Scholarly article on topic 'Armed conflict women and girls who are pregnant, infants and children; a neglected public health challenge. What can health professionals do?'

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Abstract of research paper on Economics and business, author of scientific article — David Southall

Abstract Without security, adequate healthcare is not possible. Armed conflicts continue to be waged with pregnant women and girls, babies and children affected most. Most countries in conflict are poorly resourced and their mortality and morbidity statistics so much higher than rich countries that nothing short of a global revolution to create equity is going to solve the problem. When the arms trade is added in and analysed the maternal and child mortality rates for those countries exporting most of these killing machines is so much lower than the countries in which they are used that we have an ethical issue that must be addressed by health professionals. Armed conflict is probably the most serious global public health challenge and two solutions are proposed. Health professionals have a major voice and must support the currently progressing Arms Trade Treaty and call for more effective protection for healthcare in areas of conflict.

Academic research paper on topic "Armed conflict women and girls who are pregnant, infants and children; a neglected public health challenge. What can health professionals do?"

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Armed conflict women and girls who are pregnant, infants and children; a neglected public health challenge. What can health professionals do?^

David Southall *

Maternal and Childhealth Advocacy International-MCAI, 83 Derby Rd, Nottingham NG1 5BB, United Kingdom

ABSTRACT

Without security, adequate healthcare is not possible. Armed conflicts continue to be waged with pregnant women and girls, babies and children affected most. Most countries in conflict are poorly resourced and their mortality and morbidity statistics so much higher than rich countries that nothing short of a global revolution to create equity is going to solve the problem. When the arms trade is added in and analysed the maternal and child mortality rates for those countries exporting most of these killing machines is so much lower than the countries in which they are used that we have an ethical issue that must be addressed by health professionals. Armed conflict is probably the most serious global public health challenge and two solutions are proposed. Health professionals have a major voice and must support the currently progressing Arms Trade Treaty and call for more effective protection for healthcare in areas of conflict.

© 2011 Elsevier Ireland Ltd. All rights reserved.

Families internally displaced by conflict in Pakistan June 2009.

1. Introduction

"I tell you, you cannot feel the pain of this suffering if you don't see it physically. If you only glance at it, a sword of sorrow will pierce your heart... What on earth is it that man today does not care for his fellow humans?"

☆ "War. is when some adults who don't know what good is and what love is, are throwing dangerous war toys which injure innocent people" Tamara aged 10 years during the war in Bosnia and Herzegovena.

* Tel.: +44 7710674003(Mobile), +44 115 950 6662; fax: +44 115 950 7733. E-mail address: davids@doctors.org.uk. URL: http://www.mcai.org.uk.

0378-3782/$ - see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.earlhumdev.2011.08.020

—Ugandan schoolgirl who escaped abduction by the Lord's Resistance Army [1].

"Wars have always victimised children and other non-combatants, but modern wars are exploiting, maiming and killing children more callously than ever". Graca Machel 2000 [1].

For certain, we should add to the second statement above the effects of armed conflict on pregnant women and girls.

This article addresses armed conflict as a public health challenge and looks to ways in which health professionals can try and influence its prevention in a similar way to malaria, HIV, pneumonia and road accidents. In many respects, armed conflict is more serious than these other disasters and yet has received relatively little input from health professionals. The key is advocacy based on an understanding of the complexity of the problem.

Most deaths of women, babies and children are not from the direct effects of weapons but are due to preventable illness, malnutrition and lack of care for the complications of pregnancy and delivery [2]. During and for long after conflicts have ended, the main consequences of conflict on the family are: fear, flight for survival internally or to another country, loss of home, death of relatives (particularly for infants and children the loss of parents), damaged/targeted/absent healthcare, absence of skilled birth attendants, no functioning health facilities and no essential medicines. As if this was not enough, there is horrific brutality including physical and sexual violence to both sexes and all age groups (including infants) with death, permanent morbidity, HIV and family rejection. Women and girls are vulnerable to sexual violence, trafficking and mutilation, whether at home, in flight, or in camps. The trauma for female victims of violence continues even when the conflict is over, as they are frequently shunned, ostracized and further stigmatized. To help with this the UN Security

Council in 2000 adopted its first resolution on women, peace and security calling for the prosecution of crimes against women, increased protection of women and girls during war, and ensuring that more women participate in decision-making in conflict resolution and peace processes [3]. There is also the continuing problem of child soldiers, both boys and girls [4] and the trafficking of women and children during and after conflict [5].

Two stories illustrate the devastating consequences of armed conflict when it occurs in countries where existing extreme poverty and lack of protective policing for the community enable extreme abuse.

1. In Somalia during last month of pregnancy and knowing the very dangerous nature of pregnancy and birth an event is held at each pregnant mother's home attended by elderly mothers in the community. Women share food, drinks and sweets and sing traditional songs with religious connotations, praying for the safety of the women and the new born baby during the remainder of the pregnancy, delivery and post-partum period.

2. In Darfur, Sudan a doctor witnessed militia "surrounding a girls' school and holding over 40 girls, as young as eight, and their teachers in a primary school, and, while the army stood guard, the militia repeatedly gang-raped the girls". A film accompanying this report describes how the fetuses of pregnant women were ripped out by armed gangs and the newborn girls raped before being killed [6].

