Health care in danger: Making the case

8/6/2019 Health care in danger: Making the case

1/24

HEALTH CARE IN DANGERMAKING THE CASE


2/24

International Committee of the Red Cross

19, avenue de la Paix

1202 Geneva, Switzerland

T +41 22 734 60 01 F +41 22 733 20 57

E-mail: [email protected] www.icrc.org

ICRC, August 2011

Front cover: Atef Safadi An ambulance flls with tear gas shot into it during a demonstration.


3/24

HEALTH CARE IN DANGERMAKING THE CASE


4/244

A VITAL CONCERN OF

THE INTERNATIONAL

RED CROSS AND RED

CRESCENT MOVEMENT

During the aternoon o 7 January 2009, personnel

rom the International Committee o the Red Cross

(ICRC) and the Palestine Red Crescent Society made

a shocking discovery in a house in the Zaytun neigh-

bourhood o Gaza City: our young children crouched

beside the lieless bodies o their mothers. The house

had been shelled our days earlier, yet the ambulance

teams had not been permitted to reach the victims. By

the time they arrived, twelve corpses lay on the oor o

the room and the children were too weak to stand. Sol-

diers at a nearby checkpoint had oered no assistance

to the injured and ordered the ambulances to turn back

once they reached the devastating scene. The ambu-

lance crews disobeyed and rescued the survivors.

Less than one month later, in northern Sri Lanka, the

Puthukkudiyiruppu hospital in the Vanni region was

shelled, killing and wounding many o the 500 patients

seeking treatment in the last unctioning hospital o

the war-torn north. The hospital compound sustainedtwo direct hits and had to be evacuated. The patients

were transerred to a community centre that had no

potable water.

In September o the same year, soldiers entered the

Ghazi Mohammed Khan Hospital in the Wardak prov-

ince o Aghanistan late one night, searching or a

wounded enemy combatant. Unsuccessul in their

search, they rounded up the sta and ordered them to

report the presence o enemy ghters seeking treat-

ment. When the sta reused, citing medical ethics,

the soldiers threatened them at gunpoint, saying

they would be killed i they did not comply. Several

members o the sta quit their jobs ater this incident,

too araid to return to work.

And in December 2009, a man blew himsel up at a

university graduation ceremony in the Somali capital,

Mogadishu, killing medical students who had studied

hard to help pull their country rom suering and

despair wrought by two decades o civil war. This was

only the second batch o medical graduates to emerge

in the last twenty years, depriving the Somali people o

desperately needed doctors.

These our incidents rom our dierent conicts

in 2009 represent the tip o the iceberg: attacks on

health-care acilities, health-care personnel and medi-

cal vehicles, and impediments to the wounded and

the sick reaching health-care services have become

common in conicts and upheavals all over the world.

And they provoke ar-reaching secondary conse-

quences as health-care proessionals ee their posts,

hospitals close, and vaccination campaigns come to a

halt. These knock-on eects leave entire communities

without access to adequate services. Violence, both

actual and threatened, against patients and health-

care workers and acilities is one o the most crucial yet

overlooked humanitarian issues o today.


5/245

ChristopherMorris/VII

Rr Ds dr

Providing assistance to the wounded, regardless o

the side on which they ought, is the idea that gave

birth to the International Red Cross and Red Crescent

Movement over 150 years ago on the blood-stained

battleeld o Solerino, Italy. Henry Dunant, a Swiss

businessman, witnessed the carnage o June 1859

and horried at the suering mobilized the local

townsolk to help the injured with no consideration asto whether they were rom the Austrian or the French

side. Tutti ratelli they are all brothers was the

rerain as the 40,000 soldiers who lay wounded or

dying were oered common decency as human beings:

some water to quench their thirst, a clean bandage to

dress a wound, a last word home so that a mother,

wie or daughter would know what became o her son,

husband or ather.

From these humble beginnings emerged internation-

al law to assert the right o combatants and civilians

alike to be spared urther suering during armed

conict and to receive assistance. To assure this in prac-

tice, health-care acilities and personnel, and medical

vehicles, had to be protected: attacks upon them are

orbidden as long as they retain a neutral unction and

treat all patients equally, irrespective o political, reli-

gious or ethnic afliation. Protective symbols such as

the red cross, red crescent and red crystal were intro-

duced to clearly identiy medical installations, vehicles

and personnel as protected entities. These provisions,enshrined in the our Geneva Conventions o 1949 and

their Additional Protocols and in customary interna-

tional law, match the right to receive health care with

an obligation on all parties to a conict to search or

and collect the wounded ater battle, and to acilitate

access to health-care acilities. Human rights law pro-

tects health care at all times, including during internal

disturbances. These laws are binding on all States and

parties to conicts around the world. But they are not

always respected.

In 2008, the ICRC launched a study to look at how

violence aects the delivery o health care in 16 coun-

tries where it is operational. Reports o incidents were

collected rom a variety o sources, including health

organizations, Red Cross and Red Crescent sta, and

the media. These were analysed to identiy the most

serious orms o violence, which are presented in the

ollowing pages. But while the statistics paint a bleak

picture o the widespread nature o the attacks on

patients, health-care workers and acilities, and on

medical vehicles, they all short o capturing the ull

scope o the problem, particularly in areas inacces-sible to aid organizations and reporters, such as many

regions o Pakistan and Aghanistan. Furthermore,

the statistics do not reect the indirect and multiplier

eects o these attacks as health-care acilities close

and sta leave. Thus, this publication rst looks at the

general disruption to health care that occurs during

conict and civil strie, beore looking more closely at

specic types o violence.


