Healthcare Systems During Wartimes

Posted on by BUJPH

By Izzy Fish 


Conflict-related deaths have been increasing rapidly in the last decade.1 Since 2001, conflicts related to the U.S. military have produced the most combat casualties in the world.2 Service members are being sent home with PTSD, smoking habits that lead to cases of lung cancer and cardiac disease, and even marital discord and divorce.3 The number of lives affected is huge, so perhaps by comparison, the effect of war on our healthcare systems seems secondary. Yet the added traumas and damage being done to healthcare facilities causes a more long-term consequence, decreasing access to services for entire populations. Many of these wars are concentrated in low- and middle-income countries with unstable economies, governments, and health care systems.3 Especially as we see more conflicts unwinding around us, these systems are breaking down more and more. 

During the Geneva Conventions, laws of war were created to protect the wounded, the sick, non-combatants, and prisoners of war.4 These laws were meant to protect civilians from both physical threats and other acts of terror.4 Unfortunately, these so-called “humanitarian laws” have been all but abandoned as of late.5 It’s become a strategy: reduce a country’s ability to heal, reduce their ability to fight. Syria, Yemen, Iraq, and South Sudan have all experienced targeted attacks on hospitals and other locations providing health services.5 Since 2014, over 1,500 health care workers have been directly attacked and many more have been threatened, injured, tortured, or driven away from their line of work.5  Not only does this hurt the physician population in countries with weakened healthcare systems, but it could hinder younger generations from entering this line of work. Many facilities have been forced underground, into basements or other unsafe places where staff work in fear of helping their patients.6 In Ukraine, 120 facilities have been damaged, causing over 50 casualties of workers.6 In the Tigray region of Ethiopia, 80 percent of hospitals are fully destroyed, with the remaining lacking the necessary utilities and staff to work at full capacity.6 And it’s not only health facilities that are suffering–conflicts have also escalated to targeting supplies, electricity, water, and transportation (including ambulances).7 Even when a war ends, these facilities and healthcare workers cannot be replaced overnight. It takes years to rebuild a system when it’s been torn down like this, leaving entire populations without access to necessary care. 

Because of the reduced capacity of health systems in areas of conflict, civilians’ health suffers. After 100 days of war in Ukraine, providers report that the most common complaints coming from patients are sleeplessness, anxiety, and grief.8 Surprisingly, these are all psychological concerns, not physical, like one may expect during a war. Patients are also discouraged from seeking care. If they perceive hospitals as a threat, they won’t make appointments, or seek necessary treatment  to stay at home.7 Afghanistan, despite the official end of conflict in 2021, continues to suffer from a lack of supplies and workers, causing an increase in child mortality, a decrease in immunizations, and a decline in prenatal care visits.6 Since these services are no longer available, costs rise. The cycle continues: fewer services, higher costs, worse access. In Ukraine, 50 percent of residents reported a barrier to care, the majority being cost.9 Twenty percent could not access medication, again due to either high costs or to them not being available at pharmacies.9 Women are being impacted at higher rates. Households of only women have significantly less income, and are therefore unable to access care.9 It appears that health disparities hold true, even in war. Members of minority groups or marginalized communities are suffering the most, people who already have worse health outcomes. A lot of this money is being diverted elsewhere: service members are being sent home with higher rates of trauma, utilizing almost $100,000 more of healthcare services than controls.2 This is not to mention the loss of productivity (from a purely economic standpoint) from the trauma and injury inflicted upon these working-age populations. Health students are also suffering– their training is shorter and less extensive, more focused on critical care than on chronic and primary care.10

Wars will not stop in our lifetime. We will see more conflict and more attacks on our healthcare systems; the consequences will play out for the next several decades. Proposed solutions have been to call upon organizations to advocate for upholding the principles outlined at the Geneva Conventions, or rely on local systems to restore peace.1 We need stronger solutions to maintain our fragile health systems. This starts with enforcing humanitarian laws to discourage attacks on health facilities and establishing safe havens for people to seek out care.

 

References

  1. Druce, P et al. (2019, January 29). Approaches to Protect and Maintain Health Care Services in Armed Conflict. BMC. https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-019-0186-0. 
  1. Dalton, M et al. (2023, January 1). The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-Related Trauma. Pubmed. https://pubmed-ncbi-nlm-nih-gov.revproxy.brown.edu/33651722/. 
  1. Korinek, K et. al. (2019, October 23). Design and Measurement in a Study of War Exposure, Health, and Aging: Protocol for the Vietnam Health and Aging Study. BMC Public Health. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7680-6.
  1. Kaplan, J. (2022, April 12). Targeting Healthcare in War: A Tragically Tried and Tested Strategy that Humanity Must Disown. BMJ. https://www.bmj.com/content/377/bmj.o884.
  2. Druce, P et al. (2019, January 29). Approaches to Protect and Maintain Health Care Services in Armed Conflict. BMC. https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-019-0186-0. 
  1. Rogers, L. (2022, April 14). The Vulnerability of Health Care in Conflict: Ukraine and Beyond. Johns Hopkins Bloomberg School of Public Health. https://publichealth.jhu.edu/2022/the-vulnerability-of-health-care-in-conflict-ukraine-and -beyond 
  1. WHO. (2023, May 30). WHO Records More than 1000 Attacks on Health Care in Ukraine Over the Past 15 Months of Full-Scale War. https://www.who.int/europe/news/item/30-05-2023-who-records-1-000th-attack-on-healt h-care-in-ukraine-over-the-past-15-months-of-full-scale-war. 
  1. WHO. (2022, June 3). One Hundred Days of War has Put Ukraine’s Health System Under Severe Pressure. https://www.who.int/news/item/03-06-2022-one-hundred-days-of-war-has-put-ukraine-s health-system-under-severe-pressure. 
  1. WHO. (2022, October 24). Accessing Health Care in Ukraine After 8 Months of War. https://www.who.int/europe/news/item/24-10-2022-accessing-health-care-in-ukraine-afte r-8-months-of-war–the-health-system-remains-resilient–but-key-health-services-and-me dicine-are-increasingly-unaffordable.
  2. Dobiesz, V et al. (2022, August 25). Maintaining Health Professional Education During War: A Scoping Review. Wiley Medical Education. https://www-ncbi-nlm-nih-gov.revproxy.brown.edu/pmc/articles/PMC9540571/.
Izzy Fish