Violent Attacks on Healthcare Workers a Growing Problem
By Matt Watson, September 13, 2013
The Geneva Convention of 1864 declared for the first time that hospitals, ambulances, and medical staffs of opposing militaries are neutral and protected from direct aggression during armed conflict.1 The Geneva Conventions currently in force were negotiated in 1949 and have since been updated with Additional Protocols to account for the emergence of new types of conflict. In particular, Articles 7, 9, and 11 of the 1977 Additional Protocols address protection of the sick and wounded, medical personnel, and medical facilities and vehicles, respectively.2 It has thus long been held that medical care providers and their patients and places of practice should be held safe, and that norm is a core tenet of international humanitarian law, which seeks to protect civilians and other noncombatants from the harms of violent conflict. However, recent reports of violence targeting healthcare workers provide evidence that the prohibition of violence against healthcare workers has degraded and requires strengthening and enforcement.
Documenting the Problem
In 2008, the International Committee of the Red Cross (ICRC) began to document incidents of violence against healthcare workers and patients in the 16 nations where it was conducting operations. In July 2011, ICRC released Health Care in Danger: A Sixteen-Country Study, which aimed to catalogue discrete incidents and better describe the scope of the problem.3 Before the ICRC began this project, characterizing the magnitude of the threat was difficult because of a paucity of data and the lack of a central reporting agency or data repository. The ICRC’s first report documented 655 violent incidents between July 1, 2008, and December 2010, 33% of which were perpetrated by state security forces and 36.9% by violent nonstate actors. In concluding the report, the authors asserted that “the right of the wounded and the sick to health care is not respected in the contexts studied,” and that this problem cannot be solved by medical and humanitarian advocacy alone. Engaging a broader coalition, including practitioners in the legal, political, and national security realms, is necessary to make meaningful progress.
On May 15, 2013, the ICRC released Violent Incidents Affecting Health Care, which documented “921 violent incidents affecting health-care during armed conflict and other emergencies in 22 countries” that occurred in 2012. Their research indicates that local healthcare providers are most often the victims and state security forces are the most frequent perpetrators (38%). The report describes the following types and instances of violence against healthcare workers: killing (150), wounding (114), beating (92), kidnapping (73), threatening (266), arresting (92), denying passage (160), and robbing (85). The 2013 report also documented the rise of 2 dangerous trends: follow-up attacks directed against first responders and the violent disruption of vaccination campaigns.4
Recent Events Illustrate the Threat
Pakistan: Between December 2012 and February 2013, 16 members of polio vaccination teams operating in Pakistan and 1 law enforcement officer were killed by militants linked to the Taliban. To some degree, these attacks were motivated by the Taliban’s mistrust of medical personnel, which has been linked to the alleged involvement of a Pakistani physician in the lead-up to the raid that killed Osama bin Laden. The Taliban also attempted to leverage their assent to polio vaccination to bring about a cessation of US drone strikes.5,6
On June 15, 2013, violent extremists in Pakistan’s Balochistan province detonated an improvised explosive device on a university bus, killing 14 female students. Injured patients were transported to Bolan Medical Complex for further care. That facility was subsequently targeted by militants, who killed 4 nurses and a deputy commissioner and held 35 people hostage—including healthcare workers and patients—until security forces regained control of the facility.7 In Pakistan’s Federally Administered Tribal Areas, which are adjacent to the Pakistan-Afghan border, the Taliban has reportedly damaged or destroyed 128 health facilities since 2008, forcing the population of 6 million to seek medical care in the relative safety of nearby Peshawer.8
Syria and surroundings: Healthcare workers were the targets of violence, repression, and intimidation during the multiple uprisings now collectively referred to as the Arab Spring, as documented by Amnesty International in its 2011 report, Health Crisis: Syrian Government Targets the Wounded and Health Workers.9 On 4 occasions, physicians and nurses were arrested, interrogated, and detained by Syrian security forces for suspicion of providing support to the opposition. More recently, Al Jazeera reported the death of Dr. Muhammad Abyad, a Syrian surgeon who was working with Médecins sans Frontières (MSF, aka Doctors Without Borders) in Aleppo. Dr. Abyad had reportedly been kidnapped from his home by Islamic extremists on September 2.10
More broadly, the ongoing conflict has had a significant impact on Syria’s healthcare infrastructure. The WHO regional office recently reported that 20% of the nation’s public hospitals have been damaged and 37% rendered out of service. Emergency response capacity has been degraded, with 78% of ambulances damaged and 52% completely out of service.11
Elsewhere in the region, Turkey,12 Bahrain,13 and Egypt14 have all reported instances of violence, intimidation, detention, and persecution of medical providers.
Somalia: On August 14, 2013, Médecins sans Frontières announced that, after 22 years of service in Somalia, it was suspending operations as “a direct result of extreme attacks on our staff.” The effects are expected to be devastating: As reported by the New York Times in 2012, MSF provided outpatient care to more than 600,000 Somalis, admitted an additional 41,100 people for inpatient care, and performed 2,750 surgeries.15 Long regarded for bravery, dedication, and an exceptionally high tolerance for risk, MSF’s healthcare workers provide medical care in the most dangerous locations. The organization’s withdrawal from Somalia demands the attention of the international humanitarian and security communities.