6/246

PeterDiCampo/VIIMentorProgram

Abidjans Abobo SudHospital, normally a

2-bed acility, held over30 patients duringhe 2011 post-election

violence.

THE COMPOUNDED

COST OF VIOLENCE

V dsrs r srvs

w r dd s.

Armed conict and internal disturbances such as

violent protests and riots cause injuries among those

directly participating and those who get caught in the

way. Serious injuries require medical attention, yet itis precisely at these moments o greatest need that

health-care services are most vulnerable to disrup-

tion, intererence and attack. Violence, both actual

and threatened, aects the delivery o health care in

several ways.

First, active ghting in the vicinity o health-care

acilities prevents access to them by the wounded

and the sick, health-care sta, and vehicles carrying

essential medicines and medical equipment to re-

supply these acilities. Fighting can also disrupt the

ow o water and electricity, as well as uel supplies or

back-up generators. For instance, heavy ghting in the

Ivorian capital, Abidjan, in March 2011, prevented

ambulances rom collecting the wounded, and the

medical, humanitarian organization Mdecins Sans

Frontires (MSF) rom resupplying Abobo Sud Hospi-

tal, the only unctioning hospital in the northern hal

o the city. Dozens o wounded arrived at the hospital

each day by whatever means they could, and medical

stocks soon began to run low. The head o the MSF

team, Dr Salha Issouou, worried that i this continues

or a ew more days, the hospital will run out o anaes-thesia, sterile compresses, and surgical gloves.

Second, violence can set o the displacement o

civilians, including health-care personnel and theiramilies, to saer areas. Iraqs health ministry reported

that 18,000 o its 34,000 doctors ed the country

between 2003 and 2006. Libya has also been aected

by the exodus o health-care proessionals since unrest

began in early 2011 because a large percentage o the

medical workorce, particularly nurses, were migrant

workers. When oreign governments ordered their

nationals to evacuate the country in February, many

vital medical acilities, such as hospitals in Benghazi

and Misrata, were let critically understaed. The

shortage o personnel not only aects those wounded

in the ghting, but also Libyans suering rom chronic

illnesses that require regular care.


7/247

AndrLiohn/ICRC

One o the frst victimso war is the health-caresystem itsel.Marco Baldan, the ICRCs chief war surgeon

SecuRing acceSS in the ightto eRaDicate polio

For over twenty years, major eorts have

been under way to eradicate the devastating

disease o poliomyelitis. Enormous progress

has been made in reducing the transmission

and number o cases worldwide, but violence

in a ew key countries is a major obstacle to its

total elimination. In two o the our countries

with endemic polio Pakistan and Aghani-

stan vaccination coverage is hampered by

ghting and/or a lack o security guarantees

that would enable vaccination teams to reach

all areas o polio transmission. Military oen-

sives also cause population displacements

that can spread the disease rom inected to

uninected areas: the province o Punjab in

Pakistan, which had been polio-ree or two

years, experienced an outbreak in 2008 ollow-ing the inux o people eeing violence in the

province o Khyber Pakhtunkhwa and in the

Federally Administered Tribal Areas. Hundreds

o thousands o children remain beyond reach

in parts o Aghanistan and Pakistan.

In 2007, the Aghan health ministry and the

World Health Organization asked the ICRC

to use its unique contacts with the armed

opposition in Aghanistan to negotiate sae

passage or polio vaccinators. Although some

areas remain inaccessible, the oppositions

agreement to this plan enabled the country-

wide vaccination campaigns to resume and

coverage has dramatically increased.

The main clinic in Misrata, Libya had to be evacuatedwhen it was taken over to be used as a military base.

Third, violence hampers the implementation o im-

portant preventive health-care programmes (such asvaccination campaigns), which might have implications

long into the uture. The ght to eradicate polio, or

example, has aced setbacks in countries like Aghani-

stan, Pakistan and the Democratic Republic o the

Congo, where the saety o vaccination teams is di-

cult to assure. Furthermore, conict causes the dis-

placement o people to areas that are oten beyond

the reach o regular health-care systems, just at the

moment when they are most vulnerable to disease.

These disruptions to health care caused by violence are

less visible and more difcult to measure than overt

attacks against health-care personnel and acilities.

But they are just as deadly or all the wounded and sick

who never manage to reach the help they require.


8/248

VIOLENCE AGAINST HEALTH-CARE FACILITIES

V ds bombing, shelling, looting,

orced entry, shooting into, encircling or other

orceul intererence with the running o health-care

acilities (such as depriving them o electricity

and water).

hr s d hospitals,

laboratories, clinics, rst-aid posts, blood transusion

centres, and the medical and pharmaceutical

stores o these acilities.

KarimSahib/AFPPhoto

A doctor surveys the rubble let in the Adnan KhairallahHospital in Baghdad ater it was hit by a missile.

