On the Issues with Michele Goodwin

Collateral Damage: Preserving Health and Humanity During War (with Larry Gostin)


November 22, 2023

With Guests:

Larry Gostin: Professor Larry Gostin co-directs the O’Neill Institute for National and Global Health Law and is a  university professor and the Founding O’Neill Chair in Global Health Law at Georgetown University. He is also the Director of the World Health Organization (WHO) Collaborating Center on National and Global Health Law.

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In this Episode:

This episode marks the first in a new On the Issues series: “Collateral Damage.” In these episodes, we probe where news typically falls off, and its neglect of the impact of war on women. The crises of sexual violence they face, which is a deliberate tactic in war. We examine maternal and reproductive health, the role of women in peacekeeping, and so much more.

In this episode, we start with health and why it’s sacred and must be protected even in war, delving into issues of bioethics and health care during conflict. In times of war, who protects the patients, the mothers, the babies?  Are there bridges too far that shouldn’t be crossed, even in war?

Background Reading:


0:00:01.4 Michele Goodwin: Welcome to On the Issues with Michele Goodwin at Ms. Magazine. As you know, we’re a show that reports, rebels, and we tell it just like it is. On this show, we center your concerns about rebuilding our nation and advancing the promise of equality. Join me as we tackle the most compelling issues of our times. On our show, history matters. We examine the past as we think about the future. 

This episode marks the first in our “Collateral Damage” series. We look to probe where news typically falls off. The sexual actual violence inflicted on children and women during times of war. We focus on bioethics and health care during conflict, what are the bridges too far and hard or impossible to justify during conflict, and as a trigger warning, for this series, we are concerned about health care, who protects the patients, the mothers, the babies during times of war, and also, we pick the scab of sexual violence during conflict. According to the United Nations, wartime sexual violence is one of history’s greatest silences and one of today’s most extreme atrocities. 

To be clear, rape and sexual violence are not confined to the thugs of war such as rogue soldiers. Rather, sexual violence, according to UN omen, is a deliberate tactic of warfare. It displaces, terrorizes, and destroys individuals, families, and entire communities reaching unthinkable levels of cruelty against women of all ages from infants to grandmothers. 

The harms against women and girls are not only perpetrated by soldiers or armed government forces but also by paramilitary groups, militia, the mercenaries, and guerillas. And what are the effects? According to the European Institute for Gender Equality, violence experienced by women and girls during armed conflict includes murder, unlawful killings, torture, and other cruel, inhuman or degrading treatment or punishment, abductions, maiming and mutilation, forced recruitment of women combatants, rape, sexual slavery, sexual exploitation, involuntary disappearance, arbitrary detention, forced marriage, forced prostitution, forced abortion, forced pregnancy, and forced sterilization, and here’s more.

In a report from UN Women, we learn that the fear of sexual violence holds communities hostage and prevents women and girls from participating in public life or attending school. The cost and consequences last for generations, and often, mass rape continue after the guns fall silent and peace treaties are signed. These are truly crimes of impunity. The tolls of men’s wars on women and children are devastating. It can leave the survivors with emotional trauma and psychological damage, physical injuries, unwanted pregnancies, social stigma, and sexually transmitted infections such as HIV. And so I return to the question, as this series unfolds, what are the bridges too far and hard or impossible to justify during conflict, what is the role, the rules for doctors. 

These are important questions given the history of militaries coopting medical providers to inflict harms. Indeed, the very principles of bioethics are rooted in the aftermath of the Holocaust, the Nuremberg Code of medical ethics. 

Joining me is to unpack these issues and more is Larry Gostin. He’s the director of the World Health Organization collaborating center on national and global health law. Professor Gostin is also a university professor at Georgetown University where he serves as the co-faculty director of the O’Neill Institute for national and global health.

Larry, it’s such a pleasure to be joined by you on this podcast as we think about matters of war and matters of conflict, and what’s been in the news since October seventh has been the conflict in Israel and Gaza. As you well know because of the work that you do all around the world there are other conflicts that are taking place as well, other war-torn areas and in this podcast I’d like for us to talk about all of that but to center it in thinking about the unique space and role of healthcare in times of conflict. And so, I want to start off with just a level setting with you in terms of what makes in your opinion what makes healthcare medicine different from so many things in times of conflict and war.

00:01:04 Larry Gostin:

That’s such an important question and I thought I might just reflect at the beginning that as we all know we rarely see the divisiveness and the hate on all sides as we have been since the Israel-Gaza conflict but there’s one thing we should all be able to agree on and that is protecting health, protecting healthcare workers, patients, humanitarian corridors, foods, medicines, water. And so, that should be an area where we should all be able to agree on. So, why is it important.

