Damaged either deliberately or as collateral (or through structural violence, negligence on the part of their nation or the international community), health systems face an onslaught of violence.
Bombings, looting, forced closure of facilities, chemical attacks, shooting of healthcare workers, hijacking vehicles, targeting patients or patients being killed in medical facilities, deliberate interruption of electricity, water, and withholding supplies (such as medicines) to medical facilities; health facilities being taken over for non-medical purposes - the list of types of attacks health systems have faced across the world is distressingly long.
Across the globe, there are attacks on healthcare facilities and personnel. In Yemen, health facilities are routinely and increasingly attacked through shelling and aerial bombardment. In Afghanistan, between 2014 and 2015 the number of attacks on health facilities doubled; similarly between 2014 and 2016 the number of health facilities forced to close had more than doubled.
Data from 2017 shows that Syria has more than double the number of attacks on health facilities than any other country. Or put another way, combining all the other most dangerous conflicts for health care workers - Central African Republic, the Occupied West Bank and Gaza, and Yemen - only just surpass the attacks that Syrian health systems have experienced.
Syria is the most dangerous country in the world to be a health worker. More than 796 medical personnel have been killed and 446 health facilities have become non-functional since the beginning of the conflict. Medical personnel have been killed by shelling and bombing (55%), by shooting (23%), by torture (13%), and by execution (8%), and many more have been imprisoned or driven from the country.
United Nations investigations into the attacks in Syria found that: “In the first half of 2017, the Health sector reported a 25% increase in attacks against health facilities as compared to the same period in 2016, with attacks on health facilities numbering approximately 20 per month between January and April, or one attack every 36 hours.”
Even under close international scrutiny, medical personnel are being attacked and killed frequently and with impunity. You may remember the story of the Canadian doctor who was shot in both legs by the Israeli army whilst treating injured Palestinians during the “Great March for Return” demonstrations which began in March 2018. He was wearing clearly visible and identifiable medical attire and standing away from the demonstration.
His rescuer - the Gazan paramedic Musa Abuhassanin- was shot and killed later that same day whilst trying to save another life. A few weeks later, a 21 year old nurse - Razan Alnajjar - was also shot dead by the Israeli army whilst treating unarmed Palestinians injured by live fire. International condemnations continue to fall on deaf ears.
Respecting and protecting health care
Deliberate attacks on health systems are illegal and contravene International Humanitarian Law and the Geneva Conventions, which are the rules that govern armed conflict. States are always obliged to protect the human right to health, in times of conflict and peace. The 2016 UN Security Council Resolution 2286 strongly condemned all attacks on medical facilities and personnel in conflict settings; deploring “the long-term consequences of such attacks for the civilian populations and health-care systems of the countries concerned.”
UN Res 2286 was brought about by attacking of healthcare, which has continually been used as a tool of war, in Syria. This interactive map reveals the anatomy of the crisis in Syria and the attacks on health care facilities and personnel. 67% of the documented medical facility attacks have been attributed to the Syrian regime, backed by Russian forces. Despite this resolution attacks have continued.
All health conditions pay the price
The forced closure of facilities - through attack and damage, either deliberate or as collateral damage - affects the whole population of a country. The on-going conflict in the Central African Republic has resulted in a quarter of the 1010 health facilities becoming either partially or totally destroyed. Pre-crisis, the Syrian public and private health system was well functioning, with a highly skilled medical force. Now only 48% of health facilities remain fully functional.
The result is a huge number of avoidable deaths, alongside the deaths caused by the conflict. In Afghanistan, for example, the attacks on health system is currently affecting around 3 million people’s access to healthcare.
MSF issued this statement to the UN Security Council in their plea for zero-tolerance to attacks on health systems: “The effects of the attacks against health facilities emanate far beyond those immediately killed and injured. They demolish routine and lifesaving healthcare for all. They make life impossible. Full stop.” This was more than 2 years ago. The situation has subsequently deteriorated.
As already mentioned with Ebola, the ramifications on the health of the populations from medical losses extended beyond the immediate crisis. Researchers believe “that the indirect effects of Ebola virus on health system functioning might have adversely affected more people than the virus itself”. And the legacy of a weakened health systems stretches far into the future.
What happens once the crisis is over?
A seminal study which undertook a “comprehensive worldwide analysis of the post-conflict consequences for health life expectancy” showed that the great majority of mortality and morbidity came after the acute phase of a crisis.
This means that once the deaths which result directly from the crisis - be it violent conflict or infections - have stopped, the other health condition that never went away (chronic diseases, cancers, pregnancies) cannot be dealt with adequately for years to come.
If we are to use history as a guide of what this means for the crises we are living through, it would mean that in Syria where more than 400,000 people have lost their lives directly due to the conflict over the past seven years, we can expect double that figure to die from preventable causes in the years to come.
This should be a wake-up call for zero-tolerance on attacks on healthcare and real enforcement of international rules to safeguard healthcare provision.