Introduction
The safety and security of health care workers in danger zones is a serious problem. While not a new phenomenon, recent trends indicate that increased understanding of and action on this issue is required. The operational landscape has changed drastically since the events of September 9, 2001, with changes in perceptions about the neutrality and independence of relief and development providers, greater access challenges, a large increase in the number of development and humanitarian actors on the ground, and expansions of organizational mandates that sometimes create new security challenges. Humanitarian operating environments have also become increasingly complex and are too often marked by crime and terrorism that affect both aid workers and beneficiaries.1
Today, health care workers face a variety of dangers during armed conflict situations and other situations of violence. This report addresses the issue of insecurity of health care in the context of armed conflicts and violent urban settings. These security issues take a wide range of forms from road blockades and check points which delay access, to the direct targeting of hospitals, attacks against medical personnel, and armed entry into health facilities.2 This report provides an overview of some of the work currently being undertaken by the Red Cross and Red Crescent Movement and other organizations, identifies gaps, and points to three areas that require further action related to research, policy, and practice.
In 2011, the International Committee of the Red Cross (ICRC) published a report “Making the Case.”2 This report highlights the widespread problem of intentional and unintentional attacks against health care systems, infrastructure, health care personnel, and patients. There continues to be a lack of respect for the neutrality and impartiality of health care services and systems in many contexts globally. Unfortunately, health care providers and, in particular, the local workers, can be the target of attacks. When this occurs, critically-needed humanitarian aid cannot be delivered effectively and, in the case of health care workers, patients do not receive the care that they require and are entitled to as prescribed by the 1949 Geneva Conventions and their Additional Protocols of 1977. Additionally, health care personnel are given protected status under international humanitarian law as long as they do not take part in hostilities and ensure impartiality when treating patients.3 While these protections exist, they are unfortunately not always respected and, in some cases, deliberately undermined.
A more recent ICRC report collected information on 921 violent incidents affecting health care during armed conflict or emergencies in 22 countries.4 These incidents involved the use or threat of violence against the health care system, including health care personnel. Preliminary data suggests that doctors, nurses, and paramedics accounted for about 60% of the people affected. The majority of these health care providers were local (only seven percent were international). First aiders were also identified as targets because of the threat of “follow up” attacks. Attacks, whether intentional or not, weaken the entire health system when it is needed most by local populations and the impact is most felt by already vulnerable populations including women, children, the elderly, and the disabled. It should also be noted that the existing data may be underreported because it may be more difficult for men and women to report incidents of sexual violence, as this is most often sensitive and mired in self-blame, shame, fear of being stigmatized, and denial.5
In November 2011, a resolution by the Red Cross and Red Crescent Movement together with state authorities urged the ICRC, governments, and the international community to take steps to address this issue.6 The resolution seeks to increase respect for, and protect the delivery of, health care in armed conflicts and other emergencies and to raise awareness and promote preparedness to address the serious humanitarian consequences arising from violence against the wounded and sick, health care services, facilities, medical transportation, and health care personnel. This resolution includes the safety and security of health care personnel as one important component of the problem. In terms of action, this resolution calls upon the ICRC to initiate consultations with experts from governments, the International Federation of Red Cross and Red Crescent Societies, National Societies, and other actors to formulate practical recommendations for making health care delivery safer.
Report
The ICRC's Health Care in Danger Initiative
To achieve the objectives set out in the above-mentioned resolution, the ICRC has spearheaded the “Health Care in Danger” initiative aimed at strengthening the protections for health care workers, patients, and facilities during times of conflict and other emergencies. This initiative brings together experts from around the world in a series of workshops to generate concrete recommendations to address specific issues and improve protections. This has included an ICRC and Canadian Red Cross workshop on ensuring the safety of health facilities which partly addressed ways to mitigate stress faced by health care personnel working in high intensity environments. It has also included workshops by the ICRC, Norwegian Red Cross, and Iranian Red Crescent on the rights and responsibilities of health care personnel which focused on the provision of emergency health care in conflict situations.7 The goals of these workshops were to identify practical ways to increase acceptance of health care workers providing emergency health care and professional supports available to personnel working in these contexts.8 Furthermore, the ICRC produced a publication on the roles and responsibilities of health care personnel in conflict and emergency contexts, intended to serve as a tool for humanitarian and health workers dealing with difficult dilemmas in insecure environments. While the guide does not provide answers to all potential dilemmas, it does provide guidance for practice and vital information on the rights and obligations of health care and humanitarian personnel operating in conflicts.3 The series of workshops culminated in a final workshop held in Pretoria in April 2014 with a view of producing a consolidated set of concrete recommendations to enhance the safety of health care workers and facilities by 2015.
