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
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.