We are living in a historical moment where the political elites of most countries and many global corporations are preparing for major wars. In Europe, governments and most political parties agree that more tax money has to be spent on re-armament – currently the figure is 800 billion Euro. In the UK, cabinet ministers told NHS nurses that they “must drop their pay demands to send a clear message to Putin”, while Prime Minister Starmer promised to station thousands of British troops for ‘peace-keeping’ missions in Ukraine and increase the military budget by over £13 billion a year. The declared aim of the political elite is to ‘get society war ready’.
It is impossible to fight large scale wars without diverting major resources from the civilian health sector to the war effort. In modern wars, the civilian health sector becomes part of the armed forces. Its role is to patch up wounded soldiers in order to sustain the supply of manpower for the frontlines. This is why the health sector is one of the main focuses of the current process of militarisation. As health workers we have to discuss the current moment and refuse the role as cogs in the war machine that we are supposed to play. Most soldiers in all countries are from poor and working class backgrounds – we address them as fellow workers and call them to refuse to fight and die in wars that only benefit the rich and powerful. On the Vital Signs Blog we have already circulated two shorter related articles, which can be read here and here.
In this longer text we want to look in more detail at the process of the militarisation of health.
What are the reasons for modern wars and how are they fought?
What role did the health sector play historically to enable modern wars?
What is the war scenario that the ruling class wants the health sector to prepare for?
What are current collaborations between the health sector and the military?
What role do global corporations play in the militarisation of health?
What is the situation of the health sector in the current war in Ukraine?
Why are health workers and health infrastructures under major attack in current wars?
What can we do to resist the current drive towards war?
What are the reasons for modern wars and how are they fought?
In the current public debate, we are told that wars are a constant feature of human history. This disguises the fundamental changes that warfare underwent with the development of capitalism. In pre-industrial ages, wars were fought by generally smaller armies of individual rulers over often limited territory. Due to the lower level of social productivity, a large section of the population had to continue working in agriculture and were rarely or only temporarily involved in warfare. The main impact on the poor peasantry was an increase in taxation, which often sparked rebellions. From the 18th century onwards, with the emergence of capitalism – meaning, the development of industrial production, a global market, a money economy and a central nation state – both the reasons for wars and the form of wars transformed drastically.
With the emergence of industrial capitalism wars became an in-built feature of the political-economic system. Rather than expressions of individual strife between certain rulers, they became a regular systemic event, closely related to the cyclical economic crises. In pre-capitalist societies crises emerged due to a lack of products, e.g. through bad harvests, and a scarcity of productive capacities. In industrial capitalism, on the other hand, crises emerged primarily because of an over-capacity of production facilities that were able to swamp the market with goods, but couldn’t make a high-enough profit in money terms. With an industrial system that is geared towards over-production, and a limited global market, we see frequent phases where nation-state competition leads to protectionism, e.g. through tariffs or monetary measures. Protectionist measures are followed by scrambling for resources, e.g. in the so-called ‘colonies’, and finally by military conflict. Money that, due to the crisis, cannot be invested profitably in general manufacturing anymore is funnelled into re-armament.
Not only the reasons for wars have changed, also their form. In an industrial society, fewer and fewer people are employed in basic goods production, such as agriculture. This means that from the Crimean and American Civil War onwards, we see the emergence of large-scale armies that involve the whole of society and that are supplied with industrial goods. In industrial warfare those nations tend to dominate militarily that are able to produce large amounts of powerful weapons and are able to sustain large armies over a prolonged period of time. All sectors of society, from science to industry to transport to health, are subjected to the war effort and therefore also become targets of warfare. The result was the mass slaughter and destruction of the 20th century World Wars.
With the emergence of an international working class, the political nature of wars also changed. During regular economic crises we see an increase in unemployment, impoverishment and working class discontent. During these times each national ruling class needs external enemies in order to contain and channel popular anger in the form of nationalist aggression. The ruling class employs a large layer of society, from mainstream media to academia, that helps disguising their war efforts as a ‘just cause’: ‘against Iraq’s weapons of mass destruction’ (war criminals Blair and Bush), ‘for the de-Nazification of Ukraine’ (war criminal Putin) or ‘for the defence of western democratic values’ (war criminals of basically all western governments). At the same time, working class revolts and revolutions were also able to put an end to wars, for example, the rebellion of workers and working class soldiers in Russia and Germany contributed significantly to the end of World War I and to the colonial war of Portugal against Mozambique in 1974.
What role did the health sector play historically to enable modern wars?