The following statement by UN Office for the Coordination of Humanitarian Affairs (UNOCHA) in 2011 sums up the problem: "Grave violations of international humanitarian and human rights law and blatant disrespect for the normative framework of humanity that has emerged over the past 50 years is common to many of these conflicts. Civilians have become the primary target of attack motivated by ethnic or religious hatred, political confrontation or simply ruthless pursuit of economic interests" [7].

2. Definitions of armed conflict

WHO defines violence as: "The intentional use of physical force or power-threatened or actual-against oneself, another person or against a group or community that results in or has the likelihood to result in injury or death, psychological harm, mal-development or deprivation" [8]. Armed conflict is an extreme form of this.

According to the Uppsala University Conflict Data Program (UCDP) [9] a state based armed conflict is "a contested incompatibility that concerns government and/or territory where the use of armed force between two parties, of which at least one is the government of a state, results in at least 25 battle-related deaths in one calendar year". Incompatibility can exist either over Government or Territory.

A non-state conflict is "the use of armed force between two organised armed groups, neither of which is the Government of a state, which results in at least 25 battle-related deaths in a year".

Finally the UCDP defines a 3rd category "one-sided violence" as the use of armed force by the government of a state or by a formally organised group against civilians which results in at least 25 deaths in a year.

A war is an armed conflict where there are > 1000 battle related deaths in any one year.

The database accepts that many more deaths occur than are documented either as battle-based or indirectly.

3. State based armed conflicts between 1990 and 2010

The Uppsala University Conflict Data Program (UCDP) database [9] was used to undertake the following analyses.

Between 1990 and 2010 state based armed conflicts occurred in 72 of the 196 countries in the world (37%) see Table 1.

4. Health and poverty related indices in the 72 countries where armed conflicts occurred between 1990 and 2010 (Table 1)

This analysis was undertaken using the database within the State of the World's Children report by UNICEF 2011 [10].

37 (51%) of these 72 countries had under 5 year mortality rates

> 100/1000 live births (10%) and 23 (32%) had infant mortality rates

> 10%.

25 (35%) countries had a Gross National Income (GNI) <995 US$ in 2009 (defined as low income countries).

39 (54%) countries had maternal mortality ratios >200/100,000 live births with 22 > 500 and 4 > 1000/100,000 live births.

5. Armed conflicts active/ongoing in 2010

26 countries were involved in state based conflict in 2010: 4 classified as wars (Somalia, Iraq, Afghanistan and Pakistan) and 22 others (USA, Colombia, Peru, Mauritania, Algeria, Chad, Sudan, Ethiopia, Russia, Yemen, Israel, Occupied Palestinian territories, Turkey, Iran, Tajikistan, India, Myanmar, Thailand, Philippines, Central African Republic, Uganda, Rwanda).

Non-state conflicts occurred in 8 countries in 2010 and these concerned religious, tribal or ethnic conflicts and conflict between drug trafficking gangs (Mexico, Nigeria, Sudan, Somalia, Yemen, Kyrgyzstan, Pakistan and Afghanistan).

One sided violence occurred in 13 countries in 2010 (Mexico — criminal gangs, Colombia — paramilitary (eg AUC) and guerrilla groups eg FARC and ELN, Myanmar-government, Russia, Afghanistan, Pakistan, India, Somalia, Democratic Republic of the Congo, Uganda (e.g. the Lord's Resistance Army), Rwanda, Iraq and Thailand).

Table 2a summarises the maternal and child health indices and the duration of the 26 state-based armed conflicts that were continuing in 2010.

Table 2b summarises the additional non-state based and onesided violent conflicts that were continuing in 2010 and some of the maternal and child health indices of these countries

6. Major consequences of armed conflict on families and in particular on maternal, infant and child health

Maternal and child mortality is much higher in conflict [11] and post-conflict countries than in countries exporting arms (see Tables 2a, 2b, 3-5). Mortality is a combination of direct deaths (that is they were killed) and indirect deaths from illnesses or the complications of pregnancy which cannot be properly treated because of conflict. In 9 African conflicts indirect deaths were 14 times greater than those occurring in combat. [2,12]. In poorly resourced countries, a combination of existing health system failure and conflict are responsible for deaths. However, there are far more terrible consequences than death.

Girls and women are particularly at risk as they are less likely to be able to protect themselves from violence. Rape is used as a weapon of war [13]. In addition to the psychological effects in women who have been sexually assaulted, they are at risk of serious infection, such as HIV and hepatitis, the possibility of pregnancy that may result in miscarriage and heavy blood loss which, in the absence of blood transfusion or basic surgery, can be life threatening. There is also a high prevalence of septic abortion following self or non-professional attempts to end the pregnancy.

"I've seen people get their hands cut off, a ten-year old girl raped and then die, and so many men and women burned alive... So many times I just cried inside my heart because I didn't dare cry out loud," said a 14 year-old girl, abducted in January 2000 by the Revolutionary United Front, an armed group in Sierra Leone [14].

Table 1

Countries in conflict since 1990-2010.

