observation report visits by ttb ses tİhv tpd delegations...
TRANSCRIPT
1
Türk Tabipleri Birliği
Sağlık Ve Sosyal Hizmet Emekçileri Sendikası
Türkiye İnsan Hakları Vakfı
Türkiye Psikiyatri Derneği
OBSERVATION REPORT
Visits by TTB ‐ SES ‐ TİHV ‐ TPD ‐delegations to
Nusaybin, Cizre, Silopi, Van, Bitlis and Tatvan
1. Introduction:
As health workers our basic duty, and further, our raison d’être is to protect and improve human
health.
Naturally, our primary task is to cope up with and overcome any factor that poses a threat to human
life.
For us as health workers, there have been two major causes, throughout history, that threaten and
destroy human life: war and infections. So, the first one too is a public health problem that we as
health workers must fight out and eliminate.
As health workers we don’t want to witness pain and suffering caused by wars/armed conflict let it
be our country, region or in any other place in the world; we just want to wage efforts to ensure that
people live in peace and in health. Since no cause can be more valuable than human life, “What
really counts after all is peace”.
The environment of armed conflict/violence that is recently climbing and where each single pain
becomes a pain of us all is of grave concern for us both as citizens of this country and health workers.
It is our primary wish and request that there should be an immediate end to this environment that
leads to deaths, injuries and destruction of nature as well as many values. It is clear that as health
workers we are ready and determined to make all necessary efforts to this environment of
violence/armed conflict which means no less than denial of humanity and our ground as health
workers.
Meanwhile, to mitigate at least to a certain extent health‐related adversities and sufferings
accompanying armed conflicts/violence, the concept of “healthcare during extraordinary situations”
was developed and “regulations in times of armed conflict and other situations of violence” were laid
down in the light of scientific and ethical principles. We want to share a part of these regulations
which were lastly updated in 2012 by the World Medical Association (Attachment 1):
Whether civilian or combatant, the sick and wounded must receive promptly the care they
need. No distinction shall be made between patients except those based upon clinical need.
Advocate and provide effective and impartial care to the wounded and sick (without
reference to any ground of unfair discrimination, including whether they are the "enemy".
2
Provision of health care should not be impeded or regarded as any kind of offence. Physicians
must never be prosecuted or punished for complying with any of their ethical obligations.
Governments, armed forces and others in positions of power should comply with the Geneva
Conventions to ensure that physicians and other health care professionals can provide care
to everyone in need in situations of armed conflict and other situations of violence. This
obligation includes a requirement to protect health care personnel and facilities (including
their extensions).
We regret to state that recently there have been many cases and events stemming from the
environment of armed conflict where there are threats and assaults to health workers and health
facilities (including ambulances) and interventions to working environments including denial of
professional independence.
In order to observe the state of people affected directly or indirectly by armed conflict, identify cases
detrimental to public health, develop suggestions for solution and determine what respective
organizations can do in this regard, the Turkish Medical Association (TTB), Union of Health and Social
Service Workers (SES), Human Rights Foundation of Turkey (TİHV) and The Psychiatric Association of
Turkey (TPD) formed two delegations for two different areas. On 11‐12 August 2015, the first
delegation conducted in situ observations in Nusaybin, Cizre and Silopi districts where events
intensified. The first delegation was composed of Fatih SÜRENKÖK (TTB), Şeyhmus GÖKALP (TTB),
Fikret ÇALAĞAN (SES), Metin BAKKALCI (TİHV), Atike ÇITA (TPD) and leaders/representatives from
SES Branches and medical chambers in Mardin, Nusaybin, Şırnak and Cizre.
While conducting its observations and contacts in these places on 11‐12 August 2015, the delegation
had interviews with health workers from state hospitals in three districts as well as the following:
Nusaybin State Hospital Head Doctor Zeynep Burcu SÖĞÜT
Nusaybin District Governor Murat SARI
Nusaybin Co‐Mayors Sara KAYA and Cengiz KÖK
Cizre State Hospital Head Doctor Mehmet ERZEM
Cizre District Governor Ahmet ADANUR
Silopi State Hospital Director Mehmet Sait YAPITEKİN(in lieu of Head Doctor)
Silopi Co‐Mayor Emine ESMER.
