Attacking healthcare must not become the norm

Our Researcher Audrey Mahieu is part of the “Researching the Impact of Attacks on Healthcare” (RIAH) programme. In this blog, she discusses the need to bring evidence on the longer-term and wider impact of attacks on healthcare, and her own experience in Central African Republic.

In May 2016, the United Nations Security Council unanimously adopted Resolution 2286, strongly condemning attacks and threats against health workers, patients, medical facilities and their means of transport and equipment. The resolution was a fierce reminder of the 1949 Geneva Conventions that demanded that all parties to armed conflict respect and protect healthcare in all circumstances. Over the years, however, attacks on healthcare have not ceased. If anything, they have become more common.

In some countries, targeting healthcare is a deliberate military strategy. This is described as the weaponisation of healthcare, a strategy of using people’s need for healthcare as a weapon against them by violently depriving them of it. In countries like Syria, the Red Crescent symbol – supposed to protect health facilities, health workers and medical vehicles from attacks – has become a target for armed groups. Ambulances need to be camouflaged with mud, and hospitals are built underground.

“Documenting the nature, the scale and the consequences of attacks on healthcare is key to improve the resilience of health systems, to inform accountability mechanisms and to provide evidence for advocacy efforts aimed to prevent attacks.”

Despite such attacks violate International Humanitarian Law (IHL), there is a risk of them becoming inherent to the conduct of hostilities. There is a risk of them becoming the norm. It is, therefore, essential that the international community keeps documenting and denouncing these attacks and makes every effort to prevent them.

As a researcher of the Geneva Centre of Humanitarian Studies, I am honoured to be part of the “Researching the Impact of Attacks on Healthcare” (RIAH) research programme. RIAH brings together an interdisciplinary team from different research institutions to improve our collective understanding of the longer-term and wider impacts of attacks on healthcare on populations in armed conflicts. Documenting the nature, the scale and the consequences of attacks on healthcare is key to improve the resilience of health systems, to inform accountability mechanisms and to provide evidence for advocacy efforts aimed to prevent attacks.

Ten years ago, I worked as a humanitarian health project coordinator in a very remote area of the Central African Republic (CAR). The ambulance of the health centre was the only vehicle in the district. It was used to refer patients to the capital, Bangui, and bring back medicines and supplies.

With the help of the INGO I worked for, the health centre managed to set up a cost recovery mechanism. Members of the community were elected to form Health Facilities Management Committees and were trained to manage the resources. Consultation fees and drugs prices were increased progressively to give time to the community to adapt and accept the changes. This way, health facilities moved from being subsided by the INGO to a financial autonomy.  Achieving this financial autonomy was the “Holy Grail” to sustain the delivery of healthcare services after the departure of the INGO. Unfortunately, in 2013, the armed conflict in the area intensified. Armed groups looted and burnt health facilities. There was nothing left. All the efforts made by the community during all these years were reduced to nothing. Most importantly, people no longer had access to healthcare. 

Some attacks are “opportunistic”: they do not target intentionally healthcare, but the consequences on the population’s health are equally dramatic. Using the example I mentioned above, stealing the only ambulance of a health district has disastrous consequences. Patients, medicines and supplies cannot be transported anymore. This has an immediate impact with populations not accessing the needed care, but it has also longer-term effects. For example, people living with HIV and tuberculosis may have their treatment interrupted, which increases the likelihood of developing resistance to their treatment. This has an impact as well on health-seeking behaviour, pushing people to buy illegal street medicines. In the area where I worked in CAR, it took three years to achieve a sustainable and autonomous delivery of healthcare services. How many years will it take to regain it? Eight years later, CAR is still riven by armed conflict and attacks on healthcare have become more and more violent.

While recent studies have focused on documenting instances of attacks and their immediate effects, there is still a lot to do with bringing evidence on the longer-term and wider impact of attacks on healthcare. With RIAH, I am conducting case studies on the impact of attacks on healthcare in Afghanistan and the Central African Republic. In January 2021, we published a working paper on conceptual issues and methodological approaches to evaluating the wider and longer-term impact of attacks on healthcare in conflict. The paper is aimed to help researchers reflect on key issues when studying the impact of attacks on healthcare, such as the different types of attacks and the different dimensions of healthcare to consider, the perspective from which to approach the study – whether it be IHL or Human Rights –  the delimitation of the scope of impacts, the characteristics of longer-term impacts, and the different study designs and methodologies that could apply. This paper is a first version, we aim to update and complement it as we learn from the case studies.

By providing evidence on the longer-term and wider impact of these attacks on healthcare and looking into the mitigation measures, our findings will help strengthen the health system resilience, support the work of organisations promoting IHL among armed groups and contribute to the advocacy efforts with the international community to prevent these attacks.

Attacks on healthcare in conflict must not become the norm. We must keep on documenting and denouncing them. We need to make every effort for the rules of war being respected.