Managing Healthcare During Conflicts
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Armed conflicts mean devastating loss of civilian life, massive displacement and violations of human rights and international humanitarian law. Wars and armed conflicts have direct and indirect effects on public health including increased susceptibility to outbreaks, sexual and gender-based violence, and maternal and child health problems among others. The conflict has a critical effect on the competence, confidence, and morale of healthcare professionals. Consequently, it affects patient care too.
Across the humanitarian's operations, whether in Yemen, Gaza, Ukraine or Sudan the health care providers are seeing the deadly effects of conflict on health systems and health care. While the direct impact of violence often focuses public attention, the cumulative destruction of large-scale, interconnected infrastructure and systems is also putting the lives of millions in jeopardy. Essential medications are in short supply or prohibitively expensive. People with chronic diseases go without treatment. Rapidly spreading contagious diseases, like cholera, diphtheria and many others, pose huge threats to whole communities. Beyond death and injury, wars also leave invisible scars on entire societies, including psychological trauma or untreated mental health disorders.[1]
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Essential Health Services In Conflict Affected Settings
Conflict zones tend to create vulnerable settings, particularly for healthcare mainly destruction of health infrastructure, lack of health care workers (HCWs), potential for increased physical danger to HCWs, and limited access to essential medicines. Humanitarian emergencies can directly cause both physical and mental injury, blast injuries linked to debris or inadequate shelter, gunshot wounds and post-traumatic stress disorder. Additionally, humanitarian emergencies can trigger risk factors of communicable disease outbreaks.[1]
Today’s conflicts increasingly focus on the purposeful destruction and destabilization of civil society, making non-combatants a main target. It is characterized by disregard for the rules of war, international humanitarian law and human rights. Thus, conflicts have a tremendous impact on healthcare provision and access to healthcare. Medical issues in conflict zones range from non-communicable diseases, communicable diseases, traumatic injuries, mental health issues, and issues related to maternal and child health. The specific dynamics of each of these issues and the countless conditions they cover can be vastly different. However, the effect that humanitarian emergencies have on these medical issues is similar and the main mechanisms through which humanitarian emergencies have these detrimental effects are the same.
Nearly a quarter of the global population, currently lives in settings affected by conflict, displacement and natural disasters. Combined with weak national health systems, these settings make it difficult to deliver basic health services where they are most needed and would make the biggest difference. As a result, countries that host fragile, conflict-affected and vulnerable settings also have high burden of disease and death.[2]
The Challenges Of Providing Care In Conflict
During conflict, the demand for health care increases while the resources for care become scarcer. The challenges of delivering care in impacted areas include logistics, impartiality and neutrality in providing treatment, safety of staff and community, and access to those in need. Health care workers and systems do their best to adapt, especially since many health care workers, like the general population, are displaced. For example, doctors and nurses who have no prior training in trauma care learn and provide care for the injured. Medical assistants place intravenous lines to give medications, blood, or fluid, a skill that is traditionally performed by nurses who also assume greater responsibility.