I could just begin by saying that, you know, what our mother told us that if you’ve got your health you’ve got everything and that seems counterintuitive in the midst of war and just an intentional killing and maiming of the other but ethics and international law carve out a very special place for the continuation of the health system because without the health system the noncombatants literally can’t thrive. They can’t live. They can’t be healthy, and so we have to do all we possibly can to keep the health system intact and that is particularly difficult in Gaza where even before this conflict the health system was under real stress, and I think that’s an underestimate. 

It was just really crumbling to begin with and now it’s entirely destroyed and beyond the conflict itself and who’s right and who’s wrong, what that tells us is that, you know, mothers giving birth, newborns, children with diseases in hospitals, people with diabetes, cancer, cardiovascular disease, those in need of kidney dialysis, these are all routine things that every health system should guarantee and that has just simply crumbled and we should be all concerned about it ethically and from a legal perspective. 

00:04:06 Michele Goodwin:
You mention how fragile and vulnerable the healthcare systems were already in Gaza before now as something that we should be deeply concerned with and the way in which war affects those matters that were the day to day health concerns which you were mentioning, diabetes, people who become pregnant and are in labor, people who give birth, people who have the kinds of conditions that exist whether there is not conflict and in conflict that just happens to be exacerbated in so many ways. Where does, and you mentioned that there’s an ethical obligation, in your opinion where does that ethical obligation stem from to be concerned in a way that should make us think about just sort of distinguishing it from just what war is?

00:05:14 Larry Gostin:
Yeah. I think it’s grounded, and you know this Michele as well or better than me, it’s grounded in the duty to care. We see it in human rights language and the right to health. The WHO constitution calls it among the most fundamental rights but from a bioethics point of view it’s simply the duty to care and that duty is we tend to think of it as it exists on health workers, doctors, nurses, and other health personnel but it is also a duty that the state owes to its citizens. A social contract whereby the governed citizenry gives authority and power to governments and governments have a duty to protect them. First and foremost in that protection is to provide a health system and people think of health systems as hospitals and certainly they are but they’re much more than that. Basically, a public health system, so that there’s access to medicines, the basic necessities of life, food, water. 

00:06:45 Michele Goodwin:
You know at times of war you’re absolutely right and I don’t mean to cut you off. Maybe I do Larry, but you know how do we get governments at war, institutions at war, groups at war to understand that?

00:07:07 Larry Gostin:
It’s very difficult. I mean let me just start with some of the basics here. The WHO, the World Health Organization, has a healthcare surveillance system. That’s been ongoing in Ukraine in places like Yemen, Ethiopia and other parts of the world for a long time. What that surveillance system tells us through November 12 is nearly 300 attacks on health infrastructure and facilities in Gaza and the West Bank including health facilities, medical transport. Most of them impacted health personnel but also a majority also affected patients and in total there were 232 deaths in all the world last year. So, that gives you an idea that this is a conflict that pales the rest of the world’s conflicts in comparison. But the WHO surveillance system has been subject to considerable criticism mostly because it underreports.And so, the likely toll is likely to be much greater than that. 

And the issue here in Gaza and with Israel is an extreme version of what you see everywhere that peoples and countries believe on both sides that its an existential crisis and because it’s an existential crisis they will ignore the ethics and the humanitarian norms and even international law, and they justify that simply by the fact that they’re protecting their own survivals. One can see it on both sides of this conflict.

00:09:30 Michele Goodwin:

That’s what makes this such an incredibly painful time. The horrors inflicted by Hamas including kidnap, murder and rape. Hostages are still being held by them. More Jewish people were killed on October 7 than at any time since the Holocaust, and then, there’s been Israel’s response to Hamas, which has devastated Gaza, and the bombings have destroyed or significantly damaged the medical infrastructure. And this all raises really important questions for law in bioethics as we are discussing what the health tolls are and whether there can be a standard discourse, a kind of standard of understanding with regard to health care as being important to protect at all time, and so all of this, Larry, truly aches the heart, and it’s why I really wanted to have this conversation with you.

00:09:40 Larry Gostin:
I’m particularly saddened Michele because my parents were Holocaust survivors but I’m also been very deeply steeped in the World Health Organization and the importance of health and it’s so painful to see this happening that I sometimes just want to close my eyes and I don’t want to see it anymore but of course we have to see it and we have to do something about it. 

