Health worker attacks are up, but numbers might not tell the full story

NEW YORK — Reported attacks on health care workers spiked last year, but that may not mean violence against vaccination workers, doctors, nurses, paramedics, and other health workers is actually on the rise.

New reporting mechanisms on health care worker attacks are making it easier to document the ongoing issue and potentially giving it more visibility, according to Leonard Rubenstein, chair of the Safeguarding Health in Conflict Coalition and the director of Johns Hopkins Bloomberg School’s program on human rights, health, and conflict.

There were an estimated 973 attacks on health care workers in 2018, the coalition documented in its annual report released May 14. At least 167 workers died in attacks in 17 countries, while at least 710 were injured. These figures compare to the total number of 701 attacks the Safeguarding Health in Conflict Coalition, composed of international nonprofit members, recorded in 2017.

The World Health Organization released a new surveillance system in December 2017 that documents real-time attacks on health care and feeds the coalition data for its report. So far, WHO has documented 310 recorded attacks in the first months of 2019.

“We cannot say if these higher numbers signify greater number of attacks, or if the reporting mechanisms by the WHO and others are improving,” Rubenstein said. “We don’t know exactly why people do or do not report, and at some point, we will have to do the work to better understand that.”

In 2018, Israel and the Palestinian territories, Syria, and Afghanistan had the greatest number of reported attacks, totaling 308, 257, and 98, respectively.

Room for improvement

While surveillance systems have improved, reported numbers still don’t necessarily accurately reflect the situation on the ground. The exact number of health care attacks in conflict areas remains unclear, for example. In Yemen, the 53 reported attacks last year likely does not represent the full picture for health care in the ongoing conflict, Rubenstein explained.

The new WHO database also has some gaps, noted Carol Bales, a senior communications and advocacy expert at Intrahealth International, who oversaw the report’s production. The database does not include intentionality behind the attacks, for example, leading the Safeguarding Health coalition to decipher each reported attack to better understand if it was deliberate or incidental.

The coalition received reports of specific perpetrators in 47% of the incidents and found that 71% of them could be attributed to state forces, while 27% were linked to nonstate forces.                 

The findings come three years after the U.N. Security Council adopted a resolution that condemns attacks on health facilities, workers, and patients, and calls for conflict parties to respect and help enable safe health care delivery.

Few tangible steps have been taken following this resolution, Bales said.

“The U.N. Security Council should schedule briefings on situations in countries where health care is the most affected by the attacks and the briefings should include information on investigations and accountability steps,” she explained. “For member states, we have recommendations focusing on ministries of health and ministries of defense.”

In some cases, the targeting of health care work in conflict has pushed clinics in Syria, for example, to operate underground and out of caves.

In other cases, violence has halted vaccination programs in countries such as Afghanistan, Pakistan, and Nigeria — the only three countries where polio has not been eliminated, Rubenstein said.

“Attacks on health workers administering vaccines is a way to get a vaccination campaign shut down really quickly,” Rubenstein said. “Conflict and attacks on vaccination workers is a major reason why polio has not been eradicated in Pakistan, Afghanistan, and Nigeria.”

The report found an increase in attacks against vaccination workers in six countries — Afghanistan, the Central African Republic, the Democratic Republic of the Congo, Pakistan, Somalia, and Sudan.

While government action is key to reducing attacks on health care workers, increased visibility of the problem could also create safer conditions.

Better reporting of health care attacks could help experts such as Rubenstein understand the trends more cohesively, he said. And communication — with warring parties, but also the broader public — is also key, according to Bales.

“Somehow, health workers and facilities have become a target for parties to the conflict and governments. It is about changing the mindset, or reminding people that health workers are not a target, that they are protected by international norms and should be off limits,” she said.