Attacks on Healthcare are Beyond the Limits of War

In the spring of 2016, the 15 members of the United Nations Security Council adopted Resolution 2286, which had been cosponsored by more than 80 Member States. The issue behind the Resolution, which brought such overwhelming support from a sometimes fractious body, was the increase in attacks on medical staff and facilities in conflict zones. The Resolution was broad, covering attacks or threats against patients, personnel, transportation mechanisms, and medical facilities. It emphasized that such attacks are not only detrimental to those immediately affected, but for the long-term consequences on already fragile health outcomes and systems. Of course, these protections are not new, codified by the Geneva Conventions in 1949 and the Additional Protocols from 1977 and 2005. However, an unprecedented number of attacks on health, many of which were occurring in the same few countries, led to this new push to pressure antagonists to cease their attacks and provide medical and humanitarian personnel with their due protections under humanitarian and human rights law. “Even wars have rules,” said then-UN Secretary-General Ban Ki-moon.

Despite the strong words from the UN and organizations like Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC), little action was prompted by the newfound interest in health-related attacks. As a result, attacks have only increased since the year before the resolution was passed; while there were 256 attacks in 2015, there were 302 recorded attacks in 2016, 322 in 2017, and 149 attacks in the first quarter of 2018 alone. Not surprisingly, attacks in Syria propel the bulk of these numbers, with the Central African Republic, Pakistan, Libya, and Nigeria rounding out the top five countries featuring attacks in 2017. Of course, with the imperfect methods of collecting data in these fragile countries, as well as fears of witnesses or survivors to speak out about perpetrators, it is likely that more threats and attacks exist than can be captured by these data. In fact, as attacks continue and even proliferate, medical workers who risk their lives documenting attacks and their outcomes have questioned whether their work is worthwhile.

In these fragile countries, where access to health care is vital in maintaining a civilian population’s ability to stay, fifty-six health programs were closed due to increased insecurity to the facilities and staff in 2017. Ambulances are destroyed or hijacked. Health workers are arrested or kidnapped. Some countries have attacks that are more specific to the nature of their conflict- for example, the occupied Palestinian Territories, where movement restrictions are common, reported the highest numbers for obstruction to the provision of healthcare. In countries affected by polio, such as Nigeria, vaccination efforts are common targets of attacks. Countries where terrorist groups such as the Islamic State reside see reports of fighters disguised as medical personnel to attack or occupy hospitals. While the mechanism of attack differs, the outcomes are the same: terrorized civilians, diminished health infrastructure, demoralized health workers, prolonged conflict, and a frustrated but ultimately immobilized international community.

Despite these grim reports, there are still actions that can be taken by stakeholders of all levels that can hope to at least minimize these attacks. A two-pronged approach is required: one focusing on investigation and the other on penalties. First, a robust investigation and data collection mechanism must be developed and, most importantly, implemented where needed. MSF president Joanne Liu urged the UN Security Council to conduct robust, independent, and impartial investigations of such attacks, noting that previous calls for such initiatives have been disregarded. In almost all cases where investigations are conducted, they are led and settled by the perpetrator themselves. Independent, well-funded, and rigorous investigations, coupled with new methods of surveying and interviewing witnesses and survivors, should be supported by the UN and civil society in such nations. Additionally, it is apparent that such attacks persist due to the lack of consequences on offenders. Perpetrators on or allied with members of the UN Security Council would be tasked with condemning or punishing themselves and each other, unlikely in the current environment of norms in the international order. While a strengthening of the commitment of states to international humanitarian law is long overdue, in the meantime, action is not necessarily limited to the walls of the UN. Some humanitarian organizations, such as Oxfam, are taking a more direct approach, petitioning states to stop selling arms to countries that have used these weapons to attack civilian infrastructure like hospitals.

Addressing the World Humanitarian Summit in 2015, ICRC President Peter Maurer said “Wars without limits are wars without end. Limiting wars is an intrinsic test of our civilization, and probably of all civilized worlds.” Public health advocates must insist that the international community draws a line on protecting those serving the world’s most vulnerable in the most challenging environments imaginable. While war may be inevitable, the erasure of the human rights of those involved is entirely preventable through collective advocacy and action. Much of the needed action lies at the institutional level, but individuals concerned with these issues can follow social media campaigns like #NotATarget, started by the UN and the theme of World Humanitarian Day 2017, or support NGOs tasked with delivering healthcare in conflict environments, either on the local level or with international organizations such as the ICRC and MSF. Lastly, organizations like Safeguarding Health in Conflict, Insecurity Insight, and Physicians for Human Rights produce data and reports about these issues that can be used to direct advocacy or propel research efforts.