As accessibility to primary care becomes more constrained, complications for those with chronic illnesses like diabetes, kidney, heart, or lung disease increase. Routine public health campaigns like vaccinations are often put on hold, too. Rates of mental health disorders also dramatically increase, especially in children. Non-emergency surgeries to repair hernias, remove cancerous tumors, or replace failing joints are delayed as surgeons and operating rooms prioritize life-threatening traumatic injuries. Each delay has the potential to cause a cascade of significant impacts on patients and their families or gravely worsen their underlying conditions. [2]
Healthcare Systems During Wartimes
During the Geneva Conventions, laws of war were created to protect the wounded, the sick, non-combatants, and prisoners of war. These laws were meant to protect civilians from both physical threats and other acts of terror. Unfortunately, these so-called “humanitarian laws” have been all but abandoned. As of late. Gaza, Yemen, Ukraine , and South Sudan all have experienced targeted attacks on hospitals and other locations providing health services. Not only does this hurt the physician population in countries with weakened healthcare systems, but it could hinder younger generations from entering this line of work. Many facilities have been forced underground, into basements or other considered safe places where staff work in fear of helping their patients. It’s not only health facilities that are suffering–conflicts have also escalated to targeting supplies, electricity, water, and transportation (including ambulances). Because of the reduced capacity of health systems in areas of conflict, civilians’ health suffers. Patients are also discouraged from seeking care. The conflict zones, continue to suffer from a lack of supplies and workers, causing an increase in child mortality, a decrease in immunizations, and a decline in prenatal care visits. Women, children, older and disabled are being impacted at higher rates. Members of minority groups or marginalized communities are suffering the most, people who already have worse health outcomes. Health students are also suffering– their training is shorter and less extensive, more focused on critical care than on chronic and primary care. [2]
Access To Medical Care In Armed Conflict
Military operations can greatly undermine both safe access to and the delivery of health care, especially when such operations require setting up checkpoints, conducting search operations within health centres, or attacking military locations near a health-care facility. The misuse of medical facilities or medical transport for military operations may cause them to lose their protection under international humanitarian law (IHL) and hence expose them, along with the wounded and sick and the medical personnel inside, to the risk of attack.
Access to health care may also be impeded in the immediate aftermath of conflict due to ongoing safety risks such as explosive devices and hazardous waste. Supporters in an assistance relationship may be able to help partners by providing the specialist personnel or equipment needed to identify and remove these risks. [3]
Strategy To Ensure The Delivery Of Basic Healthcare During Conflicts: Ensuring universal access to healthcare during armed conflicts through:
· Technologies and Strategies for Protecting Vulnerable Populations: Universal access to healthcare is a fundamental human right that should be protected at all times, including during armed conflicts. In times of war or conflict, access to healthcare can become severely limited, leaving vulnerable populations, especially women and children, without necessary medical care. Here are a few ways that universal access to healthcare can be protected during armed conflicts: [4]
· Respect for International Humanitarian Law: International humanitarian law provides protection for civilians, medical personnel, and medical facilities during armed conflicts. All parties involved in the conflict should respect these laws and ensure that medical personnel and facilities are not attacked or targeted.
· Strengthening Health Systems: Strong health systems can better withstand the challenges of armed conflict. Investing in healthcare infrastructure, training healthcare workers, and ensuring adequate medical supplies can help ensuring that healthcare services continue to be available during times of conflict.
· Supporting Humanitarian Aid: Humanitarian organizations can provide critical medical assistance in conflict zones. Governments and other stakeholders should support these organizations and ensure they have the resources they need to deliver essential healthcare services.
· Promoting Telemedicine and Other Remote Services: Telemedicine and other remote healthcare services can help bridge the gap in healthcare access during armed conflicts. Governments and other stakeholders should promote the use of these technologies and ensure that they are available to those in need.
· Providing Safe Access for Healthcare Personnel: Healthcare personnel should be able to access conflict zones safely and without fear of attack or harm. Governments and other stakeholders should provide safe passage for medical personnel and ensure their protection. During armed conflicts, access to healthcare can be severely limited. The use of following new medical technologies in healthcare are highly helpful during armed conflicts:
· Mobile Field Hospitals: These portable and self-contained medical facilities can be deployed in conflict zones. They are equipped with operating rooms, intensive care units, and other essential medical equipment including: Portable Ultrasound Machines, X-ray, Lab equipment, and Ventilators. These portable medical devices enable medical professionals to provide diagnosis, treatment, and monitoring even in resource-constrained settings.
· Telemedicine: This technology allows healthcare professionals to diagnose and treat patients remotely using video conferencing and other communication tools.
· Wearable Health Devices: These devices, such as smartwatches or fitness trackers, can monitor vital signs, track activity levels, and collect health data. They can provide valuable information both for the patients and healthcare providers.
· Drones for Medical Supply Delivery: Drones can be used to transport medical supplies, blood, and medications to areas that are difficult to reach due to conflict.
· Artificial Intelligence (AI) in Diagnostics: AI algorithms can analyze medical images, such as X-rays or CT scans, to assist in diagnosing injuries or diseases.
