April 7, 2011
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Health facilities in Bahrain have been drawn into the center of the country’s current unrest and clashes between government and opposition protestors that began in February 2011. The result is an unacceptable circumstance in which medical facilities—which are generally functioning well in terms of material, infrastructure and skilled staff—now no longer impartially serve the medical needs of the population.
Hospitals and health clinics are no longer places to go for the sick or injured, but are rather places to be feared. As the military cracks down on protestors and medical personnel Médecins Sans Frontières/Doctors Without Borders (MSF) has witnessed patients with critical and life-threatening injuries refusing to go to the hospital due to high levels of fear.
Their fear is not unfounded. Wounds are used to identify demonstrators, restricted access to health care is being used to deter people from protesting, and those who dare to seek treatment in health facilities are being arrested.
Although MSF has been blocked from addressing this issue on a larger scale, the organization has been able to provide basic medical care to the patients it has met in their homes when there has been no other option for them.
All patients have a right to seek and receive treatment in a safe environment, and all medical staff have a fundamental duty to administer treatment without discrimination. To ensure that this is able to happen, all health facilities—particularly Salmaniya, the only public referral hospital in Bahrain—must be demilitarised and depoliticized, and health care must not be used as bait to lure patients into situations where they are identified and arrested.
As the situation continues to evolve, MSF will remain prepared to respond to any further medical needs or potential casualties that could arise out of the ongoing tension.
Climate of Fear
I. Salmaniya: from a political platform to an occupied hospital
SalmaniyaHospital is the public referral hospital for the whole of Bahrain. However, when MSF visited the hospital on 21 March, it was virtually empty. This is a direct result of the way in which the hospital has been used in the clashes between the military and opposition protestors.
Following a military operation against protestors on 17 February, many sought refuge in the Salmaniya Hospital grounds. Salmaniya was seen as a safe place for the opposition protestors to go. During this time, as the protests continued, wounded demonstrators were received in Salmaniya as well. When ambulances were blocked from reaching patients, the doctors at the hospital began leading protests themselves.
Regardless of the reasons, health professionals making speeches and leading protests directly from the steps of the entrance to the hospital undermined the concept of a neutral hospital, as did the anti-government slogans painted onto the walls of the hospital.
Instead of asserting the neutrality of the medical structures, the government declared Salmaniya Hospital a legitimate military target, calling it a “stronghold of the opposition protestors.” This completely and wrongfully undermined the notion that all patients have a right to treatment and all medical staff have a fundamental duty to administer treatment. This military reaction was exponentially more damaging to the trust in the health system than the activities of the opposition protestors.
On 16 March, the military took over the hospital and established checkpoints with tanks and masked military personnel all around its perimeter. Patients arriving at the hospital were searched and their identity numbers checked. The cordon blocked doctors who had gone home between shifts. The wounded within Salmaniya were centralized in one ward, which was controlled by the military. MSF has met different patients in their homes who confirm that they were systematically beaten and intimidated within the ward, to the point that some tried to escape but where caught, arrested, and taken to police stations where they were further beaten and humiliated. Many patients with whom MSF was in contact with, had not only suffered physically from the beatings, but also psychologically.
The disregard shown by the military within Salmaniya also extends to health centers in the villages. MSF has visited health centers that were attacked by the military on 15 March. Tear gas was shot into health facilities, protestors were arrested within the facilities, health workers were questioned and threatened, ambulances were shot at, and health workers were beaten, including those who had travelled out of the health facilities to reach the patients. Overall, this has undermined the status of health facilities as safe places and resulted in a high level of trauma among health workers, compromising the ability of the facilities to function effectively.
