Newsletter December 2014

Editorial 1 Field focus: Nepal 4 Latest 2 Experts’ corner 6 New tool for State armed forces 3 Community of concern 8 New e-learning tool for health-care workers 3 we must learn from each other

And the lessons are All of us – medical professionals, government National Societies working in different to be found every- officials, representatives of international contexts. It is therefore in a unique position where, not only in organizations, members of civil society to enrich the HCiD project with a variety places ravaged by – have a role in building a protective of good practices derived from the field conflict, like Gaza environment for health-care systems, experience of thousands of staff and

ERCS and Syria. The nationally and internationally. The president volunteers. As ambassadors for HCiD in number and the of the International Committee of the Red their own countries, National Societies can seriousness of attacks against health-care Cross (ICRC) and other panellists made this provide evidence-based recommendations, workers and facilities and medical vehicles point during the high-level debate that took adopt practical measures based on their recorded in 2014 are proof that safe provi- place on the sidelines of the 69th General experiences and propose contextualized sion of health care is still a pressing issue in Assembly of the (p. 2). responses that contribute to the safety of many contexts. health-care delivery. The example of Nepal As neutral, independent and impartial in this newsletter (p. 4) is one of many that The International Red Cross and Red Crescent humanitarian actors, we must make show how parties concerned can work Movement, together with various partners, ourselves heard by the parties concerned, together to respond to HCiD challenges and undertook the Health Care in Danger (HCiD) whether they are State or non-State groups. develop activities adapted to the context. project because it understood the urgency Data on violent incidents since 2011, of protecting the delivery of health-care collected by the ICRC within the framework Finally, sharing our experiences and learning services during armed conflicts and other of the HCiD project, show that 90% of all from each other’s good practices is of crucial emergencies. The project got under way in the victims of violence against health-care importance if we want to protect and 2011, and the global advocacy, networking, workers are local, not international, staff. improve the delivery of health-care services and consultations that ensued have expanded The consequences for victims and entire during emergencies. I invite you to read the beyond the Movement. This is as it should be, communities may be extremely serious: interview with Abdoul Aziz Ould Mohamed HCiD having emphasized from the outset that because of such violence, health care may no (p.7). See what he did to save a hospital from an issue of such common concern needs not longer be available where it is needed most, being targeted. only universal attention, but also concrete and entire health systems may be severely actions by all those involved: health-care undermined. For National Red Cross and Dr Nehal Hefny providers, national legislators, policy-makers, Red Crescent Societies, the stakes are high. Programs and armed actors, the international humanitarian We must remember that the Movement Projects Coordinator community and civil society. contains the cumulative experience of 189 Egyptian Red Crescent Society

