Roundtable discussion: Safety of Health Workers in Conflict Settings

ANNA KALBARCZYK: Hi, everyone. I’m Anna Kalbarczyk, and I’m here with Dr. Malabika Sarkar and Dr. Assefa Seme. And today, we’ll be talking about ethical issues and human resources for health. So the question I’d like to pose to you today is do you think it’s ethical for the international alliance to require or even encourage health workers to be in conflict areas, or areas where their safety might be at risk? Malabika?

MALABIKA SARKAR: Actually, definitely, we need to provide the service in the conflict region, because we cannot leave anyone behind. And we cannot put a risk, like an all for life, because there’s ethical issue. But it is ethical, as long as we take the correct measure for the security and safety of the health workers. So I strongly believe that definitely, we need to give the service to those populations. Those are already vulnerable and disadvantaged, and we cannot deprive them. But we have the moral, ethical responsibility to secure and ensure the safety of the health worker so that they can actually complete their task successfully and effectively.

ASSEFA SEME DERESSE: Yeah, I totally agree with Dr. Malabika’s idea. When we talk about this condition, it has to be from both sides. People should get the service. They shouldn’t be left behind. But they should get the service in a way that the service givers should also be not affected in terms of health, in terms of safety. And then in terms of all the support that they need, in providing the service for the need.

ANNA KALBARCZYK: Is there an additional layer to this, as we talk about the international alliance encouraging people to be working in these areas? Right, I mean, we’re thinking then about many people who might not work in those areas themselves, might not live in those countries. What are maybe some implications of that?

MALABIKA SARKAR: Actually, the prime responsibility, I think, is the national government. Because the international alliance, they don’t actually structure the system. They don’t give the guideline where to go, what to do. So the national government, they know the context. They know the capacity of the health worker. They know the situation. They know what do they need. So the national government has more responsibility to kind of develop a guideline to help them to develop the capacity to ensure even if there’s a conflict and there are other rebel groups or the political volatility, then they need to talk to them and then ensure days of tranquility or ceasefire.

So the more responsibility, to me, is the national policy policymaker rather than the international alliance.

ANNA KALBARCZYK: Any reflection from you?

ASSEFA SEME DERESSE: In addition to the national government, we should also think of the local government, particularly when you go to developing countries in Africa, for example. We have such states, local government, who are responsible for the safety and for everything in the district or in their areas. So as Malabika said, in addition to the international government’s responsibility, the local have the main. But the international donors and the partners can support the local government and the national government financially, and with some sort of aid so that the safety of health workers in reaching the hard to reach areas, the conflict zones, and also the war zones, can be issued.

ANNA KALBARCZYK: And we’ve also had discussions about how there are other challenges within the health care workforce, right, so people not getting paid on time or not being compensated well for their time. How do you think that’s related to asking, then, health care workers to work in zones where their safety might be at risk?

MALABIKA SARKAR: I think one of the major issues is that, do we have the database? Do we know exactly– there should be a kind of a live database that we should know exactly how many health workers are affected in the unsafe areas, and also segregation by sex, segregation by the level, so exactly we know that what is the magnitude. Because we cannot come to a solution that we don’t know in the database. So that’s very important. And in terms the health workers, those who work in that area, definitely, they will require more financial incentive and support, because they are endangering their life and risking their life for providing the service.

So if they have the double burden of anxiety at one hand not getting paid, and also the risk, that will not ensure the quality of service. So whatever the objective, that will be completely spoiled if we don’t ensure that all these, not only the safety, but the financial security, the support they need, creating an enabling environment for them. So that’s much, much more important for the workers in the conflict region. Definitely, it’s important for everybody, but we need to pay attention and to make sure that they should not be punished because they are working and they’re in an unsafe area and they’re risking their life.

ANNA KALBARCZYK: Maybe that allows a follow up question. I mean, you talk about an enabling environment. When we talked yesterday, you mentioned mental health, so not just physical safety of people, but also mental safety. Could you maybe talk a little bit about that today, or you, Assefa?

