The Health Status Amid Ongoing Conficts
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Armed conflicts are a global health issue. They ultimately convert into a humanitarian crisis which can be defined by four characteristics that have a profound adverse impact on health: dislocation of population; destruction of social networks and ecosystems, including destruction of livelihoods and health and social systems; insecurity; and abuse of human rights, including acts of violence. Armed conflict is generally caused by factors, including competition over land, religious issues, nationalism, imperialism, racism, ethnic and religious hatred, massive violations of human and minority rights, and ethnic cleansing propagated by hate media. Bad economic conditions seem to be the main cause of internal conflicts. Repressive political systems are war-prone. Degradation of renewable resources (erosion, deforestation, scarcity of water) may contribute to the possibility of armed conflict.[1]
Wars and armed conflicts have direct and indirect effects on public health including increased susceptibility to outbreaks of various contagious diseases, sexual and gender-based violence, and maternal and child health problems. During humanitarian emergencies such as conflict, people living with chronic diseases such as diabetes, cardiac diseases, and HIV become more vulnerable due to limited access to essential health services.[1]
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Social Determinants Of Health In Conflict Settings[2]: Structural determinants include:
The loss of human rights;
Breaches of Medical Neutrality
Intermediate determinants include:
Stress, distress, and disease that result from constant, unremitting exposure to a life-threatening situation.
Thematic areas as guides to action include:
Vulnerable groups: everyone is vulnerable;
Loss of livelihood;
Loss of community support and social networks;
Provision of, and access to, health services.
In conflict settings, the loss of these rights is most acutely expressed as:
Lack of security; a daily fear of the next assault on life and dignity; inability to protect one’s family; vulnerability to bomb attack; rape; absence of water or food;
Displacement, movement from “home” place, and becoming a refugee or an IDP;
Loss of social networks and family structure
Loss of livelihood; and loss of daily activity, access to land and employment opportunities that provide for daily life and needs, resulting in extreme poverty;
Food insecurity due to loss of land and resources for livelihood;
Lack of shelter; a plastic sheet, the shade of a tree, or a ruined home;
Lack of safe water and sanitation;
Lack of essential health and other social services, such as education for children;
Lack of communication leads to isolation.
Attack On Health Care – WHO Definition
WHO defines an attack on health care as any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access, and delivery of curative and/or preventive health services during emergencies. Examples of types of attacks on health can include:
Violence with small/heavy weapons
Psychological violence/threat of violence/intimidation
Obstruction to delivery of care
Assault without weapons
Sexual assault
Denial of access to services
An armed or violent search of health resource
Removal of healthcare assets
Setting fire to health resources
Militarization of healthcare facility
Removal of healthcare assets.
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Sexual violence continues to be used as a tactic of war, torture, terrorism, and political repression, amid deepening security crises with civilians, particularly displaced, refugee, and migrant women and girls, targeted with rape, gang rape, and abductions by State and non-State armed groups. The annual Report of the Secretary-General covering the year 2023 recorded 3,688 UN-verified cases of conflict-related sexual violence, reflecting a dramatic increase of 50 percent as compared with 2022. Every year, conflict-related sexual violence is chronically underreported, and most cases never reach a clinic, let alone a courtroom. Sexual violence has profound adverse effects on women’s physical, sexual, reproductive, and mental health.
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Challenges – Armed Conflict And Public Health:
The challenges encountered vary depending on the context, the type of conflict and forces involved, the health system in place, and the humanitarian capacities on the ground. However, these challenges can be categorized as constraints related to the:[3]
· Breakdown of Infrastructure: Health systems fail to support health as these are among the first to become disrupted. Conflict adversely affects the health infrastructure, which may be intentionally or unintentionally be damaged, destroyed, or looted by warring parties. Those health facilities that are not destroyed may end up shutting down or reducing their services. The damage to a conflict-affected country’s health system is vast, particularly when armed conflict is being waged in urban areas. This has important health consequences. It makes it difficult or impossible to treat conflict-related injuries, as well as health issues that are indirect consequences of conflict. Conflict leads to shortages in medicines, medical supplies, health personnel, and financial resources. It also increases the burden on already strained health systems.
