A Scoping Review of the Wider and Long-Term Impacts of Attacks on

Healthcare in Conflict Zones

Mohammed Hassaan Afzal [corresponding author]

Humanitarian and Conflict Response Institute, University of Manchester, Manchester,

United Kingdom

hassaan.afzal@manchester.ac.uk

Mohammed Hassaan Afzal is an emergency medical doctor and research associate at HCRI

(University of Manchester). His research interests regard violence directed against healthcare in

conflict zones and what measures can be taken to reduce the risk and impact of attacks. 

Anisa Jafar

Humanitarian and Conflict Response Institute, University of Manchester, Manchester,

United Kingdom

anisa.jafar@manchester.ac.uk

Anisa Jafar is an emergency medicine trainee in the North West of England.  She is undertaking

a PhD at the HCRI (University of Manchester) focussing on medical documentation by

emergency medical teams in sudden onset disasters.

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A Scoping Review of the Wider and Long-Term Impacts of Attacks on

Healthcare in Conflict Zones

Attacks on healthcare in conflict zones are widespread and show no signs of

relenting. Since 2011 several organisations have systemically collected data of

these attacks and revealed their scale. However little is known of the

consequences of these attacks. The purpose of this scoping review was to explore

the literature on attacks on healthcare in conflict zones to understand what is

known of the wider and long-term impacts. Using the Arksey and O’Malley

framework we identified 233 articles for inclusion. Extracting descriptions of

impacts, we were able to categorise this information into 15 broad themes.

However, there are limitations in the data collection on impacts. Firstly it is not

systemically collected after every attack or in all regions where attacks take

place. Secondly, this data stops short in working down the chain of impacts to

describe the full range of consequences. Lastly, the literature does not often

distinguish between the impacts of attacks on healthcare and the impact of

conflict on health. Discussion is needed as to how we define and understand

attacks on healthcare and therefore the impacts of these attacks. Systematic

methods for data collection on impacts of attacks on healthcare are also needed to

produce comprehensive data sets.

Keywords: attacks on health, violence against health, impacts, consequences,

conflict zones

Introduction

Healthcare in conflict zones is under attack. In at least 23 countries experiencing

conflict or violent unrest, health workers, health facilities and patients are subject to

bombings, shootings, lootings, intimidation, assault, arrest, abduction, obstruction of

access to facilities, takeover by armed groups and the blockade of vital supplies (SHCC

2017). Despite the right to healthcare and protections offered to health workers and the

sick and injured under the Geneva Conventions, and the passing of UN Security

Council resolution 2286 calling for the respect of those engaged in medical duties (UN

Security Council 2016), attacks on healthcare in conflict zones continue unrestrained.

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The scale of the problem has been highlighted by a number of organisations

which have collected data from these attacks since 2011, including the International

Committee of the Red Cross’s (ICRC) ‘Healthcare in Danger Project’, the World Health

Organisation (WHO) and the Safeguarding Healthcare in Conflict Coalition (SHCC).

While these have provided some data on the immediate impacts, including the number

of attacks, deaths and injuries of health workers and patients, less clear are the long-

term consequences of these attacks. The WHO (2016a) has stated that documenting and

describing these consequences should be a priority for data collection.

Analysts have stressed how attacks on healthcare will destroy health systems,

degrade public health and harm the publics’ trust in health institutions (Bernard 2013).

But empirical data is needed to give weight to these claims. Furthermore, expanding the

evidence base to include all impacts will play a critical role in strengthening the call for

attacks to end; helping develop strategies to reduce the impact on healthcare delivery

(Rubenstein and Bittle 2010); and improving the security of impartial healthcare

delivery in conflict (Coupland 2013).

The aim of this scoping review is to explore what is known of the wider and

long-term impacts of attacks on healthcare.

Methodology

Why a scoping review?

Scoping reviews bring together evidence on a topic across a variety of study designs for

the purpose of informing future research, programmes and policy. (O’Brien et al. 2016).

The scoping review process is the most appropriate method to answer this study

question for the following reasons.

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Firstly, scoping reviews are particularly useful when analysing a body of

research that has not been extensively reviewed (Peters et al. 2015) as is the case with

the impacts of attacks on healthcare.