NEWSLETTER LATEST

States have a key role in preventing involved in ensuring the implementation it was suggested that long-term support violence against health-care personnel of concrete measures to protect access from governments for promoting respect for and facilities. In this connection, a high- to and delivery of health care. Specific health-care workers was crucial for realizing level panel debate took place in New York reference was made to implementing the the MDGs. in September, on the margins of the 69th measures that emerged from the HCiD *** session of the UN General Assembly. It experts’ consultations and workshops, In October, an HCiD event – “Responses from brought together ICRC President Peter such as adopting strong domestic the Movement, States and the health-care Maurer, WHO Director-General Margaret legislation for protecting health-care community” – was held on the margins of Chan, UN Deputy-Secretary-General Jan personnel and facilities, medical vehicles the 9th Asia Pacific Regional Conference of Eliasson, OCHA Under-Secretary-General and patients, sharing good practices and the International Federation of Red Cross Valerie Amos, government representatives adopting a UN resolution on preventing and Red Crescent Societies in Beijing. It from Norway and Sweden, and the former violence against health care. The ICRC was hosted by the Afghan Red Crescent Minister of Health of Côte d’Ivoire. All presented a position paper containing Society and the , the panellists, and speakers from the key recommendations for States, on and highlighted the part National Societies audience, called for all those concerned, protecting their health-care systems and could play in protecting health care, not particularly States, to be more actively making them more resilient. only through their own activities, but also by lobbying influential parties concerned. In July, the Colombian Ministry of Health, The group developed recommendations for The event was moderated by the Australian with support from the Colombian Red ambulance personnel and discussed best Red Cross. Cross and the ICRC, organized a regional practices in connection with the conduct of *** workshop in Bogotá, Colombia. The event personnel, coordination in the field, training, The Stockholm International Peace Research gave National Red Cross and Red Crescent and preventing misuse of Red Cross and Institute, in cooperation with the Swedish Societies and government representatives a Red Crescent ambulances and equipment. Red Cross, organized a day-long event platform for exchanging good practices from *** entitled “Violence against health-care throughout Latin America and for finding The World Medical Association’s 65th workers: Translating research into action.” It solutions to the problem of disregard for general assembly, which took place in was held in November and gathered experts health services. Participants described the October, in Durban, South Africa, offered from various backgrounds to consider various risks to health-care services across an excellent opportunity to discuss the how research could support humanitarian the continent; afterwards, working groups links between the Millennium Development action more effectively. The participants discussed the measures that have been taken Goals (MDGs) and the HCiD project. It was also discussed the various obstacles to to reduce the vulnerability of health-care clear to participants in a session titled collecting data on the scope, nature and services, and further action in this regard. “Universal Access to Healthcare after MDGs” impact of violence against health care, *** that no progress could be made in the MDGs and how these data could be used most In September, the HCiD project was presented related to health without securing the safety effectively to provide pertinent and timely at the annual conference of the International of patients and health-care providers. In fact, humanitarian action. Pharmaceutical Federation (FIP) in Bangkok. During the HCiD session, participants learnt The 12th joint African Union (AU)- and the continental level, which included about the risks pharmacists were exposed ICRC joint seminar – on protection for strengthening domestic legislation and to during emergencies and about strategies health-care services in armed conflict providing training for the armed forces, for mitigating them. The recommendations and other emergencies – took place in civil servants and health-care workers. The that emerged from the HCiD experts’ Addis Ababa in October. Participants seminar drew on the experiences of WHO, consultations and the HCiD platform discussed the role of the AU and its the South African Medical Association, the attracted a great deal of interest. The FIP member States in addressing the issue Egyptian Red Crescent Society and certain declared its willingness to pursue the subject of violence against health care. The AU’s AU member States that were dealing with of HCiD further with the Movement. Permanent Representatives’ Committee the adverse effects of armed conflict and *** made 20 recommendations for dealing other emergencies on national health- In September, the with the problem, both at the national care services. organized a workshop in Cartagena, Colombia, on ambulance and pre-hospital services in risk situations. The workshop was hosted by the and attended by representatives from the National Societies of Colombia, El Salvador, Guatemala, Honduras, Mexico and Israel. ICRC

2 LATEST

NEW TOOL FOR STATE ARMED FORCES

Data gathered by the ICRC since 2012 in in conflict zones – drew on their experiences 23 operational contexts, and published to discuss how health-care delivery could be in an annual interim report titled Violent protected more effectively. Incidents Affecting the Delivery of Health Care, show that weapon bearers are among The measures that emerged from this the main perpetrators of violence against process are presented in a report entitled patients, health-care workers and facilities, Promoting Military Operational Practice and medical vehicles. Involving armed that Ensures Safe Access To and Delivery forces in the implementation of protective of Health Care. They focus on three areas: measures is therefore vitally important for checkpoints, search operations in health- ensuring that health care can be provided care facilities, and the consequences of and obtained in safety. deploying or attacking military objectives inside or near health-care facilities. With this in mind, the HCiD project began a process of consultations with Checkpoints can make use of a clearly ICRC representatives of State armed forces. The marked ‘fast lane’ to hold up medical aim was to develop measures to minimize vehicles as little as possible. When this is not the impact of military operations on the feasible, signs permitting medical vehicles delivery of health care. The Australian to drive to the front of the queue can be government and the HCiD project jointly displayed. This is just one example of the can make certain that their operations will organized a workshop on military practices measures described in the report. not have an adverse effect on access to health in armed conflicts and other emergencies, at care. The report can now be ordered online at which the participants – military, operational, By adopting such measures whenever the ICRC’s e-shop (www.shop.icrc.org). medical and legal experts recently deployed possible, military personnel and authorities NEW E-LEarnING TOOL FOR HEALTH-CARE WORKERS

