By Timothy C. Okeke

For the Salisbury Post

Although the world is saturated in different shades of terrorism now evident in the Sahel, Syria, Iraq, Yemen, Pakistan and Europe, among other places, terrorist acts against health-care workers who risk their lives in service to civilians and victims of conflicts and disasters plague the mind as illustrating the worst against nature and humanity.

Physicians, nurses, pharmacists, lab technicians, financial officers, cooks, social workers, drivers and cleaners voluntarily strive after conflicts and disasters to restrict damage, often in situations dangerous to physical and psychological health. They help stabilize the staggering shortage of global health-care workers, thus reminding us that having a mix of skilled workers is fundamental for a functioning health system. Without enough trained and employed workers, people cannot access the care they need.

With no specific law to protect them, health-care workers run the risk of threats, attacks, kidnapping and robbery of vital supplies. According to the World Health Organization’s (WHO) 2014 report, Yemen has no laws that criminalize attacks on health-care workers, and most attacks in India, Pakistan, Yemen, Syria, South Sudan, Gaza and Nigeria are carried out by warring tribes, tribesmen or groups skeptical of outsiders in their communities. Health-care workers are either accused of offering services to some groups and not to others or are viewed as providers of care to the opposition rather than staying neutral. Seventy polio vaccination workers were murdered last year in Pakistan and Nigeria, and in India, the Taliban opposed the vaccination with women refusing health-care workers’ services thinking it is a “Western ploy.” In Afghanistan, the killings and abduction of health-care workers led to a shortage of qualified women providing needed care. In Turkey and Bahrain, doctors are arrested and detained for providing care and, as the severity of attacks increase, hospitals and clinics are forced to close down. A Central African Republic attack that killed 16 civilians and three Medecius Sans Frontieres (MSF) workers forced the NGO to close down its hospital in Bangui.

In addition to physical attacks, health-care workers confront the psychological “culture of fear” which the Ebola virus disease creates inside communities. People are driven out of their villages, stigmatized and the sick cast out to die on their own. Caring for the sick carries high risks, and many health-care workers in the Sahel do not have protective gear. People outside their clinics are afraid of them. As reported by MSF, a nurse in Liberia sums up the peoples’ perception of local health-care workers thus: “Whenever you are in uniform, people shy away from you on grounds that you have been infected with Ebola virus. They don’t want to see you. They don’t want to ride in any car you are entering.”

This is how another worker describes the daily routine at one of the centers: “With gloves in hand, with buckets, health-care workers walk along in open air corridors while a clergy reads the Bible story of Lazarus to a handful of gaunt survivors.” Anne Looks, reporting in 2014 on the role the Bible has played in combating such “fear,” narrates Dr. Melvin Korkor’s first reaction as he was being admitted into a clinic after testing positive for EVD: “One of the patients had just died, and I said to myself, I was going to make it and I said to my wife ‘bring me my Bible’ and that’s that, I’m going to go by.” He survived. “It was like being reborn,” he said.

Aware that the cure for Ebola is yet to be found, CDC acknowledges that “there is a world of difference” in the search. According to the New England Journal of Medicine’s editorial report, Dec. 25, 2014, big U.S. medical centers still sit on the fence; they should make it easier for their staff to help fight Ebola in Africa. Peter Piot, a microbiologist and discoverer of EVD, warns that “Europe is vulnerable if it does not regard the virus as a national security issue.” In response to these demands, the United States is sending 3,000 military personnel to Liberia to train healthcare workers, build 17 health-care facilities with 100 beds, set up a joint command headquarters in Monrovia, provide home health-care kits to households and train local population on how to handle exposed patients. WHO figures show 358 healthcare workers have died of EVD. As of October 2014, EVD has claimed 3,800 lives, and this could double.

Despite setbacks and terror, the EVD survival is improving in the hardest-hit Sahel due to efforts of health-care workers. According to the Associated Press, about 70 percent of patients now survive, and death rates are falling due to treatment with antibiotics, malaria medicine, Ibuprofen for pain and fever, intravenous nutrients, anti-nausea medicine and other supportive care even though this access to care lacks clinical trials  and the value of any specific treatment is unknown.

According to the National Institute for Occupational Safety and Health, health-care workers face a wide range of hazards on the job, including needlestick and back injuries, latex allergy, violence and stress. Other serious safety and health hazards encountered by health-care workers include blood-borne pathogens and biological hazards, potential chemical and drug exposure, respiratory hazards, ergonomic hazards from lifting and repetitive tasks, laser hazards, workplace hazards, hazards associated with labs, and radioactive material and X-ray hazards. WHO estimates 35 million people make up the global health workforce. There are 2 million incidents each year of worker injury on the job by sharp instruments, with 66,000 hepatitis C cases and about 1,000 HIV infections yearly, worldwide.

I have asked my social work students why they think people volunteer to work in dangerous conditions. The answer: Someone has to do it and who better than caring health-care workers (social workers)? The urgency to volunteer hinges around caring, shortages and consequences for not volunteering. According to WHO, 57 countries face a severe health-care workforce crisis. The shortage of health-care workers represents a major roadblock toward achieving the Millennium Development Goals (MDGs) blueprint agreed by all countries and leading developmental institutions to meet the needs of the world’s poorest people by 2015. WHO adds that about 2.36 million health-care workers and 1.9 million managerial and support positions are needed worldwide and that nearly 1 billion people worldwide have almost no access to essential health services due to a shortage of 7.2 million healthcare workers. WHO calls on wealthy countries to do more; without additional health-care workers to deliver essential health services, prevention, treatment, and advances in health care cannot reach those who need them most.