The second reason pertains to the diversity of literature within which the impacts

of attacks on healthcare can be found. Prior to starting this review, we carried out a pilot

search of the literature on the impacts of attacks on healthcare to understand the types of

media within which it is reported. The platforms in which impacts can be found are

wide-ranging; from mainstream and local press articles, to personal accounts from staff

of humanitarian and non-governmental organisations and, less frequently, in peer-

reviewed studies. Often data on impacts are not the primary purpose of the written

piece, but rather are embedded within the text. The spread and heterogeneity of the

literature and the lack of a clear focus on the impacts of attacks on healthcare does not

suit it to the precision of a systematic review, which tends to adopt precisely defined

questions and a narrow selection of appropriate study designs (Arksey and O'Malley

2005). Scoping reviews are most suited to addressing broader topics in which many

different study designs are applicable (ibid), making them ideal to examine the impacts

of attacks on healthcare.

Third, scoping reviews do not involve an assessment of the quality of included

studies and therefore allow for inclusion of a wider range of literature (Arksey and

O'Malley 2005, Pham et al. 2014). As our priority was ensuring comprehensive

coverage of available evidence on the topic, and not a particular standard of evidence,

this again made the scoping review a better fit.

Despite not involving all the stages of a systematic review, a scoping review still

adopts the same the rigour, transparency and replicability, and therefore there can be

confidence in the reliability of its findings (Mays, Roberts, and Popay 2001).

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The process

We used the 5 stages of the Arksey and O'Malley (2005) framework, considered the

best for conducting scoping reviews to date (Daudt, van Mossel, and Scott 2013). The

stages include:

(1) Identifying the research question

(2) Identifying relevant studies

(3) Study selection

(4) Charting the data

(5) Collating, summarising and reporting the results.

The Research Question

The question for this review was, ‘What information is being reported on the impacts of

attacks on healthcare in conflict zones?’

For the purposes of this review, we defined an impact as ‘the consequences, intended

or unintended, that can be directly attributed to an attack on health care as per the

WHO definition’. An attack on healthcare is defined by the WHO (2018a) as ‘any act

of verbal or physical violence or obstruction or threat of violence that interferes with

the availability, access and delivery of curative and/or preventive health services during

emergencies’.

Search Process

A literature search was performed between 1st January 2018 and 31st January 2018 for

studies, publications, reports, press releases, news bulletins and public statements from

online journal databases and the websites of non-government organisations (NGOs) and

human rights groups (see Appendix 1 for a full list of databases and organisations

searched and search terms used). No limits were set for date range to ensure reporting of

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impacts on attacks on healthcare from historical conflicts as well as modern.

Study Selection

We took a wide two-stage approach to the screening process so as to ensure all relevant

literature was included. The first stage involved screening the literature for reference to

attacks on healthcare using either the title, abstract, description of reports or

interrogation of the database (see Appendix 1 for the type of screening used for each

database). Eligible texts were then entered into the second stage of screening in which

the full texts were manually searched for documentation of the impacts of attacks on

healthcare. Impacts had to be addressed with empirical examples, namely observation,

experience or data of actual attacks. Any literature providing a generalised narrative of

impacts with no reference to empirical evidence was excluded from the review. The

attacks also had to occur in regions and at times when there was conflict, defined as

more than 25 battled-related deaths per year (Strand, Wilhelmsen, and Gleditsch 2003).

Lastly the literature had to be available in English.

Charting, Collating, Summarising and Reporting the Data

We used an analytical framework to extract and chart the data from the literature. This

framework should extract both general information about the study and information

specific to the research question (Daudt, van Mossel, and Scott 2013). We adapted the

framework below from Arksey and O'Malley (2005).

Organisation/body collecting the data

Date and location of data collection

Primary objectives (if stated)

Methods used (if stated)

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Subjects or objects targeted for data collection (i.e health professionals, health

facilities, public health records, secondary sources of data)

Documented impacts of attacks on healthcare

Extracted information was tabulated using Microsoft Word 2011. A thematic

framework was developed using the types of impacts as our ‘themes’. Arrangement of

data by theme created the template to present our findings.

Results

We identified 2639 records from searching of databases and 912 through the websites of

non-governmental organisations (NGOs). Following the screening process and removal

of duplicate reports or literature using duplicate data, 233 records met the criteria for

inclusion in this review (see Figure 1).

[Figure 1 here]

The impacts of attacks on healthcare have been categorised by the type of

impact and are presented as such below.

