Written evidence provided by MSF to the International Development Committee

Humanitarian access and adherence to international humanitarian law

1. About MSF

1.1  Médecins Sans Frontières/Doctors Without Borders (MSF) welcomes the International Development Committee’s inquiry into humanitarian access and adherence to international humanitarian law (IHL).

1.2  MSF provides medical assistance to people affected by conflict, epidemics, disasters and exclusion from healthcare. Our teams are made up of tens of thousands of health professionals and logistic and administrative staff, who are bound together by our charter. Our actions are guided by medical ethics and the principles of impartiality, independence and neutrality. We are a non-profit, self-governed, member-based organisation.

1.3  More than one-third of MSF’s current projects assist people living in areas affected by war and armed conflict.[1] This submission of written evidence is grounded in the first-hand experience of MSF teams, with a particular focus on those working in Gaza and Sudan, where restricted humanitarian access and a lack of adherence to IHL significantly impact the safety and security of our teams, the ability of our staff to deliver medical care, and the welfare of our patients.

2. Trends in adherence to IHL in conflict zones

2.1  Today, more than 120 armed conflicts are ongoing around the world, involving more than 60 different states and 120 non-state armed groups.[2] The changing nature of modern conflicts and emerging technologies in warfare present numerous and complex challenges for the legal application of and practical adherence to IHL. One overarching trend that deeply concerns MSF is a growing culture of non-compliance to IHL by both state and non-state actors. All too often, the obligation to respect and protect medical facilities, medical staff and ambulances is disregarded by parties to the conflict.

2.2  Patients have been killed in their hospital beds and dragged out of ambulances and shot dead; health workers have been attacked as they rescued the wounded, and have been imprisoned and even killed. In times of war, hospitals are where the sick, the injured and other vulnerable people gather in search of safety. Attacks against medical facilities and health workers, whether deliberate or indiscriminate, are a part of the generalised violence and the atrocities committed against civilians during armed conflict. Such attacks deprive people of medical services, often at the time when they need them most.

2.3  Violations against medical facilities, health workers and patients are often carried out with impunity, with too little done to effectively investigate IHL violations and hold perpetrators to account, or to prevent future violations. For example, the brutal murder of three MSF staff in the Tigray region of Ethiopia in 2021 remains unresolved, despite MSF’s repeated calls for an investigation.[3] Similarly, following the 2015 attack by US forces on MSF’s hospital in Kunduz, Afghanistan, the US refused to cooperate with MSF’s call for the establishment of an International Humanitarian Fact-Finding Commission.[4]

2.4  Although the UN Security Council has adopted resolutions which emphasise respect for IHL in increasingly specific terms[5] – including those addressing indiscriminate attacks, targeting of health infrastructure and the need to protect humanitarian workers – their practical impact remains minimal. In 2015, after the destruction of the MSF hospital in Kunduz, Afghanistan, MSF pushed for the adoption of UN Security Resolution 2286, which condemns attacks against medical facilities and personnel in conflict situations, demands that all parties to armed conflict comply fully with their obligations under international law, and calls on all parties to armed conflict to facilitate safe and unimpeded passage for medical and humanitarian workers. However, nearly 10 years later, such resolutions have done little to alter the growing trend of violations of IHL in the conflicts where MSF works.[6] The persistent disconnect between the adoption of these resolutions and their enforcement underscores the urgent need for mechanisms that ensure accountability and compliance.

Trend #1: Deliberate targeting of healthcare

2.5  Despite the specific protections stipulated in IHL, MSF has recently witnessed an alarming increase in the frequency of attacks on medical facilities, health workers and patients. Between 2015 and 2021, we tragically lost 26 MSF staff members in 10 separate events; these included violent raids by armed actors and shelling of healthcare facilities including hospitals.

2.6  Across MSF programmes, attacks on healthcare have a significantly detrimental impact on the safety, security and wellbeing of MSF staff, on their ability to provide quality and timely care, and on patients’ ability to access that care. MSF is frequently forced to close or suspend its programmes in response to attacks on healthcare and, in exceptional cases, our teams have been forced to withdraw altogether, leaving people without access to critical medical services.