Attacks on health-care acilities during armed violence

and internal disturbances tend to all into our main

categories. The rst is the deliberate targeting o

such places to gain military advantage by depriving

opponents and those perceived to support them o

medical assistance or injuries sustained. Some attacks

might also be intended to terrorize a local population

by targeting a protected acility. Occasionally, attacks

have been mounted to rescue wounded comrades

detained while being treated in hospital: the attack

on Jinnah Hospital in Lahore, Pakistan, in June 2010

aimed to ree a wounded militant captured ater a

mosque bombing that killed over 80 worshippers.

Three gunmen dressed as police ofcers entered

the hospital and opened re indiscriminately, killing

medical personnel, visitors and security guards.

The second category o attack is also deliberate, but

this time or political, religious or ethnic reasons rather

than or military advantage per se. Such assaults

against health-care acilities include the burning

down o an Uzbek-run clinic in Kyrgyzstan during

ethnic violence in June 2010; the cordoning o and

military takeover o Salmaniya reerral hospital in

Bahrain in early 2011 ater it was perceived to support

the cause o anti-government protesters; and the

explosion at a hospital in Karachi in February 2010 that

targeted survivors o an earlier sectarian attack on a

bus carrying members o a minority Shiite sect.

The third type o attack is unintentional bombardment

or shelling collateral damage rom a missile or

mortar aimed at a military target. This occurs most

requently when military operations are carried out

in densely populated, urban areas. Those ring the

weapons are supposed to take all easible precautions

to distinguish between legitimate and illegitimate

targets, but conicts in Libya, Sri Lanka, Somalia, the

occupied Palestinian territory, Lebanon, Yemen and

Rwanda have all seen serious damage to health-care

acilities that was claimed to be in error. The risk to

health-care acilities rises with their proximity to

military installations. Although it is hard to believe,

the twelve shells that landed on Medina Hospital in

Mogadishu on 12 April 2011 were not intended or

the clearly marked hospital, but targeted ofcials o


9/249

the icRc hoSpital in Kigali: an iSlanD o humanity in a Sea o inhumanity

An extraordinary example o success in ensuring respect or the sanctity o a hospital, its personnel and patients, occurred in the Rwandan

capital, Kigali, during the 1994 genocide. As the organized slaughter o the Tutsi minority and those deemed to support them continued

relentlessly or three months, the ICRC and MSF teams saved ten thousand lives in a compound protected only by the Red Cross ag. They

ventured onto the streets to collect the wounded, with only their badge, their courage and the strength o their arguments to prevent

the wounded rom being torn rom the back o ambulances. The hospital was threatened several times, and was damaged by rocket re

more than once, but was never orcibly entered by those scouring the city or more victims. It even inspired some killers to stop: beore

eeing the city when they knew they were deeated, some militiamen brought a Tutsi nurse they had held or the last three months to the

hospital to release her. We have decided not to kill her despite the act that she is a Tutsi, they said to the head o the ICRCs delegation,

Philippe Gaillard. As a nurse she will be more useul in your hospital than dead.

DmitryKostyukov/AFPPhoto

Patients had to be moved tothe basement o this hospital ater thebuilding was partly destroyed.

the Somali Transitional Federal Government (TFG)

attending a high-level military event not ar away.

Miraculously, eleven o the shells did not explode,

but the one that did injured two guards and sowed

panic among patients and sta. Some shells did reach

their target, though, killing at least three people at

the TFGs military headquarters.

The ourth and perhaps most common orm o violence

committed against health-care acilities is the looting

o drugs and medical equipment. Occasionally, the

motive might be to obtain medical supplies or injured

combatants too araid to enter a acility, but purely

criminal motives are more common. Baghdad in 2003

saw the pillage o medical acilities and destruction

o inrastructure and supplies on an enormous scale,

which brought the whole medical system in Baghdadto virtual collapse. Hospitals were orced to close and

the wounded and dying let unattended.

t ss r s

Health-care acilities retain their protected status

as long as they are exclusively devoted to the care

o the wounded and the sick and are not used to

advance military goals. Unortunately, there have

been many occasions when the neutrality o a health-

care acility has been compromised through its use

to store weapons or launch attacks. For instance,

hospitals have been used as cover in inter-Palestinian

violence, putting patients and hospital sta in great

danger o being caught in the crossre. Reports rom

Libya suggest that the Ajdabyah Hospital was used

as cover or snipers. The presence o armed combat-

ants inside a medical acility or other than medical

reasons also compromises its protected status. In

August 2009, a group o armed insurgents entered a

clinic in the province o Paktika in Aghanistan, seek-

ing treatment or their wounded commander. They

exchanged gunre with army personnel outsideuntil a helicopter gunship red rockets into the clinic,

killing all but one o the insurgents and burning the

male ward to the ground.

What the laW SayS:

Health-care acilities shall be respected and protected at all times and

shall not be the object o attack.

Protective emblems such as the red cross, red crescent and red crystal

identiying medical units shall be respected in all circumstances.

Small arms are permitted in health-care acilities or the purpose o

sel-deence or deence o the wounded and the sick

(against bandits, or example). The presence o all other weapons

compromises the neutral status o a acility.

Health-care acilities lose their protection i they are used to commit

acts harmul to the enemy. Acts harmul to the enemy include the use o health-care acilities

to shelter able-bodied combatants, to store arms or ammunition,

as military observation posts or as a shield or military action.


