Health Care in Danger - Australian Red Cross

magazineIssue 1, 2013healthcareindanger

thedistortion of conflict:health servicesinseverely disruptedenvironmentsPeter Hill (correspondingauthor) is an AssociateProfessor in the Schoolof Population Healthat the University ofQueensland.This paper is an abridged versionof a paper prepared by PeterHill, Enrico Pavignani, MarkusMichael, Maurizio Murru andMark E Beesley.Sa’ada, Yemen, 2007. Patients waiting infront of the tent of the primary health carecentre project organised by the ICRC andYemeni Red Crescent Society.Photo: ICRC/P. DudaThe impact of conflict on healthprofessionals is, at last, being openlyexamined. But in addition to the directimpact on individual lives, conflict alsoimpacts on health systems as a whole.The distortions that it causes last wellbeyond the cessation of violence andbecome structured into the systemsthemselves. In many cases, thesehealth systems are already fragileand the problems they face are oftencompounded, but are rarely new. Yet,even for those vulnerable systemsconflict may provide opportunities forchange and, in fact, is an imperativefor change.Recent research by the Universityof Queensland has examined healthservices in severely disruptedenvironments: Afghanistan, CentralAfrican Republic, the DemocraticRepublic of the Congo (DRC), Haiti,Palestine and Somalia. The findingsof this research point to the diffuseand pervasive penetration of violence,affecting each of the six building blocksthat make up a health system.Health servicesWhile the pre-existing coverage ofhealth services is often poor, servicescontract even further away from activeconflict – as in Afghanistan – and tend toconcentrate development resources inthe limited number of secure provinces,inevitably privileging their developmentover the long term. The mal-distributionof staff exacerbates existing disparities,with those who have portable skills oftentaking advantage of these to migrate.The health services gaps, however,do not necessarily remain a vacuum.They are filled by health workerswith limited, incomplete or expeditedtraining, retired staff, traditionalpractitioners, volunteers andquacks. The services that will thenbe available to the community willdepend on which staff remain, theavailability of drugs, accessible supplylines and adaptability to the dynamicsof conflict. Preventive programsbecome more difficult to sustain;immunisation and child healthservices may be curtailed due to therisks of congregating, or threats tostaff during outreach activities.Human resourcesThe health sector itself is increasinglya focus for violence, for a varietyof complex reasons. In conflictswhere the state is being challenged,it may be targeted through itssocial services; destroying healthinfrastructure undermines links togovernment. The loss of humanresources through death andinjury, relocation and migrationcontributes to the distortion of thehealth workforce, exacerbatingalready problematic rural-urban maldistribution.Training is often patchyand of poor quality, with qualificationswhose standards are difficult toconfirm, and the resultant workforceis frequently bloated and underskilled.FinancingIn conflict, local financing for healthis frequently reduced, with securityconsuming a disproportionatepart of the budget – military healthservices the one potential exception.State funding frequently contractsto (irregularly) cover salaries alone,with limited allocations for drugsand outreach activities. Out-ofpocketexpenditure rapidly becomesintegral to health service provision:departmental health services in Haitiare heavily dependent on user-fees; inAfghanistan, patients prefer to spendtheir money in the private for-profitsector; with state financing for healthin the DRC among the lowest in theworld, district administrations, oftenwith no other sources of financialsupport, rely on user fees to supportthe Health Zone with a cut sent on tothe Provincial Health Directorate.Drugs, vaccines andtechnologyConflict and its aftermath arecharacterised by a conspicuouscommodification of health, with drugs,vaccines and technology providingan economic rationale for sustainingprivate provision of selected servicesin the absence of the state. Porousborders in Somalia have allowedincreased importation of drugs froma range of sources, including informaland at times illegal elements. Thelimited regulation means that poorquality drugs, or fraudulent drugs,many with European brand-names,have easy access. Without prescribingcontrols, self treatment results ininadequate therapy and the lack ofWestern medicines in some conflictlocations means that traditionalmedicines are frequently substituted.Health informationThe Health Information Systemis frequently vulnerable prior toconflict, but further