While we find many examples of pre-capitalist surgery that took care of wounded soldiers, with the large-scale nature of military operations, the health sector becomes an essential part of the war machine. This is not because of humanitarian motives, but because of a military requirement for soldiers to ‘return to duty’. Modern wars depend on the fact that large numbers of wounded soldiers are sent back into the firing line after they have received medical treatment. This means that the general aim of healthcare is inverted. This is a concept known as ‘reverse triage’, meaning that instead of our usual way of triage, where we assess a patient and treat those most in need of healthcare first, instead we will have to start looking for the least injured military personnel in order to treat them as a priority, because they are needed back at the frontline.
During the Crimean War (1853 to 1856), the French and Turkish army performed 25,000 chloroform surgeries on wounded soldiers, while the British army was supplied with prefabricated hospital units. The American Civil War (1861 to 1865) is seen as the first truly capitalist war, using railroads, the electrical telegraph, steamships, the ironclad warship, and mass-produced weapons, such as the newly developed repeating firearms. Around 650,000 soldiers died on the battlefield or from war-related diseases and over 1.6 million were wounded. The warfare required and was enabled by an industrialised medical army corps, Surgeons performed 60,000 amputations during the war in mass lazarettes, with a fatality rate of 26%, and in total 80,000 operations under anaesthesia. The industrial nature of medical supplies became an advantage for the Union troops during the war, as nearly all of the chloroform manufacturers were situated in the north of the US.
During the trench-warfare of World War I (1914 to 1918) around 23 million soldiers and 17 million civilians were wounded. The war produced 752,000 permanently disabled veterans in Britain alone, who all underwent one or multiple surgeries – during the Battle of the Somme, hospitals received between 2,000 to 5,000 wounded every day. Hospitals were put under army command and many surgeons were formally integrated into the army as military officers.
The Second World War (1939 to 1945) wounded around 24.5 million soldiers and 43.5 million civilians. Due to the increased use of tanks and bombers it was more difficult to set up frontline hospitals, they had to be more mobile. The Invasion of Normandy, named Operation Overlord, best demonstrates the massive number of casualties. Allied medical forces established 97,400 hospital beds in Great Britain, mobilized 8,000 doctors and 10,000 nurses, and gathered more than 800,000 pints of blood.
The ‘return-to-duty’- rate in the Second World war varied greatly, but a rough estimate is that around 50% of soldiers were returned to the front after having been patched up. The return rate was much lower for Russian soldiers, where the medical logistics were less developed. The German military head-quarter estimated that in 1942, the Soviet armies received 764,000 soldiers as replacements. New conscripts formed 56.5% of the total, 22.5% were convalescents who had been treated for earlier injuries. During the war between the USA and Korea in the 1950s the return rate was relatively higher. Frank A. Reister analysed that 72,961 were battle casualties from July 1950 – July 1953. Of these soldiers 2.2% (1,574) died of wounds, 87.9% (64,159) returned to duty, 8.5% (6,239) were separated for disability.
Since then, war strategists have developed a general rule of thumb when it comes to the ‘return to duty’-rate in wars. Trevor Dupuy reckoned in his “Handbook on Ground Forces Attrition in Modern Warfare”, from September 1986: “Finally, there is a general rule of thumb for estimating returns to duty from casualties. For each 100 personnel casualties (battle casualty, disease, or injury) 75 will be returned to duty at the end of 20 days at a rate of five per day between the 6th and 20th days after admission, and 25 will never be returned to duty as a result of death, evacuation to the Zone of the Interior, or discharge.”
As we will see later on, this estimation is very ‘optimistic’ when compared to the current figures that we know about war casualties in Ukraine.
A high return rate requires that the command over the health sector is handed over to the military and the deployment of enormous resources to the front lines. During the World Wars, on average half of all doctors and nurses in the warring nations were deployed as part of the war effort. In the UK during World War II, a Control of Engagement Order was used to help deploy nurses to areas of need. Even closer to home, the Memorial Building of the Bristol Royal Infirmary was handed over to the military authorities and, along with Southmead Hospital, it became known as the Second Southern General War Hospital. During World War I, Bristol’s temporary war hospitals treated an estimated 118,000 men from across the Empire.
Unsurprisingly, such monopolisation of resources for the war effort meant that civilian patients were left with much less care and morbidity levels increased drastically. In addition, the concentration of wounded soldiers and civilians meant that the risk of pandemics and untreatable infections aggravated, something that we witness today again in Ukraine and Gaza.
