Across Iran, Iraq, Lebanon, Palestine, Syria, Jordan, Israel, Kuwait, Bahrain, Qatar, UAE and Saudi Arabia, over 3,000 people have been killed as of 25 March. And the toll will continue to increase. We do not have accurate figures for either deaths or injuries. Health information is highly sensitive and difficult to verify, but the daily reporting of casualties across the region reflects the brutal reality of major civilian casualties. Iran has reported significant casualties, with some of the most severely injured transferred to major hospitals in Tehran, Isfahan, Shiraz, and Mashhad, cities which are themselves under sustained bombing by US-Israeli forces. Attacks against healthcare facilities have also been reported by the World Health Organisation, with hospitals such as the burns facility Khatam al-Anbiya Hospital, the Motahari Hospital and Valiasar Hospital in Tehran sustaining damage and evacuating patients to alternative settings. Once again, however, the full extent of the damage is difficult to assess accurately, given limited access to a highly contested and sensitive information space.
The direct targeting of healthcare facilities is only part of a wider infrastructure problem. Munitions used in Epic Fury generate an explosive blast that produces an intense overpressure wave capable of levelling buildings and causing severe casualties over a wide radius of up to 1 km. Even at 5 km from the impact, under the right conditions, the shockwave can be sufficient to incapacitate sensitive hospital equipment and destroy critical infrastructure such as water and power supplies. As we saw in previous conflicts in the Middle East, the ongoing threat of aerial attack creates new therapeutic geographies – routes of travel and patterns of care-seeking that are both shaped and perturbed by conflict dynamics. Patients radically alter their behaviour, only going to clinics or hospitals if absolutely necessary. Direct or indirect effects also alter the amount and type of health care services provided. Health across the spectrum is impacted from basic public health issues through to the decompensation of non-communicable disease control. With evidence from other conflicts demonstrating an increase in diabetic complications, and the late presentation of cancers. Longer-term consequences inevitably follow, such as increased conflict-driven antimicrobial resistance and mental health issues.
Displacement dynamics across the region have been dramatic and complex. UN migration has estimated that as of 30th March, over four million civilians are displaced across Iran, Iraq, Syria, Lebanon, Armenia, Azerbaijan, Turkiye, Turkmenistan, Afghanistan and Pakistan - with at least half of these now being refugees. In Iran, many civilians are fleeing urban centres like Tehran into safer rural areas or up North. The sheer complexity and speed of this displacement have left the international humanitarian community behind. Despite calls from UNHCR for additional funding, the reality is that for most internally displaced people and refugees, their basic needs and healthcare will have to be met through local charity or national assistance programs. Both of which are in short supply. For some, such as Afghans returning from Iran, reported conditions are seriously worsening, with little prospect of humanitarian support. Such massive displacement needs to be put in a wider context. Interlocking conflicts across the Middle East have already led to massive displacement, with an estimated 25 million people prior to Epic Fury. This latest conflict simply drives this number up. The downstream effects will repeat previous experience: dangerous returns (lost livelihoods and exhausted resources), overwhelmed host countries, humanitarian aid disruptions and serious escalation of protection risks to displaced women and girls. Furthermore, this new wave of displacement and humanitarian need comes at a time when the international system is also exhausted. The humanitarian aid funding gap is now at a record high, with a $32 billion shortfall reported as of late 2024, as needs outpace available resources. The health impact on those displaced will be generational and, even if the conflict ceases tomorrow, long-lasting. Prior to the conflict, major shortages and soaring costs were already the norm in Iran. The events of the last few weeks will lead to worse health outcomes for an already compromised health system and a long-suffering population, who will, in many instances, be driven to seek care abroad.
The broader impact of Epic Fury on global health and humanitarian actions requires significant consideration. Europe can expect another wave of refugees from the region who will flow into already politically contested national health systems. Heterogeneous Western health systems have faced increasing difficulty keeping up with the growing global movement of people. Further waves of refugees will face even greater barriers to humanitarian assistance. And the result will be worse health outcomes. Europe has never managed to collectively address healthcare for refugees, even within the context of the Ukraine war. With the inevitable wave of further refugees from the Middle East, systems remain ill-prepared and, potentially, even more hostile than they have been.
More broadly, global humanitarian efforts have been severely disrupted by the closure of major logistical hubs, such as Dubai, and by ongoing maritime restrictions in the Strait of Hormuz. Major supply chains for every type of medical-related product, from cancer drugs to surgical sutures, are being degraded. NGOs such as Save the Children have reported blockages to their shipments of lifesaving medications for children in Afghanistan, Yemen and Sudan. The sheer volume and complexity of the affected supply chains have created extreme volatility in product prices and availability. While high-income countries may be able to ‘buy’ their way through these bottlenecks, the impact on global health economies more broadly is likely to be significant. For those high-income countries, such as the USA, the knock-on impact will be more expensive healthcare and medicines. The economic shock and energy volatility will also accelerate and intensify the contraction of welfare and health services worldwide. The extent and depth of all these interlocking threats are immeasurable. Too many factors might either worsen or mitigate the impacts. China may yet swing course and utilise the crisis to broaden its public goods, particularly in the health space.
Epic Fury is recapitulating new ecologies of war on old ones. The truth about the extent of suffering and death has become a tradable commodity in the conflict-disinformation space. Each of the actors has their reasons for corroding the reality of Epic Fury’s impact on long-term health and welfare, not just of Iran and the region, but also of patients in the West. Immediate regional humanitarian suffering will be compounded by significant global health impacts. The impact of today’s conflicts cannot be contained. In health, their effects are truly global and long-lasting.
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