Attacks on Health Care Hit Record High as Experts Demand a New Diplomacy

More than 3,600 attacks on health care were recorded around the world in 2024, a 15 percent rise over 2023 and a 62 percent jump from 2022, according to a new opinion piece published in PLOS Global Public Health by a team of researchers affiliated with the Public Health in Emergencies and Disasters Working Group of the World Federation of Public Health Associations. The same year saw more than 900 health workers killed, 470 detained and 140 kidnapped, while over 1,100 health facilities were destroyed amid systematic obstruction of ambulances and humanitarian access. Fatal attacks on humanitarian personnel were reported in the Democratic Republic of Congo, Gaza and the West Bank, Lebanon, Myanmar, South Sudan, Sudan and Ukraine. For the authors, these figures are not simply tragic statistics from distant wars. They are symptoms of what they call a governance gap: the failure of global health institutions to treat violations of international humanitarian law as a core public health problem rather than as a separate humanitarian, geopolitical or security issue.

The argument lands twelve years after the Lancet-Oslo University Commission on Global Governance for Health concluded that the political origins of health inequity demanded institutional reform. In the view of lead author Ellen Beer of Karolinska Institutet and her colleagues, that reform has not materialised. Global governance frameworks for protecting health in conflict are still managed in silos, divided between humanitarian agencies, security councils and diplomatic fora, while routine public health governance rarely engages with the upstream political decisions that expose populations to violence, deprivation and displacement in the first place. The team contends that governance for health must explicitly govern the political, commercial, environmental and epistemic determinants of health at an institutional level, and that protecting life in conflict should become part of everyday public health discourse rather than an emergency afterthought.

The technical backbone of the argument rests on international humanitarian law, the body of rules codified in the 1949 Geneva Conventions and their additional protocols, which restricts the methods of warfare in order to protect civilians, health systems and the environment. Attacks on hospitals, restrictions on humanitarian aid and the destruction of civilian infrastructure mark, in the authors’ framing, the point at which political and commercial determinants of health produce their most system-destroying consequences. Political determinants, meaning the decisions of governments and armed actors, shape whether populations are exposed to violence. Commercial and regulatory decisions shape the circulation of resources, including weapons. When those decisions fail, the result is the collapse of the very systems that public health depends upon: supply chains, electricity, water treatment, cold chains for vaccines and the trained workforce that operates them.

The commercial dimension is where the authors draw their most provocative parallel. Public health has built binding regulation around other harmful industries, from tobacco marketing restrictions to conflict-of-interest safeguards that limit industry influence on policy, and has established norms requiring disclosure and management of tobacco industry links across publications, funding and employment. Yet outside international arms trade treaties, everyday policies governing institutional relationships with the arms sector are far less ubiquitous, despite the sector’s documented relationship to mortality, displacement and environmental harm. The authors ask a pointed question: if public health has decided that institutional entanglement with the tobacco industry must be disclosed and managed, should comparable norms not apply to institutional relationships with the arms industry? They argue that the arms sector, as a structural and upstream driver of violations of humanitarian law, warrants similar governance standards.

Environmental harm in conflict supplies some of the most durable evidence for the case. Armed conflict contaminates agricultural land, water systems and air, threatening health through chronic disease, malnutrition and intergenerational trauma. Attacks on water infrastructure contribute directly to cholera outbreaks, a mechanism epidemiologists understand well: destruction of treatment and distribution systems forces populations onto contaminated sources, and Vibrio cholerae follows. The carbon footprint of modern warfare is also enormous. Recent analyses cited by the authors estimate that carbon emissions from military operations can exceed the annual emissions of entire countries, folding war into the planetary health agenda alongside climate change and biodiversity loss.

