Attacks on doctors rise as rules of conduct in conflict zones are abandoned

BMJ 2012; 344 doi: (Published 24 April 2012) Cite this as: BMJ 2012;344:e2973
  1. Nigel Hawkes
  1. 1London

Modern conflicts are placing healthcare and healthcare workers in unprecedented danger, as the rules of humanitarian conduct are abandoned and attacks on doctors, nurses, and hospitals multiply, a conference in London heard this week.

Between the middle of 2008 and the end of 2010 the International Committee of the Red Cross (ICRC) catalogued more than 600 attacks on healthcare facilities and workers—but, bleak as the figures are, they underestimate the full scale of the problem, which as well as costing many lives undermines and weakens healthcare systems in some of the world’s most needy countries.

The one day meeting—“sounding an alarm and calling for action,” in the words of Geoff Loane, the ICRC’s head of mission in London—was organised by the ICRC, the British Red Cross, the World Medical Association, and the British Medical Association and brought together more than 100 experts.

Nobody questioned the scale of the problem, though several speakers called for better documentation. Andy Haines of the London School of Hygiene and Tropical Medicine said that better data coordination and better measures of the true scale of the impact would make the case stronger and show that “millions are at risk” as a result.

A start has been made by the ICRC in its recent report Health Care in Danger, which lists some of the more egregious examples. In Gaza City in January 2009 the Red Cross and the Red Crescent discovered four young children crouched beside the bodies of their mothers. The house in which they were sheltering had been shelled four days earlier, but ambulances had not been allowed through checkpoints to bring aid to the wounded, nor had the soldiers manning those checkpoints responded to the cries of the injured.

Later in 2009 a hospital in northern Sri Lanka was shelled, killing and wounding many of the 500 patients; and in December 2009 a suicide bomber blew himself up at a university graduation ceremony in Mogadishu, Somalia, killing medical students whose skills the country desperately needed.

Nor have attacks diminished since the report was published. In the Democratic Republic of Congo, said Paul-Henri Arni of the ICRC, there have been more than 15 acts of violence against healthcare personnel since November last year. And just last week, he said, Médecins Sans Frontières had been forced to abandon a 56 bed hospital in Khost, Afghanistan, opened only in March, after an explosion.

Although reports of such incidents often focus on the effects on foreign doctors and nurses, the effect on indigenous staff can be much greater. Peter Hill of the University of Queensland said that healthcare systems in such countries are fragile and already have problems that are compounded when they become the target of attacks.

“Health coverage contracts; gaps are filled but not necessarily by the right people; the quality of training suffers; and public health measures such as vaccination campaigns may be abandoned,” he said. Well meaning foreign interventions may not help. “Free services provided by non-governmental organisations may compete with and disrupt existing local systems.”

The London meeting was one of a series planned by the ICRC designed to produce practical recommendations that can be applied at a local level.

Although such attacks on healthcare staff and facilities can induce “a sense of inevitability and powerlessness,” said Leonard Rubenstein of Johns Hopkins Bloomberg School of Public Health in Baltimore, there had in fact been relatively little study of the causes and motives behind the attacks and of what works in preventing them.

Some examples exist of simple persuasion achieving results. The international force in Afghanistan agreed to revise rules on the use of private taxis as makeshift ambulances after General Stanley McChrystal, then commanding the force, was persuaded that roadblocks were preventing injured people from reaching hospital.

And the Taliban leadership in the same country condemned the use of an ambulance by one of its own suicide bombers, declaring the act “perfidy” and promising that it would not happen again. Diplomacy also played a part in persuading the government of Bahrain to backtrack on its legal threats against staff who had treated injured demonstrators.

International laws designed to protect humanitarian action exist, and several participants, including Rudi Coninx of the World Health Organization, called for more prosecutions of governments to set an example. “Prosecutions are rare,” said Rubenstein. But dealing with “non-state” actors was agreed to be much more difficult.

WHO has begun collecting data on a global level, and the 2012 World Health Assembly will discuss the issue. But if the campaign is to be more than “a launch, a lunch, and a logo” in the words of one of those present, greater coordination was needed among the many organisations with an interest in it. The first step, said Coninx, was to gather the data.


Cite this as: BMJ 2012;344:e2973


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