Other Initiatives to Protect the Medical Mission
A wide range of other organizations are also mobilized and engaged in critical work on these issues. This includes the World Medical Association (WMA), the leading authority on establishing medical ethics. The WMA has issued several statements and resolutions condemning attacks against health care personnel and facilities and calling on states to fulfill their obligations under international humanitarian law. They continue to explore the application of ethics in conflict and violent contexts and have produced a set of “Regulations in Times of Armed Conflict and Other Situations of Violence” for medical practitioners.9 Furthermore, the WMA helps ensure protection at the local level through mobilizing national medical associations.10 The Humanitarian Healthcare Ethics (HHE) research group, comprised of researchers across disciplines, is also engaged in a number of research projects aimed at clarifying ethical issues that arise in humanitarian situations. Projects include examining professional ethics for personnel working in military contexts, disaster research ethics, and the application of ethics in acute crises responses.11
Médecins Sans Frontières (MSF) has also been deeply engaged in these issues. As their medical personnel and operations have been directly and routinely targeted in certain contexts such as Afghanistan, South Sudan, Syria, and Somalia,12 they have also taken measures to strengthen protections for MSF workers and health facilities. They have launched a 3-year project entitled “Medical Care under Fire” which seeks to improve safe access to health care by patients and improve security and protections for MSF personnel and facilities. As part of this project, MSF intends to collect data on violent incidents to further analyze trends across contexts, examine the public health impacts of violence against health care on local populations, and implement local and regional advocacy initiatives to improve access and security. For MSF, local acceptance, negotiated access, and cultivating a network of relationships are fundamental strategies to ensuring the security of personnel. In contexts such as South Sudan, contingency plans included evacuation of staff, suspension of services, and a reduction in programming as a means to mitigate security risks.13 In Afghanistan, part of the security strategy included limiting access into medical facilities by training guards on techniques to recognize threatening behaviors of individuals trying to enter. Médecins Sans Frontières has recognized that different protections and support will be needed for international and local staff and also has recognized the need for strong Human Resource management policies and psychosocial programs to offer support to personnel.14 Other factors for consideration include an analysis on how program choices and operational decisions impact the security of local populations and staff, and an ongoing understanding of the context.15 Médecins Sans Frontières continues to work on these critical issues to strengthen their operations in a range of contexts.
“Safeguarding Health in Conflict” is another important coalition that collaborates with the ICRC and is comprised of a number of international and nongovernmental organizations (NGOs) that aim at improving the security of health workers, increasing the evidence base of violent incidents impacting health care, holding perpetrators accountable, and developing strategies for protection, by using a human rights approach.16
As highlighted above, there are numerous initiatives and organizations engaged in protecting patients and personnel operating in armed conflicts and other situations of violence, yet fundamental gaps remain.
NGO Security Sector
There have been significant developments and initiatives since the mid-1990s in the management of security for humanitarian and development organizations. This includes critical research, guidance papers, the development of standards, and essential interagency sharing and learning forums, such as the European Interagency Security Forum and InterAction's Security Advisory Group. There has also been the participation of donors such as Humanitarian Aid and Civil Protection Department of the European Commission (ECHO), United States Agency for International Development's (USAID's) Office for Foreign Disaster and Assistance in these forums, and the funding of security initiatives to benefit the humanitarian sector. Additionally, there has been ongoing dialog between the United Nations and certain NGOs through the “Saving Lives Together” initiative. Still, as humanitarian operating environments continue to be very complex and fluid, continued efforts are required to best address the collective needs and challenges. With the continued professionalization of the humanitarian assistance sector, there must also be the preparation for the eventual increase in security standards and certification.17
Red Cross and Red Crescent Measures to Enhance Protection for Health Care Delivery
Most importantly, local National Red Cross and Red Crescent Societies staff and volunteers are at the forefront of these issues, and have developed innovative coping mechanisms and techniques to provide health care safely to vulnerable populations while safeguarding their own security.