All this has to be taken into account when we deal with the claim that the collaboration with the military has led to advances in medical technology and knowledge. The proponents suggest that the extreme conditions at the frontline lead to more inventiveness when it comes to aseptic and antiseptic measures and to new surgical techniques, such as tourniquet use. They state that, for example, penicillin was developed by the US army (while it was actually developed by a small team of researchers in Oxford), that the first sterile instrument sets were used during the Suez war and that remote surgery technology came out of the war experience in Iraq and Afghanistan. Most famous doctors and surgeons – from Charles Bell to Florence Nightingale to Ernst Sauerbruch – served in wars and developed their knowledge in wars. The German surgeon and public Nazi supporter Sauerbruch echoed Hippocrates when he said that war was “my bloody teacher”.
While it is true that the military complex has the financial power to fund certain medical research projects, the actual applicability for civilian medical use is often limited or could have been developed more effectively by the civilian medical sector had funds not been diverted. Secondly, the type of surgeries (primarily emergency surgeries to stem blood loss and amputations) are less relevant for civilian medical issues and the conditions are not comparable. So overall, wars have been a massive drain on medical provisions and progress in general.
What is the war scenario that the ruling class wants the health sector to prepare for?
Since the USA lost the war in Vietnam, partly due to a considerable anti-war movement in the USA itself and mutinies by US soldiers, the western ruling classes try to avoid large-scale deployment of troops. The wars in Iraq and Afghanistan were attempts to use the technological superiority of the US army in order to avoid having to ‘put boots on the ground’. The fact that the US had control over the airspace meant that wounded soldiers could be evacuated fairly quickly: of the over 10,000 documented cases in the Joint Trauma Registry from January 2007 to mid-March 2020, 37 percent returned to duty within 72 hours after surgical treatment.
But you don’t win a war, not even against relatively underdeveloped countries, from remote control rooms – you need to change social reality on the ground. It became clear that this ‘remote control’ military strategy of the 2000s failed and today the political and economic tension pushes the Western powers towards confrontations with much better equipped opponents, such as Russia, Iran and China – something that war strategists call ‘near-peer’ adversaries. Since governments in Europe and the US announced a ‘turning point’ in 2022 and politicians such as former German Minister of Defence Pistorius demanded that the country should be “war ready within 5 years”, the scenario of large-scale warfare has also entered the health sector. Here are some quotes that demonstrate that these ‘medical experts’ are not primarily sharing their academic insights, but that they play an important role in getting the field ‘war ready’ by shaping opinions within the sector:
“In the face of emerging threats and global aggression from China, Iran, North Korea, and Russia today, it is necessary that all surgeons—both military and civilian—understand the operational and medical aspects of World War II and consider how these experiences might apply to combat casualty care in the present day.”
(Dr. Jeremy Cannon, Professor of Surgery at the Hospital of the University of Pennsylvania)
“In a future conflict with a “near-peer” adversary such as China or Russia, the U.S. may not have the ability to evacuate wounded troops quickly. Without reliable helicopter or airplane transport, many casualties may not reach trauma care within the “golden hour.” This is the critical first 60 minutes after a severe injury, when rapid treatment is essential. The ongoing war in Ukraine illustrates the challenge of prolonged casualty care. In hospitals across Ukraine, doctors are increasingly having trouble treating the wounds of civilian and military patients because of rising antibiotic resistance. Future military conflicts in the Indo-Pacific regions will present similar challenges, including long patient transport times and concerns about wound infections due to prolonged casualty care.”
(Vikhyat Bebarta, Adit Ginde and Arthur Kellermann, Professors for Emergency Medicine, USA)
“On the back end of trauma care, definitive care military facilities in the continental US will be overwhelmed by the sheer magnitude of required hospital bed capacity and will require a whole-nation approach that integrates civilian trauma systems. Large-scale warfighter exercises estimate approximately 50,000 casualties (10,000 killed, 30,000 requiring evacuation, 10,000 returned to duty) with a daily estimate of up to 3,000 casualties in a battle of 100,000 soldiers. In addition to the need for the rapid expansion of bed capacity, a medical draft is likely. The Selective Service System maintains a standby plan called the Health Care Personnel Delivery System which, in the event of a national emergency, would allow the draft of health care personnel including women between the ages of 20 years to 45 years.”