Table 1 (continued)

Country Under 5 year Infant mortality / Maternal GNI 2009

mortality / 1000 live mortality / US$/person

1000 live births 100,000

births 1990-2009 live births

1990-2009 2008 adjusted

Iran 73-31 55-26 30 4530

Philippines 59-33 41-26 94 1790

India 118-66n 84-50 230 x 1170

Pakistan 130-87 n 101-71 260 x 1020

Myanmar 118-71 n 84-54 240 x < 995 w

Yemen 125-66 n 88-51 210 x 1060

Guatemala 76-40 57-33 110 2630

Israel 11-4 10-3 7 25 740

Occupied 43-30 35-25 - 996-3945

Palestinian

territories

Iraq 53-44 42-35 75 2210

Lebanon 40-12 33-11 26 7970

Laos 157-59 n 108-46 580 xx 880 w

Ethiopia 210-104n 124-67 470 x 330 w

Nepal 142-48 n 39-27 380 x 440 w

Eritrea 150-55 n 92-39 280 x 300 w

DRC 199-199 n 126-126 670 xx 160 w

Burundi 189-166 n 114-101 970 xx 150 w

Chad 201-209 n 120-124 1200 xxx 620 w

Colombia 35-19 28-16 85 4950

Peru 78-21 62-19 98 4160

Nigeria 212-138n 126-86 840 xx 1140

Cambodia 117-88n 85-68 290 x 650 w

Guinea 231-142 n 137-88 680 xx 370 w

Sudan 124-108 n 78-69 750 xx 1230

Sri-Lanka 28-15 23-13 39 1990

Uganda 184-128 n 111-79 430 x 460 w

UK 10-6 8-5 12 41 520

El-Salvador 62-17 48-15 110 3370

Bangladesh 148-52 n 102-41 340 x 590 w

Angola 258-161 n 153-98 610 xx 3490

Indonesia 86-39 56-30 240 x 2230

Mozambique 232-142 n 155-96 550 xx 440 w

Afghanistan 250-199 n 167-134 1400 xxx 370 w

Nicaragua 68-26 52-22 100 1010

Somalia 180-180 n 109-109 1200 xxx <995 w

Liberia 247-112n 165-80 990 xx 160 w

Spain 9-4 8-4 6 31 870

Turkey 84-20 69-19 23 8730

Papua New 91-68 67-52 250 x 1180

Guinea

Kuwait 17-10 14-8 9 43 930

Mali 250-191 n 139-101 830 xx 680 w

Niger 305-160 n 144-76 820 xx 340 w

Rwanda 171-111 n 103-70 540 xx 460 w

Senegal 151-93 n 73-51 410 x 1040

Russia 27-12 23-11 39 9370

Trinidad and 34-35 30-31 55 16 560

Tobago

Djibouti 123-94n 95-75 300 x 1280

Georgia 47-29 41-26 48 2530

Haiti 152-87 n 105-64 300 x -

Sierra Leone 285-192 n 166-123 970 xx 340 w

Serbia 29-7 25-6 8 5990

Algeria 61-32 51-29 120 4420

Azerbaijan 98-34 78-30 38 4840

Bosnia 23-14 21-13 9 4700

Croatia 13-5 11-5 14 13 810

Egypt 90-21 66-18 82 2070

Moldova 37-17 30-15 32 1590

Tajikistan 117-61 n 91-52 64 700 w

Mexico 45-17 36-15 85 8960

Ecuador 53-24 41-20 140 3940

Cameroon 148-154n 91-95 600 xx 1170

Comoros 128-104n 90-75 340 x 870 w

Congo 104-128 n 67-81 580 xx 1830

Guinea-Bissau 240-193 n 142-115 1000 xxx 510 w

Lesotho 93-84 74-61 530 xx 1020

Uzbekistan 74-36 61-32 30 1100

Country Under 5 year Infant mortality / Maternal GNI 2009

mortality / 1000 live mortality / US$/person

1000 live births 100,000

births 1990-2009 live births

1990-2009 2008 adjusted

Central African 175-171 n 115-112 850 xx 450 w

Republic

Macedonia 36-11 32-10 9 4400

USA 11-8 9-7 24 47 240

Cote d'Ivoire 152-119 n 105-83 470 x 1060

Thailand 32-14 27-12 48 3760

Mauritania 129-117 n 4 781 550 xx 960 w

KEY Data from State of the World's Children 2011.

n = Under 5 year mortality > 100/1000 live births at any stage during the conflict. x = MMR>200; xx = MMR >500; xxx = MMR> 1000 deaths per 100,000 live births. w = GNI < 995 US$ /person = low income country.

The Maternal Mortality ratio used represents the 2008 UN interagency estimates (WHO, UNICEF, UNFPA and World Bank) released in 2010. This figure is reached by trying to compensate for under-reporting and misclassification as well as estimates for countries without data.

Gross national income (GNI) is the sum of value added by all resident producers, plus any product taxes (less subsidies) not included in the valuation of output, plus net receipts of primary income (compensation of employees and property income) from abroad. GNI per capita is gross national income divided by midyear population. GNI per capita in US dollars is converted using the World Bank Atlas method.

