Delivering healthcare in situations of conflict or violence

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4671 (Published 10 August 2011) Cite this as: BMJ 2011;343:d4671
  1. Vivienne Nathanson, director of professional activities
  1. 1BMA, BMA House, London WC1H 9JO, UK
  1. vnathanson{at}bma.org.uk

The International Committee of the Red Cross sets out how to do it

This week the International Committee of the Red Cross (ICRC) launches a global campaign—“It’s a matter of life and death”—which aims to improve security and delivery of effective and impartial healthcare in situations of armed conflict and other contexts of widespread violence.1 This is timely. Events in Libya, Bahrain, Yemen, and elsewhere make it clear that when people take up arms for whatever reason, violence perpetrated against healthcare facilities and personnel is all too common.

In such contexts, healthcare is often suspended, withdrawn, or impossible. The wounded and sick are denied effective healthcare when hospitals are rendered non-functional by explosive force or forcibly entered by fighters; when ambulances are hijacked; and when healthcare personnel are killed, injured, threatened, kidnapped, or arrested for treating insurgents.

Ultimately, the ICRC campaign is about something intuitive to all health professionals who have worked in a context of conflict: that a secure environment is a prerequisite for the delivery of healthcare.2 It is surprising that currently no mechanism exists for reporting violent events that affect healthcare.3

In a study of violent events affecting healthcare, the ICRC makes the case—and convincingly so—that insecurity of healthcare is one of the biggest, most immediate, and yet unrecognised humanitarian problems in today’s conflicts.4 Using all possible sources, the ICRC has collected and analysed reports pertaining to 655 violent events that have affected healthcare in 16 unnamed countries where it is operational. The study details the different types of perpetrators of violence, the means used by the perpetrators, who is affected, and in what way people are affected. The main findings ultimately relate to the nature of the threats to healthcare and the vulnerabilities of healthcare in the contexts concerned, and they are divided into three main categories (box).

Reports of violent events that have affected healthcare

Hospitals and other healthcare buildings
  • Use of explosive weapons by state armed forces during active hostilities, which hit (intentionally or unintentionally) healthcare infrastructure, and at the same time kill and injure people

  • Armed entry into healthcare infrastructure by state actors (state armed forces and police), with the principal purpose of arrest or interrogation of the wounded and sick

  • Armed entry into or takeover of healthcare infrastructure by armed groups to harass personnel, to steal materials, or to occupy the buildings or vehicles for their own medical or tactical purposes

Healthcare transportation
  • Attacks on healthcare vehicles and personnel en route by state armed forces or armed groups

  • Damage to ambulances caused by state armed forces and to a lesser extent armed groups using improvised explosive devices

  • Harassment and delay of ambulances or other vehicles transporting wounded or sick people at checkpoints by state armed forces and police

Healthcare personnel
  • Use of explosive weapons by state armed forces during active hostilities that results in death and injury

  • Kidnapping of healthcare personnel from their place of work by armed groups

  • Killing of expatriate healthcare personnel by armed groups

  • Arrests of healthcare personnel

  • Threats by a variety of actors (usually representatives of governments, insurgents, or similar groups)

The importance of the study goes beyond identifying the threats to healthcare and the vulnerabilities of healthcare. Each such incident will have a knock-on effect that constrains healthcare in some way for tens, hundreds, thousands, or even tens of thousands of people. In addition, as the authors point out, the study will have underestimated the number of and effect of such events. The methods used may have captured most major events, such as the killing or kidnapping of healthcare workers, but they will not have captured the thousands of small security events that, together, generate a climate in which it is impossible or at best difficult to deliver healthcare.

As a result of the study, the ICRC will actively promote appropriate measures to improve security and the delivery of healthcare in its entire field of operations. For example, hospitals and all those in them urgently need better protection from the effects of explosive force. Safeguards must be put in place to deter armed entry into any healthcare facilities. State armed forces must be better trained to organise and manage checkpoints so that ambulances are given rapid and unhindered passage.

These measures clearly do not lie within the health community but principally in the domain of law, politics, humanitarian dialogue, and operating procedures of military bodies. The motor for action outside the health community is routine, consistent, and credible information gathering about violent events that affect healthcare. The acknowledgement of the problem and the governmental interest shown at the World Health Assembly in May of this year is encouraging.5

The ICRC’s study and work highlights two broad roles for the health community. Firstly, healthcare professionals who are likely to be working in insecure environments must have adequate training on how medical ethics apply in these different and difficult circumstances. Secondly, there is a need to build a community of concern that goes beyond the health community to those who are in a position to ensure security of healthcare in places and situations where they are most needed.


Cite this as: BMJ 2011;343:d4671


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; VN works for the BMA, which is going to be involved with this ICRC campaign.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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