A Scoping Review of the Wider and Long-Term Impacts of Attacks on Healthcare in Conflict Zones Mohammed Hassaan Afzal [corresponding author] Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom [email protected]Mohammed Hassaan Afzal is an emergency medical doctor and research associate at HCRI (University of Manchester). His research interests regard violence directed against healthcare in conflict zones and what measures can be taken to reduce the risk and impact of attacks. Anisa Jafar Humanitarian and Conflict Response Institute, University of Manchester, Manchester, United Kingdom [email protected]Anisa Jafar is an emergency medicine trainee in the North West of England. She is undertaking a PhD at the HCRI (University of Manchester) focussing on medical documentation by emergency medical teams in sudden onset disasters. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
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A Scoping Review of the Wider and Long-Term Impacts of Attacks on
Healthcare in Conflict Zones
Mohammed Hassaan Afzal [corresponding author]
Humanitarian and Conflict Response Institute, University of Manchester, Manchester,
There are a few examples where mortality or morbidity rates related to the
reduction in health services have been reported. MSF doctors in Taiz Yemen state that
212 war-wounded died in facilities where capacity was reduced (MSF 2015b). During
the August 2013 chemical attacks in Damascus a doctor stated 22 people died for lack
of equipment (Rubenstein 2015). And Iraqi doctors writing in the British Medical
Journal claim half of the civilians who died in their emergency departments could have
been saved if there were sufficient trained medical staff (Sheibani, Hadi, and Hasoon
2006).
Changes in practices of health workers/facilities
Health facilities under or at risk of attack have had to change the way they operate. In
Syria, because hospitals have been regularly targeted, doctors created a network of
underground field hospitals established in basements, farms, abandoned buildings,
mosques and factories. These field hospitals have become more sophisticated
throughout the conflict and can include emergency rooms, operating theatres and
intensive care units (Fallon and Kieval 2017). An estimated 270,000 lives have been
saved by Syria’s field hospitals (Sankari, Atassi, and Sahloul 2013).
MSF-supported facilities in Syria no longer share GPS coordinates with warring
parties as it is believed to increase the risk of direct targeting (MSF 2016). They also
manage facilities remotely using mobile technologies to decentralise care and reduce the
risk posed to their staff. They acknowledge this brings challenges in managing staff,
providing capacity building and understanding and responding to the conditions on the
ground (MSF 2017a).
Other changes to practices of health workers include medical workers living in
the hospitals as travel to work has become too risky (MSF 2017b), working longer shifts
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in order to compensate for the absence of staff (Rubenstein 2015), adapting treatment
and prescription plans to reduce the number of visits patients need to make to facilities
and shifting to home-based care (Armstrong 2016).
Consequences from the different forms of administrative and physical
obstruction
Obstruction can occur in various forms but all with negative consequences for the
delivery of healthcare. In Yemen the naval blockade and the closure of the airport by the
Saudi Arabia-led collation is one of the main contributing factors to the collapse of the
healthcare system. Yemen imported 90% of its medical supplies but the blockade
prevents these reaching hospitals (Monaghan 2017b). Unicef (2016) has said the decline
in health services caused an estimated additional 10000 deaths in children under 5 in the
past year. 90% of Yemen’s fuel is also imported. The destruction of power plants has
forced facilities to rely on generators, but the shortage of fuel means they cannot power
essential equipment such as ventilators and incubators (Save the Children 2016). The
only oxygen plant supplying facilities closed in April 2015 due to a lack of fuel (OCHA
2015). Although there are no figures to indicate how many facilities have closed due to
fuel shortages, only 45% of the country’s facilities are fully functioning (Ministry of
Public Health & Population and WHO Yemen 2016). Yemenis are also heavily reliant
on overseas medical care but the closure of the capital’s airport has prevented 20000
civilians from travelling aboard to receive care (OCHA 2016a). Again, it is not known
what health consequences this has had, but these people were said to be seeking serious
or urgent medical treatment (ibid).
