Aid Under Fire: Health Care and the Costs of Conflict

Aid Under Fire: Health Care and the Costs of Conflict
Photo: Haitians receiving cholera treatment, L’Estere, Haiti, Oct. 26, 2010 (U.N. photo by Sophia Paris).
In recent years, the security threats facing humanitarian aid workers have been the subject of headlines and debates. The humanitarian advocacy community has been filled with discussions of a perceived increase in the politicization of humanitarian aid—attributed in part to declining respect for the humanitarian principles of humanity, neutrality, impartiality and independence—and growing difficulties ensuring operations can be conducted in accordance with those principles. These discussions frequently highlight attacks on relief personnel and assets to show that humanitarian workers are under attack. In the past year, the focus has narrowed to a particular area of humanitarian operations: medical and health care personnel and infrastructure. The image is of an increasing vulnerability for health care providers in countries affected by conflict. The past year has seen a series of alarming reports on the dangers faced by health workers in some countries. In northern Afghanistan, health workers were reportedly in retreat after killings of aid staff. In Pakistan, polio workers have been targeted with violence. And in Somalia, Medecins sans Frontieres (MSF) withdrew citing violence against its staff. Subsequent media coverage of these events has painted a picture of a global crisis in health care assistance. Under the headline “Violent Attacks on Health Care Workers a Growing Problem,” one writer asserted that “recent reports of violence targeting health care workers provide evidence that the prohibition of violence against health care workers has degraded.” Another insisted that “as conflicts around the world multiply and drag on, the respect once accorded to humanitarian workers is eroding. Medical personnel are particularly vulnerable.” Accordingly, the “international community” is called upon “to make violence against health care workers in conflict zones a priority.” Despite the depiction of a growing crisis, historically, attacks on humanitarian workers and the politicization of medical assistance in war zones are not new developments. Yet the media coverage of dead and injured medical relief workers, ambulance drivers and vaccination campaigners appears to suggest that this practice is getting worse and that the “sanctity of the untouchable status of health care” afforded to it under international humanitarian law “has been eroded, leaving medical workers increasingly vulnerable to attacks.” In assessing the two aspects of this claim—violence and politicization—what becomes clear is that the trend does appear to be worsening, but only in some contexts. Moreover, even for those countries where targeted violence is rising, while the cause might be broadly attributed to politicization, how it manifests and the extent to which it represents a change varies. As such, available information challenges suggestions of a global shift in the increasing risks and vulnerability of health care workers. The underlying significance of attacks on health care workers and facilities, targeted or otherwise, is not that they may violate the international protections or “sanctity” afforded to medical assistance but the consequences such violence has for the conflict-affected populations. As such, this debate raises a more important and much more complex question in terms of global trends that requires greater attention: Are the costs of conflict now greater for affected populations, particularly when it comes to health? Is Violence Rising? A recent article in the Lancet medical journal on the dangers of providing health care in conflict noted that “sometimes the level of violence aimed at health care workers—irrespective of how neutral they are—means that providing humanitarian aid can become untenable.” The article cited what has become a commonly used example of the consequences of the increasingly volatile and potentially “untenable” circumstances of medical assistance in conflict-affected countries: the August 2013 withdrawal of MSF from Somalia after 22 years of operation in the country. During the two decades of operation, 16 staff members were killed, and several others were kidnapped or injured in attacks. According to the Aid Worker Security Database (ASWD), since 1997, at least 161 aid workers were killed in Somalia. Some of these certainly worked with medical organizations, including MSF, and some may have been targeted for providing health care, but available information does not indicate that a specific relief sector in Somalia was increasingly intentionally targeted. Operating in war zones has always come with risks. Initially, attention focused on the general risks associated with operating in conflict-affected areas, such as being caught in the crossfire. More recently this attention has shifted to targeted violence. When MSF reached its “limit” in 2013 and withdrew from Somalia, it was a strong symbol in the debate over the limits of what is acceptable or tenable for humanitarian organizations providing assistance in war zones. But it is not immediately clear that MSF’s decision to withdraw is representative of a wider trend in which medical assistance, in particular, is being targeted. Targeted attacks on humanitarian workers, including those providing medical assistance, have a history as long as the modern humanitarian movement, which is commonly regarded as