Last year, members of the health community came together to commemorate Alma Ata. While there was cause for celebration in Astana, it was nonetheless clear that progress had been uneven and people in some parts of the world were in danger of being left behind. There are of course many reasons why 40 years after the initial declaration, the world had failed to realise the promise of Alma Ata. One of the most important however, is the lack of peace in many countries.
Conflict, instability or unrest all affect health outcomes, either through their direct impact on physical, mental and psychosocial state, or indirectly through their impact on the health system and other determinants of health. Yet the world is becoming less peaceful according to the Global Peace Index; in 2018, the average level of global peacefulness declined for the fourth consecutive year. While some dispute the veracity of these claims, almost everyone agrees that the nature of conflicts is changing – they are becoming increasingly complex and lasting longer than they did in the past. The situation is further exacerbated by the fact that countries which emerge from conflict remain at high risk of relapse.
Evidently, against this global backdrop of more and more protracted conflicts, efforts to improve global health must necessarily include conflict prevention and resolution measures. Recently there have been growing calls for health to be seen as a tool for peacebuilding.
The idea of “health as a bridge for peace” defined as “the integration of peace-building concerns, concepts, principles, strategies and practices into health relief and health sector development” is not new. In fact, as early as 1981 the World Health Assembly, recognising the importance of peace as a determinant of health, adopted resolution 34.38 which acknowledged that “the role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all.” However, in a world where attacks against health workers are increasingly common, implementing this is a serious challenge. Just last month Dr Kiboung, an epidemiologist deployed as part of the Ebola response team in the Democratic Republic of the Congo (DRC) was killed, and as most of you know, there have been multiple reports of attacks against health workers in Nigeria, Palestine, Libya and Syria amongst others, in recent years. This is in spite of the adoption, three years ago, of UN Security Council Resolution 2286 which urged states to “ensure that violations of international humanitarian law related to the protection of the wounded and sick, medical personnel and humanitarian personnel exclusively engaged in medical duties, their means of transport and equipment, as well as hospitals and other medical facilities in armed conflicts do not remain unpunished” and affirmed “the need for States to ensure that those responsible do not operate with impunity, and that they are brought to justice, as provided for by national laws and obligations under international law.” As is the case with many other obligations under international humanitarian law, the enforcement of this resolution which is not legally binding, is poor. It is often violated with impunity; in some cases, even by the states themselves.
It is clear that while health workers in conflict and fragile affected settings are an important resource that can be harnessed for conflict prevention and peace-building, they are also highly vulnerable, and the overriding goal should thus be to protect them. Health workers should not be involved in any extraneous initiatives, unless and until mechanisms which mitigate their risk of becoming targets as a result of such initiatives, have been devised and put in place. Health workers are first of all human and should not be asked to sacrifice themselves on the altar of peace- or nation-building.