In the Gaza Strip, the Israeli military blockade restricts the movement of goods
and people in and out of the region. For those who need to access healthcare outside
Gaza, they must enter into an application process for a permit to cross the border. In
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2017, 47% of applications were rejected and 44% delayed. At least 20 people died
waiting for approval or after having the request rejected last year alone (Al Mezan
2018). On the other side of the Occupied Palestinian Territories (OPT), ambulances
from the West Bank are not permitted to cross the border into East Jerusalem. Instead
they must transfer the patient from a Palestinian ambulance to an Israeli registered one
at the checkpoint. This transfer process can take up to five times as long. The
Palestinian Red Crescent Society found in December 2015 the average delay was 27
minutes, 12 more minutes than the recommended time (MAP 2017). These delays can
be fatal: between 2000 and 2007 10% of pregnant women were delayed at checkpoints
resulting in 69 births, 35 infant deaths and five maternal deaths at the checkpoints
(Shoaibi 2011). Rytter et al. (2006) found those who were delayed by Israeli
checkpoints or by detours on their way to the emergency department were more likely
to be admitted into hospital, indicating the restrictions in access negatively influenced
the severity of their presenting condition.
Rates of chronic diseases
Care for chronic diseases has suffered. In Yemen, the commercial blockade has led to
nationwide shortages of medicines for conditions such as hypertension, diabetes and
cancer. Because facilities no longer have the necessary medications, patients have
resorted to market stores and even the black market (Save the Children 2016). However
the scarcity has raised prices by as much as 300% (ibid). Doctors report increased
numbers dying from chronic diseases but there are no supporting data (MSF 2015b).
Syria’s health facilities also struggle to treat chronic diseases, not only because
of a shortage of medication, but also because the increase in trauma-related cases has
diverted resources away from primary care. Furthermore, frequent cuts to the electricity
supply mean medicines which require refrigeration deteriorate (Baker and Heisler
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2015). The president of the Syrian American Medical Society (SAMS) believes that by
2013, more than 200000 Syrians had died from chronic diseases, twice as many as those
who had died from combat (Murugen 2013).
Difficulties in accessing treatment for chronic diseases has also been reported in
Ukraine, risking the health of patients with HIV and tuberculosis and cancer (OHCHR
2016). Again there are no figures to indicate how many people cannot access treatment
for chronic disease or their health outcomes.
Outbreaks of vaccine-preventable diseases
Vaccination coverage has dropped in conflict regions and with it a rise in communicable
diseases. Most examples in the literature talk of a general decrease in coverage with
populations at risk of outbreaks but there are a few detailed reports.
Vaccination in Syria has dropped as a result of the insecurity, destroyed vaccines
and wastage resulting from disruptions to storage mechanisms (Baker and Heisler 2015,
Armstrong 2016). Polio re-emerged in 2013, 18 years after it was eradicated from the
country. Vaccination coverage has dropped from 83% prior to 2011 to 48% in 2016
(WHO and Unicef 2017). Measles coverage dropped 20% over the same time period
and there have been almost yearly measles outbreaks since 2013 (WHO 2018b).
80 polio vaccinators in Pakistan were killed between July 2012 and February
2015 (Farooq 2015). This correlated with an increase in reported polio cases from 58 in
2012 to 306 in 2014 (End Polio Pakistan 2017). In response to the rising attacks, the
Pakistani government deployed security forces to accompany polio workers, since when
polio cases have fallen (ibid).
For the first half of 2015 in Afghanistan, reported measles cases jumped 141%,
the majority of outbreaks occurring in districts with frequent conflict and known
restrictions in the delivery of health services (OCHA 2016b).
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Change in health-seeking behaviours
Patient health-seeking behaviours have also changed for fear of accessing healthcare
facilities. In Afghanistan, patients described how they were taking longer routes to reach
safer hospitals, or were not seeking treatment at all because of the insecurity (MSF
2014). Staff noted patients dying as a result of delayed treatment (Monaghan 2017a).
Doctors in Aleppo Syria have stated the fear of travel and believing hospitals are targets
has resulted in a 50% drop in clinical visits and surgical cases. Women are also
choosing to have Caesarean sections to avoid the risk of going into labour at night and
making the dangerous journey to a health facility (Rubenstein 2015).
Even when a patient attends a facility threatened by attack, they may insist on
minimising the time they spend there. MSF has noted how in Yemen some patients in
critical condition will only stay long enough to be able to physically leave again; and
new mothers will leave a within hours of delivering their baby (Armstrong 2016). It is
not stated whether the health outcomes for these patients are known or documented.
The loss of trust of hospitals as safe spaces is being felt in many countries. MSF
Canada’s Executive Director has said some communities refuse the building of hospitals
or clinics in their locality because of the unwanted attention they bring (Vogel 2016).