The indirect effects of armed conflicts cause most fatalities in mothers and children and include: food deprivation, spread of disease, in part due to disruption of public health systems, psychological and emotional damage (two thirds of Angolan children living through that conflict had witnessed murder [1]), disability, separation of families (in 1995, 20% of Angolan children were separated from their families [1]), loss of education, sexual abuse, including deliberate rape to drive out ethnic minorities, abduction, torture, and slavery, to become Child Soldiers. Children were actively involved in armed conflict in government forces or non-state armed groups in 20 countries between April 2004 and October 2007. These were: Afghanistan, Burundi, Central African Republic, Chad, Colombia, Côte d'Ivoire, the DRC, India, Indonesia, Iraq, Israel, the Occupied Palestinian Territories, Myanmar, Nepal, Philippines, Somalia, Sri Lanka, Sudan, Thailand and Uganda [15].

Conceptions continue during conflict and, with the absence of contraception and the pressures on women to support often highly disturbed young men, the rate of pregnancy often rises. Women who are pregnant are subject to potentially life-threatening complications which cannot be placed on hold until the conflict has finished. Most pregnancy-related emergencies can only be treated within hospitals and, apart from the fact that hospitals may have been incapacitated; there is also the great risk of travelling to hospital for treatment. The absence of functioning hospitals leads to many maternal deaths and results in permanent disabilities from untreated complications of pregnancy such as vesico-vaginal fistulae.

Infants and young children, because of their immaturity and dependency on mothers, are most vulnerable to malnutrition and infections such as gastroenteritis, pneumonia, malaria, tetanus, pertussis and meningitis. There are an estimated 45,000 deaths per month due to readily treated illnesses in the Democratic Republic of the Congo (DRC) [16]. A lack of immunisation in Afghanistan and Pakistan is leading to cases of polio.

When food is scarce because of conflict, it is usually women and children who are least able to access adequate or appropriate nutrition. Whilst primary healthcare can do much to prevent these infections through immunisation and early recognition and treatment, inevitably there will be around 20% of children who, when ill, will require hospital/health facility levels of care.

Emergency care and surgical services to manage obstetric complications, major trauma from violence and from accidents, and other

Table 2a

Maternal and child healthcare Indicators from UNICEF's State of the World's Children 2011 for the 26 countries where there was ongoing state based armed conflict in 2010 in descending order of Under 5 year mortality rates.

Country U5MR/ IMR/ NMR/ MMR GNI (gross Onset of

1000 1000 1000 deaths/ national conflict

live live live year / income) US $ in this

births births births 100,000 live births per person / year country

Chad 209 124 45 1200 620 1966

Afghanistan 199 134 52 1400 370 1978

Somalia 180 109 52 1200 (< 995) 1982

Central 171 112 45 850 450 2001

African

Republic

Uganda 128 79 30 430 460 1971

Mauritania 117 74 41 550 960 2008

Rwanda 111 70 33 540 460 1990

Sudan 108 69 36 750 1230 1971

Ethiopia 104 67 36 470 330 1964

Pakistan 87 71 42 260 1020 1990

Myanmar 71 54 33 240 <995 1948

India 66 50 34 230 1170 1948

Yemen 66 51 29 210 1060 1948

Tajikistan 61 52 24 64 700 2005

Iraq 44 35 23 75 2210 1958

Philippines 33 26 15 94 1790 1946

Algeria 32 29 17 120 4420 1991

Iran 31 26 17 30 4530 1972

Occupied 30 25 NR NR 996-3945 1948

Palestinian

territories

Peru 21 19 11 98 4160 1965

Turkey 20 19 12 23 8730 1983

Colombia 19 16 12 85 4950 1964

Thailand 14 12 8 48 3760 1965

Russia 12 11 6 39 9370 2007

USA 8 7 4 24 47 240 2001

Israel 4 3 2 7 25 740 1948

surgical emergencies are essential requirements for conflict-affected populations. This is particularly the case for conflicts in Africa, where essential surgical services are usually poor or absent before the conflict [17]. In one report, there were no operating theatres in 7 post-conflict camps for displaced populations [18].

Table 2b

Additional countries where the armed conflict in 2010 was non-state based or one sided violence and not covered in Table 2a.

Country U5MR/ IMR/ NMR/ MMR deaths/ GNI (gross national

1000 1000 1000 year /100,000 income) US $ per

live live live live births person /year

births births births

DRC 199 126 52 670 160

Nigeria 138 86 39 840 1140

Kyrgyzstan 37 32 17 81 870

Mexico 17 15 7 85 8960

U5MR = under 5 year mortality rate. IMR = infant mortality rate. NMR=neonatal mortality rate. MMR=maternal mortality ratio (2008 data).

NR = not recorded The Maternal Mortality ratio used represents the 2008 UN interagency estimates (WHO, UNICEF, UNFPA and World Bank) released in 2010. This figure is reached by trying to compensate for under-reporting and misclassification as well as estimates for countries without data.

Gross national income (GNI) is the sum of value added by all resident producers, plus any product taxes (less subsidies) not included in the valuation of output, plus net receipts of primary income (compensation of employees and property income) from abroad. GNI per capita is gross national income divided by midyear population. GNI per capita in US dollars is converted using the World Bank Atlas method.

In June 2011, the UN High Commission for Refugees (UNHCR) reported on World Refugee Day that the number of people forcibly displaced worldwide had reached 43.7 million, the highest number for 15 years [19].

