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An Anatomy of a Mortar Attack: Good Health and Well-Being

SDG 3 – Good Health and Well-Being

3.1.1 – Number or proportion of health facilities damaged or destroyed by explosive weapons

Case Study

Official records do not mention damage or destruction to health care facilities. However, an Abobo resident told AOAV that after the incident: “Lots of hospitals were closed, holes on the walls and all over the neighbourhood”.  

Global

According to AOAV’s EVM, between 2011 and 2020, at least 14 mortar attacks occurred on hospitals. 50% of these attacks took place in Syria. There are several other organisations which monitor attacks on healthcare facilities, resources and professionals throughout the world. These include the Safeguarding Health in Conflict Coalition (SHCC) and the World Health Organization’s Surveillance System for Attacks on Healthcare (SSA). However, published datasets compiled by these organisations do not currently disaggregate depending on weapon type, though they do provide information on whether attacks were carried out by ground-launched or air-launched explosive weapons.

3.1.2 – Number of health workers killed or injured by explosive weapons, disaggregated by gender

Case Study

Health care workers may have been among the casualties, but AOAV found no evidence to suggest that educators had been targeted.

Global

Of the 14 mortar attacks on hospitals in the last decade, 90 civilians were killed and injured. We can assume that a number of these civilian casualties were health workers. 

3.1.3 – Shortages in essential medical supplies

“Inventories fell to dangerous levels.”

Case Study

Concern for essential medical supplies reaching Abobo was present before and after the shelling. Two months after the attack, police sergeant Fofana Sory told Abidjan.Net, “We must admit that there is a glaring shortage of drugs, especially basic necessities”.  In April 2021, Médecins Sans Frontières (MSF) reported that Abobo’s functioning hospital had run out of morphine, and while antibiotics such as penicillin were still in good supply, basic clean bandages are running low.

Global

The links between mortar attacks and shortages in medical supplies requires further investigation. 

3.1.4 – Number or proportion of ambulances destroyed (locally)

Case Study

None recorded. According to MSF none of the injured could be brought to the hospital by ambulance, Dr Chibuzo an MSF emergency doctor said “Some of the wounded were brought in trucks that usually transport food”. In 2012, Abobo had access to only one ambulance.  

Global

Cases of mortar attacks damaging ambulances have not been collated. WHO SSA records incidents that impact on health transport, but, as mentioned previously, the data is not disaggregated by weapon-type. There are examples in their data of mortars used to target ambulances, such as in 2016, when Houthi forces fired shells on an ambulance in Taiz governorate, killing the driver. 

3.2.1 – Number or proportion of health facilities with service disruptions

Case Study

A week after the attack, MSF reported that only one hospital in the Abobo neighbourhood, Abobo Sud, was functional. Service disruption led to delays in treatment, which in turn contributed to the deterioration in the condition of many of the injured. During field work in Abobo, AOAV met with Mathurin Kahoun. He was injured when a shell was fired near the SOS Children’s Village. Mathurin was unable to access medical care at the time of attack, and today he told AOAV, “I still suffer from the effects because 10 years later the wound has not yet healed, and I still have pain. Doctors tell me the residue is still in the wound so I can’t be fully healed”.  

Mathurin Kahoun, injured by the shelling near Abobo SOS.  Source: Verity Hubbard 2021.  

Global

When mortar shelling damages hospitals, it typically brings about some disruption to their services. Since there is no universal monitoring of this indicator, it must be assessed on a case-by-case basis. In 2015 in Cizre, a town in Turkey’s south-east, PKK operatives were reportedly aiming mortar fire at an armoured police vehicle but hit a wing of a hospital for dialysis patients. No casualties were reported, but heavy damage to the building and its facilities forced authorities to relocate more than 30 patients to other hospitals.  

3.2.2 – Health worker density and distribution per 10,000 population, compared with pre-conflict

Case Study

Conclusive data unavailable. While there is evidence of health care workers leaving Abobo due to the insecurity caused by mortar attacks such as 17 March Abobo shelling, international organisations were able to recruit volunteers to make up for the deficiency, in May 2011, MSF had recruited 250 volunteers to work at Abobo Sud hospital.

Global

There is currently insufficient information available to present causal links between mortar attacks and changes in health worker density and distribution. The vast majority of mortar use, as recorded by AOAV, occurred within an environment of conflict, where other weapon types were regularly used. Attributing any national or regional changes in health worker density directly to mortar attacks would ignore other factors.

3.2.3 – Difference in proportion of births attended by skilled health personnel, compared with pre-conflict

Case Study

Data unavailable.

Global

Whilst national data is available on the proportion of births attended by skilled health personnel in some countries, there is insufficient information to draw linkages between the use of mortars and this indicator. However, exact figures are not currently available.

3.2.4 – Difference in proportion of the population with access to affordable medicines and vaccines, compared with pre-conflict

Case Study

Unknown. The Ivorian conflict overall had a profound effect on routine immunisations with coverage falling from 85% in 2010 to just 62% in 2011

Global

There is no global data on the effect of mortars on access to vaccines and medicines. If we look at the country where mortars have been most prevalently used, in Syria, we find that in 2013 only two years into the country’s ongoing conflict, vaccination rates had plummeted to 68% compared to its pre-conflict rates of 90%. 

3.3

1 – Difference in maternal, neonatal and under-five mortality, compared with pre-conflict

2 – Difference in mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease, compared with pre-conflict

3 – Difference in reported cases of and number of deaths from preventable diseases such as cholera, measles or polio or changes in the life expectancy of HIV-positive patients, compared with pre-conflict

Case Study

The post-electoral violence in Côte d’Ivoire profoundly disrupted healthcare in Abobo, Abidjan and other parts of the country. Evidence of the specific effects of the 17 March 2011 shelling have not been obtained since aid agencies tend to report on the effects nationally. Equally, the specific effects of the Abobo shelling are difficult to disaggregate, given that shelling incidents in Abobo also took place on 11 March 2011 and potentially 15 March 2011. Any disruptions to healthcare would have been exacerbated by the cholera outbreak in January 2011.

Regarding infant mortality, a WHO briefing from 2016 stated that “the health situation of the population is characterized by high maternal and under-5 mortality owing to poor-quality health care.”

It is worth noting that data collection on maternal health and other preventable diseases was profoundly disrupted by the conflict; this was frequently noted in briefs from international monitoring organisations, such as this one from the WHO: “The surveillance system is challenged due to the volatile security situation and information on the epidemic trend is not rapidly available.”

Global

Mortars can damage health facilities, kill health workers, and interrupt services key to health systems, such as water and electricity. Nonetheless, to attribute long-term health consequences to a single weapon ignores a myriad of other factors, such as security concerns, economic deprivation, political chaos, and poor post-conflict service management. It is worth noting that an event of explosive weapon use in a resilient, economically advanced country, not blighted by conflict, would be unlikely to cause drastic changes to the above indicators. Therefore, it is important to be wary in drawing direct, causal links, when the reality is far more complex.

Report continues:

Chapter 6: SDG 4 – Quality Education
Chapter 7: Other Considerations
Conclusion and Recommendations

More in this series: An Anatomy of an Explosive Weapon Attack