Introduction: A Growing Need for Emergency Medical Teams in Conflict
While climate disasters and outbreaks continue to threaten the health of communities globally, the number of conflict-affected individuals is climbing with an estimated 2 billion people affected by conflict as of 2022. 1 This is partially due to an increase in complex emergencies, defined as humanitarian crises where a breakdown in authority occurs due to internal or external conflict, resulting in numerous civilian victims and high security risks for humanitarians. 2 The Geneva Conventions, which form the basis of international humanitarian law (IHL), require that parties involved in conflict provide care for those wounded as a result of that conflict. 3 Governments and involved parties may not always have the capacity to care for citizens affected by conflict. In these instances, humanitarian organizations may be called upon to respond as providers of last resort, as seen in several recent responses. 4 – 9
Today, the World Health Organization’s (WHO) Emergency Medical Team (EMT) initiative provides verification and classification for organizations seeking to provide health care during and in the aftermath of disasters and public health emergencies. These classified organizations are deployed based on the affected community’s needs and requests from the Ministries of Health. Spurred by lessons learned from the Haiti 2010 earthquake, the WHO EMT initiative provides minimum standards for medical teams, aiming to “improve timeliness and quality of health care services in the aftermath of various disasters and emergencies.” 10 These standards focus on health care provision with a goal of providing affected communities with quality assurance regarding international EMTs who arrive in their country to provide care.
Humanitarian emergencies in conflict pose unique operational challenges, yet the current classification process does not address operational preparedness for deployment to conflict settings. 11 WHO has published A Guidance Document for Medical Teams Responding to Health Emergencies in Armed Conflicts and Other Insecure Environments or the “Red Book,” which serves as a reference for EMTs deploying to humanitarian emergencies in conflict settings. 12 This guidance supports EMTs in conducting self-assessments regarding readiness for deployments, but there remains a lack of operational standards and quality assurance in this process. This could result in EMTs’ self-deployment to insecure environments without the necessary skills and protocols to safely and ethically operate in that space. Without appropriate preparation, team members and communities are at risk of violence and inadvertently contributing to socio-economic and political variables that may fuel the conflict further. One solution to address this gap is the implementation of a supplemental process similar to the current verification procedures, wherein WHO would adopt a policy encouraging teams to complete an additional conflict-oriented verification if they plan to operate in conflict settings.
Discussion
Competencies for Addressing Challenges to Medical Care Provision During Conflicts
EMTs operating in conflict-affected environments face unique operational considerations that compound the difficulties faced when operating in a disaster setting. Aside from specific medical complexities related to conflict such as military ballistic wound patterns, prolonged transport times due to unsafe locations, lack of trauma stabilization points, and prolonged field care, 13 , 14 these challenges include addressing perceptions of non-neutrality and the complexities of civilian-military coordination; understanding the application of IHL; building a comprehensive safety and security plan; and incorporating conflict variables into demobilization strategies.
During the coordination of a response with affected communities, governments, and international organizations, one such challenge is the perception of non-neutrality despite best efforts to uphold humanitarian principles. Operating near frontlines may result in actual or perceived improved access to care for one side of the conflict. The shift toward localization and community partnerships may further complicate the neutrality of EMTs, where relationships can make providing impartial care to those most in-need challenging. While coordination across the spectrum of disaster response agencies is critical, perceptions of bias may deter patients from seeking medical care, harm the reputation of the organization, and lead to violence. EMTs need to be aware of protocols, mechanisms, and best practices regarding coordination within conflict-affected environments. But they must also actively engage with community perceptions regarding neutrality.
EMTs operating in conflict-affected settings require a working knowledge of IHL to understand their rights and responsibilities as medical providers and those of patients and the community. It may fall on the EMT to remind involved parties of their obligation to provide medical assistance or, if they are unable to do so, to allow other groups to provide medical assistance to civilians and those who are no longer engaged in combat. 3 EMTs that lack applicable training may not recognize that a wounded combatant can seek medical assistance or may be unable to adequately articulate these rights to communities in which they are operating. EMTs must balance this while respecting the sovereignty of host nations, who ultimately dictate scope of practice and provide credentialling.