Are you a doctor in a conflict zone wondering life; they will also find guidance for making Access is completely free, and no login how to conduct yourself with the media, or a decisions in difficult situations. They can is required. Would you like to get nurse wondering how to respond to requests explore the various chapters comprising started? The module is available online at from the police or the military for information the module, which contain resources and www.healthcareindanger.org/elearning. on patients? Are you an ambulance driver reference materials that provide detailed unsure what to do when driving through a information on specific topics. checkpoint? Are you a hospital administrator wondering how to deal with a large number of dead bodies? Our new e-learning module, entitled “Rights and responsibilities of health- care personnel in armed conflicts and other emergencies” may be just the thing for you.

The module will help health-care personnel to understand their rights and their legal and ethical obligations in situations of armed conflict and other emergencies. Using an engaging multimedia interface, it presents various dilemmas that health- care personnel face every day. Users of the module can explore these issues in depth by interacting virtually with experts in the Michael Greub/ICRC field and studying situations taken from

3 Field focus Field focus P RomotING RESPECT FOR AMBULANCE SERVICES IN NEPAL Nepal Red Cross Society

The Nepal Red Cross Society takes part Some facts about health care in Nepal in several joint initiatives with the Nepal Medical Association and the ICRC to improve • The armed conflict in Nepal (1996-2006) ended a number of years ago, but violence the delivery of health care in Nepal – for continues to occur sporadically, and this has an impact on the health-care system and on instance, organizing HCiD sessions for the provision of health-care services. Political parties, as well as organizations affiliated health-care personnel, authorities and to them, and others with grievances often resort to strikes to make their demands heard; other parties concerned that focus on the on these occasions, health-care workers trying to evacuate the wounded are often rights and responsibilities of health-care attacked. Ambulances carrying patients and vehicles carrying health-care personnel personnel; and implementing a programme are frequently reported to have been obstructed or destroyed. Providers of ambulance aimed specifically at promoting respect for services have themselves often failed to respect their code of ethics; instances of ambulances. ambulances being misused have also been in the news.

During emergencies, ambulance services • Doctors are often accused of negligence by family members, and assaulted. There is a play a crucial role in opening up access general tendency among people to take the law into their own hands, and health-care to health care and saving lives. If these personnel feel unsafe and under threat as a result. At times, doctors themselves go on services are poor or the ambulances’ strike and stage protests to air their grievances. passage obstructed, the consequences for the wounded or the sick can be extremely • The Nepal Red Cross Society has 203 ambulances in 67 districts. Its ambulances have been serious. During the armed conflict, and vandalized during strikes, but not a single instance of their misuse has been reported. afterwards, ambulances were often vandalized, obstructed, or misused. As a • All the ambulance drivers with the Nepalese Red Cross have received first-aid training. consequence, in 2008, the Nepalese Red As ambulance drivers are now given priority for first-aid training, the number of drivers Cross and the ICRC began to conduct joint with such training at other providers of ambulance services is growing. ‘ambulance round-table (ART) meetings’ with the broad objective of improving • Some providers of ambulance services have started carrying first-aid equipment and ambulance services. paramedics in their ambulances.

