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Afghanistan: assistance to the war-wounded

08-04-2009 Feature

In 1979, following the Soviet invasion of Afghanistan, the ICRC started providing medical and surgical assistance in Pakistan to Afghans wounded in the fighting. Based in Kabul since 1987, the ICRC has consistently sought to provide neutral, independent support to health structures and staff across Afghanistan, and to care for conflict victims.

 The role of the ICRC  

    

In accordance with the mandate entrusted to it by the States signatory to the Geneva Conventions of 1949, the ICRC works with governments, weapon bearers and civil society to prevent violations of international humanitarian law (IHL) and to protect and assist all victims of armed conflict. The ICRC is an impartial, neutral and independent humanitarian organization that was founded in 1863.

   
  ©ICRC/M. Kokic/af-e-01140    
 
  Mirwais Hospital, Kandahar, intensive care unit. A man receiving treatment for gunshot injuries.    
    IHL is a set of rules which seek, for humanitarian reasons, to limit the effects of armed conflict. It protects persons who are not or are no longer participating in hostilities and restricts the means and methods of warfare.

Who are the victims of armed conflict assisted by the ICRC? They are all persons who do not, or no longer, participate directly in hostilities, notably civilians and wounded or captured fighters. These persons are explicitly protected by IHL, which prohibits attacks against them. It also requires certain actions be taken to assist them. The ICRC is mandated by the Geneva Conventions to assist victims of war when the parties to the conflict, themselves, are unable to provide for them.

 Promoting respect for the war-wounded and the 'medical mission'  

    

As part of its dialogue with the different parties to the conflict in Afghanistan, the ICRC seeks to make them aware of their obligations towards the wounded, be they injured fighters from the enemy side, or civilians. In Afghanistan the Afghan security forces, international forces, and the armed opposition are all required by IHL to provide medical assistance whenever they encounter a wounded combatant or civilian, no matter what their political affiliation may be. IHL strictly forbids the killing of wounded fighters who are no longer participating in h ostilities.

Similarly, the ICRC promotes respect for its medical mission, with the different armed forces. The term'medical mission'refers generally to all activities aimed exclusively at assisting persons in need of emergency medical care, most notably through first aid and evacuation to hospital. The ICRC in Afghanistan remains extremely concerned by the numerous killings, arrests, abductions and harassment of medical staff whilst performing their medical duties that have taken place over recent years, and appeals to all warring parties to respect the inviolability of health staff, as required under the Geneva Conventions (see below for details of relevant Articles)

 ICRC response to those in need  

   
  ©ICRC/M. Kokic/af-e-01142    
 
  Mirwais Hospital, Kandahar. A young boy being treated for serious injuries from an explosive device he found near his home.    
     Support to government medical facilities  

The ICRC has been providing emergency surgical materials to Ministry of Public Health hospitals for some years in response bombings and similar mass casualty incidents. It also provides Afghan security forces with first aid kits and runs first aid training courses.

 
  • The ICRC supports and trains national health staff in Mirwais, the regional hospital in Kandahar, and also in Sheberghan hospital in Jawzjan. This enables them to provide essential and quality surgical services to victims of the conflict or other emergencies.

  • Ad-hoc medical supplies are distributed to hospitals in Kabul and eight others countrywide. They are also provided to the central blood bank and the radiology department of the Ministry of Public Health. The supplies have helped these government structures to cope with the influx of war-wounded in the aftermath of suicide bombings and heavy armed confrontations, for example in Chora in Uruzgan in June 2007, Spin Boldak in February 2008, and following the bombing of the Indian embassy in July 2008 in Kabul.

  • A 50-patient war-wounded kit is permanently pre-positioned at the Ministry of Public Health, ready for use in sudden emergencies, such as the Indian embassy bombing in July 2008.

   
   
 
War-wounded, the medical mission and IHL

  Who
 
  • According to Article 3 common to the four Geneva Conventions, 'persons taking no active part in the hostilities' – including wounded fighters – must be treated humanely, and without any adverse distinction founded on race, colour, religion or faith. It is prohibited to subject them to any form of violence or ill-treatment (the specifically prohibited acts are listed in common Article 3).

  •   What
     
  • Pursuant to common Article 3, paragraph 2, "the wounded and sick shall be collected and cared for". This is the obligation of all parties to the conflict, to be applied to all wounded and sick regardless of their status or allegiance, i.e. regardless of which side they may have been fighting on.