2.7  The destruction of healthcare systems, through attacks on facilities or medical staff, has severe and long-term consequences for populations. Damage or destruction of health facilities, particularly hospitals, significantly reduces access to essential medical services, including emergency and trauma care, maternal and paediatric services, and treatment for chronic diseases such as cancer and diabetes. These attacks exacerbate existing barriers to healthcare and erode communities’ trust in medical facilities as safe places to seek medical care.

Trend #2: Use of force against civilian populations

2.8  Civilians have suffered immeasurably from the direct and indirect consequences of war. The disproportionate and indiscriminate use of force has a severe impact on civilians, particularly vulnerable groups including women, children, the elderly and people with chronic illnesses. Furthermore, the deliberate obstruction and blockade of aid by warring parties is spurring widespread malnutrition and epidemics, for example in Gaza and Sudan. In these contexts, MSF has witnessed numerous violations of the fundamental principles of IHL which pertain to the protection of civilians, namely distinction, proportionality and precaution. These are set out in the case studies below (3 & 4).

2.9  The deliberate obstruction or blocking of humanitarian aid is an alarming trend in recent conflicts. While malnutrition and increased morbidity and mortality may occur as an unintended consequence of conflict, they are increasingly a common and entirely foreseeable result of actions carried out by parties to the conflict. Tactics such as the siege of populated areas and the blockade or diversion of humanitarian aid are frequently deployed in many places where we work.

3. Case study: Gaza

3.1  MSF teams in Gaza are offering surgical support, wound care, burns care, physiotherapy, maternity and paediatric care, basic healthcare, vaccinations, and mental health services, as well as distributing clean drinking water. MSF staff currently work in two pre-existing hospitals (Al-Aqsa hospital in Deir Al-Balah and Nasser hospital in Khan Younis), two field hospitals in Deir Al-Balah, five basic healthcare centres in Rafah, Khan Younis and Deir Al-Balah, and two clinics in Khan Younis and Gaza City. 

3.2  Israel’s war on Gaza has so far killed more than 46,600 Palestinians, wounded more than 109,000 and displaced some 1.9 million people – 90 per cent of the population – from their homes, according to the Gazan Ministry of Health. In response to the horrific attacks carried out by Hamas and other armed groups on 7 October 2023, in which 1,200 people were killed and 251 taken hostage,[7] Israeli forces are crushing an entire population under bombs and rubble.

3.3  In the north of Gaza, in particular, the recent military offensive clearly illustrates the brutality of the war being waged by Israeli forces on Gaza. MSF teams are witnessing clear signs of ethnic cleansing as Palestinian lives are being wiped out. The firsthand observations by our staff of the medical and humanitarian catastrophe inflicted on Gaza are consistent with the descriptions provided by an increasing number of legal experts and organisations, who have concluded that genocide is taking place in Gaza. While we do not have the legal authority to establish intentionality, the signs of ethnic cleansing and the ongoing devastation – including mass killings, severe physical and mental health injuries, forced displacement, and impossible conditions of life for Palestinians under siege and bombardment – are undeniable. Attacks on civilians, the dismantling of the healthcare system, and the deprivation of food, water and other essentials are a form of collective punishment inflicted by the Israeli authorities on the people of Gaza.

3.4  Over the past 14 months, MSF teams have witnessed repeated attacks on civilians, the dismantling of essential civilian infrastructure including healthcare facilities, and a systematic denial of humanitarian assistance, underpinning an apparent campaign by Israel to unravel the very fabric of society in Gaza.

3.5  The violence unleashed by Israeli forces has caused physical and mental damage on a scale that would overwhelm any functioning health system, let alone one already decimated by a crushing offensive and a 17-year-long blockade. As of mid-October, only 17 of Gaza’s 36 hospitals are partially functioning,[8] while unabated fighting often puts them out of reach of those who need them. The other 19 hospitals are out of service. As of mid-January 2025, only one hospital in North Gaza remains partially functional. For the sick and wounded, seeking care outside Gaza is made extremely difficult by the Israeli authorities. Between early May 2024, when the Rafah crossing was closed, and the following September, just 229 patients were authorised for medical evacuation – which amounts to just 1.6 per cent of those who needed medical evacuation over that period.

