In conflict zones around the world, violence and threats against hospitals, health care facilities and their personnel reached a grim milestone in 2022, according to a new report from the Safeguarding Health in Conflict Coalition (SHCC). It documented 1,989 such incidents last year — a 45% increase over 2021 and the worst total number since the group began tracking the data a decade ago.

The report notes that its numbers are probably an undercount due to difficulties in gathering personal accounts. Still, "we've never had this many events," says Christina Wille, director of the Insecurity Insight and Aid in Danger Project, which collects the data. "This was a shockingly violent year against health care, especially in Ukraine and in Myanmar," which accounted for half of the total.

The report details that at least 232 health workers were killed, 298 were kidnapped and 294 arrested on charges such as supporting anti-government forces, participating in protests or even just reporting the causes of protesters' injuries and deaths. These incidents are depleting an already diminished, understaffed health care workforce. The destruction of 704 different health facilities in 25 countries adds to the dearth of health care in conflict zones, leaving patients without a place to seek treatment or fearful of visiting facilities that may be attacked.

The attack by a non-state armed group on the Mada Hospital in Cameroon in 2022 is one example of this ripple effect. Before the attack, "It was one of the few health facilities equipped to provide comprehensive services, including for treating injuries from explosives," according to the report. Afterward, "thousands of people had no other option than to travel 100 kilometers through an insecure region with poor roads to access hospital treatment."

The picture that emerges from these statistics, says Leonard Rubenstein, chair of the Safeguarding Health in Conflict Coalition and professor at the Johns Hopkins University School of Public Health, is that "in addition to attacks on hospitals, violence in conflict zones is often inflicted on health clinics, health workers vaccinating children, transports carrying supplies and medication, and patients seeking to get to facilities. These practices add immensely to the deprivation and trauma of people already suffering in war."

Vaccination violence and other issues

The report highlights several increasingly worrisome trends. One is the rising number of attacks on vaccination campaigns — many of them drive-by shootings — in Afghanistan, Pakistan, Mali, Myanmar, Nigeria, South Sudan and Sudan. In one example, the U.N. suspended its campaigns in two Afghan provinces after 10 polio vaccination workers were killed — including eight in one day in four separate shootings.

News of such killings and the suspension of vaccination efforts rarely makes major headlines around the world, but "these are huge impact events," affecting hundreds of thousands of children, says Rubenstein. "More than 20 years ago polio was supposed to have been done away with. But it has remained endemic in Pakistan and Afghanistan because of the violence." Even when suspended vaccination campaigns resume, many parents are more hesitant to permit their children to receive vaccines, because of both heightened vaccine hesitancy and fear of attack, Rubenstein, says.

Danger for mothers and newborns

Maintaining women's reproductive health is essential to the well-being of any community, but the report cites several ways in which attacks on health care endanger mothers and their newborns.

A study in Syria found that many pregnant people ask to undergo a cesarean section instead of a vaginal birth, to make sure they have access to a doctor when the time comes. Many also postpone or miss regular check-ups due to fear of violence, the limited number of health facilities remaining and the long travel required to reach such a facility. The skipping of appointments puts both the mothers and the newborns at higher risk.

Elsewhere, in South Sudan, the study reports "maternal mortality is among the highest in the world, with a ratio of 789 deaths per 100,000 live births. According to WHO, only 11% of health facilities across the country provide the minimum level of services. Attacks on health care were identified as one of the main drivers of this health crisis."

Adding to the concerns, the report notes that two incidents in Malta and in the Democratic Republic of Congo were related to extreme views on abortion. According to the report, in the DRC, a police officer raided a hospital and stabbed and injured a nurse "allegedly performing an abortion without consent" and in Malta, abortion opponents threatened and assaulted health care professionals.

Those incidents, political in nature rather than in the context of war, bear similarities to the very disturbing violence and threats in the United States" related to abortion, Rubenstein notes.

Health care workers struggling to cope

"Health workers in conflict zones are dealing with a triple whammy," says Rohini Haar, an emergency physician and adjunct professor in the School of Public Health at the University of California, Berkeley. Not only are they working in the midst of conflict and violence, they are treating a population that is often either wounded or more acutely ill because they have been unable or too scared to come in for preventive care. Add to that the anxiety that they may be targeted precisely because they are working at a health care facility. It all adds up, Haar says, to "a spiral of fear, intimidation and burnout."

That observation is quantified in a report from South Sudan, in which 126 health staff exposed to violence in the course of their work experienced one or more symptoms of distress, including difficulty sleeping, losing interest in life both at and outside of work, and increased anxiety at work.

In addition, the continuous strain and exhaustion under which they work can create dilemmas, forcing health workers to balance life-saving care, their patients' safety and their own welfare. Haar says she is working on a study focusing on medical personnel in Syria, where she is finding that doctors sometimes must weigh the pluses and minuses of providing the best care, which might mean a longer in-patient stay at the facility, with the need to treat and discharge patients as quickly as possible to minimize the danger of being attacked while in the hospital.

Haar has also observed health-workers in Colombia and in Syria who feel ethically torn between their obligation to stay in a conflict zone to help or to leave for a place where they and their families are out of danger. "They are in a tough spot, with no easy answers," she says.

Another danger of enduring long bouts of unremitting stress is that the atmosphere of fear, anxiety and overwork can become normalized, Haar adds. It may be taken for granted, for instance, that health care supplies will be looted or an ambulance stolen, and these incidents will therefore go unreported, giving the perpetrators no reason to stop.

Are there any solutions?

"When you start attacking hospitals in a conflict, it opens up so many problems and issues for the health workers, for the patients, for systems of health care. The ripple effects are everywhere," says Haar.

Increased data collection could help a great deal, says Wille. If governments and aid organizations better understand the damage such attacks cause, we can begin to improve medical supply chains, for instance, in order to mitigate the impact. And specific mechanisms could be put into place, such as better protection for vaccinators.

Even small-scale efforts could make a big difference to health workers, says Haar. For example, she proposes creating an international consortium that could provide continuing education credits or validation for those caught up in conflict zones and unable to complete their degrees. That would help pave the way for the next generation of health care workers in areas where they are desperately needed but that lack training and accreditation programs. Otherwise, she asks, "What will be the health care workforce landscape in years to come if there aren't ways to educate and keep people practicing in the community?"

Most of all, says Leonard Rubenstein, global accountability must be strengthened at WHO, the U.N. and other international organizations. "This past decade has been marked by rhetoric and resolutions about how unacceptable these attacks against health care are, but the persistence and the scale of the attacks have not been matched by actions to stop them," he says. The lack of strong pressure will only continue to "reinforce the willingness to attack health workers and hospitals. We're at a crossroads and need to start reversing that trend."