MASTER FOR CHANGES as of 4.5.2012
Report
Health Care in Danger
The London Symposium
23 April 2012
Coorganised by:
International Committee of the Red Cross
British Red Cross
British Medical Association
World Medical Association
1. Background
Insecurity of health care in armed conflicts and other emergencies is a
massive humanitarian problem; it denies health care to millions of people.
From 2008 to 2010, the International Committee of the Red Cross (ICRC)
analyzed 655 violent events affecting health care in 16 operational
contexts. The study shows patterns of violence affecting health care that
range from direct attacks on patients, health infrastructures and
personnel, inadvertent hits by explosive weapons, denial of access to
care, general insecurity, arrests, looting and kidnapping. The study was
not able to capture all events. Nor was the study able to calculate the full
impact of insecurity of health care on the health of whole communities or
even nations; this can only be established by further epidemiological
work.
Armed conflict and other emergencies increase the need for health care at
precisely the moment when, because of insecurity, it is most difficult to
address this need. Inevitably, any existing health-care infrastructure is
likely to be both overwhelmed and disrupted at the same time. The
consequences are dire for whole communities; even basic health care may
be difficult and public health programmes such as vaccination
programmes can be rendered impossible. In terms numbers of people
affected, insecurity of health care is one of the biggest humanitarian
problems today. Yet it is a largely under-recognised issue.
The ICRC has decided to address this humanitarian challenge with the
"Health Care in Danger" Project. This will involve mobilizing the ICRC's
network of delegations, the National Red Cross and Red Crescent Societies
globally, the States party to the Geneva Conventions, the health
community and other actors to develop practical recommendations and
engage in their concrete implementation.
To this end, the 31st International Red Cross & Red Crescent Conference
held in Geneva in November 2011 called upon the ICRC to:
 initiate consultations with experts from States, the Red Cross & Red
Crescent Movement and other actors in the health-care sector with
a view to formulating practical recommendations that will assure
the security and delivery of effective and impartial health care in
armed conflict and other emergencies;
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
to report to the 32nd Conference in 2015 on the progress made.
The 'Health Care in Danger' project will organise a series of expert
consultations that will address five broad areas:
 Military practice and operational orders with respect to the wounded
and sick and to the security of health-care personnel and facilities;
 The role and responsibility of National Red Cross and Red Crescent
Societies to deliver safe health care in armed conflict and other
emergencies;
 The responsibilities and rights of health-care personnel working in
armed conflict and other emergencies;
 The physical security of health facilities;
 The development of pertinent national law.
The Health Care in Danger London Symposium of 23 April 2012 addressed
the security and delivery of effective and impartial health care in armed
conflict and other emergencies. It discussed the responsibilities of health
professionals and institutions and sought recommendations for the policy
community about assuring security of health care. A second ICRC-led
event co-organised with the Egyptian Red Crescent Society is foreseen for
the end of 2012; this will examine the "rights" of health-care personnel to
security and adequate preparation for working in these contexts.
Recommendations about real and practical aspects of security and
delivery of pre-hospital care will be sought. The experience of health-care
professionals involved in treating the wounded and sick from the uprisings
throughout the Arab world offer the opportunity to learn more about and
make recommendations for delivering health-care “on the street” and in
difficult and dangerous circumstances.
2. Symposium outline and background documents
Participants were sent an outline of the Symposium including examples of
the questions that might be addressed in the panel discussions. They were
also sent the following documents as background:
 The International Committee of the Red Cross 16 Country Study of
Health Care in Danger [link]
 The British Medical Journal editorial of 10 August 2011 by Vivienne
Nathanson[link]
 Protection of Health Care in Armed and Civil Conflict by Len
Rubenstein for the Centre for Strategic & International Studies,
January 2012 [link]
 The Resolution of the 31st International Conference of the Red
Cross and Red Crescent Movement, November 2011 [link]
The programme of the Symposium is in annex; it gives the full titles and
affiliations of the speakers, moderators and panellists.