3.6  MSF staff in Gaza have themselves endured 41 separate attacks and violent incidents, including airstrikes, shelling, violent incursions into health facilities, direct fire on our shelters and convoys, and arbitrary detention by Israeli forces. Eight MSF staff and many of their family members have been killed, while many more have been injured. Medical staff and patients alike have been forced to urgently evacuate health facilities on 17 separate occasions, often literally running for their lives. MSF has only been able to restart medical activities in three of those evacuated health facilities.

3.7  Evacuation orders have been repeatedly used by Israel as a weapon of war. These orders can more accurately be described as forced displacement orders, as they are often aimed at hundreds of thousands of people at once and give no time or viable options for a safe route or destination. Israel has failed to ensure that those evacuated are provided with shelter, hygienic living conditions, healthcare, nutrition or safety, as required under IHL.[9] By early October 2024, 86 per cent of Gaza’s territory was affected by more than 40 unreversed evacuation orders issued in 2024 alone. An MSF survey indicates that our staff were displaced an average of five times between the start of the war and the end of July 2024. Most of their original homes have been destroyed, either totally or partially, while some staff members have no information on the status of their home.[10]

4. Case study: Sudan

4.1  MSF is one of a very few organisations to work in areas controlled by both sides of the conflict in Sudan. We currently have more than 1,500 staff, including 130 international staff, working in 11 of Sudan's 18 states, supporting 21 medical facilities as well as running mobile clinics in many of the hardest hit areas.

4.2  The conflict in Sudan has been marked by brutal violence, with a complete disregard for key aspects of IHL by warring parties. This can be evidenced through direct attacks against civilians, indiscriminate attacks on healthcare and healthcare workers, and the obstruction and deliberate blockade of humanitarian aid by the warring parties. In Sudan, where an estimated 70-80 per cent of hospitals in conflict-affected areas are no longer functional, MSF recorded at least 84 incidents of violence and attacks on our staff, assets and infrastructure from the beginning of the war until August 2024.

4.3  One example of the relentless attacks on healthcare is Bashair teaching hospital, one of the last functioning hospitals located in South Khartoum, an area of the city controlled by the Rapid Support Forces (RSF). In this hospital alone, MSF teams treated more than 4,200 patients for violent trauma injuries from January to mid-November 2024, 16 per cent of whom were children under 15. In the same period, our teams treated 314 children for gunshot and blast wounds.[11] In the 20 months that MSF teams have supported the hospital, it has been subject to repeated and violent attacks. On 11 November 2024, armed fighters stormed the hospital, fired shots and killed a patient receiving treatment. On 18 December 2024, RSF troops entered the hospital and fired weapons inside the emergency ward, directly threatened medical staff, and severely disrupted the provision of lifesaving care.[12] Despite extensive engagements with all stakeholders, MSF has taken the very difficult decision to suspend all medical activities in the hospital, as security for MSF staff to operate safely has not been guaranteed.[13]

4.4  Repeated attacks on healthcare facilities in El-Fasher, in North Darfur, are causing the already heavy death toll in the city to rise even further. For example, between May and mid-August 2024, more than 2,500 casualties arrived at the MSF-supported hospital; 370 of these patients died due to their injuries. In mid-August 2024, the MSF-supported Saudi hospital, one of the last remaining two public hospitals in El-Fasher, was hit by shelling. The same hospital was hit a further three times in December 2024.

4.5  In nearby Zamzam camp, where 450,000 displaced people have sought shelter, and where famine was official declared in August 2024, intense shelling of the camp by RSF forces has added to the extreme levels of danger for the population. Since 1 December 2024, Zamzam has been hit 80 times by shelling, resulting in 14 people dying of their injuries in MSF’s hospital, 44 injured being treated at the hospital, and 24 deaths reported in the community. The heavy shelling forced MSF to withdraw from some areas of the camp and to focus on providing lifesaving activities only. Two of our outpatient programmes remain suspended as of early January 2025.

