The International Health Protection Initiative (IHPI)
A resolution on the need to ensure the protection of healthcare during armed conflict
“We [the UN] have not been able to protect innocent people from violence” UN Secretary General, Ban Ki-moon concerning the war in the DRC (Democratic Republic of the Congo)
“The medical community has a responsibility to speak out collectively to protect health workers in fulfilment of their ethical duties to the people in their care, without risk of arrest or attack on themselves or medical facilities. Governments and non-state actors should be held accountable for abiding by obligations to respect medical functions in war.”
Current situation regarding healthcare and conflict
According to the Uppsala Conflict Data Program 25 countries in 2010 had active state based armed conflict within their territories. 8 countries had non-state conflicts and 13 one-sided armed violence against civilians.
Increasingly, warring factions are targeting vulnerable patients through attacks on healthcare professionals, health facilities, and medical transport vehicles, including ambulances and those supplying essential life-saving drugs and medical supplies. Such actions are “part of generalised violence directed towards civilians to achieve a political goal-e.g., ethnic cleansing, government destabilisation, control or forced movements of populations, or demoralisation of a population sympathetic to an enemy” In addition, some attacks on health facilities, health professionals or patients are designed for military advantage, such as preventing injured combatants from receiving healthcare.
In violation of humanitarian law, in particular the Geneva Conventions and their Additional Protocols, warring factions attack wounded or sick individuals, threaten, intimidate and attack nurses and doctors, attack health facilities, especially hospitals, attack ambulances transporting sick or injured patients and illegally use health facilities for exacerbating conflict. In effect, this targeting of health facilities and patients results in the use of patients as human shields.
Furthermore, there is the influx of weapons that are used to terrorise, injure and kill civilians creating even more danger for people who cannot protect themselves.
In some conflict zones, it is impossible for local staff or incoming international organisations to provide healthcare because healthcare is not only unprotected from conflict, but is also specifically and explicitly targeted. An example of this illegal situation is the “corridor” outside Mogadishu in Somalia, where approximately 150,000 civilians are unable to access any healthcare.
Under the auspices of anti-terrorism, in conflict zones and in countries at peace, health care workers have been subjected to harassment, arrest imprisonment and even death for complying with their ethical duty to provide healthcare, irrespective of the political, religious or other affiliation or allegiance of their patients.
Effects of armed conflict on maternal and child healthcare
Maternal and child mortality is higher in conflict and post-conflict countries than in poorly resourced countries which are not directly affected by conflict.
Girls and women are particularly at risk as they are less likely to be able to protect themselves from violence. Rape is used as a weapon of war. In addition to the psychological effects in women who have been sexually assaulted, they are at risk of serious infection, such as HIV and hepatitis, the possibility of pregnancy that may result in miscarriage and heavy blood loss which, in the absence of blood transfusion or basic surgery, can be life threatening. There is also a high prevalence of septic abortion following self or non-professional attempts to end the pregnancy.
Conceptions continue during conflict and, with the absence of contraception and the pressures on women to support often highly disturbed young men, the rate of pregnancy often rises. Women who are pregnant are subject to potentially life-threatening complications which cannot be placed on hold until the conflict has finished. Most pregnancy-related emergencies can only be treated within hospitals and, apart from the fact that hospitals may have been incapacitated; there is also the great risk of travelling to hospital for treatment. The absence of functioning hospitals leads to many maternal deaths and results in permanent disabilities from untreated complications of pregnancy such as vesico-vaginal fistulae.
Infants and young children, because of their immaturity and dependency on mothers, are most vulnerable to malnutrition and infections such as gastroenteritis, pneumonia, malaria, tetanus, pertussis and meningitis. When food is scarce because of conflict, it is usually women and children who are least able to access adequate or appropriate nutrition. Whilst primary healthcare can do much to prevent these infections through immunisation and early recognition and treatment, inevitably there will be around 20% of children who, when ill, will require hospital/health facility levels of care.
