Tuesday, 16 April 2013

Healthcare Under Attack

The right to health is understood as the right to have access to medical services. While this legal aspect is applicable at all times, including during armed conflicts, many of today's armed conflict have been characterised by a breach of the International Hummanitarian Law.

The wounds inflicted by armed conflicts on heathcare facilities, healthcare providers and those receiving the care are the affronts to every impulse that inspired the development of International Humanitarian Law.
The development of International Humanitarian law, in particular through the Geneva Conventions, was based on moral and humanitarian concerns that seek to limit the barbarity of war.

The law protects life and health. It alleviates human suffering in situations of armed conflict. Those protected are those who do not participate in the fighting:- civilians, medics, and aid workers, and those who nolonger fight: wounded, sick or shipwrecked troops or prisoners of war.

Several articles in the Geneva Conventions and their additional protocols protect medical structures, medical personnel and those requiring medical care. In addition, the principle of medical neutrality ensures protection of medical personnel, patients, facilities, and transport from attack or interference, unhidered access to medical care and treatment; the humane treatment of all civilians, and indiscrimatory treatment of the injured and the sick.

Contemporary armed conflicts often turn civilians, health facilities and health workers into delibarate targets. The conflicts impede the delivery of healthcare services that are essential for a healthy living.
Through displacement and trauma, armed conflictsincrease the need for health services. At the same time, the services are distrupted by the conflict. Destroying health facilities, for instance, undermines the very foundation of human life.
People die in large numbers not necessarily because they are direct victims of a roadside bomb or a shooting, but because an ambulance fails to get there in time, healthcare workers are prevented from doing their work, hospitals destroyed or simply because the environment is too dangerous and hostile for effective healthcare to be delivered.
In most cases, health workers carryout their life saving work in extremely difficult situations.

A major impact of armed conflicts is the loss of health workers. These medical care providers flee to neighbouring countries as refugees or become displaced in their own countries. In countries like Syria and the Democratic Republic of Congo (DRC), authorities have griviously violated the law of armed conflict by targeting and killing medical personnel.
Volunteers and first-aid providers have in the last two years been killed in Syria despite wearing uniforms clearly marked with the neutral sign of a red crystal. These deaths confirm the painful truth that healthcare is often the first victim during armed conflicts.

Violence, both real and threatened, against healthcare personnel is the most serious and least recognised humanitarian issue facing the world today. However, protections do exist for the provision of medical care in times of conflict. The Geneva Conventions and their additional protocols set out the right of the wounded and sick, combatants and civilians alike, to be protected during armed conflicts and to receive timely medical treatment. This means that deliberate assaults on healthcare personnel violate the International Humanitarian Law.

Anytime a physician is kidnapped, attacked or killed, the provision of healthcare is adversely affected. Children become vulnerable to mulnutrition and infections such as pneumonia, malaria, tetanus and meningitis. This is occassioned by the absence of working medical personnel. This therefore exposes them to great danger, including death.

In addition, influx of weapons that are used to terrorise, injure and kill civilians creates even more danger for healthcare providers who cannot protect themselves. They are not only unprotected from conflict but also specifically and explicitly targeted. An example of this illegal situation is in Mogadishu, Somalia.
In the recent years, healthcare workers in Mogadishu have been subjected to harassment, arrest, imprisonment and even death for complying with their ethical duty of providing heathcare- irrespective of the political, religious or other affiliation and allegence of the patients. Worse still, Syrian prisons contain tens of doctors, nurses and intensive care specialists who have been detained while performing their respective duties.
This is a clear violation of the 1997 Additional Protocil I, which requires that all the wounded, sick and shipwrecked, to whichever party they belong, should be respected and protected. In all circumstances, they must be treated humanely and receive the medical care and attention of their condition.

For the right to health to be protected, health services must function normally and populations allowed to access them. However, in violation of the International humanitarian Law, most of today's armed conflicts attack health facilities (hospitals, dispensaries and clinics).
Moreover, the different violations of physical and mental integrity of persons: torture, ill-treatment, sexual violence, mutilations and attacks on the social integrity of populations (ethnic purges, forced resettlement and breaking up of families) all have dramatic consequences on health. Girls and women are particularly at risk since they are less likely to be capacitated to protect themselves from violence; being that combatants use rape as a tool of violence.

Apart from the psychological effects that accompany rape, the victims are exposed to serious infectious diseases such as HIV/AIDS and heavy blood loss which in the absence of blood transfusion or basic surgery, can be life threatening. There is also a high prevalance of septic abortion following self or non-professional attempts to end the pregnancies.

