Protecting and Prioritizing Healthcare in Conflict

People gather among the rubble of a Médecins Sans Frontières hospital hit by airstrikes. Maaret al-Numan, Syria, February 15, 2016. (Ghaith Omran/AFP/Getty Images)

There have been several high-profile cases of healthcare facilities being attacked in conflict situations since late last year. The bombing of a Médecins Sans Frontières (MSF)-run trauma center in Kunduz, Afghanistan, in October 2015 received worldwide attention. On February 15 this year it was reported that two Syrian hospitals had been attacked, with Physicians for Human Rights declaring that the resulting nine deaths made it “the deadliest day for medical personnel throughout the conflict.” Most recently, another MSF-backed hospital in Aleppo, Syria, was hit by airstrikes as part of what The Guardian called “a broader pattern of systematic targeting of hospitals by the government of Bashar al-Assad.”

These instances are in fact the tip of a much larger iceberg. The International Committee of the Red Cross’s (ICRC) Health Care in Danger project seeks to highlight the frequency of such attacks and champion greater respect for international humanitarian law (IHL) provisions designed to ensure access to, and safe delivery of, healthcare.

In what was a major breakthrough by the ICRC, MSF, and other advocates of greater protection of health services during conflict, the United Nations Security Council on May 3 convened its second meeting on the protection of humanitarian workers, specifically looking at healthcare professionals and medical facilities. Addressing that meeting, MSF President Joanne Liu urged the Council to more seriously address the issue. “We can no longer assume that fully functioning hospitals—in which patients are fighting for their lives—are out of bounds,” she said. “Hospitals and patients have been dragged onto the battlefield.”

The meeting led to the adoption of Security Council Resolution 2286, outlining the need for all conflict actors to fulfill their obligations under IHL by not attacking medical facilities, training their personnel on the laws of war, and protecting humanitarian workers by respecting the neutrality and impartiality of medical facilities. The Security Council agreed that the UN secretary-general would provide them with regular reports on this matter and “bring to the attention of the Security Council situations in which the delivery of medical assistance to populations in need is being obstructed by parties to the conflict.”

The resolution also outlined a potential role for UN peacekeepers in healthcare, expressing “the intention to ensure that the mandates of relevant United Nations peacekeeping operations can, where appropriate and on a case by case basis, help to contribute to a secure environment to enable the delivery of medical assistance, in accordance with humanitarian principles.”

This resolution has the potential to have a major impact both in terms of drawing attention to deliberate attacks on medical facilities that do not hit the headlines and also in raising the broader issue of healthcare needs in conflict and fragile situations. As Annie Sparrow, Assistant Professor at the Icahn School of Medicine, argued in a recent interview on the Global Observatory, it is not only direct attacks on medical facilities—serious though these are—that endanger health in conflict. She highlighted that conflict also creates “the perfect conditions for epidemic disease.”

Dr. Sparrow was particularly critical of the failure of the UN’s High Level Panel on the Global Response to Health Crises, which delivered its report in January 2016, to take the impact of conflict into due consideration.

We contend that Resolution 2286, while primarily concerned with deliberate attacks on healthcare workers and facilities, could nevertheless go some way toward addressing these concerns. Although the Security Council may not itself be the body best placed to respond to every health crisis, the secretary-general’s responsibility to report to it on health matters in situations of armed conflict could improve the chances of early detection and response in three specific ways.

First, it could help promote more timely UN-wide responses by ensuring that both technical and political actors within the UN system are alert to the early signs of (and even the potential for) disease outbreaks. As we argue in a recent paper, for too long the technical delivery of healthcare has been separated from the political process of healthcare reform and delivery in fragile and conflict situations. While the World Health Organization has been widely criticized for its slow response to the recent West African Ebola outbreak, the UN-wide response was even slower to get off the ground. But the reverse was also the case: prior to Ebola, the Security Council was receiving regular political situation reports on Guinea and mission reports from Liberia that did not seem to prompt a system-wide awareness of the potential for the political context in these countries to compromise health situation reporting, healthcare delivery, and healthcare response.

Second, isolated outbreaks of wild type poliovirus—a virus that has been close to global eradication—among Syrian and Iraq refugee populations over the past four years reveals the dramatic reversals that conflict can impose on global health campaigns and also the threat to the health of vulnerable populations, particularly children, not only from the fighting itself but from the wider breakdown of healthcare services. Given infectious disease outbreaks can be more difficult to contain in politically fragile contexts, annual country-specific reports submitted to the Security Council could serve to highlight the “response gap” between healthcare staff, health logistics, and humanitarian corridors. This should mean that those who inform these reports, like the UN Secretariat’s Inter-Agency Standing Committee, should be better placed to predict and prepare for a better response to early outbreak reports.

Finally, reporting has the potential to clarify responsibilities and open up information sharing within UN peacekeeping missions. We have found that information about the health-related activities of UN missions is quite often limited, even though there have been concerns raised—including by the UN’s Office of Internal Oversight Services—that the quality of care provided to civilian populations can sometimes be problematic. The secretary-general’s country-specific reporting to the Security Council will often relate to situations where UN peacekeepers are deployed and are providing medical care. The new provision under Resolution 2286 to identify where peacekeeping mandates could help secure such assistance may provide that essential, but presently missing, additional step towards standardizing the quality of healthcare being provided by UN missions in fragile situations.

Sara E. Davies is Associate Professor in the Centre for Governance and Public Policy, Griffith University. Simon Rushton is a Faculty Research Fellow in the Department of Politics, University of Sheffield.