  •   How
     
  • It must be remembered that while IHL prohibits attacking wounded or sick fighters, in the context of a non-international armed conflict such as Afghanistan, IHL does not prohibit their being arrested and (once their medical condition allows) detained and tried under the country's criminal laws. The same applies to persons who are providing medical assistance to the war wounded: IHL protects them from attack, but it would not prevent them from being arrested and tried for violating national laws.
      In this context, it is crucial to note that providing medical assistance to wounded or sick fighters is not a violation of the law, certainly not of IHL, which on the contrary requires that such assistance be given. A person cannot be arrested solely because he or she has provided medical assistance to "the enemy". Indeed, customary IHL prohibits the punishment of a person for performing medical duties compatible with medical ethics.
  •    
     
 Support to the wounded and sick in areas not covered by government medical services  

The intensification of the conflict over the past two years in much of rural southern and south-eastern Afghanistan has increasingly prevented the delivery of health services to those regions. As a result, the local population is mostly left alone to cope without even rudimentary health care. This lack of access to health services is a major concern for the ICRC, which is also unable to move freely in the south and southeast owing to poor security. Therefore, in line with its mandate to bring assistance to victims of armed conflict, the ICRC endeavours to help people in need in difficult-to-reach areas, especially those requiring medical assistance. In Afghanistan it does this by providing medical materials for first aid, and pre-hospital care for the war-wounded in remote areas. This is done through the following channels:

 Red Crescent community-based first aid volunteers  

Since June 2006, the ICRC has been training first aid volunteers of the Afghan Red Crescent Society and providing them with medical supplies. Equipped with very basic material such as bandages, iodine or oral re-hydration salts, the role of the volunteers is to provide first aid to both civilians and wounded or sick fighters. In each pr ovince there are 10-20 first aid teams comprising up to 20 volunteers.

 Other first aid workers  

With a view to extend its services to all conflict-affected areas, the ICRC has been training additional first aid workers who are based in areas not covered by the Afghan Red Crescent. Living within the local community, the first aid workers posses the basic medical skills necessary to stabilize and evacuate the war wounded to a competent medical facility. The first aid workers have no contractual link with the ICRC, but as part of their medical training they acquire a basic understanding of the organization’s mandate and working principles.

 

The current security situation prevents the ICRC from directly monitoring the work of these first aiders. Therefore, the ICRC relies on external medical consultants to oversee the delivery of medical equipment to the first aid workers in the districts, and to ensure that ICRC medical supplies reach the intended beneficiaries. Consultants have an ID card, which indicates that they are working on behalf of the ICRC. They report back to the ICRC frequently

 Medical evacuations  

Neither Afghan Red Crescent first aid volunteers nor other community first aid workers have the required medical skills to provide extensive medical treatment. If necessary, after stabilizing patients they arrange for their evacuation to the nearest medical facility. Evacuations are carried out by road using private taxis. The medical consultants have selected a small number of taxi drivers in each province who can take the wounded to the nearest medical structure, for example, to Mirwais hospital in Kandahar. The tax i drivers are not ICRC employees, but carry a stamped, signed letter explaining they are evacuating the wounded on the ICRC's behalf. The ICRC reimburses the taxi fare. 

 ICRC first aid posts  

One of the organization's core objectives is to establish and operate neutral, independent health structures in rural areas experiencing conflict. To this purpose, the ICRC is in the process of opening first aid posts in selected rural areas. The posts are staffed with ICRC national employees and are clearly marked with the red cross emblem. The exact location is communicated to all armed forces operating in the area, so that they may seek medical help if needed, and also to ensure the safety of the staff, and respect for their humanitarian activities. There are first aid posts in Kandahar, Uruzgan, Helmand and Zabul provinces. The ICRC has recently opened another post in Wardak province, and plans to open others in one or two locations in Kunar.

 Support to armed opposition health workers  

When there are many casualties, the ICRC is approached for help by interlocutors treating wounded armed opposition (AO) fighters and civilians living in conflict-affected areas. As with governmental structures, the ICRC, in line with its neutral, independent status, and its mandate to assist victims of armed conflict, will respond to their needs by providing medical material and supplies. Whilst the ICRC is not informed precisely where in Afghanistan these medical services are provided, the ICRC insists upon verifying the medical skills of those making the request and providing care.