right to health, such as the prin ciples and rules governing the means and methods of warfare. While one may primarily think of civilians as persons whose health is affected by war, combatants are affected too. Indeed, IHL rules first devel oped by focusing on ways to alleviate the suffering of wounded combatants on the battlefield and to ensure access by health services to those persons. This chapter first seeks to look at the legal bases of the right to health in armed conflict to show that IHL provides for a broad protection. Second it offers a brief overview of the protection of this right in practice. Finally it gives elements on the underlying humanitarian and political background to understand the current evolution with respect to the protection of the right to health in armed conflict.

The legal bases of the right to health The right to health The right to health is understood as the right to have access to health ser vices. However, it is not an absolute right, as such, to be in good health.2 The WHO defines health services as all activities intended to restore and maintain health.3 One therefore has to include vaccinations, medical care, but also sanitary services related to water and hygiene, and a clean environment under this heading, as well as all activities ensuring access to food resources. Those underlying determinants of health 4 imply con sideration of the right to health in a broader perspective, which is the basis of Article 25 of the Universal Declaration of Human Rights.5 The corollary of this right is the idea that states are responsible for adopting appropriate sanitary and social measures for the populations to have effective access to health services.6 Such obligations are found in sev eral legal instruments, including the International Covenant on Econom ic, Social and Cultural Rights (Articles 12, 24), the International Conven tion on the Elimination of All Forms of Racial Discrimination (Article 5), the Convention on the Elimination of All Forms of Discrimination Against Women (Articles 10, 12, and 14), the Convention on the Rights of the Child (Article 24). While all these legal instruments are applicable at all times, including during armed conflict, this chapter will focus primarily on the provisions of international humanitarian law. Having defined the right to health as

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the right to access to health care, it applies to all persons whether they are wounded or not. As this chapter covers situations of armed conflict how ever, it will address mainly the right to health for persons, be they combat ants or noncombatants, who are injured.

The right to health in armed conflict Within possible limits, medicine has always responded to the needs of in jured persons and tried to limit the means and methods of warfare, includ ing through describing and providing expertise to better understand the ef fects of weapons. In his work On The Physician, Hippocrates refers to war injuries as an area of surgical specialization.7 Based on reports of the con sequences on health of the use of nuclear weapons, two physicians, a Rus sian and an American, launched the idea of an association of medical doc tors to prevent a nuclear war. This idea was the origin of the creation of the organization called International Physicians for the Prevention of Nuclear War in Geneva. In 1985, this association received the Nobel Peace Prize for making people aware of the catastrophic consequences a nuclear conflict would entail. The development of IHL, in particular through the First Geneva Con vention,8 was aimed at protecting and caring for persons injured during armed conflict, firstly combatants. This constituted a major turning point in modern humanitarian thinking and offered a legal framework for provid ing assistance to the wounded in wars.9 In parallel, various legal instruments were elaborated with a view to limiting the means of warfare, and to forbid the use of certain weapons. In 1863, during the American Civil War, the Lieber Code 10 was elaborated, limiting the militarys means of warfare. Several international instruments were later adopted, prohibiting the use of expanding bullets,11 biological 12 and chemical weapons.13 Such regulations are relevant when considering health issues in armed conflicts. Although the International Court of Jus tice, following a request by the World Health Organization on the legality of the use of nuclear weapons, ruled in its 1996 advisory opinion that such re quest did not relate to a question which arises within the scope of WHO ac tivities,14 this finding was limited to the purpose of assessing the conditions to file a request for an advisory opinion. It does not mean that IHL norms regarding means and methods of warfare are not relevant rules offering a protection of the right to health against the effects of certain weapons.

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This dual approach to provide care and to prevent the effects of weapons has been consistent throughout the development of the law of armed conflict.