00:10:27 Michele Goodwin:

If you’re just joining me, I’m with Larry Gostin, the director of the World Health Organization’s collaborating center on national and global health law. He’s also the co-faculty director of the O’Neill Institute for national and global health at Georgetown Law School, and this is your host, Michele Goodwin.

Larry, my heart is heavy. In thinking about that, as you mentioned, your parents were Holocaust survivors, and I think about the Nuremberg Code, the principles that we get from Nuremberg to help us understand and guide our ethical principles, our moral commitments in times like this. Let’s listen to part of the doctor’s trial for a moment.


One-hundred and twelve Jews were selected for the purpose of completing a skeleton collection for the Reich University of Strausberg. Their photographs and anthropological measurements were taken. Then they were killed. Thereafter comparison tests, anatomical research, studies regarding race, pathological features of the body, form and size of the brain, and other tests were made. The bodies were sent to Strausberg and defleshed. The execution of the so-called euthanasia program of the German Reich, in the course of which the defendants herein murdered hundreds of thousands of human beings, including nationals of German occupied countries. This program involved the systematic and secret execution of the aged, insane, incurably ill, deformed children, and other persons by gas, lethal injections, and diverse other means in nursing homes, hospitals and asylums. Such persons were regarded as useless eaters and a burden on the German war machine. The relatives of these victims were informed that they died of natural causes such as heart failure. The German doctors involved in the euthanasia program were also sent to the eastern occupied countries to pursue the mass extermination of Jews. 

Michele Goodwin:

Larry, it was horrific then and still chilling and deeply disturbing now. Before our break, I think that you were making the point that in these times when you have entities at battle those underlying bioethical principles and even international law and humanitarian law can seemingly go out the window.

00:11:10 Larry Gostin:
And they do, and the truth is that there really is very little if any accountability. We’ve seen that in Ukraine. In Ukraine there’s been a deliberate destruction of hospitals, humanitarian corridors, patients, health workers have all been attacked. The Russian federation is certainly part of the Geneva conventions. The federation is not a part of the international criminal court but nonetheless the court has already tried to indict President Putin but there’s very little accountability and if you think all the wars that have been going on for a long, long time, many of them, you know, are just really out of our radar but they’re really…

00:12:16 Michele Goodwin:
I think about the Congo.

00:12:18 Larry Gostin:
The Congo, Ethiopia, Yemen, Syria, Ukraine. It’s happening all over the world and I’m unaware of any single consequence or accountability with respect to any of them.

00:12:44 Michele Goodwin:
And that too just makes me bristle. You’re absolutely right. very little at all. 

00:12:54 Larry Gostin:
And we’re numb to it. The public becomes numb to it after a while. We’re obviously not numb to the Gaza situation because it’s on our televisions all the time but that will fade probably and so have all the other conflicts that the public barely knows about. 

00:13:14 Michele Goodwin:
So, then I’m wondering what is to be done about that. It brings to mind 1966 Doctor King gives this speech in Chicago before a broad group of doctors and this is after the U.S. 1964 Civil Rights Act and ’65 Voting Rights Act and he gives a speech where he basically says of all the injustices of all and we know that he had endured so many of them and saw them first hand but that of all of them the absolute worst was inequity in healthcare and many people were stunned by that. Why healthcare, and he said because ultimately it means that people can die. 

00:14:03 Larry Gostin:

Yeah. And you know what’s so fascinating for me to hear you say that and I’ve heard you say it before is that I’ve often said it and used that exact quote from Martin Luther King and since then you and I have become so close and so inseparable in so many ways that I’m not surprised that we’ve both come to this same stark realization that health really is special. There’s nothing as important as our health. We’ve talked about many of the consequences and there are direct ones. 

If you see a bomb going onto a hospital or onto a medical transport facility we automatically understand that and we also understand when there’s a withdrawal of food, water, medicines, electricity that are needed but the everyday functioning of the health system of all the everyday needs, AIDS, TB, tuberculosis, COVID, diabetes, heart disease, injuries, childbirth, you name it these are all things that suffer if you don’t have an intact health system and as we’ve said before the one in Gaza has always been as vulnerable as it can be but now we might see things that increase risk of infectious diseases for decades if not generations. People will be dying in excess deaths of diabetes and heart disease and all the other undiagnosed things that go on. So, this can’t be understated how important it is and it’s kind of stunning when we see it so widespread around the world that we really have no solution to it, no answer to it, no compliance with the norms.