10/2410

They entered through

the parking lot,ordered us at gunpointto lie on the ground,then shot dead thepatient on the stretcherand let again as inothing had happened.Red Cross volunteer describing the executionof a patient on Red Cross premises

VIOLENCE AGAINST

THE WOUNDED

AND THE SICK

V ds killing, injuring, harassing and

intimidating patients or those trying to access health

care; blocking or interering with timely access

to care; the deliberate ailure to provide or denial o

assistance; discrimination in access to, and quality

o, care; and interruption o medical care.

t wdd d sk d all persons

whether military or civilian who are in need o

medical assistance and who rerain rom any act

o hostility. This includes maternity cases,

newborn babies and the inrm. AlejandroBringas/Reuters

One o the worst recorded cases o assault on the

wounded and the sick occurred in November 1991 in

the Croatian town o Vukovar. The same day that the

ICRC secured agreement on the neutral status o the

hospital, 300 patients and their relatives were orced

onto buses: the bodies o 200 were later ound in a

mass grave and 51 individuals are still missing today.

The execution o patients in ambulances or health-care

acilities has also occurred in Sierra Leone, Colombia,

Lebanon, the Democratic Republic o the Congo and

the occupied Palestinian territory, and in gang-related

violence in Mexico. It is also alleged to have occurredin Libya. In September and October 2000, tit-or-tat ex-

ecutions o patients in ICRC ambulances in Colombia,

rst by paramilitaries and then by rebels, led to the ICRC

suspending its role in the evacuation and transer o

patients until it received guarantees that its ambu-

lances and patients would be respected.

More common than these deplorable attacks are the

impediments placed in the way o wounded and sick

people having rapid access to health care. Sometimes

access is deliberately blocked, but most impediments

take the orm o road closures and checkpoint delays

or security reasons. No matter how valid the security

concerns, lengthy delays at checkpoints while vehicles

are searched and passengers questioned can cost

lives. And bypassing the queue can be perilous: stories

abound in Iraq and Aghanistan o vehicles being shot

at as they tried to circumvent the queue. Roads are

sometimes closed or hours on end during sweeping

operations or explosive devices or ollowing security

incidents, with sometimes dire consequences. A girl in-

jured by an explosion in Chahar Dara district o Kunduz

province in Aghanistan died soon ater arriving at hos-

pital on 3 February 2010: she had been carried on oot

or an hour because the military had closed the road.


11/2411

Gunmen pulled over this ambulance to killa police commander who was beingtransported to hospital.

AsmaaWaguih/Reuters

Under international humanitarian law,no one may be let wilully without medicalassistance and care.


12/2412

ZurabBurduli/ICRC

Wounded civilians are evacuated by erry romPuttumatalan to Trincomalee in Sri Lanka.

Sometimes the military and law enorcement agencies

want to arrest or detain a patient or questioning, which

is a perectly legitimate demand. But the detaining

authorities have an obligation to ensure the continuity

o medical care or the patient, something that is difcult

in contexts where detention acilities lack proper health-

care services. In Aghanistan and Pakistan, the local

authorities have been receptive to the ICRCs requests

to prioritize treatment over interrogation, permitting

the wounded to see a doctor beore being questioned.

But other contexts are more challenging: our o MSFs

patients were removed rom its Katanga health-care

centre in south Kivu in the Democratic Republic o theCongo by soldiers in March 2010, despite protests by

the MSF surgeons that their medical condition advised

against it.

In some contexts, the wounded and the sick ace

discrimination in access to, and quality o, health care.

Although prohibited by international humanitarian law

and human rights law, as well as contrary to medical

ethics, health-care personnel have reused to treat, or

given inerior treatment to patients on the basis o their

ethnicity, religion or political afliation. This occurred

during ethnic violence in Kyrgyzstan and Rwanda, dur-

ing periods o political tension such as in Zimbabwe

and Lebanon, and in countries where minorities are

oppressed, such as the Muslim Rohingyas in Myanmar.

In recent unrest in Bahrain, Syria and Yemen, protesters

have been too araid to use medical acilities or ear

that their wounds will identiy them and provoke

harsh reprisals.

One nal violation o the rights o the wounded and

the sick that requently occurs in armed conict but

is difcult to document is the ailure o combatants

to search or, assist, and evacuate the wounded. Theincident in Gaza described above, where checkpoint

soldiers ignored the cries o the wounded, the dying

and their distraught children, is not an isolated case.

In conicts all over the world, combatants overlook

their responsibility to care or civilians caught in the

crossre. Invariably, it is relatives and neighbours who

bring civilian casualties to hospital, not men and wom-

en wearing uniorms or bearing weapons. And these

relatives and neighbours are as vulnerable as any pa-

tient to attacks and discrimination on the way to and

in health-care acilities.


13/2413

tReating eVeRyone,Without DiScRimination

In two o the worlds most dangerous places,

Somalia and Pakistan, the personnel in ICRC-

supported hospitals make no distinction

among patients according to the side on

which they ought. In the tense atmosphere o

Pakistan, it took one year o negotiations and

several setbacks to ensure the neutral status o

the hospital in Peshawar. In Somalias Medina

and Keysaney Hospitals, the personnel do not

ask patients questions about their clan or po-

litical allegiance. In October 2009, pamphlets

showing pictures o grenades and handguns

were thrown into the compound o MedinaHospital, warning the sta to stop treating the

enemy. But the hospital director, Mohammed

Yusu, said that the threat would not change

the way they worked. People need to under-

stand that health-care workers are neutral and

provide treatment to everyone, even the ones

writing the leaets and their relatives.