Safety and security risk management for EMTs, clinics, and patients in a conflict zone pose an additional challenge to EMTs. The Safeguarding Health in Conflict Coalition report (2023) highlights these security risks, reporting a 25 percent increase in attacks on health care workers and facilities when compared to 2022, with a total number of attacks noted to be the highest on record. 15 EMTs need to be skilled at navigating the complex scenario of providing medical care in areas with accentuated risks; for example, when caring for patients from opposing sides of a conflict. It is imperative to develop an understanding of how this may impact community relationships and the safety of the medical team and their patients. Security concerns may lead EMTs to security management choices that may compromise their independence during a conflict if they resort to the military or local government for protection. In addition to these many challenges, health care facilities and providers may also be attacked if either side of the conflict views their aid as supporting the opposition.Reference Nickerson 16 – 17 Building capacity to create proper risk-aware behavior and security management in deployments can reduce the likelihood of incidents and better mitigate negative outcomes.
While a demobilization strategy is essential to any humanitarian operation, there are further considerations when operating during a conflict. The dynamic nature of active conflicts can lead to unpredictable changes in risk, requiring the ability to rapidly evacuate for the protection of team members. This process requires careful planning and clear communication to all parties involved, including the team members, authorities, and community members. 17 With the evacuation of an EMT and/or closure of a clinic, community partnerships and trust can suffer due to the perception of abandonment, leading to potentially long-lasting impacts on future engagement. Care must be taken to manage expectations and maintain the bond that was established with the community.
Recommendations: Adoption of an EMT Conflict-Specific Verification Process
One feasible approach to address these challenges is to expand the existing EMT classification process to include criteria specific to operations in conflict settings. The WHO Red Book builds on experiences of EMTs who provided care during conflicts, addresses many of the previously discussed challenges, and provides a detailed Readiness Checklist that EMTs can use for self-evaluation. 18 Additionally, the Red Book references several recommended trainings for EMTs but does not identify which of these are required for deployment into insecure environments.
WHO is currently developing a process of classification based on the Red Book that mirrors that of the existing EMT verification process (Falvio Salio, email communication, March 2024). A WHO Red Book Implementation Working Group, consisting of multidisciplinary and multinational subject matter experts, has been established to operationalize the utilization of the Red Book to classify EMTs and to provide teams with resources to strengthen their capacity to operate in insecure settings. 18 The working group could also develop a rubric specific to the provision of health care in conflict settings that can be utilized by WHO to audit EMTs. Based on the Red Book and challenges discussed, this rubric should minimally contain the following critical sections: core principles and education around IHL; safety and security risk management; coordination platforms and modalities; additional clinical competencies including sexual and gender-based violence; and logistical technical standards pertinent to conflict zones. 19 , 20 Currently classified EMTs seeking to operate in conflict settings would have the opportunity to seek this supplemental verification. The EMT initiative would be the final reviewing body for organizations seeking this classification and would maintain a database of “conflict-classified” EMTs.
Conclusion
A Way Forward to Improve Medical Care in Insecure Environments
Establishing a mechanism to classify the abilities of EMTs to engage in conflict-affected communities is critical. In 2023 alone, the complex humanitarian emergencies in Ukraine, Afghanistan, Sudan, Syria, Libya, and Gaza are putting millions of people at risk, and the number of individuals impacted by conflict continues to grow. The EMT initiative possesses expertise and the convening authority to drive international standards for EMTs providing care in health emergencies and is the obvious platform to create a rigorous process to ensure that EMTs operating in conflict zones are appropriately trained, vetted, and accountable. This can feasibly and efficiently be accomplished through the WHO EMT initiative guided by the Red Book recommendations.
Author contribution
Jessica Ryder: Provided the initial proposal, initial draft compilation, and contributed to the review and revision of entire manuscript. David Callaway: Contributed to the review and revision of the entire manuscript. Erica Nelson: Contributed to the envisioning, direction guidance, drafting, and revision of entire manuscript.
