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The impact of explosive violence on a child’s access to healthcare

In medical slang, the ‘Golden Hour’ refers to the sixty minutes following traumatic injury which can determine a person’s chances of life or death – a crucial hour where life hangs in the balance. For children, this Golden Hour is even more critical. And none more so when the child is a victim of an explosive weapon – especially as repeated studies have shown that children are more likely to die from blast injuries than adults.

As other work by AOAV has demonstrated, explosive weapons destroy the human and material infrastructure of healthcare systems. Such devastation all too often prevents children from accessing treatment within the critical Golden window. In a study on healthcare provision in Syria, less than 10% of child casualties arrived within one hour of injury. Almost one-third arrived six hours or more after the blast occurred.

Such harm, such impact, is all too often predictable and, in some ways, avoidable. Damage to healthcare systems reverberates far beyond the initial impact of the blast, comprising a child’s long-term health and wellbeing. In this brief report we look at such reverberations and chart how explosive violence impacts children’s access to healthcare in numerous complex and predictable ways.

Direct targeting of healthcare facilities
Over the past decade, healthcare facilities have been targeted with seeming impunity, so much so that attacks on hospitals and humanitarian workers in conflict has been labelled the “new normal”, according to Médecins Sans Frontières (MSF) humanitarian specialist Michiel Hofman.

Despite protection under International Humanitarian Law, explosive weapon attacks has been a notable feature of the conflicts in Syria, Iraq and Afghanistan (see Figure 1). AOAV data shows a concerning increase in attacks on hospitals with explosive weapons in 2019 (see Figure 2). Some of these incidents a consequence of poor military targeting; the wide area effects of explosive weapons means that when such weapons are used in urban areas armed forces are often unable to target military objectives without hitting civilian sites. However, many of these strikes have been callous and intended. These violations form part of military strategies of disruption, where healthcare is ‘weaponize‘ and hospitals and clinics are seen as targets in themselves. Such strategies, most alarmingly seen in Syria, aim to destabilise, intimidate, and demoralise the opposition into submission.

Figure 1: Data collected from AOAV’s Explosive Violence Monitor. Incidents included when casualties are reported.

Indeed, today Syria has become the most dangerous place on earth for health-care providers. The insecurity generated by explosive weapons has caused thousands of healthcare workers to be driven out of the country, depriving communities of already scarce medical resources.

In 2016, in Aleppo, it was reported that there was only one paediatrician left in the entire city. Targeted attacks had destroyed the paediatric centre and equipment stores there, while other paediatric staff, including paediatric surgeons, had either fled, or been killed. As a result, child mortality rates shot up as specialist treatments and vital operations could not be completed.

That year, MSF were to report on the fatal consequences of medical staff shortages throughout Syria: “We had a child who required surgery for an oesophageal diverticulum, but we couldn’t find a doctor available in the whole of east Aleppo. Any paediatric surgeon could have done it, as it’s an easy operation. But there was no such surgeon, and the child died.”

Ambulatory vehicles are vital for a child’s survival. September 2011 marked the first intentional attack on a clearly marked ambulance in Homs, after which attacks in Syria became ubiquitous. Between 2016 to 2017, there were at least 204 individual (mainly explosive) attacks on 243 ambulances in the country. Half (49%) of these ambulances were either heavily damaged or put out of service. The main perpetrators of these strikes were found to be the Syrian regime (60%), followed by the Russian armed forces (29%). Shelling, air-to-surface missiles, and cluster bombs accounted for the majority.

This targeting has consequences. When healthcare facilities or equipment are destroyed by explosive weapons, the distance that children must travel to access healthcare can be vast, often worsening the injuries they had initially sustained.

Or families may fear taking their children to hospital in the first place. In 2016 MSF reported that patients in Syria said that attacks on healthcare facilities have made them too afraid to go to hospitals. Patients in east Aleppo generally stayed for as short a time as possible in hospitals, as they were “known as dangerous places to be”.

The pressure on medical staff and on hospital beds also contributes to patients spending less time in hospital than they may need, with sometimes tragic consequences.

“Premature babies can need a long period in the intensive care unit before they are ready to leave, but as the time is not available, we are losing many of them,” AOAV was told.

If a child is considered to have a ‘less urgent’ medical problem they are less likely to be taken to a hospital. An administrative manager of a paediatric hospital in Aleppo recounted how parents “wait for the warplanes to leave, and when they reach the hospitals, the children are in a far worse condition”. When children were finally brought to hospital it was often “too late”.

Figure 2: Data collected from AOAV’s Explosive Violence Monitor. Incidents included when casualties are reported.

