Human Resources and Welfare - DEFENCE MANAGEMENT JOURNAL, Issue 41
Healthcare in action
Stéphane Du Mortier, of the International Committee of the Red Cross, highlights the difficulty of providing healthcare in wartime.
In wartime, when functional health services are more crucial than ever, access can be difficult, dangerous or even prohibited for different sectors of the population. Moreover, medical facilities themselves may be in ruins, with shortages of qualified staff and medical supplies, while those medical services that are still working are often overwhelmed with emergency cases.
Disruption of routine health services, such as vaccination programmes, can quickly lead to a health emergency, while ongoing conflict and displacement exacerbate an already difficult situation. For example, in 2004, measles fatality rates amongst children under five of 14-17% – one child in seven – were documented in West and North Darfur, prompting the World Health Organization and aid agencies to undertake a large-scale vaccination campaign.
The International Committee of the Red Cross (ICRC), founded in 1863, traces its origins back to helping to evacuate and provide emergency healthcare on the front line for wounded soldiers in wartime, which, in turn, gave rise to the Geneva Conventions setting out the rules of conduct of warfare. The ICRC's work continues to be based on protecting and assisting victims of conflict: it works in over 80 countries around the world, monitoring compliance with International Humanitarian Law during wartime, and provides assistance to those affected by the fighting.
The ICRC response is grounded in years of field experience: over the last 20 years in Afghanistan, over 82,000 amputees and disabled people, many of whom lost limbs due to landmines, have been given new prosthetic limbs. The organisation is also a leader in war surgery and has developed global standards for the treatment of war injuries: over the past 25 years, ICRC surgeons have treated over 100,000 weapon wounded patients.
Where possible, the ICRC tries not to do the work that should be the responsibility of the authorities. However, sometimes the needs are so acute where traditional fixed health structures are unavailable, absent, overburdened or dysfunctional, that other measures are needed. And in wartime, there is a particular necessity for a neutral and impartial actor that can cross the front lines in order to provide these needs.
Mobile Health Units (MHUs) are one option used in unstable situations to provide preventive measures (immunisation, health promotion, disease screening), as well as curative services (usually surgical or dental care).
On 4th July 1993, the warring Rwanda Patriotic Front (RPF) and Rwandan Government signed a peace agreement, leading to the disengagement of troops and the establishment of a huge buffer zone, with the RPF in the north and government troops in the south. During the transition period, this buffer zone was left without an administration.
In order to ensure that health services were available in remote areas, the ICRC, in co-operation with the Rwandan Red Cross, developed a mobile health service in October 1993. During this period, two 12-person health teams, with fully equipped ambulances, delivered services in eight former health centres in the disengagement zone. The number of consultations was high – an average of 600 patients per visit. Screening lines were set up – one line was for scabies and skin infections, another for diarrhoeal disease. Under fives and pregnant women were picked up in the lines for special attention. The worst cases were referred to the central hospital in Kigali and then to the 100-bed Rutongo Hospital, supported by the Belgian Red Cross.
Providing health services under these circumstances was a way of showing people in the demilitarised zone that they had not been forgotten, as well as giving the ICRC an opportunity to better understand and document breaches of international law.
In conflict situations, more than in development contexts, the issue is not a just lack of health services per se, but lack of access to existing services due to security risks. In a volatile environment such as the Jebel Marra region of Darfur, travelling by road is often dangerous, as the area continues to be the stage for skirmishes between rebels and soldiers of the Sudanese Army. Many civilians, particularly men of military age, cannot risk crossing the front line, and access to healthcare is difficult for all communities.
In such situations, a neutral, impartial organisation like the ICRC, which can work in areas controlled by rebels and government forces alike, is more important than ever. Sudan is currently the ICRC's second largest operation worldwide after Iraq.
ICRC mobile medical teams visit villages and nomadic communities in remote areas to provide the population with basic preventive and curative care, including vitamin A and iodine supplements, as well as taking part in immunisation campaigns, particularly in areas that are inaccessible to Sudanese government officials. The most common complaints are diarrhoea, dysentery, painful joints, chest infections, stomach infections (due to the poor quality of the food and water), conjunctivitis (due to the dust and the flies), and coughs. Nomadic communities are especially vulnerable and in need of attention, because they have less access to water and so their health problems are often aggravated by dehydration.
It is not only basic medical services that are needed: in April 2005, in response to the high number of weapon-wounded, the ICRC established a fast response, mobile Field Surgical Team in Darfur. The four-person team comprises a surgeon, an anaesthetist, a theatre nurse and a ward nurse.
The field surgical team travels all over Darfur, in both opposition and government-controlled areas where fighting has occurred, to operate on weapon-wounded people wherever adequate surgical structures and staff are not available. Its services are impartial and available to all based on needs alone, civilians and combatants alike.
Such mobile surgical teams and health units can serve an invaluable role in emergency situations, in order to reach those who most need help. However, the ICRC views such services as essentially an interim measure, due to their high cost, complex logistics, and irregular service provision, which may mean, even with weekly visit schedules of health units, that acute illnesses are still not diagnosed in time.
In reflection of this reality, the ICRC in Darfur continues to support its mobile health and surgical teams, while also increasing its assistance to local clinics, on all sides of the divide, by providing medical supplies and staff training. In 2007, around 252,000 people living in rural areas had access to primary healthcare thanks to the six clinics supported by the ICRC in Darfur. Over 111,000 consultations took place and over 72,000 doses of vaccines were administered.
Mobile health units should really be a last resort. While there are a variety of treatments they can offer, they cannot be a long-term solution. Mobile health units can be used effectively to provide a package of selective primary health services, but there comes a point at which patients must be able to have access to a fixed healthcare facility where they can receive more follow-up treatment.
However, where normal health services cannot access all areas, particularly in volatile situations, mobile health units can fulfil an essential role, and for many war affected communities, this continues to be the only option available.
For more information, please visit www.icrc.org