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Conference Reflections: Emergency Preparedness & International Health – Different Fields, Same Goals

Last week I was given the opportunity to attend the Preparedness Summit in Atlanta. This conference is the first and longest running national conference that discusses and revolves around the world of public health preparedness (think: natural disasters, medical countermeasures, flu, Zika and Ebola responses, biological threats and much more). There were many different opportunities to learn about preparedness activities including plenaries, small discussions, learning sessions and networking with local, state and federal partners. It was overwhelming, but in a good way!

As an epidemiologist, I have some experience and background in public health preparedness activities, but my main interests and time have always been spent with infectious diseases and global health initiatives. When I worked for the state health department, I actually was on a team that was half epidemiologists and half preparedness staff and we continually supported each other’s activities. Those experiences helped me with preparedness lingo and acronyms used during the conference so that things didn’t go completely over my head. However, I would not consider myself a preparedness expert by any means and soaked up as much as I could from the various sessions I attended.

One of the most exciting activities from the week was visiting the Emergency Operations Center (EOC) at the Centers for Disease Control and Prevention (CDC). This EOC is the center that gets activated in a public health emergency and where experts gather and get ready to respond. The main room of the EOC is spacious, with many computers, television screens and telephones set up and ready to be filled with points of contacts from different divisions and organizations. When there’s not an emergency response going on (like on our tour), it’s actually pretty quiet. However, staff are still on call working to monitor information and sift through potential threats. During a response, I’m sure the place is bustling with people, calls, information sharing and meetings. It was a neat experience to be in the center communication hub where past emergency responses like Hurricane Katrina in 2005 or the 2014 Ebola outbreaks took place.

I did some research after attending the summit and found that the EOC has become an integral part of meeting the goals of the “Global Health Security Agenda (GHSA)”. This agenda is focused on “accelerating progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Over 50 countries have joined in partnership with the U.S. to meet this objective and the CDC aims to activate the EOC and respond within 2 hours of any mandated public health emergency. There’s even a fellowship offered by the CDC called the “Public Health Emergency Management Fellowship” that provides an opportunity for public health workers to learn and train over a four-month course then go back to their respective countries and create their own local EOCs. Emergency management experts can also be sent to these countries and help guide and train responders in their own environment if needed.

This post-tour research made me start thinking about the importance of the EOC and preparedness in relation to international health. Public health threats (like pandemic flu, Zika, Ebola) of any degree can happen at any time at the local, state, national, or international level. Bill Gates recently spoke out about the necessity of being prepared for public health threats such as these at the Massachusetts Medical Society 2018. He stressed how unprepared we are for the next epidemic and the world’s need for a “global approach” with “better tools, an early detection system, and a global response system”. Gates’ is most likely alluding to the poor handling of the Ebola outbreaks in the recent past. These are a perfect example of why the field of preparedness is so important to global health. During Ebola, public health response was “too late” and there were too many “deaths that could have been prevented”. There were many disagreements among global health leaders over things like travel bans, how to handle public panic and how to best respond. The aftereffects of the outbreak point to the integral link between a strong preparedness field and international health that was lacking. Gates’ argues that we weren’t prepared to handle prior outbreaks, but we are capable and should spend time and money on planning and preparing for similar epidemics in the future.

Overall, these events – the conference, EOC tour and recent news and outbreaks – have helped hit home that these different public health fields, although working in slightly different capacities, are really aligned and influential on each other. Ultimately, preparedness and global health are working to reach the same goals of keeping our planet safe and healthy and we must first be prepared for any global threat in order to achieve these goals. Today, I feel refreshed in my perspective of the field and inspired and hopeful of future preparedness efforts. I no longer feel that preparedness and international health belong in the different boxes or divisions I’ve created in my mind, but as two parts to the same path.

I challenge other public health workers to also think about the important link between preparedness and global health and advocate for changes that strengthen this partnership. The Preparedness Summit conference is a great starting place and I encourage all fields of public health workers to look into it! I truly believe the more you learn, the more you see how everything is connected and the better you are able to achieve your public health goals … and maybe find some new teammates from other fields to help you along your journey, too.