Conflict zones and healthcare – 2023 worst year for patients and caregivers alike  

More people in conflict zones than ever before were unable to access adequate healthcare in 2023, according to the Safeguarding Health in Conflict Coalition
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The Safeguarding Health in Conflict Coalition (SHCC) notes that in 2023, more people in conflict zones than ever were unable to access adequate healthcare. It identified 2,562 incidents of violence against or obstruction of healthcare in conflicts during this period. This is a 25 per cent increase from 2022, representing 500 more attacks than documented last year and the highest ever since the Coalition began reporting. In its 11th annual report, Critical Condition: Violence Against Health Care in Conflict, the coalition documented arrests, kidnappings, and killings of health workers and damage to or destruction of health facilities in conflicts across 30 countries, regions within countries, or territories.

There was intense violence against healthcare in new conflicts in Gaza and Sudan and continuing violence in Myanmar, Ukraine, and Haiti. Health facilities, transports, and patient access to care were also at high risk in the Sahel.

“Violence against healthcare reached appalling levels in 2023,"  said Leonard Rubenstein, Chair of the Safeguarding Health in Conflict Coalition (SHCC), which comprises more than 40 nongovernmental organisations. “Whether a product of recklessness, indifference, or intentional targeting, fighting forces’ contempt for the law brought catastrophic harm to those in need of care and the health workers and systems intending to aid them. The world fails to ensure accountability for this violence at its peril.”

Critical Condition reports the killing of more than 480 health workers, almost double the number reported in 2023. The toll included doctors, nurses, ambulance drivers, pharmacists, lab technicians, paramedics, and psychologists. The total is likely an undercount, as data collection on violence is impeded by insecurity, communication blockages, and the reluctance of entities to share the data on violence. 

The report details that both government forces and non-state armed groups bombed, occupied, raided, and vandalised health facilities throughout the year. Health facilities were increasingly occupied or repurposed for military use, in violation of humanitarian law. In the conflict in Gaza, Israel hit hospitals and ambulances by air and from the ground. In Sudan, health facilities suffered mortar shelling, missile attacks, and bombing and were often vandalised in the country’s capital, Khartoum. Airstrikes on hospitals persisted in Myanmar and Syria. Russian forces entered and repurposed hospitals for military use in eastern Ukraine, and in Myanmar, armed forces similarly took over hospitals.

A rise in the use of explosive weapons – increasingly deployed via drones  –  affecting health facilities and health workers was reported in at least ten countries.

“The current use of explosive weapons in populated areas and the consequent harm to civilians that results from the destruction of the health system are at alarmingly high levels. Transfers of weapons used to target health facilities remain unrestrained,” said Christina Wille, director of Insecurity Insight, the lead author of the report, whose organisation led data collection and analysis. “Destruction of the health system causes immediate and long-term harm not only to those injured by conflict but also to expectant mothers, young children, and the chronically ill, often with lifelong consequences.”

Health workers were killed in 2023 in large numbers, especially in Gaza, where the 2023 total killed is the highest in any conflict documented by SHCC since 2016. Russian forces killed military medics in Ukraine, many while providing care to wounded soldiers on the frontlines. In Israel, first responders and hospital staff were killed while administering aid to victims of the Hamas attacks of October 7.

Health workers were kidnapped, often for ransom, in conflicts across Africa, as well as a large number in Haiti. Health worker arrests increased in Afghanistan and the Occupied Palestinian Territory and continued at high levels in Myanmar. Arrests and long-term detentions of health workers persisted in Sudan and Syria.

In Sahel and elsewhere, rising insecurity limits health workers' ability to reach patients and access healthcare, which has devastating consequences for health outcomes.

“The hundreds of attacks on healthcare in just a year have meant catastrophe for the people of Sudan, as hospitals ceased to function and health workers had to flee," said Dr Yasir Elamin of the Sudanese American Physicians Association. “Women and children are especially at risk. As long as the consequences of violence against healthcare are borne only by the victims, perpetrators will continue to disregard the law and attack healthcare workers and infrastructure."

The most severe effects of these attacks involved the virtual collapse of health systems, as in Gaza, where most hospitals have been destroyed and closed, access to essential supplies blocked, and infrastructure damaged. This was also true in Sudan, Burkina Faso, the Central African Republic, and Tigray in Ethiopia. Attacks also created a fear of seeking care in health facilities perceived to be unsafe. Looting and hijacking of vehicles and supplies resulted in impaired health services and erosion of health worker safety and morale, despite heroic efforts by them to repair facilities and overcome obstacles.

In addition to the chronically ill, who are deprived of care, and those directly injured by attacks, the report highlights those most affected by violence against healthcare: children and pregnant women. The report noted declines in the health monitoring of children under the age of five in the Democratic Republic of the Congo and reports on how the Afghan Taliban’s gender restrictions harm women’s health. Children's hospitals were bombed in Gaza, Sudan, and Ukraine. Health workers and providers engaged in vaccination campaigns were attacked on at least 24 occasions in ten countries in 2023, leaving populations, especially children, vulnerable to infectious diseases.

Among the report’s recommendations are:

The International Criminal Court and national courts, through principles of universal jurisdiction, should, at long last, initiate prosecutions for war crimes and crimes against humanity involving attacks on the wounded and sick and on health facilities.

Governments should cease arms transfers to parties to conflicts that engage in grave breaches of international humanitarian law.

Ministers of Health should engage with their own military and security forces and armed groups to protect healthcare from violence and strengthen mechanisms to mitigate the effects of attacks on communities, health workers, and the health system.

Regional bodies and the UN humanitarian cluster system should expand initiatives to protect healthcare in conflict and mitigate the effect of violence against it.

This article was originally published at reliefweb.int and has been shared here under Creative Common License.