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Conflict of Roles and Duties – Why Military Doctors are Doctors

In today’s armed conflicts, all too often health-care personnel and  facilities become the targets of deliberate attacks, or are the victims of indiscriminate warfare. Medical ethics and impartiality towards patients are not upheld and the Red Cross ceases to be a symbol of protection. The immediate impact of such violence is straightforward for the sick and the wounded.  However, the knock-on effect on the entire population and the country’s healthcare system is even more dramatic. Hospitals are destroyed or close, healthcare personnel are killed or flee, facilities are unable to function for lack of essential supplies. Access to essential services such as primary healthcare, vaccination programs, maternal and child care, assistance for chronic diseases is simply denied. The issue at stake is immense.

One hundred fifty-one years have passed since the First Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field was adopted. The main principles laid down in the Convention are: relief to the wounded without any distinction as to nationality; neutrality (inviolability) of medical personnel and medical establishments and units; the distinctive symbol of the red cross on a white background as an emblem protecting medical personnel, establishments and units. 

Since their establishment, Red Cross and Red Crescent National Societies have played an essential role as auxiliaries to the military medical services and together with the International Committee of the Red Cross, strive to provide victims of armed conflict and other emergencies with access to healthcare services. Nonetheless, one hundred fifty-one years after the adoption of the First Geneva Convention, the violation of the main principles laid down therein constitute a dramatic yet often overlooked humanitarian issue.

Alarmed by the challenges posed by today’s armed conflict to the safe delivery of and access to healthcare, in 2008 the International Committee of the Red Cross (ICRC) started collecting and analyzing data on violent incidents jeopardizing healthcare in 16 countries affected by conflict or other emergencies. The 16-country study emphasized how the problem of insecurity and violence affecting the delivery of healthcare should not be regarded as the simple sum of single incidents, but rather, due to its consequences, as a complex humanitarian problem to which solutions lie not exclusively with healthcare professionals but more comprehensively in the domain of law and politics, in humanitarian dialogue, and in appropriate preventive measures devised by a variety of stakeholders.

The results of this study were presented to around 3,700 participants from over 180 states party to the Geneva Conventions in 2011 at the International Conference of the Red Cross and Red Crescent. This prompted the adoption of Resolution 5 – Health Care in Danger, giving mandate to the ICRC to initiate consultations with experts from states, the International Red Cross and Red Crescent Movement, and others in the health sector, with a view to making the delivery of healthcare services in armed conflict and other emergencies safer. The Health Care in Danger (HCID) project was born. 

This initiative has since brought together various stakeholders such as legislators, policy makers, government health-sector personnel, arms carriers, humanitarian agencies, representatives of academic circles, and civil society leaders to identify concrete and practical recommendations whose implementation could ensure better respect and protection for healthcare delivery.

Tackling the issue of violence against healthcare from different perspectives, 12 workshops were conducted worldwide as well as direct consultations with the above-mentioned actors, including domestic legislation, state military practice, ethical principles in healthcare, the role of civil society leaders, the safety of healthcare facilities, ambulance and medical transportation, practice of non-state armed groups. Accordingly, a set of measures to improve safe access to and delivery of healthcare have been produced, including measures directly relevant to military operational practice in the following circumstances: conduct of search operations and arrests in healthcare facilities; manning of checkpoints, and conduct of hostilities in the proximity of a healthcare facility. Indeed, through the HCID data collection exercise, the ICRC continues to observe that military forces are among the major perpetrators of incidents against health care, particularly in the three contexts described above.

Many, if not most, of the recommendations elaborated in the HCID project are of a preventive character, so as to ensure, for instance, adequate preparedness of healthcare providers, authorities, or armed actors to anticipate challenges posed by insecurity and violence against healthcare delivery and/or mitigating their effects in the event of armed conflict or other emergencies. 

The preventive character of HCID recommendations is apparent, particularly in the following areas:

Military doctrine and training1  that will contribute to ensuring safe access to, and delivery of, healthcare in the event of armed conflicts and other emergencies.

Preparedness of healthcare facilities. Through adequate contingency planning the impact of violence against healthcare facilities can be mitigated, if not avoided completely.

Training of healthcare personnel2,  not only relating to technical aspects of how to deliver healthcare, but also, and especially on their rights and responsibilities and on ethical dilemmas they may confront in the event of armed conflicts and other emergencies.

Training and engagement of Red Cross and Red Crescent National Societies.

Appropriate coordination between all stakeholders involved in providing emergency healthcare. This requires both plans for such coordination as well as scenario-based training during peacetime.

Development of domestic normative frameworks3  to implement international legal obligations relevant to the protection of the provision of healthcare in armed conflicts and other emergencies. To be effective in the event of armed conflicts and other emergencies, suitable domestic normative frameworks need to already be in place during peacetime.

Over the years, strong partnerships with relevant actors, such as the World Medical Association, the International Council of Nurses, the International Council of Military Medicine, the International Federation of Medical Students Association and the World Health Organization came into existence. Indeed, tackling the far-reaching humanitarian consequences of violence against healthcare requires efforts by different actors. 

The issue is gaining momentum at the global level and a number of important achievements can be highlighted. For example, in December 2014 during the 69th session of the United Nations General Assembly the Foreign Policy and Global Health Resolution was adopted, together with other three resolutions. The four resolutions call on states to 1) protect the delivery of health care, 2) reinforce the resilience of national health systems, and 3) take appropriate measures to prevent and repress violence against healthcare; thus paving the way to stronger international engagement to ensure safer access to and delivery of healthcare.

Looking ahead, the International Conference  of the International Red Cross and Red Crescent Movement, taking place in December 2015, will represent another important milestone. There, participants will have the opportunity to reiterate the importance of the issue, recognize its potentially far-reaching humanitarian consequences, both immediate and long-term, and commit to the implementation of the recommendations issued from the HCID project. 

1 For details, see the HCID publication: “Promoting military operational practice that ensures safe access to and delivery of health care”.

2 For details, see the HCID publication: “Ambulance and pre-hospital services in risk situations”; “Health care in danger: The responsibilities of health-care personnel working in armed conflicts and other emergencies”.

3 For details, see the HCID publication: “Domestic Normative frameworks for the Protection of Health Care”.

Author

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Babak Ali Naraghi has been in charge of the Health Care in Danger project since November 2014. He has more than 10 years of field experience with the International Committee of the Red Cross (ICRC) at various managerial levels in areas such as Afghanistan, Guinea-Conakry, Sudan, Uganda, and Sri Lanka. Since 2000, he has been based at the ICRC headquarters in Geneva, where he acted first as deputy then ad interim Head of Operations for North and West Africa. Naraghi holds a Master‘s degree in Political Science.

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