|Year : 2015 | Volume
| Issue : 2 | Page : 118-119
The challenges of healthcare delivery in conflict zones
Robert B Sanda
Department of Surgery, Alberta Health Services, South Health Campus, Calgary, Alberta, Canada
|Date of Web Publication||19-Feb-2015|
Robert B Sanda
Department of Surgery, Alberta Health Services, South Health Campus, Calgary, Alberta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sanda RB. The challenges of healthcare delivery in conflict zones. Ann Afr Med 2015;14:118-9
It has been 5 years since a little-known Islamist group going by the name Boko Haram (BH) became an international headline grabber through an indiscriminate violent campaign to create an Islamic state in Nigeria. The group's militant activities have so far been confined to the northeastern corner of Nigeria with its base of operation in Borno state which borders three other African countries: Cameroon, Chad, and Niger. Such is the reputation for ruthlessness of the group that according to a statement credited to the state governor of Borno, Kashim Shettima, by July 2014 the group has been responsible for the destruction of 900 schools and the death of 176 school teachers.  Not listed is the number of students in institutions of higher learning who have met their death at the hands of BH. The well-known abduction of over 200 high school girls in the state in April 2014 has evoked international condemnation and five months on, apart from a few who managed to escape, the bulk of the girls remain in the custody of their abductors. The bombing of the Nigeria's national police headquarters, as well as the country headquarters of the United Nations in Abuja in 2011, were carried out by the group. The imposition of a state of emergency in the affected areas of the country has not deterred the battlefield successes of the group against the formally-trained forces of the Nigeria army. According to reports emanating from the region, the past five years has seen a permanent state of insecurity, breakdown of law and order, ineffective government services, economic stagnation, and political uncertainty. In effect, the population in this part of Nigeria is living under siege. The conflict has resulted not only in a rising casualty figure among civilians caught in the crossfires of the militants and the security forces but also allegation of serious abuses against suspected members of BH including extra-judicial killings by members of the Nigeria armed forces according to human right watch. 
A full catalogue of the unfolding human tragedy in the area is beyond the scope of this paper. Of relevance is the degradation of healthcare services in the region due to a combination of mass migration of health professionals as well as the dwindling allocation of resources in the face of increased demand for healthcare services. From one of the few health institutions still functioning in the area, the University of Maiduguri Teaching Hospital, comes a review of their experience (on which this article is commenting) in meeting the challenges in caring for victims of the insurgency ad interim. 
Nigeria is not alone in the man-made tragedy affecting civilian population by way of internal armed conflict. Cambodia, Yugoslavia, Rwanda, Sierra Leone, Liberia, and Sri Lanka are some of the countries that have shared this experience in recent times. Other countries such as Afghanistan, Iraq, Syria, South Sudan, Congo DRC, the Central African Republic, and Somalia are still embroiled in civil conflicts. The shared experience in these countries is that prevention of injury is to be preferred over damage-control. Lessons have been learnt that can be applied in Nigeria, which itself being the birthplace of the medical charity, Medecins Sans Frontieres (Doctors Without Borders) during the Biafran war in the 1960s, the lessons of which cannot be ignored. Some excellent reviews on the key issues in meeting the needs of combatants and noncombatants in military medicine are recommended references for civilian application. ,, Ultimately, the promotion conflict resolution through dialogue and political inclusiveness have resulted in political stability in places such as Mozambique, South Africa, Angola, Liberia, Nicaragua, Colombia, and Sierra Leone.
The mass migration of rural dwellers in Nigeria, who are farmers by occupation, for an indefinite length of time implies a diminishing capacity for the country to feed itself. The insurgency hampers cross-border trade in food items. Food scarcity is the order of the day in places like that. So far, the Nigerian government has not embarked on food distribution to the affected population. Chronic malnutrition has a predictable negative impact on the health of the population even if health facilities in the region are fully functional. As long as the conflict lasts scarcity of food and rising costs thereof will predictably exacerbate malnutrition.
With its determined and categorical antieducational manifesto, the BH has dedicated itself to reverse the gains of medical education in the area it controls. The impact of this ideology may not be felt now but what if Nigeria proves incapable of containing this insurgency in the next decade or more? What if BH succeeds in its quest to create an Islamic State in a vast territory of Nigeria? How then is the region to find the health professionals to run a viable health system? What will become of the medical school? Would female university professors be dismissed from their jobs as happened in Afghanistan during the brief reign of the Taliban? Will male gynecologists and obstetricians be barred from performing their professional duties as happened after the Islamic revolution in Iran? These are questions that cannot be ignored for too long since BH has a shared ideology with these actors.
Humanitarian donor agencies like the world food program, Oxfam, Care, Red Cross, Doctors Without Borders are stretched at the moment with rising global population in need of care in many more countries apart from those listed above. A global economic stagnation and international trade wars will only spur donor-apathy and thereby impact on the ability of those charities to solve global population problems. Even if they are able to, the situation with BH is untenably volatile. The coordination of efforts to fight terrorism in Nigeria by the combination of efforts from the intelligence services of the United States, Britain, and Israel among others certainly has not escaped the attention of BH. Aid and personnel from these countries will be viewed as a Trojan horse by BH. This increases the difficulties many of these donor agencies will encounter in attempts to reach the population cutoff from medical services. Worse still, it looks increasingly unlikely that a politically neutral party will be found that is capable of brokering a ceasefire to allow negotiations between the federal government of Nigeria and BH.
There appears to be not much that health professionals in this part of Nigeria can do to assuage the suffering of the civilian population except to treat those who survive their injuries and make it to the relative safety of cities such as Maiduguri, Damaturu, Potiskum, Bauchi, Yola, and Gombe to get help. Even if they do, most of these people who have left their resources to escape BH marauders will not hope to have the financial means to pay for their treatment once they arrive at places where medical services are available. The only solution for now will be for all stakeholders in the country including health professionals to pressurize the government of Nigeria to reach out to the BH leadership through intermediaries to open ways for cessation of hostility and to commence dialogue toward political inclusiveness. The antecedent adoption of Sharia law in this part of Nigeria should make it easier for the different Muslim legal experts to reach a compromise as to which version of the law should be actively put to practice. Health professionals can help the situation by adopting neutrality and impartiality in religious and political matters while asserting high standards of professionalism in humanitarianism and medical ethics in the conflict and appeal to both sides to allow civilians safe passages to safety and medical services. To an objective optimistic observer, this conflict has all the ingredients to be drawn out like the Taliban and Al-Shabab insurgency in Afghanistan and Somalia, respectively. This author dares to say that judging by current trends in efforts at finding a solution it is not likely that a permanent ceasefire is feasible in the next twenty years. The cost of such a long, but not unprecedented conflict, human lives and material cost is staggering and Nigeria cannot afford it. Nigeria must learn from its colonial master, Britain that no matter what it threw at the Irish republican army in the end it proved pragmatic and wiser to have negotiated with them and shared political power in Northern Ireland.
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