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Doctors in danger

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When doctors and paramedics respond to emergency calls for assistance, they can never know exactly what they will encounter – though few would expect to be the target of bombers or snipers when they arrive on the scene.

But this is an all-too-real risk for those working in some of the world’s worst trouble spots, where the International Committee of the Red Cross (ICRC) has recorded 26 follow-up attacks where emergency workers responding to an initial bomb blast were themselves killed and injured by a secondary explosion timed to coincide with their arrival at the scene.

Unfortunately, there is nothing new about attacks on health workers.

As many emergency department doctors and ambulance paramedics can attest, being the target of vicious threats and assaults is a depressingly common aspect of their work.

In Victoria alone, police were called to major hospitals and medical centres 265 times in 2012-13, and more than 7000 “code grey” alerts were issued over aggressive and threatening behaviour, according to crime statistics obtained by the Herald Sun.

But, distressing and harmful as these incidents are for the individuals affected, they pale in comparison with the dangers faced on a daily basis by medical staff working in countries marred by political strife and instability, where hospitals, ambulances, doctors, nurses and patients are often the target of attacks by armies, militia, rebels, criminal gangs and violent individuals.

More than 2000 attacks on health workers

According to figures compiled by the ICRC as part of its Health Care in Danger project, 168 health workers were killed in 2624 assaults documented in 21 countries in 2012 and 2013, along with 481 of their patients and dozens of ancillary staff, aid workers, relatives and by-standers.

The litany of violence during the period also included 267 health workers who were wounded or beaten and 564 who were threatened. A further 143 reported being blocked or delayed in attempting to get to injured people or taking patients to hospital, while almost 90 were robbed and 35 suffered other assaults including torture, kidnapping, being thrown out of health facilities or surviving unsuccessful attacks.

Not only individuals are at risk.

In recent and current conflicts in Syria, Iraq, and Gaza combatants have been accused of deliberately targeting hospitals and other health facilities.

Of 1809 incidents documented by the ICRC, 40 per cent involved attacks on or within hospitals and clinics, more than a third of which were carried out by state troops and police, while militias, rebels and insurgents were responsible for 32 per cent of these assaults.

National armed forces and police were the most likely to bomb or fire upon such facilities, while rebels and militias were more likely to invade and loot.

For ICRC employee Dr Bruce Eshaya-Chauvin, who is medical adviser to the project, such incidents are disappointingly familiar.

With more than 20 years of experience working for the Red Cross around the world, including stints in Lebanon and parts of Africa, Dr Eshaya-Chauvin has firsthand experience of the dangers many health workers face in doing their job in conflict situations.

He said the problem was not just the threat to health workers, but the corrosive effect such threats and violence had on access to health care, often when need was greatest.

Dr Eshaya-Chauvin, who visited Australia late last month, told Australian Medicine attacks on hospitals and health clinics – whether intentional or not – could have far-reaching effects.

“It is very difficult to know whether it is intentional or not, but the result is unfortunately the same,” he said. “The knock-on effect is that if you prevent a doctor going to hospital, it means patients have to wait longer for treatment, or not receive it at all.”

It is why he is passionate about the Health Care in Danger project and what it could do to help ameliorate the risks health workers face in conflict situations, and improve their ability to provide care for those who need it.

 “It has a very simple objective, with wide ambition – to make sure that patients can access proper treatment, and that health care practitioners can do their work in areas of conflict and other emergencies,” Dr Eshaya-Chauvin said. “We want to not only find solutions, but implement them.”

Not one, but many solutions

There are three strands to the strategy the ICRC has developed to achieve this – working with governments to improve recognition and respect for the neutrality of health workers in conflict situations, bringing together practitioners and experts from around the world to share experiences and ideas, and engendering community understanding and regard for the care provided by health workers to all who need medical treatment, irrespective of political affiliation, gender, race or religion.

The dilemma humanitarian organisations face is that, aside from the inherent danger of working in conflict zones where need is often greatest, measures taken to improve health worker safety can put barriers in the way of people who need treatment.

Dr Eshaya-Chauvin said the complexity of the issue meant there was no simple set of recommendation or procedures for health workers to follow.

“You always have to balance security and access,” he said, citing the example of possible responses to bombings and the threat of follow-up blasts targeting emergency workers.

“We don’t have one response, but we have learnt the elements that need to be taken into consideration by ambulance despatchers in these situations.”

The merits of some measures that might, on the face of it, seem straightforward are also debated.

At a workshop on ambulance safety organised as part of the project, the pros and cons of personal protection gear for paramedics, such as helmets and flak jackets, were hotly debated.

Some thought the case for their use was obvious, but others argued wearing such equipment put paramedics at greater risk by making them appear more like participants in the conflict rather than independent and neutral actors.

In addition to attacks by armies, police or militias, health workers can also find themselves under assault from angry families or communities.

Mobs in West Africa have attacked health teams working to help control the devastating Ebola outbreak in the mistaken belief they are actually spreading the disease, and there have been deadly assaults on vaccination workers in Pakistan from both Islamic militants and those who believe that are poisoning children.

Engaging governments, communities

“The role of communities is very important,” Dr Eshaya-Chauvin said. “We need to work with communities on issues of perception and acceptance. In the case of Ebola, there is the perception of the disease, and acceptance of people coming to try and help with the problem.”

He said one of the issues was often differences in the understanding of what was meant by neutrality, and the impartiality of the medical profession in the way it treated patients – something that was often not understood or appreciated.

Dr Eshaya-Chauvin said it was easy to look at places like Syria and become discouraged, but there were examples where the situation was improving, sometimes significantly.

“We cannot just look at where there is no hope – I am not saying we will not see any improvement in Syria, but it is a very difficult place to work,” he said.

“It is very important that people keep in mind examples like Colombia [see Columbia: a case study in doctor protection], Afghanistan and Yemen, where people are able to find and implement solutions.”

He said his own experience in Beirut was instructive. During the civil war that wracked Lebanon, Red Cross crews were able to move around the country and cross fiercely contested battle lines because the value of their work, and their neutrality, was universally understood and respected.

Similarly, Keysaney Hospital in the Somali capital Mogadishu provided uninterrupted care in one of the world’s most dangerous environments by adhering to its priority of delivering care solely on medical grounds.

Dr Yusuf Mohamed Hassan, who has been the hospital’s director for the past decade, said “the hospital serves everyone on Mogadishu, regardless of their clan affiliation or political views. I believe we have been able to function over time simply because of our impartiality and neutrality”.

Broadening this understanding across other conflict-riddled countries, Dr Eshaya-Chauvin believes, could go a long way to saving more lives and make providing health care safer.

Adrian Rollins