Protecting the right to health through international humanitarian law Numerous aspects of international humanitarian law address the protec tion of the right to health in armed conflict; they concern the protection of the right to be given care and the protection of essential services to main tain health. The 1977 Additional Protocol I states that:
all the wounded, sick and shipwrecked, to whichever Party they belong, shall be respected and protected. In all circumstances they shall be treated humanely and shall receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their con dition. There shall be no distinction among them founded on any grounds other than medical ones. 15

Several articles in the Geneva Conventions and their Additional Protocols protect medical structures and medical personnel. It is forbidden to attack hospitals, and medical staff must be able to perform their work without any discrimination whatsoever.16 Protection is also required for essential services aimed at maintaining health, namely food, drinking water, hygienic measures, and habitat. To en sure such protection, it is forbidden to attack or destroy these services, or to render them inoperable. With respect to access to food, it is forbidden to attack food stocks, agricultural zones, harvests, cattle, and irrigation installations.17 International humanitarian law also contains rules regarding the re sponsibilities of the parties to the conflict. For instance, in case of occupied territories, the occupying power has the duty to ensure and maintain the medical and hospital establishments and services, public health and hygiene in the occupied territory in cooperation with the national authorities.18 Restrictions on the means and methods of warfare Restrictions on the means and methods of warfare, be they through general principles or through specific rules covering particular weapons, are also rel evant when considering the protection of the right to health in armed con

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flict. These restrictions affect a range of aspects, from the effects of weap ons that may impact upon the health of combatants, to the indirect effects on civilians. It is for example forbidden to use famine as a weapon of war.19 Pillag ing, and poisoning of water supplies, is also prohibited. The development and use of weapons is an area where the interface between the law and health is particularly important. In this regard, the health impact of a weapon is used in order to assess the effects of a weapon when determining whether it causes superfluous injury or unnecessary suf fering. This rule also requires medical considerations to be applied in order to identify the nature of the effects of a means of warfare. Moreover, the quality and availability of hospitals and health services in the enemy area may be an element to take into account when assessing the superfluous or unnecessary character of the effects of a weapon compared to its military utility, depending on the peculiarity of the effect. For example, if a party to a conflict has no means to treat a particular type of injury, it may be rel evant in applying the prohibition of superfluous injury or unnecessary suf fering rule. Recently, several humanitarian organizations 20 have shown that civil ian populations are particularly affected by the use of cluster munitions.21
Cluster munitions are weapons that spread hundreds of tiny explosive devices over wide areas and leave hidden unexploded bomblets that keep on killing for many years. In modern wars, civilians pay a high price from the use of such weapons. 22

In May 2008, 107 states adopted a draft Convention on Cluster Munitions which effectively prohibits the use, production and transfer of all existing types of cluster munitions. The draft Convention establishes important commitments regarding assistance to victims, clearance of contaminated areas and destruction of stockpiles. Further, the adoption of the Protocol on Explosive Remnants of War in 2003 obliges the parties to the conflict to remove all explosive remnants. This is a step forward in the protection of the populations in the postconflict phase, but the essential issue here is to protect the civilian population during the conflict. More and more, govern ments and other actors are committing to prohibitions on such weapons, since their use goes against the principle of distinction between military objectives and the civilian population/objects.23

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The problem of landmines and explosive remnants of war shows the diffi culties encountered in the efforts to ban weapons having harmful postcon flict effects, particularly when they are already being widely used. It is pref erable to adopt a strategy of primary prevention, with a view to prohibiting the development of certain weapons right from the initial concept, if their potential effects violate the principles of international humanitarian law. This approach had been successfully adopted for banning the use of blind ing laser weapons.24 International humanitarian law and human rights law is expressed in a variety of legal instruments that are applicable in armed conflicts. These situations are often accompanied by displacements of the populations to a country other than that of their origin. These populations may be spe cifically protected by extra protections under the 1951 Refugee Convention and its Protocol of 1967, which define the responsibilities of states visvis refugees, and the Guiding Principles on Internal Displacement, which sets out the situation visvis internally displaced persons (IDPs).25 Health staff can also have recourse to the recommendations of the World Medical Association (WMA). While these are not binding legal in struments in the strict sense of the term, they outline the position of the medical profession on difficult problems such as torture,26 or economic em bargoes,27 which are sometimes encountered in armed conflicts. Moreover, a certain number of recommendations concern armed conflict directly.28 For instance, the WMA defines the position of health personnel in the case of surgical triage,29 which may result in limited access to care for certain groups of wounded. This ethical framework complements the legal framework, so as to help health staff to work for the highest possible standards of ethical behaviour and care by physicians, at all times.30

These examples give a general overview of the legal framework that exists to ensure the protection of the right to health in armed conflict. The en joyment of this right depends on the willingness of the parties involved in these situations to carry out their responsibilities in this regard.

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In practice: Protection of the right to health in armed conflict For the right to health to be respected, health services must function cor rectly and populations must have access to them.

