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
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
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
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
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
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 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
An Afghan man carries his wounded daughter to a hospital
in Herat, Afghanistan.
Photo: ©AFP PHOTO/Arif Karimi
Findings of ICRC
A new ICRC report,
shows that during a two-and-a-half-year research
• 1834 people were killed or injured
in health care facilities of which 368 were patients
and 159 were health care personnel.
facilities were damaged by explosion in 116 incidents.
were damaged in 32 attacks.
• States’ armed forces
and other armed groups are equally responsible for
• All events have serious ‘knock-on’ eff
ects that diminished health care for people in need.
For a link to the report, see: www.icrc.org
Doctors receiving a patient, a civilian wounded in the leg
by a bullet, at the ICRC-supported Medina hospital in Mogadishu,
Photo: ©André Liohn/ICRC
An ambulance near the front line in Misrata, Libya.
Photo: ©Reuters/Zohra Bensemra,
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
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
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
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.”
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
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
region is full of home-made mines. We who have sheep
and work in the pastures are constantly fearful of
them. I pray to God to bring us peace and security.”
a nomadic shepherd who lives near Qalat, Zabul province
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
“We do our best to treat the children but
sadly some die. What’s hardest is that sometimes
these children are dying of illnesses that are very
easy to treat in developing countries.”
ICRC paediatric nurse