Medical care under fire
By Dr Unni Karunakara, international president of Médecins Sans Frontières, and Peter Maurer, president of the International Committee of the Red Cross
Armed men in hospitals, harassing patients; health facilities used to identify and apprehend enemies; clinics abandoned and hospitals destroyed. Overwhelmed emergency services, where medical staff are in terror of reprisals for having provided care for a patient; ambulances blocked from accessing the wounded, or held up for hours at checkpoints; entrenched animosities and divisions denying certain groups of people the medical assistance they need.
The International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF) strongly condemn any act that deliberately aims to distort medical action, and to deny healthcare to the wounded and the sick. A patient cannot be an enemy. The sick and the injured are not combatants. Medical ethics oblige all health workers to care for all patients and to keep the medical act free from interference. Medical staff must act impartially, prioritising the delivery of care solely on medical grounds. In order to do that, the places where they work - ambulances, mobile clinics, health posts and hospitals - must be safe, neutral spaces.
However, from Syria to the Democratic Republic of Congo, from Bahrain to Mali to Sudan, it seems that this impartiality is not being respected. And civilians are paying a heavy price, as several thousands are being deprived of medical attention.
Since last December, 29 people have been killed while carrying out polio vaccination campaigns in Nigeria and Pakistan, two of the three countries where the disease remains endemic. As in all many other cases of violence against health facilities and workers, the tragedy of the victims' deaths and the pain of their families are only the most direct consequences of these attacks. Thousands of children who would have been immunised have been left at risk of polio and paralysis. Health organisations have been forced to review their activities, and add security issues to the challenges of health care provision.
The overall scale of the problem is alarming. Most incidents that in one way or another deny the right of wounded and sick people to health care go unreported. Hidden from health workers, governments and international organisations, unknown but certainly large numbers of people continue to suffer illness or injury without recourse to medical care.
MSF and the ICRC are seeking to expose the scale and the consequences of the threat to health care. The objective is to bring about real change on the ground, so that people can access the medical care they need without fear, whoever and wherever they are.
The performance and behaviour of health workers themselves - staff involved in management, administration and transportation as well as diagnosis, prevention and treatment - is critical. Securing acceptance for their work from all communities and political and military groups is an essential prerequisite to being able to operate in sensitive and volatile contexts. This requires an unequivocal demonstration of respect for medical ethics and impartiality.
And there are cases, for example in places in Afghanistan in which our organisations work, where medical facilities have been kept safe, and healthcare has been assured, despite a context of brutal violence. If we have to make sure these cases do not remain remarkable exceptions to the rule, if we have to foster responsibility for the protection of healthcare among all actors, we need a concerted, global effort.
Symbols clearly indicate medical services, such as the Red Cross and Red Crescent, or the MSF insignia, must oblige respect and the protection of medical practice. When they are exploited, or ignored, no amounts of sandbags will offer protection to patients and health workers.
The real challenge is to find ways to prevent such acts in the first place. The primary responsibility to prevent the targeting, obstruction, or abuse of the delivery of medical assistance lies with states and all parties engaged in conflict. Health workers must be supported in carrying out their medical duties, and states must ensure that all possible measures are taken to protect medical action through national legislation, and that these measures are implemented.
The protection of the sick and the injured lies at the heart of the Geneva Conventions, yet violence - in all its forms - against health facilities and personnel represents one of the most serious yet neglected humanitarian issues of today. The medical act benefits everyone - combatant and non-combatant - and anyone in need should be able to access it, unconditionally.