Suspension, closure and relocation of facilities

One of the more commonly reported impacts was the suspension or closure of

healthcare facilities and programmes. In South Sudan, as of December 2017, 20% of

health facilities have closed (OCHA 2017) and 50% function with extremely limited

capacity (Monaghan 2018). In early 2016, 40% of all healthcare facilities were closed in

Libya (SHCC 2016). In Yemen, as of January 2017, only 45% of facilities were

functioning (OCHA 2016c). Sometimes, these figures will include the size of the

population who were without care as a result of the closures. For example, in South

Sudan’s Upper Nile region, one million people were left with access to only one

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hospital (SHCC 2016).

Health facilities may also be forced to relocate their services to less than ideal

locations. In Syria, because formal health facilities have been regularly attacked,

medical workers have moved their services to schools, farms and even caves. They can

be cramped, poorly lit and poorly ventilated, presenting challenges for infection control.

This also redirects essential time and resources away from patient care into

reconstruction and reorganisation (Armstrong 2016).

Loss of healthcare workers

The loss of healthcare workers is also another commonly reported statistic. Libya has

lost 80% of its nurses (WHO 2016b), Ukraine has lost between 30-70% of its health

workers (WHO 2015b) and as of 2015 only two doctors remain in the whole of northern

Bono in Nigeria (MSF 2015a). It is not possible to say what proportion is due to deaths

and injuries, fleeing from the region or leaving the profession, but all three are used to

explain the losses. In Afghanistan, the shortage of female staff is especially problematic

as this has reduced the availability of healthcare for women; 2016 Ministry of Public

Health (MoPH) figures show less than a quarter of all doctors and nurses are women

(MoPH, WHO, and UNFPA 2016). The violence has compounded the challenges of

recruiting and retaining female medical staff in a country where women face societal

hurdles to participating in the labour force (Monaghan 2017a).

With a lack of appropriately qualified staff, facilities are relying on junior

doctors, medical students and volunteers. The shortages of specialist physicians and

surgeons are especially troublesome because their skills are hard to replace. As a result

doctors are forced to practice beyond their training (Rubenstein 2015, Baker and Heisler

2015, Monaghan 2017b). Although it is expected this will result in worse health

outcomes there is no data to confirm if this is the case.

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Médecins Sans Frontières (MSF) has also recounted the challenges in recruiting

international staff for its medical missions due to the risk of attack, especially

kidnapping. This significantly reduces their capacity to provide clinical and managerial

expertise (Armstrong 2016).

Most examples of reduced staff numbers focus on doctors with a handful

highlighting the lack of nurses. But there are few references to changes in the number of

auxiliary health staff or those in non-clinical roles.

Lack of essential materials

Reports from facilities in Yemen (MSF 2015b, Monaghan 2017b), Afghanistan

(Monaghan 2017a), Syria (Armstrong 2016) and Gaza (Bachmann et al. 2014) all state

shortages of pain medications, antibiotics, blood transfusion materials and surgical

equipment. There have been recorded cases of surgeons operating without anaesthetic

drugs (Defenders for Medical Impartiality 2016, Bachmann et al. 2014). Shortages can

occur due to damage from direct attacks, failed deliveries because of insecurity on the

roads, blockade of entry by warring parties, looting or the inability to procure due to

market scarcities. Doctors are treating trauma patients with only physical examination to

aid them because X-rays and CT scanners have been damaged, increasing the risk of

inaccurate treatment and complications (Armstrong 2016) though there no figures are

available to verify the degree to which this has happened.

The lack of electricity, clean water and fuel also affects the ability to deliver

healthcare. A recurrent theme in reports out of Syria and Yemen is the heavy reliance on

fuel, the shortage of which is causing facilities to shutdown or reduce their services

(Monaghan 2017b, MSF 2015b, 2017b, Rubenstein 2015). Ambulances have been

unable to collect emergency patients and doctors have resorted to using the torches on

their mobile phones as operating lamps during electricity outages (MSF 2015b). The

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lack of electricity also presents problems with storage: medications and vaccines that

require refrigerating deteriorate and have to be discarded (Baker and Heisler 2015).

Facilities that have their water supply disrupted struggle with infection control measures

and running equipment such as dialysis machines (Baker and Heisler 2015, Armstrong

2016).

Increased care demands

The violence itself creates increased demands for care, placing additional burdens on

facilities and their resources. For example, a field hospital in Idlib Syria saw an increase

in their daily caseload from 15 to 200-250 patients, though there is no reference to the

time period (Rubenstein 2015). Doctors are then forced to make difficult decisions

about who can be treated. One surgeon in Aleppo reported, “If an operation is likely to

take more than two hours, we have to forget it, and the patient dies.” (Ibid, p.7).

