Executive Summary

For the past decade, Yemen has been wracked by multiple armed conflicts. The parties to these conflicts have flouted the most basic international laws and norms, including by disregarding the special protections afforded by international humanitarian law to medical facilities and personnel. A particularly destructive phase for Yemen began in 2014, when the Houthi armed group (also known as Ansar Allah) took over Yemen’s capital, Sana’a, by force, and escalated in 2015 with the intervention of the Saudi-Emirati-led coalition on behalf of the internationally-recognized government of Yemen against the Houthis. Even prior to that escalation, Yemen was one of the poorest countries in the world, with the lowest human development indicators in the Middle East and North Africa. The years of conflict have turned Yemen into a humanitarian catastrophe. Its economy is crumbling. Its infrastructure is in tatters. Its health care system has almost collapsed. This state of affairs is not an arbitrary consequence of war. It is the direct result of how the conflict has been prosecuted by warring parties: with utter disregard for international law and humanitarian norms. The parties to the conflict in Yemen have waged war with a disregard for international norms that has increasingly obliterated Yemenis’ capacity to survive. Aerial attacks by the Saudi-Emirati-led coalition have taken a particularly devastating toll on the country’s critical infrastructure, including its medical units.The warring parties in Yemen – including the Saudi-Emirati-led coalition, the Houthi armed group, and the Yemeni government – have over the course of the conflict perpetrated serious violations of international human rights law and international humanitarian law. One of the more distinctive—and devastating—abuses of the conflict has been attacks on medical infrastructure and health workers. The warring parties have damaged or destroyed health facilities through airstrikes and shelling, depriving Yemeni civilians of desperately-needed medical services. Parties to the conflict have also occupied medical facilities, commandeered the provision of medical facility services to exclude large swathes of the population, and assaulted medical professionals, among other abuses. Together, these actions violate standards firmly rooted in international humanitarian law and international human rights law to protect health facilities, health workers, and patients during conflict. They further interfere with health professionals’ ability to act in accordance with their ethical obligations.  This research report, produced by Physicians for Human Rights (PHR) and Mwatana for Human Rights (Mwatana), examines attacks on medical facilities and personnel by parties to the Yemen conflict that took place between March 2015 and December 2018. Based primarily on testimonies of witnesses and survivors, this report documents 120 attacks on health facilities and medical personnel in Yemen over a 45-month period. According to data collected by Mwatana, nearly 50 percent of all documented attacks took place in 2015, 16 percent in 2016, 21 percent in 2017, and 13 percent in 2018. The attacks killed at least 96 civilians and health workers, including 10 children and six women, and wounded 230 others, including 28 children and 12 women. Taiz was the governorate most affected by attacks on medical facilities, with 67 documented incidents. Saada governorate was also significantly affected by attacks on health care facilities, with 25 documented incidents, 22 of them airstrikes. The impact of each attack goes far beyond the civilians killed or injured. These attacks have contributed to the virtual collapse of Yemen’s health system, an outcome that has had devastating impacts on the country's civilian population.The documented incidents fall into four main categories of attacks: aerial attacks (35), ground attacks (46), occupation of medical facilities (10), assaults against medical personnel (24), and other violations affecting health care access (7). These categories overlap in many of the documented incidents, with aerial and ground attacks often affecting medical personnel, and occupation and militarization leading in some cases to the direct targeting of health facilities by opposing forces. The documented incidents are not comprehensive and do not represent the total number of attacks on the health sector. Nevertheless, they illustrate patterns of attacks on health, their impact, and specific violations committed in their execution. Saudi-Emirati-led coalition forces have primarily destroyed and damaged hospitals, clinics, vaccination centers, and other medical points through aerial attacks. The coalition’s attacks impacting health facilities assigned exclusively to medical purposes are evidence of its disregard for these structures’ protected status and apparent unwillingness or inability to comply with the principles of distinction and proportionality – including through target verification, timing of attacks, weapons choice, and prior warning. The Houthi armed group’s and other warring parties’ use of indirect fire weapons with wide-area impact– including mortars – that affected health facilities as documented in this report appears indiscriminate in nature. The Houthis’ and other armed groups’ occupation of health facilities points to a more deliberate violation of the protected status of medical structures and effectively denies medical services to populations in need. Other armed forces, including those supported by individual coalition member states, have commandeered and looted medical facilities and intimidated, and threatened health workers. International humanitarian law provides special protection for medical personnel and facilities to ensure the functioning of health care throughout a conflict. Yet, attacks on health care, many appearing to amount to serious violations of international humanitarian law, have been routine throughout the course of the conflict in Yemen. The coalition forces’ airstrikes on civilians and civilian infrastructure and the Houthis’ use of weapons with wide-area impact in densely populated urban settings have–over and over again–violated the principles of distinction, proportionality, and precaution set out in treaty and customary international humanitarian law. In Mwatana’s and PHR’s assessment, many of these violations may amount to war crimes. Military commanders and civilian leaders may be prosecuted for war crimes when they knew or should have known about these crimes and took insufficient measures to prevent them or punish those responsible.  The warring parties in Yemen have repeatedly violated foundational principles of international humanitarian law in their attacks on health care and have perpetrated these abuses with total impunity. This report seeks to contribute to documentation and investigation efforts, so that perpetrators of war crimes and other violations can be held accountable and survivors given redress.

Key Recommendations

To the Parties to the Conflict:

• Immediately cease unlawful attacks on medical facilities and personnel and end occupation of medical facilities.
• Respect the protection afforded to medical units and health services and permit health workers to fulfill their ethical responsibilities of providing impartial care to those in need.
• Facilitate safe, rapid, and unhindered access for humanitarian supplies and personnel to all affected governorates in Yemen.

To the Houthi Armed Group:

• Respect the protected status of medical facilities and withdraw armed personnel from in or around medical centers.
• Cease using medical centers for military purposes.
• Abide by the “no weapons” policies of hospitals and other health facilities.
• Investigate all incidents of restricting, denying, or confiscating humanitarian aid, and hold those responsible accountable.

To the Yemeni Government and Saudi-Emirati-led Coalition:

• Abide by the principles of distinction, proportionality and precaution in conducting military operations
• Conduct credible, impartial, and transparent investigations into alleged violations of the laws of war and prosecute military personnel, including as a matter of command responsibility, responsible for war crimes in Yemen.
• Provide prompt and adequate redress for civilian victims and their families for deaths, injuries, and property damage resulting from wrongful attacks, and adopt a unified, comprehensive, and easily accessible mechanism for providing ex gratia (condolence) payments to civilians who suffer losses due to military operations, regardless of the attack’s lawfulness.