The responsibilities within health services Providing appropriate care to persons affected by armed conflict is the re sponsibility of national (military and civilian) authorities. Depending on the willingness and capacity of the authorities to face this responsibility, humanitarian organizations concerned with health care should adopt a strategy that combines the following various approaches: Reminding the authorities of their responsibility by referring to the rules of international humanitarian law and human rights law, in particu lar when the authorities appear insufficiently concerned about populations that are affected by the conflict, specifically the ones at the highest risk, such as prisoners and detainees. Supporting national health services with a view to assisting them in re sponding to the needs of the civilian population. Of course, the authorities still need to have a minimum functional capacity and be willing to cooper ate with humanitarian organizations. Providing direct care to the populations concerned. This approach must not contribute to relieving the authorities from their responsibility. The last approach is required when the capacity of the national health ser vices is overtaxed by the increase in demand for health services (for example, through massive displacements of people), deterioration due to structural problems (dysfunctional government or insufficient budget al locations for health services), health personnel fleeing for security reasons, or the refusal of authorities to provide health assistance to certain groups of people based on ethnic, political, religious or other criteria.
if circumstances cause it to provide services to the affected populations, the ICRC does not have the vocation to substitute the responsibilities of the authorities. It will continue its efforts towards the latter so that they take care of these services and thus fully fulfil their obligations. 31

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The interface between the authorities and humanitarian organizations de pends on the applicable legal frameworks; thus, in noninternational armed conflicts, humanitarian organizations may offer their services to the auth orities based on the right of initiative,32 and on the political willingness of the authorities to give access to the people to humanitarian organizations.

The good functioning of health services is a first, necessary stage for ob taining respect for the right to health, but health services must also be ac cessible to all persons without discrimination.

Responsibilities for protecting access to health services In many armed conflicts, people no longer have access to health services for different reasons, such as: Insecurity which limits the access to health facilities:
[The] Mortality rate was higher in unstable eastern provinces, showing the effect of insecurity. Most deaths were from easily preventable and treat able illnesses rather than violence. Regression analysis suggested that if the effects of violence were removed, allcause mortality could fall to al most normal rates.33

Discrimination at the point of access to health facilities, based on eth nic, religious, political, or other factors:
these conflicts are often characterized by rampant and gross disrespect for the principle of medical neutrality, which guarantees the provision of health care without discrimination to all injured and sick combatants and civilians in time of conflict.34

Access to health services depends on whether the parties to the conflict take all measures required to ensure free access to health facilities. The role of humanitarian organizations is to assess whether people do have access to health services and, if necessary, to identify the obstacles which hinder

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such access. Based on this analysis, humanitarian organizations should ini tiate the following: Dialogue with all parties concerned: With the parties to the conflict, to remind them of their responsibil ities and to request that measures be taken with a view to ensuring the security of the population. Respecting the principles of international hu manitarian law requires that all those bearing arms be informed of the ap plicable standards. Teaching the basic rules of international humanitarian law is therefore a first step. With health staff, to remind them of the rules of international human itarian law and of the ethical recommendations applicable to the medical profession. Mobilizing the international community by means of declarations, re ports, interventions with multiple players (states, media, nongovernmen tal organizations ) who have influence in a given context, with the ob jective of exerting pressure on the parties to the conflict and to encourage them to guarantee access to health services. Humanitarian organizations can sidestep the prerogatives of authori ties and offer health services without the approval of the latter. This ap proach has been at the origin of the without borders movements. As one observes a radicalization of violence in armed conflicts,35 there fol lows a certain radicalization in the protection of the right to health, which is integrated into the strategies that include protection by armed means to ensure the direct protection of persons. For example, the humanitarian in tervention approach is used, or le droit dingrence, based on ethical con siderations regarding the obligation to provide care to people in emergency health situations. Such interventions may serve to maintain peace or to re store peace.
Most United Nations multidimensional peacekeeping operations are therefore mandated to promote and protect human rights by monitoring and helping to investigate human rights violations and/or developing the capacity of national actors and institutions to do so on their own. 36

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The decisions to establish peacekeeping forces to protect populations are based on political and humanitarian factors. Whatever the share of one or the other may be, health considerations will play an important role. In a study on mortality in the Democratic Republic of the Congo (DRC), the authors recommended an increase of the UN peacekeeping forces to fight insecurity, which is the main factor that prevents populations from access ing health services in times of armed conflict.37 This type of epidemiological study has a positive impact on political decisions, especially when they are conducted with a high degree of pro fessionalism. Following a study on mortality in Iraq,38 the respective po litical players tried to discredit the results of the study by criticizing the method used to gather data.39 There is a risk of focusing the discussion on the methods, instead of on the recommendations to overcome the prob lems encountered.