(Danielle B. Holt, MD, Department of Surgery, The Uniformed Services University of the Health Sciences)
“The UK must begin to prepare for potential high-casualty scenarios now. The scale of casualties in state-on-state war is magnitudes greater than recent modern experience. It is not unreasonable to expect hundreds of casualties per day during periods of heavy fighting, compared to a total casualty rate (military of all nationalities) in Afghanistan which peaked at around 160 killed and 500 injured per month. This will require some resources to be diverted from those who need them most, in order to treat less badly injured soldiers. ‘Reverse triage’ is a well-established concept, but it is unclear how tolerable it would be for wider society, or even what its impact would be on the moral component and will to fight of UK troops.”
(Ed Arnold is a Senior Research Fellow for European Security, Colonel Si Horne was the Chief of the General Staff’s Visiting Fellow at the Royal United Services Institute)
“Ukraine is teaching British medics how to prepare for war – The NHS ‘would have to be all but shut down’ to only treat war casualties in a full-scale conflict owing to new challenges like drones. Britain’s medics are rewriting their plans for a full-scale war as they learn lessons from the conflict in Ukraine, a leading NHS trauma surgeon has said. Dr Hettiaratchy, the lead trauma surgeon at Imperial College Healthcare, suggested the NHS would have to be all but shut down to only deal with war casualties if Britain was to be dragged into a full-scale conflict. Last year, General Sir Roland Walker, the head of the Army, warned Britain must be ready to fight a war against Russia in three years. `If we get to a scenario where we are having that level of casualties and that kind of war-fighting, the health system would be only doing that. That’s where we’re scaled at now,´ he added.”
While these pundits of the sector and the mainstream media push for an ideological shift from the top, there are already various forms of collaboration between the civilian and military health sector happening on the ground. The Covid pandemic management has intensified this intertwinement and has created new legal frameworks for the influence of the military in the name of ‘emergency or disaster medicine’. Equally, the regulation of what counts as a justified military intervention has been expanded in recent years, beyond the NATO support of an attacked ally, e.g. with the so-called „host nation support“ and various scenarios of UN or future EU military missions.
What are current collaborations between the health sector and the military?
During the pandemic we watched young and rather buff men in camouflage uniforms struggling to operate a hospital tea trolley or getting lost in the mothership that is Southmead hospital while carrying a couple of cardboard boxes with theatre mop-heads. They tried to be useful. In other areas the army actually took over important logistical roles, e.g. a comrade told us about his experiences of working with the army distributing vaccines in Greece. Whether these were largely publicity stunts in order to improve the standing of the army within society, we don’t know. What we do know is that since then, laws and institutional responsibilities have changed – as part of ‘emergency medicine’ or ‘disaster management’ – that haven’tt subsumed the military to social tasks, but the civilian health sector to military needs. We have also seen how during that process large funds were shifted from civilian medical research to the military-industrial complex.
In the US, this process of militarisation was criticised even from within the army itself, when President Donald Trump announced “Operation Warp Speed” in 2020, which was supposed to provide “substantial quantities of a safe and effective vaccine” to 300 million Americans by January 2021. Instead of US health officials, however, the US military was in charge of the program. General Gustave Perna, commander of the US Army Materiel Command, was chosen to lead the task force together with Moncef Slaoui, a venture capitalist who used to work for GlaxoSmithKline, a major pharmaceutical company based in the United Kingdom, and who currently sits on the boards of multiple vaccine developers. This marriage between the army and Big Pharma gave them the command over a $10 billion vaccine fund. COVID-19 vaccine and test makers and other pharmaceutical and health firms were awarded more than $36 billion in contracts from the Pentagon.
In Germany, the legal reforms from Covid times concerning the extent to which the army can be used in internal affairs have recently been expanded. The ‘Health and Resilience’ expert council of the government, for example, which emerged from the Covid expert council, is concerned with ‘future challenges’: In addition to pandemics, natural disasters and terrorist attacks, it also includes ‘war or (NATO) alliance’.
On the 5th of June 2024, the federal cabinet in Germany passed the ‘Framework Directive for Overall Defence’ [Rahmenrichtlinie Gesamtverteidigung] under the leadership of the Federal Ministry of the Interior. This also provides for the extensive integration of the civilian health system under the leadership of the Bundeswehr. In March 2024, Health Minister Lauterbach announced a Health Security Act. The law is intended to regulate medical care in the event of a disaster or war under the command of the army. In the meantime, there are expansions of the joint training programs for soldiers and medical students, e.g. as part of the elective subject “Mission and Disaster Medicine” at the public hospital Charité in Berlin. There is a general acknowledgement that Germany will bear the brunt in terms of treatment of wounded soldiers in future wars in Europe and that the network of 650 local trauma clinics and 36 university hospitals will be the main military treatment hub in central Europe – as it already plays a significant role in treating casualties from Ukraine.