compromisedthrough loss or relocation of the staffresponsible for recording, reportingor analysing information. There isdisrupted communication, reportingand supervision, and key staff maymigrate or be reallocated to higher‘priorities’ as capacity contracts. Theaggregate data often conceals greaterinequities between provinces withincountries. Health information is apolitical commodity – used with oftenlaudable intentions. But the politics ofhealth information make it contentious:challenges to the estimates of deaths– particularly civilian deaths – in recentconflicts have pitted claim against counterclaim, methodology against methodology.Leadership and governanceLegitimate authority in conflict situationsis often contested or lost and theopportunity for local ownership ofhealth systems change is already underchallenge. Even where the state isrecognised its ‘reach’ may be truncatedby its limited capacity. In all the casestudies, health services are compromisedby the limitations of the state: recurrentcivil disturbance and insecurity has leftthe Haitian state with control of only 15per cent of its own health facilities; andAfghanistan’s fragile control of contractedhealth services, with substantialinternational support, provides accessfor over 85 per cent of the population,but only 25 per cent of service utilisation.Health systems in conflictFor health systems, the acute, theimmediate, the unpredictable, and thechaotic need to be managed with thelong term in view. Afghanistan rightlydecided to add a ninth MillenniumDevelopment Goal to the existingeight: that peace is a pre-requisite fordevelopment. Without peace and security,the state cannot rebuild, and healthsystems cannot be comprehensivelyre-established and extended. Withpeace, the post-conflict phase offers acritical opportunity to address the healthsystems’ distortions of violence.Children are weighed and vaccinated at a primary health community centre in Iraq.During the wave of sectarian violence, health facilities were difficult to reach. Photo: ICRC/O. MoeckliIHL magazine 9

perspectives from the fieldMongo, Chad, 2012. Training of volunteer hygiene promotion workers during the Cholera outbreak.Photo courtesy Ruth Jebb.Ruth Jebb is anInternational HealthDelegate with theInternational Red Crossand Red CrescentMovement.I was being driven home from theFeeding Centre in one of our clearlymarked ICRC land cruisers, unawarethat we were being followed.It turned out three armed personshad been following the land cruiser.What I later discovered was thatthe minute I entered my residence,the armed persons approachedthe driver and demanded the keysto the land cruiser. They were allarmed with AK-47s. He managedto narrowly avoid any harm, but asa result security was heightenedand ICRC staff were unable to movearound in land cruisers.The goal ofICRC healthactivities:To give peopleaffected by armedconflict and othersituations ofviolence accessto basic healthcare, in order toreduce mortality,morbidity, sufferingand disabilities.The stories I will share with youoccurred in 2008 in Darfur, Sudanwhere I was coordinating andmanaging a Feeding Centre formalnourished children. At the time,there were 2,500 malnourishedchildren enrolled in the feedingprogram.The compounding effect of thissingle event on my ability to carryout the work I was there to do, wassignificant. All activities, includingthose conducted at the PrimaryHealth Clinic, Feeding Centre andall outreach clinics were temporarilysuspended for three days, until themotivation behind the attack couldbe established.What this meant was that moderatelyand severely malnourished childrendid not receive the essential nutritionalsupplements and medical treatmentthey required to survive. For somechildren this was the only food theywere receiving. Children that werealready on the brink of life and deathwere further compromised and as aresult some died.Following security clearance, it wasdecided that all ICRC activities had tobe conducted using local transportmethods, such as donkey and horsecarts, impacting significantly on ourability to respond to emergencies,and transport supplies and patients tothe hospital. Sometimes you had towait an hour for the transport, limitingthe medical work you could carry outin one day.Because of the increase in violenceand unpredictable armed movementsin the camp after dark, securitycould not be guaranteed by all thegoverning parties. This limited ourability to provide adequate health andnutritional services to the internallydisplaced population over a 24-hourperiod.As a result, the Feeding Centreprogram was limited to eight hoursper day. Malnourished children wereseen and treated for a short eighthour period during the day, and thensent home in the hope that theywould not deteriorate