For example, the Lebanese Red Cross (LRC) is the only public provider of Emergency Medical Services (EMS) that has full access and acceptance by local populations in all areas of the country, even during instances of internal disturbances and international armed conflicts. At all levels of the organization, staff and frontline volunteers have continually demonstrated their neutrality and impartiality in the delivery of services which has resulted in trust, credibility, acceptance, and access among local communities.18 Furthermore, EMS volunteers are equipped with ballistic-resistant vests and helmets and engage in tactics such as prearranging specific actions to verify their identity to relevant authorities at checkpoints and using code names to hide religious identities of volunteers. These actions help increase the safety and security of volunteers while also helping to ensure the perception of neutrality.19
The Colombian Red Cross (CRC) is another National Society that has dealt with decades of armed violence. In the Colombian context, the Government of Colombia has been engaged in numerous initiatives to protect medical personnel and facilities.20 Furthermore, the CRC and the ICRC successfully mobilized a range of stakeholders within the country, including armed groups and government agencies, to come together and adopt a symbol to represent the medical mission. This national emblem has been promoted by a government decree and when worn by health personnel, is recognized by all groups as signifying the neutral and impartial delivery of health care and therefore must be respected and given access.21 Both of these examples highlight current practices being utilized by humanitarian workers to enhance safety. However, it should be noted that protection mechanisms are highly context specific, as a method used by one National Society may not necessarily work in another context. Furthermore, despite the many coping mechanisms, National Societies operating in conflict situations often face serious consequences when trying to provide neutral and impartial aid to all communities. For example, the Syrian Arab Red Crescent has lost 34 staff and volunteers to date while attempting to provide lifesaving humanitarian assistance to affected communities inside the country.22
This further emphasizes the need to enhance organizational security mechanisms as there is increasing evidence that the targeting of health care and humanitarian workers may be used as a deliberate tactic of war.23
Discussion
Safety and security management considerations for humanitarian personnel only started to have political and operational importance over the past two decades. Its growing momentum, in relation to institutional mainstreaming, transference to field operations, research on trends, and data analysis has been relatively slow. It has taken time for agencies to modify their policies and operational measures and to adapt to the reality that operational contexts have become significantly more complex within the current nature of armed conflicts and increasing natural disasters.
Despite positive advancements in general security risk management approaches, there remain important areas for improving security approaches, methods, and culture. This is particularly challenging within a fluid operational landscape. Outlined below are areas for action related to policy, research, and future practice.
Policy
The core elements for building a culture of security consist of the development of an organizational policy and appropriate frameworks that define security accountability at all levels: organizational duty of care, management, and individual accountability.
An organization's security architecture should consist of essential components that come together in an interdependent fashion throughout the entire organization.Reference Macpherson and Burkle24 This framework is a strategic element comprised of defining all levels of security responsibility and accountability, and related policies, procedures, guidelines, and standards, along with consistent efforts to comply with security regulations and policy. A security policy, or a set of security principles, is a foundation that informs the organization's duty of care toward their staff, the cornerstone of security risk management.
Legal liability has been, in recent years, the driver of security management; moral and ethical dimensions are often sidelined, yet are relevant, when considering the increasing tendency of organizations to use risk transfer measures. The transfer of risk to national staff and implementing partners has ethical, moral, and legal implications. There need to be more robust ethical and moral decision-making processes in situations of risk transfer. This could be considered as a positive and proactive initiative to better equip and support Red Cross and Red Crescent National Societies to continue providing lifesaving activities within a security framework, informed by the operating context and situational specific security considerations.
The foundations of good security management consist of an organization's self-awareness and its awareness and analysis of the environments in which it operates.
In addition, best practices mechanisms and procedures to protect workers and facilities during natural disasters could be further adapted for situations of armed conflict and violence, borrowing from the existing work in diverse fields such as architecture, engineering, and psychology. For example, the Pan American Health Organization/World Health Organization's “Safe Hospitals” initiative, spearheaded in the Americas region, aims to ensure that hospitals are able to continue functioning during times of disasters. The development of the Hospital Safety Index (HSI) is one of the most widely used instruments to undertake safety evaluations of facilities in order to prioritize which functions are most critical during an emergency and evaluate a hospitals ability to withstand a disaster.25 The HSI could potentially be adapted to help evaluate security concerns and the prioritization of functions during an armed conflict or situation of violence and is one example of a best practice that currently exists.
Research
There is very little analysis and evidence demonstrating whether current security practices are actually effective in increasing safety and security of an organization's humanitarian staff and assets.