00:16:28 Michele Goodwin:
That’s right and you mentioned something in terms of the intergenerational effects and part of that is that when there’s no infrastructure it makes it really hard and if the infrastructure is gone because it’s been blown away that it has become a subject of war, whatever it is, the artillery that’s been used accidentally by a military in its own community or as a target from someplace else, rebuilding infrastructure, health infrastructure can be so challenging and so difficult. 

00:17:04 Larry Gostin:
Yeah. You know it’s even more difficult to rebuild dignity and people’s lives and their trust in the health system. So, you have a double worry of deep concern is that the infrastructure will take such a long time to rebuild and become refunctioning but also the population will lose touch with the health system, and we haven’t even mentioned health workers. 

00:17:48 Michele Goodwin:
You are so right. It’s so profound what you’ve just shared Larry because it is so true. I mean we see that certainly in so many countries. We see that even in the United States what that means rebuilding trust within communities of color. African American people in various communities where they have literally been preyed upon in some ways finding it very difficult to trust health institutions or the people that can be very well meaning in those health institutions and sometimes of course to acknowledge that there has been people who have not always been well intentioned towards African Americans, but trust can be something that is very difficult to repair, restore. 

You also mentioned something else Larry and then it is important that we turn to health workers who are trying to hold it together all around the world but the trauma, the trauma and terror that comes during times of war no matter which party has the upper hand, right. That trauma can be felt all around, and I think that that is so important that we understand.

00:19:06 Larry Gostin:
Yeah. I’m really glad you are raising this Michele because there are multiple problems with the health workforce generally. I mean I’m working closely with WHO right now on strengthening health workforces and their rights throughout the world and we’re setting up international standards and the like but in times of conflict the problems are infinitely greater. At the most basic level how do we get health workers. We need medical schools. You need nursing schools. They can’t exist in times of conflict, and so, the critical training that’s needed for health personnel is gone and could be gone for years or decades or weakened. And then health workers I can’t even begin to describe how hard, traumatic, painful it is for a health worker to be working in a conflict zone. The burnout, the despair. You’re trained to save people and you can’t, and so, some of them will flee. Some of them will stay and brave circumstances without sleep but eventually all bodies and minds wear out.

And so, we’ve got a health worker crisis, not just a patient crisis, not just a medicine crisis but one where we could be seeing current and future generations of skilled health personnel unavailable in wartorn zones and particularly so when that war or that state of conflict continues on for not just weeks and months but years and even decades as we’ve seen in places like Syria and Yemen and the Congo and so many other places around the world.

00:21:35 Michele Goodwin:
Well, and on that note there have been doctors, nurses, other medical providers that have been speaking out. There was a letter published in the Lancet by a group of health providers speaking to aspects of what it is that you’ve just been talking about and then going into greater detail. One can only imagine the vulnerability that they feel the urgency and ethical obligation to serve their patients and yet at the same time realizing that their lives are deeply vulnerable too because at any moment right.

00:22:27 Larry Gostin:
And it’s interesting Michele that if you go back to…you don’t even have to go back very far but you can go back very far both about the medical ethics of caring for patients when your health and life is at risk. There’s a long bioethics literature on this. For most of our history it was considered all right for doctors, nurses, and other health workers to flee or not to stay. During plagues and famines and conflict throughout history the health workforce has fled and that was thought to be all right and even as recently as 10 or 20 years ago, the American Medical Association said that it was all right not to treat if your health or life was at risk. 

A lot of that changed with the AIDS pandemic and the norms began to shift but it was literally only, I can’t say the exact number of years but pretty recently where the AMA has updated its ethical guidelines that doctors and nurses have an obligation to stay and treat even if it puts their lives at risk but of course there’s got to be a balance and we’re asking an awful lot of brave health workers. They didn’t sign up for this. They signed up to save people and they signed up in ways that they never thought that they were going to be put in jeopardy but now they’re put in jeopardy and they also can’t do what their calling is which is to help patients because they don’t have the equipment, the medicines, the electricity that enables them to do the job that they were trained to do.

00:24:37 Michele Goodwin:

If you’re just joining me for this inaugural episode of our collateral damage series, I’m Michele Goodwin, your host, and I’m joined by Professor Larry Gostin from Georgetown University. 

Larry, I want to pick up where we left off. A week ago, we had the WHO stating that the world can’t stand silent while hospitals, which should be safe havens, are transformed into scenes of death, devastation, and despair and you know and that gives us much to think about and much to think about as you say with an ethical obligation on behalf of doctors to stay and what that means.