3. Opening remarks
In his welcoming comments, Geoff Loane, indicated that the objective of
the day was to generate recommendations around three themes each of
which had a corresponding panel discussion. The four co-organising
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organisations would be responsible for drawing out the most useful
recommendations.
Paul Henri Arni described the scope, timescale and format of ICRC's
foreseen process of expert consultation. He pointed out that some of
these recommendations can be taken up by participants for work
immediately in their own domain; other recommendations will feed into
the Heath Care in Danger project with a view to presentation to
governments at the 32nd International Conference of the Red Cross and
Red Crescent in 2015.
The first keynote speaker, Dr Unni Karunakara, stated the support of
MSF for the ICRC's Health Care in Danger project. He described with
authority and passion the nature, extent and full impact of the violence
affecting MSF’s field operations in the very recent past. He called upon
States and other armed actors to recognise the sanctity of health care.
Professor Sir Michael Marmot, the second keynote speaker, made the
case - and convincingly so - that insecurity is a major social determinant
of ill-health; one reason being that it contributes to inequitable access to
health care on a global scale. He recommended an integrated approach to
human security as a matter of social justice. He emphasised that
promoting the social determinants of health empowered the most
vulnerable; an example being the obvious need for education of women in
the developing world. He challenged the Red Cross and Red Crescent
Movement to consider its responsibilities with regard to the social
determinants of health.
3. First panel discussion: Building a community of concern about
"Health Care in Danger"
This panel, chaired by Sir Nicholas Young, discussed how greater
awareness of the issue of insecurity of health care can be raised, pertinent
aspects of campaigning and how a “community of concern” might be built.
Professor Sir Andrew Haines outlined the many and varied forms of
attacks on health care. He referred to the multiple responsibilities of the
health care community that should arise as the extent of the health
impact of insecurity of health care becomes increasingly recognised.
Foremost was the responsibility to gather pertinent data. He pointed out
that the academic world has been slow to recognise this issue. Carolyn
Miller, having already organised a campaign advocating security of health
workers, pointed out there were already groups concerned by and
communicating about the issue. She emphasised the need for "clear calls"
to action and described the importance of solidarity when campaigning for
security of health care workers in all contexts in particular with respect to
“local voices and forgotten people.” Mohini Ghai Kramer described the
strategy behind and tools used in the ICRC’s “Life and Death” campaign.
She showed some research data indicating a low level of personal
engagement among the general population in countries with a higher
standard of health care i.e., the western world and emphasized the
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importance of raising awareness and mobilizing relevant target audiences
to improve safer access to health care.
The discussion focused on:
 The need for continued data gathering;
 The need for creating greater awareness of the issue and the
important voice of health-care institutions;
 The role of health-care institutions with regard to promoting
security of health care on a global basis;
 The paucity of academic literature that focus on insecurity of health
care;
 The need for better communication on the issue within the health
care community and more widely within a “community of concern;”
 The importance of reaching non-state armed actors and the
communities in which they exist;
 The personal security implications of raising concerns about
insecurity of health care in certain contexts;
 The complexities inherent in communicating about insecurity of
health care and possible solutions;
 The possibilities brought by new communication technologies
especially social media;
 The importance of engagement of the media in raising awareness of
this issue.
Recommendations drawn from the first panel discussion
1.1. Health-care professionals and institutions should raise awareness of
this issue at all levels including within policy-making circles.
1.2. Health-care professionals and their institutions should find and speak
with one coherent voice with respect to insecurity of health care. This
needs regular communication about the nature and extent of the problem
and what can be done to address the problem in its many forms.
1.3. The health-care community across the world should find the means to
show solidarity with colleagues working under difficult circumstances in
armed conflict or other emergencies.
1.4. Any organisations working in health-care, especially academic
institutions, should make efforts to gather data about and report on
insecurity of health care and more importantly about the ultimate impact
of that insecurity on the health of whole populations.