· Breaches Of Medical Neutrality: These are especially relevant for the right to health care, as combatants attempt to weaken the resistance of civilians by deliberately depriving them of access to care, especially at the times when they most need it. These are violations of the Fourth Geneva Convention, Article 18. Examples of such violations include:[3]
Attacks on health facilities and staff;
Attacks on health care providers and patients;
Attacks on medical convoys and ambulances; barriers, checkpoints, and barrier walls that obstruct access to care;
Attacks on medical educational institutions during times of war have been observed in various countries thus creating an acute shortage of medical staff including doctors, nurses, and paramedics,
The politicization of health services, results in discrimination in the provision of health care based on social identity.
· Stress, Distress, And Disease[3] The progression from stress to distress to disease is seen as the major determinant, that results from constant, unremitting exposure to life-threatening situations, the outcome of which is a disabling mental and other serious health problem. The immediate effects of conflict are starkly clear. They include deaths and injuries. Long-lasting and protracted conflicts in particular have consequences not only for the war-wounded but also for the health of entire communities.
· Access To Needy Populations/Health Services: Armed conflict makes access to health services more difficult. It is especially essential in emergencies to maintain services at all levels. It is important to ensure an essential package of health services to all, covering areas such as emergency medical care (surgical and obstetric services), maternal and child health, childhood immunization, provision of essential medicines, and treatment for other common health problems. In armed conflict-affected countries, the public sector delivery systems become progressively destroyed and replaced by nongovernmental organizations in service delivery.
· Shortage of Health (and Other) Personnel: During the conflict, health workers face both personal and professional challenges. They are often threatened, harassed, intimidated, or attacked by parties to the conflict and sometimes death. They are also at risk of contracting infectious diseases due to inadequate medical supplies or equipment. Health workers often witness terrible events, potentially traumatizing them. In addition, health workers are overburdened and overworked. The shortage of specialized health staff is a particular challenge. Given these challenges, many health workers flee, leading to health worker shortages. Staff shortages extend to administrators and managers required to oversee and coordinate effective service delivery.
· Gaps in Health Data: Many conflict-affected countries generally lead to a complete collapse of those systems. Population surveillance and conducting sample surveys are difficult due to general insecurity. Information coming out of health facilities may be lost or destroyed in attacks, or it may be less comprehensive as people have more difficulty accessing these facilities. This results in poor-quality data and a lack of proper documentation. Without the necessary evidence and data, it is difficult for policymakers to make decisions about where to target resources, which interventions to prioritize, and which policies to implement.
· Financial Constraints: Donors and other states engage in humanitarian and health issues, provide insufficient or short-term funding, and allocate aid in a way that does not align with local needs.
Impact of Conflicts on Healthcare Systems – Specific Zones[4][5]
According to SHCC Report, violence against healthcare workers and facilities in conflict zones is on the rise specifically in countries like Ukraine, Sudan, Yemen, and Gaza. The statistics gathered till May 2024, report about 2562 incidents of violence against or obstruction of health care, a 25% increase from 2023. Arrests, kidnappings, and killings of health workers and damage to or destruction of health facilities in conflicts across 30 countries, or regions within countries, or territories have been documented. Health facilities, transport, and patient access to care were also at high risk in war zones. Reportedly more than 480 health workers, including doctors, nurses, ambulance drivers, pharmacists, lab technicians, paramedics, and psychologists have been killed. The total is likely an undercount, as data collection on violence is impeded by insecurity, communication blockages, and the reluctance of entities to share the data on violence. The situation in conflict zones has had a devastating impact on people’s health, starting from the delivery of therapeutic food and vital medical supplies against malnutrition to the emergency missions in war-affected zones in various countries aimed to bring emergency medical aid to the people affected by the conflict and cut off from healthcare services, due to the escalation of the fighting.
The report details that both government forces and non-state armed groups bombed, occupied, raided, and vandalized health facilities throughout the year. Health facilities were increasingly occupied or repurposed for military use, in violation of humanitarian law. Hospitals and ambulances were hit by air and from the ground, mortar shelling, missile attacks, and bombing. A rise in the use of explosive weapons– increasingly deployed via drones – affecting health facilities and health workers was reported in at least ten countries.
The current use of explosive weapons in populated areas, and consequent harm to civilians that results from the destruction of the health system, is at alarmingly high levels. Destruction of the health system causes immediate and long-term harm not only to those injured by conflict but also to expectant mothers, young children, and the chronically ill, often with lifelong consequences. Health workers were kidnapped often for ransom, arrested, and in long-term detention in several countries facing armed conflicts.[6]
Hospitals ceased to function as health workers had to flee, a virtual collapse of health systems, as in Gaza and Sudan, where most hospitals have been destroyed and closed, access to essential supplies blocked, and infrastructure damaged. In addition to the chronically ill, who are deprived of care, and those directly injured by attacks, the most affected by violence against health care are children and pregnant women. Health workers and providers engaged in vaccination campaigns were attacked on at least 24 occasions in 10 countries in 2023, leaving populations, especially children, vulnerable to infectious diseases.