There is an interaction between humanitarian and political activities. In the short term, this tendency may have repercussions on the perception of the responsibilities of the players in armed conflicts.

The protection of the right to health in armed conflict: What is its evolution? Two factors have to be considered: Integration of the right to health in the general concept of human se curity; and The search for some consistency between the political and humanitar ian management of armed conflicts.

The right to health and human security The right to health and other fundamental human rights are interrelated. The different violations of the physical and mental integrity of persons (tor ture, ill treatment, sexual violence, mutilations, etc.), and attacks on the social integrity of populations (ethnic purges, forced resettlements, break ing up of families, etc.), all have dramatic consequences for health. In more

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general terms, health professionals feel that it would be unethical to care for people without also taking into account the serious violations of human rights and IHL, of which they could also be victims. For some years now, this global approach to human rights has been found in the concept of human security, which allows for the integration of all dimensions of human rights.40

The search for coherence between the political and humanitarian ap proaches to armed conflict The political management of armed conflicts, and their humanitarian con sequences, are increasingly considered to be an exercise that needs to be conducted in a coordinated manner. The current trend is to search for coherence between the handling of armed conflict and its humanitarian consequences:
The original concept of coherence envisioned a collective rallying of mili tary, political, economic and humanitarian assets to support peace and se curity. It assumed a common understanding of the nature and dynamics of conflict between these different domains, and a shared vision of the means of resolving such conflict and of the nature of peace. 41

In practice, this global strategy designed to ensure the protection of human security will require interventions from several angles:
Civilians are the main casualties in conflicts. Both norms and mechanisms to protect civilians should be strengthened. This requires comprehensive and integrated strategies, linking political, military, humanitarian, and de velopment aspects. 42

This integration has repercussions on the specific strategies for protecting the right to health. For instance, preventing health problems in the context of massive population resettlements primarily rests on making the zones where these populations live safe, in order to prevent them from having to move for reasons of insecurity. If, in spite of everything, evacuations are unavoidable and people find themselves in camps, ensuring their safety is an essential element for the prevention of violations of their fundamental rights, and also to allow for the regular organization of medical assistance.

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Integration also has repercussions for the sharing of responsibilities be tween the parties involved in armed conflict. To guarantee access to health services, we find ourselves in a twoway flow of responsibilities between ci vilian organizations (NGOs, specialized UN organizations), and the mili tary either under a UN mandate (peacekeeping forces), or acting within the framework of agreements with national authorities (for example, the Unit ed States in Iraq). The integration of political and humanitarian activities within a com mon strategy is not without risk. Humanitarian organizations will have difficulty in distinguishing themselves from the political actors, who are parties in this strategy, and consequently to comply with the principle of neutrality visvis the par ties to the conflict. The financing of humanitarian interventions by do nor countries runs the risk of being conditioned by the progress achieved in the political handling of the armed conflict. A certain confusion may arise in the minds of the population regarding the perception of the mandates. For instance, in Afghanistan the International Security Assistance Force (ISAF)43 mission is to assist the Afghan government and the inter national community in maintaining security. In practice, this means that there will be joint interventions between ISAF forces and the Afghan po lice, and the Civil Military Cooperation (CIMIC)44 projects concerning edu cation, health, and drinking water.45 This mix of activities creates some confusion relating to the perception of the mandates, both among the population and the authorities. OXFAM notes: As a result of the U.S. engaging in aid for information, Oxfam was forced to close its program in Kandahar in 2003 Communities that we work with have become confused as the lines between aid agencies and the military have become blurred in Afghanistan. 46 In an attempt to avoid this confusion, some coherence will have to be sought, both at the political and the humanitarian levels. In the political handling of armed conflicts, the United Nations Organization plays this role with regard to bilateral interventions. In the handling of humanitarian matters that arise as a consequence of armed conflict, the current reforms of the UN system have the objective of achieving greater coherence in the realm of humanitarian action. In the more specific area of health, the emergence of the World Health Organization (WHO) as a player in emergency situations, including those

