Those Who Heal: Doctors, War, and Lebanon's Health System Under Fire

And into all of that walks a new war in 2026.

So when the health minister says 108 health workers have been killed, you have to understand those 108 people were already working in an almost impossible situation.

Sin suministros suficientes, sin electricidad garantizada, sin medicamentos esenciales, y en muchos casos sin el personal mínimo necesario porque sus compañeros habían huido al extranjero.

Without enough supplies, without guaranteed electricity, without essential medicines, and in many cases without the minimum staff needed because their colleagues had fled abroad.

Y aun así se quedaron.

And still they stayed.

Eso dice algo sobre esas personas.

That says something about those people.

Let's talk about the legal dimension of this, because there are rules.

Geneva Convention rules, specifically.

The protection of medical personnel in conflict zones isn't a preference or a guideline.

It's one of the oldest and most fundamental parts of international humanitarian law.

Desde 1864.

Since 1864.

El Convenio de Ginebra original, el primero, fue precisamente para proteger a los heridos y al personal sanitario en los campos de batalla.

The original Geneva Convention, the first one, was precisely to protect the wounded and medical personnel on the battlefield.

Henry Dunant lo impulsó después de presenciar la batalla de Solferino en 1859, donde los heridos morían abandonados porque nadie tenía permiso de cruzar las líneas para atenderlos.

Henry Dunant pushed for it after witnessing the Battle of Solferino in 1859, where the wounded died abandoned because no one had permission to cross the lines to treat them.

Esa imagen lo obsesionó hasta que logró cambiar el derecho internacional.

That image obsessed him until he managed to change international law.

Dunant essentially invented the modern Red Cross out of what he saw that day.

And the principle he established, that medics are protected, that ambulances are protected, that hospitals are protected unless they're being used for military purposes, has been the baseline of wartime law for over 160 years.

Y se viola con una regularidad que debería avergonzarnos a todos.

And it is violated with a regularity that should shame all of us.

No es solo en Líbano: lo hemos visto en Siria, en Yemen, en Gaza, en Sudán.

It's not just in Lebanon: we've seen it in Syria, in Yemen, in Gaza, in Sudan.

Los hospitales se convierten en objetivos, o se destruyen como daño colateral, o simplemente quedan inaccesibles porque las carreteras están bombardeadas.

Hospitals become targets, or are destroyed as collateral damage, or simply become inaccessible because the roads are bombed out.

El derecho existe, pero la aplicación es prácticamente nula.

The law exists, but enforcement is practically nonexistent.

The enforcement question is the one I keep coming back to.

Who enforces it?

The International Criminal Court can theoretically prosecute, but even that takes years and depends on political will that never quite materializes when it's a powerful state doing the bombing.

Hay que ser francos aquí: Israel argumenta sistemáticamente que Hezbolá utiliza infraestructura civil, incluidos hospitales, para sus operaciones.

We have to be frank here: Israel systematically argues that Hezbollah uses civilian infrastructure, including hospitals, for its operations.

Eso está prohibido también por el derecho internacional, y si fuera cierto, complicaría la evaluación legal.

That is also prohibited under international law, and if true, it would complicate the legal assessment.

Pero los periodistas y organizaciones humanitarias que han podido verificar sobre el terreno han documentado ataques a instalaciones sanitarias que no mostraban ninguna evidencia de uso militar.

But the journalists and humanitarian organizations that have been able to verify on the ground have documented attacks on health facilities that showed no evidence of military use.

And this is where the information environment gets brutal.

Each side produces evidence, each side produces counterclaims, and meanwhile the medic is dead.

The legal debate happens at a speed that has no relationship to the speed at which people are dying.

En Siria se llegó a documentar que algunos hospitales habían sido atacados dos, tres, incluso cuatro veces.

In Syria it was documented that some hospitals had been attacked two, three, even four times.

El patrón era tan sistemático que varios investigadores lo calificaron de política deliberada, no de error.

