In 2018, 165 ongoing conflicts were reported worldwide, including state-based, non state-based, and one-sided violence. Each conflict unarguably violates international humanitarian law by attacking healthcare provisions in its respective nation. 2020 alone has already witnessed 26 deaths of healthcare personnel and 45 injuries in 7 different countries. Recently, on 20 February 2020, two major hospitals in Yemen’s Marib Province were badly damaged by crossfire, limiting the access of 15,000 people to healthcare. In Benazir University, which sits in Somalia’s Mogadishu district, 34 medical students were attacked, of which only 18 survived.
Attacks on healthcare are carried out on medical personnel, facilities, and transport. Because these attacks prevent the wider population from accessing medical care, protection from them is crucial. More specifically, violence against medical personnel has a multifold effect, as it also constitutes a loss of medical knowledge. Often, such attacks on health personnel are triggered by displays of partiality in treatment, or even the order of treatment of victims, often resulting from immense pressure from opposing sides of the conflict to prioritise their patients over others.
Destruction of medical facilities also stems from a multitude of reasons. Perception of healthcare as a weapon, as is the case in Syria, where government forces deliberately target hospitals to gain military advantages by depriving anti-government forces of medical assistance, is a common ‘justification’. Armed rebel groups and national forces also use destruction of medical facilities as a display of power. Finally, attacks on facilities to gain access to drugs and other materials that can be traded for weaponry and even to use as a base for battle are not uncommon.
Ambulance targeting with attacks on drivers, who are made to navigate through landmines, is a frequent occurrence in conflict zones. Additionally, medical transport requires protection from obstacles that delay the delivery of medical services. Along the West Bank in the occupied Palestinian territories, ambulances are required to pass several checkpoints en route to the nearest hospital in East Jerusalem, despite their passengers’ rights as Palestinians to freely access the city; entry is also frequently denied to those who hold legitimate permits.
Protection from such violence proves to be challenging as patients and patient treatment facilities are increasingly integrated into conflicts. By adhering to the principles of medical neutrality, services are meted out to victims from both sides of the conflict and healthcare personnel endanger themselves by doing so. Armed groups settle scores in hospitals and disrupt ongoing medical treatment in the process, and the generally uncertain nature of contemporary war implies that those engaging in conflict are often unaware of the international conventions protecting the rights of civilians. Above and beyond these challenges, a shift in the media narrative portraying hospitals as conflict hotspots pressures medical staff to victimise certain groups over others, further exacerbating the issue.
At present, the International Committee of the Red Cross’ programme ‘HealthCare in Danger’ has made noteworthy progress in securing healthcare in conflict zones. This includes consolidating best individual field practices, such as covering windows with plastic adhesives to prevent glass shattering during explosions, no arms rules in all medical centres, and establishing makeshift underground surgical theatres to avoid accidental attacks on health personnel. The creation of a global database that records attacks on healthcare and the establishment of ‘parameters of intervention’ resulting from pre-negotiations before the conflict demarcating safe zones has also been undertaken.
However, considering the erratic and dynamic nature of the issue, such measures alone are insufficient. Dr. Sophie Roborgh of King’s College, University of Cambridge advocates the use of local knowledge to understand why and under what circumstances and timings healthcare is attacked. Her work illustrates the importance of acknowledging and acting on the link between the attacks on healthcare and the nature of the ongoing conflict. The success story of healthcare provision during the Hosni Mubarak protests in Egypt in 2011 illustrates this perfectly. During the uprising, government forces identified anti-Mubarak protesters by the nature of the injuries inflicted and immediately arrested them. As hospitals transformed into a place for persecution, medical personnel shifted efforts towards creating pop-up medical tents and makeshift field hospitals away from major hospitals to fairly treat protestors and return them to the frontline without government identification.
Unfortunately, protecting healthcare in the face of adversity is predicted to become progressively arduous as wars within nations outnumber wars between nations, and armed groups expand whilst being uninformed of the laws that determine acceptable action. Effective responses require a shift towards approaching each case within its context and relating it to the power-balance that was interrupted by the conflict. Considering the ever-changing nature of conflict worldwide, it is essential for healthcare and humanitarian responses to adapt in order to ensure and prioritise civilian relief.
Shivani Menon is a member of the Global Health policy centre’s working group.
The featured image (top) from 2016 in which ‘Luigi Pandolfi, a technical expert with EU Humanitarian Aid in Iraq’s Kurdistan region, discusses healthcare strategy with staff from ECHO’s partner International Medical Corps (IMC)’ in war-torn Mosul is by EU/ECHO/Peter Biro and is licensed under Attribution-NonCommercial-NoDerivs 2.0 Generic.
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