AndrLiohn/ICRC

Ater being attacked, Mohammed Yusu,

director o the Medina Hospital in Mogadishu,is now guarded 24 hours a day.

What the laW SayS:

The our Geneva Conventions o 1949 and their Additional Protocols o 1977

contain the ollowing rules:

The wounded and the sick, as well as the inrm, and expectant mothers,

shall be the object o particular protection and respect.

The wounded and the sick must be protected against ill-treatment and

pillage.

No one may be let wilully without medical assistance and care.

Whenever circumstances permit, and particularly ater ghting, each party

to a conict must, without delay, take all possible measures to search or,collect and evacuate the wounded and the sick without adverse distinction

between them.

The special role o the ICRC is recognized in acilitating the establishment

o neutralized zones to protect the wounded, the sick and civilians rom

the eects o war.

Parties to a conict have the rst obligation to care or the wounded and

the sick. Any care provided by the local population, humanitarian

organizations or other third parties does not relieve the parties o

their obligations.

Human rights law, in accordance with the Universal Declaration o Human

Rights, the International Covenant on Civil and Political Rights, the Interna-

tional Covenant on Economic, Social and Cultural Rights, and several other

conventions, afrms that:

Everyone has the right to lie. States must rerain rom deliberately

withholding or delaying health care to the wounded and the sick in

lie-threatening circumstances.

Whenever the use o orce is unavoidable, law enorcement ofcials must

ensure medical assistance to those aected as early as possible.

Everyone has a right to the highest attainable standard o physical and

mental health. States must provide at least essential primary health care.

Everyone has a right o access to essential health-care acilities and services

on a non-discriminatory basis. States must rerain rom arbitrarily denyingor limiting such access, or instance, against political opponents.

States must take active measures to enable and assist individuals to enjoy

their right to health.


14/2414

VIOLENCE AGAINST

HEALTH-CARE PERSONNEL

V ds killing, injuring, kidnapping,

harassment, threats, intimidation, and robbery;

and arresting people or perorming their

medical duties.

hr rs d doctors,

nurses, paramedical sta including rst-aiders, and

support sta assigned to medical unctions;the administrative sta o health-care acilities;

and ambulance personnel.

Health-care personnel ace many challenges working

in situations o armed conict and other violence,

having to adapt standards o care to the resources

available and dealing with large inuxes o patients

requiring immediate lie-saving attention. Beyond

these proessional challenges oten lie grave dangers

associated with the nature o their work.

Iraq has been the site o some o the worst attacksagainst health-care proessionals. In 2008, the Iraqi

health ministry estimated that over 625 medical

personnel had been killed since 2003. Many doc-

tors were deliberately targeted in a spate o kill-

ings in 2007 that claimed the lives o physicians like

Ibrahim Mohammed Ajil, head o a Baghdad psychi-

atric hospital, who was shot dead on his way home by

men on a motorcycle. Hundreds more doctors have

received death threats or been kidnapped sometimes

or ransom, but sometimes or political or religious

reasons. Over hal the countrys doctors have ed

abroad; many o those who stay are orced to live

in the hospitals where they work, to avoid the risky

journey home each day.


15/2415

A doctor cries or our o his colleagues a doctor,an ambulance driver and two nurses who were killed byan air strike on the road between Ajdabyah and Bregain Libya.

AndrLiohn/ICRC

Violence against health-care personnel is also common

in Aghanistan, where they are exposed to threats,

harassment and attacks. Dozens o health-care sta

have been abducted, sometimes or ransom payments

and other times or their skills, or treating wounded

ghters who ear arrest i seeking treatment in a

government clinic. During the long war in Sri Lanka,

doctors and other health-care personnel were threat-

ened and killed or treating the enemy. In December2008, hal o the doctors working in Vavuniya received

anonymous death threats in a letter posted rom

Colombo, which said that a Tamil doctor would die in

revenge or the death o a Sinhalese doctor in Batticaloa.

Although local health-care personnel bear the brunt o

the threats and assaults, the sta o oreign aid orga-

nizations have on occasion been specically targeted.

In December 1996, six expatriate sta members work-

ing in the ICRC eld hospital in Novye Atagi, Chechnya,

were assassinated, at point-blank range while in bed,

in a premeditated attack on the hospital premises.

A seventh delegate was shot and let or dead but

survived. The assassins had silencers on their guns

and clearly aimed to kill all the expatriate sta members,

but stopped when the alarm was raised. Four nurses,

a hospital administrator and a construction technician

were among the dead. The ICRC suspended operations

throughout Chechnya and handed over responsibility

or the hospital to the Chechen health ministry.

Perhaps the most dangerous job in the eld o health-

care during armed conict is that o the rst-aiders

and medics who go to the ront line to provide im-mediate lie-saving assistance to the injured and

evacuate them to saety. They risk being directly

targeted, caught in the crossre o an unnished

battle, or injured by unexploded ordnance scat-

tered around the area. Between 2004 and 2009, 57

volunteers rom the International Red Cross and Red

Crescent Movement were killed or wounded in the line

o duty. Such incidents are not limited to situations

o armed conict: in 2010, ear among health-care

workers in Mexico led them to strike to demand a halt

to violence. Health-care personnel in many parts o

the country are increasingly reluctant to treat victims

o gunshot wounds suspected o belonging to crim-

inal gangs or ear o being caught in the midst o

urther violence.