Not having been part of large-scale combat in recent decades, the military medical forces in the US and western Europe deemed as too inexperienced when it comes to treatment of casualties. One study found that in 2019, only 10.1% of military surgeons in the US met the goal readiness threshold for combat casualty care. They are dealing with the so-called ‘Walker Dip’, which refers to “a pattern whereby military medical care improves in wartime and these advances are lost by the time the next conflict occurs”. This is not primarily a technical question, but a wider social issue, as post-war societies tend to abhor war and militarisation and try to minimise military spending. Even in the US, there is only one military-only Level I trauma center that could offer surgeons the necessary professional experience, the Brooke Army Medical Center in Fort Sam Houston, Texas. The US army therefore depends increasingly on civilian-military partnership. In 2022 there were around 87 such partnerships between army and local hospitals.
Who could military surgeons practice on, if not on wounded soldiers? On the victims of the battlefields of urban poverty and gang-warfare, of course. A comrade who works as a nurse in Chicago told us that military surgeons practice on wounded urban poor who arrive with shot or stab wounds. From the hospital website:
“As the University of Chicago Medicine’s Level 1 trauma center marks five years of service, it celebrates a key tool in its success: partnerships that provide new resources for the center and skills sustainment to members of the military. Members of the Army’s 759th Forward Resuscitative Surgical Team (FRST), based at Fort Bragg in North Carolina, integrate seamlessly with civilian counterparts to provide critical care to patients at the South Side academic medical center. The patients include those with blunt or penetrating wounds. That means the FRST members sustain their trauma care skills – that they may need on a future battlefield – while providing more resources to the trauma center. The UChicago Medicine’s comprehensive trauma program cared for nearly 5,000 patients in 2022, including more than 1,700 people with penetrating trauma wounds, often the result of shootings or stabbings.”
As the number of casualties of the south-side Chicago or other deprived US areas are not sufficient, the US army has to go further afield, for example to South Africa. The Department of Defense (DOD) has granted army researchers of the University of Colorado School of Medicine $15.6 million to go to South Africa and study questions related to prolonged care for patients with major bleeding, traumatic brain injury (TBI), polytrauma, and complex wounds – “injuries often seen in South Africa and modern battlefield settings”. The same university also sends researchers to Ukraine: “faculty members in the Department of Emergency Medicine have been awarded $5 million by the Department of Defense to work with partners in Ukraine on clinical and logistical challenges associated with modern large-scale combat operations and prolonged casualty care”.
What role do global corporations play in the militarisation of health?
Many global corporations, in particular the so-called ‘tech-companies’, have their fingers in both pies, the military and the health sector. This is partly due to business opportunism, as both sectors guarantee state-sponsored contracts, which are less dependent on market volatility. But as we have seen with the new alliance between Trump’s aggressive nationalism and the Silicon Valley capitalists, first of all Elon Musk, the bond between tech and (military) state forces goes deeper. The sector is in need of a large supply of energy, for example data-farms in Ireland consume 21% of the total national electricity resources. It also requires rare earth minerals for its batteries and microchip production. Finally, they need a strong state that enforces patent- and copyrights globally and protects their market shares against ‘cheap’ competitors from China. All this requires an authoritative state, e.g. to enforce new nuclear power plants, secure natural gas fields or to capture and defend mining opportunities, such as Trump’s current post-war ‘mineral deal’ with Ukraine. Unsurprisingly, Google, for example, has erased the promise not to use AI for surveillance and weapons in February 2025. This interest of the tech-sector in military superiority makes their influence within the health sector particularly dangerous.
One such tech company is the US company Palantir. The company was initially funded by the CIA and specialises in AI-powered military and surveillance technology and data analytics. Palantir describes its military technologies as offering customers (which include the US military, ICE, the UK Ministry of Defence and the Israeli government) “mission-tested capabilities, forged in the field” to deliver “a tactical edge – by land, air, sea and space”. Palantir provided services to the US military for wartime operations in Iraq and Afghanistan. In January 2024, Palantir signed a deal with the Israeli Occupation Forces (IOF) to increase its “advanced technology provision” to Israel in support of war related missions. As of January 2025, at least 46,645 Palestinians have been killed in Gaza – around 70 per cent were women and children.