1.5. Academic institutions (health, legal or other) should recognise that
insecurity of health care and its impact is a legitimate field of research.
1.6. Issues related to insecurity of health care should be incorporated into
academic agendas at university level and into training of all health
professionals.
1.7. Raising awareness of the issues relating to insecurity of health care
includes putting forward suggestions for practical solutions.
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Implementation of such practical solutions should begin as soon as
possible; it does not have to wait for approval by policy-makers.
1.8. The need for greater security of health care should be brought to the
attention of health care professionals from military bodies, faith based
communities, various diaspora and in communities affected by conflict.
1.9. Efforts should be made, where feasible, to use the issue of insecurity
of health care to bring together health-care professionals on either side of
a conflict or of ethnic, religious or political divides.
1.10. A platform for hosting "a community of concern" - the different
individuals and groups already advocating for greater security of health
care - should be created. This community could share an on-line space
where experiences and information could be shared along with solutions
and practical advice.
1.11. When communicating and campaigning on this issue, individuals and
organisations must work together; competition should be avoided.
1.12. The potential of International Red Cross and Red Crescent
Movement to raise awareness of and take action on insecurity of health
care should be fully realised.
1.13. Where pertinent, opportunities should be grasped to link the issue of
insecurity of health of care to other security issues such as work on the
Arms Trade Treaty and the emerging advocacy by a number of nongovernmental organisations against the use of explosive weapons in
populated areas.
1.14. All interested in communication about awareness of and solutions
for insecurity of health care should collaborate to ensure coherence of
messages and together address a number the following challenges:
 The misperception that the main issue is about “attacks on
doctors;”
 Interacting with non-state armed actors on this issue;
 Ensuring that the voices of health workers in the more inaccessible
places are heard;
 Ensuring facts are verified before communication however difficult
the verification;
 Keeping the issue in the headlines;
 Ensuring that different agencies communicate consistent and
complementary messages.
4. Second panel discussion: Recommendations of the health
community to governments and intergovernmental organisations
This panel, chaired by Angela Gussing, discussed the legal framework
pertinent to insecurity of health care, the difficulties of delivering health
care in situations where there was lack of governance and what
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recommendations could be made by the symposium to governments and
intergovernmental organisations.
Gilles Thal Larsen gave a concise overview of applicable international
humanitarian law and international human rights law. He outlined the
potential role of international criminal law and how development of
pertinent domestic law is recommended. Dr Peter Hill used recent
research findings to highlight the multiple and complex constraints on the
delivery of health care in “disrupted environments” characterised by lack
of governance. Displacement and uneven distribution of health care
resources in many such environments is a particular concern. Dr Rudi
Coninx emphasised the concern about insecurity of health care expressed
publicly by senior figures in the World Health Organisation. He described
what the WHO has done to date and might be able to do in the future
especially when mandated by the World Health Assembly in relation to
gathering pertinent data. Leonard Rubenstein framed possible
recommendations for governments and intergovernmental organisations
from the perspective of a human rights advocate; namely: establishing
and promoting norms; monitoring and reporting; protection and
prevention; and accountability for violations.
The discussion focussed on:
 Possible deterrents to and accountability for attacking health care;
 The roles and responsibilities of different United Nations agencies
including the UN Human Rights Council and the UN Security
Council;
 The need for and possible form of an international protection
system to prevent attacks on health care;
 The importance of the WHO’s Executive Board draft proposal for
possible adoption by the World Health Assembly (EB 130.R14) in
May 2012;
 The continued need to document the full impact of insecurity of
health care as a driver of policy change;
 Some promising developments within the UN system such as UNSC
Resolution 1998 of July 2011 which, in the frame of protecting
children, refers to the need for protecting schools and hospitals;
 The growing coalition of influential non-governmental organisations
concerned by insecurity of health care and the importance of such a
coalition for bringing about policy change. A parallel was drawn with
the NGO coalition that became the International Campaign to Ban
Landmines
Recommendations drawn from the second panel discussion
2.1. Governments should recognise their prime responsibility in relation to
assuring the security and delivery of effective and impartial health care in
armed conflicts and other emergencies. To this end, the means to better
apply existing international law - including international criminal law should be found; there is not at present a need for further development of
international law. By contrast, governments should, where appropriate,
develop and apply pertinent national law.