4 Field focus Roland Sidler/ICRC

These meetings bring together all parties out information on ambulance services for the The Nepalese Red Cross and the ICRC concerned – public health officers, police and first time in their district,” says ICRC medical have produced a number of jingles in military officials, members of civil society and assistant Shashi Kumar Lal Karna. “And, at Nepali and four other local languages, Red Cross representatives – to discuss the these same meetings, providers of ambulance which request everyone concerned problems that ambulance services face and services have promised to improve their not to misuse ambulances and to allow how to address them. So far, such meetings services, by standardizing rates, providing them free passage at all times; the jingles have taken place in roughly 30 districts. 24-hour service, etc.” are broadcast on local radio stations just before and during strikes. People “Earlier, before we started conducting ART Implementation of the recommendations involved in providing ambulance services meetings, we used to hear of ambulances made at ART meetings is monitored: have found the jingles quite useful. An being misused or vandalized, but nobody some months after an ART meeting, a ambulance driver told ICRC field officer knew the full scale of the problem,” says follow-up meeting is organized to reassess Ajay Kumar Yadav, “When we hear them Pushpa Raj Paudel, executive director of the situation, gather best practices or on the radio during a strike, it lifts our the Nepalese Red Cross. “Now, the people lessons learnt and share them later on with spirits. We say to ourselves that if the mob concerned understand the conditions under the parties concerned at ART meetings in tries to obstruct the ambulance, we’ll just which ambulance services operate and, other places. tell them to remember the jingle.” especially, the challenges they face.” One of the main challenges is improving services: ambulance services are not available round the clock, and ambulances do not travel with paramedics or carry first-aid equipment. Ambulances are also misused: they transport illegal items and passengers for money, providers of ambulance services impose transportation fees arbitrarily, and so on. And ambulances are not given the respect due to them: for example, they are not given priority during fuel shortages, and are obstructed or damaged by mobs during riots. Finally, there is government neglect: no proper record of ambulance services is kept, funds are not set aside for maintenance or repairs, etc.

After identifying the problems, participants in ART meetings discuss how to deal with them and recommend concrete actions. By this means, the parties responsible for directly or indirectly harming ambulance services can rectify the situation afterwards. “At these ART meetings, we have seen political parties promise to direct their cadres not to obstruct Jon Björgvinson/ICRC Jon ambulances, and district health officials hand