Emergency care and surgical services to manage obstetric complications, major trauma from violence and from accidents, and other surgical emergencies are essential requirements for conflict-affected populations. This is particularly the case for conflicts in Africa, where essential surgical services are usually poor or absent before the conflict. In one report, there were no operating theatres in 7 post-conflict camps for displaced populations.
What can be done to minimise the effects of armed conflict on healthcare?
Existing attempts at protection
The expectation that countries or non-state factions involved in conflict will adhere to existing humanitarian laws, human rights law and medical ethics has proved to be invalid. The Geneva Conventions of 1949 and their additional protocols 1977 contain statements designed to protect healthcare. However, as documented by Rubenstein and Bittle these conventions were violated with impunity in most of the armed conflicts between 2003 and 2008. Recognising the challenges involved in providing robust information, regular and systematic documentation of attacks on health workers, facilities, transport and patients is lacking. International criminal justice institutions have potential power, but do not operate in the time frame necessary to protect healthcare during conflict.
UN or other peace-keeping forces are difficult to fund, have been themselves involved in abuses of women and children, and have been inadequately mandated with regard to how far they can act in protecting civilian healthcare.
The International Red Cross and Red Crescent Movement, has been the most powerful global organisation “to protect life and health and prevent and alleviate human suffering wherever it is found in the world”, particularly in situations of armed conflict.
Recently, Merlin, a UK based international medical charity, has produced a campaigning paper exploring the impact of conflict on health workers and the damage this has had on achieving the Millennium Development Goals. Their campaign, “Hands Up For Health Workers” “calls for national governments and international donors to fund and implement comprehensive national health workforce plans , to ensure health workers in crisis countries are trained, paid, supported, equipped and protected”.
A NATO led peace-keeping force (KFOR) under UN Security Council Resolution 1244 in Kosovo in June 1999
In conclusion, conference delegates agreed that a resolution is now necessary to address health protection during armed conflict and that attempts should be made to obtain as many signatories of international healthcare organisations as possible to support this.
In response to escalating abuses of the rights to the provision of healthcare for all injured or ill persons affected by armed conflict, this resolution reinforces current international conventions. It aims to ensure the security of all health workers and healthcare facilities in situations of armed conflict by enforcing all appropriate measures as follows:
1. We call for international health organisations and their individual members, with the assistance of governments and the United Nations, to advocate urgently for the protection of the following basic rights for all people, particularly women and children, in areas of conflict:
a. freedom of all health care workers, patients and facilities from attack or interference, including the freedom of health personnel to provide care consistent with their professional duties.
b. freedom from interference with humanitarian initiatives to provide essential drugs and medical supplies
c. freedom from interference with safe transport of sick or injured people to and from health facilities
2. We call for support to improve the effectiveness and integrity of healthcare during armed conflict and to ensure that humanitarian health activity is more robust, predictable and accountable.
3. We call for States and non-State actors to fulfil their legal obligations to comply with international humanitarian law, including the Geneva Conventions and their Additional Protocols and customary international humanitarian law.
4. We call for leadership by the World Health Organization to develop methods and mechanisms for the documentation of all violations of international humanitarian law against patients, health workers, facilities, and transports and to provide guidance to member States in how to increase protection of health functions in zones of armed conflict.
5. We call for domestic and international prosecution of those responsible for intentional attacks on healthcare facilities, health workers, patients and the transport systems for providing drugs and medical supplies, which constitute war crimes under the laws of war.
6. We advocate for further support to be given to the efforts of the International Committee of the Red Cross in its ongoing and innovative attempts to protect healthcare in conflict.
As indicated in a recent editorial in The Lancet: “ it is time for a different group to step in and sign up to be the guardians of, and advocates for, the humanitarian health needs of civilians caught up in conflict. Who better to take up this role than the medical profession?”
Sign up to the resolution now