I want us to take a listen to Dr. Mads Gilbert, and emergency physician, who treated patients in Gaza. Right now, he’s in South Africa, but he recorded this before he left Gaza.

Dr. Mads Gilbert:

Prime Ministers and presidents of the European countries, can you hear me? Can you hear screams from Shifa hospital? From Al-Quds hospital? Can you hear the screams from people, refugees sheltering, trying to find a place, being bombed? When are you going to stop this? You’re all complicit. 

Michele Goodwin:
Larry, those are strong words. What do you make of this, and of course, recognizing that war atrocities and suffering are taking place around the world.

00:25:15 Larry Gostin:
Yeah. I mean Tedros the head of the World Health Organization extremely well. He was the Ethiopian health minister and also the foreign minister, so he’s very, very used to dealing in conflict situations. He’s been very outspoken on le Tigre situation, also Ukraine and now the Gaza Israeli war and we’re seeing our leaders from the UN and others call out and we’re seeing doctors write to prestigious medical journals like the Lancet to try to have this end but both sides don’t do it. I mean it’s also a violation of international law to embed yourself in a hospital. 

00:26:13 Michele Goodwin:
A hospital. Right. exactly. This is the sort of strategic tool of war now is to use a hospital as a shield.

00:26:22 Larry Gostin:
You say well I want to take a stand. I want to support this side or the other side, it’s actually all right and in fact more than all right to say both sides are wrong and that there does need to be a sacred space for the health system but what do you do when both sides are misbehaving and how do you come to an ethical and legally accountable way to protect people’s lives, patient’s lives, health worker’s lives, health infrastructure. That’s why whenever I watch I think I’m pained not just by the vision of it, but I’m pained because I feel I don’t know what to do about it and normally I’d pride myself. I’d always pride myself in finding actionable solutions to problems. This one does seem so deep that it’s very, very hard to do. You do want to say just one thing which is stop on both sides. That’s the one thing we can safely do, stop.

00:27:42 Michele Goodwin:
You also mentioned something which is the word sacred. You know, that there should be something sacred and that something sacred at times of war and conflict is protecting healthcare, protecting healthcare workers. Perhaps if there’s one thing that could be a message perhaps and sort of taken away from our conversation would you say that that would be it.

00:28:14l Larry Gostin:
I would say that’s exactly it. I would say that combatants in a conflict none of us like what they do to each other but there is one thing that’s sacred and that both sides need to respect are the health and lives of patients, healthcare workers and the health infrastructure that exists. The hospital infrastructure but also the public health infrastructure and the public health infrastructure is in many ways as if not much more important because it requires governments to provide food, water, medicines, electricity, all the things, all the basic necessities of life and we need potable water. You need nutritious food. You need electricity to protect. And so, the idea of respect and protect is the human rights notion but here it applies to that sacred place which is the health system.

00:29:33 Michele Goodwin:
Larry it’s been such a pleasure to be in conversation with you. I’m almost spoiled by using the term pleasure to talk about something that is so painful but I can’t imagine anyone else that I would want to have this conversation with about that which is sacred and healthcare and that we keep that front and center not only as we look at the conflict in Israel Gaza but around the world, Ukraine, in the Congo, so many places around the world that are struck now with a conflict and in recognition of those spaces where as you say perhaps we’ve become numb. Thank you so much Larry for joining me.

00:30:25 Larry Gostin:
Thank you very much Michele. 

0:00:01.5 Michele Goodwin: To our listeners, we thank you for tuning in to our special series on the collateral damages of war and conflict. For more information about what we discussed today, head to msmagazine.com. 

Now, if you believe, as we do, that women’s voices matter, that equality for all persons cannot be delayed, and that rebuilding America, being unbought and unbossed, and reclaiming our time are important, then be sure to lift up and support independent feminist media. Look for our Ms. Studio’s podcast at msmagazine.com for new content and special episode updates, and if you want to reach us to recommend guests for our show or topics that you want to hear about, then write to us at ontheissues@msmagazine.com. We are ad free and reader supported. 

This has been your host Michele Goodwin reporting, rebelling, and telling it just like it is. On the Issues with Michele Goodwin is a Ms. Studio’s production. Our producers for this episode are Roxy Szal, Oliver Haug, Allison Whelan, and Morgan Carmen. The creative vision behind our work includes art and design by Brandi Phipps, editing by Will Alvarez and Natalie Holland, and music by Johannes Kaiser, Marscott Diego, and Nick Paparo.