Documenting attacks on health workers and facilities in armed conflicts

During armed conflicts, international humanitarian law (which regulates the conduct of parties engaged in war) protects health-care workers and health facilities, the wounded and the sick. In the first half of 2016, however, the international medical charity Medecins Sans Frontieres (MSF) reported several attacks on health facilities and workers in Afghanistan, the Central African Republic, South Sudan, the Syrian Arab Republic and Yemen. (1) These events have attracted media attention to a phenomenon of contemporary armed conflict that has important ramifications for the health, humanitarian, legal and security sectors. (2) In December 2015, the Stockholm Peace Research Institute and the Conflict and Health Research Group at King's College London convened a workshop in London on Eliminating violence against health workers: from theory to practice. Participants from MSF, the International Committee of the Red Cross (ICRC), Medical Aid for Palestinians and academic organizations discussed current trends in violence against health workers and attacks on health facilities, presented research findings and highlighted key debates and research gaps in evidence. Some important lessons can be drawn from ICRC's Health Care in Danger campaign, MSF's Medical Care Under Fire campaign, as well as other organizations such as Physicians for Human Rights, which has recently documented mass atrocities in the Syrian Arab Republic as well as the impact of the Syrian conflict on the health sector. (3-5) There is a perception Of an increase in the number of health workers being killed and facilities being accidentally destroyed (so-called collateral damage) or deliberated targeted during armed conflicts. Comprehensive databases have been set up by independent research organizations to record major incidents of violence against aid workers, such as the Aid Worker Security Database of Humanitarian Outcomes and the Security in Numbers Database from Insecurity Insight. (6) However, even these do not currently provide health-specific data. The absence of baseline and routine data relating to attacks on health workers and health facilities makes it difficult to identify actual rising trends. Most of the available data sources do not capture violence on local health workers, who seem to bear the brunt of most attacks. Data disaggregated by sex are also lacking. (6) Box 1 Key needs for documenting attacks on health workers and health facilities in armed conflicts * Analysis of trends of attacks on patients and health-care workers, facilities and transport during armed conflict and other violent incidents. * Collection of systematic routine data, prospective and retrospective, which are disaggregated by sex. * Examination of the context of each conflict to understand the dynamics and motives for attacks. * Disaggregation of data on humanitarian databases to distinguish between types of aid workers, including local and international health-care workers. * Public availability of anonymized data collected by humanitarian organizations to support a global response on prevention and accountability. * Assessment of open threats and impact on health facilities and health-care personnel by security staff both before deployment and immediately after conflict. * Systematic analysis of the immediate and longer-term impact of violence on the providers of health care. These gaps in the evidence seem incongruous in an era of increasingly accessible and globalized data. Yet there are many factors that inhibit systematic data collection: poor or non-existent data collection by those in the field (for a variety of reasons ranging from security risks to insufficient research capacity); bias in data collection; insufficient research funding for the topic; and a lack of developed method. Some efforts have been made to monitor and study attacks (both quantitatively and qualitatively), particularly by the ICRC and MSF. However, multidisciplinary, collaborative, long-term retrospective and prospective studies are absent--often for valid reasons. …