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2.2. With respect to insecurity of health care, there should be a global
integrated approach of UN agencies especially the UN Human Rights
Council and the UN Security Council. A commission of enquiry needs to be
established to examine specific incidents of violence affecting health care
and to follow up in terms of accountability. At the same time, a UN Special
Rapporteur should be appointed to examine and report on the issue
globally and to recommend action.
2.3. WHO Executive Board resolution (EB130.R14) should be adopted by
the World Health Assembly in May 2012.
2.4. All institutions in a position do so should pursue a policy of "quiet
diplomacy" with all parties to a conflict respect to security of health care.
2.5. Governments and intergovernmental organisations should focus
increasingly on the state of health care in situations where governance of
health care is disrupted by the insecurity accompanying armed conflict
and other emergencies.
5. Third panel: Medical ethics in Health Care in Danger
This panel was chaired by Professor Vivienne Nathanson. It addressed
some dilemmas faced by health care providers in armed conflicts and
other emergencies. It also raised the issue of whether medical ethics
("health-care" ethics) as understood today, apply in these contexts and, if
so, is further work necessary to facilitate their application when delivering
health care in these contexts.
Dr José Luiz Gomes do Amaral presented a summary of the
Resolutions and Declarations of the World Medical Association that are
pertinent to practice of medicine in armed conflict and other emergencies.
He emphasised that medical ethics apply in all situations. Philippa
Parker described some of the difficult dilemmas she had faced in her
many years as a Head Nurse in ICRC field hospitals. She emphasised that
looking at some every day problems as dilemmas helped decision –
making even if the right answer was not obvious. Surgeon Rear Admiral
Lionel Jarvis described difficult ethical dilemmas faced by military health
care providers in contexts such as Afghanistan. He emphasised the
importance of training of military medical personnel in medical ethics and
left participants in no doubt that correct health care was provided by UK
military medical services to the extent possible to any wounded person in
Afghanistan including civilians and “enemy” fighters.
The discussion focussed on:
 How discussion about medical ethics in armed conflict and other
emergencies to date have largely focussed on the role of health
professionals in matters relating to detention, interrogation and
human experimentation;
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Whether medical ethics apply in armed conflict and other
emergencies and if so, how their application may differ in
peacetime;
How the health-care services of a military body and civilian health
care (including health care delivered by outside humanitarian
agencies) can interact without generating yet more dilemmas and
difficulties;
The need for ethics training of all health-care personnel working in
armed conflicts or other emergencies;
The possible differences, when working in armed conflict or other
emergencies, between “medical” ethics as applied to managing
individual patients and “public health” ethics as applied to
managing populations such as vulnerable people in refugee camps;
The issues at the interface of impartiality of care, discrimination and
the Hippocratic Oath;
Problems of consent posed by treating wounded child soldiers;
How in guiding practitioners, considerations of the security of
oneself, one’s patients or one’s colleagues are not at present
adequately taken into account when considering ethical dilemmas;
How consideration of the security of health care personnel and
patients may be an issue for ethical committees when reviewing
research that is based on gathering data from hospitals about the
impact of violence in the contexts of concern;
Whether the imbalance in reporting about casualty statistics
(highlighting the number of casualties among “western” troops) is
an ethical issue for health professionals working in contexts like
Afghanistan;
Issues relating to military medical personnel carrying weapons and
whether the red cross or red crescent emblems carried by medical
personnel or transports make them targets in certain contexts.
