The rising civilian toll of death and disease in today’s intensely-fought wars is not inevitable if health and humanitarian aid providers shift mindsets and practices.

25 June 2024 – Mukesh Kapila

First released 25 June on Devex

We live in most violent times with around 180 armed conflicts smouldering or raging. Most violence is concentrated in some 50 countries, but no region is untouched. The trends are ominous with conflict events increasing by 40% since 2020.

While 2022 saw more than 200,000 battle-related deaths, a quarter of humanity — some 2 billion people — is exposed to wider impacts: destruction, disruption, impoverishment, displacement, hunger, and disease.

As humanitarian needs peak with over 117 million people forcibly displaced by the end of 2023, and over 40 million facing emergency hunger levels, international aid cannot keep up. Less than a fifth of the United Nations’ $49 billion emergency appeal is funded half-way through this year, while aid delivery is often attacked, blocked, obstructed, and looted.

Humanitarians recognize that business-as-usual is failing. But what to do? The emergency health sector offers a window into understanding the prevailing malaise and necessary adaptations.

Sustaining health is central to survival in crises. And thanks to traditional values that are common across cultures, it has had huge moral value that limited the cruelties of warmaking. Less so nowadays.

Over 2,500 attacks on health care were recorded in 2023, often deliberate. In Ethiopia’s civil war in Tigray, over three-quarters of health facilities were devastated. Similarly also in Sudan, and war-torn parts of Myanmar. Most Gaza health facilities have been destroyed right down to incubators for babies. Over 1,000 health workers were killed, arrested, abused, and kidnapped worldwide last year apart from thousands of vulnerable patients hauled out of sickbeds.

Health care has moved into the crosshairs of warring parties. This reflects fraying of the long-standing consensus behind health as a common global good and its weaponization for other objectives, be it pandemic-related competition for essential medical products, or as a tool for border and migration controls.

This is accompanied by the new rhetoric of “health security” in debates of the United Nations, World Health Assembly, and regional groupings such as the European and African unions. Although well-intentioned for promoting health-for-all, the militarized language can cause misunderstanding.

Rebuilding respect for health as a bridge to humanity requires policymakers to avoid its instrumentalization for partisan or nationalistic interests. It implies reviving the do-no-harm Hippocratic medical ethics, which are direct ancestors to modern humanitarian principles, especially neutrality and impartiality, and human rights concepts around fairness and justice.

What can the health sector do?

The health sector can help by reorienting itself. This can start by remembering that health care is mostly provided by local doctors and therapists with knowledge and motivation to best serve their patients.

It demands overcoming international technical elitism and enabling local skills to lead. Examples abound, from traditional birth attendants reducing maternal and infant mortality in Bangladesh, community workers conducting vaccinations in Ethiopia or setting fractures in Yemen, and Indian para-surgeons removing cataracts to restore sight.

Accelerating task shifting or redistributing health care roles must be accompanied by boosting self-care skills, especially for chronic afflictions such as diabetes and hypertension that are responsible for two-thirds of the disease burden in fragile and conflict contexts.

Meanwhile, don’t overlook humble first aid, the science of which is as old as warfare itself. In emergencies, 90% of lives saved are due to timely first aid. That goes beyond plaster and bandage to the treatment of common conditions and handling psychological trauma.

Unfortunately, first aid skills among the public have atrophied. Urgent campaigns — perhaps by the omnipresent Red Cross and Red Crescent — could turn everyone in a conflict zone into a lifesaver. This could be helped by the mass distribution of low-cost first aid kits and local language copies of David Werner’s 1970 classic, “Where There Is No Doctor.”

New technologies also open exciting possibilities. Suitably programmed artificial intelligence and remote-sensing methods can hasten needs assessments and responses. Assistance can also be better tailored to specific scenarios. Remote consultations worked well during the COVID-19 pandemic and surgeons have even supervised emergency operations down mobile phones. Drones to deliver lifesaving blood and medication are becoming more common.

Finally, rethinking infrastructure is also a must. The significant injury and illness burden of conflict does not require large hospitals that are vulnerable to destruction. Small-scale facilities can allow less ostentatious deliveries of medical supplies, rather than convoys of shiny equipment and medicines that tempt looters or can get easily blocked.

None of these “small-is-better-and-safer” modes are novel or radical. In some form or other, they are already practiced. But only here and there, now and then. Why not everywhere, at all times?

Perhaps that is because of the wide gap between aid givers and receivers. The humanitarian — including health — enterprise is a “wholesale” affair dominated by multibillion-dollar agencies. With size comes complexity and heavy-footedness. In contrast, receiving aid is a one-by-one or “retail” transaction. And even more so in the highly personalized health vocation.

The incompatibility between wholesale and retail mindsets can lead to disappointed and disgruntled service users, and further erodes trust. Could the emergency health component lead the way to a more accessible and resilient humanitarianism?