16/2416

I have no doubtthat one missile wasaimed at us.

I do not know or certainwhether it was meantto kill us or warn usto keep away,but it was defnitelyaimed in our direction.Palestinian Red Crescent ambulancedriver Khaled Abu Saada

On occasion, health-care personnel have also been

arrested or carrying out their proessional responsi-

bilities to treat all in need regardless o who they are

and what they have done. Three doctors who had

been working in northern Sri Lanka were detained

in mid-2009; Red Crescent volunteers in Yemen were

detained on suspicion that they sympathized with

protesters during the unrest in early 2011; and in Bahrain,

47 doctors and nurses who treated protesters have been

detained in sweeping arrests o health workers that

ollowed the crackdown on protesters and ace trial in amilitary court on a range o other accusations.

Even during peacetime, health-care personnel in many

countries ace unacceptable threats rom patients

and their relatives related to the quality o health care

delivered. One study carried out in six Lebanese

hospitals in 2009 ound that 80 percent o the emer-

gency room sta had been verbally abused and

25 percent physically assaulted over the past

12 months. More than two-thirds o the perpetrators

were relatives or riends o patients. This tendency is

exacerbated during the heat o war: emergency rooms

and operating theatres were invaded by gun-toting

ghters in Somalia and Iraq, demanding that their

riend, relative or comrade be treated immediately.


17/2417

SaeR acceSS oR health-caRe

WoRKeRS in colombiaThe remote village o Santa Cruz in south-eastern

Colombia is littered with landmines and other

explosive remnants o war. The only health-

care worker in this village risks her lie and

limbs every time she ventures rom the health-

care centre to conduct a home visit or make

a round o vaccinations with her cool box.

Everyone walks at their own risk here, she

says with a smile that hides her unease. She

is well aware o the repercussions or hersel

and or the whole community were she to puther oot in the wrong place. To improve her

saety and that o thousands like her all around

Colombia, the ICRCs weapons contamination

team trains health-care workers in techniques

to help them avoid driving over or stepping on

explosive devices. They learn what to look out

or and what to do when hit by, or in the midst

o, these deadly objects. The ICRC also talks to

all sides in the conict about the consequences

o these weapons or civilians.RogerArnold

RaulArboleda/AFPPhoto

Health-care personnel who give lie-saving assistance tothe injured are oten at risk themselves.

What the laW SayS:

Health-care personnel, whether military or civilian, may not be attacked

or harmed.

Health-care personnel shall not be hindered in the perormance o their

exclusively medical tasks.

Parties to a conict shall not harass or punish health-care personnel

or perorming activities compatible with medical ethics, nor shall theycompel them to perorm activities contrary to medical ethics or

to rerain rom perorming acts required by medical ethics.

Medical personnel may not be required to give priority to any person

except on medical grounds. Medical personnel decide, in accordance with

medical ethics, which patient receives priority.

The protection o medical personnel ceases when they commit, outside

their humanitarian unction, acts harmul to the enemy.


18/2418

VIOLENCE AGAINST MEDICAL VEHICLES

V ds attacks upon, thet o and

intererence with medical vehicles.

md vs d ambulances, medical

ships or aircrat, whether civilian or military; and

vehicles transporting medical supplies or equipment.

AbrarTanoli/Reuters

The nal example o violence aecting the delivery

o health care concerns attacks against medicalvehicles. There is, o course, considerable overlap in

the law protecting health-care acilities, health-care

personnel and medical vehicles, and similarities in the

types o attack directed against them. Nevertheless,

the sheer number o attacks on medical vehicles, and

their more requent misuse to trick the enemy, war-

rants their discussion as a separate subject.

Circulating in the midst o conict to collect and

assist the wounded, ambulances sometimes come

under re, both accidental and deliberate. The Libyan

Red Crescent reported that over one our-day period

in May 2011, three o its ambulances were hit in three

separate incidents, resulting in the death o a nurse

and injuries to a patient and three volunteers. Another

volunteer was killed in Zlitan. Such a toll is reminiscent

o the conict in Lebanon in 2006, when on one day,

11 August, two ambulances came under attack in

separate incidents. One Lebanese Red Cross ambu-

lance that was attacked rom the air while transporting

supplies rom Tyr to Tibnine caught re, injuring the

paramedics aboard; another was shot at in the Mar-

jayoun region when coming to aid victims o an air at-

tack. A Lebanese Red Cross paramedic was shot dead

in the second incident.