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arising from armed conflicts, has given it a certain formalized credibility due to its status as head of the health cluster. In 2008, the declaration of the WHO concerning the situation in the Gaza strip not only indicates that the WHO takes part in the analysis of health problems in situations of armed conflict, but also that it tries to achieve some coherence with its political management:
WHO urges and requests: 1. Access of all urgent patients to specialized medical care outside the Gaza strip, without unnecessary delays which reduce their possibility of surviving; 2. Free and unhindered passage into Gaza of all necessary medical equip ment, drugs, and consumables; 3. Provision of sufficient amounts of fuel and electricity for the Gaza strip to ensure the full functioning of hospitals, ambulances, generators, water and sanitation systems, and other vital infrastructures; 4. Availability of primary and secondary health care, water and food for people living under curfew within the Gaza strip. WHO advocates for all parties concerned to bring to an immediate end all military operations and resume peace negotiations. Furthermore, WHO calls all parties involved to abide by and conform with the International Humanitarian Laws and the Human Rights Treaties including the respect and fulfilment of the right to health. 47

Conclusion The protection of the right to health in armed conflict requires reliance on a legal framework that recognizes the many facets of this right. While IHL integrates specific considerations, striking a balance between humanitarian considerations and military necessity, human rights law remains relevant to complement IHL in order to fill the potential gaps. Considering the current and future evolution of armed conflicts and their impact on health, it is no longer a matter of thinking in terms of man aging the humanitarian consequences of war, but rather of having to choose between war or health, because the consequences of war on the right to health will no longer be manageable for the medical corps.

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Health professionals are also responsible for participating in the elabora tion of a true strategy for the prevention of conflicts. In practice, they can contribute to this goal by: Rationally using the epidemiological tools to promote health concerns in the context of current and future armed conflicts. Exercising their ability to influence political players. Controlling research and biotechnological work, for example through ethical committees, to ensure such research will not be applied towards de veloping new weapons. Paradoxically, one major risk may derive from medical research: The use of genetically engineered germs, or even germs produced by nanotechnol ogy, would have effects on the population, which would extend beyond any therapeutic capacity. Only a strategy of preventing armed conflicts will allow us to safeguard the right to health for future generations.

This chapter was originally written by the author in French and translated into English by Salom Hangartner. The author would like to acknowl edge with gratitude Theo Boutruche for his con tribution to this chapter. See, for example, Robin Coupland, The effects of weapons and the Solferino cycle 319(7214) British Medical Journal (1999), at 864865. Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 14 on the

3 4 5

right to the highest attainable standard of health, 11 August 2000, UN Doc. E/C.12/2000/4, at paras. 9 and 11. See further http://www.who.int/topics/health_ services/en/. CESCR, supra note 2. Article 25 of the Universal Declaration of Human Rights reads: 1. Everyone has the right to a standard of living adequate for the health and wellbeing of himself

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10 11

12

and of his family, including food, clothing, hous ing, and medical care and necessary social ser vices, and the right to security in the event of un employment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 2. Motherhood and childhood are entitled to spe cial care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection. Preamble of the Constitution of the World Health Organization (WHO) (1946), available at http:// www.who.int/gb/bd/PDF/bd46/ebd46_p2.pdf. Hippocrates, On The Physician, 14: Surgery con cerning the injuries by war weapons is related to our topic, insofar as it has to do with the extrac tion of arrows. First Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field (1864). The IHL rules for protecting noncombatants in armed conflicts are contained in the four Geneva Conventions of 1949 and their two Additional Pro tocols of 1977. IHL depends on classifying a con flict as either an international armed conflict or a noninternational conflict. International armed conflicts are those in which at least two states are opposing each other. These conflicts are ruled by a vast range of rules, among them the ones stated in the Geneva Conventions of 1949 and the additional Protocol I of 1977. In noninternational armed con flicts, dissident armed forces are confronting each other on the territory of a single state, or armed groups are fighting each other. More limited rules, overall, are applicable to this type of conflict. Instructions for the Government of Armies of the United States in the Field (1863). Declaration (IV, 3) concerning Expanding Bullets (1899), available at http://www.icrc.org/ihl.nsf/ FULL/170?OpenDocument. Convention on the Prohibition of the Develop ment, Production and Stockpiling of Bacteriologi cal (Biological) and Toxin Weapons and on their Destruction (1972), available at http://www.icrc. org/ihl.nsf/FULL/450?OpenDocument.

