COVID-19 exacerbates violence against health workers.

Hundreds of incidents of violence and harassment have been recorded, but these are likely to be just the tip of the iceberg. Sharmila Devi reports.

More than 600 incidents of violence, harassment, or stigmatisation took place against health-care workers, patients, and medical infrastructure in relation to the COVID-19 pandemic, the International Committee of the Red Cross (ICRC) said in a statement on Aug 18.

These incidents were probably only the “tip of the iceberg”, with many others unrecorded, Maciej Polkowski, the head of the ICRC's Health Care in Danger initiative, told The Lancet. “Unfortunately, these figures were not a surprise because violence is often exacerbated by emergencies”, he said. “We know from cross-sectional studies that the majority of health workers have experienced violence in the workplace that varies from country to country and their thresholds of violence.”

The ICRC said that 611 incidents were recorded between Feb 1 and July 31, 2020. Although patients and medical infrastructure were often targeted, 67% of incidents were directed at health-care workers. More than 20% involved physical assaults, 15% were incidents that the ICRC classed as fear-based discrimination, and 15% were verbal assaults or threats.

The incidents included doctors at a hospital in Pakistan being verbally and physically attacked after a patient died of COVID-19 and relatives entered a high-risk area while shouting that coronavirus was a hoax. In Bangladesh, bricks were thrown at the house of a doctor after he tested positive for COVID-19 in a bid to force him and his family from the area.

“It's difficult to capture all incidents using surveillance and not just the high-profile, high-intensity attacks involving international staff. Local workers in national health systems bear the brunt of violent attacks that don't get reported”, said Polkowski.

“Many professional associations of health-care workers have been sounding the alarm for the past decade about violence getting worse and worse, not just in conflict zones but also in high-income, industrialised, and peaceful countries.”

Humanitarian Outcomes, an independent research organisation that tracks major attacks on health workers engaged in an aid response, recorded its highest annual death toll last year, since it began compiling data in 1997. 483 humanitarian aid workers were killed in 2019, including 53 health workers, according to a report on Aug 17.

The Humanitarian Outcomes report said health staff were repeatedly targeted in Syria, the most violent country for aid workers, with 47 attacks and 36 deaths last year. Violence against humanitarian health workers also surged in DR Congo. Many of the incidents reported in DR Congo last year were committed against health workers responding to the Ebola virus disease outbreak.

“Internal, fragmented civil conflicts with international elements have been on the rise since the second world war. In a traditional war, the parties have an incentive to maintain a humanitarian presence to treat their war wounded or prisoners of war. Non-state groups have few [such] incentives and quite a few to attack”, said Abby Stoddard, a partner at Humanitarian Outcomes.

The Safeguarding Health in Conflict Coalition, a group of non-governmental organisations working to protect health workers in conflict zones, said in a report released in June that 151 such workers were killed in 2019.

Humanitarian health workers were being targeted in two main ways, said Stoddard: through attacks on health facilities, such as air strikes on hospitals; and through attacks by patients, patients' families, and the wider community.

The pandemic will likely further the trend of aid agencies using more local staff than international staff. “It is very problematic that casualty rates are three times higher for local staff compared with internationals”, she said.

In May, 13 humanitarian organisations including the ICRC called on governments to implement laws against attacks on health-care workers during the COVID-19 pandemic, to provide safer working environments, offer mental health support, and tackle misinformation.

Some countries have taken action. Sudan announced on May 23 that it would create a police force to protect health facilities after doctors threatened to go on strike following attacks. In April, India made violence against health-care workers a non-bailable offence punishable by up to 7 years' imprisonment. The Indian Medical Association had demanded legislation after many incidents of violence and harassment of doctors

In June, the ICRC, along with partners including WHO, produced a checklist for managers of health-care services, practitioners, and policy makers worried about violence during the pandemic. The checklist encourages local risk assessment, informed response measures, and accountability towards those receiving care as a means to prevent violence.