Saving Those Who Save

15 July 2015

A new report being published for the 2016 World Humanitarian Summit will no doubt become part of a broader global debate on the need to improve the safety and security of humanitarian healthcare workers deployed in unstable contexts throughout the world. The report, “Managing risks: Study and meta-analysis on violence against healthcare personnel in unstable contexts”, is a collaborative work from a number of high-profile frontline humanitarian organizations – the International Committee of the Red Cross (ICRC), Médecins Sans Frontières (MSF), Office for the Coordination of Humanitarian Affairs (OCHA), and Humanitarian Outcomes.

The ICRC and South Sudan Red Cross staff and volunteers present on the ground collect the airdropped food, unpacked them and divide them into family rations. (Photo: International Committee of the Red Cross)

While the full meta-analysis is featured on the Frontline Safety and Security website, the following summary will highlight the critical aspects of the report’s research as well as its key findings and recommendations.

The growing plight of healthcare workers in the field
Humanitarian healthcare aid was first recognized as a specialized field in the mid 19th century. Flocking to stricken and sometimes volatile areas, these impartial healthcare workers have found themselves in the midst of violence. Over the last several decades, the safety and security of healthcare professionals who travel to dangerous areas to provide medical help to those in need has entered into the broader global debate as an urgent and systematic issue. With the rise of unconventional warfare by small groups capable of wielding global impact, we see combatants exhibiting a lack of respect for the principles of humanity, neutrality, impartiality, and independence. This has resulted in increased risks to healthcare workers through the actual and threatened use of violence by a plethora of state and non-state actors.

The Red Cross was the first major organization to initiate investigations into incidents of violence against healthcare workers. Their 2008 Health Care in Danger (HCiD) project, which sought to address the lack of a central reporting agency on attacks, has since been mirrored by other like-minded organizations. Despite many strategic gains in discerning best practices to improve the safety and security of healthcare workers in the field, much remains to be done in terms of examining the motivations behind targeted attacks, risk factors that contribute to them, the accountability of perpetrators, and long-term impacts of these incidents in the healthcare field specifically and the humanitarian field more broadly.

These attacks come in a daunting variety of forms, all of which are blatant examples of the decreasing lack of respect for the humanitarian principles that have served to protect healthcare workers over the course of decades. Even more common than the deliberate and systematic targeting of healthcare workers (such as the killings of polio vaccination workers by the Pakistani Taliban) are instances of indirect assault on these personnel, including impeding access to the wounded or sick. Routine harassment and threats to humanitarian convoys in Syria since 2011 is just one of many examples).

Ambulance damaged by gunfire and explosion emphasizes the danger health workers are often in the field. (Photos: ICRC)

Perhaps most common, however, are threats of opportunistic violence and common crime against healthcare workers. Medical personnel have fallen victim to assaults, muggings, thefts, and other forms of violence that are typically seen as being spillover effects from pre-existing and chronic instabilities.

Many attack case studies are discussed in detail throughout the report. For example, after multiple incidents against MSF personnel in Somalia, the organization withdrew its services from the country in 2013 in order to protect its volunteers).

Key findings

  • The rate of violent attacks against healthcare workers has increased dramatically in recent years, with opportunistic threats being more prevalent than deliberate threats;
  • Three-quarters of attacks against healthcare workers are perpetrated in six countries (Afghanistan, Pakistan, Somalia, South Sudan, Sudan, and Syria).
  • 91% of affected healthcare workers are nationally based, rather than internationally based (International Red Cross and Red Crescent, MSF, etc.);
  • Approximately half of attacks take place while healthcare workers are travelling on the road, in transit from one site to another; and
  • Almost one-third (32%) of attacks against healthcare workers are perpetrated by non-state armed groups, while 25% are inflicted by state armed forces.

Preliminary conclusions
The humanitarian community broadly, and the healthcare field specifically, are in need of improvements in practices, equipment, and training, in order to properly ensure the sustainable safety and security of healthcare workers in unstable contexts.

More quantitative research must be done in determining risk factors, complemented by qualitative reports submitted by those in high-risk areas, so that mitigation strategies can empower contextually sensitive practices and policies on the ground.

A paradigm shift is needed in quantifying attacks based on motivation and inputs, not merely impacts and outcomes. This will help enable preventative over-reactive measures.

Syrian Arab Red Crescent teams from Damascus provided first aid services to the evacuated people from Moadamiya (Photo: Syrian Arab Red Crescent)

The healthcare community is required to develop standard operating procedures (SOPs) in order to enforce the recognition and protection of humanitarian workers, as accorded by international humanitarian law.