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14 15 16

17

18 19 20

21

22 23

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Convention on the prohibition of the develop ment, production, stockpiling and use of chem ical weapons and on their destruction (1993), available at http://www.icrc.org/ihl.nsf/INTRO/ 553?OpenDocument. Legality of the Use by a State of Nuclear Weapons in Armed Conflicts, I. C. J. Reports (1996), para. 31. Article 10, First Additional Protocol to the Gene va Conventions (1977). Article 12, paragraph 1, and Article 15, paragraph 1 of the First Additional Protocol to the Geneva Con ventions; Article 19 of the Fourth Geneva Conven tion, Article 15 of the First Additional Protocol and Article 11 of the Second Additional Protocol. Starvation of civilians as a method of combat is prohibited. It is therefore prohibited to attack, destroy, remove or render useless, for that pur pose, objects indispensable to the survival of the civilian population, such as foodstuffs, agri cultural areas for the production of foodstuffs, crops, livestock, drinking water installations and supplies and irrigation works: Article 14, Second Additional Protocol to the Geneva Conventions. Article 56 of the Fourth Geneva Convention. Article 14, Second Additional Protocol to the Ge neva Conventions. International Committee of the Red Cross (ICRC), Handicap International, Human Rights Watch, United Nations Mine Action Service. Cluster munitions are defined as all ammuni tions or explosive charges designed to blow up at a specific moment after having been launched or ejected from a parent cluster munition: 10th Ses sion of the Group of Government Experts of the Parties to the 1980 Convention on Certain Classi cal Weapons, 8 March 2005. Human Rights Watch, Cluster Weapons: Scourge of Civilians, 23 September 2008. ICRC, Cluster Munitions: Decades of Failure, Decades of Civilian Suffering (Geneva: ICRC, 2008), available at http://www.icrc.org/web/eng/siteen g0.nsf/html/p0946. Protocol on Blinding Laser Weapons, Protocol IV of the 1980 Convention on Certain Conventional Weapons (1995).

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25 26

27 28 29 30

31 32 33

34

35

36

37 38

39

See further http://www.unhchr.ch/html/menu2/ 7/b/principles.htm. Tokyo Declaration of the World Medical Associa tion Directives for physicians concerning torture and other punishments or cruel, inhumane or de basing treatments in the context of detention or imprisonment. World Medical Association Resolution on Eco nomic Embargoes and Health (1997). World Medical Association Regulations in Times of Armed Conflict (1956). World Medical Association Statement on Medical Ethics in the Event of Disasters (2006). World Medical Association Mission Statement, available at http://www.wma.net/e/about/index. htm#mission. ICRC, Assistance Policy, reproduced in 855 International Review of the Red Cross (2004), at 677693. Common Article 3 of the four Geneva Con ventions. Benjamin Coghlan, Richard J. Brennan et al. Mortality in the Democratic Republic of the Con go: A Nationwide Survey 367 The Lancet (2006), at 4451. World Health Organization (WHO), 25 Questions on Health and Human Rights (Geneva: WHO, 2002), available at http://www.who.int/entity/ hhr/NEW37871OMSOK.pdf. Report of the SecretaryGeneral of the Unit ed Nations on the Protection of Civilians in Armed Conflict, 28 November 2005, UN Doc. No. s/2007/643. JeanMarie Guhenno, UnderSecretaryGener al for Peacekeeping Operations, United Nations Peace Keeping Operations: Principles and Guide lines, March 2008. Coghlan, supra note 33. Gilbert Burnham, Riyadh Lafta, Shannon Doocy, Les Roberts, Mortality after the 2003 invasion of Iraq: A crosssectional cluster sample survey, 368(9546) The Lancet (2006), at 14211428. U.S. President George Bush dismissed the methodology as pretty well discredited: CNN,

