International Committee of the Red Cross (ICRC)

Evidence to the House of Commons Foreign Affairs Committee inquiry:

Global Health Security (GHS0023)

Background

1. The International Committee of the Red cross (ICRC) is an impartial, neutral and independent organisation whose exclusively humanitarian mission is to protect the lives and dignity of the victims of armed conflict and other situations of violence and to provide them with assistance. The ICRC also endeavors to prevent suffering by promoting and strengthening international humanitarian law (IHL) and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the Geneva Conventions and the International Red Cross and Red Crescent Movement. It directs and coordinates the international activities conducted by the Movement in armed conflicts and other situations of violence.

Introduction

2. The Covid-19 pandemic does not stop at national borders and crosses swiftly any frontlines in armed conflict, an experience seen by the ICRC every day. And it is from this standpoint that we focus our inputs for this important call for evidence which could not come at a more crucial moment. For example, Yemen is one of the worst affected contexts where Covid-19 has become an additional, devastating layer of destruction to an already protracted conflict.[1]
    
3. ICRC’s internal Covid-19 Economic Vulnerability Index (CEVI), which is based on ICRC data and publicly available sources, shows that the drivers for countries’ vulnerability to the pandemic are diverse and intertwined.[2] The most common underlying factor of vulnerability is, first of all, conflict, followed by macroeconomic instability, which was already affecting the economies and the lives of the most vulnerable in such contexts.
    
4. Prime Minister Johnson at the G20 Summit urged leaders to “work together to defeat the pandemic and protect the planet”.[3] He is right. The promising prospect of a vaccine to halt the devastating spread of Covid-19 presents the UK with the unique opportunity to realise its global force for good ambition[4] - by safeguarding humanity with equitable vaccine access. Putting this at the centre of the FCDO’s Covid-19 diplomacy, at one of the most critical points of global cooperation since the end of the Cold War, can advance UK’s standing in the world and save millions of lives.

Summary of our actionable recommendations

5. The UK uses it full diplomatic weight to guarantee equitable access to the Covid-19 vaccine, especially to those affected by armed conflict.
   
   Committing to equitable access as Prime Minister Johnson did at the G20 summit means to turn towards critically vulnerable populations and pivot diminishing UK aid resources to those most in need.
   
   Concretely, the UK
    

-          uses its full diplomatic weight to protect and safeguard the health of people affected by conflict and violence to mobilise states to commit to equitable access.

-          influences government and non-government stakeholders in armed conflicts to respect localised ceasefires to allow access for vaccinators across front-lines in hard to reach areas.

-          initiates in the UN Security Council (UNSC) the drafting process of key recommendations for equitable access in conflict contexts based on International Humanitarian Law (IHL),[5] humanitarian principles and the non-discrimination principle underpinning the right to health.[6]

-          advocates to avoid the “Covid-19-only tunnel vision” through its lead role at the WHO and GAVI to maintain and strengthen routine immunisations and essential health services.
 

6. The UK invests in the protection of health workers and independent, impartial delivery of health services, creating the foundations for an effective health response to battle Covid-19.
   
   The UK rises to the occasion and leads decisively the promotion of the safeguarding of health professionals. Without protection of health services, there is no effective health delivery.
   
   Concretely, the UK
    

-          reinforces and advocates for unconditional support of UNSC resolution 2286 (2016)[7] which calls for the protection of the health care provision in armed conflict.

-          improves through its privileged relationship with armed forces around the globe the primacy of safeguarding patients and health workers as stipulated under IHL.

-          supports the need to separate security enforcement and medical roles to enhance respect for medical principles and ethics and avoid over securitization of health services.

-          calls for governments and communities to address misinformation fueling incidents that lead to stigmatization of health professionals and patients.
 

7. The UK takes the lead in protecting critical medical infrastructure against cyber-attacks and thus reduces populations to be exposed to devastating consequences in the event of cyber incidents.
   
   In today’s era of a pandemic, cyber-attacks against critical infrastructure such as health facilities that are moving increased digitization are nothing else than a humanitarian crisis in the making.[8]
   
   Concretely, the UK
    

-          leads by example, commits to the application of IHL in cyberspace, especially the preservation of medical infrastructure, and advocates that other states do the same.
 

-          fulfils the vision expressed by Prime Minister Johnson on ethical and responsible technology[9] and leads a global effort to reaffirm applicable international law, norms and standards in the protection of medical assets.
 