The second delegation was composed of Hüseyin Demirdizen (TTB), Ümit Biçer (TİHV), Birsen Seyhan
(SES), Özgür Deniz Değer (TPD) and leaders/representatives from SES Branches and medical
chambers in Van and Bitlis.
This delegation visited Van, Bitlis and Tatvan on 11‐12 August 2015 to conduct observations and
interviews. During this visit, there were interviews with health workers in all three settlements as
well as with officials from the following: Van Regional Training and Research Hospital; Van 112
Command Centre and UMKE (National Medical Rescue Team) members; Van Chamber of Medicine;
Tatvan Military Hospital; Bitlis Health Directorate; Bitlis 112 Command Centre; Tatvan Municipality
and representatives of Tatvan Eğitim‐Sen and Tatvan Tüm Bel‐Sen. Persons interviewed are as
follows:
Van Regional Training and Research Hospital Head Doctor Cafer Alhan
3
Van 112 Command Centre and UMKE members
HDP Van Deputy Remzi Özgökçe
Tatvan Military Hospital Head Doctor Osman Tan Fırat
Bitlis Provincial Health Director Erkan Akagündüz
Bitlis 112 112 Command Centre, Sefa Kılınçer((in lieu of doctor in charge)
Tatvan Mayor Fettan Aksoy.
Our visiting delegations confined their mission to investigating the experience of health workers,
situation of health facilities and their extensions and problems faced in the delivery of health
services. Therefore, issues related to human rights violations are presently being covered by other
working groups also formed by organizations mentioned above.
2. Summary of interviews and observations:
NUSAYBİN: During clashes bursting out on 27 July 2015, a wounded person was not taken by
ambulance for a long time and the person died while being taken to hospital. There were events
taking place around the hospital when the person killed was sent for autopsy. The presence of
security forces and special operation teams in the hospital yard with their vehicles known as
“Scorpion” and long barrel weapons and their search in hospital service rooms prevented the entry
of patients to hospital besides exerting heavy pressure on health workers inside. The hospital
became unsafe and turned out as a target since there were fake bombs at the yard and security
forces used the hospital as a base to intervene in demonstrations going on outside.
Meanwhile the delivery of health services was critically affected when a 112 ambulance was attacked
by unidentified persons using “Molotov cocktails” along with another outreach service vehicle. More
recently, on 11 August 2015, the hospital environment was rather tense when members of the media
were beaten while trying to shoot threats and pressures to health workers by security forces when
two wounded police officers were being brought to the hospital following the attack targeting the
Government building around 22:00 hours. Disturbed by this tense environment and worries about
their own life, health workers expressed their reaction in a press statement made on August 12th. At
present, health workers in Nusaybin do not feel safe and are troubled to deliver even routine health
services. Further, there are many health workers trying to evade by taking leave or quitting their jobs
by submitting resignation. Presently 15 out of 30 specialists and 6 out of 8 practicing doctors working
in emergency services are on leave with determination to fully resign. Besides, there is apparent
decline in the number of inpatients and the number of daily policlinics.
Particularly in Nusaybin, health workers and patients are affected by pepper spray used by security
forces starting early in working hours since the hospital is located in a quarter where there are
intensive clashes. Specialists say they face difficulty in reaching the hospital when they are urgently
called for duty.
CİZRE: It is said that events started on 26 July 2015 when a young person named Abdullah Özcan was
shot while in the balcony of his home. In the morning of the following day, on July 27th two bullet
4
holes were found on a window in the state hospital which built tension in the hospital and in the
town. Though there were rumours saying that the hospital was targeted by gunfire, health workers
and hospital administration informed the Health Directorate and Ministry that it was not an attack of
that kind but stay bullets randomly hitting the unused part of the building. On 27 July 2015 there
were also other events further aggravating tensions and violence in the hospital environment.
Events include the following: Forcible referral to Elazığ of Mehmet Emin Oflaz who were brought to
the hospital as wounded; forcing health workers to examine Hasan Nerse who was shot in a civilian
vehicle as he was handcuffed; surrounding of the hospital by security forces with their vehicles called
“scorpion” and “hedgehog”; vacation of emergency services section and not letting health workers
in; security forces taking de facto control of the health facility and blocking the ambulance carrying
Hasan Nerse, the person wounded during events. During these events, health workers felt
themselves alone and isolated, which further triggered their worries about their life.