Health-care staff is often among the first to be attacked in war or disaster situations of violence, according to the Peter Maurer, president of the International Committee of the Red Cross, and Kristalina Georgieva, the European commissioner for International Cooperation, Humanitarian aid and Crisis Response who describes attacks as the “most serious and pressing issue of humanitarian concern.”

Some encouraging developments do emerge out of conflicts and disasters. There is the sense of international cooperation and solidarity to fight disasters and violence and to acknowledge those who help to shape them. A team of health-care workers from Cuba sent to battle Ebola in Africa stand out among international medical workers not only as “skilled” but also as “efficient.” U.S. Rep. David N. Cicilline and Karen Bass introduced a Congressional Resolution in November 2014, to acknowledge and thank medical professionals and volunteers for their extraordinary courage responding to the Ebola outbreak. Britain’s Queen Elizabeth II recognized them for working in “harms’ way” in conflicts abroad in her Christmas message.

Philip Carrols, reporting on health-care workers’ efforts to fight Ebola in 2014, maintains that Ebola has revealed the devastating impact a crisis can have on an already fragile health-care system, and the life-saving, heroic works of frontline health-care workers risking their lives to protect and save lives of vulnerable children in remote communities. Mohammed Jallo of IntraHealth International reports that health-care workers have paid the ultimate price in the fight against Ebola. He quotes Dr. Sheik Umar Khan, who died in the very hospital where he had treated more than 100 Ebola victims, as saying: “I’m afraid for my life, I must say, because I cherish my life.”

Chris Thomas of USAID has described frontline health-care workers as “unsung heroes of global health progress.” The American investment made through the President’s Malaria Initiatives (PMI) led to an annual decline in malaria deaths of 4.5 percent between 2000 and 2012. PMI trains more than 60,000 health-care workers in administering malaria treatment and identifying its parasites in patient’s blood through finger-stick test, and more than 25,000 in malaria diagnosis as well as in diagnosing and treating diarrhea, pneumonia and child illnesses. Community health-care workers are frontline soldiers in the fight against malaria. Malaria remains the African continent’s foremost health problem, with an estimated 10,000 African women and 200,000 infant deaths resulting from malaria infection during pregnancy per year. Dr. Benjamin Black argues in the British Journal of Obstetrics and Gynecology, June 14, 2014, that health-care workers who treat women with pregnancy-induced problems have to face life or death decisions for patients and themselves. These health workers have very little time to  decide whether pregnant women with complications are free from Ebola, and so should have the necessary treatment, or may have Ebola and so should have minimal procedures. Dr. Black adds that poor infrastructure and limited access to lab services means test results for patients could take more than 24 hours to arrive, during which a woman and her fetus may die. According to MSF, the survival rate from Ebola for pregnant women is virtually zero. According to a recent John Hopkins School of Public Health report, 3.6 million children could be saved yearly by investing in more community health-care workers.

What does the world expect from the West in addressing issues of safety, security and attacks on health-care workers? The world looks to the West for leadership. Health Ministers of Global North need to re-examine a resolution past two years ago pledging to do more on surveillance and to do more to respond to it. The Human Rights Council, the Ministers of Health from countries involved, the WHO and NGOs can view this as a priority as attacks undermine access to health care. Susannah Sirkin, director of  International Policy and Partnerships at Physicians for Human Rights, and Leonard Rubenstein of the Johns Hopkins Bloomberg School of Public Health, suggest that governments must do more to educate the public more about Ebola to prevent attacks. Governments should know that when using interventions that restrict peoples’ rights, they might meet resistance and violence. The use of quarantine and national lockdowns, as implemented in Sierra Leone and Liberia, may increase animosity toward health-care workers and undermine efforts to build confidence in health system.

The U.S. can contribute its expertise in evidence-based practice approaches that have reduced risks of contracting terrible diseases and other hazards faced by health-care workers. The UN can offer visible protection and work with international agencies to coordinate response sto address issues and train workers to defend themselves in times of danger. Global campaigns to promote health care take little account of the need to address attacks on health-care workers. Protection and accountability can only improve if the broader global health community takes ownership of the problem as a fundamental feature of health and human security.

Violence against health-care workers is not only morally reprehensible but also illegal under international law. The primary responsibility rests with the states and combatants. National legislators, courts and stakeholders must fulfill their moral duty of ensuring that domestic legislation recognizes the criminal responsibility of anyone violating international humanitarian law and enforce such legislation. Education is crucial in reducing conflicts and addressing disasters such as Ebola. Providing psychological support to patients and families in form of organized participatory health promotion activities with healed patients, and conducting sensitization campaigns to inform people how EVD spreads. The main problem facing health-care workers today is less of the direct attack against those providing care but the inability of the wounded and sick to obtain care which is just as deadly.

None of the suggestions advanced here constitutes a “silver bullet” to address any problem; rather, a multiplicity of efforts can help highlight the problem, promote accountability and reinforce these various efforts. Health-care professional organizations at the national and global level should promote universally accepted standards of professional conduct among health-care workers in armed conflicts and internal disturbances, including training health workers on human rights, medical ethics and advocating for the protection and security of workers and services.

Timothy C. Okeke, PhD, is the Chair of Social Work Department at Livingstone College. He can be reached at Tokeke@livingstone.edu.