New Delhi: Quratul Ain Razavi, a second-year postgraduate in dermatology at Tehran University's Razi Hospital, is one of six international medical students who refused evacuation, choosing to stay in Iran as tensions rose in February.

While her Kashmiri family living in Jammu insisted on her return, she remained adamant. Her decision, she said, had nothing to do with politics but was grounded in principle. “It's the Hippocratic Oath,” she added.

“How could I leave when people need doctors the most?” she asked.

The hospital, she said, provided her with proper accommodation, and there was no pressure to leave. While her hospital was saved, a branch on the other side of the city was hit. “Our university was one of the first ones to be hit as well,” she added.

In March, the WHO verified 13 attacks on health facilities in Iran since the conflict began in February, with nearly 1,000 deaths reported in Iran, and 50 in Lebanon. The WHO said Lebanon witnessed the closure of 43 primary health-care centers and two hospitals.

In April, however, Iran's health ministry estimated that 3,375 people had died, with the HRANA rights group reporting 1,701 civilian deaths, including at least 254 children.

Similarly, at least 2,167 people have been killed in Lebanon now, compounding the regional toll.

Razavi, 25, has attended to scores of patients injured during the conflict. “Most of the patients were injured after building collapses; sometimes the injuries were grave, and we lost many patients,” she added. Razavi said that as attacks escalated, the doctors from the university hospital would visit other smaller hospitals and dispensaries to treat the injured.

Most Indian medical students were evacuated from Tehran to Armenia, crossing the land border as the airspace was closed, followed by special flights from Yerevan to Delhi.

Attacks on health infrastructure

Early this week, Tehran reported that more than 210 health centres had been targeted across the country. The health ministry stated that a considerable number of these centres were “rural health houses, serving small and local populations”.

Deputy health minister Shahin Akhondzadeh, in a press statement, said six hospitals have been forced out of service, including Shahid Khalij Fars Hospital in Bushehr, a key medical province.

In what he called a devastating blow to the country’s health sector, the minister said: “Many dedicated medical workers, including doctors, pharmacists and paramedics, have been martyred in the attacks.”

He said a sea ambulance traveling from Hormuz Island to Bandar Abbas, transporting critical patients, was attacked and destroyed. “It was a shameful act of aggression,” the minister said.

Waseem Reza, a Kashmiri scholar teaching and researching theology in Iran, mourns the loss of Mahatma Gandhi Hospital in Tehran. “It was one of the largest multi-specialty children's hospitals in Tehran, now it's all shattered buildings, defunct equipment and broken cribs,” he added. Reza especially mourned the hospital's loss because of its association with Gandhi.

A study showed that despite formal humanitarian exemptions, sanctions in Iran have caused critical shortages of medicines and medical supplies, with a 10-20% foreign currency shortfall for pharmaceutical procurement predating the first strike.  A “foreign currency shortfall” in Iran refers to the inability of the Iranian government and pharmaceutical importers to secure sufficient hard currency (such as US dollars or euros) to purchase imported medications and raw materials for domestic drug production.

The war is said to have further affected supplies.

While Razavi and Reza chose to stay back and serve the country in war, funded by voluntary donations, the Iranian embassy in New Delhi facilitated the shipment of 65,000 kg of medicines to Iran in March and April, including via the Red Crescent Society of Iran.

Consequences far greater than the war

Experts say the indirect consequences of conflicts are likely to be far greater than the fatalities. Disruptions in the management of maternal and neonatal care, chronic diseases and mental health services generate excess mortality and long-term morbidity that often surpass direct battle-related fatalities. Controlling infectious diseases also takes a hit.

The onslaught on medical care unfolds against the backdrop of decades of economic sanctions and the structural weakness of the healthcare system.

“Inflationary pressures, restricted procurement pathways for essential medicines and environmental stressors such as water scarcity have already strained institutional resilience. Although humanitarian exemptions exist in principle, practical obstacles in banking, insurance and trade frequently impede access to medicines and medical equipment. Women, children, refugees and socioeconomically marginalised populations bear disproportionate burdens, [further widening] pre-existing inequalities in access to care,” says a commentary in the April issue of The Lancet Regional Health.

Eminent public health expert and founder chancellor of the Public Health Foundation of India, Dr K. Srinath Reddy, agrees that armed conflict amplifies these vulnerabilities and accelerates health system deterioration. “The conflict has impacted health services. Look at what’s happening to hospitals and even ambulances – everything is being shattered. Hospital care cannot be assured because the infrastructure and health care personnel are affected.”

The indirect consequences are visible in the supply chain: as of mid-March WHO's Global Health Emergencies Logistics Hub in Dubai was on hold. At least $18 million in humanitarian health supplies were blocked, affecting more than 50 emergency supply requests from 25 countries. This blockade included $6 million worth of medicine for Gaza that could not be delivered.

“Surging oil prices are affecting the supply chain, which can result in a shortage of drugs. Shortage of raw materials is hitting the plastic and pharmaceutical industries. While I don’t have a complete list, a lot of raw material for pharma is dependent on the Gulf,” Dr Reddy added.

Global effect on healthcare

Emerging evidence suggests that increases in military spending come at a cost. A study analysing cross-country data says that for every 1% increase in military spending, there is a 0.62% reduction in public health spending per capita. The smaller countries are affected more, with a 1% increase in military spending resulting in a drop of 0.96%.

The Lancet in its April issue says that evidence from 1990 to 2017 links conflict to an estimated 29.4 million excess deaths from indirect causes alone, such as disrupted health services. These include the ones due to disrupted access to care.

While these deaths don’t make headlines, they constitute the bulk of the human cost.

“While the budgets may decrease, the healthcare spending of the households is increasing,” said Atul Sharma, a pharma expert working in the pharma industry and an adviser to many hospitals.

A study found that 70% of households surveyed in Gaza reported increased healthcare costs during the conflict. “Ukraine was forced to increase the budget manyfold,” Sharma added.

“A lot of impact will be not only on Gulf countries but also on Africa and others as well. Spending on war will affect the amount of foreign aid and impact healthcare worldwide, Dr Reddy added.

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