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Health, gender and explosive violence: access to treatment after incidents of explosive violence

In a recent meeting focused on the gendered impacts of explosive violence, convened in 2019 by Action on Armed Violence (AOAV) and Chatham House, it was highlighted that of 2,741 civilians treated at Camp Bastion, a former British Army airbase, located northwest of the city of Lashkar Gah in Helmand Province, Afghanistan, less than 1% were recorded as female. Though it is important to note that some women’s treatment may have gone unrecorded, of the women treated at Camp Bastion, most were treated for disease, non-battle injuries and other health complications, including some ectopic pregnancies and a Caesarean delivery.

One doctor who had served in military tours of Afghanistan, and was posted to Camp Bastion, said that they did not remember treating any adult women there and that the children he did treat were almost always accompanied by their fathers. The doctor said that the figures cited above reflected their personal experience to the letter.

Despite this, we know that women were injured by the conflict in Afghanistan, yet clearly they were not coming to Camp Bastion to seek medical assistance. This raises concern as to why women may not have been able to seek treatment at Camp Bastion, and what other factors may prevent women accessing medical treatment in conflict.

Barriers to medical treatment

Others at the Chatham House meeting spoke from their own experience. Some highlighted that in many situations, it was almost impossible to imagine women being treated by foreign male doctors. If injured, it is likely that they would either be ‘treated locally or left to die’. 

In some contexts, there are many barriers to women receiving treatment. For example, if rescuers are male, women may be left under the rubble and untouched until a family member or a female rescuer can attempt to rescue female casualties, or at the very least, a blanket is found to ensure they can remain covered. Female rescuers, however, are rare. Of the 3,000 rescue workers that volunteer for the Syrian Civil Defense, the White Helmets, less than 5% are women. Nevertheless, this addition of female volunteers is said to have had an impact in ensuring injured females receive treatment.

This delay to treatment for female casualties is often due to cultural or religious norms in some areas experiencing high levels of explosive violence. The rescue of these women may be prevented, for example, due to concern that hair or body parts may be uncovered.

Beyond the immediate rescue, there are also barriers to receiving medical treatment. For instance, they may have to wait for a female health professional to be available or for a close relative to accompany them.

There are dangers to breaking such cultural norms, which mean that even if the life of a woman is saved she may, in the process of being treated, lose the connection to her family, home and way of life. One attendee at the meeting who was stationed at Camp Bastion recounted an incident where there was an attack in which a woman was injured. They described how soldiers immediately rescued the woman and took her to Camp Bastion for treatment. However, this had severe reverberations for the woman treated, as she was unable to return to her village. The cultural norms of the area had been broken; she had been treated by foreign male doctors and was therefore prevented from returning home.

This provides useful insight into some of the gendered health impacts from the use of explosive weapons. However, this also raises further concerns.

66th Expeditionary Rescue Squadron from Camp Bastion, deliver a wounded patient to British Army medics from the Role III hospital on Camp Bastion (U.S. Air Force photo/Senior Airman Nancy Hooks/Released)

Female casualties not recorded

One of the impacts that may result from the barriers to treatment may be that many female casualties from explosive weapons go unrecorded. Journalists and other civilian casualty monitors often rely on, or give preference to, hospital and morgue data to report casualties. However, it may be the case that as women may be more likely to remain trapped within the rubble, they go unrecorded in casualty data.

Furthermore, even if injured women are physically able to attend hospital, cultural barriers may still prevent them from going and being treated, such as a lack of female healthcare professionals. The injured women may instead be treated at home by female relatives. Not only does this reduce the level of care, but it also means that their injuries, again, go unrecorded.

The need for better data on gender among casualties of explosive violence was one the key issues identified at the Chatham House discussion on this issue. The monitoring of gender among casualties of explosive violence is already inconsistent and these further barriers to recording female casualties on the ground reinforces the concern that many female casualties may be going unrecorded.

Treatment accessed

Concerns also arise over the quality of treatment women may be able to access. At Camp Bastion, for example, the level of care provided was likely to be far better than other local treatment. This is due to the experience of the doctors at Camp Bastion in treating conflict-related injuries, as well as the likelihood that the local capacity of health facilities in a conflict setting is likely to be reduced due to the violence in the area – there will be higher levels of patients seeking care, medical supplies may not be reaching the medical facilities, and the medical infrastructure itself may be severely damaged.

Hospital in Ukraine’s Donbas

When women are unable to reach quality foreign or local care, their chances of recovery decrease and female fatality rates can be expected to increase. Furthermore, in many cases there may be other barriers to treatment based on gender and gender stereotypes. While there is little research on this in a conflict-setting, this a global problem that has seen some investigation in recent years.

In the United States, for example, it was found that women were less likely to receive CPR from a bystander and more likely to die. It was suggested this could be due to fear of touching or pushing hard on a woman’s chest. There were also concerns that large breasts may impede the proper placement of defibrillator pads. While gender bias in medicine has long been an issue, as far back as Aristotle, the presence of gender bias continues to affect women’s experience of healthcare. Other recent studies have found that women are more likely to receive sedatives for pain, while men will receive pain medication: a woman experiencing pain is likely to be treated less seriously than a male experiencing pain.

Such concerns are extremely important in a conflict-context, particularly in conservative areas where there may already be barriers to touching women and where there may be medicine shortages.

The number of female health professionals may also be lower in contexts where gender impacts access to not only treatment but education and work opportunities. A lower number of female health professionals in these areas also reduces access to treatment for women. In remote areas in Ghazni, Afghanistan, the lack of female healthcare workers is cited as a significant barrier for female patients, who instead have to travel to other districts or the provincial capital to access care from female health professionals. In intense periods of violence, casualties may not be able to reach these areas due to fear of using the roads or otherwise getting caught up in the violence. Additionally, violence and conflict can increase the barriers for female health professionals to work in these areas due to security concerns that may particularly impact women.

Moreover, this lack of female health professionals is likely to be exacerbated in intense conflict settings. In Aleppo, for example, there was just one female doctor still working in the eastern part of the city by November 2016. This is likely to have severely impacted women’s access to care.

Female health professionals are also more likely to face criticisms due to their gender and face backlash for the work they do. However, while their work may be more open to criticism, they undoubtedly have a substantial impact on addressing the gendered impacts.

Further considerations

There are clearly gendered health concerns that arise from the use of explosive weapons, though some may be dependent on the context in which the violence takes place. While little research has been conducted on the subject, it appears that women face bleaker physical health outcomes when injured by explosive violence. However, more research needs to take place to understand this fully, as well as the best means to address these. It is typically the case that where women are given more opportunity and training to carry out health roles the situation improves for women. Further, when women are involved in roles typically dominated by men, mind-sets can also change, often improving the lives of both men and women. Though often this is not without some backlash from more conservative elements of society.

In other areas of health, there are further gendered impacts which have not been discussed here. For example, with mental health, men and women are also likely to have different experiences. Gender stereotypes for example, particularly surrounding masculinity, may prevent men from seeking treatment for mental health issues as a consequence of explosive violence. While if female mental health practitioners are unavailable, women may not be able to access the support needed. Gender stereotypes also influence typical coping mechanisms, some of which can be harmful. More investigation into these areas is also essential.