To open this issue on ‘Violence against Health Care’, the Review sought the perspective of a health-care professional who has worked in the context of an armed conflict.

Dr Walter T. Gwenigale is the Minister of Health and Social Welfare of the Republic of Liberia. A practising surgeon for more than 30 years, including during the civil war, he has served as Bong County health officer, director of Phebe Hospital and president of the Christian Health Association of Liberia. He has also served on the World Health Organization's executive board and as a board member of the Roll Back Malaria campaign.

In this interview, Minister Gwenigale explains how the armed conflict in Liberia impacted on the work of remotely-located Phebe hospital, on the needs of its patients and on the ability of the hospital staff to provide them with adequate medical care. He describes the main security challenges and the way in which the hospital staff attempted to address them. He also recalls instances in which the hospital staff and facilities were the direct target of this violence, sometimes leading to tragic consequences. In addition to the short-term impact of the armed conflict he witnessed as a doctor, Minister Gwenigale also reflects on the long-term effect of this conflict on the health system in Liberia today.

This article explores the methodology and main findings of field studies conducted for the ICRC's Health Care in Danger project in Afghanistan, Somalia, and the Democratic Republic of the Congo between 2010 and 2013. It discusses some of the actions that the ICRC takes in its health programmes to facilitate access to health care, and its approach to promoting better respect for the laws protecting it. It then suggests what more needs to be done to curb the violence.

This research examines the impact on health-care provision of advanced state failure and of the violence frequently associated with it, drawing from six country case studies. In all contexts, the coverage and scope of health services change when the state fails. Human resources expand due to unplanned increased production. Injury, threat, death, displacement, migration, insufficient salaries, and degraded skills all impact on performance. Dwindling public domestic funding for health causes increasing household out-of-pocket expenditure. The supply, quality control, distribution, and utilisation of medicines are severely affected. Health information becomes incomplete and unreliable. Leadership and planning are compromised as international agencies pursue their own agendas, frequently disconnected from local dynamics. Yet beyond the state these arenas are crowded with autonomous health actors, who respond to state withdrawal and structural violence in assorted ways, from the harmful to the beneficial. Integrating these existing resources into a cohesive health system calls for a deeper understanding of this pluralism, initiative, adaptation and innovation, and a long-term reorientation of development assistance in order to engage them effectively.

Health-related data provide the basis of policy in many domains. By using a methodology specifically designed to gather data about any form of violence and its impact, violence affecting health-care personnel, health-care facilities, and the wounded and sick in these facilities can be quantified on an objective basis. The impact of this form of violence and its accompanying insecurity goes beyond those directly affected to the many who are ultimately denied health care. Reliable data about both the violence affecting health-care personnel and facilities and the ‘knock-on’ effects of this violence on the health of many others have a critical role to play in influencing the policies of all stakeholders, including governments, in favour of greater security of effective and impartial health care in armed conflict and other emergencies. The International Committee of the Red Cross has undertaken a study that attempts to understand on a global basis the nature and impact of the many different kinds of violence affecting health care.

The Colombian National Permanent Roundtable for the Respect of the Medical Mission (hereinafter ‘the Roundtable’) is a platform launched in 2008 on the initiative of the Ministry of Health and Social Protection and the Emergency Control Centre of the Ministry of Health of Cundinamarca with the support of the International Committee of the Red Cross (ICRC) and the Colombian Red Cross. It provides a space for discussion on topics related to the protection and safeguarding of health services, in the context of the non-international armed conflict taking place in Colombia. The permanent members of the Roundtable include a representative of the Ministry of Health and Social Protection, a representative of the Presidential Programme for Human Rights and International Humanitarian Law, the Colombian Red Cross and the ICRC. In this interview, the members of the Roundtable give their perspectives on the motives that inspire its work and the main challenges that it faces for the protection of the medical mission in Colombia.1

Ensuring respect for, and protection of, the wounded and sick and delivery of health care to them were at the origin of the Red Cross and Red Crescent Movement, as well as the development of international humanitarian law (IHL). In today's armed conflicts and other emergencies, the problem is not the lack of existing international rules but the implementation of relevant IHL and international human rights law (IHRL) which form a complementary framework governing this issue. Against the backdrop of the different manifestations of violence observed by the ICRC in the field and expert consultations held in the framework of the Health Care in Danger Project, this article identifies commonalities between the two legal regimes, including with respect to obligations to provide and facilitate impartial health care; prohibitions of attacks against wounded and sick and health-care providers; prohibitions to arbitrarily obstruct access to health care; prohibitions to harass health-care personnel, in violation of medical ethics; or positive obligations to ensure essential medical supplies and health-care infrastructure and protect health-care providers against violent interferences by others. The article concludes by indicating certain areas where implementation of existing IHL and IHRL is needed, including in domestic normative frameworks, military doctrine and practice, as well as training of health-care personnel on these international legal frameworks and medical ethics.

Armed conflicts have numerous adverse health consequences for the affected populations, many of which occur in the long-term. This article analyses in detail how international humanitarian law (IHL) and the right to health complement each other in obliging states to mitigate the direct and indirect health consequences of non-international armed conflicts. With its historical origin and purpose of protecting wounded and sick combatants of standing governmental armies, IHL focuses on the protection of the wounded and sick suffering from the direct health consequences of armed conflicts, such as injuries resulting from ongoing hostilities. The right to health is more expansive: it obliges states to prioritise the provision of primary health care through creating and maintaining an accessible basic health system. This focus enables it to highlight and address the indirect health consequences of armed conflicts, such as the spreading of epidemic and endemic diseases and rising child and maternal mortality and morbidity.

Attacks on and interference with health care services, providers, facilities, transports, and patients in situations of armed conflict, civil disturbance, and state repression pose enormous challenges to health care delivery in circumstances where it is most needed. In times of armed conflict, international humanitarian law (IHL) provides robust protection to health care services, but it also contains gaps. Moreover, IHL does not cover situations where an armed conflict does not exist. This paper focuses on the importance of a human rights approach to addressing these challenges, relying on the highest attainable standard of health as well as to civil and political rights. In particular we take the Committee on Economic, Social and Cultural Rights General Comment No. 14 (on Article 12 of the International Covenant on Economic, Social and Cultural Rights) as a normative framework from which states' obligations to respect, protect and fulfil the right to health across all conflict settings can be further developed.

Health-care workers face ethical dilemmas in their decision-making in every clinical intervention they make. In times of armed conflict the decisions may be different, and the circumstances can combine to raise ethical tensions. This article looks at the tensions in peacetime and in times of armed conflict and examines the types of cases that doctors and other health-care workers will face. It also discusses the common ethical decision-making framework and the role of communication within both clinical care and ethical analysis.

Military medical personnel and objects, as well as wounded and sick combatants, are protected against direct attack under the principle of distinction in international humanitarian law. However, some authors argue that they are not covered by the principles of proportionality and precautions. This opinion note explains that military medical objects constitute civilian objects under the rules governing the conduct of hostilities. It also demonstrates that, in view of the object and purpose of the First Additional Protocol to the Geneva Conventions, expected incidental casualties of military medical personnel and wounded and sick combatants must be included among the relevant incidental casualties under the principles of proportionality and precautions. This stems in particular from the interpretation of the obligation ‘to respect and protect’ as the overarching obligation of the special protection afforded to all medical personnel and wounded and sick. Support for this conclusion can be found in a number of military manuals and in the Additional Protocol's preparatory work and Commentaries. This conclusion also reflects customary law.