HEN I STARTED working as anICRC ield surgeon, I oundtreating people wounded inconfict both challenging and rewarding.One day, when ghting erupted in suburbsnear our hospital, the security environmentbecame severely degraded and I wasunable to do what I thought best or themany wounded.Our sta could not cross town to get towork. The lights went out when the gen-erator was hit by a stray bullet. Armed menentered the hospital and threatened someo the nurses. Later, I was struck by a simple act: just asthe need or health care peaks, confictand insecurity make the delivery o andaccess to health-care most di cult. Thisis not only because wounded people re-quire emergency surgical care but alsobecause confict makes whole populationsvulnerable to disease. Cholera epidem-ics are requently associated with confictbecause thousands o people’s access toclean drinking water may be impossible es-pecially i whole populations are displaced.Even during times o peace, many commu-nities have only basic health care; this maysimply evaporate when confict erupts. Insecurity o health care takes many orms.Hospitals are hit by shells and mortars.Health-care workers are threatened and, inthe worst cases, killed or kidnapped. Am-bulances are ambushed. These incidentsare the most obvious and are most likely tobe reported on by the media. However, or each event that gets mediaattention, there are thousands o others.Ambulances are oten held or hours atcheckpoints. Soldiers enter hospitals look-ing or wounded enemies and disruptinghealth care at the same time. Authorities
RED CROSS RED CRESCENT
Health care: most dif cultwhen it is most needed
may deny a particular ethnic group ac-cess to a hospital. Armed groups may stealhospital supplies. All o these are obstacleswhich impinge on the right o woundedand sick people to health care. It is becoming clear that the insecurity o health care is a major — but largely unrec-ognized — humanitarian issue. For eachviolent event bringing insecurity to health-care acilities or workers, there is a ‘knock-on’ eect through which the wounded andsick suer even more because health careis rendered impossible or, at best, di cultto provide or access. Yet outside the humanitarian sector, thisproblem is barely acknowledged, under-stood or addressed — either by the publicat large or by those obliged to protect thewounded and sick, hospitals, ambulancesand health-care workers under interna-tional humanitarian law. This is why the health unit o ICRC’s assis-tance division began in July 2008 to collectreports o violent events, including eventsinvolving threats o violence, rom 16countries where confict had an impact onhealth care delivery. The data were drawnboth rom the media reports (news wires,newspapers and major TV or radio newsoutlets) and rom the internal and publicreports o humanitarian agencies. The resultant ICRC report,
Health care inDanger: a sixteen-country study
, released inAugust 2011, collected, processed and ana-lysed a total o 1,342 reports detailing 655separate events o violence or threats o vio-lence aecting health care over a 30-monthperiod. In that time, the study revealed that733 people were killed and 1,101 injureddirectly as a result o an incident or attack related to armed violence. Aside rom suchstatistics, the study revealed real threats tohealth care, as well as serious vulnerabilities,in countries where the ICRC is operational.(See also pages 4 and 5.) How should the Red Cross Red CrescentMovement respond? First, it is critical thateld activities increase in scope to tacklereal, everyday issues about the saety o health care acilities and personnel. Thisinvolves closer cooperation with NationalSocieties. Second, the Movement mustintensiy its diplomatic eorts to securea powerul resolution at the 31st Interna-tional Conerence with buy-in rom majorstakeholders. Third, we must use publiccommunication to build a community o concern about insecurity o health careand a culture o responsibility among thosewho can make a real dierence. Those who take up arms or whateverreason must understand and ull theirobligation to respect international human-itarian law and protect both those whoneed health care as well as those who risk their lives to deliver care when and whereit’s needed most.
Robin M. Coupland
Robin M. Coupland is a ormer ICRC feld surgeon andnow works as a medical adviser or the ICRC in Geneva.
Insecurity of health careis a major — but largely unrecognized — humanitarianissue.
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. All views expressed in guest editorials arethose o the author and not necessarily those o theRed Cross Red Crescent Movement or this magazine.