The pattern was so systematic that several researchers classified it as deliberate policy, not error.

Médicos Sin Fronteras ha desarrollado un protocolo especial en los últimos años: no revelar las coordenadas GPS de sus instalaciones a las fuerzas militares, precisamente porque los datos de ubicación en Siria se correlacionaban con los ataques.

Doctors Without Borders has developed a special protocol in recent years: not disclosing the GPS coordinates of their facilities to military forces, precisely because location data in Syria correlated with the attacks.

That's a remarkable thing to think about.

MSF, one of the most trusted humanitarian organizations on earth, has decided that telling armies where their hospitals are makes those hospitals less safe.

That's where we've arrived.

Volviendo a Líbano: hay un elemento político que no podemos ignorar, y es el papel de Hezbolá en el sistema sanitario libanés.

Getting back to Lebanon: there's a political element we can't ignore, which is Hezbollah's role in the Lebanese health system.

Durante décadas, Hezbolá construyó una red paralela de servicios sociales, incluyendo clínicas y hospitales, especialmente en el sur y en el Valle de la Bekaa.

For decades, Hezbollah built a parallel network of social services, including clinics and hospitals, especially in the south and the Bekaa Valley.

Para una parte importante de la población chií, esos servicios de Hezbolá eran mejores y más accesibles que los del Estado.

For a significant part of the Shia population, those Hezbollah services were better and more accessible than those of the state.

Which creates this hideous dilemma.

If Hezbollah's medical infrastructure is also, from Israel's perspective, Hezbollah's logistical infrastructure, then what's the line between a protected clinic and a military asset?

And who gets to draw that line in real time, from a cockpit?

Ese es uno de los grandes debates del derecho internacional humanitario contemporáneo: el concepto de doble uso.

That is one of the great debates in contemporary international humanitarian law: the concept of dual use.

La respuesta jurídica tradicional es que mientras una instalación esté prestando servicios médicos reales, conserva su protección aunque la organización que la gestiona sea considerada terrorista por algún gobierno.

The traditional legal answer is that as long as a facility is providing real medical services, it retains its protection even if the organization managing it is considered terrorist by some government.

Pero en la práctica, esa distinción se ignora cuando conviene.

But in practice, that distinction gets ignored when it's convenient.

And the people who pay for that ignored distinction are the patients.

And the 108 dead health workers.

Fletcher's quiet for a second.

I spent time in southern Lebanon in 2005, just before the 2006 war, and I visited some of those Hezbollah-run clinics.

They were clean.

They were well-staffed.

The doctors were young and clearly well-trained.

Whatever you thought about Hezbollah politically, those were real doctors doing real medicine.

Y esa es la tragedia particular del Líbano: el Estado nunca pudo o nunca quiso proporcionar esos servicios de manera universal, lo que dejó un vacío que llenaron actores políticos con su propio interés.

And that is the particular tragedy of Lebanon: the state never could or never wanted to provide those services universally, which left a vacuum filled by political actors with their own agenda.

Hezbolá no construyó hospitales por altruismo puro;

Hezbollah didn't build hospitals out of pure altruism;

los construyó para generar lealtad.

they built them to generate loyalty.

Pero las personas que atendían esos hospitales, los médicos, las enfermeras, los técnicos, eran simplemente profesionales sanitarios haciendo su trabajo.

But the people who staffed those hospitals, the doctors, nurses, technicians, were simply health professionals doing their jobs.

Let's zoom out for a second, because this isn't just a Lebanon story.

The pattern of health systems collapsing under conflict is almost universal at this point.

Yemen, Syria, Gaza, Sudan.

Is there a common thread beyond the obvious?

Hay varios.

There are several.

Primero, todos estos son países donde el sistema sanitario ya era frágil o dependía de financiación externa antes del conflicto.

First, these are all countries where the health system was already fragile or depended on external funding before the conflict.