overnight. Manychildren required 24-hour intensivenutritional and medical treatment, butdue to the security risks associatedwith running a 24-hour program, themost severely affected had to beflown one hour out of camp in orderto access appropriate care.There were obvious limitations insending children away from the campfor specialist treatment. Mothers wereoften unable to accompany theirunwell children (as they had otherchildren to care for, or may have beenthe primary breadwinner for theirfamily); and many of these childrendied, which added the challenge ofdealing with the death and burial ofa child away from their family andcommunity.As a health care worker, though Ihave not been the victim of violencein the field, the threat of violence hasdirectly impacted not only on mypersonal sense of safety and security,but also on my ability to meet theICRC health goal to “give peopleaffected by armed conflict and othersituations of violence access to basichealth care”.The compounded costs associatedwith violence against health careworkers, facilities and beneficiariesare health care staff leaving theirposts, clinics running out of supplies,and suspension of essential healthservices. These effects dramaticallylimit access to health care for entirecommunities, meaning that thesick and wounded do not get thetreatment they need, which is oftenthe difference between life and death.The ICRC HCiD project is one stepforward for finding tangible solutionsto address one of the biggesthumanitarian issues facing us today– ensuring health care workers suchas myself can effectively deliver timelyhealth care to those in need.Gerida IDP Camp, Darfur, 2009. Severely malnourished child at IFRC Feeding Centre.Photo courtesy Ruth Jebb.IHL magazine 13

perspectives from the fieldSurgical teams working in Taiz, Yemen, 1994. Photo courtesy Jenny Stedmon.An early influence in my career washearing a talk by a young anaesthetistwho had worked for ORBIS (a nonprofitorganisation fighting blindnessin developing countries), givinganaesthetics for large numbersof eye operations on board anaeroplane. Shortly after this, in 1990,I found myself flying out to the Thai-Cambodian border to work at a RedCross hospital called Khao-I-Dang forthe ICRC. On the plane, I sat next toan experienced New Zealand nursewho had worked with the ICRC formany years and was going to spenda year there, as opposed to my threemonths. Her name was Sheryl Thayer.Sheryl and I not only worked togetheron my first placement for the ICRC,but we became friends and holidayedtogether after my work was finished.In December 1996, Sheryl was oneof six Red Cross health delegatesassassinated by gunmen in theRed Cross hospital located at NoviAtagi, Chechnya. This was not onlypersonally shocking, but it seemedto herald an unprecedented patternof kidnappings, assaults, attacksand murders on health care and aidworkers, ranging from those involvedin primary health care projectsthrough to ambulance drivers andsupport staff.The significance of the emblems (redcross, crescent or crystal) seemed tooffer less protection than previouslyand it was from this observation,and early studies to document andmonitor these transgressions, thatthe current HCiD campaign hasarisen. International concern is notonly related to attacks on healthworkers of all kinds, but to the lackof access to areas where the mosthelp is needed, and to denyinghumanitarian support and supplies tofacilities and patients most in need.Since my first mission I have beento three more countries all affected,usually in a long-term way, by war.I worked in Taiz in the Yemen, onthe Kenya-Sudanese border atLokichokio Hospital, and in EastTimor. There have been a variety ofhospital facilities available, rangingfrom Red Cross-led long termhospitals, to utilising mobile fieldequipment in the form of a FinnHospital which comes packed inDr Jenny Stedmon is aConsultant Anaesthetistand Deputy Head ofDepartment at FremantleHospital. She is on theWestern AustralianMedical Assistance Team(AUSMAT) for disastermedical response,the Indigenous HealthCommittee for theAustralian and NewZealand College ofAnaesthetists, and is anICRC delegate.boxes designed to allow operatingon a particular number of patients.The wide variety of patient injuriesand illnesses differed in each place,and related not only to the weaponryused in the war, but to the availabilityof local health facilities and personnel.My experience has led me to becomea passionate supporter of theprinciples underlying the InternationalRed Cross Red Crescent Movementand, recently, to become more awareof IHL. At first the legal aspectsof IHL can be daunting, but whenthe purpose of the laws relating tothe conduct of war, and treatmentof prisoners of war and civiliansare examined, they constitute afundamentally