Such medical complications can only be treated in medical strucures such as hospitals, and apart from the fact that hospitals may have been incapacitated, there is also the great risk of travelling to access them for treatment. The absence of functional health structures therefore results to numerous maternal deaths and cause permanent disabilities from untreated complications.
Whilst primary healthcare can do much to prevent such eyesores through treatment, inevitably there will be a percentage who, when ill, will require hospitalisation. This is particularly the case for most armed conflicts, where patients are hopitalised due to their complex and extreme medical conditions.
Damage on hospitals, clinics and dispensaries therefore perpetuates human suffering which contravenes the four Geneva Conventions of 1949 supplemented by their additional protocols. In particular, the law provides for the protection of hospitals, medical apparatus and instruments used exclusively in caring for the sick.
Human beings and especially the female population depend on these medical elements for their well-being. Health education, care, counselling and treatment are particularly crucial for those of them who have been raped or forced into prostitution.

Another typical violation, more often committed with impunity, is the unlawful killing of patients receiving medical care. Patients in the Democratic Republic of Congo (DRC) have previously been dragged from their hospital beds and killed.
Such actions are generalised violence directed towards the patients to achieve a political goal: ethnic cleansing, government destabilisation, control or forced movement of populations, or demoralisation of a population sympathetic to an enemy.
The warring factions attack the wounded and sick individuals, threaten, intimidate and unlawfully use them for exacerbating conflicts. In effect,this phenomenon on health patients results in the use of patients as human shields.
The International Humanitarian Law prohibits causing great suffering or serious injuries to the wounded and the sick. As a matter of fact, parties of the conflict must protect these people from pillage and ill-treatment. This means that patients posses a significant risk as compared to other people in armed conlicts. Warring factions are therefore required by law to demostrate humanity in the fullest sense of the term. They are obliged to keep the humanist vision of a world which dignity of an enemy deserves as much respect as that of a friend or indeed as one's own dignity.

The rule applying to ambulances or other ground vehicles are also captured in the International Humanitarian Law. Like patients and medical personnel, they “may in no circumstances be attacked,” but must be, “respected and protected,” in line with articles 35 and 19 of the first Geneva Convention. However, today's armed conlicts belong to a family where the Geneva Conventions are honoured more in breach than in observance. Even when medical transports are clearlly marked with a red cross and are obviously and purely carrying casualties and medical personnel, they are often shot at and burned down. Attack on such vehicles present far-reaching secondary and knock-on effects that deny the civilian population the much needed medical care.

Besides poor infrastructure and other logistical obstacles that have obstructed the delivery of humanitarian aid, restriction on nationwide movement has even complicated trasportation of medical supplies. In blatant disregard to the law of war, conflicting parties in the Democratic Republic of Congo for example, have literally turned away ambulances marked by internationally recognised symbols at their check points.
Heavy fighting and lack of security has also cast a dark shadow on the delivery of drugs and pharumacetical equipment to hospitals. In Ivory Coast, medical structures have closed down as a result of lack of medical supplies occassioned by restriction of movements and transport.

The obstruction of medical supplies also compromises the quality of heathservices. Health personnel lose experience through non-practice of skills occassioned by lack of equipment, medicine and phaumacetical supplies. In this case, an armed conflict becomes a humanitarian catastrophe, where needs outstrip the aid that is being provided.
Article 55(1) of the 1949 Geneva Convention (IV) prescribes that the party occupying a territory has a duty of ensuring supply of relief and medical supplies. It incurs a definite obligation to maintain at a reasonable level the material conditions under which the population of the occupied territory lives. Furthermore, the belligerent party, at good will, could distribute medical supplies without undue difficulty. Yet, it persues a deliberate policy of denying supplies to those inneed. This is categorised as a war crime persuant to article 8(b) (xxv) of 1998 Rome Statute of the International Crimminal Court (ICC). This, among others, are just but a tip of the ice-berg on the challenges facing the delivery of healthcare during armed conflicts.

The expectation that countries or non-state factions involved in a conflict will adhere to the existing medical ethics, in line with the International Hummanitarian Law (IHL), has proved to be inoperable. The Geneva conventions of 1949 and their additional protocols of 1977 contain statements designed to protect healthcare. However, these conventions have been violated with impunity in most armed conflicts. Recognising the challenges involved in providing robust information, regular and systematic documentation of attacks on healthcare is lacking.
International Crimminal justice institutions have potential power, but do not operate in the time frame necessary to protect healthcare during armed conflict. Peace-keeping forces have been themselves involved in grand-scale violation and abuse of healthcare. As a matter of fact, they have been inadequately mandated with regard to how far they can act in protecting civilian healthcare.

Unless the world wakes up to this reality, many innocent lives will forever be lost.

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