-          continues to support the work at the UN open-ended working group on developments in the field of information and telecommunications to ensure that information communication technology activity does not harm medical services.

“What role should the FCDO play in bringing about a resolution to the Covid-19 pandemic and preventing future pandemics?”

What is at stake: equitable access to the Covid-19 vaccine to those most in need requires dedicated UK leadership to those affected by armed conflict to avoid potential vaccination “blind spots”.
 

8. The political dynamics around the development and distribution of a COVID-19 vaccine risk further exacerbating the secondary impacts of the pandemic in humanitarian settings. While the ACT Accelerator is the main initiative pooling efforts to develop and distribute a COVID-19 vaccine, and while USD8.8 billion surpassed the ask-for USD7.4 billion at the June 2020 GAVI conference, political uncertainties remain about how ensuring “equitable access” will function in practice.
    
9. There is a concern that protectionist tendencies in the early stages of the crisis may be harbingers of future political dynamics which will not be conducive to an equitable roll-out of the vaccine, including in low resource countries where public health measures to prevent and curb infections are harder to implement. Still, the history of overcoming deadly diseases shows that at moment of global dissonance, global cooperation is possible. The end of smallpox 40 years ago at the height of the Cold War proves this.[10]
    
10. This is why, at the height of the pandemic, on 3 June 2020, the ICRC together with the International Federation of Red Cross (IFRC) and the United Nations (UN), issued a call[11] for a “people´s vaccine” for equitable access to a vaccine to the hardest to reach populations: vulnerable girls and women, boys and men. The elderly. Detainees. The 26 million refugees.[12]
     
11. There is another population of the most vulnerable that too often goes unnoticed. ICRC estimates that 66 million people who live under the state-like governance of a non-state armed group and remain out of reach of government services due to conflict. Reaching these populations underline the critical nature of the full and safe access by impartial and independent humanitarian agencies like the ICRC to negotiate with any parties to a conflict and provide humanitarian support to affected populations anywhere in the world.[13]
    
12. Committing to equitable access means to turn towards critically vulnerable populations, especially in armed conflicts. This is fully consistent with the first principle of the new UK Humanitarian Reform policy: “(UK’s) steadfast support for international humanitarian law and humanitarian principles and protecting the most vulnerable.”[14] Not only the ICRC, but the 216 million people affected by humanitarian crisis[15] hope that the UK embraces this formidable challenge and pivots diminishing UK aid resources to those most in need.
     
13. Our actionable recommendations for the FCDO to achieve equitable access of the Covid-19 vaccine to the most vulnerable, especially in contexts of armed conflict and violence.

-          Besides its role as the largest contributor to the GAVI COVAX AMC, the UK takes its full diplomatic weight to protect and safeguard the health of affected people by conflict and violence to mobilise states to commit to equitable access now by supporting global vaccine efforts implemented without adverse distinction.

Concretely, through its seat at the UNSC, the UK could rectify the UNSC’s lukewarm response to the UN General Secretary call for a global ceasefire at the beginning of the pandemic and the UK could encourage, and where it has influence support directly, government and non-government stakeholders in armed conflicts to respect localised ceasefires to allow access for vaccinators across front-lines in hard to reach areas. ICRC stands ready to advise the UK how these complicated and delicate, often local arrangements provide a neutral space for vaccinators, local communities and authorities, including non-state armed groups (NSAG).
 

-          In times of reduced donor state budgets and given that supply of a vaccine will initially be limited, target the most vulnerable first must be the obvious choice of UK’s stated commitment for equitable access. Access to the populations affected by conflict and violence should be the priority. Ensuring vaccination of the most vulnerable is today’s endurance test for adhering to the principles of Humanity and Impartiality. IHL provides a basis for this.

Concretely, UK through its permanent seat at the UNSC could initiate the drafting process of key recommendations for equitable access in conflict contexts based on IHL, humanitarian principles and the non-discrimination principle underpinning the right to health can guide such criteria. ICRC stands ready to advise the UK in drafting such recommendations that can save the lives of the most vulnerable.
 

-          UK should take the lead to remind others to avoid the “Covid-19 only tunnel vision”. Covid-19 has severely hit routine childhood immunisations in at least 68 countries; measles campaigns have been suspended in 27 countries; and polio campaigns put on hold in 38 countries. At least 80 million children under one are at risk of diseases with significant mortality such as measles, diphtheria and polio.