humanitarian view.The HCiD campaign seeks to ensurethat those aspects of IHL andthe Geneva Conventions, relatingto health care and humanitarianaid, are internationally recognisedand adopted. I would encourageeveryone to engage with this cause,attend local events relating to bothHCiD and IHL, and above all readand talk about the issues.The only specialised surgical centre in northernAfghanistan, is an MSF facility in the provinceof Kunduz. It is equipped with an emergencyroom, two operating theatres and an intensivecare unit, and 70 beds across four wards.Photo: MSF/ Michael Goldfarb.Françoise Duroch is theMedical Care Under FireProject Manager with theMédecins Sans Frontières(MSF) International Office.Caroline Abu Sa’da is theHead of the Research Unitwith MSF Switzerland.Since its foundation, MSF has faceddifferent forms of violence against itspatients, staff, health facilities andmedical vehicles, as well as againstnational health systems in general. Thecurrent situation in Syria is a forcefulreminder of how health systems canbecome the target of attacks and howmedical practice can be perverted forpolitical and martial purposes. Thisviolence deprives entire populationsof vital assistance and is a means forthe parties to the conflict to exert,both symbolically and practically, theirpower over people’s lives.Although attacks against patientsand medical facilities can be a signof intensification of hostilities, orthey can be a part of other types ofviolence, as witnessed by MSF inour programs, they can also (as inthe case of the Democratic Republicof Congo, Pakistan, Bahrain orSyria for example) be adoptedas political or military strategiesfrom the outset, indicating either adeterioration or complete rejectionof the agreed norms and standardsof warfare. Likewise, the corruptionof the medical act, for example todisguise a covert military operation,similarly demonstrates a total lackof respect for the medical missionand therefore the neutrality andprotection it should be afforded.Act of care, act of war?MSF has often condemnedsituations where a health facilitypasses on the whereabouts of itsformer patients, where confidentialmedical records are stolen or wherehealth staff are abducted or killed.It is a sad reflection when a surgeonworking for MSF in Syria reportsthat he was advised to tell peoplehe was a journalist rather than ahealth professional.How can those dynamics becountered or simply limited, otherthan by stressing the principlesof reciprocity that aim to obtainacknowledgement that a placewhere care is administered benefitseveryone and its preservation isin the clearly understood mutualinterest of all parties?Moreover, throughout the historyof the organisation, violence hasbeen uncontrolled or chronic withvarious types of consequences.These include a general preventionof access to and provision of care- either because the access ofpatients to facilities are blocked(such as at checkpoints) or thefacilities are inoperative due to alack of skilled health personnel,and a shrinking of organisations’working spaces.The internalisation and toleranceof forms of violence experiencedrepeatedly by MSF teams andpatients, who must sometimesendure harassment, threats andeven blackmail on a daily basis,should also be noted. As such, asignificant number of incidents areonly partially reported. Although it iseasy to understand the adoption ofmechanisms to adapt to situationsof tension, we should be waryof these forms of violence beingperceived as a normal part ofconflict and justifying their repetition.Reaffirming the organisation’sethical principles will assist with theireffective application. For example,triage policies guided by classicmedical emergency factors, aswell as assistance to all parties tothe conflict and their respectivecommunities, are core ethical values.These values must be reflected inpractice and not just in rhetoric.Confrontation andnegotiationWhile the manipulation of medicalservices and violence againsthealth personnel must not betolerated, it should never justifythe establishment of a politicalagenda intended to put an endto it. For MSF, it is a question offocusing on preserving the medicalworking space, on patients’ needsfor adequate care under the bestpossible conditions, on openingas broad a space for discussionas possible and on involving allstakeholders participating directlyor indirectly in the delivery of aid orcontrolling the area. Consequently,MSF plans to concentrate itsaction on establishing the medicalconsequences of attacks onpatients and on health personneland facilities, insofar as they resultin serious short- and medium-termrepercussions on health systemsand disastrous impacts on bothindividuals and public health moregenerally.IHL magazine 15