Beşir Eğitmiş (aged around 55‐60) who was shot in front of his house on August 4 was then taken to
hospital by his neighbours where health personnel who wanted to give treatment were stopped by
security forces there. On August 7th, two persons (a repairer and a client) were wounded upon the
alleged gunfire by the police around industrial district of the town. Ambulance arriving to the place
for their transfer to hospital was first stopped and kept waiting by the police and even when
wounded persons were taken to hospital two security personnel rushed in with their arms to prevent
treatment.
On August 8th security forces conducted an operation in which 9 persons in Silopi were detained and
taken to Cizre. In Cizre, medical examination of these persons was made not in the hospital but in a
police vehicle while they were handcuffed. This situation naturally ruled out any possibility for issuing
a sound forensic medicine report.
On August 10th, the bombing in Silopi caused the lives of 4 police officers. The Cizre State Hospital
made necessary preparations after having been informed there were too many people injured. After
some time, a wounded person was brought to the emergency while inside and surroundings of the
hospital were filled by special operation forces with their long‐barrel guns as well as “scorpions” and
“hedgehogs”. Upon shots heard around 12:30 the police started firing guns into the air and
prevented any service delivery for some hours by fully vacating the emergency service as con1irmed
by witnesses present there.
Especially when wounded security personnel and suspects were brought in, the hospital is fully
surrounded and dominated by security forces, health workers are obstructed while trying to deliver
services and patients applying to hospital for their health problems are questioned by the police.
SİLOPİ: As a result of police operation starting early in the morning of 7 August 2015 3 civilians and
one police officer were killed, tens of people were wounded and detained, 2 houses were burned
down and many dwellings were destroyed. Health related problems faced upon these events are as
follows:
According to many witness statements that are consistent, security forces arrived at the emergency
service around 6:00 in the morning and wanted to take Dr Serdar Acar to the conflict area by
threatening him. Not supposed to leave his place of duty Dr Acar refused which invited further oral
and gun supported threats by the police. It is clear that normal legal procedure requires investigation
5
of the use of force and threat by security forces against a doctor who was on duty early in the
morning and obliged to stay there including remedy for the trauma that the doctor had suffered.
Strange enough, the prosecution launched targeted the doctor and, what is more, he was deposed.
Many people were wounded during this conflict in Silopi; security forces did not allow ambulances to
transfer wounded people to health facilities and these people could be taken to hospital by civil
vehicles. There are serious allegations that during this transfer to health facilities H.T. (age 17) and
Hamdin Ulaş (age 60) were shot and killed by security forces while getting out of cars in front of the
hospital.
It is stated that all these events including the experience of health workers and what happened at
the hospital on that day can be found in camera recording of the hospital which was delivered to the
public prosecutor.
It is also stated that Hasan Aşulan, a hospital intern and his sister who left home in the morning for
hospital were both wounded as a result of fire from the vehicle called “hedgehog” at a distance. They
first wanted to go to hospital with their own car, but taken out and beaten by the police before they
were transferred to Şırnak State Hospital. Hasan Aşulan was arrested without having complete
treatment for his wound.
Kamuran Bilin, who is said to be shot in front of his home was taken to the emergency ward by his
neighbours. However, his medical treatment was blocked by the police and it could start only after
some delay with the efforts of health personnel. Bilin was referred to another hospital in Cizre but
died while being transferred there.
Meanwhile 7 wounded persons were taken to hospital by citizens, but their entry to the emergency
ward was blocked by the police. In spite of this barrier, wounded persons were ultimately taken to
the emergency ward with the efforts of health workers and citizens. It was stated by many eye
witnesses confirming each other that the emergency ward and the hospital were surrounded by the
police, that there were many “scorpions” and “hedgehogs” around and security forces were around
and inside the hospital with their long‐barrel guns. In the face of all these, some health workers left
the premise thinking that their life was under threat. The presence of so many security people
around the hospital prevented citizens from receiving services normal ways. Also many health
workers were troubled in commuting while some missed their duty.
VAN: Events starting after general elections created problems in access to health services. Attacks to
ambulances and health workers and tougher interventions to demonstrations including wider use of
pepper spray and other instruments give rise to concerns that health problems will further
aggravate.
