Violence against health-care must end: it’s a matter of life and death

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“One of the first victims of war is the health-care system itself,” according to Marco Baldan, the chief war surgeon of the International Committee of the Red Cross (ICRC) And sadly, he is absolutely right.

In 2008, the ICRC launched a study to examine how violence and armed conflict affects health care in 16 countries where it works.  The resulting report, health care in danger: making the case, was launched in Geneva on the 10th August (last Wednesday) and gives a shocking factual narrative of the widespread nature of the attacks on patients, health-care workers and facilities, and on medical vehicles: For example, the Iraqi health ministry estimates that over 625 medical personnel were killed between 2003-2008. And in 2007, many doctors in Iraq were deliberately targeted in a spate of killings. Hundreds more doctors have received death threats or been kidnapped and over half the country’s doctors have fled abroad. Many of those who stay are forced to live in the hospitals where they work, to avoid the dangerous journey home.

Although appalling, the factual information and statistics do not do justice to the scale, scope and widespread consequences of attacks on healthcare the problem, particularly in areas that are inaccessible to humanitarian and human rights organizations because of the level of danger, such as many regions of Pakistan, Afghanistan, and Somalia. Such information also doesn’t capture the individual human tragedies of every single act that violates the Geneva Conventions or the cataclysmic impact that these violations have on health and health care. Thus the need for the following stories, also included in the report:

In a house in the Zaytun neighbourhood  of Gaza City where ICRC staff found  four young children crouched beside the lifeless bodies of their mothers after the house had been shelled  but the ambulance teams had not been permitted to reach the victims. By the time they arrived, four days later, twelve corpses lay on the floor and the children were too weak to stand. Soldiers at a nearby checkpoint had offered no assistance to the injured and ordered the ambulances to turn back but the brave crews disobeyed and rescued the survivors.

Soldiers entered the Ghazi Mohammed Khan Hospital in the Wardak province of Afghanistan late one night, searching for a wounded enemy combatant. Unsuccessful in their search, they rounded up the staff and ordered them to report the presence of “enemy fighters” seeking treatment. When the staff refused, citing medical ethics, the soldiers threatened them at gunpoint, saying they would be killed if they did not comply. Several members of the staff quit their jobs after this incident, too afraid to return to work.

So what can be done? Much more, obviously, but the report makes the point that safeguarding health care cannot be addressed by the health-care community alone. Rather, the primary responsibility lies with politicians and combatants. To increase awareness of violations of the Geneva Conventions and to generate action, the ICRC is seeking support for the following ten initiatives:

1. Building a community of concern

2. Regular and methodical information gathering

3. Consolidating and improving field practices

4. Ensuring physical protection of health care facilities–specifically, hospitals and other health-care facilities in countries affected by armed conflict or other violence will be assisted in organizing the physical protection of the premises and in developing procedures for notifying others of their location and of the movements of their vehicles.

5. Facilitating safer access for Red Cross and Red Crescent staff and volunteers

6.  Engaging with States

7. Engaging with national armed forces

8. Engaging with non-State armed groups

9. Engaging with professional health-care institutions and health ministries

10. Encouraging interest in academic circles

All valid and rational points but do they go far enough? Although point four mentions protection will it be enforceable? As shown recently in Sri-Lanka, ICRC coordinates given to government troops to protect a field hospital were used to deliberately target the hospital. International codes and best practices are no guarantee of protection of health care in the face of unshakable determination to destroy. Enforcement of health care protection, a controversial but necessary action, has been proposed by the International Health Protection Initiative. Please show your support for the protection of health care during armed conflict by signing up to the resolution now. Thank you

Rhona MacDonald is a freelance editor for PLoS Medicine. Competing interest:  RM is the co founder of the International Health Protection Initiative

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