Health Care in Danger First steps at the London Symposium Kidnapped medical workers, murdered doctors, ransacked clinics,

, vaccinations denied to tens of thousands of children vivid examples of health care interrupted by armed violence that galvanised a London meeting of health experts and humanitarian professionals to consider urgent action. The meeting on Monday was the first of its kind to bring policy makers, academics, medics and civil society together to focus on the global problem of violent threats to health care. The symposium took the first steps towards agreeing a response to a problem that denies health care to tens of thousands every year, causes untold unnecessary deaths and worsens the suffering of the sick and wounded caught up in conflict. What did the150 participants say was needed to tackle the challenge? Firstly there needs to be a concerted campaign of awareness raising based on systematic data gathering that quantifies and specifies the scale and nature of the problems facing health care. Secondly governments need to consider bold solutions ranging from adopting standing operational orders on the battlefield to bolstering protection for health workers and facilities to stronger national legislation on protecting medical neutrality. And thirdly there needs to be a re-examination of medical ethics to ensure there is adequate guidance for health workers to help them deal with the dilemmas they face while working amid conflict. Some practical recommendations from the symposium could be implemented immediately, while others will help create policy proposals to be considered by governments and international bodies. Further suggestions for tackling the problem will emerge from workshops over the next 18 months that will involve other groups such as militaries and state representatives. High-profile speakers laid out the extent of the problem. The abduction of two Spanish MSF workers and the shooting of a Kenyan colleague had deprived 470,000 Somali refugees of medical care, and the ransacking of an MSF hospital in Pribor, South Sudan meant 160,000 people had a 100km further to travel to reach a clinic, MSF International President Unni Karunakara told the conference. Obstructive rules on the import of medical supplies, cumbersome procedures at checkpoints and deliberately excessive fees and taxes were other ways in which swift and effective medical provision was impeded, added Karunakara. Professor Sir Andrew Haines of the London School of Hygiene and Tropical Medicine called for better links between health and human rights, noting indiscriminate attacks against health workers had occurred from Sri Lanka to Pakistan to the Democratic Republic of Congo. Social factors such as inequality and poor education often lie behind ill-health, pointed out Professor Sir Michael Marmot, disempowering people from accessing care. And conflict is an extreme form of disempowerment, he added. He called on the Red Cross and Red Crescent movement to use the great respect in which it is held to push for more equal access to care and a redefinition of health in terms of well-being. Moving personal testimony from local health workers in DRC and Congo was given by Carolyn Miller, chief executive of the medical charity Merlin. She set three challenges to the forum, calling on health professionals and the NGO community to take practical action quickly, for local people to be given a strong voice in fashioning responses and for charities to work in forgotten and underserved places, such as the Central Africa Republic.

Merlin has campaigned vigorously on the risks to health care, and Miller expressed the hope that building sets of 'communities of concern' would deliver the critical mass of attention that is needed for policy makers to be persuaded to respond. WHO expert Rudi Coninx emphasised the need for reliable data on the extent of attacks on health workers and health facilities as the basis for identifying and analysing trends, which in turn can lead for advocacy to improve behaviour and reduce risks. Health activist Professor Len Rubenstein noted the difficulty in creating incentives for irregular armed groups to respect international humanitarian law that protects health care in conflict. Reinforcing perceived impartiality and neutrality of health workers is critical, he said. A United Nations special rapporteur could be appointed to respond to threats to health care on behalf of the world's states, he suggested. Whatever action governments take, health professionals have their own responsibilities, the audience was reminded. Medical ethics are not a luxury which only apply in times of peace, noted the BMA's Professor Vivienne Nathanson, since the requirement to offer impartial and fair care is equally pertinent in emergencies. A mosaic of measures is needed, the ICRC's medical adviser Robin Coupland noted, but what is critical now is to build awareness of the threats to health care. Without awareness nothing will be done by policy makers, he underlined. "At this point it really is up to us," he said. The event was organised jointly by the International Committee of the Red Cross, the British Red Cross, the British Medical Association and the World Medical Association.