Attacks on ambulances have also occurred in the oc-cupied Palestinian territory, Colombia, Mexico, Yemen,

Iraq and Libya, and in Nepal during the conict rom

1996 to 2006. Some o the deliberate attacks and

many o the impediments and delays imposed upon

ambulances in Libya, the occupied Palestinian terri-

tory, Aghanistan and Nepal were due to mistrust o

the ambulance service that stemmed rom its misuse

in the past. Not all misuse is intended to cause harm:

in Nepal, ambulance drivers complain o politicians

using ambulances as a private taxi service or o others

riding in them to avoid being inconvenienced by

roadblocks during general strikes that paralyse the

country. But some armed groups engage in perdy

the deliberate misuse o the medical mission to ool

the enemy. In Aghanistan, the armed opposition sent

ambulances packed with explosives across security


19/2419

By violating theneutrality o health-careservices, such actso deception endanger

medical personnelengaged in caring orthe injured and sickin hospitals, clinics andrural health posts.From the ICRC statement condemningthe use of an ambulance in the 7 April 2011attack in Afghanistan

ambulanceS in mexico: caught in the cRoSSiRe

Over the last ew years, drug-related gang violence has claimed thousands o lives across Mexico. As violence increases, so does the

demand or ambulance services. The Mexican Red Cross operates around 80 percent o all the emergency ambulances in the country and

sometimes nds itsel caught in the crossre between rival gangs or between the police and gangs, when trying to evacuate the victims.

There has never been direct aggression against the Mexican Red Cross, said the Sinaloa branch coordinator, Valentin Castilla Astrada.

The groups see us as an organization that wants to help, not as being or one side or another. Nevertheless, the ambulance crews live in

constant ear o being caught in the middle. We never know when something is going to happen to us, said the deputy coordinator o

the Ciudad Juarez branch o the Mexican Red Cross. We are really araid. Beore, we just had to worry about the sick or someone injured

in an accident. We worked in security. But now everything has changed. When a car approaches the scene we are scared that something

will happen. The ICRC is helping the Mexican Red Cross to review its current procedures and practices and introduce new ways to assure

the saety o these dedicated ambulance crews.

What the laW SayS:

Medical vehicles shall be respected and protected at all times and shall

not be the object o attack.

Medical units may not be used to launch attacks or to shield ghters

or other military objectives rom attack.

Medical vehicles cease to be protected when they are used, outside

their humanitarian unction, to commit acts harmul to the enemy.

Examples o acts harmul to the enemy include the transport o healthy

troops, arms or munitions, as well as the collection or transmission

o military intelligence.

Examples o acts not harmul to the enemy include the carrying o light

arms by medical personnel or use in sel-deence or arms that have

just been taken rom the wounded.

Isolated incidents implicating medical personnel, acilities or vehicles

in acts harmul to the enemy do not entitle armed actors to attack them

indiscriminately. A warning and reasonable time limit must be given

beore an attack is launched. An attack must also respect the principleso distinction and proportionality.

cordons. The ICRC publicly denounced this grave

violation o international humanitarian law ollowing

the 7 April 2011 ambulance attack on a police training

centre in Kandahar that killed twelve people. A Taliban

spokesman pledged to conduct an inquiry in response

and said that such attacks would not happen again.

In Libya, the ICRC is also receiving allegations o the

misuse o the red cross and red crescent emblems

to support military operations and the use o ambu-

lances to transport arms and armed combatants.

The abuse o trust that occurs through the misuse o

the protective emblems, and o protected acilities

and vehicles, can spiral into a vicious circle that under-

mines the whole purpose o creating neutral entities

in conict. When ambulances are misused, whetherto trick the enemy or or some other purpose, they

all under suspicion and are, at best, subjected to the

same delays and impediments as other vehicles or, at

worst, become the object o attack. In both instances,

they lose the advantage meant to preserve lie in

conict, to the detriment o the wounded and the

sick who require urgent medical attention.


20/2420

WHAT THE ICRC DOES

AmnonGutman/ICRC

pRactical i nitiatiVeS> The ICRC negotiates ceaseres or sae passage with

parties to a conict to organize the collection o the

wounded and dead, access to health care, or preventive

health programmes such as vaccination campaigns. It

also negotiates a ast track or ambulances through

checkpoints in some contexts, such as the occupied

Palestinian territory.

> It reinorces the physical integrity o health-careacilities through the placement o sandbags, build-

ing o bunkers and application o bomb-blast ilm

to windows.

> The ICRC marks health-care acilities with a red cross

or red crescent emblem (ags, roo painting) and equips

health-care centres with signs barring weapons inside.

In some contexts, like Somalia, it establishes a system

or the collection and retrieval o weapons at the

hospital entrance. It also equips health-care personnel

with aprons to signiy their protected status.

> The ICRC takes the GPS (Global Positioning System)

coordinates o health-care acilities and provides these

to all parties to a conict.

legal i nitiatiVeS> The ICRC spreads knowledge o international human-

itarian law among military personnel, government

ofcials, non-State opposition groups, inuential mem-

bers o civil society, and the medical establishment.

It encourages States to incorporate international

humanitarian law into domestic legislation and enorce

respect or it. This includes laws to restrict use o the

red cross and red crescent emblems. It also spreads

knowledge o the rules protecting health-care acilitiesand o the obligations o weapon-bearers and medical

personnel to avoid compromising the neutrality o

these acilities.

> The ICRC appeals to all parties to a conict to prevent

obstruction o health care and respect and acilitate

the work o health-care personnel and volunteers.

> The ICRC engages in dialogue with all parties to a

conict regardless o whether they are considered

legitimate or not by the opposing side. It brings

allegations o violations o international humanitarian

law to the parties concerned and engages in

condential dialogue on measures to prevent such

violations in the uture.

The ICRC mounts emergency responses to outbreaks o conict around the world: this includes a range o

medical activities, rom collecting the wounded to war surgery. It also undertakes many initiatives behind

the scenes both immediate during conict and longer-term during peacetime to create an environment

o respect or the work o the International Red Cross and Red Crescent Movement and or international

humanitarian law.


