Arming Hospital Ships of the Future: Hybrid Wars Require a Major Change.

INTRODUCTION: It is time to provide heavier defense systems to U.S. Navy hospital ships. They serve vital functions in both the military and emergency management spaces. They provide medical support for combat operations and can also convey the empathy and generosity of the American people when used in humanitarian assistance and disaster relief response. Hospital ships are often key to success in scenarios that require the international deployment of resources and medical expertise. Hospital ships serve a dual purpose and hence are subject to regulations that do not address all wartime mission requirements and necessary defensive capabilities. The current U.S. Navy's interpretation of the Geneva Conventions regarding the visibility, lack of defensive capabilities, and inability to use encrypted communications needlessly endangers medical platforms and personnel in the modern environment.

METHODS: The authors (including senior author F.M.B.-a recognized (International Health Law expert) reviewed relevant literature and have evaluated the policies of belligerent parties in past and current conflicts. These increasingly appear to target civilian infrastructure including medical facilities and may increase the risk to hospital ships. This demonstrable current hybrid warfare appears to include purposeful attacks on health care facilities and as such hospital ships should have additional defensive measures.

RESULTS: Hybrid warfare and its focus on civilian infrastructure and health care targets are highly visible in the acts of both state and non-state actors and may encourage others to purposefully target health care facilities and personnel. Evidence of this is seen in the current Russian invasion of Ukraine, where since the invasion a year ago 1,218 Ukrainian health facilities have been damaged, including 540 damaged hospitals, 173 of which were totally destroyed and turned into "piles of stones."

CONCLUSIONS: In today's conflicted global environment, the clear identification of hospital ships leaving them relatively undefended and denying encrypted communication is the folly of a bygone era. Hospital ships may be targeted because they are brightly lit soft targets that can deliver a large payoff by their destruction. It is time to adapt to the global reality and move on from the tradition of painting hospital ships white, adorning them with red crosses, keeping them unarmed, maintaining open communications, and illuminating them at night. The increasing threats from hybrid warfare and unprincipled adversaries to medical platforms and providers of health care demonstrate that hospital ships must be capable of self-defense. The U.S. Navy is designing new platforms for medical missions and the debate, no matter how uncomfortable, must now occur among major decision-makers to make them more tactical and defensible.