Concretely, through its support to the health of populations through its lead role at the WHO and GAVI, the UK should lead by example to maintain and in fact strengthen routine immunisations and essential health services to ensure efforts to combat this pandemic do not cause resurgences in other preventable diseases.

“How effective is the UK’s current approach to global health security?”

What is at stake: Without protection and safeguards for health workers and the space for independent, impartial delivery of health services there is little chance for effective Covid-19 vaccination campaigns.

14. The Covid-19 pandemic has reinforced the importance of safeguarding health workers, health assets and, crucially, patients. Health professionals, especially in armed conflict, have as much protection under IHL as, for example, as journalists - referring to the UK’s recently announced plans to improve the safety of journalists, in the UK as well as in conflict zones.[16] There is now a similar opportunity for the UK to take the lead to promote the safety of health professionals. Any response to tackle health problems can only be effective, if those who deliver it can do so in full confidence that they are never under attack.
     
15. Earlier this year, health professionals around the globe were rightfully applauded for their indefatigable efforts to provide care for Covid-19 patients. Sadly, at the same time the very same staff experienced violence and aggression. For example, the UK South Western Ambulance Service (SWASFT) NHS Foundation Trust reports about 100 of their staff being assaulted per month while on duty.[17]
     
16. The ICRC makes the same experience in its 80 operations in today’s armed conflicts around the globe. In May 2020, ICRC President Peter Maurer highlighted to the UNSC that “at a time when helpers are most needed, they are under attack. Health systems are targeted, health workers are abused. Since March this year, the ICRC has recorded 208 COVID-19-related attacks against healthcare in more than 13 countries.”[18] The situation has not improved. By August, ICRC reported from February to July at least 611 reported incidents across more than 40 countries. More than 20 per cent involved physical assaults, 15 per cent were incidents of fear-based discrimination, and 15 per cent were verbal assaults or threats.[19] Health care workers in all regions of the world have often experienced stigmatisation from their own communities, sometimes leading to verbal or physical violence as recently highlighted by ICRC.[20]
     
17. The protection of health workers is also about the safeguarding of the space for independent, impartial delivery of health services, especially in armed conflicts. Securitised pandemic responses can easily jeopardize patients’ rights and confidentiality and undermine faith in the government and health care providers. State security measures can undermine community trust in health care and endanger health workers, as highlighted in a recent ICRC research about the interface between healthcare and law enforcement.[21] When incidents are committed by community members, fear of the spread of Covid-19 played a significant role. The ICRC therefore calls for governments and communities to address misinformation fueling these incidents.
     
18. Our actionable recommendations for the FCDO to make UK’s and the international community’s current approach to global health security more effective, especially in contexts of armed conflict and violence.
     

-          At the global and multilateral level, through its seat in the UNSC, the UK should reinforce the commitments of the UNSC resolution 2286 (2016) that condemned attacks against medical facilities, personnel and patients in conflict.[22] This rare moment of consensus within the UNSC must be revived now in the roll out of the Covid-19 vaccine to the most vulnerable in armed conflict.

Concretely, the UK, through the weight of its permanent seat at the UNSC and its often stated ambition to lead by example to protect IHL, should decisively and repeatedly recall for a unequivocal and unconditional support for all measures for the protection of the health care provision as highlighted in UNSC resolution 2286 (2016), namely that under IHL medical personnel, units and transport exclusively assigned to medical purposes must be respected and protected in all circumstances. In occupied territories, the occupying power must ensure and maintain medical and hospital establishments and services, public health and hygiene. In addition, IHL provides for the possibility of setting up hospital zones that may be dedicated to addressing the current pandemic. The ICRC stands ready to advise the UK how IHL provides crucial safeguards during pandemics.[23]
 

-          At the national and local level in fragile, conflict prone and conflict affected contexts, the UK can through its privileged relationship with numerous states and their respective armed forces and security services improve the primacy of health safeguards that puts an emphasis on safeguarding patients and health workers over securitization of health services. This could be an important contribution of the UK to the refinement of the Global Health Security Agenda (GHSA), a group of states, international organizations, INGOs and private sector united by the ambition of a world safe and secure from global health hazards posed by infectious diseases.[24]

Concretely, the UK can play a unique role to advocate for safeguarding health services to operate, instead of securitising health services at “gun point”.[25] Communities trust in health services as well as vaccination cannot be forced, but it can be earned. Where UK and/or their partner armed forces or law enforcement agencies are involved in supporting public health measurers, there is a need to separate security enforcement and medical roles to enhance respect for medical principles and ethics. The UK, with its privileged relationships with many armed forces, can do exactly that. The ICRC stands ready to advise the UK how to best handle the delicate interface between healthcare, armed forces and law enforcement in armed conflict.