health care in danger:the Solomon Islands storySolomon Islands RedCross DisseminationOfficer Oligao Niniuspeaks about health carein danger in the Pacific.Manaoba Island, Solomon Islands.A Red Cross volunteer visits the north tip ofMalaita. Photo: IFRC/R. FewThe Solomon Islands RedCross (SIRC) recently ran someawareness raising activities in thecommunity on the theme of healthcare in danger. Can you tell usabout that?The sessions have been part of ourIHL dissemination program and wehave found the health care in dangertheme has been a great vehiclethrough which to approach IHLtraining. The students are introducedto IHL, the humanitarian auxiliarynature of SIRC and the notion thatin times of violence the health caresystem must be respected.Each session has been designedto be as interactive as possibleand the students have askedlots of questions. We have usedsome of the ICRC HCiD campaignfilms as part of our presentationsand they send a very powerfulmessage that health care workersand facilities need greater respect.At the end of each session wehave distributed IHL and HCiDcampaign leaflets to the students,to give them something to takehome and importantly to sharewith others who did not attend thesession.Why did you choose the healthcare in danger theme for theseawareness raising sessions?We wanted to get across to thestudents an IHL message, butalso to make it relevant to their lifeexperience. By using the healthcare in danger theme, students canrelate specifically to something whichhas affected our country – duringthe Guadalcanal ethnic tensionperiod and 2006 riots – but alsothat is, sadly, very much a featureof the recent violence of our time,in countries like Syria and Libya.In short, young people need tounderstand IHL not as a subject in abook, but rather as something whichis meaningful to them and that affectstheir lives. A lot of interest has beenshown by the students.As you mention, the SolomonIslands has been affected byethnic tensions and riots. Do youhave any reflections to sharewith regard to the protection ofthe medical mission and medicalworkers during these times?During the time of the ethnic tensionon Guadalcanal, I was a form sevenstudent and lived in Honiara. I neverknew that IHL and Red Cross existedto protect those who are not, or nolonger, taking direct part in conflictand other situations of violence. ButI did know that medical workers andRed Cross workers took great risksto provide their life-saving servicesbeyond the frontiers.There were incidents of Red Crossworkers being blocked at the roadblocks. I also recall some incidentswhich had significant effects for theNational Referral Hospital staff. Onone occasion, nurses and doctorsof the National Referral Hospitalin Honiara were threatened by anunidentified armed man, and onanother, two wounded militants werekilled while in the hands of the nursesand doctors in the hospital.Generally, however, the red crossemblem was well respected on bothsides of the conflict and also by theaffected populations which RedCross helped both on Guadalcanaland Malaita. The neutrality andimpartiality which the staff and RedCross volunteers demonstrated madetheir most needed humanitarianmission (which included medicalservices) possible, and allowedthem access to those in need onGuadalcanal. I have a great deal ofadmiration for their work.What lessons do you think SIRClearnt from the challenges it facedin terms of access to health careduring the ethnic tensions?SIRC accessibility to thepopulation in need of assistanceon Guadalcanal came with hugesacrifice and dedication from itsstaff and volunteers, who weretireless advocates for the Red CrossFundamental Principles – particularlyindependence, impartiality andneutrality – through their actions. Theirmission was to save lives and thisrequired ensuring they had the supportof all parties to the conflict in orderto protect the health and dignity ofthe population affected by the ethnictensions.The humanitarian auxiliary nature ofRed Cross, and the FundamentalPrinciples and ways of working of theorganisation, have to be understoodto be respected – by all parties to anyconflict and by the general population.This reminds us that, in peacetime,education about these principles tothe general population, in particularthe young people who are veryactive and dominate the SolomonIslands population, is of paramountimportance.Why do you think advocating forthe protection of the medicalmission is so important now in theSolomon Islands?It is the right time to strongly advocateon behalf of the health care systemin the Solomon Islands. We needto stop the violence against healthcare and to avoid the spillover costs,which have been witnessed during theGuadalcanal ethnic tension.IHL magazine 17