Hospitals in Gaza during the 2014 military offensive were ‘overwhelmed’ with the large

numbers of complex injuries. WHO staff found patients were not having their wounds

redressed and as a result maggots entered the wounds. Overcrowding resulted in early

discharge of patients to make way for new arrivals, and only the critically injured could

be admitted (Bachmann et al. 2014).

Reduced functioning capacity of facilities

As a result of the above, remaining facilities function at a reduced capacity. In addition

to the lack of specialists and diagnostic capabilities, there have also been accounts of

hospitals losing or shutting down intensive care units, laboratory services, blood

transfusion capabilities, dialysis services, surgical units and nutritional programmes.

Pharmacies lack essential medicines, and materials that are available are rationed

because it cannot be known when or if they will be replenished (MAP 2017, Monaghan

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2017a, b, MSF 2015b, 2017b, Rubenstein 2015, Baker and Heisler 2015).

There are a few examples where mortality or morbidity rates related to the

reduction in health services have been reported. MSF doctors in Taiz Yemen state that

212 war-wounded died in facilities where capacity was reduced (MSF 2015b). During

the August 2013 chemical attacks in Damascus a doctor stated 22 people died for lack

of equipment (Rubenstein 2015). And Iraqi doctors writing in the British Medical

Journal claim half of the civilians who died in their emergency departments could have

been saved if there were sufficient trained medical staff (Sheibani, Hadi, and Hasoon

2006).

Changes in practices of health workers/facilities

Health facilities under or at risk of attack have had to change the way they operate. In

Syria, because hospitals have been regularly targeted, doctors created a network of

underground field hospitals established in basements, farms, abandoned buildings,

mosques and factories. These field hospitals have become more sophisticated

throughout the conflict and can include emergency rooms, operating theatres and

intensive care units (Fallon and Kieval 2017). An estimated 270,000 lives have been

saved by Syria’s field hospitals (Sankari, Atassi, and Sahloul 2013).

MSF-supported facilities in Syria no longer share GPS coordinates with warring

parties as it is believed to increase the risk of direct targeting (MSF 2016). They also

manage facilities remotely using mobile technologies to decentralise care and reduce the

risk posed to their staff. They acknowledge this brings challenges in managing staff,

providing capacity building and understanding and responding to the conditions on the

ground (MSF 2017a).

Other changes to practices of health workers include medical workers living in

the hospitals as travel to work has become too risky (MSF 2017b), working longer shifts

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in order to compensate for the absence of staff (Rubenstein 2015), adapting treatment

and prescription plans to reduce the number of visits patients need to make to facilities

and shifting to home-based care (Armstrong 2016).

Consequences from the different forms of administrative and physical

obstruction

Obstruction can occur in various forms but all with negative consequences for the

delivery of healthcare. In Yemen the naval blockade and the closure of the airport by the

Saudi Arabia-led collation is one of the main contributing factors to the collapse of the

healthcare system. Yemen imported 90% of its medical supplies but the blockade

prevents these reaching hospitals (Monaghan 2017b). Unicef (2016) has said the decline

in health services caused an estimated additional 10000 deaths in children under 5 in the

past year. 90% of Yemen’s fuel is also imported. The destruction of power plants has

forced facilities to rely on generators, but the shortage of fuel means they cannot power

essential equipment such as ventilators and incubators (Save the Children 2016). The

only oxygen plant supplying facilities closed in April 2015 due to a lack of fuel (OCHA

2015). Although there are no figures to indicate how many facilities have closed due to

fuel shortages, only 45% of the country’s facilities are fully functioning (Ministry of

Public Health & Population and WHO Yemen 2016). Yemenis are also heavily reliant

on overseas medical care but the closure of the capital’s airport has prevented 20000

civilians from travelling aboard to receive care (OCHA 2016a). Again, it is not known

what health consequences this has had, but these people were said to be seeking serious

or urgent medical treatment (ibid).

