Attacks on and obstruction of health-care facilities and personnel in armed conflicts and other emergencies is a massive humanitarian problem resulting in the denial of health care to millions of people.
ICRC was prompted to address this humanitarian challenge with the "Health Care in Danger" campaign, which involves mobilizing the ICRC's network of delegations and other components of the International Red Cross and Red Crescent Movement, States party to the Geneva Conventions, the health community and other actors, to develop practical recommendations to resolve this problem and engage in their concrete implementation.
"This is a general probem, so reaching the solutions should be a joint effort", said Mr Pierre Gentile, ICRC's head of the "Health Care in Danger" project.
From this perspective, the Workshop entitled "Security of Emergency Health Care in the Field", co-organized by the ICRC and the Egyptian Red Crescent Society (ERC), convened in Cairo and gathered together nearly forty specialists from 12 Arab and non-Arab countries. These expert participants brought their experiences and expertise to Cairo in an attempt to identify the best practices that would enhance the security of the wounded and sick as well as that of emergency health-care providers.
Expert participants in this three-day meeting, drawn from ambulance services, emergency care organizations and National Red Cross and Red Crescent Societies, discussed in working group sessions various aspects of the issue at hand. Debate focused mainly on the rights of ambulance staff, paramedics, first aiders, and others who provide care in a variety of emergencies, to a safe working environment and to adequate preparation for this task. Debates during the workshop also broached practical measures to ensuring the security of the wounded, sick and health-care providers in emergencies, as well as the safety of vehicles, vehicle movements, and first-aid posts.
"We are not heroes, said Dr Eric Bernes, ICRC's first-aid officer, describing the risk surrounding health-care providers in the event of armed conflicts and other emergencies. "There is always a limit to our ability to work and save lives. What we learn in books and practice is not always applicable because of the risky conditions we work in, which sometimes demand of us to be very flexible in order to perform our tasks."
Risk assessment first
Mr Adam Salem Shanaisheh, Head of Ambulance Services in the Libyan Red Crescent in Misrata, says, "Some perceive ambulances as easy targets." He relates how "we lost three first aiders in Tripoli during the incidents in Libya, as they were lured into a place, under the pretext that there were casualties there. They were eventually murdered." "We have also witnessed attacks by armed insurgents on an ambulance. Arms carriers halted the ambulance and killed the wounded on board," he informed the participants.
It does not matter which party did this; the targeting of ambulances, paramedics and first aiders in Libya and other countries is in line with the general trend concluded by a study carried out by the ICRC from 2008 to 2010, which analyzed 655 violent events having influenced health care in 16 countries. The study shows patterns of violence affecting the wounded and sick, health-care infrastructure and personnel. Almost 200 incidents (30.4%) occurred "en route", i.e. to medical vehicles or personnel trying to reach the wounded and the sick, or the wounded and the sick trying to reach or being transported to health-care facilities.
Participants concluded with the answer to the following question: "Should we send first aid teams to a certain place or not?" by arguing that this step should be preceded by a preliminary risk assessment using available information about the situation on the ground, then determining the best location to set up a clinic or ambulance station.
Dr Mohamed Fayek Abdul Aleem, Relief Project Coordinator at the Arab Medical Union and participant to the workshop asserted that, "we rely on volunteers in our relief operations. When a crisis erupts, our response is often swift and prompt, which impels us sometimes to overlook issues of security and acceptance from our priority list. What is important for us is to provide assistance to those in need. We might go as far as not announcing our presence in some places for fear of being targeted by any of the parties."
Acceptance: a basis for protection
Throughout the discussions, the principle of acceptance emerged as a key factor to ensuring the security of emergency health care in the field, irrespective of the nature of the conflict or emergency situation. "The ambulance service run by the Ministry of Health might be perceived for instance as being affiliated with the government", says Dr Mohamed Sultan, Director of Ambulance Service in the Egyptian Ministry of Health. "We have been affected by this perception at the beginning of the events surrounding the 25th of January Revolution, when rumours spread that ambulances were transferring weapons and ammunition to the government, an accusation we have utterly denied. Perhaps our continuous presence in the field and our delivery of the service for all regardless of their affiliation reshaped people's perception of the ambulance service," he added.
However, this acceptance did not hamper the targeting of Egyptian ambulances. More than a hundred vehicles have been damaged over the past two years, according to Sultan, in addition to the injury of a number of ambulance staff.
While some participants stressed field action as a means to foster the acceptance of ambulance teams, and ensure the safe delivery of emergency health care, discussions throughout the workshop also concluded that the role of communication and media in building trust within the surrounding environment was crucial.
Shanaisheh thinks that, "The promotion of ambulance team acceptance is necessary, through regular communication with various actors on the ground, building trust with the community, while taking into account the conditions within each region or work environment." Health-care staff should not seek acceptance from armed parties exclusively. This acceptance should extend to any local authorities, communities, and local media.
Participants agreed on the need to provide training to health-care providers to ensure their preparedness to perform their duty, through training programs on anticipated security issues, how to deal with such issues on an equal footing with important "medical" aspects of emergency health care in the field in such contexts. Training should also include stress management in difficult and risky situations, and commitment to a code of conduct for paramedics, first aiders and health-care providers.
The Cairo workshop is one of a series of ten workshops scheduled to take place between 2012 and 2014, and designed to come up with practical measures to enhance the protection of health-care providers and beneficiaries in armed conflicts and other emergencies.
Recommendations reached by workshop participants are expected to assist the International Red Cross and Red Crescent Movement and the States party to the Geneva Conventions scheduled to convene in 2015 in the 32nd International Red Cross and Red Crescent Conference, in formulating resolutions relevant to the measures to be taken to address this urgent humanitarian issue. "We count on these workshops over the next two years not only to report their conclusions, but also to make a difference on the ground," says Mr. Gentile.