21/2421

ThomasPizer/ICRC

PanchoDuda/ICRC

JuanCarlosSierra/Sem

anaNews

BorisHeger/ICRC

> It conducts rst-aid training or various groups

exposed to violence to enable them to stabilize patients

beore their arrival in a health-care acility. The ICRC

may also take this opportunity to discuss directly with

combatants the importance o respecting international

humanitarian law.

> In places where violence against health-care workers

and acilities is a requent occurrence, the ICRC runs

inormation campaigns such as a radio series with the

BBC Trust Fund in Aghanistan and a poster campaign

in the occupied Palestinian territory.

> The ICRC accompanies the sick and the wounded to

hospital i they ear discrimination.

> It mounts mobile health-care services in areas that

are diicult o access: such as the lying surgical

team in Darur that operated rom 2005 to 2009 or

the mobile clinics transported by canoe to remote

areas in Colombia.

> The ICRC conducts saer access campaigns with

the National Societies o countries acing conict and

other violence to increase awareness o ways to

minimize the danger when accessing potentially

dangerous areas. Work is also done on improving

local knowledge and public perception o the

National Societys role and unction.

> The ICRC addresses specic problems, such as

impediments to ambulances, with all those concerned.

For instance, to improve the reputation o, and increase

respect or, ambulance services in Nepal, the ICRC

holds periodic meetings with ambulance services, the

National Society, and State and non-State actors to ironout misunderstandings and to reiterate the roles and

responsibilities o ambulance drivers, political parties,

and the people manning checkpoints.


22/2422

WHAT NEEDS TO BE DONE

Violence, both real and threatened, against health-care workers, acilities and beneciaries must be recognized as one o the

most serious and widespread humanitarian concerns o today. As this booklet has shown, there is an urgent need to secure

the saety o the wounded and the sick, and o health-care personnel, health-care acilities and medical vehicles during armed

conict and other violence. More must be done to ensure that the wounded and the sick have timely access to health care

and that the acilities and personnel to treat them are available, adequately supplied with medicines and medical equipment,

and secure. Saeguarding health care cannot be addressed by the health-care community alone. Primary responsibility or it

lies with politicians and combatants.

1. bd r

The ICRC aims to mobilize support or this issue rom

within the International Red Cross and Red Crescent

Movement and among the health-care community,

medical aid organizations, military orces, and govern-

ments around the world. Working together to enhancerespect or the law, this community should cultivate

a culture o responsibility among all concerned to

saeguard health care.

2. Rr d d r r

In order to better understand and react to attacks on

patients, health-care workers and acilities, and medical

vehicles, reports o incidents should be more system-

atically collected and centralized with the data o other

organizations.

3. csd d rv d rs

The ICRC has undertaken many initiatives to improve

access to and saeguard health care in the various

contexts in which it is working. Experiences and best

practice need to be shared more widely within the

International Red Cross and Red Crescent Movement

and broader health-care community to encourage

more and better initiatives on this ront.

4. esr s r

Hospitals and other health-care acilities in countries

aected by armed conict or other violence will beassisted in organizing the physical protection o the

premises and in developing procedures or noti-

ying others o their location and o the movements

o their vehicles.

5. sr ss r Rd crss d Rd

crs sf d vrs

The ICRC will encourage greater involvement o Red

Cross and Red Crescent sta and volunteers in collect-

ing data on, and responding to, threats to patients,

health-care sta, volunteers, health-care acilities and

medical vehicles.

t rs wrss s ss d r rv , icRc s sk sr r

w vs:

6. e w Ss

All States that have not yet introduced domestic legis-

lation to saeguard health care in situations o armed

conict and internal strie will be encouraged to do so.

This includes enacting and enorcing legislation on lim-

iting use o the red cross and red crescent emblems.

7. e w rd rs

All national armed orces that have not yet incor-

porated provisions into their standard operating

procedures with respect to saeguarding health care

will be encouraged to do so. These standard operating

procedures must address, among other issues, man-

agement o checkpoints to acilitate the passage o

medical vehicles and entry into health-care acilities.

8. e w S rd rs

Armed groups operating outside the purview o the

State will be engaged in dialogue on laws and practices

pertaining to saeguarding health care.

9. e w rss r

ss d srs

Increase dialogue with health ministries and health

associations to generate solidarity on this issue and

improve reporting on, and responses to, violence

against health-care workers, acilities and beneciaries.

10. er rs d rsAssist universities, other educational institutions and

think tanks to incorporate modules on the implications

o, and means to address, violence against patients and

health-care workers and acilities into courses in public

health, political science, law and security studies.


23/24

Mission

The International Committee o the Red Cross (ICRC)

is an impartial, neutral and independent organization

whose exclusively humanitarian mission is to protect

the lives and dignity o victims o armed conict and

other situations o violence and to provide them with

assistance. The ICRC also endeavours to prevent suering

by promoting and strengthening humanitarian law and

universal humanitarian principles. Established in 1863,

the ICRC is at the origin o the Geneva Conventions and

the International Red Cross and Red Crescent Movement.

It directs and coordinates the international activities

conducted by the Movement in armed conicts and other

situations o violence.


24/24

0208.2

0113,50

0

Documents

Health care in danger: Making the case