In the Gaza Strip, the Israeli military blockade restricts the movement of goods

and people in and out of the region. For those who need to access healthcare outside

Gaza, they must enter into an application process for a permit to cross the border. In

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2017, 47% of applications were rejected and 44% delayed. At least 20 people died

waiting for approval or after having the request rejected last year alone (Al Mezan

2018). On the other side of the Occupied Palestinian Territories (OPT), ambulances

from the West Bank are not permitted to cross the border into East Jerusalem. Instead

they must transfer the patient from a Palestinian ambulance to an Israeli registered one

at the checkpoint. This transfer process can take up to five times as long. The

Palestinian Red Crescent Society found in December 2015 the average delay was 27

minutes, 12 more minutes than the recommended time (MAP 2017). These delays can

be fatal: between 2000 and 2007 10% of pregnant women were delayed at checkpoints

resulting in 69 births, 35 infant deaths and five maternal deaths at the checkpoints

(Shoaibi 2011). Rytter et al. (2006) found those who were delayed by Israeli

checkpoints or by detours on their way to the emergency department were more likely

to be admitted into hospital, indicating the restrictions in access negatively influenced

the severity of their presenting condition.

Rates of chronic diseases

Care for chronic diseases has suffered. In Yemen, the commercial blockade has led to

nationwide shortages of medicines for conditions such as hypertension, diabetes and

cancer. Because facilities no longer have the necessary medications, patients have

resorted to market stores and even the black market (Save the Children 2016). However

the scarcity has raised prices by as much as 300% (ibid). Doctors report increased

numbers dying from chronic diseases but there are no supporting data (MSF 2015b).

Syria’s health facilities also struggle to treat chronic diseases, not only because

of a shortage of medication, but also because the increase in trauma-related cases has

diverted resources away from primary care. Furthermore, frequent cuts to the electricity

supply mean medicines which require refrigeration deteriorate (Baker and Heisler

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2015). The president of the Syrian American Medical Society (SAMS) believes that by

2013, more than 200000 Syrians had died from chronic diseases, twice as many as those

who had died from combat (Murugen 2013).

Difficulties in accessing treatment for chronic diseases has also been reported in

Ukraine, risking the health of patients with HIV and tuberculosis and cancer (OHCHR

2016). Again there are no figures to indicate how many people cannot access treatment

for chronic disease or their health outcomes.

Outbreaks of vaccine-preventable diseases

Vaccination coverage has dropped in conflict regions and with it a rise in communicable

diseases. Most examples in the literature talk of a general decrease in coverage with

populations at risk of outbreaks but there are a few detailed reports.

Vaccination in Syria has dropped as a result of the insecurity, destroyed vaccines

and wastage resulting from disruptions to storage mechanisms (Baker and Heisler 2015,

Armstrong 2016). Polio re-emerged in 2013, 18 years after it was eradicated from the

country. Vaccination coverage has dropped from 83% prior to 2011 to 48% in 2016

(WHO and Unicef 2017). Measles coverage dropped 20% over the same time period

and there have been almost yearly measles outbreaks since 2013 (WHO 2018b).

80 polio vaccinators in Pakistan were killed between July 2012 and February

2015 (Farooq 2015). This correlated with an increase in reported polio cases from 58 in

2012 to 306 in 2014 (End Polio Pakistan 2017). In response to the rising attacks, the

Pakistani government deployed security forces to accompany polio workers, since when

polio cases have fallen (ibid).

For the first half of 2015 in Afghanistan, reported measles cases jumped 141%,

the majority of outbreaks occurring in districts with frequent conflict and known

restrictions in the delivery of health services (OCHA 2016b).

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Change in health-seeking behaviours

Patient health-seeking behaviours have also changed for fear of accessing healthcare

facilities. In Afghanistan, patients described how they were taking longer routes to reach

safer hospitals, or were not seeking treatment at all because of the insecurity (MSF

2014). Staff noted patients dying as a result of delayed treatment (Monaghan 2017a).

Doctors in Aleppo Syria have stated the fear of travel and believing hospitals are targets

has resulted in a 50% drop in clinical visits and surgical cases. Women are also

choosing to have Caesarean sections to avoid the risk of going into labour at night and

making the dangerous journey to a health facility (Rubenstein 2015).

Even when a patient attends a facility threatened by attack, they may insist on

minimising the time they spend there. MSF has noted how in Yemen some patients in

critical condition will only stay long enough to be able to physically leave again; and

new mothers will leave a within hours of delivering their baby (Armstrong 2016). It is

not stated whether the health outcomes for these patients are known or documented.