Segundo, en todos estos casos hay actores que entienden que destruir la capacidad sanitaria de una población es una forma de quebrar su resistencia.

Second, in all these cases there are actors who understand that destroying a population's health capacity is a way of breaking their resistance.

No tienes que matar a todos: si consigues que la gente no pueda recibir atención médica, el efecto acumulativo es devastador.

You don't have to kill everyone: if you can prevent people from receiving medical care, the cumulative effect is devastating.

That second point is disturbing in a specific way, because it implies intent.

Not collateral damage, not tragic miscalculation.

Intent.

La palabra que se usa en el derecho internacional es 'privar a la población civil de los objetos indispensables para su supervivencia'.

The phrase used in international law is 'depriving the civilian population of objects indispensable to their survival.' That includes medical services.

Incluye los servicios médicos.

And it is explicitly prohibited as a method of warfare under Additional Protocol I of the 1977 Geneva Conventions.

Y está explícitamente prohibida como método de guerra en el Protocolo Adicional I de los Convenios de Ginebra de 1977.

But here we come back to the enforcement problem.

Pero aquí volvemos al problema de la aplicación.

The gap between what the law says and what actually happens on the ground is one of the longest gaps in modern history.

And it seems to be getting wider, not narrower.

Lo que más me preocupa del caso libanés a largo plazo es la fuga de cerebros sanitarios que ya no tiene vuelta atrás.

What worries me most about the Lebanese case in the long term is the medical brain drain that no longer has a way back.

Si antes de la guerra ya se había ido la mitad de los médicos, después de esto, ¿quién va a quedarse?

If half the doctors had already left before the war, after all this, who is going to stay?

¿Quién va a reconstruir eso?

Who is going to rebuild that?

Líbano tardó décadas en construir algunas de las mejores facultades de medicina del mundo árabe.

Lebanon took decades to build some of the best medical schools in the Arab world.

La Universidad Americana de Beirut, la Universidad Saint-Joseph.

The American University of Beirut, Saint Joseph University.

Eso no se reconstruye en cinco años.

That can't be rebuilt in five years.

I interviewed a Lebanese cardiologist in London about four years ago, for a piece I never finished about medical migration.

He told me he felt guilty every day for leaving but that his children would grow up in a country with electricity.

I've thought about that a lot since.

Esa tensión entre la responsabilidad profesional y la responsabilidad familiar es real y no tiene una respuesta fácil.

That tension between professional responsibility and family responsibility is real and has no easy answer.

No puedes pedirle a alguien que sacrifique el futuro de sus hijos por un Estado que les ha fallado sistemáticamente.

You can't ask someone to sacrifice their children's future for a state that has systematically failed them.

Y al mismo tiempo, cuando esos profesionales se van, los que pagan el precio son los que no pueden irse.

And at the same time, when those professionals leave, the ones who pay the price are those who can't leave.

Which brings us back to the 108.

Each one of those 108 people was someone who stayed.

Who made that choice.

And the number keeps climbing.

Y hay que recordar que estos ciento ocho no son solo un número abstracto.

And we have to remember that these one hundred and eight are not just an abstract number.

Cada uno de ellos deja un hueco que es casi imposible de llenar en un sistema ya esquilmado.

Each one leaves a gap that is nearly impossible to fill in a system already stripped bare.

Un médico de urgencias en el sur de Líbano no se reemplaza en semanas ni en meses.

An emergency doctor in southern Lebanon cannot be replaced in weeks or months.

El daño se acumula de maneras que no aparecen en ninguna estadística de la guerra.

The damage accumulates in ways that don't appear in any war statistics.

There's a phrase I keep using with my journalism students: the second-order death toll.

The people who die not from the bomb but from the absence of the doctor who would have saved them.

Wars have two death tolls and we almost never count the second one.

Es una manera muy precisa de describirlo.

That's a very precise way to describe it.