serving undertheHMAS Stirling, Western Australia, 2011.Australian Defence Force medical facility.Photo: Australian Red Cross.red cross:reflections from acareer inmilitary medicalmanagementW D Bullock is a retired British Army Major.The unfortunate truth is that we donot have to look too far in order toidentify that the provision of medicalassistance to those in need, intimes of conflict, is a dangerousundertaking. This is exacerbated byabuse and ignorance of the protectionafforded to military medical personalby the recognised emblems of theGeneva Conventions of 1949 andtheir Additional Protocols.The advent of technology has allowedattacks on military health careworkers, equipment and facilities tobecome more prominent in our lives.I will take a brief look into medicsin danger from a British militaryperspective, based upon historicalevidence and personal diaries in orderto explore this subject further.The Victoria Cross (VC) is the highestCommonwealth award for braverywhich can be given to a person.Interestingly, the Royal Army MedicalCorps has the highest count of VCsamongst any organisation, two ofwhich are Double VCs. The recipientsof the double VCs – Captain NoelGodfrey Chavasse and SurgeonCaptain Sir Arthur Martin Leake –both won for actions conducted inretrieving casualties, under heavyenemy fire and whilst wearing redcross emblems during WWI.Medics operating in positions ofdanger, whilst displaying or operatingunder protected emblems, are notnew to the battlefield. Throughoutmy own British Army career, withinExpeditionary Health OperationsManagement, I have been witness toa number of such incidents.1999 bore witness to numerousreports of systematic attacks onKosovan health care workers. BritishArmy health staff found themselvesin a similar situation. Staff from theBritish Army Field Hospital, deployedsouth of Pristina in Kosovo, wereinvolved in ‘capacity building’ postmilitaryoperations. They wereinvolved in the re-establishmentof the Pristina General Hospital,through coaching and supportingreturning health staff, renovating andestablishing capabilities, and fillingstaff shortages whilst recruitmenttook place. Approximately five daysafter the facility had re-opened,with a steady patient flow and anextraordinarily busy EmergencyDepartment (ED) manned bymilitary and civilian staff, a gunmanbrandishing an AK47 AutomaticAssault Rifle burst into the hospitalreception and ED area and beganto open fire causing numerouscasualties. Military health staff wererequired to intervene to protect theirpatients and themselves.During preparations for the US andBritish-led invasion of Iraq in 2003,there was much deliberation regardingthe arming of military ambulances andevacuation helicopters with ‘standoff’weapon systems (a weapon systemdesigned for offensive actions asopposed to defensive actions).Following lengthy debate regardingthe levels of understanding andapplication of IHL, the decision wasmade that medical transports wouldnot receive any extra weaponrysupport.Following the initial post-invasionlull in hostile activities, the offensiveresponse by insurgent groupsincluded attacks upon ambulancesand health staff, despite visualdisplays of the red cross and crescentemblems. As attacks increased, sotoo did the level of ferocity and thestyle of weapon systems being used.Insurgent tactical procedures includedfiring Rocket Propelled Grenades atlightly armoured ambulance vehicles,using the red cross as a target. Inorder to protect vehicles and staff inthe course of their medical duties,armoured ambulances were fittedwith ‘standoff’ offensive weaponsystems and escorted by othermilitary hardware.There are many similar reports ofattacks on evacuation transports inAfghanistan, which have now resultedin the requirement for an AeromedicalEvacuation platform in Afghanistanto be escorted by two offensive ‘gunship’ platforms on all missions.More recently, I spent some time inAfghanistan during which I witnessedan incident whereby a local Afghanviolently abused clinical staff at a localhospital and then hijacked the localambulance to take his child to thelocal military base for treatment.Disturbingly, there are also many otherreports of attacks against Red Crosshealth care facilities and workers,as well as abuses of the protectedemblems including, but certainly notlimited to, Israeli forces attackingan ambulance with rockets and theSerbian forces using helicopters withthe red cross emblem to conductraids in Kososvo.Unfortunately, in light of continuingviolence and conflict across manyareas of the globe, I believe thatboth direct and indirect attacks onprotected health care facilities andstaff will continue to be a feature ofconflict. Continued education aboutthe true meaning of the protectedemblems and of Red Cross neutralityremains the key to reducing attacks.References:1. Bowler, A. 