Armed conflict, insecure environments and disasters in the COVID-19 era

Doctors, nurses and other healthcare workers in conflict zones work under challenges most of us can’t imagine; treating frequent injuries from bombs and bullets, dealing with disrupted supply lines, and managing hospitals and clinics that are damaged or even under attack.
Now imagine adding COVID-19 into that mix.
Hossam Elsharkawi pictured in front of an IFRC logo backgroundRed Cross Talks reached out to Hossam Elsharkawi to discuss the additional threat that the global pandemic poses to those who live and work in areas of conflict.
He is Regional Director at the International Federation of Red Cross and Red Crescent Societies (IFRC) in the Middle East and North Africa and works with local teams to coordinate with national responders, the International Committee of the Red Cross and the World Health Organization as needed.
Red Cross Talks: Before we start talking about COVID-19, what kinds of challenges were medical professionals in conflict zones already facing?
Hossam Elsharkawi: There are all types of insecure environments that challenge many in the world now, including protracted crises, narco-trafficking wars, civil unrest, migrant routes in North Africa, violence in mega-slums and many regions within countries where law and order have broken down, to name a few. 
Medical and humanitarian personnel have been, and continue to be, under attack in many parts of the world, and not just as a result of armed conflict. Our approach is to gain access - trusted access - to the population in need by working with local leaders to gain admission. ‘Acceptance & neutrality’ is our key to managing the risk and mitigating against attacks. We do not use armed escorts or armed guards as a rule and opt to negotiate and re-negotiate. Patience and perseverance often work, but not always! 
And I would like to recognize upfront, with much respect, the frontline local and national nursing and medical staff who continue to work despite the threat of injury or being killed.
Red Cross Talks: How much more difficult does it become to manage a healthcare system when you add in a global pandemic?
Hossam Elsharkawi: In insecure environments we have seen medical missions and teams stigmatized and attacked, partly because of huge doses of misinformation and false news, as well as fear. Facilities have been overtaken by angry families or militant groups demanding that their patients and family members receive priority to the very limited - and sometimes non-existent - beds, medicine and care.
We have also seen deliberate attacks on medical facilities to ‘take out’ wanted persons, and for other reasons.

Red Cross Talks: What are some things you have learned about disease outbreaks in conflict zones, based on your past experiences?
Red Crescent members walking through a destroyed street in Syria.Hossam Elsharkawi: For most of the countries hardest hit by conflict, like Syria, Yemen, Libya, Afghanistan and Iraq, COVID-19 comes as one emergency after another, after another. 
In the past six months, Yemen has had outbreaks of cholera and dengue, and experienced severe floods, hunger, continued war and COVID-19. Couple that with a lack of funding and challenges to accessing internally displaced people, it becomes the perfect storm for what could be a humanitarian catastrophe beyond anything we have seen in modern history.
It is so difficult for medical personnel to deny access to families who wish to accompany loved ones in hospitals. COVID-19 response measures preclude this and result in tense confrontations. And it is often the nursing staff who deal directly with such anger and emotions.
Red Cross Talks: How are medical personnel and facilities protected during conflict?
Hossam Elsharkawi: The best approach is for the teams to behave and be perceived as neutral, impartial and independent. This is critical! Experience shows that many medical teams do not understand what this looks like in the field; how their behaviours, comments, social interactions, triage practices, clothing and even the location of a facility can impact the perception of their approach and undermine their safety. It can also create an environment in which the local population will not approach the team for care, even if needed, because they will be viewed as party to the conflict.
International Humanitarian Law is key to ensuring armed combatants are aware of the protected status of medical teams and facilities. However, we see that the foot soldier at a random checkpoint has not necessarily benefited from training or orders to understand this.
The World Health Organization drafted a guidance document for medical teams responding to armed conflict and insecure environments, entitled the “Red Book”. The document included contributions from Médecins Sans Frontières, International Committee of the Red Cross and key global and local NGOs, militaries, the UN and academics. ‘International Humanitarian Law in action’ is the most central theme in this document.
Hossam Elsharkawi is based in Beirut, Lebanon. He is one of the panelists in the upcoming “Healthcare, COVID-19 and Armed Conflict” International Humanitarian Law conference hosted by the Canadian Red Cross and University of Alberta Faculty of Law. The free panel discussion is happening on Zoom on October 22. 
Register here for “Healthcare, COVID-19 and Armed Conflict” 

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