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Dicing with death: doctors in war zones

Would you paint a red cross on an ambulance knowing it would attract bullets and bombs as well as mercy? Doctors came together recently to discuss their life and death decisions in the world’s conflict zones

London consultant general surgeon David Nott‘My friend the ambulance driver would pick people up under gunfire and bring them to our hospital but because it had Red Cross markings it was targeted by snipers,’ says London consultant general surgeon David Nott (pictured right).

‘He painted it grey but that wasn’t any good either because people thought it was transporting military supplies. This guy used to take his life into his own hands every day.’ 

Mr Nott was relating his experiences of working in the Syrian city of Aleppo at the Healthcare in Danger conference at the Royal Society of Medicine.

The event, hosted in December by the ICRC (International Committee of the Red Cross), brought together healthcare experts to discuss how to deliver safe care in violent situations.

Talking about the ambulance driver, a volunteer from Beirut whom he describes as ‘one of the nicest people I ever met’, Mr Nott explains: ‘We had patients who were very severely injured and had to be transported to Turkey. He couldn’t work at night because snipers would see his lights and he’d be targeted. He really did run the gauntlet.’

Hospitals levelled

Facilities in Aleppo were also under constant threat, he says: ‘The big hospital there had been completely levelled and all the patients and staff were killed with one Scud missile.’ 

However Mr Nott, who has volunteered in conflict zones for 20 years, says violence against medical staff is nothing new. His first experience was in Sarajevo in 1993 when he saw an ambulance worker, who was transporting a patient, killed by snipers. 

He says: ‘I’ve always seen health workers being targeted and something really has to change. Enough is enough.’

Although the Geneva Convention and international law states healthcare workers must be protected, medical neutrality is breached frequently.

In a bid to raise awareness and improve delivery of healthcare in emergency situations, the ICRC launched the Healthcare in Danger project in 2012, which will run until next year.

In the firing line

It follows a 2011 ICRC study that described 655 violent incidents affecting healthcare in 16 countries over a two-and-a-half year period.

Medecins Sans Frontieres‘Violent attacks against healthcare in armed conflict and the impact on healthcare workers, hospitals and ambulances is one of the most severe humanitarian crises we face today,’ says ICRC deputy director of operations Christophe Martin.

A single act of violence against a healthcare worker has the knock-on effect of depriving a number of patients of potentially life-saving treatment.

As well as violence, attacks can include threatening workers to prevent them giving treatment, blocking ambulances and demanding or destroying supplies.

There have been instances of vaccinators being threatened or killed, and polio has returned to Somalia and Syria because of difficulty of administering vaccines.

Medics under attack

World Health Organisation policy, practice and evaluation unit coordinator Rudi Coninx says: ‘We now see cases of polio in Syria where it was eradicated and horrific attacks on healthcare workers trying to deliver vaccines. 

‘There are cases when we need to go public and say this is unacceptable. People who are delivering vaccines for children are being hunted down and killed. We have to make a public stand on that.’ 

Reliable information is needed to provide better understanding and as a basis for policy decisions, according to Dr Coninx. ‘We can’t end the conflict but by getting the data we can influence the people who have the real power,’ he says. 

However, obtaining and verifying data is far from easy in chaotic conflict zones. ICRC Healthcare in Danger project medical adviser Bruce Eshaya-Chauvin explains: ‘Data is very complicated to gather. We can’t compare the situation in Syria with the situation in Nigeria. It has to be contextualised. In each country we need a specialised way to collect data.’ 

There are security measures workers can take to improve the safety of healthcare facilities. A Canadian Red Cross conference last year made recommendations such as providing safe waiting areas, planning escape routes, and creating buffer zones at entrances. The decision whether to brand a facility can also be crucial, as in some areas this could offer protection whereas in others it could attract attacks.

Canadian Red Cross programme adviser Sharonya Sekhar says: ‘Medical personnel and healthcare professionals have a role in making sure health facilities are safe. It’s not just the role of the military.’

Building a safer path

One way in which doctors can contribute to creating a safe environment in conflict zones is by following ethical guidelines, according to BMA director of professional activities Vivienne Nathanson (pictured below).

Vivienne Nathanson‘Trust is one of the prerequisites for security. Medical care should be delivered according to clinical need, impartiality and without discrimination. 

‘Doctors should not be involved in or cooperate with torture or cruel, inhumane and damaging treatment.

‘The more trust you can develop with all parties the more chance you have to practice some kind of safety,’ she says.  

Building trust is the strategy adopted by non-governmental organisation MSF (Médecins Sans Frontières), which works with all members of the community and political groups to secure acceptance for their activities.

Workers killed

The organisation recently had to withdraw from Somalia after it became impossible to secure the safety of workers, with 16 killed since the 1990s.

MSF head of programmes André Heller Pérache says: ‘It’s important to have close proximity with the population we’re working for so we really understand we’re required and wanted in the area we work in and they understand us. Communication is absolutely key. 

‘Anyone who is a stakeholder is consulted in any decision we take. We won’t proceed unless we have a relatively clear indication of our safety.’

Ultimately the real solutions remain at the political level of ending violence and enforcing international law, but healthcare workers can play a role in raising awareness. 

Dr Nathanson says: ‘Making people realise what’s going on will help bring people to the table.’

Closing the conference, World Medical Association president Margaret Mungherera concludes: ‘Keep off health facilities and health workers. Let us get on with our work to provide access to quality healthcare.’

 Read about the BMA's work on human rights

The story so far

 Pictures courtesy of Médecins Sans Frontières