The man, no older than 25 and dressed in civilian clothes, lay helplessly on the floor at an emergency room in an African country devastated by civil war. Seriously wounded in the chest, he had lost a great deal of blood and urgently needed help, yet the locally well-known doctor was beating him in the stomach. I tried to intervene, but the doctor kept shouting that opposition members like the young patient did not deserve treatment. I managed to wrap the young man in a blanket and remove him to a corridor where he died soon after. The memory still haunts me. It pains me to know that even health personnel themselves might prevent the impartial delivery of care for the wounded and sick.

Because of such incidents, my professional life as a nurse will forever be marked by the years I spent in some of the world's conflict zones working with the International Committee of the Red Cross (ICRC). This experience made me aware of how people's lives can be devastated when security concerns prevent them from obtaining the health care they need, especially in situations where the already fragile healthcare system has been disrupted by armed conflict and other violence.

Working in war zones in Afghanistan, Sudan, Somalia, the Congo and Colombia, I had many occasions to observe just how complex the problems can be when health care is not available. This can arise in a number of different ways, not just when doctors, nurses or first-aid workers are directly attacked. For example children may die from common, preventable diseases because vaccines, health staff and/or medical supplies were blocked or destroyed by armed groups or the authorities.

In 2004, while working in an extremely poor area controlled by an armed group, I witnessed an outbreak of measles. Normally this childhood disease can be easily contained with timely vaccination. The measles vaccination is one of the least expensive in the world – one dose costs approximately 25 cents. Unfortunately, the armed group did not allow our health teams to immediately access most of the villages affected by the disease. When some weeks later we had at last the possibility to visit, we faced the profound despair of families mourning hundreds of dead children.

Other problems include the forced movement of people fleeing from areas of fighting into hostile natural environments such as desert or volcanic regions, or unhealthy and unsafe urban areas. The result was often outbreaks of disease such as cholera. These outbreaks were extremely difficult to contain for many reasons including disrupted supplies of water, food and medicines, the absence of skilled health staff, disorganised health infrastructure and/or difficult geographical access.

In other instances the wounded and sick, combatants, detainees and civilians were left untreated because health staff had fled and hospitals had been severely damaged, looted or taken over by armed forces. Situations also occurred where armed people, both combatants and civilians, entered hospitals or health centres seeking wounded enemy, threatening personnel and stealing drugs, thereby destroying the ability to offer health care. On some occasions, health staff also refused to provide treatment because of either a personal breakdown in their medical-professional ethics or an external threat.

In armed conflict, often those who do manage to find transportation to the nearest health facility succumb to disease or injuries while being delayed at check points, both official and unofficial. Some patients or health workers in the medical vehicles were killed deliberately merely because of being suspected of membership in an opposing group. I also experienced patients disappearing during their hospitalisation for those reasons already mentioned.

Growing evidence shows a lack of respect for the healthcare delivery system during a conflict. This increased vulnerability has led to a shocking human cost. Civilians, fighters and other weapon bearers often die from their injuries or illness simply because they are prevented from receiving timely medical assistance due to the environment being too dangerous for the delivery of effective health care.

Violence that prevents the delivery of health-related services, thereby infringing upon the basic right of individuals to health care and to dignity, is currently one of the most urgent, yet overlooked, humanitarian tragedies. It affects millions.

The ICRC recently set out an ambitious four-year initiative aiming to put the delivery of health care amid armed conflict and other violence on a more secure footing. The initiative will bring together healthcare staff, military personnel, States, the ICRC Movement and others to identify the measures, both legal and operational, needed to put an end to the lack of security that all too often prevents people from receiving health care.

As nurses, especially when working in situations of armed violence, we frequently witness human suffering. We are an essential part of the solution and can help identify measures to assist people in accessing health care safely.

Maïté Pahud is a registered nurse with master degrees in Public Health and Health Economics and a PhD in Health Sciences. She has worked for the past 25 years in war and conflict zones with the International Committee of the Red Cross (ICRC), and in developing countries with Médecins Sans Frontières-CH, Save the Children UK and Médecins Pour Tous les Hommes (MPTH).

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