4.6  The situation in Zamzam camp is a clear example of how the blockade on urgently needed medical supplies is putting lives at risk. Most supply roads to Zamzam are controlled by RSF forces, who have made it all but impossible to bring supplies of therapeutic food, medicines and other essentials into the camp. As essential supplies to treat malnutrition ran low at the end of September 2024, MSF was forced to stop providing outpatient malnutrition care for 5,000 children, including 2,900 children with severe acute malnutrition. To understand the scale of the needs: providing a month's worth of emergency food rations (around 500 calories per person per day) to the 450,000 people in Zamzam represents around 2,000 tons of rations. It would take 100 trucks a month to deliver what is needed to this single camp.

4.7  In Sudan, conflict-related sexual and gender-based violence has become shockingly pervasive, including rape, gang rape and sexual exploitation. An MSF survey of 135 survivors of sexual violence treated by our teams between July and December 2023 in refugee camps in Chad found that 90 per cent had been raped by an armed perpetrator. Of those, 50 per cent were raped in their own home and 40 per cent were raped by multiple attackers.[14] MSF teams have provided care to only a limited number of sexual violence survivors, but we know that this is just the tip of the iceberg, as fear of further violence, stigma and lack of knowledge about available services continue to critically impede access to care for survivors.

4.8  The conflict in Sudan has taken a significant toll on pregnant women, new mothers and newborn babies who have been dying in shocking numbers from preventable and treatable health complications. In South Darfur, MSF teams recorded 46 maternal deaths in just two hospitals during the first eight months of 2024. In July alone, one in 30 women admitted to Nyala hospital’s maternity unit died from pregnancy or childbirth-related complications. To put that into context, more women died in this single maternity ward in one month than the average number of maternal deaths in the Netherlands over one year.[15]

4.9  People in Sudan are at risk of starvation as a direct result of the conflict. Famine was declared in Zamzam camp in August 2024 and now the Integrated Food Security Phase Classification (IPC) famine warning has been extended to include areas of North and South Darfur, Nuba and South Khartoum.[16] MSF teams are seeing concerning levels of malnutrition wherever they work. The current escalation of the conflict limits MSF's ability to collect new robust data, and the mortality rate of children is not known, but previous malnutrition assessments conducted by MSF in Zamzam camp in 2024 found that 30 per cent of children were malnourished and that one child was dying of causes linked to malnutrition every two hours.[17] Malnutrition levels have likely deteriorated since then, as the warring parties continue to impede the delivery of humanitarian assistance and very little food or medical care is available in the area around Zamzam camp.

4.10        The impact of nearly two years of conflict and the perpetual access constraints have created a complex and compounded humanitarian emergency across Sudan. From widespread hunger and malnutrition, to the lack of sexual and reproductive health services, to the lack of care for survivors of sexual violence, to the complex needs caused by mass displacement and recurring disease outbreaks – any one of these issues would constitute a humanitarian emergency in its own right, yet in Sudan these crises overlap and exacerbate one another. IHL obligates warring parties not only to protect civilians during hostilities, but also to allow impartial humanitarian assistance to reach those in need. Yet in Sudan we see a complete abrogation of responsibility by the warring parties and a complete failure by international bodies to respond accordingly.

5. The UK’s critical role

As a party to the Geneva Conventions, the UK has a legal obligation not only to respect IHL, but also to ensure its respect in all circumstances, wherever the conflict takes place and whoever the victims may be.[18] The UK holds a critical role in promoting IHL and ensuring the protection of civilians and medical workers in conflict zones. With its enduring diplomatic influence, strong convening power among donors, and unique position in multilateral platforms – notably as a permanent member of the UN Security Council – the UK is strategically positioned to advocate for IHL compliance and uphold the principles of humanitarian protection during the most challenging conflict situations.