5 Experts’ corner Experts’ corner WE STILL NEED TO DO A LOT OF ADVOCACY

Veronica Kenyi, Health Manager,

SSRC South Sudan Red Cross

Since December 2013, when the conflict began, the South Sudan Red Cross (SSRC), the ICRC, the International Federation of Red Cross and Red Crescent Societies and other Movement partners have been Marco Di Lauro/Getty Images/ICRC Lauro/Getty Di Marco working hard to provide relief to hundreds of thousands of people in dire need. To Juba, South Sudan. SSRC volunteers at a course for first-aid instructors. make matters worse, in May 2014, there was an outbreak of cholera. We asked Veronica How are Red Cross health-care workers of merging the ICRC and SSRC incident Kenyi, SSRC health manager, to tell us how and volunteers dealing with the cholera reporting forms to make sure that key HCiD her National Society was dealing with this outbreak? security aspects are taken into account exceedingly difficult situation. First, we realized that there were difficulties whenever an incident occurs. We are aware in coordination and information sharing that South Sudan is a very particular context How is the violence in South Sudan among the various humanitarian organiza- where still more needs to be done. Given our affecting the delivery of health care? tions involved with the national task force, extensive volunteer network, at the SSRC Health facilities are being looted and burnt particularly the flow of information to and we can do more to raise awareness of HCiD down, and medical equipment and supplies from the states affected. So we decided to among communities. We are developing stolen; staff and patients are denied access create a Movement task force chaired by the an HCiD project and adding HCiD training to health-care facilities; and deliveries of SSRC. We also had to find a way to protect in areas where SSRC volunteers are already medicines are often blocked. Many health- staff and volunteers who were helping to training health-care workers to be part of care workers are afraid to come to work. transport cholera patients from the oral community health programmes. Our next The result of all this is that patients suffer rehydration points in emergency vehicles; step will be to organize meetings with the even more. the risk to their health was extremely serious relevant authorities to ensure safe access to because the equipment was not sanitized. health care for everyone. With regard to delivering health care, We solved this problem by ensuring that the what are the main challenges confronting vehicles were disinfected after use. What must be done to increase protection Red Cross workers and volunteers? for health-care workers and facilities, The poor security conditions, to begin with. What measures have you taken so far to medical vehicles, and patients? That is a major problem. Weapon bearers often ensure that health care can be delivered I think that we still need to do a lot of know nothing about the rights of health-care in safety? And what will you be doing next? advocacy and dissemination locally and personnel, that they are protected by law, I can give you a few examples: to ensure that internationally. Volunteers must ensure that for instance. During crises, weapon bearers we learn from our experiences and improve communities understand their own role in target, and even occupy, health facilities. our services, if there is an incident, the SSRC protecting their health units and health–care Since health-care workers are fleeing their staff or volunteer involved must fill in an workers; this is crucial. It is just as important posts, the Ministry of Health has to depend on incident report form. Afterwards, we might, that health-care personnel be fully aware of first-aid volunteers. You can imagine how this depending on the incident, have a meeting their role and their responsibilities. And we affects the quality of the health care provided. with the communities to clarify the role and also need to involve the authorities, as well Bad roads and limited means of transport status of the SSRC. For instance, during the as weapon bearers, more than at present. At make it even more difficult for people to get ongoing conflict, when SSRC volunteers the international level, cooperation with all access to health care. Ethnic tensions are a were attacked by internally displaced the parties concerned must be strengthened, major obstacle as well: sometimes, the ethnic persons (IDPs), we had a meeting with IDP and training institutions should include identity of volunteers is a more important community leaders to ensure that they aspects of HCiD in their curricula. consideration than the fact that they are understood the importance of respecting health-care providers. health-care workers. We are also thinking

6 Experts’ corner WE STRESSED THAT WE HAD TO BE LEFT TO GET ON WITH OUR WORK

providers and that proved effective. Several medical evacuation from a rebel-controlled attempts were made to steal our only area to an army-controlled area, we called ICRC remaining ambulance, but we managed to someone who knew the military leaders Abdoul Aziz save it through our contact with the leaders well. We would tell him that there was an Ould Mohamed, of the group in question. ambulance of ours leaving Timbuktu for Representative of The Alliance for Mopti, for example, and ask him to inform International Medical All of these steps helped to calm the hospital the checkpoint guards so that they would Action (ALIMA) in Niger staff and give them some assurance of let us through. Constant dialogue with their safety. the rebel groups and armed forces was The general hospital in Timbuktu, where therefore crucial. Abdoul Aziz Ould Mohamed was working What exactly did you talk about with the in 2012, was the only medical facility in different armed groups? Do you have any other advice for protect- the region to have been spared an attack We stressed that we had to be left to get ing health-care services? during the armed conflict in northern Mali. on with our work. We pointed out that It’s essential that the health-care facility In this interview, the former emergency the situation was catastrophic and that, as reflect the ethnic diversity of the society in project coordinator for ALIMA tells us what health-care providers, we could help people which it operates. At the hospital in Mali, we made the difference. – but that we would not do so at the risk of made sure we recruited staff from different our own lives. We also explained that if any communities. This helped to ensure our What were the main challenges to provid- members of their group were injured, they safety, as we had a link with the community ing health care in Mali? could bring them to our hospital. It was even in the chaos of the fighting. Patients The first challenge was obviously keeping made clear to them that, as a humanitarian were always able to talk to a member of staff health-care personnel safe. The lack of organization, we offered treatment to from their own community, whether that qualified staff was also a problem, as were everyone, irrespective of ethnicity, religion was a nurse or a caretaker. difficulties in accessing certain areas. Quite or anything else. simply, if we cannot physically get medicine From a longer-term perspective, it’s and personnel to a health-care facility in the What precautions did you take to ensure important to raise awareness among midst of conflict, we cannot meet people’s your own safety and the safety of medical the political authorities of the problem health-care needs. personnel? of violence against health-care workers, We used local knowledge to make sure we facilities and patients. It’s also crucial to get The hospital where you were working in approached the armed groups in the right the local communities themselves involved 2012 was not attacked during the fighting. way. For example, we sought permission in health-care matters, for example, through What saved it? from the parents of one of the group committees that include community leaders, We took a number of measures. First of all, leaders to speak to him and explain our to make them aware of the fact that health- we really had to gain a good understanding humanitarian aims. Similarly, before each care facilities must be treated with respect. of the context. We identified which groups were fighting each other and their different power relations. With that insight, we then knew who we had to speak to in order to protect our hospitals and staff from danger.

