Just as the COVID pandemic was about to engulf the world in 2020, the O’Neill Institute, housed at Georgetown University Law Center in Washington, D.C. published an interesting article on public health and – not pandemics – but war. Law Fellow Lidiya Teklemariam asked an intriguing question: “What Does International Humanitarian Law Have to Offer to Public Health in Situations of Armed Conflict?” She made the point that international humanitarian law (IHL) and international human rights law (IHRL) are inter-related and therefore everyone involved in an armed conflict, whether state or non-state, is “obliged to respect” human rights to health:
IHL (also called Law of Armed Conflicts/ Law of War) is a type of international law governing conduct of States and non-State actors as well as situations of both international and non-international armed conflicts. IHRL is applicable in all kinds of situations… state and non-state actors in armed conflict situations are obliged to respect the human right to health protected under the International Covenant on Economic, Social and Cultural Rights.
It should be noted however that these international laws seem primarily focused on medical services to affected civilian populations and combatants. The extent to which there was or is attention to possible infectious disease transmission is largely ignored.
The trajectory of conflict and civil unrest has been trending upward, with continuing events and new ones adding to heightened risks, notably the Ukraine war and now the Israel-Hamas war in Gaza.
According to the Geneva Academy of International Humanitarian Law and Human Rights, there are now approximately 112 armed conflicts described as non-international armed conflicts (NIACs), ranging from hot wars to insurgencies. Listed by region, the NIAC numbers are heavily concentrated in the Middle East and North Africa (45); followed by Africa (35); then Asia (19), with Europe (7) and Latin America (6).
Some of these “NIACs” are longstanding, country or sub-region-focused, others with much newer and wider implications. Taken together they represent significant dimensions of global unrest, and in so doing underscore the impossible challenges of those engaged in public health at national, regional, and international levels who are trying to maintain what had been accomplished or seeking to improve collective well-being.
This state of affairs has significant implications with respect to infectious diseases, and prospects of endemic, epidemic or even pandemic outbreaks.
How public health systems are damaged in armed conflicts
While this is a concern in stable environments, such failures in conflict areas have greater potential to occur, to affect others, both near and further away.
As a result, it is in all of our interest to better understand how and in what ways health systems are compromised by the disruptive effect of physical conflict and civil unrest. It is important to realize that both very weak and stronger healthcare systems can be severely impacted, and in several ways:
1. Infrastructure damage:
Healthcare facilities, including hospitals, clinics, and laboratories, may be targeted or damaged during conflicts. Bombings, shelling, or deliberate attacks on healthcare infrastructure can render them inoperable, limiting the availability of essential utilities such as power, communications, and water and sewerage.
The damage to the latter even beyond the health facilities means heightened risks of waterborne diseases, and the absence of pest and rodent controls, resulting in increased rabies threat.
2. Healthcare workforce shortages:
Many healthcare professionals, including doctors, nurses, pharmacists, and technicians, may fear for their personal safety, threatened by the violence or feeling that the work environment has become impossible to function in. So they may opt to leave or are simply displaced due to the conflict.
A shortage of trained personnel to provide medical care develops, especially in conflict-affected areas where the number of victims requiring attention increases. This means there are not enough health service providers in relation to rising needs. And even when the conflict ceases or subsides, healthcare workers may be reluctant to return to conflict zones.
3. Impact on individual access to healthcare:
Conflict disrupts transportation systems, making it difficult for individuals to reach healthcare facilities or for medical supplies to be delivered to them. Roadblocks, checkpoints, and damaged infrastructure can restrict access to medical services and discourage people willing to leave their homes or communities fearing such dangers.
Furthermore, health care intended for civil populations may be requisitioned by militants.
4. Impact on health supply chains:
Conflict disrupts supply chains for medical equipment, pharmaceuticals, and other essential supplies. This shortage of medical resources limits the ability of the public health care system to continue to function and provide adequate care to those in need.
5. Increased demand for services:
Conflicts often lead to a surge in injuries, including those caused by violence, rape, explosions, or displacement.
This means that healthcare systems theoretically (and practically) have to contend with higher demands for emergency and trauma care, just at a time when they are least well positioned to do so.
6. Reduced or inadequate funding:
Conflicts divert resources away from healthcare, as governments, international organizations, and others allocate or reallocate funds toward military expenses or other priorities.
Such lower financial investment and available operating resources mean that healthcare services will have to try and do the same (or more) with less.
7. Displacement and refugees:
Conflicts often result in displacements of populations, both internally and across borders. These displaced individuals often come with little, and sometimes require immediate healthcare assistance. The net effect is to overwhelm the capacity of receiving healthcare systems.
These seven factors combine significantly to reduce capacity, limit access to care, and compromise the quality of healthcare services.
What can be done
There are several consequences in terms of public health system management:
- It means that increased importance should be given to what is already a key aspect of public health system management: data collection, surveillance efforts, and monitoring of existing and/or emerging health-affecting situations;
- not explicitly stemming from conflict, but other factors such as child morbidity and mortality, maternal care, age dependency ratios, and food insecurity/malnutrition are also all negatively affected and require special attention.
The intention here is not to make any moral or political judgment about any conflict or civil strife – there are cases where such actions, however unfortunate, are warranted.
But what is true in all instances is that when and if a time comes for peace, the costs of health investments and in rebuilding confidence in the healthcare system are huge. And they may be huge just to return to past levels.
All too often, the voices of those caught in the crossfire are barely heard and yet those are the very people who risk immediate health-related deterioration. For us remote from a conflict zone, there could be risks of infectious diseases emerging from such situations.
The short answer is, we all live on one planet.
Editor’s Note: The opinions expressed here by the authors are their own, not those of Impakter.com — In the Featured Photo: Medics transport an injured Palestinian child into Al-Shifa hospital in Gaza City following an Israeli airstrike on October 11, 2023 Source: Wafa (Q2915969) in contract with a local company (APAimages) – cc Wikimedia