beginning with the response to the war and famine in Biafra, Nigeria, in the 1960s. In 1969 three International Committee of the Red Cross (ICRC) relief workers were killed when the Nigerian military shot down an ICRC aircraft fully marked with the Red Cross emblem and carrying relief aid to Biafra. Many other medical workers have been targeted since then. In 1996, six ICRC workers were shot dead while sleeping in a hospital in Chechnya—at the time, it was the bloodiest attack on aid workers in the ICRC’s 130-year history. In 2001, six ICRC staff members were brutally killed, this time in the Democratic Republic of Congo while traveling in two vehicles marked with the Red Cross emblem. In 2004, five MSF staff members were killed in an ambush in Afghanistan. In the past 40 years, the movement has expanded not just in the size of its personnel and assets but also in scope, extending “its reach and ambitions into types of conflict and crisis that were previously off-limits.” It is therefore perhaps not surprising that the sheer numbers of attacks have also increased. Yet recent headlines highlighting attacks on humanitarian health care workers in South Sudan, Syria, Pakistan and Somalia suggest something new in the pattern of targeted violence. While there is a scarcity of comprehensive data on this question, there are two sources we can turn to for more insight: the ASWD and the ICRC-led Healthcare in Danger project. The ASWD is one of the most commonly cited data sources in the discourse on attacks on humanitarians. The database records “major incidents,” defined as “killings, kidnappings and armed attacks that result in serious injury” affecting international and local staff of the United Nations international and local nongovernmental organizations as well as the Red Cross/Crescent Movement. At first glance, the ASWD statistics appear to support a global trend of rising security incidents involving aid workers, with an annual average of 147 incidents in 2006-2013, compared with an annual average of 64 incidents in 2000-2005. However, the vast majority of the 2006-2013 incidents were concentrated in 10 countries, with the top three—Afghanistan, Somalia and Sudan—accounting for more than 50 percent of all incidents during this period. Afghanistan is the leader for most of the years, accounting for 30 percent of all incidents between 2006 and 2013 and 47 percent of all incidents in 2013 alone. The ASWD does not break down the data by function, so looking for specific trends related to humanitarian health care providers from this dataset is difficult. But one thing is clear: It is more appropriate to speak about trends in a handful of specific countries than a global trend. Aiming to raise awareness of how medical assistance is targeted in conflict-affected countries, the Health Care in Danger project, spanning 2011-2015, collects information on incidents involving the “use or threat of violence against health care personnel, the wounded and the sick, health care facilities and medical vehicles.” Incidents are defined more broadly in this study, which also includes local health care workers in addition to those working for the institutions covered by the ASWD. However, the findings still reflect the principal observation above—that the majority of incidents take place in a handful of countries. For example, in 2012, the study recorded 921 violent incidents affecting health care in 22 countries; these incidents were concentrated in eight countries that each recorded 40 or more incidents. Unfortunately, the Health Care in Danger study does not name the countries, but considering news coverage of incidents and available public data it would be reasonable to assume that there is some overlap with the ASWD top 10. The ICRC study also indicates variation by country as to the perpetrators of these attacks. For example, in one country, 80 percent of the incidents were reported as perpetrated by state security forces, while in another, armed nonstate actors were reportedly responsible for 52 percent of the incidents. Other incidents involve individuals, such as relatives unhappy with patient treatment, and international military or police, while still others involve multiple perpetrators or lack sufficient information to attribute responsibility. Given the localization of the trend, the question becomes, in countries where there is an increase of violent incidents involving humanitarian medical personnel and assets, are they being specifically targeted because they are providing medical services? Moreover, are there common patterns to be found in the motivations for or drivers of these attacks? For example, there does appear to be a trend targeting polio vaccination workers in some countries, particularly Pakistan, Nigeria and Afghanistan. The motivations for these attacks can vary, however, with examples including accusations that polio workers are U.S. spies, the use of attacks against vaccination campaigns to gain or increase visibility and beliefs in some communities that vaccination efforts are actually part of a sterilization campaign. Though these motivations are context-specific, they can be broadly captured under a common theme: politicization. In the past decade, there has been a shift away from debates emphasizing the impact of aid on politics to that of politics on aid. But while “politicization” is commonly bandied about as a main cause of the supposedly increasing vulnerability of assistance in times of conflict, including medical assistance, it too is not a new development. Like