Mental health deterioration
The extent of the psychological consequences for healthcare workers has been detailed
through interviews. Healthcare workers remaining in Syria are found to be working
longer hours and often with no guarantee of pay, dealing with high volumes of horrific
cases, and under constant fear of bombardment, arrest and torture. Depression, burnout
and psychological trauma are common (Baker and Heisler 2015, Rubenstein 2015). This
issue has also been raised in interviews with staff in Yemen (Monaghan 2017b),
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Afghanistan (Monaghan 2017b), Congo and Pakistan (Merlin 2010). However, these
examples give no figures describing the extent of the problem. Abu-El-Noor et. al
(2016; 2018), using cross-sectional surveys of physicians and nurses working in the
Gaza strip after military offensives, was able to find rates of PTSD as high as 89.3%,
which remained at such levels when repeated 2 years later.
Loss of transport
In addition to the challenges of keeping vehicles mechanically sound, medical transport
can be difficult to find for a number of reasons; either it has been destroyed or stolen so
there are fewer to go around, or there is a shortage of fuel so they are non-functioning.
Ambulances in conflicts such as that in Syria also avoid travelling at night because the
headlights make them a target. At desperate times they’ll risk driving with the lights off
(Rubenstein 2015).
As of June 2015, 25 out of the 131 ambulances in the whole of Yemen were
partially or completely damaged (WHO 2015a). Coupled with the blockade of fuel into
the country, the costs of transport have become unaffordable for many. These factors
have contributed to the decrease in the numbers of patients able to access healthcare in
the country (MSF 2015b). Although there are no data to indicate the scale of the
problem, healthcare staff have seen patients arriving in critical states because of delays
in transportation, ultimately resulting in their deaths (Monaghan 2017b).
The lack of safe transport itself is causing health complications. Patients have
resorted to using whatever means of transport is available, including motorbikes and
being carried physically, sometimes by their arms and legs. As a result, they arrive with
additional injuries to the backbone and neck (MSF 2017b).
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Disruptions to medical education
Attacks on healthcare also have consequences for medical education. Physicians for
Human Rights documented disruptions to medical teaching in conflicts in El Salvador
and Indian Kashmir. The only medical school in El Salvador was forced to close by the
military government in 1980, at the same time killing students and faculty. When it was
allowed to reopen four years later, it was not provided with a sufficient budget to run
effectively. The campus was again closed in 1989 (PHR 1990). In Kashmir, medical
students stated the quality of teaching was affected by the attrition of doctors, and how
curfews imposed by the military affected their ability to participate in clinical rotations
(Iacopino and Gossman 1993). In both cases it is not stated how many students were
affected. SAMS Syria report notes ‘hundreds’ of medical students have had their
training interrupted by the conflict (Rubenstein 2015).
Fear of speaking out
The INGO Merlin found healthcare workers afraid to speak out about the risks they
faced for fear of losing their much needed income. Healthcare workers in large INGOs
in conflict areas tread a tenuous line, because an evacuation of INGOs would result in a
huge financial loss to the people it employs. This was succinctly expressed by one nurse
in Sudan, ‘If we admit how bad we feel we may lose our jobs. It is better to pretend and
keep everyone happy’ (Merlin 2010, 21).
An underestimation of the full extent of impacts
The extent of the impacts of attacks on healthcare can only be fully understood by
reference to complete health-related data sets (Coupland 2013). The burdens that
violence puts on health workers and their facilities, the infrastructure it destroys and the
shift of resources towards security and reducing risk to life places data collection far
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down the priority list for providers of healthcare (Rubenstein and Bittle 2010,
Rubenstein 2015). Therefore, attacks on healthcare preclude a full understanding of the
impacts these very attacks cause (Spagat 2018).
Discussion
Although information on the impacts of attacks on healthcare in conflict zones is
available, it is rarely collected as the primary objective of field research. Instead, this
information is often embedded within the literature reporting attacks on healthcare or
describing the consequences of conflict. This review has been able to extract, collate
and organise this information into 15 categories that describe the type of impact and a
range of its consequences. These relate to access to and delivery of healthcare, changes
in mortality and health outcomes for affected healthcare staff and the populations they
serve, and changes in the behaviour and practice of healthcare facilities and patients in
need of care. By using the WHO definition of an attack on health care we have
identified the full range of impacts of attacks; as well as immediate violence these
include the obstruction to supplies and the effect of threats of violence and insecurity on
health staff.