Palantir expands its reach into the global health sector. In March 2020, Dominic Cummings and Simon Stevens (then NHS CEO) called a meeting on how to tackle Covid-19 with several big tech companies, including Palantir. Palantir was given a contract for its software to be used to create a Covid-19 database the following day. This contract was given without competitive tender. Matt Hancock used special ministerial powers to bypass patient confidentiality rules and allow the company to process patient data. In November 2023, Palantir was awarded a £330 million contract to create a new data management system to provide ‘joined up’ NHS services. This would possibly be the largest population health dataset in the world and there are concerns about what happens with the data if it is in the hands of a private global corporation.
The personal links between NHS management and Palantir are close. For example: Dr Indra Joshi was director of AI for NHSX until 2022 when she took a role as Director of Health, Research and AI with Palantir, Paul Howells was the leader of the National Data Programme between 2018 – 2021 for NHS Wales before joining Palantir to work on health and care, Harjeet Dhaliwal has been a deployment strategist at Palantir since 2022. She was Deputy Director of Data Services for NHS England from 2019 to 2022. These fluid transfers between public positions and well-paid tech jobs are problematic, as we have seen in the US recently, where Elon Musk has just been handed over major authority over the public administration. Another company that has both essential NHS contracts and close collaboration with the military sector is Oracle.
Since the 1990s large parts of public infrastructure has been privatised, which now causes major problems. Firstly, a lot of the private infrastructure companies stand on shaky grounds since ‘cheap money’ has been drying up in 2008 and further during the Covid pandemic. Secondly, the state has additional problems to enforce a coordinated austerity attack on working class social welfare, since its influence has been fragmented during decades of neoliberalism. In this sense the militarisation has to be seen as an attempt to centralise the control over social infrastructure, often in collaboration with large global corporations, and to attack both the working conditions and the access of workers – something that we can see, for example, in the health sector in Ukraine.
What is the situation of the health sector in the current war in Ukraine?
The war in Ukraine is a prolonged industrial slaughter that has blown away the myth of a ‘clean’ military conflict that can be led from distant control rooms. Around 95,000 Russian and 45,000 Ukrainian soldiers have been killed since the war started in February 2022. Both states have massive problems replacing killed and severely injured soldiers and are using increasingly repressive measures to draft younger and younger men into the army. One of the issues for the Ukrainian army is the relatively low ‘return-to-duty’ rate of wounded soldiers. According to perhaps optimistic government figures, 50% of the 370,000 injured Ukrainian soldiers returned to military duty. At least 50,000 Ukrainians have lost limbs according to the country’s health ministry. This is partly due to the severity of the impact of industrial weaponry, partly due to prolonged tourniquet use because soldiers could not be evacuated and treated quickly enough.
“These people have tourniquets on for five, 12, 24 hours, because they can’t be moved back to the next line of medical support, which means they are having a high level of amputation,” said Dr Hettiaratchy, a UK surgeon who has been training Ukrainian medical staff. The Ukrainian state does not only depend entirely on arms supply from Europe and the US, but also on the European health sector in order to patch soldiers up enough to send them back into the firing line. As of March 2024, over 1,000 injured Ukrainians were treated in German hospitals, most of them soldiers.
Another major issue is the rising antibiotic resistance that ensues if you have to treat large amounts of wounded. Due to growing resistance to available medicines, the nation’s morbidity rates are increasing. “They’ve got bugs that are not cured by antibiotics. What they are describing is going back almost to the First World War, pre-antibiotic-era of surgery. These people now have wounds that are uncontrolled, infections are uncontrolled and uncontrollable with antibiotics, and you have to revert to First World War techniques.” (Dr Hettiaratchy)
If conditions in Ukraine are so bad despite the active support of the world’s most developed nations we can only imagine how much worse conditions must be in Gaza, where according to The Lancet, life expectancy of the general population decreased by 34.9 years during the first 12 months of the war, about half the pre-war level of 75.5 years.
The conditions for health workers under a military regime in Ukraine are hard. Many nurses face the problem of outstanding wages, longer working hours and the threat of hospital closure. Before the full-scale Russian invasion, approximately 720 hospitals were operating in Ukraine. By April 2023, only 450 Ukrainian hospitals were operational. This has at least three reasons.