2009,’The double Victoria Crosses ofthe RAMC’. Helium, available at http://www.helium.com/items/1606386-the-double-victoriacrosses-ofthe-royal-army-medical-corps2. Ayotte, B 1999. ‘The Crisis in Kosovo: SystematicAttacks on Health Professionals’ Wolters KluwerHealth.Journal of Ambulatory Care Management. Vol22(4), p. 81-853. Dyer, O. 2006, ‘Israel attacks Red Crossambulances,’ British Medical Journal, available athttp://www.ncbi.nlm.nih.gov.libraryproxy.griffi th.edu.au/pmc/articles/PMC1523489/?tool=pmcentrez&renderty pe=abstract4. Gutman, R, 1998, ‘Serbs attack with helicoptersbearing the Red Cross,’ Seattle Times andEdmonton Journal. available at: http://community.seattletimesnwsource.com/archive/?date=19980622&slIHL magazine 19

health careindangerThere are many humanitarian problemsassociated with such violence – manyof them directly related to healthcare. In situations of state repression,road blocks often prevent accessto health care. In the initial stagesof the violence, protestors mightbe too hemmed in by the crowdsfor those who have been injured toseek medical care and for medicalassistance to reach them. As theviolence intensifies, lack of respectfor impartial humanitarian assistanceincreases. In Bahrain in 2011, doctorsassisting protestors were attacked,sentenced for sedition or preventedfrom working. In Syria, people arefinding it very difficult to accesshealth care because of the violencein and around towns, and becauseservices are limited and medicinesare not available. In drug gang runenvironments, access to healthcare and humanitarian assistanceis difficult because the normal stateservices often cannot function in the‘farvela’ (urban slums or shanty towns)environment. Moreover, there is oftenlack of respect for state institutions likehospitals. In tribal violence situations,there is often a complete mistrust ofhumanitarian assistance. It is assumedvery clear. IHL requires that civilianmedical personnel must be affordedall available help in areas where civilianhealth care is disrupted by fighting.They must have access to any placewhere their medical services areessential.There is a fine line between regulatingarmed conflict and regulating ‘othersituations of violence’ and it is oftenhard to determine when violencereaches the level of armed conflict.However, even if violence neverreaches the threshold of an armedconflict, we need to be able to regulatesome aspects of this violence in orderto allow humanitarian assistance andhealth care to access those whoare affected by the violence. Theconsequences in human terms of‘other situations of violence’ are oftenas dramatic or intense as those intraditional armed conflicts, in terms ofinjuries, long-term displacement andchronic problems.There have been a number ofproposals over the years to attemptto develop some international legalframework or guidance for theapplication of humanitarian principles inthese situations (as domestic regulationin ‘other situationsof violence’Kelisiana Thynne hasworked as a LegalAdvisor with the ICRCin Afghanistan and thePacific. Eve Massinghamis an InternationalHumanitarian Law Officerwith Australian Red Cross.An ambulance fills with tear gasshot into it during a demonstration.Photo: ICRC/A. SafadiAs the contributions in this magazinemake clear, a lack of respect forhealth care personnel and facilities,and a lack of access to such healthcare in times of armed conflict, isa concern that should be of vitalimportance to the internationalcommunity. It is also a problem forthose situations of violence fallingshort of the threshold of armedconflict, known in IHL as ‘othersituations of violence’. The natureof these situations is perhaps bestunderstood through considering threetypes of violence that characterise‘other situations of violence’: staterepression (including civil unrest andlow level insurgency against thestate), gang related violence (oftendrug related), and tribal violence.The civil unrest and brutalsuppression of that unrest sweepingthrough northern Africa and theMiddle East, the intense armedviolence gripping urban parts ofseveral Central American states(more than 35,000 deaths wereblamed on drug gangs in the 2006-2010 period) and the clan or tribalviolence we see in parts of Africa, theMiddle East and Asia, demonstratenot a new type of armed violence(indeed such forms of violencehave long been part of humanhistory), but a comparativeincrease in situations of armedviolence which do not reachthe threshold of an armedconflict and are therefore notregulated internationally by theuniversally agreed laws of war.The ICRC has said that theseinstances have confirmed that‘other situations of violence’ willgenerate high numbers of victimsand could become one of themost significant forms of armedconfrontations and