SDG 3: Good Health and Well-Being
3.1.1 – Number or proportion of health facilities damaged or destroyed by explosive weapons
The airstrike on the farm in Kustay did not hit or damage any medical facilities.
In Syria, there has been a sustained bombing campaign on hospitals by Syrian and Russian forces over the past decade. Physicians for Human Rights, an advocacy group that tracks attacks on medical workers in Syria, has documented at least 583 such attacks since 2011, 266 of them since Russia intervened in September 2015.
Comparatively, air-launched attacks on health facilities in Syria were proportionally far more common and far more deadly than ground-launched attacks.
3.1.2 – Number of health workers killed or injured by explosive weapons, disaggregated by gender
The airstrike on the farm in Kustay did not kill or injure any health workers. However, the threat of explosive violence is pervasive in Garmsir. The doctor who treated the victims, Dr Taj Mohammad, was himself killed by a roadside bomb not long after he saved the lives of the four young children.
Health workers are frequently at risk in conflict zones. Some of the deadliest attacks for health workers have come from airstrikes targeting health facilities. In 2015, UNAMA documented 20 health workers killed and 43 injured in Logar, Nangarhar, Balkh, Kandahar, Paktya, Ghazni and Kunduz. The vast majority of these casualties were caused by a US airstrike, in October 2015, that hit a Médecins Sans Frontières (MSF) hospital in Kunduz on 3 October, which resulted in the death of 14 health workers including doctors, nurses and pharmacists and four caretakers, as well as 24 patients.
Similarly, to the Kustay airstrike, the US “claimed they had received reports that the hospital building was holding active Taliban militia.” This was despite the fact no MSF staff had reported this to be the case. Also both the US and Afghan militaires had been made aware of the coordinates of the hospital by MSF.
Airstrikes are one of the primary causes of violent death for medical workers. Between 2011 and 2019, at least 916 medical professionals were killed in Syria. Another study found the majority (55%) of deaths were caused by shelling and bombing.
The recent airstrikes by Israel resulted in two of Gaza’s most senior doctors being killed. In conflict-ridden areas, where medical experts are often few and far between, this can have greater reverberating effects to the wider local medical management. The death of the head of internal medicine at Gaza’s largest hospital, as well as a senior neurologist, resulted in a “huge loss to the medical community.”
3.1.3 – Shortages in essential medical supplies
There were no shortages caused by the airstrike. However, the closest facility, able to treat the burns of the young five-year-old, was a four hour journey away.
Conflict-ridden areas have fragile supply chains. One airstrike hitting a hospital, pharmacy, road or fuel reserve could lead to a shortage in medical supplies.
The constant aerial bombardment on Yemen has contributed to medicine shortages. The main paediatric hospital in the north of the country was forced to close due to damage from airstrikes and a lack of fuel and medical resources.
Health centers containing medical supplies have been destroyed and subsequent blockades have led to shortages. The problem is particularly acute in Yemen as it relies on imports for 100% of its medicines.
3.1.4 – Number or proportion of ambulances destroyed (locally)
There were no ambulances destroyed in this attack. The victims were driven to the hospital by relatives. AOAV was told that it was unlikely that an ambulance would venture into the dangerous rural district.
Paramedics are very susceptible to attack. Their ambulances are mobile, highly visible and pass through multiple military checkpoints. Plus, they frequently attend scenes of recent violence which puts them at risk of ‘double-tap’ attacks, where a location is bombed twice several minutes apart with an intention to target first responders. This tactic has been used by Syrian and Russian air forces.
According to the British Medical Journal, from 2016 to 2017 in Syria, there were 204 individual attacks involving 243 ambulances. The majority (55%) of ambulances were damaged or destroyed by air-to-surface missiles.
Half (49%) were either heavily damaged or put out of service. The main perpetrators were the Syrian regime (60%) and the Russian armed forces (29%). Half (52%) of ambulances were directly targeted. This is despite ambulances being protected under international Humanitarian Law and the Geneva Convention.
In the space of one month in eastern Aleppo, in 2016, five ambulances were bombed, with two completely destroyed, leaving just 11 working ambulances for a population of 250,000.
3.2.1 – Number or proportion of health facilities with service disruptions
No health facilities were disrupted by this attack. Dr Khushal, a doctor at the EMERGENCY Hospital in Lashkar Gah, said he did not remember treating the young burn victim since they have so many wounded civilian patients in the province.
The Kunduz Trauma Centre (mentioned above) has been closed ever since it was struck in 2015. According to MSF: “the need for life-saving trauma care is extremely high in Kunduz and the availability of free, quality medical care is still very low.” A new centre has been built and is set to be opened in 2021 – meaning the region has gone six years without a specialist trauma centre. In the five days prior to the attack, the centre had treated 376 patients in the emergency room.
Health facilities that are open in areas facing aerial bombardments are extremely likely to face service disruption. In north west Syria, for example, a survey of healthcare workers found that 78% of health care personnel had witnessed at least one attack on a healthcare facility, with airstrikes being the most common form (72%) of attack.
Arguably, service disruptions may lead to more deaths than the airstrikes themselves. The World Bank estimated that the collapse of basic amenities and the health sector in Syria meant more had died from medical failures and disease than from bombing and other military activity.
