GENEVA -- A month after a U.S. AC130 aircraft raked a Doctors Without Borders trauma hospital in Afghanistan with canon fire, killing 30 including a dozen staff members, there is still no official U.S. report on what the United States believed led to the assault.
But in the time since the attack, other medical facilities have been targeted in a range of conflicts around the world, heightening growing concerns among humanitarian workers that the long tradition of sanctity for hospitals, clinics and medical workers in combat zones has vanished in an era of scorched-earth combat.
Last week, Doctors Without Borders denounced what it said was an airstrike by a Saudi-led coalition on a hospital in northern Yemen, where Saudi Arabia, with American logistical support, has been waging war against rebels backed by Iran.
And on Saturday, U.N. Secretary-General Ban Ki-moon, after meeting with the head of the International Committee of the Red Cross, Peter Maurer, issued a denunciation of what he called "the brazen and brutal erosion of respect for international humanitarian law."
"These violations have become so routine there is a risk people will think that the deliberate bombing of civilians, the targeting of humanitarian and health care workers, and attacks on schools, hospitals and places of worship are an inevitable result of conflict," he said.
He called for action to be taken against those responsible, providing a lengthy list of countries where such violations, citing a laundry list of troubled nations "Afghanistan, Iraq, Nigeria, South Sudan, Syria, Yemen, and elsewhere."
"International humanitarian law is being flouted on a global scale," Ban said. "The international community is failing to hold perpetrators to account."
Mauer, too, was grim: "Attacks on health facilities, health workers, ambulances is now a reality that we observe on the ground not on a monthly, but on a daily or weekly scale in most of the conflicts in which we are engaged," he said.
According to Doctors Without Borders, no one was killed in the strike last week, which occurred over a two-hour period starting at about 10:30 p.m. Oct. 27 in the Haydan district of Saada province, the home of the Houthi rebellion that last year swept across Yemen and captured the capital, Saana.
The hospital, which Doctors Without Borders said served a local population of 200,000, was destroyed, however.
Just as with the Oct. 3 American strike on the Doctors Without Borders hospital in Kunduz, Afghanistan, the international aid group said that it had shared the Yemen hospital's GPS coordinates with the Saudi-led coalition and that the group's logo was clearly displayed on the hospital's roof.
"Even 12 hours after the airstrike, I could see the smoke coming out of the facility," said Miriam Czech, Doctors Without Borders project coordinator in Saada, said in a statement. "The in-patient department, the out-patient department, the maternity ward, the lab and the emergency room are all destroyed."
"It was the only hospital still functional in Haydan area," the statement said.
Ban said the Oct. 27 attack was the 39th health center attacked in Yemen since Saudi Arabia began its campaign there in March.
The U.N.'s Office for the Coordination of Humanitarian Affairs last week said that Russian or Syrian government aircraft had attacked at least five hospitals in Syria's Aleppo, Hama and Idlib provinces in recent days, and that attacks on health facilities and health workers "remain relentless."
At least 603 health care workers were killed and 958 injured in 32 countries in 2014, according to Bruce Aylward, the WHO's top official for emergency risk management and humanitarian response.
Doctors Without Borders continues to demand an independent investigation of the attack on the Afghanistan hospital, calling the assault a "war crime."
A Pentagon spokesman told reporters last week that there is now no date certain for completion of its investigation into the Kunduz attack.
On Saturday, Ban urged an independent probe. "I have been urging them to have a thorough, independent, credible investigation," he said.
The lack of ramifications in such a wide range of attacks concerns international aid officials, who say that failure to punish those who attack protected medical facilities simply encourages more attacks.
"There has to be a credible, independent and rapid accountability system in place if there's going to be a deterrent against such attacks," said Dennis McNamara, humanitarian adviser at the Geneva-based Centre for Humanitarian Dialogue, and a former senior U.N. humanitarian official and special envoy to Kosovo, East Timor and Cambodia.
"There is a huge problem of impunity and it affects ordinary civilians, hospitals and clinics. Impunity feeds more abuses," said Donatella Rovera, the senior crisis response adviser at Amnesty International, the human rights advocacy organization.
The sanctity of health facilities dates back to the founding of the International Committee of the Red Cross in 1863 and the first Geneva Convention in 1864 on the amelioration of the conditions of the wounded in armies in the field.
The main principles, maintained by the later Geneva conventions, included treatment for wounded without regard to what side they were on, the neutrality of medical personnel and medical establishments and units, and the recognition of a red cross on a white background as a sign of a neutral location or vehicle.
The Geneva Conventions agreed in August 1949 also stipulated that "civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack."
That prohibition was reiterated in 1977.
Ban on Saturday blamed the use of high-explosive weapons in populated areas for much of the destruction of medical facilities. Maurer said the nature of protracted conflicts that last for years makes attacks on medical facilities a long term problem.
"We have entered a new era, and it is not a peaceful one," he said. "It is an era of protracted armed conflicts, which add up to a world at war."
A spate of reports by human rights and health advocacy groups document an alarming trend of attacks by warring sides ranging from government forces to armed rebel groups.
Physicians for Human Rights (PHR), an advocacy group, reported in early October that they had confirmed that Russian air strikes damaged three medical facilities in Syria. They included an Oct. 2 airstrike on a field hospital in Latamneh in northern Hama province, an airstrike the same day on an ambulance depot in Benin in rural Idlib, and an airstrike Oct. 3 that damaged al Burnas Hospital in northern Latakia province, near the Turkish Border.
PHR also reported that in May alone, it had documented 15 attacks on 14 medical facilities in Syria, and noted that seven of those had been attacked previously. Eight of the attacks "were with barrel bombs," improvised bombs that are a favored tactic of the Syrian government.
Medical facilities in neighboring Iraq have also been targets of violent attacks, according to the advocacy group Human Rights Watch.
In a report, Human Rights Watch accused Iraqi government forces of repeatedly targeting the general hospital in Fallujah with mortar shells and other munitions while battling armed groups in Anbar province in the first half of 2014. It accused the Iraqi Air Force last year of striking an ISIS-controlled hospital near Kirkuk, killing seven patients and wounding 22. And it blamed British aircraft for an Oct. 1, 2014, attack on a hospital controlled by the Islamic State in the Iraqi town of Rabia.
Advocacy groups also have documented attacks against health facilities and personnel in Gaza during last year's hostilities between Israel and Hamas, and in Somalia and Nigeria by the militant groups al-Shabab and Boko Haram, respectively.