Abstract
Médecins sans frontières (MSF, or Doctors Without Borders) recently suffered an armed attack on their maternity ward at Dasht-e-Barchi hospital in Kabul, Afghanistan. 1 This is not the first attack on MSF facilities where both patients and healthcare providers were killed. 2 After the bombing of several MSF hospitals in Syria, Yemen, and Afghanistan, former MSF president Dr. Joanne Liu appealed directly to the United Nations Security Council, calling for a resolution to ensure “the impartial provision of healthcare in conflict.” 3 Any unnecessary loss of life is a tragedy. Importantly, the attacks on hospitals in conflict zones represent both a direct risk to healthcare workers on site and global risk in the form of infectious disease epidemics.
There is substantial overlap between emerging infectious disease hotspots and regions of civil conflict, including eastern China, Southeast Asia, eastern Pakistan, Northeast India and Bangladesh, Central America, and Central Africa from Guinea, through Nigeria, the Democratic Republic of the Congo, Rwanda, and Burundi, and into Ethiopia.4,5 Regions affected by civil strife are likely to have weak governance and poor health systems; this is in part why only experienced organizations such as MSF are able to provide care in these areas. Forced migration and associated refugee camps bordering animal habitats generate ideal conditions for zoonotic spillover and subsequent spread of human-to-human infectious diseases. 6 Conditions of malnutrition and poor shelter, hygiene, and sanitation reinforce the importance of MSF's work to provide basic healthcare in these regions.
Perhaps less well appreciated on the geopolitical stage is the critical role hospitals and clinics play in conflict zones in controlling local infectious disease outbreaks. The attack on a hospital in these zones represents the creation of a high-risk location where a local outbreak may spiral into a global pandemic. Consider the crucial role MSF played in controlling Ebola outbreaks in West Africa from 2014-2016, 7 including running rural Ebola management centers. 8 The premise of the Global Health Security Agenda, the largest international agenda for securing the world from infectious disease threats, is that one country's health security depends on that of all others. 9 Strengthening our weakest links, such as healthcare in conflict zones, is critical to this mission. It is thus a major oversight of the Global Health Security Agenda that protecting hospitals in conflict zones from attack is omitted. Despite the adoption of a “security mindset” for the global health community, physical or diplomatic protection from attack for hospitals is not included in current Global Health Security Agenda goals.