Next, I went to speak with the various armed groups. We knew that we couldn’t work in safety without the support of the forces that were effectively occupying the area at that time. Our hospital was officially recognized by the Malian army and authorities, but they were no longer in control of the territory. So I called on the leaders of the armed groups to respect the work of health-care C. Amadou/ICRC

R egional hospital, Gao, Mali. A mother and her sick child. 7 Community of concern RULES OF WAR (IN A NUTSHELL) Agn e da

This year marks the 150th anniversary of the original Geneva Convention, the first set of rules to protect the sick and the wounded, as well as health-care personnel and facilities, during 9-11 JANUARY 2015 armed conflict. The four Geneva Conventions of 1949 are the cornerstone of international humanitarian law, which seeks to limit the effects of war; they also reaffirm the need to Lebanese Red Cross: Safer Access protect medical workers. However, these rules are often ignored, which is why violence training module, against patients and medical personnel remains a major problem in armed conflicts today. This course concentrates on training The ICRC has created a video titled Rules of War (In a Nutshell), which presents the essential leaders of emergency medical services in elements of international humanitarian law, including the rules protecting patients and health- taking decisions in conflict zones. It will care workers, in less than five minutes. It is a perfect introduction to the subject for people of all be held in and will be supported ages and backgrounds, and is now available in English, French, Spanish, and Portuguese. by the Norwegian Red Cross. For more information, visit: http://www.redcross.org.lb

17-22 MAY 2015

ICMM World Congress on Military Medicine, Indonesia

The International Committee of Military Medicine (ICMM) will hold its 41st World Congress in Bali, Indonesia. Pascal Hundt, Head of the Assistance Division at the ICRC, will talk about ‘health care in danger’. For ICRC more information, visit: http://www.cimm-icmm.org

ONLINE TIP: Want to know other members H ealth Care in Danger of the HCiD community who are active in your country? Just go to “MEMBERS,” click on the web “Advanced Search,” and then select the country of your interest. On 14 August 2014, membership in the in number. We are happy to see that our HCiD Network went past the 500 mark, network is continuing to grow: every a figure we expected to reach at the day, we add valuable organizations and Health Care in Danger is an ICRC-led end of 2015. From the beginning of the individuals. Help the HCiD cause by inviting project of the Red Cross and Red Crescent project, we wanted the members of other organizations to join us! Movement aimed at improving the our HCiD Community of Concern to be efficiency and delivery of effective and very committed, even if they were few See you online! impartial health care in armed conflict and other emergencies. This is done by mobilizing experts to develop practical measures that can be implemented in the field by decision-makers, humanitarian organizations and health professionals.

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Front cover: Zaidan Primary Health Care Centre, Abu Ghraib, Iraq. Child being vaccinated. 12.2014 4224/002 Olivier Moeckli/ICRC