There are a number of important data analysis initiatives such as the Security in Numbers Database, the Overseas Development Institute's Humanitarian Policy Group reports, the Aid Worker Security Database, and many organization-specific and internal incident reporting and data analysis platforms. However, there is a need to further collect, share, and analyze disaggregated data particularly indicating the sex, gender, nationality, religion, and job position of personnel or patients involved in security incidents. The ability to capture data relies on the reporting of security incidents, and on how some organizations elect to share their data with the initiatives mentioned above. Currently, most agencies do not yet disaggregate data according to sex or even nationality. Only 22% of inter-agency field survey respondents indicated that the incident reporting forms or mechanisms asked for the sex of the person reporting or involved in the incident (with 38% responding they do not know). This percentage is 33% for country office respondents (20% do not know) and 8% for headquarters respondents (20% do not know).5
The failure of organizations to share their incident data is generally based on fear of how this may affect their reputations, threaten potential funding by donors, and potentially compromise current security challenges. However, the access and analysis to disaggregated data can help in capturing trends and deciphering if security management methods (or lack of) are actually effective in reducing risk or enabling humanitarian access.
Practice
While there have been many positive developments in security management for humanitarian organizations, further improvements are needed, particularly around implementing and integrating security elements within the management structure of an organization. This should be based on providing staff with the full range of care, support, and security within the organization's programs and operations. The principle of “Do No Harm,” Mary B. Anderson's treatise on humanitarian assistance,Reference Anderson26 is still relevant today, and must be continually considered in all aspects of security and operations. Accuracy in an organization's contextual assessment and situational analysis are critical to risk assessments which then inform how to reduce risk by lowering exposure to security threats. Each operating environment is fluid and unique in its threat and risk profile, hence risk mitigation measures must be grounded in the political, economic, cultural, and technological realities of a particular context.
Furthermore, security management has been increasingly relegated to “security experts” predominantly coming from military and police institutions as well as outsourced to private security providers who often do not understand humanitarian principles or programming priorities, which severely deepens the chasm between security and operations and staff. Trainings, internships, and exposure to humanitarian contexts are required in order to ensure appropriate security frameworks and plans are in place.
Another consequence is the tendency to reduce risk by “bunkerizing” health facilities through hard protection measures which, in turn, compromises the image of an organization or facility and its relationship with local populations, beneficiaries, authorities, and other interlocutors and security stakeholders. This further highlights the commensurate need for organizations to significantly and continuously invest in local acceptance as a security risk reduction strategy. This is a critical and time-intensive endeavor, built on the premise that if an organization's presence is accepted, or at least tolerated because the programming is appropriate, well received, and relationships with various actors in the context are carefully considered, cultivated, or negotiated, then vulnerability to direct security threats can be reduced or protected by those who accept or tolerate the organization and its personnel.
Through various anecdotal data, many humanitarian aid workers feel relatively unprepared due to inconsistent and/or purely theoretical security briefings and trainings.Reference Aitkin, Leggat, Robertson, Harley, Speare and Leclerq27 Getting the right security training based on the needs and level of security risk exposure of staff members is imperative. Having the right personal security and or security management training equips workers to perform their responsibilities while staying safer and more secure through awareness, knowledge, and competency. Increasing security awareness is likely to influence an individual's behavior and judgment, which has a direct impact on individual, team, and organizational security and the security of other humanitarian staff and agencies working in proximity. This needs to be coupled with field and headquarter level appropriate humanitarian expert security advice and support. Meanwhile, developing the right security management competencies of line management and security focal points is essential to the mainstreaming of security and again, accountability and responsibility. Additionally, humanitarian actors need to be aware of ongoing political action and conflict resolution processes to avoid being instrumentalized within the context of conflict. Security measures that protect humanitarian workers and health care facilities and personnel are critically needed in all operations; however, such measures cannot be cast as a substitute for political solutions.
Furthermore, it is essential that National Societies and other local organizations working on these issues engage in peer-to-peer sharing of experiences and best practices so that concrete security measures and resources can be shared. This would allow local organizations, especially those operating in similar contexts or facing related challenges, to gain from existing and successful coping mechanisms and be able to further integrate these into their operations.
Limitations
Although there is recognition that safety and security issues of humanitarian health workers also occur in nonconflict contexts, for example during sudden onset disasters, this report does not address issues in these contexts. Furthermore, this report does not provide an exhaustive overview of all initiatives and projects aimed at addressing safety and security for health care personnel. The purpose of this report is to provide a general overview of some of the initiatives underway, as well as key issues within security management frameworks to be addressed. It does not examine any particular issue in depth, but rather aims to collate the most common and agreed-upon issues.
Conclusion
Violence against health care workers, facilities, and patients must stop. In order to address the root of this issue, there needs to be more stringent, concerted, and clear action to stigmatize attacks when they do occur. Many organizations must consider when to draw the line, their deterrent strategy of suspension, or withdrawal sending a clear message that violence against their staff is not acceptable. While exit strategies are important, these considerations must always be weighed against the need to provide protection and assistance to beneficiary populations in situations of armed conflict.
