Health Workers In Areas Of Conflict

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Health Care Workers in Areas of Armed Conflict

I’ve written in the past about the difficulties of being the healthcare provider in hostile settings, most notably in my article “The Medic Under Fire”. A nation at war must expect that its medical personnel will be targets for the enemy.

There are circumstances, however, where non-military personnel on humanitarian missions become targets in times of “peace”. This is currently the situation in the Democratic Republic of Congo; health workers combatting the Ebola epidemic there are being attacked and looted by armed groups under the control of local warlords. In February, a Doctors Without Borders treatment facility was set on fire. Recently, a World Health Organization (WHO) physician, Dr. Richard Mouzoko Kiboung, was killed at a treatment center.

The Ebola epidemic in Congo now numbers over 1350 cases and over 880 fatalities, second only to the West Africa outbreak in 2014-2016. That outbreak killed over 11,000 of the 28,000 people infected, including 500 health workers. 30 of the fatalities in 2018-2019 were health workers.

Congo has scores of armed factions constantly at odds with each other and the government. They have attacked field hospitals in contested territory with contagion hot spots right in the middle of the unrest.

Caring for large numbers of infectious patients is complex in the best of times. In unstable regions, the health risks to medical personnel come not only from contagion, but also from encounters with hostile locals. Native populations are highly suspicious of WHO workers, not to mention their own government. They either believe that the epidemic is a manufactured crisis or that the relief organization or government insiders are importing the disease for nefarious purposes. Health workers entering villages are often met with a hail of stones.

All this makes the identification and treatment of the sick problematic. Sick individuals may fear presenting themselves to treatment centers or may be hidden by their families. The remoteness of some areas makes an accurate assessment of the need for supplies difficult. Those supplies may be blocked or looted by armed militias.

These obstacles may account for the high death rate from this strain of the Ebola virus. In West Africa, the WHO was able to establish a strong transport network for supplies in the 2014-2016 outbreak. Improved logistics and outreach decreased the percentage of Ebola cases resulting in death from close to 60% to about 40%. Credit should go to the increased availability of IV fluids and oxygen for victims and personal protection gear for medical workers.

The lethal Ebola virus is transmitted to humans from animal reservoirs such as monkeys, apes, and fruit bats. This is thought to have occurred originally from the consumption of these animals as bush meat. It can also be spread by bodily fluids of those infected even if they are deceased. Infected humans develop the sudden onset of fever and fatigue, followed by vomiting, diarrhea, and spontaneous internal bleeding. Although a promising vaccine is being used in the current outbreak, it is of little use to those already sick. It may, however, decrease the rate of spread of the epidemic.

Despite the seriousness of the issue, the WHO recently opted against labeling the current crisis as an “issue of international concern”. They reason that the disease has not yet crossed borders into other countries (and, perhaps, due the dangers to WHO personnel must also play a part. The U.S. State Department has generally forbidden travel to the area for security reasons, so the Centers for Disease Control and Prevention (CDC)’s participation is limited to technical guidance.

Increased security from government troops and U.N. Peacekeepers may seem a reasonable response to stabilize the situation. Some voice concern, however, that an already suspicious population may be incited to further unrest by an increased military presence.

Although I recognize this possibility, desperate situations may require desperate measures. The key, as with many instances of infectious outbreaks, is to strategically isolate areas to prevent spread. This requires a military or police presence to decrease traffic in and out of epidemic hot zones. To some extent, such forces are probably already deployed; increasing the security presence around hospitals combined with defensive obstacles would, hopefully, receive acceptance by most of the local population.

Twelve nations, including France, Spain, Italy, Japan, Kazakhstan, the Netherlands, Peru, Senegal, Switzerland, Uruguay, Canada, and Ukraine signed a (non-binding) resolution in 2017 that would take practical measures to protect medical personnel in areas of armed conflict. As with all non-binding agreements, it remains to be seen how much of a response will be mounted.

Doctors and other hospital personnel in Congo are threatening to strike if safety concerns aren’t addressed. Medical staff are essential to snuffing out this outbreak; they’re in enough risk from contagion, and I think all can agree that they’re right to want protection. It’s time to act to keep health workers safe before a bad situation gets worse.

Joe Alton MD

(Joe Alton MD is the NY Times bestselling author of 2014’s The Ebola Survival Handbook, as well as the #1 Amazon bestsellers The Survival Medicine Handbook: The Essential Guide for When Medical Help is Not on the Way and Alton’s Antibiotics and Infectious Disease: The Layman’s Guide to Available Antibacterials in Austere Settings)

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