incidents of violence, politicization spans the history of the modern humanitarian movement. So what, if anything, has changed? Old Story, New Nuance The shooting down of the ICRC plane in 1969, noted above, was in part the result of the role that humanitarian aid played in sustaining the separatist regime in Biafra and the Nigerian government’s response. Discussions around the political effects of humanitarian assistance—direct, indirect, intended and unintended—at first emerged quietly following the Biafra War and later exploded in the wake of crises such as Rwanda, Somalia and Bosnia in the 1990s with the widespread recognition that aid could become entangled in the dynamics of war. The impact of humanitarian assistance on political groups and structures or the politicization of aid, in which assistance is deliberately manipulated to serve political purposes, can take many forms. For example, aid may serve as a financial resource for the state or armed nonstate actors to sustain or fuel conflict. It may legitimize armed nonstate actors as an unintended consequence of access negotiations or providing services in areas under their control. Or political actors may deliberately and directly co-opt humanitarian action, such as by using humanitarian assistance as a reward for peacebuilding or strategically in military campaigns, including relying on or preventing access to assistance. Syria and Somalia have both recently appeared in headlines citing the increased vulnerability of medical assistance in conflict. Somalia has a 40-year legacy of humanitarian politics, while Syria is a recent entrant into the fray. Yet they are both examples of how medical assistance can be politicized and consciously made part of military strategy. In Syria, the role of medical assistance in military strategy has come front and center since the war broke out in 2011. The country is a recent addition (2012) to the ASWD top-10 list, yet news reports tell us that among the dead are ambulance crew volunteers, doctors and, as of January 2014, 34 Syrian Arab Red Crescent volunteers. In September 2013, the U.N. Human Rights Council published a report raising alarm at the “deliberate targeting of hospitals, medical personnel and transports, the denial of access to medical care and ill-treatment of the sick and wounded.” The report continued, “The denial of medical care as a weapon of war is a distinct and chilling reality of the war in Syria.” That it is “chilling” is by no means in question, but is it new? Or more specifically, does it represent a new pattern in conflict modalities? The case of Somalia, where over the decades assistance has been entangled in the politics of the conflict in almost every conceivable way, including military strategies, suggests the answer is no. For example, since the 1980s, refugee camps have served as recruiting grounds for the government and armed nonstate actors, and warlords and other armed actors have benefitted from—and sometimes consciously sought out—the financial support and legitimacy afforded as an unintended consequence of humanitarian aid. More recently, access to medical assistance has formed part of the military strategy of the principal armed nonstate actor in the conflict, al-Shabab. It has been reported that al-Shabab made an effort to have international NGOs working in the health sector operate in areas under its control in order “to guarantee that its wounded fighters would get adequate treatment.” The significance of this medical support did not go unnoticed by either Somalis or international observers. And while some NGOs providing medical assistance were expelled from Shabab-controlled areas following accusations of spying for the U.S., other medical humanitarian agencies remained. One of those organizations was MSF, which has been relatively open about its operations in Shabab-controlled areas. Speaking in 2010 about an MSF-supported hospital in the capital, Mogadishu, an MSF spokesperson remarked how “from the rebels’ point of view, it was in their interest to support assistance for their wounded and displaced populations and to encourage the aid organizations to attest to the crimes by the Ethiopian army with the support of the government militias. . . . We are sometimes seen by some political players, the African Union mission officers, for example, as the opposition’s war surgeons.” Some actors were reportedly frustrated by the support they perceived MSF to be providing to al-Shabab, which may have made the organization more vulnerable to attack. Yet although the Mogadishu hospital mentioned above was hit by gunfire and shelling in 2012, the incident came amid renewed fighting in the capital; available evidence does not suggest the hospital or health care workers were specifically singled out. Medical personnel and facilities may have been subject to violent threats and attacks during the course of the conflict, but violent targeting of medical staff and facilities because of the medical services they provided does not appear to have formed an explicit part of the military strategy—and certainly not to the extent witnessed in Syria. When MSF pulled out of Somalia in 2013, the decision was based on the culmination of events over several years as well as recent incidents. One of those recent incidents was the 2011 killing of two staff in Mogadishu. While in no way trying to diminish the seriousness of this incident, the killing was reportedly motivated by a human resource grievance, not because of the medical services the staff were