The loss of trust of hospitals as safe spaces is being felt in many countries. MSF

Canada’s Executive Director has said some communities refuse the building of hospitals

or clinics in their locality because of the unwanted attention they bring (Vogel 2016).

Mental health deterioration

The extent of the psychological consequences for healthcare workers has been detailed

through interviews. Healthcare workers remaining in Syria are found to be working

longer hours and often with no guarantee of pay, dealing with high volumes of horrific

cases, and under constant fear of bombardment, arrest and torture. Depression, burnout

and psychological trauma are common (Baker and Heisler 2015, Rubenstein 2015). This

issue has also been raised in interviews with staff in Yemen (Monaghan 2017b),

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Afghanistan (Monaghan 2017b), Congo and Pakistan (Merlin 2010). However, these

examples give no figures describing the extent of the problem. Abu-El-Noor et. al

(2016; 2018), using cross-sectional surveys of physicians and nurses working in the

Gaza strip after military offensives, was able to find rates of PTSD as high as 89.3%,

which remained at such levels when repeated 2 years later.

Loss of transport

In addition to the challenges of keeping vehicles mechanically sound, medical transport

can be difficult to find for a number of reasons; either it has been destroyed or stolen so

there are fewer to go around, or there is a shortage of fuel so they are non-functioning.

Ambulances in conflicts such as that in Syria also avoid travelling at night because the

headlights make them a target. At desperate times they’ll risk driving with the lights off

(Rubenstein 2015).

As of June 2015, 25 out of the 131 ambulances in the whole of Yemen were

partially or completely damaged (WHO 2015a). Coupled with the blockade of fuel into

the country, the costs of transport have become unaffordable for many. These factors

have contributed to the decrease in the numbers of patients able to access healthcare in

the country (MSF 2015b). Although there are no data to indicate the scale of the

problem, healthcare staff have seen patients arriving in critical states because of delays

in transportation, ultimately resulting in their deaths (Monaghan 2017b).

The lack of safe transport itself is causing health complications. Patients have

resorted to using whatever means of transport is available, including motorbikes and

being carried physically, sometimes by their arms and legs. As a result, they arrive with

additional injuries to the backbone and neck (MSF 2017b).

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Disruptions to medical education

Attacks on healthcare also have consequences for medical education. Physicians for

Human Rights documented disruptions to medical teaching in conflicts in El Salvador

and Indian Kashmir. The only medical school in El Salvador was forced to close by the

military government in 1980, at the same time killing students and faculty. When it was

allowed to reopen four years later, it was not provided with a sufficient budget to run

effectively. The campus was again closed in 1989 (PHR 1990). In Kashmir, medical

students stated the quality of teaching was affected by the attrition of doctors, and how

curfews imposed by the military affected their ability to participate in clinical rotations

(Iacopino and Gossman 1993). In both cases it is not stated how many students were

affected. SAMS Syria report notes ‘hundreds’ of medical students have had their

training interrupted by the conflict (Rubenstein 2015).

Fear of speaking out

The INGO Merlin found healthcare workers afraid to speak out about the risks they

faced for fear of losing their much needed income. Healthcare workers in large INGOs

in conflict areas tread a tenuous line, because an evacuation of INGOs would result in a

huge financial loss to the people it employs. This was succinctly expressed by one nurse

in Sudan, ‘If we admit how bad we feel we may lose our jobs. It is better to pretend and

keep everyone happy’ (Merlin 2010, 21).

An underestimation of the full extent of impacts

The extent of the impacts of attacks on healthcare can only be fully understood by

reference to complete health-related data sets (Coupland 2013). The burdens that

violence puts on health workers and their facilities, the infrastructure it destroys and the

shift of resources towards security and reducing risk to life places data collection far

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down the priority list for providers of healthcare (Rubenstein and Bittle 2010,

Rubenstein 2015). Therefore, attacks on healthcare preclude a full understanding of the

impacts these very attacks cause (Spagat 2018).

Discussion

Although information on the impacts of attacks on healthcare in conflict zones is

available, it is rarely collected as the primary objective of field research. Instead, this

information is often embedded within the literature reporting attacks on healthcare or

describing the consequences of conflict. This review has been able to extract, collate

and organise this information into 15 categories that describe the type of impact and a

range of its consequences. These relate to access to and delivery of healthcare, changes

in mortality and health outcomes for affected healthcare staff and the populations they

serve, and changes in the behaviour and practice of healthcare facilities and patients in

need of care. By using the WHO definition of an attack on health care we have

identified the full range of impacts of attacks; as well as immediate violence these

include the obstruction to supplies and the effect of threats of violence and insecurity on

health staff.

