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Health care: one of the first casualties of war

16-11-2009 Interview

When armed conflict breaks out, hospitals and health workers are sometimes attacked, ambulances can be prevented from reaching the wounded and a lack of basic services, like water and electricity, can bring surgical procedures grinding to a halt. The ICRC’s chief war surgeon, Marco Baldan, explains why health care must be better respected and protected in situations of armed violence.


Marco Baldan, the ICRC’s chief war surgeon    

 It seems that health-care workers are increasingly coming under threat and that their safety is being jeopardized in conflict zones. How has the situation changed over the years and what challenges do surgeons like yourself face today?  

Yes, unfortunately we are always at risk... we are threatened, injured, killed, and kidnapped. This makes it difficult for us to reach wounded and sick people, who have a right to care under the rules of war. The result is that the patients with major injuries die before reaching our hospitals or local clinics, where civilian doctors are still working. This is the main problem we see nowadays. Unfortunately, preventing access to health care can become part of the warfare strategy and this has dire consequences for civilians and wounded combatants.

 Sometimes we hear of ambulances being prevented from reaching people or of hospitals being hit. Would you say that health care is literally on the front line?  

Absolutely. One of the first victims of war is the health system itself. If I’m a doctor and a war breaks out, what do I do? If I have a family, the first thing I try to do is to take them to a safe place. Maybe I flee with them but maybe I return to help those in need.

Very quickly, I’ll discover that the supply chain is blocked, so my hospital’s stock of drugs and dressing materials is likely to be used up in a few days. The water to the area m ight be shut off, meaning I can no longer sterilize instruments or clean surgical gowns. If the electricity is out, we’ll have to use the generators, which might run out of fuel.

Meanwhile, the movement of ambulances has probably been slowed down and even when people do reach the hospital, there’s no guarantee I can treat them because very rapidly, the whole health system can shut down, overwhelmed by the imbalance between the limited resources available and the needs of the wounded and sick. The end result is that people die.

 Can you give an example of a context where health workers have been targeted or forced to flee?  

A study done in Iraq, which was presented at the 2008 Geneva Forum Towards Global Access to Health, showed that more than 2,000 senior doctors were killed and 250 kidnapped following 2003 and that over 12,000 had left the country out of a total of 34,000. Those numbers have probably increased since the study was done but the point is that the country was mainly left with junior doctors, who are not prepared or trained to treat war-wounded patients. They have fewer resources, less equipment and more problems in getting supplies.

When fighting is particularly intense, it can prevent the ICRC from being present to support them. The same is true in Mogadishu in Somalia, where security constraints prevent us from being fully present and helping the few doctors and surgeons who remain to treat the patients.

Let’s not forget that doctors in war zones often have to work in incredibly difficult situations, sometimes living in the hospital for days at a time. Others might leave their homes in the morning, not knowing if they will have a house or a family to come back to when their shift is over. To continue working under such circumstances and to put the needs of others first is the true definiti on of heroism to me.

 The ICRC recently commissioned a poll, called  Our world. Views from the field  , which showed that when people are in need of help, they most often turn first towards those closest to them – their community, family and neighbours. What role can organizations like the ICRC play in strengthening the capacity of local surgeons, doctors and nurses as first responders?  

For me, this is the way forward. As insecurity grows, we can’t always be there. What we can and should be doing more is to use every window of opportunity to work with these professionals, provide them with training and show them what they can do with their limited resources.

We also preposition stocks, like surgical tools, bandages, antibiotics and painkillers, in areas prone to violence so that when fighting breaks out, the necessary supplies are on-hand. We carry on providing these supplies whenever there is a possibility to go back inside. In some cases, we can send in surgical teams and specialists, who are deployed as soon as war breaks out to boost the capacity of local doctors to cope.

But in my mind, it’s important to make sure communities are prepared in the first place and to raise awareness of the fact that health workers are there to save lives and must be respected, protected and allowed to do their work.

  See also: TV spot: Keep health workers safe!