3.2.2 – Health worker density and distribution per 10,000 population, compared with pre-conflict
The airstrike on the farm in Kustay did not kill or injure any health workers. However, the threat of explosive violence is pervasive in Garmsir. The doctor who treated the victims, Dr Taj Mohammad, was himself killed by a roadside bomb not long after he saved the lives of the four young children. These losses are likely to deter many healthcare professionals from working in the region. Helmand, the province containing Kustay, has one of the lowest densities of doctors, nurses and midwives in the country.
According to the World Health Organisation (WHO), many ‘post-conflict’ countries that have suffered from airstrikes in the past decade, such as Afghanistan, Sudan, and Somalia still have an over-reliance on international doctors, according to the WHO.
Afghanistan has the second lowest health workforce density and the highest level of rural residing population in the Eastern Mediterranean Region, with a ratio of 4.6 medical doctors, nurses and midwives per 10,000 people, considerably below the WHO’s minimum threshold of 23 health care professionals per 10,000.
Although, the same study notes that Afghanistan has made progress in that respect. from 1 doctor, 1.29 nurses and 0.24 midwives per 10,000 people in 2003, to 1.2 doctors, 2.1 nurses and 1.3 midwives in 2017.
3.2.3 – Difference in proportion of births attended by skilled health personnel, compared with pre-conflict
No data available. However, anecdotally, one of the victim’s family that was interviewed by AOAV told us there were now more clinics and maternity clinics available.
According to the UN, Afghanistan has one of the highest maternal mortality rates in the world. Some 638 women die per 100,000 live births, with fewer than 60% of births overseen by skilled health professionals, as of 2020.
In Yemen, the fourth most aerially bombed country in the past decade, maternity care resources have been significantly impacted by the conflict. As reported by UNICEF, between 2015-18, only 3 in 10 births took place in health facilities. And even those who make it to hospitals will find them struggling with even basic resources. As of 2019, only 51% of health facilities were fully functional, and nearly all suffered severe shortages of medicines, equipment and staff. One in every 260 women died during childbirth, and one in every 37 children died in the first month of life.
3.2.4 – Difference in proportion of the population with access to affordable medicines and vaccines, compared with pre-conflict
No specific data available. However, one of the victim’s family that was interviewed by AOAV told us that the children in the area had received some vaccinations, but there were still major problems with children suffering from coughs, fever, diarrhea and measles.
In the space of 10 days in early 2018, two MSF health facilities were hit by airstrikes in Idlib, Syria. The latter strike hit a center that was conducting a vaccination drive in the district of Mishmishan. In the second half of 2017, they had vaccinated more than 10,000 children there. According to MSF: “This service is now shattered. The area of the health center where the vaccination activity took place was badly damaged, destroying the stock of vaccines and the fridges required to keep the vaccines cold.”
3.3.1 – Difference in maternal, neonatal and under-five mortality, compared with pre-conflict
There is no data available. It is worth noting, however, that the only survivors from the attack were all young children, aged seven and under. They were all treated at medical facilities, one at a specialist burns unit in Lashkar Gah for 12 days.
A 2020 study that quantified various maternal and child health indicators , found that the scores for antenatal care, facility delivery, skilled birth attendance and oral rehydration therapy were “significantly lower for severe conflict provinces when compared to minimal conflict provinces.” However, any data on this indicator disaggregated by weapon type is unavailable.
In Yemen, maternal and neonatal care has been severely inhibited by airstrikes. The maternal mortality rate has risen sharply since the escalation of the conflict, from five maternal deaths a day in 2013 to 12 maternal deaths a day in 2018.
Due to the conflict, many mothers simply cannot access a health facility. For those that do, they are faced with staff and equipment shortages, such as incubators. Pregnant women and new mothers have to share beds, meaning infection control is poor. As mentioned before, the aerial bombardment in Yemen has hugely disrupted import supply chains in a country that relies on imports for 100% of its medicine.
3.3.2 – Difference in mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease, compared with pre-conflict
No data available.
The bombing of a medical facility has considerable knock-on effects. After two MSF facilities were hit by airstrikes in Idlib in 2018, for example, nearby facilities reduced services to protect staff and patients. This means those suffering with treatable problems receive no care and their conditions often worsen. So, as healthcare capacity is reduced by airstrikes, even greater demand for advanced care is generated.
“Among the most prevalent medical conditions [seen amongst displaced families that cannot access care] are respiratory tract infections and chronic diseases, such as diabetes and hypertension. Without access to care, these conditions can worsen, and, in the case of chronic diseases, become eventually life-threatening.”
- Omar Ahmed Abenza, MSF head of mission for northwestern Syria, speaking in 2018.
3.3.3 – 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
There is no data available. However, one of the victim’s family that was interviewed by AOAV told us that the children in the area were suffering from measles with people dying regularly from the condition.
A 2020 medical study, that looked at death rates in 193 countries over 27 years, found that conflict led to a significant rise in indirect deaths relating to HIV-AIDS, cardiovascular diseases, tropical diseases, enteric infections, respiratory infections and tuberculosis.
Another study, from 2016, found that rates of polio were higher in countries with political conflict and instability. “Wars and conflict have resulted in the reemergence of polio in countries that were polio-free for decades, and may contribute to the spread of the virus to neighbouring countries,” it concluded. However, the disaggregated analysis of a specific weapon type on these findings has yet to be produced.
More in this series: An Anatomy of an Explosive Weapon Attack
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