The historical record shows how long these consequences can persist. The health effects of Agent Orange, the herbicide sprayed over Vietnam, remain measurable decades later, and unexploded ordnance still maims civilians in Laos and Cambodia. Such events prompted the international community to adopt Additional Protocol I, which prohibits methods of warfare intended or expected to cause widespread, long-term and severe damage to the natural environment, and later treaties such as the 2008 Convention on Cluster Munitions. But the authors stress a critical structural weakness: only signatory states are obliged to comply. Governing the environmental determinants of conflict through commercial and political routes, they argue, must therefore become a priority within planetary health rather than being left to treaty law alone.

There is also a distributional argument running through the piece. Failure to govern conflict-related determinants of health falls hardest on populations already structurally marginalised within health systems. Women, children, Indigenous peoples, gender-diverse people, older adults, people with chronic conditions and disabilities, and displaced people experience the most severe consequences of armed conflict and of violations of humanitarian law. Advocacy for the health of marginalised populations, the authors conclude, is therefore inseparable from advocacy for the evolution of governance itself. A public health field that documents inequity without engaging the political machinery that produces it, they suggest, is abdicating part of its mandate.

The team adds a decolonial critique to this structural analysis. Scholarship on decolonising global health has documented how power asymmetries persist in agenda-setting, funding allocation, authorship, representation and control over knowledge production, and in deciding which determinants and which commercial sectors get governed at all. The devaluation of local knowledge, lived experience and political analysis, the authors argue, constitutes a form of epistemic violence, and it helps enable selective recognition of humanitarian law violations. In conflict-affected settings, these asymmetries shape whose suffering is recognised, whose security is prioritised, which crises attract diplomacy and whose knowledge is considered authoritative in humanitarian research, advocacy and policy. Decolonising public health, on this reading, requires examining how coloniality persists through governance structures and determines who is protected.

What elevates the piece beyond diagnosis is its proposed mechanism: health diplomacy. Once dismissed as soft power, health diplomacy has evolved, the authors write, into a practical instrument for managing crises, fostering trust and negotiating cooperative action under hostile conditions. It offers a channel for engaging the political determinants that lie upstream of humanitarian law violations, and a nominally neutral platform that can unblock traditional political channels by refocusing negotiations on shared health interests. Concrete applications include cross-border coordination on water and energy security, vector control and the protection of health systems in fragile contexts. Crucially, the authors frame health diplomacy as both a response tool and a preventive one: by reducing risk and building trust before crises escalate, it can support more resilient recovery pathways after them. Given its growing role in international security, they argue, public health governance actors need training in governance, negotiation and conflict-aware health policy so that a health lens can be integrated into international conflict dialogues and negotiations.

The authors close with a proposition that reframes the entire field. Violations of international humanitarian law, they argue, should be understood as failures in the governance of political, commercial, environmental and epistemic determinants of health, and preventing the disproportionate health and health-system impacts of conflict requires stronger governance of those determinants as part of broader global governance for health. That, in turn, requires confronting power asymmetries in agenda-setting, knowledge production and decision making. The message to the public health community is blunt: as one cited commentary puts it, public health has always been about politics informed by evidence, and its practitioners are agents of change working in the political arena. With attacks on health care at record levels and rising year on year, the authors argue that the era of treating war as someone else’s governance problem is over. The tools exist; what is missing, they contend, is the institutional will to connect them.

Subject of Research: Governance of the determinants of health in armed conflict, international humanitarian law violations, and health diplomacy

Article Title: The governance gap: Determinants of health, international humanitarian law violations, and the case for health diplomacy

Article References: Beer, E., Chen-Xu, J., Yuen, R., Planatscher, A., Gilmour, R., Ahmed, Z., Santamaria-Plaza, C., Zotti, N., Vasic, M., Hachem, M., Rosiello, F., & Shellah, D. (2026). The governance gap: Determinants of health, international humanitarian law violations, and the case for health diplomacy. PLOS Global Public Health, 6(10), e0007482. https://doi.org/10.1371/journal.pgph.0007482

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007482

Keywords: global health governance, international humanitarian law, health diplomacy, attacks on health care, social determinants of health, armed conflict, planetary health, commercial determinants, decolonising global health, Geneva Conventions, health systems, PLOS Global Public Health