40

41

42

43

44

45

46

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Study: War Blamed for 665 000 Iraqi Deaths, 11 October 2006. Australian Prime Minister John Howard said: Its not plausible, its not based on anything other than a housetohouse survey : Australian Broadcasting corporation, Report reignites debate over human cost of Iraq war, The World Today, Tuesday, 27 March 2007. Perrin Pierre, Sant publique et scurit dans les urgences complexes 25 Refugee Survey Quarterly (2006), at 3541. Humanitarian Policy Group, The Politics of Co herence: Humanitarianism and Foreign Policy in the PostCold War Era, Briefing Paper 1, Ju ly 2000, available at www.odi.org.uk/hpg/papers/ hpgbrief1.pdf. Commission on Human Security, Human Security Now (New York: Commission on Human Security, 2003), available at http://www.humansecurity chs.org/finalreport/index.html. The International Security Assistance Force (ISAF) is NATOs first mission outside the Euro Atlantic area. ISAF operates in Afghanistan under a UN mandate and will continue to operate ac cording to current and future UN Security Coun cil resolutions. Civil Military Cooperation (CIMIC) Projects are developed by NATO to reinforce cooperation be tween NATO and the civilian authorities of the population. NATO, NATO in Afghanistan: Factsheet, Ju ly 2007, available at http://www.nato.int/issues/ afghanistan/040628factsheet.htm. Caroline Green, OXFAM spokesperson, com ments reported by International Inter Press Ser vice, August 2004. WHO, Statement on the situation in Gaza, 3 March 2008, available at www.who.int/entity/ hac/crises/international/middle_east/WHO%20 statement%20on%20situation%20in%20Gaza. pdf.

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viously she has worked as human rights officer with the UN Human Rights Field Operation in Rwanda (19951996), and with the international commissions of inquiry on Darfur (2004) and on Lebanon (2006). Lisa holds degrees in criminology (1992) and in law (1995) from the University of Alberta, Canada, and has been a member of the Law Society of Alberta since 1997. She received her Diplme dEtudes Suprieures in International Law from the Graduate Institute of International Studies in Geneva in 1999.
Francis Omaswa is the Executive Director of the African Centre for Global Health and Social Transformation (CHEST), an independent think-tank and network initiative promoted by a network of African and International leaders in health and development. Until May 2008, he was the founding Executive Director of the Global Health Workforce Alliance (GHWA). This work culminated in the first ever global forum on human resources for health and the Kampala Declaration and Agenda for Global Action that now guides the global response on health workforce development. Before joining GHWA, he was the Director General for Health Services in the Ministry of Health in Uganda, during which time he was responsible for coordinating major reforms in the health sector in Uganda. At the global level he was Vice-Chairman of the Global Stop TB Partnership, Chair of the Portfolio and Procurement Committee of the Global Fund Board and a member of the steering committee of the High Level Forum on health-related MDGs and has served as an adviser to governments in developing and developed countries. Dr. Omaswa is a graduate of Makerere Medical School, Kampala, Uganda, a Fellow of the Royal College of Surgeons of Edinburgh, founding President of the College of Surgeons of East, Central and Southern Africa and is a Senior Associate at the Johns Hopkins Bloomberg School of Public Health.

Pierre Perrin, MD, MPH, is an Associate Professor at the University Medical Centre, Geneva, Switzerland. He has been an Associate Professor at the Institut de Mdecine Sociale et Prventive since 1998. Dr. Perrin is a graduate of the Medical Faculty of Rennes. He obtained a Master of Public Health from Johns Hopkins University (Baltimore, USA). From 1975 to 1979, he carried out several missions on behalf of Mdecins Sans Frontires in refugee camps in Africa and Asia. In 1980, he joined the staff of the International Committee of the Red Cross, working in the field and in Geneva. In 1996, he was nominated Physician in Chief of the ICRC, a position he held until leaving the ICRC at the end of 2006. In 1986, on behalf of the ICRC and in cooperation with the WHO and the University of Geneva, he created the course HELP (Health Emergencies in Large Populations) to train health professionals for missions. Initially, the course was given annually in Geneva, in English, but currently the three week training course is offered seven times per year: In Switzerland, the USA (2), Japan, Benin (French), South Africa, and Mexico (Spanish). He holds numerous academic positions: Associate at the Johns Hopkins School of Public Health; Associate Professor at the Faculty of Law and Political Sciences of AixMarseille; Guest Professor at the Universit Libre of Brussels (20072008). He has been granted The Distinguished Alumnus Award 2004 from the Alumni Association of Johns Hopkins University. Helen de Pinho is from South Africa where she trained as a physician, specialized in public health, and completed an MBA focusing on management education and systems thinking. She has worked as a health ser vice manager in the areas of reproductive health, HIV/AIDS and health service delivery in both rural and urban areas of South Africa. In addition, she was a senior lecturer in the School of