providing. New Costs of Conflict While both Syria and Somalia provide evidence of medical assistance being instrumentalized in war, the cases offer different answers to the question of whether there is an increasing vulnerability for humanitarian health care workers and the assistance they provide. In Syria the answer is clearly yes. In Somalia, it is much less clear. These admittedly brief examples reinforce the need to pause before concluding there is a global shift underway in the risks to health care providers in conflict. But what if we look at the issue another way—rather than rising risks to health workers, examining instead the rising costs for the conflict-affected populations’ health in these countries. That is, the perceived rise in threats to health workers may be a symptom of a larger phenomenon, that of the rising health costs of conflict overall, which leave health systems particularly damaged. Chronic conflict and state failure in Somalia, and the accompanying political, economic, social and security challenges, have left the country with 0.4 doctors for 10,000 inhabitants—compared with an average of 28.7 doctors per 10,000 inhabitants for the five permanent members of the U.N. Security Council. In the year before MSF pulled out of Somalia, the organization had provided more than 624,000 medical consultations, admitted 41,100 patients to hospitals, cared for 30,090 malnourished children, vaccinated 58,620 people and delivered 7,300 babies. Other NGOs have tried to fill the void left by the organization’s withdrawal. But in a country where MSF had become one of the main health care providers, it is a big role to fill. We see similar figures for health care workers in some of the other ASWD top contenders, most of which are also countries affected by chronic conflict: In Afghanistan there are 1.9 doctors per 10,000 inhabitants, while in Sudan there are 2.8. While the duration of the conflict does not match that of Afghanistan or Somalia, the public health sector in Syria already lies in rubble. Conflict has a devastating effect on the health of a population. Contemporary conflicts include battle-related deaths and injuries, as Syria has illustrated with estimates of more than 140,000 civilians killed to date. But they also include extensive indirect effects of war on health, which can lead to death tolls in the millions from disease, malnutrition and the inability to access medical care. Humanitarian medical assistance in conflict-affected countries provides vital assistance both for battle-related injuries as well as the indirect health effects stemming from the destruction of public health sector, epidemics accompanying mass population movements, and restricted or no access to basic services such as water, to name only a few. A recent MSF study on health care in the Democratic Republic of Congo observed, “Violence, or the threat of it, forces medical staff to flee and health facilities to suspend activities. Often, people in the affected areas have no other health care providers to turn to—and it is those people who suffer most.” The inference from the debate on violence against health care workers and the politicization of humanitarian medical assistance is that the health of conflict-affected populations is becoming more vulnerable, and that people are suffering more, as a result. A lesson from an earlier round of debate on humanitarian politics comes to mind here. When the political effects of aid came under heavy scrutiny in the 1990s, case studies from Somalia, the Democratic Republic of Congo, Liberia and Sudan were heavily influential in what became a generalized discussion on how aid fueled conflict. That aid has unintended effects and could fuel conflict was not and has not been disputed. However, arguably, when taking into consideration the many factors that fuel and influence conflict, the significance of aid varies extensively between contexts. The “new orthodoxy” of aid fueling war may have been too reliant on a generalization based on extreme or outlying cases. Within the current discourse on the risks to health care in conflict, not only is there a strong focus on a specific set of countries, but much of the available information on so-called new trends focuses on the health care providers rather than a thorough analysis of the effects violence has on affected populations. Understanding context-specific patterns of violence against medical assistance is important, and opportunities should not be missed to identify and learn lessons that could diminish these attacks. But in terms of global trends, the focus on allegedly growing attacks on medical assistance or changes in how it is politically instrumentalized seems to be misplaced. The evidence suggests potentially more important questions: Are the effects of conflict on health care greater than they once were? And why? These are difficult questions, and understanding what influences the health of a population is a complex endeavor. But the answers may provide greater insight into the changing vulnerabilities of health in conflict. Dr. Hannah Vaughan-Lee has more than 10 years experience working on conflict-affected countries with humanitarian, human rights and development organizations. She holds a Ph.D. in Development Studies focusing on the politics of aid. Previous articles on aid worker security and politicization include “Risks and Compromises for Aid Workers: When is Enough, Enough?” and “Humanitarian Space in Somalia: A Scare Commodity.”

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