In Van and its districts, there are security problems in reaching health facilities after dark (i.e.
difficulty in reaching patients, delays, patients having no other alternative but visiting health facilities
with their own means). It is stated that there is no significant change in the number of daytime
policlinics, there is apparent fall in the number of patients applying to emergency wards at night.
It is stated that a week ago an ambulance was stopped and kept for a while by a group of young
people on the allegation that the ambulance was carrying police officers and ISIS militants. During
these events some ambulances were damaged, health workers were subjected to violence (for
6
coming in too late) by relatives of patients and an ambulance was stoned by small children. It is also
stated in relation to earlier events that it works in efforts to prevent violence to ask for and mobilize
the support and intervention of local authorities and political party representatives. People
interviewed said ambulances could to reach remotest points until three months ago. To sum up,
there are allegations that ambulances are used for purposes other than health care and, therefore,
there is need to avoid any act that may lead to such perceptions and to build trust.
The environments of conflict prevent 112 centres’ services and activities. In fact now there are some
inactive centres. It is stated that similar problems are confronted in mobile first aid teams as well.
Insecure environments are said to demoralize health workers in anxiety, unrest and desperation. This
environment of unrest more heavily affects health workers who are hot natives of the region and
leads to problems in social relations, exhaustion and estrangement without any available
psychosocial support.
As stated, anxiety and unrest on the part of health workers causes delays or failures in rendering
health services and also leads to tendencies to leave the region to find jobs elsewhere.
Given the present shortage of health workers in the region, departures or even ideas of departure
will further worsen the state of health services and make the situation even bleaker. Indeed, the Red
Crescent is already troubled in relation to blood donations.
All health workers raise the common demand that conflicts and violence must be stopped at once to
re‐establish an environment of peace. It is also stated that political parties, NGOs and people should
raise their voice for democratization and all parties have their respective roles in achieving this end.
TATVAN‐BİTLİS, August 12: At night on 3 August 2015, the Military Hospital in Tatvan District of Bitlis
became the target of shooting with long‐barrel weapons. Leading to no death or injury, the firing
caused damage on the walls and cameras of the building. Health workers visited the hospital to
support the personnel there.
Local people say this kind of attack happens for the first time and they can attribute no meaning to
such an action. The hospital serves civilians as well besides military personnel. It is stated that there
is no change in the number of patients applying and daily routine of the hospital following the event.
Health workers were affected variably and security measures were strengthened as a result of
prevailing unrest within. Meanwhile it is stressed that health premises should be protected even
during warfare with health workers having their special status in such environments.
During an interview, the Mayor of Tatvan pointed to following problems arising after the start of
clashes besides problems in healthcare services: economic activities in the district coming almost to a
halt; people are afraid to go out for shopping at the centre of the town after hours of the day; even
better‐off residents and tradesmen starting to leave the town for some other place and disrupted
basic municipal services including fire squad and municipal controls.
It is considered that events starting in the district lead to the disruption of health services
accompanied by health workers with intention to leave the region. It is stressed that there is no
other way but stopping clashes and building peace, considering that it is the problem of Turkey as a
whole, not the region alone. It is commonly agreed by all that all will fain in an environment where
the right to survival is not guaranteed.
7
BİTLİS: During recent events there were attacks to ambulances. During interviews, people said it was
the first time in this region that ambulances were stopped and an ambulance was attacked with
Molotov cocktails in Güroymak.
In relation to this event, people say that it may be relatives of a patient who got mad at late arriving
ambulance though it was for security reasons or some unidentified persons. The lesson to draw is as
follows: As for statements made and attitudes adopted in relation to attacks against health workers,
health premises and ambulances without any serious information and investigation contribute to
vagueness and tensions instead of making progress towards a solution.
In Bitlis centre and in its districts, patients have difficulty in reaching health facilities after dark due to
security concerns. In fact, some 112 stations had to stop delivering services because of clashes. The
112 station in Mutki was closed down since all its workers asked for posting elsewhere. To be more
specific, problems related to patients and reactions against health workers derive from the following:
Checking security conditions first when there is an urgency call for a patient; not letting ambulances
go until security is confirmed and necessity to change routes to reach the patient safely which causes
delays.