Two thirds of those forcibly uprooted by conflict and fleeing for their lives are classified as being internally displaced. In 2010 27.5 million people were reported by The Internal Displacement Monitoring Centre in Geneva (IDMC) [20] as being internally displaced (so called IDPs). The countries with the largest numbers were Sudan and Colombia. In Africa in 2010, 10.7 million were reported to have been displaced in 14 countries (7 additional African countries had undetermined numbers). Unlike refugees (see below), persons individually displaced are not protected by international law and often not protected by the governments of their country who may well have initiated the flight from their homes (for example in the Sri Lankan war in 2008-9).

In June 2011, UNHCR reported that there were 10.5 million persons who had fled their country because of conflict (living as refugees) and an additional 4.7 million inhabiting camps in the Middle East. 23% of refugees are based in Africa and 54% in Asia [19].

Those families living as refugees, especially during the early part of their arrival in a foreign country, are subject to high levels of malnutrition and healthcare problems. This is particularly the case for those fleeing within Africa, where the country of refuge is often very poorly resourced with limited healthcare for its own citizens.

In 2010 the UN Security Council adopted Resolution 1894 expressing deep regret over the toll on civilians in armed conflict, reaffirming readiness to respond to their deliberate targeting and demanding strict compliance with international humanitarian, human rights and refugee law[21]. This was followed (22nd November 2010) by the Emergency Relief Coordinator for UNOCHA and Under Secretary General for Humanitarian Affairs at the UN, Baroness Amos, who said "The Secretary-General's report paints a very bleak picture of the state of the protection of civilians. Any positive and encouraging developments are heavily outweighed by what is happening on the ground: the continuing and frequent failure of parties to conflict to observe their international legal obligations to protect civilians. Complementary to this is the failure of national authorities and the international community more broadly to ensure their accountability in any meaningful, comprehensive and systematic sense" [22].

7. The effects of armed conflict on health care delivery

Increasingly, warring factions are targeting patients through attacks on healthcare professionals, health facilities, and medical transport vehicles, including ambulances and those supplying essential life-saving drugs and medical supplies. Such actions are "part of generalised violence directed towards civilians to achieve a political goal-e.g., ethnic cleansing, government destabilisation, control or forced movements of populations, or demoralisation of a population sympathetic to an enemy" [23,24]. In addition, some attacks on health facilities, health professionals or patients are designed for military advantage, such as preventing injured combatants from receiving healthcare.

In violation of humanitarian law, in particular the Geneva Conventions and their Additional Protocols [25], warring factions attack wounded or sick individuals, threaten, intimidate and attack nurses and doctors, attack health facilities, especially hospitals, attack ambulances transporting sick or injured patients and illegally use health facilities for exacerbating conflict.

In some conflict zones, it is impossible for local staff or incoming international organisations to provide healthcare because healthcare is not only unprotected from conflict, but is also specifically and explicitly targeted. An example of this illegal situation is the "corridor" outside Mogadishu in Somalia [26] where approximately 150,000 civilians are unable to access any healthcare.

Health care workers have been subjected to harassment, arrest imprisonment and even death for complying with their ethical duty

to provide healthcare, irrespective of the political, religious or other affiliation or allegiance of their patients.

A recent study by the International Committee of the Red Cross (ICRC) (August 2011) [27] examined 655 reports of violent incidents involving healthcare delivery in 16 countries. 33% of violations were undertaken by State armed forces, 37% by armed groups, 7% by police and 17% by other individuals. 23% involved explosive weapons, 34% firearms, 4% other weapons 4% and in 9% no weapons were used but heath workers were threatened by mail or telephone.

This ICRC study showed targeting of International NGOs in 35%, local health care services 26%, Red Cross/Crescent services in 17%, local NGOs in 7%, individuals transporting wounded or sick in 4%, UN Agency 3% and healthcare provided by State armed forces in 2%.

The 655 events targeting healthcare impacted on 2374 people. 733 persons were killed and 1101 injured. 166 health workers were kidnapped. 111 patients were denied access to health facilities and 18 removed from health care. 188 were threatened and 93 arrested. Denial of access to healthcare was made by State armed forces in 59%, by the police in 24%, by non-state armed groups in 10% and by others in 5%.

Two particularly shocking examples of this targeting were given in an accompanying ICRC report [28]. In 1996 six nurses employed by the ICRC working in a hospital in Chechnya were killed by gunmen. This resulted in a hospital treating 6000 patients per year being closed. In 2009 a graduation ceremony for newly qualified medical students in Mogadishu, Somalia was blown up by a bomb. Two doctors and an unknown number of medical students were killed and many more seriously injured.

Targeting of hospitals during armed conflict is sometimes accidental, but there is evidence of deliberate targeting in most cases. Some attacks are designed to drive away health workers, to steal drugs and other materials and to commandeer vehicles.

Attacks on and delays created for vehicles taking patients to hospital (ambulances and other vehicles) were common and resulted in many deaths and much suffering.

As a result of this report the ICRC emphasises that the primary responsibility for safeguarding healthcare lies with politicians and combatants. However, to increase awareness of violations of the Geneva Conventions and to generate action, the ICRC is seeking support for 10 initiatives: 1. building a community of concern 2. regular and methodical information gathering 3. consolidating and improving field practices 4. ensuring physical protection of health care facilities-spe-cifically, hospitals and other health-care facilities in countries affected by armed conflict or other violence- will be assisted in organizing the physical protection of the premises and in developing procedures for notifying others of their location and of the movements of their vehicles. 5. facilitating safer access for Red Cross and Red Crescent staff and volunteers 6. engaging with States 7. engaging with national armed forces 8. engaging with non-State armed groups 9. engaging with professional health-care institutions and health ministries 10. encouraging interest in academic circles.