· Mobile Health (mHealth) Applications: These apps can offer features such as symptom assessment, medication reminders, health education, and remote consultations with healthcare professionals.
· 3D Printing for Medical Devices: In conflict zones where supply chains may be disrupted, 3D printing can help bridge the gap by locally producing customized and essential medical equipment, prosthetics, and even certain medications.
It's important to note that these technologies have their limitations and should not replace comprehensive healthcare systems. However, they can provide valuable support and improve access to medical care during armed conflicts.
Protecting Medical Care In Conflict Zones
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Hospitals and medical care workers have suffered an alarming number of tragic attacks over the past few years against the core imperative of international humanitarian law: the protection of health care in armed conflict. Reflecting the global concern about such attacks, the UN Security Council universally approved United Nations Security Council Resolution 2286 (UNSCR 2286), Healthcare in Armed Conflict, which calls for steps States should take to better protect health care. The first step is compliance with international humanitarian law (IHL). IHL is clear about the protected status of medical facilities, the wounded and sick, and medical transports in armed conflict. Some cases of attacks on medical facilities appear to be either deliberate or reckless, which can amount to war crimes.
Over the past few decades, some countries have developed formal processes for better estimating civilian casualties and avoiding strikes on protected entities such as medical facilities: improving deconfliction measures; finding additional options for identification of medical facilities; and taking a comprehensive, life-cycle approach to protecting civilians in conflict and developing awareness of the location of medical facilities in conflict. [5]
· Improving Deconfliction Process: Medical facilities are afforded legally protected status under IHL. As such, they are generally included in a No Strike List (NSL), defined as “a list of objects or entities characterized as protected from the effects of military operations under international law and/or rules of engagement.” Militaries would need to take all feasible precautions to minimize harm in the case of a hospital, such as giving advance warning. There are a number of best practices that can guide targeting decisions and guard against inadvertently attacking these entities. These include:
· Provide Effective Advance Warning. Advance warning is required by law when feasible to allow evacuations before the facility is attacked.
· Show Tactical Patience. Instead of engaging enemy forces in proximity to protected sites, wait until they move to another location that is free of collateral concerns.
· Consider Tactical Alternatives. Instead of an airstrike, ground forces could allow consideration of alternate weapons (e.g., sniper); if there are noncombatants along with combatants.
· Coordinate. Two-way communication is important. For local medical facilities, as well as those operated by NGOs and international organizations (IOs), contact them proactively if they are in the area being targeted and make sure their activity has not been mistaken for that of enemy combatants. Maintain an effective coordination process with medical organizations. Medical organizations operating in an area of armed conflict have concerns about being inadvertently targeted or incidentally harmed. Thus, a timely sharing of information is critical to both. Provide a round the clock coalition hotline as a best practice to handle such coordination effectively.
· Seeking Additional Options For Identification Of Medical Facilities: In areas of armed conflict, they are not always easily distinguished structures such as established hospitals. In compliance to original Geneva Conventions of 1949 medical facilities may display a red cross or red crescent emblem as identification .
· Co-Location Of Military Forces With Medical Facilities: There have also been few cases where military forces collocate themselves with medical facilities, either to protect them from enemy attacks or to provide medical supplies and/or services. On the practical side, military collocation can negatively affect the ability to provide medical care.
· Developing A Comprehensive No Strike List: The medical facilities have to be on the relevant No Strike List, and thus known within the military system to be a protected site. There must be ways to automatically update the status or the location (in case of a mobile hospital).
· Understanding IHL Obligations Of Combatants Regarding Medical Care: Military forces sometimes interfere with timely provision of medical services to combatants, in contradiction to IHL obligations. It must be ensured that combatants receive adequate medical care during armed conflict, without distinction to their affiliation.