Due to curfew at night there is a significant decline in the number of patients applying to urgency
wards while health workers too face difficulties in reaching their duty stations.
There are also problems emerging in basic health services. Prior to the start of clashes, the rate of
immunization was almost 100%, with falling infant mortality rate and zero death from pregnancy
related causes. Now doctors in family medicine cannot deliver these services properly because of
fear and anxiety. Further, health workers having spouses from the military or police are not assigned
duties out of the centre of the town while others have to cope up with a heavy work burden.
There is an increase in the number of health workers who have left the region/applying for some
other post elsewhere. During our visit, we learned that 17‐18 health workers were appointed to
places out of the region.
There is bottleneck in blood donations and local people are unwilling to make donations.
The people of the region want peace now and without any reservation. They ask weapons to be
silenced and paths of democratic politics are opened. Clashes in the region negatively affect, besides
healthcare, other areas too including economic and social life; it threatens social peace and destroys
daily life. Acts targeting health workers and premises force health workers to flee the region, disrupt
and even stop services.
3. Conclusions drawn from interviews, observations and narratives:
Problems that areas visited are confronted with are similar.
i. On‐going armed conflict presents an extraordinary situation where the “WMA regulations in
times of armed conflict and other situations of violence” in relation to the protection of
health services should be carefully observed, but this is not the attitude and policy of official
authorities including security personnel in particular.
8
ii. Protection of healthcare delivery environments and professional independence of health
workers which are crucial for smooth delivery of services is not duly considered and
respected by authorities. Even worse, there are continuous violations by security forces in
particular, which virtually obstructs service delivery.
iii. There is blockage of health facilities especially when wounded security people and suspects
are brought to these facilities and this presence of security forces continue even within inner
spaces of health facilities and during medical treatment.
Hence,
• As in the case of Dr Serdar Acar many health workers face insults and threats while
trying to fulfil their professional responsibilities and they are obstructed to deliver
their services properly.
• People directly or indirectly affected by conflicts face the serious problem of difficulty
in accessing health services (i.e. wounded people abstaining from applying to a
hospital and dramatic decline compared to earlier months in the daily number of
applications to emergency wards and policlinics and the number of inpatients).
• Healthcare delivery environments are both unsafe and targeted.
iv. Hospitals turning into conflict areas and destruction of ambulances and other health‐related
equipment give rise to deep concerns of security in health workers, their families and
patients. It is also a de‐motivating factor for health workers. As a result, there are many
health workers departing by taking leave, appointment to another place or simply resigning.
v. Health workers say they are “psychologically disturbed” and do not want to work because of
on‐going clashes, pressures and threats. The trauma caused by the environment of conflict
manifests itself as anxiety, depression and acute stress reactions. During interviews, health
workers appeared quite weary, disturbed and sometimes desperate. They expressed their
need for psychological support and particularly asked for making what they experienced
more “visible”.
vi. Assaults to health facilities and their extensions including ambulances by yet unidentified
persons further aggravate the situation and prevent the exercise of the right to health by
people.
vii. Besides blocking access to health services, the present environment also causes defects and
other problems in on‐going patient treatments.
viii. Further, it is observed throughout the mission that the environment described triggers
trauma that may have long term implications on people including children in the first place.
4. SUGGESTIONS i. All parties including security forces should be behave and act in a manner to protect health
facilities and their extensions and respect the professional independence of health workers.
ii. Security forces should not be positioned within and close vicinity of hospitals.
iii. Besides local authorities, the Ministry of Health and Ministry of Interior should immediately
take action in this matter crucially important for public health and prevent these attacks
targeting health facilities and workers.
iv. Legal action including effective prosecution of perpetrators of these attacks that cannot be
legitimized in any way should be launched immediately.
v. Public sensitivity about and open protest against attacks on health facilities and their
extensions is necessary and important in preventing such acts of unidentified persons.