However, available information on the impacts of attacks on healthcare is
limited in reach; the full extent of the consequences of a specific attack or attacks in
general are rarely documented in detail. Accounts often stop short from describing the
knock-on effects these attacks may have had, and therefore are unable to provide
comprehensive descriptions of the wider and long-term consequences for the
population. It is by working down the ‘chain of impacts’ that the full public health
consequences are revealed (Coupland 2013).
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The limitations in data collected from attacks on healthcare have been heavily
stressed (Coupland 2013, WHO 2016a, Mülhausen, Tuck, and Zimmerman 2017, ICRC
2011). The same issues also exist for data collected on the impacts of attacks on
healthcare. Methods are not consistently applied to every attack or every region in
which it is known attacks take place so there is expected to be considerable
underreporting. The lack of a systematic process to collect these data precludes
establishing a reliable and comprehensive data set; one that would provide a complete
picture of the consequences of attacks on healthcare, and that would allow pattern
analysis and comparison between regions and contexts. The quality of the data that
exists varies depending on the location and context, the operators on the ground and the
objectives of the data collection process. Furthermore, there are no recommendations in
the existing literature for how data collection and associated methodologies might be
strengthened to ensure that all wider and long-term impacts are captured.
The literature also does little to distinguish between impacts specific to attacks
on healthcare and impacts on health from the wider conflict itself. The two often
overlap and it can be difficult to determine the actual cause. To give an example, deaths
from waterborne disease rise as a result of violence and the destruction of clean water
sources, but may also result from the poor availability of health services to treat the
conditions. There has hitherto been no discussion as to how we can discern the
consequences of attacks on healthcare from those of the prevailing violence, or if it
appropriate to do so. It may be agreed, as the two are so closely interlinked, that the
consequences of conflict on health should be regarded as ‘attacks on healthcare delivery
and public health’. Depending on one’s interpretation of the WHO definition of an
attack on healthcare, conflict may be regarded as an ‘attack’ as it results in ‘physical
violence or obstruction or threat of violence that interferes with the availability, access
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and delivery of curative and/or preventive health service’ (WHO 2018a). Whether we
take this stance, or we further refine the WHO definition to exclude the consequences of
conflict on health is an area for further debate.
Literature on the impacts of attacks on healthcare, like the literature on attacks
on healthcare themselves, is largely focused on regions with high profile conflicts such
as Syria, Yemen and Gaza (Mülhausen, Tuck, and Zimmerman 2017). Less attention is
paid to other regions where it is known attacks on healthcare also occur, such as
Ukraine, Northern Nigeria or the Democratic Republic of Congo.
Limitations
This review has provided little historical context; only 16 reports were identified
addressing impacts prior to 2011, largely from Physicians for Human Rights and Al
Mezan Centre for Human Rights. This is likely to be because attacks on healthcare only
became a more widely discussed phenomenon from 2011 onwards (Rubenstein 2012).
As some attacks can be reported under the broader topic of violence or insecurity in a
region, it is possible this review has missed published literature that might also include
the impacts of attacks on healthcare. Lastly, limiting the search to English sources will
have inevitability excluded reporting of impacts from local media and smaller national
organisations in non-English speaking communities.
Conclusion
Current information on the impacts of attacks on healthcare in conflict zones
demonstrates the consequences for healthcare delivery and the health of the surrounding
populations. But because of limitations in available data, this represents only the tip of
the iceberg and the full range of impacts remain unknown. With the majority of data
centred around high profile conflicts of recent times (largely from the Middle East), and
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no follow-through on the chain of impacts, the data lacks not only geographical spread
but also depth. Further discussions are required as to how we can differentiate the
impacts of attacks on healthcare from the impacts of conflict itself on health, or even if
we should be making this distinction at all. If we are to fully understand the range of
consequences for healthcare access, delivery and health outcomes, it is important to
develop systematic methods for data collection of the impacts of attacks on healthcare
and ensure their routine application following attacks, in order to create comprehensive
data sets. More attention must also be paid to low-profile conflict regions where attacks
on healthcare are known to take place but are less frequently documented. As stressed
by the WHO, the ultimate goal of expanding and strengthening the evidence base of the
impacts of attacks on healthcare is to develop ‘more effective and targeted advocacy to
stop attacks, and concrete actions to reduce the risk and impact of attacks’ (WHO
2016a, 10).
Acknowledgements
We would like to thank Duncan Shaw, Tony Redmond and Darren Walter for their
input towards reviewing this paper.
Declarations of interest
There are no potential conflicts of interest for any of the authors.
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