Back to Magazine



Health care: most difficult when it is most needed

When I started working as an ICRC field surgeon, I found treating people wounded in conflict both challenging and rewarding. One day, when fighting erupted in suburbs near our hospital, the security environment became severely degraded and I was unable to do what I thought best for the many wounded.

Our staff could not cross town to get to work. The lights went out when the generator was hit by a stray bullet. Armed men entered the hospital and threatened some of the nurses.

Later, I was struck by a simple fact: just as the need for health care peaks, conflict and insecurity make the delivery of and access to health care most difficult. This is not only because wounded people require emergency surgical care but also because conflict makes whole populations vulnerable to disease. Cholera epidemics are frequently associated with conflict because thousands of people’s access to clean drinking water may be impossible especially if whole populations are displaced. Even during times of peace, many communities have only basic health care; this may simply evaporate when conflict erupts.

Insecurity of health care takes many forms. Hospitals are hit by shells and mortars. health-care workers are threatened and, in the worst cases, killed or kidnapped. Ambulances are ambushed. These incidents are the most obvious and are most likely to be reported on by the media.

However, for each event that gets media attention, there are thousands of others. Ambulances are often held for hours at checkpoints. Soldiers enter hospitals looking for wounded enemies and disrupting health care at the same time. Authorities may deny a particular ethnic group access to a hospital. Armed groups may steal hospital supplies. All of these are obstacles which impinge on the right of wounded and sick people to health care.

It is becoming clear that the insecurity of health care is a major — but largely unrecognized — humanitarian issue. For each violent event bringing insecurity to health-care facilities or workers, there is a ‘knock-on’ effect through which the wounded and sick suffer even more because health care is rendered impossible or, at best, difficult to provide or access.

Yet outside the humanitarian sector, this problem is barely acknowledged, understood or addressed — either by the public at large or by those obliged to protect the wounded and sick, hospitals, ambulances and health-care workers under international humanitarian law.

This is why the health unit of ICRC’s assistance division began in July 2008 to collect reports of violent events, including events involving threats of violence, from 16 countries where conflict had an impact on health care delivery. The data were drawn both from the media reports (news wires, newspapers and major TV or radio news outlets) and from the internal and public reports of humanitarian agencies.

The resultant ICRC report, health care in Danger: a sixteen-country study, released in August 2011, collected, processed and analysed a total of 1,342 reports detailing 655 separate events of violence or threats of violence affecting health care over a 30-month period. In that time, the study revealed that 733 people were killed and 1,101 injured directly as a result of an incident or attack related to armed violence. Aside from such statistics, the study revealed real threats to health care, as well as serious vulnerabilities, in countries where the ICRC is operational. (See also pages 4 and 5.)

How should the Red Cross Red Crescent Movement respond? First, it is critical that field activities increase in scope to tackle real, everyday issues about the safety of health-care facilities and personnel. This involves closer cooperation with National Societies. Second, the Movement must intensify its diplomatic efforts to secure a powerful resolution at the 31st International Conference with buy-in from major stakeholders. Third, we must use public communication to build a community of concern about insecurity of health care and a culture of responsibility among those who can make a real difference.

Those who take up arms for whatever reason must understand and fulfil their obligation to respect international humanitarian law and protect both those who need health care as well as those who risk their lives to deliver care when and where it’s needed most.

By Robin M. Coupland
Robin M. Coupland is a former ICRC field surgeon and now works as a medical adviser for the ICRC in Geneva.

Insecurity of health
care is a major
— but largely
— humanitarian
















Your turn

If you would like to submit an opinion article for consideration, please contact the magazine at
All views expressed in guest editorials are those of the author and not necessarily those of the Red Cross Red Crescent Movement or this magazine.



Contact Us