9
vi. Although the perpetrators of armed attack against Tatvan Military Hospital are yet not
identified, this act should be denounced and efforts should be made to find and prosecute
these perpetrators.
vii. Remedial and rehabilitative initiatives must be launched to support health workers in what
they have experienced so far.
viii. Dr Serdar Acar who was taken off from his duty should be immediately returned and
necessary remedies should be accorded for this unfair act. Further, legal action should be
taken against those who prevented his work by threats and insults while he was trying to
perform his duties.
ix. Hasan Aşulan, the health intern now under arrest should be released and his medical
treatment should continue.
x. We want to remind that these suggestions may at least mitigate the pain and suffering of
persons exposed to armed conflict environments. It should also be considered that health
and health workers may serve as a bridge leading to peace and contribute to efforts geared
to putting an end to this environment of violence.
Lastly, we want to share the information that we have developed a programme by consulting to all
relevant institutions both within the country and at international level to have our suggestions
considered and implemented.
Activities and initiatives in the context of this programme include interviews with all official
authorities and civil organizations, actions of solidarity with our colleagues working in the region,
employing means of democratic struggle, work for immediate return of Dr Acar to his duty and
release of intern Hasan Aşulan.
15 August 2015
Turkish Medical Association
Union of Health and Social Service Workers
Human Rights Association
Turkish Psychiatrics Society
10
Attachment 1
WMA Regulations in Times of Armed Conflict and Other Situations of
Violence
Adopted by the 10th World Medical Assembly, Havana, Cuba, October 1956,
and edited by the 11th World Medical Assembly, Istanbul, Turkey, October 1957,
revised by the 35th World Medical Assembly, Venice, Italy, October 1983,
the 55th WMA General Assembly, Tokyo, Japan, October 2004,
editorially revised by the 173rd WMA Council Session, Divonne‐les‐Bains, France, May 2006,
and revised by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012
GENERAL GUIDELINES
Medical ethics in times of armed conflict is identical to medical ethics in times of peace, as stated in
the International Code of Medical Ethics of the WMA. If, in performing their professional duty,
physicians have conflicting loyalties, their primary obligation is to their patients; in all their
professional activities, physicians should adhere to international conventions on human rights,
international humanitarian law and WMA declarations on medical ethics.
The primary task of the medical profession is to preserve health and save life. Hence it is deemed
unethical for physicians to:
Give advice or perform prophylactic, diagnostic or therapeutic procedures that are not
justifiable for the patient's health care;
Weaken the physical or mental strength of a human being without therapeutic justification;
Employ scientific knowledge to imperil health or destroy life;
Employ personal health information to facilitate interrogation;
Condone, facilitate or participate in the practice of torture or any form of cruel, inhuman or
degrading treatment.
During times of armed conflict and other situations of violence, standard ethical norms apply, not
only in regard to treatment but also to all other interventions, such as research. Research involving
experimentation on human subjects is strictly forbidden on all persons deprived of their liberty,
especially civilian and military prisoners and the population of occupied countries.
The medical duty to treat people with humanity and respect applies to all patients. The physician
must always give the necessary care impartially and without discrimination on the basis of age,
disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual
orientation, or social standing or any other similar criterion.
Governments, armed forces and others in positions of power should comply with the Geneva
Conventions to ensure that physicians and other health care professionals can provide care to
11
everyone in need in situations of armed conflict and other situations of violence. This obligation
includes a requirement to protect health care personnel and facilities.
Whatever the context, medical confidentiality must be preserved by the physician. However, in
armed conflict or other situations of violence, and in peacetime, there may be circumstances in
which a patient poses a significant risk to other people and physicians will need to weigh their
obligation to the patient against their obligation to other individuals threatened.
Privileges and facilities afforded to physicians and other health care professionals in times of armed
conflict and other situations of violence must never be used other than for health care purposes.
Physicians have a clear duty to care for the sick and injured. Physicians should recognise the special
vulnerability of some groups, including women and children. Provision of such care should not be
impeded or regarded as any kind of offence. Physicians must never be prosecuted or punished for
complying with any of their ethical obligations.
Physicians have a duty to press governments and other authorities for the provision of the
infrastructure that is a prerequisite to health, including potable water, adequate food and shelter.
Where conflict appears to be imminent and inevitable, physicians should, as far as they are able,
ensure that authorities are planning for the protection of the public health infrastructure and for any
necessary repair in the immediate post‐conflict period.
In emergencies, physicians are required to render immediate attention to the best of their ability.
Whether civilian or combatant, the sick and wounded must receive promptly the care they need. No
distinction shall be made between patients except those based upon clinical need.
