Health care in danger

Around the world, people who risk their lives to provide health care in conflict areas are under increasing threat. For those trying to get to care, it’s even worse.

In the sprawling farming district of Nad Ali in Afghanistan’s southern Helmand province, a man with a gunshot wound is brought to the ICRC first-aid post at Marjah. Health staff quickly stabilize him and send him by local taxi to Mirwais Hospital in Kandahar, several hours away. Driving on roads riddled with improvised explosive devices (IEDs), the taxi is stopped at a police checkpoint at the entrance to the town. 

Time is lost as the taxi driver and security forces argue over sending the patient for interrogation or to the hospital. An ICRC delegate calls the checkpoint by mobile phone: “We understand your security concerns but please let the patient get medical care. You can question him later.”

The taxi is allowed to pass and the patient reaches the hospital.

Not all the wounded and sick are as fortunate. Some languish in pain for hours in the back of a vehicle blocked at a checkpoint before their vehicle is even inspected. Others have to get out and walk or be carried when the road is completely closed for security reasons. In one case, a young girl died soon after arriving at the Kunduz regional hospital in northern Afghanistan after being injured in an explosion in her village. Her father had carried her on foot for an hour because the road was cordoned off by military forces.

Health care under threat

These impediments to the wounded and sick reaching health facilities are one aspect of a much larger problem seen in conflicts and upheavals all around the world today: the insecurity of health care. Assaults on health structures, personnel and ambulances, and obstacles to the injured receiving help are common in conflicts everywhere.

Hospitals in Somalia and Sri Lanka are shelled; ambulances in Libya and Lebanon are shot at; medical personnel in Bahrain face trial for treating protestors; and health staff in Afghanistan receive threats from both sides to stop working with or treating ‘the enemy’. From Colombia to Gaza, the Democratic Republic of the Congo to Nepal, there is a lack of respect for the neutral status of health-care personnel, facilities and transport, by both those attacking them and those who misuse them for military gain.

It is often Red Cross Red Crescent and other medical personnel who bear the brunt of this disrespect for the sanctity of health care. First-aiders, medics and ambulance drivers are particularly exposed to violence as they rush to the front line to provide life-saving assistance to the injured and evacuate them to safety.

Between 2004 and 2009, 57 volunteers from the Movement were killed or wounded in the line of duty. Most were caught in the crossfire but some were deliberately targeted. An ambulance driver from a National Society in the Middle East remembers a harrowing moment in 2009 when his ambulance came under direct threat. “I have no doubt that one missile was aimed at us,” he says. “I do not know for certain whether it was meant to kill us or warn us to keep away, but it was definitely aimed in our direction.”

Such incidents are frequent but no one knows how frequent. A study by the medical journal The Lancet in January 2010 showed there is little systematic reporting on violations of the protected status of health workers and facilities during conflict by any international or national organization, and hence scant understanding of the scope and extent of the problem.

The ICRC had realized a similar gap in its knowledge in 2008 and began a study in 16 countries where it is working to document assaults on health workers, patients and facilities. The numbers are striking. But even more so is the realization that statistics only represent the tip of the iceberg: they do not capture all the compounded costs of insecurity as health staff leave their posts, hospitals run out of supplies and vaccination campaigns come to a halt. The problem is much larger than first imagined.

Respecting health-care workers

In August, the ICRC launched a global campaign on ‘Health care in danger’ to raise awareness of this issue and encourage action by Red Cross Red Crescent staff, other medical professionals, military forces, governments and non-state actors to improve the security of health care. This issue will also be a central part of diplomatic efforts at the 31st International Conference to ensure compliance with the Geneva Conventions, which provide for the protection of the wounded and sick during armed conflict and the personnel and structures necessary to ensure it.

The ICRC and National Societies of many countries around the world are doing a great deal to find ways of reaching and assisting people injured during armed conflict and internal strife, and of protecting health facilities. Some approaches take place on the legal front: disseminating international humanitarian law to state and non-state actors and raising violations with them when these occur. Some are physical, such as protecting hospitals with sandbags and bomb-blast film for the windows, marking them with a red cross or red crescent on the roof and sides, and teaching safer access techniques to ambulance crews. And some are innovative ways to throw a lifeline to those cut off from health care. The taxi referral service in southern Afghanistan is one good example (see next page).

As successful as these measures might be, it is important to remember that many of them would not be necessary were the laws governing armed conflict better respected by combatants on all sides. The onus must be on state and non-state actors to comply with the laws rather than on health professionals to try to deal with the life-or-death consequences of violations on the ground.

Lebanese soldiers and a Red Cross ambulance near the Lebanese–Syrian border.
Photo: ©Reuters/Omar Ibrahim, courtesy www.alertnet.org

An Afghan man carries his wounded daughter to a hospital in Herat, Afghanistan.
Photo: ©AFP PHOTO/Arif Karimi

Doctors receiving a patient, a civilian wounded in the leg by a bullet, at the ICRC-supported Medina hospital in Mogadishu, Somalia.
Photo: ©André Liohn/ICRC

An ambulance near the front line in Misrata, Libya.
Photo: ©Reuters/Zohra Bensemra, courtesy www.alertnet.org

Health care in danger

Care amid the chaos

As the task of providing medical care in southern Afghanistan becomes more perilous, Mirwais Hospital in Kandahar stands as an oasis in the midst of a danger zone.

With an ear-splitting roar, two fighter planes take off from Kandahar airport. Meanwhile, in the town’s suburbs, the steady whomp-whomp-whomp of military helicopters can be heard flying overhead. In the distance, an airship is suspended over the arid mountains, keeping a permanent watch. Kandahar province, like most areas in southern Afghanistan, is a war zone.