However, available information on the impacts of attacks on healthcare is

limited in reach; the full extent of the consequences of a specific attack or attacks in

general are rarely documented in detail. Accounts often stop short from describing the

knock-on effects these attacks may have had, and therefore are unable to provide

comprehensive descriptions of the wider and long-term consequences for the

population. It is by working down the ‘chain of impacts’ that the full public health

consequences are revealed (Coupland 2013).

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The limitations in data collected from attacks on healthcare have been heavily

stressed (Coupland 2013, WHO 2016a, Mülhausen, Tuck, and Zimmerman 2017, ICRC

2011). The same issues also exist for data collected on the impacts of attacks on

healthcare. Methods are not consistently applied to every attack or every region in

which it is known attacks take place so there is expected to be considerable

underreporting. The lack of a systematic process to collect these data precludes

establishing a reliable and comprehensive data set; one that would provide a complete

picture of the consequences of attacks on healthcare, and that would allow pattern

analysis and comparison between regions and contexts. The quality of the data that

exists varies depending on the location and context, the operators on the ground and the

objectives of the data collection process. Furthermore, there are no recommendations in

the existing literature for how data collection and associated methodologies might be

strengthened to ensure that all wider and long-term impacts are captured.

The literature also does little to distinguish between impacts specific to attacks

on healthcare and impacts on health from the wider conflict itself. The two often

overlap and it can be difficult to determine the actual cause. To give an example, deaths

from waterborne disease rise as a result of violence and the destruction of clean water

sources, but may also result from the poor availability of health services to treat the

conditions. There has hitherto been no discussion as to how we can discern the

consequences of attacks on healthcare from those of the prevailing violence, or if it

appropriate to do so. It may be agreed, as the two are so closely interlinked, that the

consequences of conflict on health should be regarded as ‘attacks on healthcare delivery

and public health’. Depending on one’s interpretation of the WHO definition of an

attack on healthcare, conflict may be regarded as an ‘attack’ as it results in ‘physical

violence or obstruction or threat of violence that interferes with the availability, access

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and delivery of curative and/or preventive health service’ (WHO 2018a). Whether we

take this stance, or we further refine the WHO definition to exclude the consequences of

conflict on health is an area for further debate.

Literature on the impacts of attacks on healthcare, like the literature on attacks

on healthcare themselves, is largely focused on regions with high profile conflicts such

as Syria, Yemen and Gaza (Mülhausen, Tuck, and Zimmerman 2017). Less attention is

paid to other regions where it is known attacks on healthcare also occur, such as

Ukraine, Northern Nigeria or the Democratic Republic of Congo.

Limitations

This review has provided little historical context; only 16 reports were identified

addressing impacts prior to 2011, largely from Physicians for Human Rights and Al

Mezan Centre for Human Rights. This is likely to be because attacks on healthcare only

became a more widely discussed phenomenon from 2011 onwards (Rubenstein 2012).

As some attacks can be reported under the broader topic of violence or insecurity in a

region, it is possible this review has missed published literature that might also include

the impacts of attacks on healthcare. Lastly, limiting the search to English sources will

have inevitability excluded reporting of impacts from local media and smaller national

organisations in non-English speaking communities.

Conclusion

Current information on the impacts of attacks on healthcare in conflict zones

demonstrates the consequences for healthcare delivery and the health of the surrounding

populations. But because of limitations in available data, this represents only the tip of

the iceberg and the full range of impacts remain unknown. With the majority of data

centred around high profile conflicts of recent times (largely from the Middle East), and

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no follow-through on the chain of impacts, the data lacks not only geographical spread

but also depth. Further discussions are required as to how we can differentiate the

impacts of attacks on healthcare from the impacts of conflict itself on health, or even if

we should be making this distinction at all. If we are to fully understand the range of

consequences for healthcare access, delivery and health outcomes, it is important to

develop systematic methods for data collection of the impacts of attacks on healthcare

and ensure their routine application following attacks, in order to create comprehensive

data sets. More attention must also be paid to low-profile conflict regions where attacks

on healthcare are known to take place but are less frequently documented. As stressed

by the WHO, the ultimate goal of expanding and strengthening the evidence base of the

impacts of attacks on healthcare is to develop ‘more effective and targeted advocacy to

stop attacks, and concrete actions to reduce the risk and impact of attacks’ (WHO

2016a, 10).

