Gunning Down Health: The Deterioration of Health During Conflict

On the 27th of November 2019, two attacks in the eastern Democratic Republic of the Congo (DRC) resulted in 4 deaths and 5 injuries among workers responding to the Ebola outbreak [1]. Among the dead were a vaccination team member, two drivers, and a police officer. These attacks were the deadliest of a series of attacks on Ebola first responders in the eastern DRC, where the outbreak response has been challenging due to armed conflict in the region. Healthcare workers have been specifically targeted or caught in the crossfire. Although viruses and bacteria are known to cause disease, war and conflict can fuel large outbreaks that become difficult to control.

The Ebola outbreak in the eastern DRC started in August 2018, and was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) in July 2019 [2,3]. To date, 3,428 cases and 2,250 deaths have been reported, making it the largest Ebola outbreak in the DRC, and the second largest in the world after the West African Ebola outbreak in 2013-16 [2,4]. The armed conflict in the eastern Kivu region is primarily between the military of the Democratic Republic of the Congo (FARDC), the Democratic Forces for the Liberation of Rwanda, the Allied Democratic Forces and other local militias [5]. Attacks on Ebola first responders have impeded prevention and control efforts on the ground. In 2019, there were 390 attacks on health facilities that resulted in 11 deaths and 83 injuries among healthcare workers and patients [6]. Insecurity in the region has made it difficult for responders to treat cases, track contacts of cases, and vaccinate high-risk communities. Violent attacks in February 2019 interfered with response activities, leading to a resurgence of Ebola cases in March-May [4].

The exacerbation of public health emergencies due to armed conflict and insecurity is not unique to the DRC. In Yemen, poor water, sanitation, and hygiene conditions created by the civil war resulted in the largest cholera outbreak ever recorded, with 2.1 million cases and over 3,800 deaths [7]. Nigeria, Pakistan, and Afghanistan are the last remaining polio-endemic countries, and conflict areas have made it difficult for vaccination teams to reach specific populations to achieve global eradication of polio [8]. In addition to infectious diseases, war and conflict have been noted to, directly and indirectly, increase the risk of malnutrition, mental health problems, noncommunicable diseases, injuries, gender-based violence, and mortality [9]. War and conflict indirectly affect health systems through economic instability, food insecurity, forced migration, and societal breakdown [9]. However, targeted attacks on healthcare facilities and workers have been noted as a military tactic to gain military advantage, create fear in populations, deny healthcare to opponents, and to steal valuable medicine and equipment [10].

To address global health problems, public health professionals must understand the effect of war and conflict on disease incidence and target its root causes [11]. One cannot address the prevention of future Ebola outbreaks in the DRC without addressing the root causes of conflict in the region, which include colonialism, poor governance, control of natural resources, and ethnic tensions. Strong global governance enforcing international humanitarian law is needed to prevent war, and to protect healthcare services during wartime. As such, the First and Fourth Geneva Conventions protect healthcare facilities and workers during conflict [12,13], and in 2016, the United Nations Security Council adopted Resolution 2886 to protect healthcare in conflict settings. However, attacks on healthcare facilities and workers continued to occur due to minimal enforcement, the lack of legal authority that the resolution has, and the lack of a mechanism in place for independent investigations of attacks on healthcare services [14,15]. The American Public Health Association cites that the role of public health professionals includes the prevention of war and conflict [16]. Public health professionals must recognize that health cannot be achieved without peace and that skills in peace-building, political negotiation, and examination of the structural causes of war are needed to ensure healthy populations globally [16,17]. The third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all, and SDG 16 of promoting just, peaceful, and inclusive societies are inextricably linked [18]. Therefore, public health inherently has an obligation to advocate for and strengthen international humanitarian law to protect healthcare facilities and workers in conflict settings [18]. In response to the recent attacks in DRC, the WHO and its partners withdrew teams from the specific location of the attacks, but remain present in the region to maintain Ebola response efforts [19]. Although it is difficult to predict the end of the current Ebola outbreak, the root causes of conflict in the region will need to be addressed to maintain outbreak response efforts on the ground.