On June 12th 2011, a further helpful development targeting those who attack healthcare was a resolution adopted by the UN Security Council (number 1998) [29]. This added recurrent attacks on schools and hospitals to the violations that may subject an entity to the listing and "naming and shaming" requirements as part of the mechanisms to protect children in armed conflict. Under the resolution, the procedure may be triggered not only by recurrent attacks against facilities but by recurrent attacks or threats against "protected persons," which under international humanitarian law include civilians not taking part in hostilities and medical personnel.

8. The trade in arms (killing machines)

Without weapons violence can continue. However, the adverse consequences for healthcare would be massively reduced. Since 1995 it has become apparent that what have been called Small

Arms and Light Weapons (SALW) are the main causes of civilian deaths in areas of armed conflict.

Small arms include revolvers, self-loading pistols, rifles, submachine-guns, assault rifles and light machine-guns. Light weapons are heavy machine-guns, mortars, hand grenades and their launchers, portable anti-aircraft and anti tank guns and portable missile launchers. Both categories are designed for use by armed forces, but are attractive to those involved in irregular warfare, terrorism and criminal activity. They have been classified as the weapon most harmful to those affected by poverty. Their low cost makes them affordable, their size makes them easy to carry and conceal. They are easy to maintain. The Kalashnikov rifle, which is the most deadly and widely used, can be bought for a bag of maize or $10. It is easy to learn how to use them and their small size makes them ideal for use by child soldiers. They are easy to transport, smuggle and hide and are not included in the UN register of conventional arms. They are particularly dangerous to staff delivering humanitarian assistance.

According to one study small arms and light weapons were the only arms used in 46 of 49 conflicts since 1990, particularly in Africa [30].

A paper in 2007 by IANSA, Oxfam and Saferworld reported that armed conflict costs Africa around 18 billion US$ per year [31]. The vast majority of the weapons and ammunition for conflicts in Africa originates from outside the continent.

To analyse the effects of the trade in SALW on the health of and healthcare for women and girls who are pregnant, infants and children, this paper has analysed the exports of such weapons (and thus their primary manufacture) in 2009 and examined the relationship between the maternal and child health indices of the countries using such weapons to wage conflict and those of the countries who supply them. These data were provided from the Norwegian Initiative on Small Arms Transfer database [32].

Table 3 lists the 14 countries who exported the most SALW in 2009. Only those countries exporting more than 100 million US$ worth of arms are listed. Most are very rich countries with extremely low infant, child and maternal mortality rates compared with countries affected by armed conflict.

Tables 4 and 5 compare essential health indicators between these 14 arms exporting countries and the 9 of the 29 (26 state based) countries where there was active armed conflict in 2010 which had under 5 year mortality rates exceeding 10%. Table 4 scales each of the arms exporting and conflict countries to have a population of 50 million. The Tables show the inhuman and unethical disparity between the two groups.

Additional issues concerning the arms trade relate to the way in which conflicts are deliberately started or maintained in order to trade weapons for a country's wealth. Examples include the diamond trade which gained so much from the wars in Sierra Leone and Angola. Other concerns relate to weapons being sold to both sides in a conflict. For example, Pakistan spends < 1% of its GDP on healthcare and yet in a cold war situation with India (including the threat of nuclear war), the UK, USA, Russia Germany and Canada provide both sides with SALW and heavy weapons.

It has been estimated that more than half of the trade in SALW is illegal and therefore very difficult to control. This has to be admitted, but without their initial manufacture there could not be an illegal trade.

9. Based on the above analysis what can health professionals do to help protect healthcare from armed conflict?

This paper proposes two approaches.

10. Advocacy for better protection for healthcare, if necessary involving the adoption of greater force than the agents of the conflict

In 2001 the UN Secretary General Kofi Annan called for a "culture of protection". He went on to say: "In such a culture, Governments

Table 3

Top 14 countries exporting small arms and light weapons SALW of > 100,000,000 US$ in value in 2009 excluding shotguns, hunting rifles and their ammunition.

Country Total exports Global rank Under 5 year Maternal GNI

in US $ in in U5MR mortality Mortality (gross

2009 to all rate -U5MR Ratio national

countries (deaths/1000 Deaths/ income)

live births/ 100,000 US $ per

year) live births / year

USA 3,195,287,000 149 8 24 47,240

Bulgaria 820,437,000 144 10 13 5770

UK 686,874,000a 157 6 12 41,520

Norway 495,126,000 184 3 7 86,440

France 300,581,000 169 4 8 43,990

Switzerland 292,445,000 169 4 10 56,370x

Germany 258,360,000 169 4 7 42,560

Israel 251,411,000 169 4 7 25,740

Italy 239,652,000 169 4 5 35,080

Japan 179,199,000 184 3 6 37,870

Hungary 150,505,000 157 6 13 12,980

Romania 146,960,000 130 12 27 8330

Sweden 127,869,000 184 3 5 48,930

Canada 120,258,000 157 6 12 42,170

The Maternal Mortality ratio used represents the 2008 UN interagency estimates (WHO, UNICEF, UNFPA and World Bank) released in 2010. This figure is reached by trying to compensate for under-reporting and misclassification as well as estimates for countries without data.