Since last winter, coalition forces have stepped up their offensive in the districts and provinces surrounding Kandahar. Amid the political rifts that have been engendered by the violence and chaos, there remains one place where everyone can receive care. The ICRC-supported government hospital in Kandahar takes in all the wounded and sick free of charge.

An unassuming, olive-green building erected in 1975 in downtown Kandahar, Mirwais Hospital serves those suffering from wounds caused by conflict. But, like any hospital serving a severely impoverished population, Mirwais also strives to offer a holistic range of services, from maternity care to treatment for infectious disease and emergency surgery for road-crash victims.

It’s a daunting task. Serving a population of roughly 4 million people over four, vast southern provinces, Mirwais is surrounded by fighting that both exacerbates chronic health emergencies and drastically limits people’s access to care.

People often walk for days or hours carrying sick children in order to avoid fighting or checkpoints — or because they simply can’t afford transportation. Those with severe injuries, including the war-wounded, often lose valuable time at the numerous roadblocks set up by warring parties. And because fighting renders normal ambulance services extremely perilous, local taxi drivers who know the roadways well are employed as an unofficial ambulance corps to bring the war-wounded to the hospital.

“The taxi drivers have the advantage of knowing the region better than anyone,” says ICRC health delegate Alexis Kabanga. “They know what roads are accessible. The drivers have also been picked for this role by their communities and we give them an ICRC identity card which enables them to pass through army or Taliban checkpoints.”

Children in the crossfire

But combatants are not the only patients directly affected by the conflict. Three children being treated in the intensive care unit were recently injured during aerial bombardments. Their faces and limbs are covered in a white cream to soothe what are evidently extensive burns. 

In the same room, a 5-year-old girl struggles to breathe after being hit in the chest by mine shrapnel. Her father, a nomad, does not conceal his anger: “Our region is full of home-made mines,” he says. “We who have sheep and work in the pastures are constantly fearful of them. I pray to God to bring us peace and security.” Ahmad Zai lives near Qalat, the capital of Zabul province, a very unstable region. As for the fate of his daughter, he prefers to rely on his faith: “We are very happy that our daughter is being cared for here, but life and death are in God’s hands.”

The insecurity has contributed to a general worsening of health conditions in the region. Many patients come to Mirwais suffering from the side effects of conflict: malnutrition, dehydration and disease caused by poor hygiene. Abdel Wasi comes from Penjwai, a district of Kandahar province where the fighting remains particularly fierce. He went to great risk to bring his child to the hospital in Kandahar. His son is suffering from acute diarrhoea and without treatment would have died of dehydration. Braving the fighting, the mines and the possibility of being kidnapped, he reached Kandahar just in time.

But many do not survive, or cannot attempt, the arduous journey to Kandahar. “Several children have died because we couldn’t get them to hospital. The fighting is going on every day,” Wasi complains. In the paediatric unit, many dehydrated children, prey to sometimes harmless viruses, were brought in at the last moment because their parents could not reach the hospital.

“We do our best to treat the children but sadly some die,” says Rachelle Cordes, an ICRC paediatric nurse. “What’s hardest is that sometimes these children are dying of illnesses that are very easy to treat in developing countries.”

Many times, the parents cannot travel for fear of being caught up in the violence. But there is also a complex range of factors that contributes to people’s access to health care here. Some parents are too poor to afford transportation to health services, while others may not have been taught how to recognize the early symptoms of disease. Others may not know what health services are available or about other important health issues such as how best to wean children during breastfeeding.

One of the world’s poorest countries, Afghanistan also has one of the highest illiteracy rates. Dr Sadiq, head of paediatrics, sees a link between the insecurity, illiteracy and the spread of disease and malnutrition in the region. “Women sometimes don’t know that after six months of age a child needs to be fed solids,” Sadiq says. “Often they wait a year, which is much too late. Most of the time, parents bring their child in for some other reason and we tell them their child is also malnourished.”

Deadly heat

The climate also degrades already poor hygiene conditions. Since extreme temperatures arrived in early summer, the number of admissions to the paediatric unit has been growing steadily. Some 120 children are already registered and, in one morning, Sadiq has admitted another 31 new patients. Some 75 per cent of these children are suffering from acute diarrhoea.

The heat — which tops 40 degrees Celcius during the daytime — coupled with poor hygiene creates ideal breeding conditions for bacteria in water and food, according to Benjamin Nyakira. The ICRC pharmacist has recorded a sharp rise in the number of bacterial infections since the beginning of spring.

Fortunately, Mirwais Hospital has been steadily improving its range of diagnostic equipment and services, enabling a far wider range of conditions to be treated.

The laboratory, which the ICRC has helped to upgrade, is a case in point. “Before we could detect only 10 per cent of diseases,” says Mohamed Nasser, a lab assistant. “Now, thanks to computers and the aid of the ICRC, we can identify at least 85 per cent of them, which we have also learnt to treat better. It is really rewarding to work in these conditions. Today, we feel genuinely useful.”

Despite all the challenges brought on by an ever more precarious security situation in the region, Mirwais Hospital remains for much of the population an island of hope in a country devastated by three decades of conflict. Working in this environment can be mentally exhausting, but ICRC paediatric nurse Barbara Turnbull has no regrets: “We come here of our own free will and I love my work. I have wanted to be a nurse — and a Red Cross one at that — since I was very small.

A man sits by his child, burned and wounded during an aerial bombardment.
Photo: ©Vincent Pulin

A taxi arriving with war-wounded patients at Mirwais Hospital in October, 2010. The patients were injured by bombings in their village of Zhari.
Photo: ©Kate Holt/ICRC