Insecurity and humanitarian health care services

Healthcare is a very important part of all humanitarian aid. Access to the right kind of healthcare during emergencies can make a significant difference to the total death toll from violence or natural disasters. Yet health infrastructure, health care personnel and patients are far too often affected violence. As part of the Aid in Danger project, the Security in Numbers Database contains incidents that affect the delivery of health care. We make this subset of our information available to the Coalition for Safeguarding Health in Conflict. This page illustrates some of the issues with selected information from our system.

2015 Report by the Safeguarding Health in Conflict Coalition

The 2016 report by Safeguarding Health in Conflict Coaliation, covers reported events from 2015 and the early months of 2016.

Read the the report here.

Selected country case from the 2015 report

Central African Republic 2006-2014

Between 2006 and 2012, the Security in Numbers Database recorded 30 distinct incidents in which health workers, services, and infrastructure were targeted in the Central African Republic. Particularly common was the ambushing of ambulances and theft of humanitarian vehicles.

Overall, fifteen of the 30 attacks affected medical infrastructures, including the theft or armed robbery of essential medical equipment, transport vehicles, food supplies, or money from either medical facilities or humanitarian offices providing health services.

For example, on May 22, 2011, unidentified armed men broke into the offices of the International Committee of the Red Cross (ICRC) and stole a vehicle. On November 25, 2011, unidentified armed men attacked an ICRC convoy. Medical and humanitarian compounds and warehouses have also been frequently raided: for example, on June 13, 2009, 600 to 1,000 people stormed a UN World Food Programme warehouse and stole the International Medical Corps’ feeding program supplies.

Many of the incidents involved direct attacks on health workers. The earliest incident, from April 10, 2006, noted the murder of two doctors on a mission for the WHO. The second, from May 19, 2007, recorded the abduction of two NGO health workers. Other attacks included the December 22, 2009 armed attack on an International Medical Corps base in which vehicles were stolen and staff kidnapped. On June 6, 2011, while stealing medical supplies, members of the rebel Lord’s Resistance Army killed the regional health director of the Mbomou prefecture, the only doctor in the region, as well as his driver.

As a result of these attacks, a number of humanitarian organizations including the International Medical Corps, Doctors Without Borders (Médecins Sans Frontières, MSF), and the French Red Cross were either relocated, or partially or completely evacuated due to insecurity. Two organizations providing health services, Cordaid and Action Against Hunger, were forced to close offices or significantly reduce their activities in the country in 2012.

The rate of attacks increased in 2013-2014, with 26 incidents noted in the database. Starting in early 2013, a series of armed robberies and looting of medical and humanitarian facilities occurred, as rebel Seleka forces systematically looted and destroyed medical centers and pharmacies around Bossangoa. The database also includes reports of robberies of an ICRC office in Ndele, the complete looting of a hospital in Mobaye and the SOS Children’s Village in Bangui, and repeated robberies of MSF offices in Bangui.

Immediately following the coup d’état in which Seleka forces seized control of the capital and presidential palace on March 24, 2013, widespread looting and robbery impeded health services. Between March 25-27 alone the offices of Cordaid, ICRC’s warehouses and residences, a UNICEF warehouse, and WHO’s warehouse were all looted.

Health workers were also specifically threatened and killed in both indiscriminate and targeted attacks. On July 30, 2013, Seleka Col. Issene Yaya confronted and threatened Red Cross workers in the remote northern village of Ouata-Nata. On April 6, 2014, armed Seleka members murdered three MSF staff during an armed robbery at a clinic in the northern town of Boguila. One month later, MSF suspended all but emergency care in the country. On August 20, 2014, a local Red Cross worker was shot and killed in Bangui.

In total, between 2006 and 2014, Insecurity Insight’s database noted 46 incidents reported by the ten groups involving violence against health infrastructure (including medical facilities, vehicles, compounds, warehouses, and other offices); four involving the kidnapping of health workers, aid workers, and medical mission personnel; and seven incidents resulting in the death of health workers, medical mission personnel, and their drivers. Many of the incidents involved a combination of violence against both infrastructure and personnel.

South Sudan 1997-2014

The Security in Numbers Database recorded 48 attacks on health services (including attacks on facilities, health workers, and patients; lootings and robberies; and forced evacuations and relocations due to violence) between 1997 and 2014. In 76 additional incidents insufficient information was available to determine if health services in particular were affected.