Gross national income (GNI) is the sum of value added by all resident producers, plus any product taxes (less subsidies) not included in the valuation of output, plus net receipts of primary income (compensation of employees and property income) from abroad. GNI per capita is gross national income divided by midyear population. GNI per capita in US dollars is converted using the World Bank Atlas method.

a On examining data base for notifications of exports of SALW to "all countries" the figure was much lower. This is the mirror figure obtained by examining each individual country's imports of arms from the UK. Other countries' declarations of "exports to" and "receipts from" broadly tally.

would live up to their responsibilities, armed groups would respect the recognized rules of international humanitarian law, the private sector would be conscious of the impact of its engagement in crisis

areas, and Member States and international organizations would display the necessary commitment to ensure decisive and rapid action in the face of crisis. The establishment of this culture will depend on the willingness of Member States not only to adopt some of the measures (outlined in the report) but also to deal with the reality of armed groups and other non-state actors in conflicts, and the role of civil society in moving from vulnerability to security and from war to peace" [7].

He also stated: "As human beings, we cannot be neutral, or at least have no right to be, when other human beings are suffering. Each of us...must do what he or she can to help those in need, even though it would be much safer and more comfortable to do nothing" [7]

To this end, the UN Secretary General identified five core challenges in his report to the Security Council in 2000 [14]:

• Enhancing compliance of parties to the conflict with their obligations under international law, in particular the conduct of hostilities

• Engagement with non-state armed groups

• Protecting civilians through UN peacekeeping and other relevant missions

• Humanitarian access

• Enhancing accountability for violations

In May 2010 at the 10th anniversary of Optional Protocols to the Convention on the Rights of the Child, the UN and UNICEF urged all countries to adopt measures protecting children from violence, exploitation and abuse with particular reference to armed conflict. [33]

However, and in reality, the governments of some countries (for example the army of Sri Lanka in 2009 [34]) and armed groups (comprised of high proportions of psychopathic young men, influenced by religious extremism, alcohol or drugs) are unwilling to concern themselves with the Geneva conventions and other international laws. Not only the civilians of a country or region but also international humanitarian personnel trying to provide healthcare, often without any military protection, are in great danger.

As stated by Rubenstein and Bittle [35]: "The medical community has a responsibility to speak out collectively to protect health workers

Table4

Comparison between the countries with the highest under 5 year mortality rates where there was armed conflict in 2010 compared to the 14 countries exporting small arms and light weapons (SALW) of > 100,000,000 US$ in value in 2009 ranked in order of size of their sales. For purposes of comparison, each country has been scaled to have a population of 50 million.

Country Under 5 year mortality Maternal mortality ratio / N under 5 deaths per yr/ N. Infant deaths/yr/50 N. neonatal deaths/yr/50 N. Maternal deaths/yr/50 rate/1000 live births 100,000 live births 50 million population million population million population million population

Countries where armed conflict 2010

Chad 209 1200 473,803 281,108 102,015 27,204

Afghanistan 199 1400 460,088 309,808 120,224 32,368

DRC 199 670 441,581 279,594 115,388 14,867

Somalia 180 1200 396,180 239,909 114,452 26,412

CAR 171 850 297,711 194,992 78,345 14,799

Uganda 128 430 293,888 181,384 68,880 9,873

Mauritania 117 550 193,752 122,544 67,896 9,108

Rwanda 111 540 229,215 144,550 68,145 11,151

Ethiopia 104 470 196,664 126,697 68,076 8,888

Countries exporting small arms and light weapons in 2009

USA 8 24 5608 4907 2804 168

Bulgaria 10 13 4830 3864 2415 63

UK 6 12 3648 3040 1824 73

Norway 3 7 1809 1809 1206 42

France 4 8 2388 1791 1194 47

Switzerland 4 10 1928 1928 1446 48

Germany 4 7 1604 1604 1203 28

Israel 4 7 3904 2928 1952 68

Italy 4 5 1812 1359 906 23

Japan 3 6 1197 798 399 24

Hungary 6 13 2970 2475 1980 64

Romania 12 27 5976 4980 2988 134

Sweden 3 5 1749 1166 1166 29

Canada 6 12 3198 2665 2132 64

Table5

Comparison between the countries with the highest under 5 year mortality rates where there was armed conflict in 2010 compared to the 14 countries exporting small arms and light weapons (SALW) of > 100,000,000 US$ in value in 2009 ranked in order of size of their sales (USA the highest).