Firstly, because the state focuses the health service on the treatment of army personnel and closed or reduced services such as cancer screening, gynecological or pharmacy services. Secondly, because the government uses the current state of emergency to enforce a neoliberal hospital reform that had been planned before the war started, where hospitals are not paid for the services they provide, but for individual services per patient. In July 2022, Ukraine’s Ministry of Health decided that hospitals outside of conflict zones would be paid only for the services they provide to patients – overriding a guarantee given immediately after the Russian invasion that the reform would be postponed. This ‘reform’ led to financial problems, redundancies and closures. Thirdly, because hospitals were directly attacked by the Russian army.
Despite the difficult circumstances, health workers in Ukraine continue to organise themselves to defend their working conditions. Rank-and-file organisations like ‘Be like Nina’ try to put pressure on the government despite the fact that mass gatherings and protests have been banned since martial law was imposed in Ukraine.
Why are health workers and health infrastructures under major attack in current wars?
Due to the expanding role that the health sector plays in war strategies it is not surprising that health infrastructure and health workers increasingly become targets of military attacks. In 2023 alone, the WHO recorded 1,520 attacks on healthcare infrastructures in global military conflicts, resulting in the deaths of at least 750 patients and health workers, and 1,250 injuries. In 2024, the recorded attacks increased further to 2,134 confirmed attacks on health care, as of 18th of November. The attacks on health workers have various overlapping military strategic reasons.
During initial popular unrest against dictatorial regimes, health workers are particularly targeted because they provide health care for injured protestors or anti-government militias. This was prevalent, for example, during the mobilisations against the dictatorship in Myanmar, where the Safeguarding Health in Conflict Coalition reported that 500 health workers were arrested in 2021.
Syria
These attacks became more brutal during the civil war in Syria, where the tactic escalated from targeting individual health workers in order to demoralise the opposition movement to bombing hospitals in order to make entire ‘opposition-held cities’, such as Aleppo, Hama, Idlib, eastern Ghouta and Homs, uninhabitable. Physicians for Human Rights report that 782 health workers in Syria were killed between March 2011 to September 2016. Shelling and bombing accounted for 426 (55%) deaths, followed by shooting (180 deaths; 23%), torture (101 deaths; 13%), and execution (61 deaths; 8%). By 2015, half of Syrians 30,000 doctors are supposed to have left the country.
“In Syria, rates of cesarean sections in some areas have doubled as women try to minimize time spent in a hospital for fear of being targeted. After attacks on the al-Atareb hospital outside of Aleppo in March 2021, Physicians for Human Rights found a 78% drop in monthly reproductive and neonatal visits. Conflict has devastating results, too, for vaccination campaigns: By 2014, three years into the war in Syria, polio vaccination coverage dropped from 83% to 52%, with nearly all the decrease taking place in opposition areas.” (The Lancet)
Gaza
We see similar strategies being carried out in Gaza, where attacks and arrests of individual health workers are escalated to the destruction of an entire health infrastructure in order to force the local population to leave. The World Health Organization (WHO) says it has verified that 297 healthcare workers from Gaza have been detained by the Israeli military since the war began. Two of Gaza’s most senior doctors – Dr Iyad al-Rantisi, a consultant obstetrician and gynaecologist at Kamal Adwan hospital, and Dr Adnan al-Bursh, head of the orthopaedic department at al-Shifa hospital – are known to have died in detention.
On the night of the 14th to 15th of February 2024, Nasser hospital, once the largest hospital in southern Gaza, was shelled by Israeli forces. In November 2023, teams of Médecins Sans Frontières had already documented similar attacks on Al-Shifa and Al-Quds hospitals, and on Al-Nasr children’s hospital in the north of Gaza. By January 2024, 84% of health facilities in Gaza had been damaged or destroyed. As of June 2024, according to WHO, the Israeli army has attacked 464 health care facilities, killed 727 health care workers, injured 933 health care workers, and damaged or destroyed 113 ambulances.
Yemen and Afghanistan
That these military strategies are not exceptions of ‘particularly authoritarian or evil states’ can be seen in less-publicized wars, such as in the Tigray region of Ethiopia, where 80% of the hospitals have been destroyed in a civil conflict, or in Yemen, where hospitals were attacked by the Saudi state with weapons from the UK and US. Also the US army deliberately attacked health infrastructures in Afghanistan in order to undermine rebel forces that they had trouble defeating in direct combat. On the 3rd of October 2015, a United States Air Force gunship attacked the Kunduz Trauma Centre operated by Médecins Sans Frontières in the city of Kunduz. 42 people were killed and over 30 were injured.