South Sudan became semi-autonomous from Sudan in 2005 following a peace deal that ended the long North-South war, and became an independent country in 2011. Attacks against humanitarian agencies (with non-health-specific mandates) during the war often significantly affected the health of civilian populations. For example, on June 11, 1998, bombs were dropped by the Sudanese Army near a World Vision feedin center in Panacier, Warrap state, and on May 18, 1999, a World Food Programme food barge was attacked in Adok. Among the earliest attacks on health workers noted in the database was the February 5, 2002 looting of an MSF health clinic in Nimne, followed four days later by the bombing of the facility, which resulted in the death of one health worker. On November 14, 2005, an immunization campaign was interrupted due to insecurity in Western Equatoria. Similarly, on April 10, 2006, MSF staff were forced to flee due to fighting in Ulang, Upper Nile state. One month later, on May 15, an MSF compound in Jonglei state was specifically targeted and staff were forced to evacuate after an attack on the facility.

Persistent attacks on MSF facilities have severely affected patients. On November 29, 2007, MSF patients fleeing violence were killed in Bor. Again, in 2009, Insecurity Insight records the evacuation of three medical NGOs in Malakal, Upper Nile state, due to intense tribal fighting in the area. Attacks against health workers and patients are recorded repeatedly in the database, including a July 2008 shooting outside a compound of an international medical NGO in the capital Juba, and a similar shooting outside an office of a medical NGO in July 2009. On June 19, 2010, police beat a security guard at a medical NGO for refusing them entry to the compound.

In 2012 alone, Insecurity Insight reports five cases where medical services were evacuated, relocated, or suspended due to violence against humanitarian facilities, including the brief evacuation of a medical NGO from Akobo, Jonglei state, following security disturbances on March 10; the closure of an NGO clinic in the contested Abyei area after staff were stopped and detained on March 19; the suspension of MSF medical services in Lekwongole and Gumuruk, Jonglei state, due to fighting in September; and the evacuation of all MSF international staff from Pibor county, Jonglei state, due to insecurity in October.

The database also describes repeated incidents in which medical services or transport vehicles were looted, including the theft of medical supplies by Murle fighters from an NGO vehicle in February 2009 in Jonglei state; the Lord’s Resistance Army’s robbery of a clinic to get hold of drugs in May 2010 in Western Equatoria state; the violent robbery of four MSF staff members traveling on a boat in Gumuruk in July 2010; the subsequent looting of MSF boats in Gumuruk and Pibor the following month; and the robbery of a warehouse of a medical NGO in July 2010. An August 23, 2011 attack and looting of an MSF clinic in Pieri, Jonglei state, resulted in the death of one staff member.

On December 15, 2013, longstanding political and ethnic rivalries in South Sudan culminated in the outbreak of a civil conflict that has consumed large parts of the country, killed thousands of civilians and displaced almost two million people. The conflict has further devastated an already-fragile national health system. Several regions have experienced horrific attacks on health amid heavy fighting. In Bor, Malakal, and Bentiu towns, where particularly intense fighting occurred in early 2014, attacks against patients, health workers, and civilians took place in main hospitals.2 For example, during a period of extreme violence in Bentiu in April 2014, opposition forces targeted people sheltering for safety in Bentiu State Hospital, killing at least 19.

Conflict has also weakened medical facilities’ ability to provide reliable and uninterrupted care to people in need. Insecurity and repeated attacks on its compounds led ICRC and MSF to relocate from Bentiu on January 9, and MSF pulled out of Malakal and evacuated non-local staff from Leer Hospital in Unity state on January 16, 2014.

In May 2014, an MSF secondary health care facility serving nearly 300,000 people in Nasir, Upper Nile state, was forced to suddenly evacuate the hospital due to intense fighting approaching the region.4 When staff returned to Nasir in June 2014, they discovered that the hospital had been looted.

An MSF report discussing violence against health care in South Sudan outlines numerous attacks this past year: patients have been shot while seeking treatment, medical staff have been killed, and hospitals and other medical equipment have been looted or destroyed. From December 15, 2013, to June 15, 2014, MSF recorded at least 58 people killed on hospital grounds, 17 cases of destroyed or stolen medical vehicles, and six incidents of hospitals looted or destroyed.