Physicians must be granted access to patients, medical facilities and equipment and the protection
needed to carry out their professional activities freely. Such access must include patients in
detention centres and prisons. Necessary assistance, including unimpeded passage and complete
professional independence, must be granted.
In fulfilling their duties and where they have the legal right, physicians and other health care
professionals shall be identified and protected by internationally recognized symbols such as the Red
Cross, Red Crescent or Red Crystal.
Hospitals and health care facilities situated in areas where there is either armed conflict or other
situations of violence must be respected by all combatants and media personnel. Health care given
to the sick and wounded, civilians or combatants, cannot be used for publicity or propaganda. The
privacy of the sick, wounded and dead must always be respected. This includes visits from important
political figures for media purposes and also when important political figures are among the
wounded and the sick.
Physicians must be aware that, during armed conflict or other situations of violence, health care
becomes increasingly susceptible to unscrupulous practice and the distribution of poor quality /
counterfeit materials and medicines, and attempt to take action on such practices.
12
The WMA supports the collection and dissemination of data related to assaults on physicians, other
health care personnel and medical facilities, by an international body. Such data are important to
understand the nature of such attacks and to set up mechanisms to prevent them. Assaults against
medical personnel must be investigated and those responsible must be brought to justice.
CODE OF CONDUCT: DUTIES OF PHYSICIANS WORKING IN ARMED CONFLICT AND OTHER
SITUATIONS OF VIOLENCE
Physicians must in all circumstances:
Neither commit nor assist violations of international law (international humanitarian law or
human rights law);
Not abandon the wounded and sick;
Not take part in any act of hostility;
Remind authorities of their obligation to search for the wounded and sick and to ensure
access to health care without unfair discrimination;
Advocate and provide effective and impartial care to the wounded and sick (without
reference to any ground of unfair discrimination, including whether they are the "enemy";);
Recognise that security of individuals, patients and institutions are a major constraint to
ethical behaviour and not take undue risk in the discharge of their duties;
Respect the individual wounded or sick person, his / her will, confidence and his / her dignity;
Not take advantage of the situation and the vulnerability of the wounded and sick for
personal financial gain;
Not undertake any kind of experimentation on the wounded and sick without their real and
valid consent and never where they are deprived of liberty;
Give special consideration to the greater vulnerability of women and children in armed
conflict and other situations of violence and to their specific health‐care needs;
Respect the right of a family to know the fate and whereabouts of a missing family member
whether or not that person is dead or receiving health care;
Provide health care for anyone taken prisoner;
Advocate for regular visits to prisons and prisoners by physicians, if such a mechanism is not
already in place;
Denounce and act, where possible, to put an end to any unscrupulous practices or
distribution of poor quality/counterfeit materials and medicines;
Encourage authorities to recognise their obligations under international humanitarian law
and other pertinent bodies of international law with respect to protection of health care
personnel and infrastructure in armed conflict and other situations of violence;
Be aware of the legal obligations to report to authorities the outbreak of any notifiable
disease or trauma;
Do anything within their power to prevent reprisals against the wounded and sick or health
care;
Recognise that there are other situations where health care might be compromised but in
which there are dilemmas.
13
Physicians should to the degree possible:
Refuse to obey an illegal or unethical order;
Give careful consideration to any dual loyalties that the physician may be bound by and
discuss these dual loyalties with colleagues and anyone in authority;
As an exception to professional confidentiality, and in line with WMA Resolution on the
Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or
Cruel or Inhuman or Degrading Treatment and the Istanbul Protocol[1], denounce acts of
torture or cruel, inhuman or degrading treatment of which physicians are aware, where
possible with the subject's consent, but in certain circumstances where the victim is unable
to express him/herself freely, without explicit consent;
Listen to and respect the opinions of colleagues;
Reflect on and try to improve the standards of care appropriate to the situation;
Report unethical behaviour of a colleague to the appropriate superior;
Keep adequate health care records;
Support sustainability of civilian health care disrupted by the context;
Report to a commander or to other appropriate authorities if health care needs are not met;
Give consideration to how health care personnel might shorten or mitigate the effects of the
violence in question, for example by reacting to violations of international humanitarian law
or human rights law.
[1] Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment, OHCHR, 1999