Posted by: rstewart1 | 08/10/2011

Turning a corner on protection of health workers and facilities?

This is a guest blog by Leonard Rubenstein, senior scholar at  the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health

The international media attention to repression in response “Arab Spring,” included reports of  and expressions of outrage about attacks by Bahrain’s security forces on health workers, obstruction of hospital access and arrest and prosecution of doctors and nurses.   The attention was atypical, as assaults on hospitals, medical personnel, ambulances and patients during armed and civil conflict usually pass without notice or protest.

An analysis by the International Committee of the Red Cross in 16 countries released on August 10 in conjunction with its new campaign, Health Care in Danger, revealed 655 violent events against health care, including kidnapping, killing, and wounding health care workers, over just two a half years.   Few of these attacks elicited a response from the medical, human rights, or the global health community.  Indeed, systematic reporting of incidents, sustained inquiry into the medium and long-term impacts of attacks on health care on health infrastructure and health worker migration, prevention and accountability strategies, are also absent.  To be sure, assaults on humanitarian workers have stimulated attention to their vulnerability and the need for better security, but local health providers, emergency personnel and facilities, which are most frequently targeted, are all but ignored.

Yet the lassitude may be ending, with new initiatives by the International Committee of the Red Cross, the US State Department, the World Health Organization and the UN Security Council to advance documentation and reporting of violations, development of prevention strategies, accountability, and mobilization of political will.

Last month, the UN Security Council expanded its mechanisms to identify and stigmatize states and armed groups that commit grave human rights violations against children in war to attacks on schools and hospitals and the personnel who work in them.  Given the broad interpretation given to the phrase hospitals, the mechanism has potential to bring needed attention to violations and accountability for perpetrators.

Almost simultaneously, in response to an initiative by the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, the State Department will begin collecting and publishing information on attacks on or obstruction of access to health care services and humanitarian access as part of its annual Human Rights Country Reports, covering 190 countries and available in 50 local languages. Although formerly subject to political bias, in recent years the reports have become credible and widely-read sources of information on human rights abuses.   Inclusion of assaults on health can increase their visibility, validate the work of local activists, and ratchet up pressure on perpetrators to cease the violations.

An even more robust plan for reporting, by the World Health Organization, is on the horizon.  At the behest of NGOs and academics, and with the support of the US and other governments, WHO plans to convene a group of experts, governments, NGOs and health providers to examine methods and strategies for WHO to systematically collect and report data on violence in civil or armed conflict against health facilities, patients and workers.  The goal is for WHO to obtain quality information directly from the field and report the results on its website as a resource for health workers, officials, NGOs, and advocates in affected countries and throughout the global community who seek to increase protection of health.

Expanded attention to assaults must be accompanied by mobilization of political will.  Toward this end, on August 10 the ICRC launched its Health Care in Danger campaign, designed to bring states, civil society, and health professionals together to galvanize international action to develop practical and effective strategies to prevent attacks.  The four year campaign seeks to increase respect for norms and rules, support front line health-care workers, engage with security forces and armed groups, and put security of health care on the diplomatic agenda.

These nascent initiatives in combination offer a hopeful way forward.  Realizing their potential depends on everyone in the global health community, including professional associations, civil society organizations, ministries of health and health providers, rallying behind the opportunity and committing to support colleagues and patients who are at risk of violence during armed and civil conflict.  The means – demanding high quality information, collaborating on protection strategies, and assuring that perpetrators suffer consequences – are within our grasp.



  1. Great blog! Clearly, it is against international norms and international law to attack health care facilities and providers who are performing their duties in a neutral, professional manner. It is also wrong to deny care to those in danger of loss of life or limb or eyesight, or in active labor. Prosecuting non-state actor is very difficult, it follows, because they already live more or less like fugitives. An easier target for prosecution, and an even more egregious one, is the state actor. State actors cannot claim ignorance. But to prosecute the state itself is the wrong approach. The individual officials responsible for the illegal orders must be identified and brought to justice. The international community must go after those officials who act with malice against their own citizens. They should be treated like the outliers they are, named, shamed and arrested.

  2. Surely it is the hard work of well established authorities on health and human rights such as Leonard Rubenstein and others more than the “Arab Spring” that has managed to focus the attention of policymakers on the need to curb violence directed at health care settings. And how grateful we should all be for their success! But if the past is any guide, it is going to take a sustained effort involving many like Mr. Rubenstein to ensure that the encouraging signs of progress that he writes about are woven into the workplace cultures of health care settings.

    It is all too true that the violence directed against health care settings resulting from armed and civil conflict is tragically under-reported, but it also must be said that there is an alarming amount of violence directed against health care workers and facilities that goes scarcely mentioned everyday.

    That is not to diminish in any way the importance of the good news that the International Committee of the Red Cross, the US State Department, the World Health Organization and the UN Security Council are aiming to boost the documentation and reporting of violence against health care settings resulting from civil or armed conflict, develop prevention strategies, increase accountability, and marshal political will. Any effort that jumpstarts action to reduce violence in health care settings is just what the doctor ordered.

    But a more expansive approach to reducing violence in health care settings is needed. Equally important is the need to ensure that the prescribed solutions are informed by the experience and the input of the very health care workers who are on the frontlines of the violence assaulting health care settings.

    Ten years ago the Joint Programme on Workplace Violence in the Health Sector, a collaborative effort of the World Health Organization, International Labour Organization (ILO), Public Services International (PSI) and the International Council of Nurses (ICN), developed “Framework Guidelines for Addressing Workplace Violence in the Health Sector.” A review of those guidelines suggests a great deal of unfinished business that could be incorporated into the “Health Care in Danger” campaign and WHO’s future consultations.

    The Joint Programme statistics then, in need of updating now, are nonetheless alarming:

    • almost 25% of all violent incidents at work are in the health sector
    • more than 50% of health care workers have experienced violent incidents at work
    • psychological violence is more frequent than physical violence
    • 40 – 70% of the victims report significant stress symptoms
    • stress and violence account for approximately 30% of the overall costs of ill-health

    Hopefully when the World Health Organization convenes its planned consultation with experts, governments, NGOs and health providers to examine methods and strategies for WHO to collect and report data on violence in civil or armed conflict against health facilities, patients and workers, it will also consider ways to build on the Joint Programme’s previous work.

    The escalating pressures on health systems and their vulnerability to violence are only likely to intensify in these times of economic uncertainty. With the all-too-familiar reminders that resources for health are already stretched too thin, it is essential to find synergies and sustainable solutions whenever possible. Having captured the attention of policymakers now would be a good time to encourage solutions that work to ensure that health care settings are free from violence not only in times of conflict, but every day.

  3. It is absolutely disheartening to even think that health care workers who are dispatched to render aid are being attacked and in some cases killed. More disheartening is the fact that these incidents are under reported. .With these attacks being swept “under the rug” health care workers are practically walking into a possible violent situation blindly with no way of knowing what to expect.It is clearly an issue which requires global participation in order for it to be resolved. I find consolation in the fact that efforts are being made by WHO and other organizations to increase international awareness of this problem, that way better precautions can be taken for protecting these health aides and their good intentions.

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