Targeting critical infrastructure
A health service is an interconnected system of hospitals and clinics, healthcare workers and doctors, medicines, equipment, and ambulances; all reliant on power, water, infrastructure, and human resources to function effectively. The interdependency of healthcare systems means that they are particularly vulnerable to disruption from explosive weapons during conflict – a disruption that adversely impacts the most vulnerable, namely children.

Indeed, a report by Save the Children found that ‘explosive weapons are one of the key security concerns, putting aid workers under threat and ruining the roads and buildings that act as the key infrastructure for delivering humanitarian aid’.

Furthermore, MSF has highlighted this issue in Yemen, noting ‘the lack of functioning health facilities, […] people’s difficulties in reaching them, and their inability to afford alternatives. Many people have to cross frontlines, pass through no-man’s land or negotiate their way through multiple checkpoints in order to reach a hospital that is still functional’. When assessing the impact of these limitations on one hospital, MSF noted that of all deaths, ‘one-third were children and new-borns who were dead on arrival’.

Unexploded ordinance (UXOs), IEDs, and landmines also impede ambulatory vehicles from reaching children in need. A report from the International Committee of the Red Cross noted that ‘roads are sometimes closed for hours on end during sweeping operations for explosive devices or following security incidents, with sometimes dire consequences’. Their report recounts how ‘a girl injured by an explosion in Chahar Dara district of Kunduz province in Afghanistan died soon after arriving at hospital on 3 February 2010: she had been carried on foot for an hour because the military had closed the road’.

Access to specialised paediatric blast care
The three-fold rise in the number of attacks on children in conflict since 2010 has placed an immense strain on paediatric care in conflict areas. Without access to specialised care more children will die from their injuries. Paediatric blast care is expensive, representing a “disproportionately large resource burden” relative to total admissions. Studies of US military medical treatment facilities in Afghanistan found that, while children comprised only 3%–6% of their total admissions, they required approximately double the total bed spaces (7%–11%). On average a child’s length of stay was three times that of coalition troops admitted.

In a 2009 survey of more than 1,600 survivors from 25 countries affected by landmines, nearly two-thirds of respondents found that services were “never” or “almost never” suited to children’s age level and needs. Another report found that prosthesis services were severely underfunded in places affected by explosive violence, like Lebanon and Columbia, which only provided replacements after “two and five years, respectively—a time-period not adapted to the needs of a growing child”.

Longer-term reverberating impacts
The longstanding impacts on healthcare access for children continue after the violence has subsided. The rebuilding of hospitals – if they are even rebuilt – takes years. In October 2015, a US AC-130 gunship carried out an airstrike on a trauma hospital in Kunduz, north-eastern Afghanistan. At least 42 people were killed and 30 were injured. The trauma hospital was a vital lifeline for civilians, and the strike left 15,000 civilians without care. Even though the US had committed condolence payments to rebuild the hospital, it wasn’t until 2017 that it was replaced by a smaller, more basic healthcare centre. The area went for two years without comparative medical provision.

When a country’s public healthcare facilities have been damaged, prohibitively expensive, private health treatment can be the only option to parents whose children need medical care. A survey conducted in Iraq in 2015 found that the cost of health services was identified as the single biggest challenge to accessing healthcare by families.

Such prohibition can have long term impacts. Children who cannot access healthcare are often prevented from receiving vaccinations against preventable diseases and vital treatments. Routine medical procedures are often disrupted. A longitudinal study of healthcare in Palestine (2000–2014) found that fluctuations in the intensity of conflict negatively impacted both maternal and child healthcare outcomes, particularly in antenatal care and immunisations. Bombings on Gaza in both 2008-2009 and 2014 were found to have also stalled the training of health professionals, depleting the pool of qualified clinicians.

Figure 3: Data collected from AOAV’s Explosive Violence Monitor. Incidents included when casualties are reported.

Conclusion
Data collected on child mortality in conflict only tells half the story. Excess mortality from non-violent causes such as access to healthcare are underappreciated in body counts. Explosive violence undermines a country’s health care capacity and disrupts the delivery of basic health services to children in need. Despite protection from the Geneva Conventions, the Universal Declaration of Human Rights, and the Convention on the Rights of the Child, attacks on healthcare continue at an alarming pace. Even more alarmingly, when the perpetrator is known, the majority of attacks on hospitals are conducted by state actors (see Figure 3). Further research on gender is required as the lack of age and gender disaggregated data obscures the full extent of the differences that boys and girls face when attempting to access healthcare.