Health services: introduction
The ICRC Health Services Unit aims to assure that victims of war have access to essential preventive and curative care of a universally accepted standard. The ultimate objective is to contribute to a reduction in mortality, morbidity, suffering and disabilities caused by excessive needs or insufficient health care provision.
The nature of a conflict and its humanitarian consequences vary from country to country, region to region, and even from one moment to the next in the same region. In practical terms, health services are affected in a number of ways.
Among the direct results of a conflict, people can be killed or injured, medical structures destroyed, supply lines disrupted and people flee their homes in search of security. During the active phases of a conflict, the numbers of people affected may reach epidemic levels and large-scale emergencies involving wounded, outbreaks of infectious diseases and serious problems of malnutrition may quickly overstretch the capacities of existing local health services.
In certain cases, health services remain operational, but access is difficult, dangerous or prohibited for a section of the population. Moreover, normal health services may find themselves overwhelmed by emergency cases, with medical facilities in ruins, a shortage of qualified staff and poor supply lines. This can result in common health problems being left unattended, children and pregnant women not vaccinated, no antenatal care, elective surgical cases not operated upon, etc.
In modern conflict situations these realities often coexist. While rapid assistance is needed to attend to the urgent needs directly caused by the conflict, assistance to the existing health system is essential to ensure that normal health services are maintained. The needs may range from reconstruction or rehabilitation work to buildings, to management support, training, medicines, medical equipment, the presence of an expatriate medical/surgical team etc. When an active conflict subsides, long-term support to the health system and the introduction of reforms often become increasingly pressing.
Depending on the specific humanitarian needs, priorities and constraints, the most appropriate response aims to ensure that the population in a conflict area has access to essential preventive and curative health services. The entire Hea lth Services Unit, or a number of the four specialist health services departments, may become involved in a particular context.
The four specialized departments of the Unit: medicine and community health, surgery and hospital assistance, physical rehabilitation programmes, and health in places of detention.
Medicine and Community Health
The role of the Medicine and Community Health Department is to deal with projects related to these problems and the ideal responses will differ from one context to another to match specific needs. At the end of 1999, the ICRC ran medicine and community health projects in 19 countries. The majority of these projects involve direct assistance to health posts, health centres and district hospitals. Assistance provided may include supplies (construction materials, medical equipment and medical supplies) and/or qualitative support (help in organisational matters, supervision and on-the-job training).
Surgery and Hospital Assistance
Pre-hospital and hospital services vary considerably from country to country in their capacity to deal with the extra burden of providing surgical treatment for the war-wounded which can very quickly overwhelm the hospital facilities available.
All these scenarios presuppose that local health structures and personnel exist and that ICRC assistance will aim to help them continue to offer their services. However, in extreme cases, local hospitals and staff may be insufficient or non-existent. Expatriate hospital teams might then be sent as replacements to carry out the work normally performed by local staff.
The training of national staff in surgery, anaesthesia, nursing care, physiotherapy and hospital management has recently become more important, particularly in situations where low-intensity conflicts have continued for many years. The ICRC is developing a series of activities, ranging from an immediate emergency response to longer-term rehabilitation of a hospital system in order to meet the everyday health needs of a community, as well as managing wounded patients. War-surgery seminars for both military and civilian surgeons are an essential part of this training.
In an unsafe environment, gaining access to the wounded, then simply being able to transport them to a hospital, can seem like almost insurmountable obstacles. Similarly, faced with financial constraints or discriminatory practices, access to treatment becomes even more difficult. The ICRC, in partnership with National Red Cross/Red Crescent Societies, develop programmes for pre-hospital first aid, and the evacuation and transportation of the injured.
Since 1979 the ICRC has supported or created 50 rehabilitation centres in 25 conflict-ridden countries world-wide, and has fitt ed over 130,000 prostheses for approximately 88,000 individuals.
Prior to handover, emphasis is placed on the introduction of appropriate technology, staff training and collaboration with the existing health care system. Appropriate technology may be defined as " a system, providing fit and alignment, which suits the need of the individual and can be sustained by the country at the most economical price. " Since 1990, plastics such as polypropylene and polyethylene are the most used. Following handover the ICRC continues to provide ongoing consultant expertise and a lower-intensity support to projects, with emphasis on upgrading courses, and material and technical assistance. The ICRC-sponsored Special Fund for the Disabled (SFD) was established in 1983, and has recently played an increasingly important role in the follow-up of " handed-over " projects. Funds from the SFD have been used to establish a training centre in Addis Ababa, Ethiopia, for courses in the manufacture and fitting of prostheses and components. This is complemented by ongoing material assistance and technical consultation to projects world-wide - beneficiaries including former ICRC projects as well as others.
Health in Places of Detention
A prison is essentially a place of constraint, and as such, it creates specific living conditions which are materially and psychologically demanding, even in times of peace. On occasion - more often than is commonly thought - these conditions can be extremely harmful and violent, and affect the health of those detained. In conflict situations, both during and before detention, detainees may have to endure torture, rape, and other physical and psychological forms of abuse which cause serious long-term mental and physical injuries. Ill-treatment or poor conditions of imprisonment (or often both) add to any existing health problems and create new ones.
Work on behalf of prisoners is one of the ICRC's most specific tasks. In accordance with its mandate, the ICRC concerns itself with the welfare of any person arrested in connection with armed conflict, internal strife or other disturbances requiring action by a specifically neutral and independent organization. The main purpose of the ICRC's work in this domain is to safeguard the prisoners'physical and mental integrity, to prevent or put an end to any ill-treatment and to ensure acceptable material conditions of detention. The ICRC assesses the situation and asks the authorities to take any steps needed to improve the detainees'treatment and material conditions. In urgent cases, the ICRC itself supplies material relief.
ICRC medical staff visiting detainees must also be able to analyze and occasionally treat diseases and conditions which are common to places of detention, such as tuberculosis, beri beri, typhus, skin diseases, venereal diseases, HIV/AIDS etc. These are particularly difficult to address as they occur and thrive in often difficult prison conditions (i.e., due to overcrowding, poor access to food and health care, sexual exploitation etc.).
Over the last twenty years, much has been learned about the effects of torture and cruel, inhuman and degrading treatment. A proper medical assessment by a physician is an essential part of any visit to victims of torture. When dealing with such difficult cases, medical staff need to be properly trained and have a sound knowledge of the phenomenon, its effects and the psychology of the torturer, as well as methods for treating torture victims.
Extract from ICRC special report: assistance