Haar et al. Conflict and Health (2021) 15:37 https://doi.org/10.1186/s13031-021-00372-7 REVIEW Open Access Violence against healthcare in conflict: a systematic review of the literature and agenda for future research Rohini J. Haar1*† , Róisín Read2†, Larissa Fast2, Karl Blanchet3, Stephanie Rinaldi2, Bertrand Taithe2, Christina Wille4 and Leonard S. Rubenstein5 Abstract Background: Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward. Methods and findings: This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, andgapsinexistingdata. Conclusion: Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized. Keywords: Attacks on health, International humanitarian law, Medicine, Violence against healthcare, Hospitals, Conflict, War, Armed conflict, Geneva conventions, Protection, War crimes * Correspondence: [email protected] †Rohini J. Haar and Róisín Read are co-first authors. 1Division of Epidemiology, University of California, Berkeley, School of Public Health, Berkeley, CA, USA Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Haar et al. Conflict and Health (2021) 15:37 Page 2 of 18 Introduction and characterize their features can enable more timely Attacks on healthcare in armed conflict violate central and systematic monitoring of attacks. tenets of human rights and International Humanitarian Better understandings of attacks on healthcare can Law (IHL) [1]. These attacks, comprising physical vio- contribute to preventing attacks, mitigating their effects, lence as well as threats, intimidation and interferences bearing witness to the costs, and prosecuting the viola- with healthcare, are a frequent but underreported facet tions of IHL and international human rights law (IHRL) of international and intra-national armed conflicts. that they represent. Documentation of attacks can Health facilities such as health centers, hospitals and pri- contribute to preventing attacks by identifying vulner- vate medical offices, and transports such as ambulances abilities, shaming perpetrators, and developing security and supply trucks, have been bombed, looted, burned, strategies. Knowledge of the scope, scale and impact of blocked, or occupied across various contexts over attacks on health can help humanitarian actors target re- decades. Healthcare personnel and patients have been sources and programs towards those have been attacked physically assaulted as well as arrested and jailed, intimi- and support recovery processes. The voices of survivors dated, threatened, or blocked from receiving or provid- are powerful in condemning violence and deepening ing care. Resolutions from the World Health Assembly, understanding of the social, psychological, physical and the United Nations (UN) Security Council, and the UN economic repercussions of attacks. Bearing witness and General Assembly have reiterated the critical need to securing accountability for perpetrators and by exposing protect health during conflict and the need for the these attacks and their human toll is an important part World Health Organization (WHO) to compile data on of ensuring justice has been served. these violations [2–5]. Interest in rigorous and system- There have already been several efforts to review some atic documentation and reporting on these attacks is aspects of data on attacks on health in conflict. These growing from the public health, medical and legal sec- include reviews focused on the impacts of attacks [22], tors. Better documentation is central to understanding reviews on the scope of attacks resulting from the Arab the true scope of the attacks on healthcare across Spring, especially in Syria [23, 24], and on incidents in- contexts, exploring their burden on health systems and volving health workers [25]. One rapid review covering populations already impacted by conflict and violence, 2011 to 2017 criticized aspects of the documentation and could assist in developing stronger protection, advo- process and the limitations of standardization in the field cacy and accountability mechanisms. [26]. The present study employs a systematic review Increased advocacy and attention in recent years has methodology to build upon these inquiries. As part of prompted calls to scale efforts to compile data on the the ongoing Researching the Impact of Attacks on nature and extent of attacks on healthcare and their Healthcare project, we ask: what is the state of evidence sequalae. Non-governmental organizations and the ICRC about attacks on health in conflict across the decades and WHO in particular have met this call with efforts to [27]? What research has been carried out? For what pur- improve documentation of incidents of attacks on health pose? Using what methodologies? And what still remains and the dissemination of research and investigations to be done? We aim to provide insight into the current [6, 7]. However, there has been significant variation state of evidence about attacks on healthcare and iden- in the objectives, types and geographic contexts of tify next steps for data collection, data utilization and attacks as well as in the methods of data collection research. and the operational definitions used to investigate and describe them. Discrepancies in these elements may Methodology obscure important dynamics, such as why attacks We conducted a systematic review of articles and reports occur and how they are counted, and limit compari- that document attacks or analyze related risks, methods son of datasets. and/or impacts. Interest in conflict data of all kinds and global programs to identify and document violence against ci- Data sources and search strategy vilians are growing alongside region-specific databases We utilized a methodology based on the Preferred [8–11]. Initiatives focus on violence against civilians, Reporting Items for Systematic Reviews and Meta- airstrikes, terrorism events, security of humanitarian Analysis (PRISMA) guidelines to identify peer-reviewed organizations and other facets of conflict [12–14]. The articles and reports pertinent to data collection and ana- growth in conflict data initiatives has allowed quantita- lysis around attacks on health in conflict settings. We tive, and increasingly disaggregated, analysis of conflict reviewed multiple electronic databases for appropriate- and conflict-related phenomena, albeit with limitations ness and selected PubMed/Medline as it covered a broad [15–21]. Within this broader conflict and human rights range of topics on attacks on healthcare in armed con- data landscape, research to document attacks on health flict without overwhelming the search with irrelevant