Acknowledgements

We would like to thank Duncan Shaw, Tony Redmond and Darren Walter for their

input towards reviewing this paper.

Declarations of interest

There are no potential conflicts of interest for any of the authors.

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Appendix 1

Search Sources and Terms

Search included the following databases:

Journal databases:

o University of Manchester database search1

o PubMed

Humanitarian-focused research/media outlets:

o Reliefweb

o IRIN News

The websites of the following organisations were also searched (using a combination of

the terms above as the search tools allowed):

Safeguarding Healthcare in Conflict Collation,

World Health Organisation – Attacks on Healthcare,

International Committee of the Red Cross – Healthcare in Danger,

Médecins Sans Frontieres – Medical Care Under Fire,

Aid Worker Security Database,

Insecurity Insight,

Physicians for Human Rights,

Syrian American Medical Society,

Al Mezan Centre for Human Rights,

1 For a full list of included databases visit http://www.library.manchester.ac.uk/search-resources/databases/

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772

773

774

775

776

777

778

779

780

781

782

783

784

785

786

787

788

789

790

1

2

3

Human Rights Watch

Search strings / sources of literature and screening process

For the University of Manchester database, PubMed and Relief Web, the following

search terms were used:

(Health OR healthcare OR health care OR medical facility OR health facility OR health

worker OR health staff OR ambulance OR clinic OR hospital OR heath transport OR

patient) AND (Attack OR violence OR threat OR obstruction OR bomb OR looting OR

theft OR arrest OR detention OR abuse OR airstrike OR blockade OR shooting)

Screened via abstract or description for ReliefWeb.

IRIN News – Keywords: attacks, violence, healthcare, Filter: Topic - Health

Screened via title.

WHO – Attacks on Healthcare database and all resources available on Attacks on

Healthcare webpage.

http://www.who.int/emergencies/attacks-on-health-care/en/

Screened via interrogation of database and title/description of reports.

ICRC – Healthcare in Danger. All resources available on webpage

http://healthcareindanger.org/resource-centre/

Screened via description of reports.

Safeguarding Healthcare in Conflict Coalition. All resources available on webpage

https://www.safeguardinghealth.org/resources

791

792

793

794

795

796

797

798

799

800

801

802

803

804

805

806

807

808

809

810

Screened via description of reports.

Médecins Sans Frontieres – Medical Care Under Fire. All resources available on

webpage

http://www.msf.org/en/topics/medical-care-under-fire

Screened via manual reading of reports.

Aid Worker Security Database. All reports and briefing papers available on webpage

https://aidworkersecurity.org/reports

Screened via interrogation of database and manual reading of reports.

Aid in Danger. All Aid in Danger monthly news briefs and health related incident trends

available on webpage

http://www.insecurityinsight.org/aidindanger/digests/

Screened via interrogation of database and manual reading of reports.

Physicians for Human Rights. All Research and reports available on webpage

http://physiciansforhumanrights.org/library/reports/

Screened via description of reports.

Syrian American Medical Society. All reports available on webpage

https://www.sams-usa.net/news-media/?filter=reports

Screened via description of reports.

811

812

813

814

815

816

817

818

819

820

821

822

823

824

825

826

827

828

829

Al Mezan Centre for Human Rights. All reports and studies available on webpage

http://www.mezan.org/en/posts/15/Reports+and+Studies

Screened via description of reports.

Human Rights Watch. Filter: Health. Search terms: Attack OR violence OR threat OR

obstruction OR bomb OR looting OR theft OR arrest OR detention OR abuse OR

airstrike OR blockade OR shooting

Screened via description of reports.

830

831

832

833

834

835

836

837

Figures

Figure 1. Flow diagram of included records for this review.

209 records with data on impacts of attacks

90 duplicate reports or using duplicate data

277 records not relevant to attacks

on healthcare

642 records relevant to attacks on healthcare.

Text manually analysed for reference to impacts

233 records included for review

36 records with data on impacts of attacks

136 duplicate reports or using duplicate data

207 records relevant to attacks on healthcare.

Text manually analysed for reference to impacts

2432 records not relevant to attacks

on healthcare

912 records identified through search of organisation webpages. Screened via title or description

2639 records identified through database searching. Screened via

abstract or description

838

839

840

841