ASSEFA SEME DERESSE: Yeah. I mean, the health workers, the support that the health workers need in such areas is not only the physical support, but the emotional support. And because both the national government and the international partners should make sure that beside all the financial support the health workers should get in time, they should be emotionally supported. They should make sure that they are safe where they know that they are working. They should also make sure that health workers can be reached at any time if there is anything that is going to risk their life.

So ensuring that emotional and mental support is one of the requirements that we need to give to the health workers in order to ensure some visibility for the people.

MALABIKA SARKAR: Just continuing that, what Dr. Assefa said, I think it’s an irony that when we send the health workers to an unsafe region, we don’t actually prepare them. We only get the technical training. But it’s very important to actually make them prepare, like the coping strategy, because it’s not only whenever I’m in danger, but I’m also working in a situation where people are suffering. So there is no kind of curriculum that actually addresses that issue, the coping strategy for the health worker for their own mental health, well-being, but also how to deal with the patient’s suffering outside the disease. Of course, they have the disease, but they also have a lot of trauma.

And as a health worker, they cannot deny themselves, OK, I don’t want to hear about your pain or suffering. I am here only to give you the antibiotic. But you don’t prepare them. And in addition to that, whenever there is an a traumatic event happening there, that unsafe area, there have to be immediate steps taken so that those who are suffering from post-traumatic syndrome, how can we reach them, how can we ensure– and not only to them. I do believe that there’s also responsibility to reach out to the family members. Because sometimes the family members are very worried when they are working there.

And they need to be also be supported, so that we can create a very stable environment in that particular area for the health worker, so that they’re prepared and ready to provide the service and to take necessary steps and the coping strategy to deal with this, the suffering, this situation.

ASSEFA SEME DERESSE: Yeah, one more point, Malabika has reminded me is when we talk of the emotional support, it is not only for the health worker and so, but some health workers leave their families behind, their loved ones behind, and they’ll go to these hard to reach or conflict zones for you know this provision. But we should make sure these health workers can– not even frequently, but at some regular time should go back to their families, visit them, or should arrange in a way that the families could come there, visit them, have two, three days vacation, and then this will really give them a sort of support.

ANNA KALBARCZYK: So we’ve talked about a couple of different solutions addressing some of these challenges. And maybe as a final wrap up thought, I’ll ask each of you to give me what you think might be a solution, and maybe we could think about it from a government level or even sort of a more international level, in terms of protecting people’s welfare in these hard to reach and conflict areas.

MALABIKA SARKAR: For me, I think the problem, I said that very important to create a database, who are the sufferings so that then we can have– we should not go for a blanket approach. We should have a very context specific, target specific approach, and looking at the gender issues, whether the women are more likely to suffer and become the victim that compared to maybe the male colleagues, or maybe vice versa, depending on where they are. So the database, and then a context-specific, the problem-specific solution, which is which should not be a static solution.

The solution has to be very evolving there, depending on so that policy makers and the implementers need to be very flexible, and then to decentralize the authority that they can make a quick decision. Sometimes, we wait for the central decision that OK, I can’t do anything. So there has to be the balance in terms of the flexibility and the decision making, decentralization of the financial authority and also the decision making authority, and then very much context-specific, problem-specific, the solution, not a blanket approach.

ASSEFA SEME DERESSE: Yeah, I agree with Malabika that not all hard to reach have the same problem. The magnitude could vary. So we have to stratify, who is affected most, which gender group is affected most, and which areas are affected most? And in terms of intervention, as we said earlier, we have to involve the local government, the local government, because we love the local leaders and the local religious leaders, or community leaders, who can take part, really, in terms of securing the safety of health workers. Then involving the local government, plus cooperating with the international community, in terms of getting support. So if all act together, then there would be a solution to bringing health.

ANNA KALBARCZYK: Well, thank you so much for your time today, and for this great discussion on human resources for health. Thank you.

MALABIKA SARKAR: Thank you.