Another effect of armed conflict is an increase in internally displaced persons (IDPs). They often reside in camps or makeshift structures with minimal or no basic amenities. These settings are usually congested, overcrowded with poor water, sanitation, and hygiene (WASH), and reduced food security with a high risk of transmission of communicable diseases and other conditions, excess morbidity, and mortality. The children if non or incompletely vaccinated suffer from outbreaks of vaccine-preventable diseases in these settings. Moreover, the presence of IDPs in host communities strains local health systems and negatively impacts health outcomes.
According to the UN Office for the Coordination of Humanitarian Affairs (OCHA), in 2024, millions of people in war-affected countries including Ukraine where about 10 million have been forced to flee their homes due to limited medical facilities and appximately14.6 million people, about 40% of Ukraine’s population, needs humanitarian assistance.
Between April and October 2023, with the outbreak of the new conflict, Sudan has nearly 6 million IDPs and driven over 1.4 million people into the neighboring countries. Out of the 59 hospitals out of service in conflict zones, 17 were attacked by artillery and 20 were evacuated, of which 12 have been forcibly militarized and converted into barracks. The remaining hospitals suspended services due to power outages, shortage of fuel for generators, lack of medical supplies, and critical lack of health workers. Violence against health workers has escalated. Outbreaks of infectious diseases like cholera, measles, and dengue are a constant threat, due to worsening water sanitation and hygiene conditions. According to UNICEF, 78,000 children under 5 years of age are dying every year and continuously rising. A significant portion of the population grapples with insufficient access to food. To date, according to the World Food Programme (WFP) nearly 18 million people are facing acute food insecurity, of whom 5 million are in emergency levels of hunger. This number is growing month by month.
Since 2014, Yemen has experienced widespread conflict, with an estimated 21.6 million people needing humanitarian assistance or protection (72 % of the total population), including 12.9 million children which is about four out of five children. Over 17 million people in Yemen cannot afford sufficient food to meet their daily needs, and 4.5 million people are internally displaced. The healthcare system has been decimated: 46% of all health facilities are only partially functioning or completely out of service due to shortages of staff, funds, electricity, medicines, and equipment. Outbreaks of cholera and diphtheria expose the precarious situation. Already lack of basic and obstetric care, clean water, sanitation, food, and shelter, has made young children and mothers even more vulnerable to infectious diseases. Millions of Yemenis are on the brink of famine due to food shortages and rising food prices.
Globally, there is now more and stronger evidence of the impact of attacks on health outcomes in armed conflict zones. The morale of healthcare workers is at lowest ebb who leave their posts because they fear for their lives, the disruption of essential healthcare services, and the closure of facilities including medical schools which were ambushed, with the majority being looted or undergoing conversion into military bases There is limited evidence about why and how attacks on healthcare have become “normal” practice amongst many combatants, despite the likely tactical and strategic costs to themselves. However, there is an important challenge in front of the world how to face this challenge and change this implicit norm of behavior. Will the global world rise to the occasion? A question awaiting an answer.
References
1. ICRC (International Committee of the Red Cross). 2008. “How is the term ‘Armed Conflict’ defined in International humanitarian law.” https:// www.icrc.org/en/doc/resources/ documents/article/other/ armed-conflict-article-170308.htm
2. World Health Organization (EMRO). Conflict as a Social Determinant of Health. 2007.
3. CRC (International Committee of the Red Cross). 2012. “Health Care in Danger: Violent Incidents Affecting Health Care (January to December 2012).” Accessed 15 December 2019
4. Krug EG et al. World report on violence and health. Geneva, World HealthOrganization, 2002 (http://www.who.int/ violence_injury_prevention /violence/ world report /en/full en.pdf
5. Haar RJ, Read R, Fast L, et al. Violence against healthcare in conflict: a systematic review of the literature and agenda for future research. Confl Health. 2021;15(1):37.
6. Sengupta S. 2017. New York Times. Attacks on Health Workers in War Zones Continue, Despite U.N. Resolution