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Skip to 0 minutes and 12 seconds LOUIS LILLYWHITE: I think there are two main issues. First is the impact on the wider population, which is frequently far longer lasting than the conflict itself, where there tends to be concentration on the injuries caused by conflict, whereas it’s the destruction of the health systems and the subsequent impact that is usually the impact. And the second and probably more recent issue is compliance with international humanitarian law. There are actually examples where health indicators have improved during a conflict. So if you actually look at Nepal, for example, during their internal conflict, the health indicators seem to continue to improve.

Skip to 0 minutes and 56 seconds That was partially due undoubtedly to the fact that the communist insurgents seem to protect health facilities, even those provided by the state. So it’s not invariably the case. It’s also the case that occasionally health will improve as a result of conflict, usually where there is a regime that does not really have health at the heart of it. So if you actually look at Ethiopia, its current health system, which I think is one of the better ones in Africa, arose from the insurgency where the Tigrayan People’s Liberation Army started investing in health care. So it’s not invariable, but those are the exceptions, I fear. The state, of course, retains responsibility during any conflict, including internal conflict for providing health care.

Skip to 1 minute and 49 seconds Unfortunately, of course, or not unfortunately, it’s a fact that you wouldn’t necessarily control the territory. So even it might have the responsibility, it may lack the control. Sometimes, exceptionally, the state will continue to provide health care even in the areas it doesn’t control, but more normally that, that is not possible. Then, of course, we have the issue of what I might call the non-democratic states, where the government or the state may not feel that it has the same responsibility to particular groups of the population than, that it, that it does to that which reflects it’s, as it were, ethnic background or culture or religion.

Skip to 2 minutes and 34 seconds And there you have a problem because the state, as it were, just abrogates all responsibility for one particular group. That can extend down beyond the government, and in the Balkans, for example, we saw health care facilities of one ethnic group refusing to treat civilians from other ethnic groups, and that of course is contrary not just to international humanitarian law but, of course, it’s also contrary to medical ethics. But you were there involved in a conflict that was particularly vicious, and the health care providers, in many ways, had suffered significantly at the hands of the opposite group and were living amongst a population that had particular antipathy to the opposition group.

Skip to 3 minutes and 20 seconds So it’s difficult to condemn them because of it, even though they were wrong. Non-state armed groups provide health care for a variety of reasons, and sometimes they change over the course of the conflict, those reasons. Quite a few of them start purely for beneficial reasons of what we might call culture or doctrine. They believe that they have a duty to the population that they control or seek to control to provide them with welfare, including health care. Arguably, some of the Palestinian organisations started that way. They then saw it had a political impact, and it may be that they invested more in it because of that political impact.

Skip to 4 minutes and 2 seconds But nevertheless, the origin was one of, we feel we have a duty to the population. The second reason is what I call a proto-state. Most non-state armed groups seek to govern in due course. They seek to overthrow the state, and it’s recognised that one of the duties of the state is health and welfare, or an element of health and welfare. And therefore, they do it to demonstrate that they have a right and an ability to govern.

Skip to 4 minutes and 29 seconds The third reason is reward, and if you, again, look at some of the health services to Palestinians, although they may provide it to the whole population, they may give enhanced access to their fighters, their fighters’ families, and the families of what they call the martyrs.

Skip to 4 minutes and 47 seconds Then there’s control. If you have a look at the Jamaican posses which is a criminal organisation in Jamaica, they actually provide health care, but they do it as a means of controlling the population. And then finally, it, it can actually be a means of fundraising. You can tax or pay for it. Some of the groups in Indonesia use access to what you might call traditional health care. They charge tax on it. I think, however, that as a kind of a health person, we have to be careful not to condemn or to be overly conscious of the motive. What we, of course, want is health care for the population. Although, we need to recognise it does cause political issues.

Skip to 5 minutes and 37 seconds Well, there’s a variety of barriers to non-health, non-state armed providing the health care. First, of course, is their legal status. They are characterised, often, as criminal by the state against which they’re fighting. Because they’re criminal that gives them, that causes them problems in terms of procuring medical equipment. Also, the way the state may itself look upon individuals that are being treated within the non-state armed groups can be a problem, particularly when the non-state armed group may only provide a portion of the system, such as primary care, initial trauma care, and then the patient has to go into the state system somewhere. Again, there are barriers, often, because of borders.

Skip to 6 minutes and 22 seconds A lot of insurgencies are centred around borders, and there can be difficulties in evacuating injured and sick over borders to where they might get secondary care. And as you’ll be aware, a lot of people in Afghanistan in Taliban areas rely on Pakistan to provide the advanced care, and, you know, borders and their control can cause a problem. The first point I think to make is attacks on health care facilities is not new. We, as it were in the United Kingdom, think very much of the Second World War between us and the Germans where we did, both sides seemed to try and avoid attacking the health care facilities.

Skip to 7 minutes and 7 seconds But that was certainly not the case in the war against Japan, for example, or indeed, on the Eastern Front between Germany and Russia. We also need to remember that within the United Kingdom, attacks on health care workers within health care facilities is not unusual. And there’s a recent, I think, a report, I think, from Barbados, which I think would reflect UK experience, which shows that something like 67% of health care workers in health facilities had experienced at least one act of violence during the previous 12 months. So violence against health care facilities and health care personnel is not new.

Skip to 7 minutes and 49 seconds It’s only since 1914 that the World Health Organisation has been systematically attempting to collect data on attacks on health care, facilities, workers, et cetera.

Skip to 8 minutes and 3 seconds What does appear to be more common, just recently, and this is particularly so in Syria, is attacks on health care, major health care facilities, including those that are run by, for example, NGOs such as MSF. There have been some well publicised examples of that. Again, it’s not clear whether these are due to accident, negligence, or are deliberate. Certainly within Syria, there seems to be a belief that many of them are systematic. We don’t know why they do it. Are they trying to force the population out by removing their health care facilities? Are they trying to demoralise the fighters by attacking the health care facilities?

Skip to 8 minutes and 48 seconds Is it just that they are taking a blanket approach to destroying the area, and health care facilities are there? So we don’t know the answer those questions, but it certainly appears to be the case that attacks against health care facilities appear to be more common.

Health and conflict

In this step we will provide an overview of the legal context in conflict situations, including international humanitarian law (IHL) and human rights law. Louis Patrick Lillywhite will introduce these concepts, and explain how healthcare is provided in conflict, discuss the main challenges to implementation and touch on the emerging trend of targeting healthcare facilities in conflict.

What are your thoughts on IHL? Are laws still relevant even if they are not upheld?

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This video is from the free online course:

Health in Humanitarian Crises

London School of Hygiene & Tropical Medicine