Ukraine
As we have already mentioned, the war in Ukraine is an industrial war that requires a high ‘return-to-duty’ rate of wounded soldiers. In this situation, an attack on the health sector is at the same time an attack on an important military institution. According to a World Health Organisation (WHO) report published in August 2024, as of that month there had been 1,940 attacks on healthcare workers and facilities since the start of the invasion. By December 2023, more than 100 health professionals have been killed as a result of a direct attack by the Russian military. There are also reported cases of deliberate attacks by the Ukrainian army on hospitals in areas held by the Russian state.
What’s to be done?
Facing these attacks, many politicians, NGOs and medical associations appeal to ‘the international community’ that the Geneva Conventions, which stipulate that during military conflict the health infrastructure should be exempt from attacks, should be adhered to and legally enforced. This is obviously a toothless appeal, as it ignores that attacks on health have become a systemic part of military strategies of all warring states. It creates the illusion that there could be a just war and that the day-to-day militarisation of the health sector – from training sessions for military surgeons in general hospitals, to outsourcing of services to trigger-happy tech companies, to legal changes that bind the health sector to the army in the name of ‘emergency medicine – is not the underlying problem.
What can we do to resist the current drive towards war?
There are many things that we can do as health workers in order to oppose the militarisation of our sector and the general drive towards war.
Don’t accept the“tighten your belt” logic, or reduce patient care for the war budget!
The government has announced that they want to pay us only 2.3% more in 2025, despite energy bills and rents going up. At the same time they want to cut jobs from the NHS, privatise more services and spend an additional £13 billion a year on the military. During the 2022 industrial dispute for better pay the UK government announced to use 750 army personnel to replace striking workers – a clear propaganda act to undermine the strike effort. As health workers we have to defend our conditions and the conditions of our patients – for example by fighting against the closure of the Acer Detox Unit at Southmead hospital. As Vital Signs we try to build a network of co-workers who support each other.
Support the campaign against outsourcing of NHS services to companies like Palantir!
There are various groups that organise against the outsourcing of NHS services to companies like Palantir, which have strong links to the military sector.
Refuse the use of NHS infrastructures and resources by the military!
As workers we make the world go round and collectively we have the power to decide what we work for and what not. Dockers in Genoa refused to load and unload ships that transported weapons to war zones. Tram drivers in Germany refused to drive trams with army recruitment advertisements and school students protested against army stalls at their schools. Google workers in the US condemned the involvement of the company in the war in Gaza. Our class has a historic wealth of similar experiences.
Support deserters and refugees!
The mainstream media doesn’t often report about the fact that also in Ukraine thousands of people try to avoid being drafted or desert from the frontline, but fortunately there are independent groups reporting from Ukraine. Deserters need support and recently there have been various demonstrations in Germany and other countries by organisations that support deserters from both Russia and Ukraine.
Many refugees try to escape from war zones, refusing to participate in or become victims of the global slaughter. Again, there are many ways to support refugees, in particular as health workers. There are friends who provide medical care to refugees in towns like Calais and there are campaigns like ‘Patients not Passports’ that make sure that refugees get treatment within the NHS. On a local level there are groups that protect refugees against police raids.
Blockade arms production!
The UK is a major arms exporter, supplying weapons to countries like Saudi Arabia and Israel, which use these against whole populations in Yemen and Gaza. Some of these weapons are manufactured in the Bristol area. There are groups that try to blockade the war machine.
Study working class history!
Of course it makes a difference whether we live and struggle under a liberal democratic or an authoritarian regime, but history shows that we cannot fight for our rights by engaging in a nationalist military alliance with our ruling class. As the war in Ukraine demonstrates, workers become entirely embroiled in a military escalation that they don’t control and in the process the liberal democracy that we try to defend turns into a nationalist war regime. Our history can teach us that workers have fought and defeated authoritarian regimes independently and with their own means with much smaller numbers of maimed and killed and with a political legacy that cannot easily be recuperated by the chauvinists and the ruling class, such as the valiant struggle against the military dictatorships in Brazil or South Korea in the 1980s.
Study your own sector!
Whether education, transport, manufacturing, IT or energy production, workers in all sectors are confronted with the tendency towards militarisation. We have to engage in research efforts of our own sectors and share them with others. We have to build political committees at our workplaces that enable us to act collectively.
Organise for a working class revolution to end all wars!
The current social system that is geared towards profits regularly produces crises and wars. As a global working class it is our responsibility to disarm the ruling class, take over the means of production and transform them into means for a better life for all. Our history of revolutionary efforts, anti-war action and international solidarity is rich. Organise yourself with others, don’t get despaired.