· Partnerships Are Key To Delivering Health Care In Conflict Zones: Threads towards healthcare in conflict are varied. Prevention and preparedness in the context of healthcare in conflict have to be seen as more holistic and transdisciplinary activities that promote conditions that are more advantageous to health delivery systems. They have to draw on disciplines as varied as medicine, epidemiology, sociology, international relations, law and others while also involving and provide training to practitioners and stakeholders from all of these disciplines, civil society, military, media, healthcare and other stakeholders. Equally, the study of healthcare in conflict has to be interdisciplinary in nature. This can be seen as a strength and even a necessity.
Along with the World Bank, UNICEF, the World Food Programme and other partners, especially WHO supports, the Member States must deliver universal health coverage in conflict affected settings and ensure that vulnerable populations have access to basic health services, such as maternal and child health, immunization, nutrition, mental health, and sexually-transmitted diseases,etc. To reach people with virtually no access to health care, WHO also deploys mobile medical teams and maintains stockpiles of essential supplies, life-saving medicines and personal protective equipment that can be dispatched quickly across any war theatre.
· The Pivotal Role Of Humanitarians: Humanitarian organizations can often rapidly provide medical and public health services across diverse environments. They range from establishing vaccination and nutrition programs, delivering primary care in refugee camps, combating infectious disease outbreaks, and establishing field hospitals or rapid training of health care personnel. They maintain supporting those providing medical aid. The demanding nature of this work is supported through United Nations cluster system which provides a framework to align strategies, identify gaps, and support collaboration within an affected area.
The Successes In Delivering Care
Creating equitable partnerships among humanitarian aid, community health workers and other relevant authorities at the outset of a response can provide more sustainable, community-driven efforts to improve care during and after the conflict. Local organizations are often the first to assist in conflict. It can improve the speed of delivery services, better interpret needs, and identify gaps in existing services.
· Training Of First Health Responders: Sending doctors, nurses, and other health care workers to provide direct care and conduct training to develop local health care workers are the two traditional constructs of humanitarian care. Capitalizing on the use of technology in modern conflict settings has also shown recent success through a series of brief, just-in-time (JiT) videos. These innovative videos are designed for laypersons or public safety professionals, whether health care workers, firefighters, emergency medical services, or law enforcement officers. The goal is to help them learn or refresh emergency care skills. Digital education has a special advantage as it can allow for the visualization of complex clinical and public health topics. The use of social media and web-based resources disseminate knowledge in a way that empowers many more providers than just those who are directly trained in classrooms, simulation centers, or hospitals. Clear, well-captioned videos can help viewers in a number of ways, from recognizing and stopping life-threatening bleeding, to responding to a potential chemical or radiological attack. Improving the evidence base for humanitarian health will better identify, expand, and sustain initiatives that improve the lives of those caught in the throes of armed conflict.
Medical care in conflict needs and deserves protection. Attacks on medical facilities in armed conflicts cause immediate victims, damage or destroy invaluable medical facilities, and harm the civilian population in longer-lasting ways by depriving them of vital medical services, exacerbating the humanitarian conditions on the ground. These attacks can disproportionately harm women and children, with higher fatality rates for that portion of the population seen in attacks on structures. This situation has to be remedied, by improving compliance with IHL through better training, education, and doctrinal development. The goal should be to develop capabilities and refine processes and policies to better protect medical care where it is most critical: in the heart of conflict.
References
1. Kaplan, J. (2022, April 12). Targeting Healthcare in War: A Tragically Tried and Tested Strategy that Humanity Must Disown. BMJ. https://www.bmj.com/content/377 /bmj.o884.
2. Rogers, L. (2022, April 14). The Vulnerability of Health Care in Conflict: Ukraine and Beyond. Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2022
3. WHO. (2022, October 24). Accessing Health Care in Ukraine After 8 Months of War.https://www.who.int/europe/news/item/24-10-2022-accessing-health-care-in-ukraine -after-8-months-of-war–the-health-system-remains
4. Druce, P et al. (2019, January 29). Approaches to Protect and Maintain Health Care Services in Armed Conflict. BMC. https://conflictandhealth.biomedcentral.com/ articles/10.1186/s13031-019-0186-0.
5. International Federation of Red Cross And Red Crescent Societies: Homepage: http://www.ifrc.org/