Country % Low birth wt < 2.5 kg 2005-2009 % under-wt below — 2 SD from median 2005-2009 % infants 3 doses DPT 2009 % pop. below international poverty line of 1.25 US$/day % government spending on health 1998-2008 % Skilled attendant at birth % Institutional delivery

Countries where armed conflict 2010

Chad 22 37 23 62 8 14 13

Afghanistan - 39 83 - - 14 13

DRC 10 31 77 59 0 74 70

Somalia - 36 31 - 1 33 9

CAR 13 29 54 62 - 44 56

Uganda 14 20 64 52 2 42 41

Mauritania 34 20 64 21 4 61 48

Rwanda 6 23 97 77 5 52 45

Ethiopia 20 38 79 39 1 6 5

Countries exporting small arms and light weapons 2009

USA 8 2 95 - 24 99 -

Bulgaria 9 - 94 < 2 11 100 100

UK 8 - 93 - 15 99 -

Norway 5 - 92 - 16 - -

France 7 - 99 - 16 99 -

Switzerland 6 - 95 - 0 - -

Germany 7 - 93 - 20 - -

Israel 8 - 93 - 13 - -

Italy 6 - 96 - 14 - -

Japan 8 - 98 - 2 100 -

Hungary 9 - 99 <2 11 100 -

Romania 8 3 97 <2 12 99 98

Sweden 4 - 98 - 4 - -

Canada 6 - 80 - 9 98 -

DRC = Democratic Republic of the Congo. CAR = Central African Republic. - data not recorded.

in fulfilment of their ethical duties to the people in their care, without risk of arrest or attack on themselves or medical facilities. Governments and non-state actors should be held accountable for abiding by obligations to respect medical functions in war."

10.1. Existing attempts at protection

The expectation that countries or non-state factions involved in conflict will adhere to existing humanitarian laws, human rights law and medical ethics has proved to be invalid. The Geneva Conventions of 1949 and their additional protocols 1977 contain statements designed to protect healthcare [25]. However, as documented by Rubenstein and Bittle [35], these conventions were violated with impunity in most of the armed conflicts between 2003 and 2008. Recognising the challenges involved in providing robust information, regular and systematic documentation of attacks on health workers, facilities, transport and patients is lacking. International criminal justice institutions have potential power, but do not operate in the time frame necessary to protect healthcare during conflict.

UN or other legitimate forces that could provide true protection are difficult to fund, have been themselves involved in the abuses of women [36] and children [37], and have been inadequately mandated with regard to how far they can act in protecting civilians and their healthcare.

10.2. Proposal for an international health protection force

A resolution (The International Healthcare Protection Initiative [38]) addressing some of the measures that need to be undertaken to protect healthcare in zones of conflict is currently "live" for signatures from health workers and healthcare organisations. The reality, as we all understand, is that an armed force seeking to disrupt healthcare or any other aspect of human existence requires an equal or stronger force to protect patients, particularly women and children.

If we accept that all life is of equal value, it is therefore essential that an international protection force is developed. Just we as paediatricians accept that the police are sometimes needed to enforce the protection of children who are being abused from the abusers, so the world must accept that a similar system is required to protect unarmed patients requiring or receiving healthcare from armed organisations or individuals who are setting out to abuse them.

Probably the most serious current situation in the world in August 2011 regarding an absence of healthcare and extreme malnutrition is that of Somalia[39]. Without an effective health protection force mandated to properly protect by the UN or other legally supported organisation many hundreds of thousands of Somalis will die or be permanently damaged by the failure of healthcare and nutrition to reach civilians because of armed factions pursuing their political goals without concern.

11. Advocacy to support the current UN proposed Arms Trade Treaty (ATT)

There is currently no global agreement regulating the trade in conventional arms and most importantly its ammunition. In 2006, 153 countries agreed to develop an ATT [40]. This contains a set of Global Principles for Arms Transfers which states that no arms transfer must occur which are likely to be used to:

Commit serious violations of international humanitarian law the 'rules

of war'

Commit serious violations of international human rights law; or

Undermine sustainable development.

At a meeting on July 15,2011 the Control Arms coalition reported that there had been considerable progress in creating "a bullet-proof treaty that will prevent irresponsible arms transfers that fuel conflict, poverty and serious human rights abuses [41]." The Control

Arms coalition welcomed the backing of key countries affected by armed violence including from Latin America, the Caribbean, Africa and the Pacific region. During their meeting, the five Permanent Member States of the Security Council (United States, Russia, United Kingdom, France and China) who collectively account for 88% of the global arms trade, made a joint statement committing their collective support to the process.

Recently the Alliance of Liberals and Democrats for Europe [42] called on the European Union (a major source of the export of arms) to support the ATT and to "guarantee a more effective use of criterion 8 of the EU-Code of Conduct that takes greater account of the economic situation in the receiving country. This criterion should be redefined in such a way that Member States will only be able to permit a transfer of arms if it can be ensured that the transfer will not harm sustainable development and the applicant/recipient can identify a legitimate defence need for the specific transfer."

In conclusion this paper calls on all professionals concerned with maternal, infant and child healthcare to support the work of the UN and the Control Arms coalition to achieve an Arms Trade Treaty, currently on track for 2012, and to lobby for the development of adequate international protection for healthcare in countries affected by armed conflict.

Conflict of interest

I declare that I have no conflicts of interest in writing this paper. Acknowledgments

Drs Rhona MacDonald and Diane Watson provided invaluable help in the production of this paper. The databases of NISAT(Norwegian Initiative on Small Arms Transfers) and UCDP/PRIO (Uppsala Conflict Data Program and International Peace Research Institute, Oslo) provided essential up to date information for this paper. The UCDP/PRIO dataset used on armed conflict was version 4-2011 (1946-2010). Almut Gadow helped check the content of this report and made excellent suggestions on content.

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