II. The use of medical needs and facilities to identify and arrest patients
The clashes between the military and the protestors have resulted in numerous kinds of wounds. The most common wound is from the use of the bird-shot gun on protestors. Bird-shot is a shot gun cartridge that contains a multitude of small pellets. The wounds associated with bird-shot range from minor superficial wounds to more serious injuries such as perforated retinas and deeper tissue wounds—depending on the range at which people are shot. Some patients can have hundreds of wounds from the small pellets. These very distinctive wounds have been used to identify who has been involved in protest action. If these marks are seen by the police or military, the person will be immediately arrested.
Those who do risk going to a health center in the villages with these wounds are at risk of being arrested within the health center, as health workers are supposed to report these wounds to the police and register the patients. If a patient is critical, they will have to be referred from the health center or go directly to a hospital. However, the same registration system exists at hospitals.
MSF was contacted about two critically injured patients who finally agreed to seek medical care at private hospitals but were arrested by police and Ministry of Interior personnel when they arrived. At least one of these patients was taken to the military hospital. However, the family has not been informed about the patient’s condition. Incidents such as these further increase the fear of going to health facilities for treatment.
In addition, the blood bank is centralized in Salmaniya Hospital, from which it is dispatched to private hospitals. This means when private hospitals request blood, the military is once again alerted to the presence of wounded individuals.
Even ambulances are no longer seen as neutral medical facilities providing a service to patients. The police now escort most ambulances. Thus, ambulance transportation is firmly associated with the police and military and is not regarded as an impartial means for people to receive treatmentregardless of their political affiliations or protest involvement.
Many wounded therefore remain at home, unwilling to seek treatment at health facilities for even the most critical needs. Many require secondary care with surgical interventions. MSF has witnessed this first hand by visiting patients in their homes in many of the villages.
III. Medical workers targeted
There is also a crackdown on medical professionals. Doctors have told MSF that they are afraid to provide treatment to people wounded in the clashes in case they are then arrested. Many doctors and other health professionals have even been too afraid to talk with MSF about the situation or discuss how MSF can help in responding to the medical needs.
IV. A breakdown within health facilities
In addition to the breakdown of trust between patients and the health facilities, there is also a high level of polarisation between health workers within the health facilities, including Salmaniya.
The high level of trauma among health workers makes this polarization even worse. They have had to deal with medical casualties on a scale that they were neither expecting nor prepared for. The subsequent military blockade of health facilities, and in some instances, the targeting of health centers, has created a high level of fear for health workers who do not feel safe inside health facilities.
These tensions are undermining the effective collaboration between health workers with different political or sectarian backgrounds, which in turn are crippling the effective functioning of the health system.
Considering the civil unrest and the involvement of armed forces in military and security operations in Bahrain, MSF wishes to stress the necessity and duty of the authorities to respect relevant rules of international humanitarian law, especially those concerning the protection and respect of medical structures and medical personnel. These rules also extend to the protection of civilians, the sick or injured, and to prisoners.
As a state party to the Geneva Conventions of 1949 and its Additional Protocols of 1977, Bahrain must comply with the mandatory rules laid down in these conventions, (including common article 3 to the Geneva conventions), as well as with the rules of customary international law.
In accordance with these rules, the military must allow health facilities in Bahrain to resume their core activity of treating patients in an impartial way.
MSF is still working on securing permissions from the authorities that will enable it to address the crucial issue of patients being too afraid to access health facilities. At the same time, MSF is currently able to play a role in responding to the trauma caused by recent events through a psychological support program for health workers.
If the military does not remove itself from the hospital and if patients continue to be arrested in health facilities, those in critical need of medical attention will remain at home, risking delayed treatment, and, ultimately, their lives.
Steps must be taken to restore the population’s ability to receive treatment without fear by removing the military from Salmaniya Hospital. The opposition protestors should also guarantee that the hospital will not be used as a political platform or a rallying point for protests.
However, the responsibility for restoring the functioning of the health services in Bahrain is in the hands of the authorities. The police, military, and intelligence services must stop using the health system as a way to crack down on the protestors and must allow medical providers to return to the primary duty of providing health care regardless of patients’ political or sectarian affiliations.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)