En epidemiología lo llaman mortalidad excesiva, y los estudios posteriores a conflictos armados muestran sistemáticamente que las muertes indirectas, por enfermedades no tratadas, por partos sin asistencia médica, por heridas que se infectan, superan con frecuencia a las muertes directas del conflicto.

In epidemiology they call it excess mortality, and studies conducted after armed conflicts systematically show that indirect deaths, from untreated illness, from unassisted childbirth, from infected wounds, frequently exceed the direct deaths from the conflict itself.

En la guerra del Congo, por ejemplo, la ratio era de veinte a uno.

In the Congo war, for example, the ratio was twenty to one.

Twenty to one.

For every person killed by a bullet or a bomb, twenty die because the health system isn't there to keep them alive.

That's the number that should be on the front page.

Y si me preguntas qué me parece lo más urgente de todo esto, no es solo la condena diplomática ni las resoluciones del Consejo de Seguridad que nadie cumple.

And if you ask me what I think is most urgent about all of this, it's not just diplomatic condemnation or Security Council resolutions that no one honors.

Es esto: necesitamos mecanismos reales, con dientes, para que atacar personal sanitario tenga consecuencias inmediatas y concretas para quien lo ordena.

It's this: we need real mechanisms, with teeth, so that attacking medical personnel has immediate and concrete consequences for whoever orders it.

Mientras eso no exista, seguiremos contando los ciento ocho de cada guerra.

Until that exists, we will keep counting the hundred and eight of every war.

Hard to argue with that.

I want to pick up on something you said a few minutes ago that I've been turning over.

You used the phrase 'no tiene vuelta atrás' about the medical brain drain.

I know roughly what it means but I'm not sure I understand what it's actually doing grammatically.

Walk me through that.

Buena observación.

Good observation.

'Vuelta atrás' es literalmente 'turn back' o 'return backward', y la construcción 'no tiene vuelta atrás' significa que algo es irreversible, que ya no hay posibilidad de deshacer lo hecho.

'Vuelta atrás' is literally 'turn back' or 'return backward,' and the construction 'no tiene vuelta atrás' means something is irreversible, that there is no longer any possibility of undoing what has been done.

Lo interesante es que en español usamos el verbo 'tener' aquí donde en inglés dirías 'there is no going back', con una estructura impersonal.

The interesting thing is that in Spanish we use the verb 'tener' here where in English you'd say 'there is no going back,' with an impersonal structure.

En español lo personalizamos: la situación 'tiene', o no tiene, esa vuelta.

In Spanish we personalize it: the situation 'has,' or doesn't have, that return.

So in English we strip the agency out of it, we make it existential: there is no going back.

In Spanish the situation itself owns its reversibility, or lack of it.

That's a genuinely different way of framing something.

Exacto.

Exactly.

Y es una construcción muy versátil: 'esto no tiene vuelta atrás', 'ya no hay vuelta atrás', 'la decisión no tiene vuelta atrás'.

And it's a very versatile construction: 'this has no going back,' 'there's no going back now,' 'the decision has no going back.' You can use it for small things and big things alike.

Puedes usarla para cosas pequeñas y grandes.

If you cut your hair very short, 'no tiene vuelta atrás.' If you destroy a country's health system, same thing.

Si cortas el pelo muy corto, 'no tiene vuelta atrás'.

Si destruyes el sistema sanitario de un país, tampoco.

Nothing like using a war to practice your grammar.

Though I will say, I think I'll actually remember 'no tiene vuelta atrás' now because of what we've been talking about.

Which is maybe how languages are supposed to work.

Ese es el único método pedagógico que te reconozco, Fletcher: aprendes mejor cuando la cosa importa.

That is the only pedagogical method I'll give you credit for, Fletcher: you learn better when the thing matters.

Ahora, si además pudieras aprender a pronunciar la 'r' como es debido, estaríamos hablando de un verdadero progreso.

Now, if you could also learn to pronounce the 'r' properly, we'd be talking about real progress.