Effects of Violence Against Healthcare Workers
The consequences of the growing violence against healthcare workers include not just the harm to the workers and their families, but also what the ICRC refers to as “knock-on effects.” When healthcare workers and healthcare facilities cannot be kept safe, health care cannot be delivered, and people suffer.3
Another direct consequence of violence against the health sector is the interruption of national and international infectious disease control. Most notably, the ongoing effort to eradicate polio is predicated on broad vaccine coverage in nations where polio remains endemic, including Pakistan, Afghanistan, and Nigeria. By limiting vaccinator access to a large, vulnerable population, ongoing violence contributes to the persistence of disease transmission.
Action Is Needed
As healthcare delivery in conflict zones grows more dangerous, decisive action is needed to protect healthcare workers and facilities. National and international governments should secure facilities and workers and provide emergency response when necessary. At the national level, enacting and enforcing laws that safeguard the rights of the sick and injured to access health care and that prohibit violence against or intimidation of healthcare workers is needed to advance the principles articulated in the Geneva Conventions and elsewhere.
ICRC’s Health Care in Danger initiative is an important first step in generating the data needed to describe the scale and complexity of the problem and to raise global awareness. The 2015 final analysis will provide additional data and offer practical guidance to organizations providing medical services in unstable regions.
The US Congress took action in May of this year when the House introduced the Medical Neutrality Protection Act of 2013. The bill states that the US considers medical neutrality “an integral part of the defense of recognized international human rights law and international humanitarian law” and confirms that the US government will work to support and defend that principle.16 Among other provisions, the bill would require the Secretary of State to identify and deny US foreign assistance to nations that have violated medical neutrality. The passage of this bill would create an additional incentive for states that receive US foreign assistance to safeguard their healthcare systems to the greatest possible extent. Now that momentum is growing, it is important to keep attention focused on addressing this threat to global health and security.
International Committee of the Red Cross. Convention for the Amelioration of the Condition of the Wounded in Armies in the Field. Geneva, 22 August 1864. http://www.icrc.org/ihl/52d68d14de6160e0c12563da005fdb1b/87a3bb58c1c44f0dc125641a005a06e0. Accessed September 10, 2013.
International Committee of the Red Cross. 1949 Conventions and Additional Protocols, and their Commentaries. http://www.icrc.org/applic/ihl/ihl.nsf/vwTreaties1949.xsp. Accessed September 5, 2013.
International Committee of the Red Cross. Health Care in Danger: A Sixteen-Country Study. Geneva: ICRC; July 2011. http://www.icrc.org/eng/resources/documents/report/hcid-report-2011-08-10.htm. Accessed September 10, 2013.
International Committee of the Red Cross. Health Care in Danger: Violent Incidents Affecting Health Care. Geneva: ICRC; 2012. http://www.icrc.org/eng/resources/documents/report/2013-05-15-health-care-in-danger-incident-report.htm. Accessed September 10, 2013.
Larson HJ, Bhutta ZA. Security, insecurity, and health workers: the case of polio. JAMA Intern Med 2013 Apr 29:1-2.
McNeil D. C.I.A. vaccine ruse may have harmed the war on polio. New York Times July 9, 2012. http://www.nytimes.com/2012/07/10/health/cia-vaccine-ruse-in-pakistan-may-have-harmed-polio-fight.html. Accessed September 5, 2013.
Quetta blasts: militant attacks kill 25 people. Express Tribune June 15, 2013. http://tribune.com.pk/story/563579/quetta-blast-11-dead-and-22-injured. Accessed August 20, 2013
Yusufzai A. Taliban show patients no mercy. Inter Press Service News Agency May 1, 2013. http://www.ipsnews.net/2013/05/taliban-show-patients-no-mercy. Accessed September 4, 2013.
Amnesty International. Syria: health crisis: Syrian government targets the wounded and health workers. October 2011. http://www.amnesty.org/en/library/info/MDE24/059/2011. Accessed September 5, 2013.
Al Jazeera. Syrian surgeon working for international aid group Doctors Without Borders killed in Aleppo. September 5, 2013. http://blogs.aljazeera.com/topic/syria/syrian-surgeon-working-international-aid-group-doctors-without-borders-killed-aleppo. Accessed September 5, 2013.
World Health Organization. Health: Syrian Arab Republic 2013. WHO website. http://www.who.int/hac/syria_dashboard_6june2013_final_small_.pdf. Accessed September 5, 2013.
Adams P. Amid the tumult in Turkey, human rights abuses abound. Lancet 2013 Jul 6;382(9886):13-14.
Devi S. Bahrain convicts more health professionals. Lancet 2012 Dec 1;380(9857):1895.
Brodney M. Medical treatment under fire in Egypt’s attacks on protesters. Physicians for Human Rights website. August 16, 2013. http://physiciansforhumanrights.org/blog/medical-treatment-under-fire-in-egypts-attacks-on-protesters.html. Accessed September 5, 2013.
Kulish N. Doctors Without Borders to pull out of Somalia. New York Times August 14, 2013. http://www.nytimes.com/2013/08/15/world/africa/doctors-without-borders-to-pull-out-of-somalia.html. Accessed August 20, 2013
US House of Representatives. H.R. 2033: Medical Neutrality Protection Act of 2013. May 16, 2013. http://www.govtrack.us/congress/bills/113/hr2033/text. Accessed September 10, 2013.