Recommendations drawn from the third panel discussion
3.1. Medical ethics are essential for health-care personnel who are
delivering health care in armed conflict and other emergencies. In these
contexts, practice based on an ethical framework is as important as in
peace time if not more so.
3.2. All health care personnel should receive adequate training in their
responsibilities and rights when working in armed conflict and other
emergencies. Appropriate training manuals, specific to these contexts and
including security considerations, should be developed and disseminated.
3.3. The World Medical Association should develop scenarios based on the
subject matter addressed in the panel with a view to promoting discussion
about the application and possible development of medical ethics
applicable in armed conflict and other emergencies.
6. Closing comments
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In closing the symposium, Dr Robin Coupland, highlighted some of the
interesting ideas and challenges that emerged from the discussions. He
stressed the importance of participants taking home messages and ideas
emanating from the rich discussions generated by the panels. He pointed
out that, with growing awareness of the full impact of insecurity of health
care at a global level, the health community and other key stakeholders
have a responsibility to take appropriate action without necessarily
waiting for formal policy documents. Finally, on behalf of the participants
and the other co-organisers of the event, he thanked the British Medical
Association for generously hosting the Symposium.
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Annex
Health Care in Danger
London Symposium, 23 April 2012
Programme
9.00 – 10.30 Opening
Geoff Loane, ICRC Head of Mission, London - Why are we here?
Paul Henri Arni, ICRC, Head of Project – Overview of the project "Health
Care in Danger"
Dr. Unni Karunakara, President, MSF International– What insecurity of
health care means at a field level
Professor Sir Michael Marmot, Director, University College London
Institute for Health Inequalities – Insecurity and social determinants of
health
10.30 – 11.00 Coffee
11.00 – 12.30 Panel 1, Building a community of concern
Moderator: Sir Nicholas Young, Chief Executive, British Red Cross
Professor Sir Andrew Haines, Dept. of Public Health and Primary Care,
London School of Hygiene and Tropical Medicine - A greater responsibility
of health care professionals?
Carolyn Miller, Chief Executive, Merlin - Health professionals speaking
out
Mohini Ghai Kramer, Head of corporate communication, ICRC - The
ICRC communication strategy to build a “community of concern”
Discussion
12.30 – 14.00 Lunch at BMA House
14.00 – 15.30 Panel 2, Recommendations of the health community
to governments and intergovernmental organisations.
Moderator: Angela Gussing, Deputy Director of Operations, ICRC
Gilles Thal Larsen, International Law Adviser, British Red Cross –
Overview of legal protection of the wounded and sick and of health care
Professor Len Rubenstein, Senior Scholar, Centre for Human Rights
and Public Health, Johns Hopkins Bloomburg School of Public Health and
the Berman Institute of Bioethics
- Intergovernmental organisations and security of health care
Dr Peter Hill, Public Health Physician and Academic, Australian Centre for
International and Tropical Health, University of Queensland
- Health systems in disrupted environments
Dr Rudi Coninx, Coordinator, Policy, Practice and Evaluation, Policy,
Practice & Evaluation, Polio, Emergencies & Country Collaboration Cluster,
World Health Organisation - The role of the international health
community
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Discussion
15.30 – 16.00 Tea / Coffee
16.00 – 17.30 Panel 3, Medical ethics in "Health Care in Danger"
Moderator: - Dr Vivienne Nathanson, Head, Professional Activities, BMA
Philippa Parker Head of ICRC Health Unit - Every day dilemmas of a
head nurse
Surgeon Rear Admiral Lionel Jarvis Medical Director General, Navy,
UK - Dilemmas for military medical personnel,
Dr José Luiz Gomes do Amaral, President, World Medical Association The need for development or application of medical ethics in armed
conflict and other emergencies
Discussion
17.30 – 17.45
Adviser, ICRC
Closing comments – Dr Robin Coupland, Medical
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