Beginning with the HCiD project in 2008, multiple frontline humanitarian organizations have begun to formulate high-level policies that seek to generate proactive discussion and raise awareness of the increasing dangers facing both national and international healthcare workers deployed in the field. The ICRC’s Health Care in Danger: Making the Case is one such initiative in which strategic considerations are listed:

  • Build a community of concern
  • Regular and methodical information gathering
  • Consolidate and improve field practices
  • Ensure physical protection
  • Facilitate safer access for staff and volunteers
  • Engage with states and national armed forces
  • Engage with non-state armed groups     
  • Engage with professional healthcare institutions and health ministries     
  • Encourage interest in academic circles

While improving security for healthcare workers is a noble starting point in spurring the conversation, there remain many gaps in real operational and tactical best practices. More information is needed before a comprehensive and holistic list can be produced. Using the meta-analysis and recommendations in this report, we may see a paradigm shift developing in terms of both policy and practice.

Carrying a ‘cold box’ filled with polio vaccines, vaccinator Nyaluak Tebuom, 14, passes other travellers on a dirt road as he journeys to Pakur Village, in Unity State. Nyaluak must walk more than 10 kilometres on the road, which is laden with anti-tank mines, to administer the vaccines to the village’s children. (Photo: Unicef)

Focusing more explicitly on operational and tactical practices, Humanitarian Outcomes prepared an initial list of “Sample SOPs for road movement.” Their report, Unsafe Passage: Road attacks and their impact on humanitarian operations (2014), focuses on analysis and recommendations to safeguard healthcare workers while en route from compounds or offices and the site of healthcare taskings itself. Many, if not all, of these Standard Operating Procedures have long been implemented by Western armed forces, in response to recurring risks from asymmetric forces while in transit from site to site.

Embracing these SOPs does not indicate a distancing from the humanitarian principles of impartiality and neutrality, but rather the sharing of best practices that can enable healthcare workers to limit their dependence on external security forces on either side of the conflict in question. This sample list of initiatives and protocols would be particularly useful to develop SOPs:

  • Defensive driver training (for drivers and staff);
  • Conflict mitigation training, including negotiation skills;
  • How-to Guides (including good practice at check-points and roadblocks, under crossfire, during armed robbery or kidnapping, when engaging with local authorities, etc.);
  • Travel/movement procedures based on programme criticality;
  • Check-in and -out procedures;
  • Curfews and no-go areas;
  • Two-car rules and vehicle-spacing guidelines;
  • Passenger policies, including the use of local community leaders to accompany movement of staff;
  • Routine changes in routes and times, often on a daily basis; and
  • Use of high-frequency radio and satellite equipment during long-distance moves.

With differing opinions on how to improve security measures for healthcare workers, and steering clear of the “one size fits all” mentality, it may be necessary to assess each scenario on a case-by-case basis.

A doctor examines a child at the hospital run by the Hawa Abdi Centre. (UN Photo: Tobin Jones)

Due to the contextual nature of these attacks, the same measures used to safeguard polio vaccination workers in rural Pakistan may not be effectively used to protect healthcare workers elsewhere from common criminal acts. The goal of this meta-analysis, however, was to study the data already available to organizations within the humanitarian community, and to pave the way to institutionally improving safety within the international healthcare industry We must prioritize safety and security of health practitioners and staff.

While much of the research was performed by like minded humanitarian organizations, it is ambitious in scope and at a very broad level. Nonetheless, there are many viable operational and tactical recommendations, and should to be implemented quickly to improve practices and policies on the ground.

Ultimately, the specifics of SOPs in safeguarding healthcare workers and facilities must come from those stakeholders within each specific environment – those who know the terrain, the people, and the threats.

Ideally, this will be developed from a holistic effort by healthcare workers and their organizations (in tandem with national and local authorities), with an aim to determine contextual best practices. A concerted effort to determine motivations and risks can help shed light on reducing impacts in both the short and long term.

That considered, a high-level discussion held within the forum of strategic policy-making, in order to prescribe feasible improvements, could help facilitate the protection of lives and assets where they are the most vulnerable.

A nurse takes care of an infant child in an incubator at the Al-Sabeen Hospital in Sanaa. Hospitals and clinics in Yemen have been paralyzed by the war; they have either been attacked, run out of medical supplies and fuel or the medical staff have been forced to flee. (Photo: Unicef)

It is becoming increasingly evident that the realities of the current humanitarian climate are demanding that healthcare workers adopt more security-responsible mentalities at an institutional level.

With more and more personnel caught in the crossfire each year, the luxury of postponing this debate any longer has long-since passed.

Casey Brunelle recently completed a full-time internship at United Nations Headquarters in New York City
Click here to view the meta-analysis in full, the risk indicator matrix conceived by the author, as well as the primary sources used in this report.
© FrontLine Security 2015