humanitariandisasters in the coming decade.that no one can be impartial in suchsituations. Codes of honour might alsoprevent someone from seeking medicalassistance. Moreover, the violencealso means that state health servicesare understaffed or non-existent sothat injuries caused by the conflict, aswell as inherent diseases and healthproblems existing, or caused andexacerbated by the violence, cannotbe treated.Whilst the rules are not alwaysrespected – hence the need for theICRC’s HCiD campaign – if thesesituations were to occur in an armedconflict, the rules of IHLwould beand law enforcement has almostalways broken down). None of theseproposals have attracted sufficientstate interest to develop further. Someexisting legal frameworks may haveapplication; states must respect certainuniversally acknowledged humanitarianprinciples, and the human rightsinstruments to which they are party.However, these frameworks haveclearly proved insufficient to protectthe medical mission and, as such,greater consideration should be givenby states to the development ofinternational standards under the IHLmodel to regulate behaviour during‘other situations of violence’.IHL magazine 21

International Humanitarian Law (IHL) ProgramAustralian Red Cross is part of the International Red Cross and Red CrescentMovement, the largest humanitarian network in the world.IHL is something Red Cross thinks everyone should be aware of. We run an IHL Programproviding training and education highlighting IHL issues to key target groups identified ashaving a role to play in situations of armed conflict.fundamentalprinciplesPhoto credit: The ICRC co-organised with the Egyptian Red Crescent Society a three-day workshop in Cairo, gatheringtogether 40 local and international experts. The purpose of this workshop is to discuss how the security situation of healthcare providers can be improved during armed conflicts and other emergencies. Photo: ERC/ M. SaadIn all activities our volunteersand staff are guided by theFundamental Principles of theRed Cross and Red CrescentMovement.IndependenceThe Movement is independent. TheNational Societies, while auxiliariesin the humanitarian services of theirgovernments and subject to the laws oftheir respective countries, must alwaysmaintain their autonomy so that they maybe able at all times to act in accordancewith the principles of the Movement.The IHL Program focuses on the following target groups:• Australian Defence Force• Australian Federal Police• Non-government organisations• Commonwealth Government agencies• Key professions (law, medicine, journalism)• Tertiary and secondary education sectors• Wider communityThe IHL Program specifically offers training programs to sectorsof the Australian Defence Force such as military medics andmilitary police, in addition to being invited to participate inAustralian Defence Force training exercises. More broadly, werun education seminars for members of the general communitywho have an interest in humanitarian issues and whose work isaffected by the application of IHL.Red Cross has a mandate topromote an understandingof, and respect for, the lawin times of armed conflict –international humanitarianlaw (IHL).For more information on the IHL Program visit:www.redcross.org.au/ihlAn IHL Officer from Australian Red Cross talks toAustralian Defence Force personnel at HMAS Stirling,WA.Photo: Australian Red CrossHumanityThe International Red Cross andRed Crescent Movement, bornof a desire to bring assistancewithout discrimination to thewounded on the battlefield,endeavours, in its internationaland national capacity, to preventand alleviate human sufferingwherever it may be found. Itspurpose is to protect life andhealth and ensure respect forthe human being. It promotesmutual understanding, friendship,co-operation and lasting peaceamongst all people.ImpartialityIt makes no discrimination as tonationality, race, religious beliefs,class or political opinions. Itendeavours to relieve the sufferingof individuals, being guided solely bytheir needs, and to give priority to themost urgent cases of distress.NeutralityIn order to continue to enjoy theconfidence of all, the Movementmay not take sides in hostilities orengage at any time in controversiesof a political, racial, religious orideological nature.Voluntary ServiceIt is a voluntary relief movement notprompted in any manner by desirefor gain.UnityThere can be only one Red Cross or RedCrescent Society in any one country. Itmust be open to all. It must carry on itshumanitarian work throughout its territory.UniversalityThe International Red Cross and RedCrescent Movement, in which allSocieties have equal status and shareequal responsibilities and duties inhelping each other, is worldwide.

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