What lessons has the COVID-19 pandemic taught us about the importance of international collaboration in securing global preparedness and resilience against biosecurity threats?

What is at stake: health facilities need immediate protection from cyber-attacks.

19. Global health security and cyber-attacks might look like an odd couple at first sight. Clearly, the are not. In today’s era of a global pandemic, cyber-attacks against critical infrastructure, especially health facilities, are nothing else than a humanitarian crisis in the making.[26] This puts already exposed populations at risk of potentially devastating consequences in the event of a major cyber incident.
     
20. The health-care sector is moving towards increased digitisation and interconnectivity. For example, medical devices are connected to the hospital’s information technology (IT) system to enable automatic electronic filing. Connected biomedical devices, such as pacemakers and insulin pumps, make it possible to remotely monitor individual patients’ health as well as the functioning of the medical devices themselves. However, increased digital dependency has not been matched by a corresponding improvement in cyber security to protect health and life.
     
21. The ICRC’s 2019 report International Humanitarian Law and the Challenges of Armed Conflict[27] presents a thorough assessment of the foreseeable humanitarian impact of new technologies on warfare. It outlines the challenges they may pose to existing IHL rules and interrelated legal, military, technical, ethical, and humanitarian considerations.
     
22. Medical facilities are particularly vulnerable to hostile or malicious cyber operations. In times of health crisis hospitals are needed more than ever. The cyber-attacks that have been made public range from ransomware operations, aimed at crippling primary and urgent care networks in exchange for pay-outs, to disinformation campaigns aimed at undermining and disrupting wider elements of the response to the pandemic, including testing and vaccine research facilities. Where successful, these attacks have interrupted the provision of health care and put additional costs on health-care providers.
    
23. Alarmingly, such incidents were on the rise already before the current Covid-19 pandemic, for example, the number of reported cyber-attacks in the United States increased by 63 per cent between 2015 and 2016 (93 major attacks in total), while breach incidents have reportedly increased by 10 per cent every year since 2010.[28]
     
24. Our actionable recommendations for the UK to secure global preparedness and resilience against biosecurity threats in the cyber space.
     

-          The ICRC is aware of UK’s recently announced ambitions to create a National Cyber Force and a new “Space Command” that aims at protecting the UK’s interests in these spaces.[29] Although the UK has recognised that IHL applies to cyber operations within armed conflict, little further detail has been expressed on how it applies. If states like the UK take clear positions about their commitment to interpret IHL in cyberspace, such as the preservation of medical infrastructure from significant disruption and protection of civilian data, this will have very clear, real world effect and limit civilian harm.

Concretely, the UK continues to support the UN open-ended working group on developments in the field of information and telecommunications in the context of international security. This could elaborate on existing norms around what is critical infrastructure, or be a new norm in of itself, both looking to find ways of ensuring that States do not conduct or knowingly support information communication technology activity that would harm medical services or medical facilities and harm.[30]
 

-          The protection of medical facilities during armed conflict is at the heart of IHL, especially in the cyber space. The Geneva Conventions leave no doubt: medical facilities and their staff must be respected and protected. Belligerents must not harm medical infrastructure through cyber operations and must take great caution to avoid incidental harm caused by such operations. Further parties to armed conflicts must take all feasible precautions to protect civilians and civilian objects under their control against the effects of attack. This is one of the few IHL obligations that states must already implement in peacetime.

Concretely, the UK could become a leader in the global effort to reaffirm applicable international law and assert norms and standards in the protection of medical assets that will guide emerging technologies, and to that end include humanitarian issues in the international summit in London proposed by the Prime Minister on the subject of ethical and responsible technology.[31] The ICRC stands ready to engage with the UK in this regard.

Regional Delegation for the UK & Ireland
International Committee of the Red Cross (ICRC)

December 2020

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