References

[1] World Health Organization. (2019, November 28). Dead and injured following attacks on Ebola responders in the Democratic Republic of the Congo. World Health Organization. Retrieved from https://www.who.int/newsroom/detail/28-11-2019-dead-and-injured-following-attacks-onebola-responders-in-the-democratic-republic-of-the-congo

[2] Médecins Sans Frontières (2019, August 2). DRC Ebola outbreak crisis update. MSF. Retrieved from https://www.msf.org/drc-ebola-outbreak-crisis-update

[3] World Health Organization. (2019, July 17). Ebola outbreak in the Democratic Republic of the Congo declared a Public Health Emergency of International Concern. World Health Organization. Retrieved from https://www.who.int/newsroom/detail/17-07-2019-ebola-outbreak-in-the-democraticrepublic-of-the-congo-declared-a-public-health-emergency-ofinternational-concern

[4] World Health Organization: Regional Office for Africa. Ebola Virus Disease Democratic Republic of Congo: External Situation Report 72. World Health Organization: Regional Office for Africa. Retrieved from https://www.who.int/publicationsdetail/ebola-virus-disease-democratic-republic-of-congoexternal-situation-report-78-2019

[5] Human Rights Watch. (2019, August 14). DR Congo: 1,900 Civilians Killed in Kivus Over 2 Years. Human Rights Watch. Retrieved from https://www.hrw.org/news/2019/08/14/drcongo-1900-civilians-killed-kivus-over-2-years

[6] World Health Organization. (2019, December 1). WHO Director-General praises bravery of health workers during visit to eastern Democratic Republic of Congo following fatal attacks on Ebola responders. World Health Organization. Retrieved from https://www.who.int/news-room/detail/01-12-2019-who-director-general-praises-bravery-of-health-workersduring-visit-to-eastern-democratic-republic-of-congo-followingfatal-attacks-on-ebola-responders

[7] World Health Organization: Regional Office for the Eastern Mediterranean. (October 2019). Cholera situation in Yemen. Accessed December 12, 2019, http://applications.emro.who.int/docs/EMRPUB-CSR-240-2019-EN.pdf.

[8] Garon, J. R., & Orenstein, W. A. (2015). Overcoming barriers to polio eradication in conflict areas. The Lancet Infectious Diseases, 15(10), 1122–1124. doi: 10.1016/s1473-3099(15)00008-0

[9] Garry, S., & Checchi, F. (2019). Armed conflict and public health: into the 21st century. Journal of Public Health, 1-12. doi: 10.1093/pubmed/fdz095

[10] Patel, P., Gibson-Fall, F., Sullivan, R., & Irwin, R. (2016). Documenting attacks on health workers and facilities in armed conflicts. Bulletin of the World Health Organization, 95(1), 79–81. doi: 10.2471/blt.15.168328

[11] Fisman, D., & Tuite, A. (2019). The DAGs of war. Proceedings of the National Academy of Sciences, 116(48), 23880–23882. doi: 10.1073/pnas.1916910116.

[12] International Committee of the Red Cross. (n.d.). Treaties, States Parties, and Commentaries – Geneva Convention (I) on Wounded and Sick in Armed Forces in the Field,1949.International Committee of the Red Cross. Retrieved from ihl-databases.icrc.org/applic/ihl/ihl.nsf/Comment.xsp?action=openDocument&documentId=84FF993DB70E67D1C1257F7A005ABDAD.

[13] International Committee of the Red Cross. (n.d.). Convention (IV) relative to the protection of civilian persons in time of war. International Committee of the Red Cross. Accessed December 13, 2019, https://ihldatabases.icrc.org/ihl/INTRO/380.

[14] United Nations Security Council. (2016, May 3). Security council adopts resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations. United Nations. Accessed December 13, 2019, https://www.un.org/press/en/2016/sc12347.doc.htm

[15] Dayoub, R. (2019, May 2). Getting Serious About Protecting Health Care in Conflict. Chatham House. Retrieved from https://www.chathamhouse.org/expert/comment/gettingserious-about-protecting-health-care-conflict

[16] Wiist, W. H., Barker, K., Arya, N., Rohde, J., Donohoe, M., White, S., … Hagopian, A. (2014). The Role of Public Health in the Prevention of War: Rationale and Competencies. American Journal of Public Health, 104(6). doi:10.2105/ajph.2013.301778

[17] Beardsley, K., Cunningham, D. E., & White, P. B. (2018). Mediation, Peacekeeping, and the Severity of Civil War. Journal of Conflict Resolution, 63(7), 1682–1709. doi:10.1177/0022002718817092

[18] Wesley, H., Tittle, V., & Seita, A. (2016). No health without peace: why SDG 16 is essential for health. The Lancet, 388(10058), 2352–2353. doi: 10.1016/s0140-6736(16)32133-x

[19] Branswell, H. (2019, December 2). Ebola-Response Workers Killed in Attacks Force Withdrawal from Critical DRC Region. STAT. Retrieved from https://www.scientificamerican.com/article/ebola-responseworkers-killed-in-attacks-force-withdrawal-from-critical-drcregion/?utm_source=dlvr.it&utm_medium=twitter

Editor’s Note: This article has been republished from our 2020 magazine – Juxtaposition Volume 13 Issue 1