Abstract
Background
The humanitarian landscape is challenged by escalating violence and complexity as conflict and disaster interface with geopolitical shifts and historical legacies. The last five years have seen crucial developments emerging from the perceived trend of violence towards health workers in humanitarian settings, exemplified by the bombing of the Médecins Sans Frontières field hospital in Kunduz by US forces in 2015. In response to this event, the United Nations Security Council passed resolution 2286 in May 2016 which affirmed the legal obligation of parties in conflict not to attack healthcare facilities and personnel. The resolution also called upon governments to develop measures to prevent, investigate and account for such attacks. 1 Violence against healthcare typifies the long-held concern regarding the blurring of boundaries in the humanitarian space between civil and military actors. The recent Ebola epidemic in West Africa has also modified the perception of such boundaries in disaster and epidemic response, provoking theoretical and practical questions of significance across all spheres of intervention.
The pressing importance of addressing the ever-murkier humanitarian space is coming to be acknowledged by a broad range of actors: military, civil, academic and political professionals all associated with humanitarian work. Despite organisational differences, pan-disciplinary affirmation of these growing challenges necessitates the development of aligned modes of operation in such contested spaces. Violence against health workers, shifting modes of engagement and novel methods of humanitarian action in violent settings are essential areas for further exploration as necessary debates on civil–military involvement shift to research agendas and practical interventions.
Violence against healthcare: protection and advocacy in the UK
Violence against healthcare raises many complex issues for practitioners in humanitarian contexts, which particularly centre on the delicate management of threats, alongside the maintenance of service integrity. Both Médecins Sans Frontières and the International Committee of the Red Cross have emphasised that their ability to work effectively in conflict is a function of their ability to work safely. As such, the principle of healthcare neutrality and protection is fundamental to their mission goal. Clearly the bombing of Kunduz where 42 people were killed, 35 were injured and 33 remain missing was a contravention of the basic tenet that healthcare workers be afforded protection in all settings regardless of political affiliation.
There is a need for a ‘community of concern’ to insist upon state adherence to the principle of medical neutrality and the enforcement of norms relating to the investigation and response towards non-state internal actors contravening this principle. Such commitments are necessary as conflict modes shift from traditional symmetric, i.e. state versus state, to increasingly asymmetric engagements that implicate a diversity of state, non-state and transnational actors. 2 Such shifts have seen the development of a concerning trend in the realm of healthcare neutrality that has seen medical work and its professionals designated as material support to terrorist forces with associated punitive measures taken against such programmes. It must be reaffirmed that according to international humanitarian law the provision of medical care should never be considered material support to any terrorist force and that states should commit to respecting this important principle.
Leonard Rubenstein, chair of the Safeguarding Health in Conflict Coalition, has decried the current standstill in implementing resolution 2286, which despite international consensus has thus far failed to materialise substantive gains. 3 The role of vested interests such as the international arms trade act as a brake to meaningful implementation. Rubenstein challenges a range of actors to look beyond powerful military, economic and diplomatic interests in order to more meaningfully navigate humanitarian zones.
Civil–military issues at a crossroad
The need for improved guidelines and new research frameworks around civil–military interaction are a core concern for future work. Often perceived as two isolated realms in academic circles, humanitarian and military cultures have in practice been intertwined for decades without much scrutiny over their modes of interaction. Issues relating to common purpose and perception across conflicting institutional cultures (both within medical military personnel and humanitarian aid workers) were made obvious in contemporary deployments from Iraq to Afghanistan and the West African Ebola outbreak. 3 Identity dilemmas seem to emerge as states increasingly involve hearts and mind approaches including medical outreach to build legitimacy for military involvement.
Military agendas and humanitarian relief efforts interact in increasingly tight spaces with limited common operational instruments and contrasting sets of intents and values. Humanitarian principles of universal impartiality, for instance, appear irreconcilable with the differential treatment responses expected of military physicians. In complex humanitarian crises, both sets of actors negotiate common spaces bringing diverging hierarchical cultures to coordinate planning, logistics and delivery. Both might be facing context-specific community resistance linked to historical legacies and current political contexts. Combat spaces that include armed actors as well as civilian emergency rescue workers and humanitarian responders exist with the risk of non-military personnel being used for intelligence gathering or becoming military targets. To better negotiate this space, there is a need for more inclusive information sharing and consensus around novel protocols. Further enquiry into common experiences of past deployments would shed light on the relevance of existing frameworks and the need for reframing operational priorities in conflict and disaster relief.
Civil–military issues in health and humanitarian contexts
There are conflicting views on military mandates in public health crises. Some voices celebrate military health operations and suggest increased military contribution to international medical action of the kind seen during the Ebola response. A prevailing argument has been that given military expertise in reconstruction and relief efforts, enhanced cooperation would lead to more effective delivery of medical humanitarian missions.
Other stakeholders stress the potential for harm in linking humanitarian and military identities in public health emergencies. In some contexts, painful historical legacies of military involvement could alienate communities and undermine medical responses. Such an example is again the Ebola outbreak in Sierra Leone, which demonstrates the disconnection of medical humanitarian actors and global health institutions unable to tackle the crisis without invoking military intervention despite the risks of blurring operational lines. 4 If the Sierra Leonean and British military interventions were central to curbing the epidemic, their involvement begs for strengthened mechanisms of coordination within the civilian realm. 5 The dysfunctional response to the Ebola epidemic is a poor justification for further military intervention in global health.
The changing face of humanitarian work in violent contexts
One of the most obvious shifts in the composition of the humanitarian space is the growing number of civilian actors involved in international humanitarian action. Improvements in technology have produced a space for utilising publicly available material to create independent reports for advocacy, such as the ability to rebuild events and moments of crisis in conflict from open source reporting. Similarly, space has opened up in terms of civilian and community involvement in civil defence such as the well publicised ‘White Helmets’ working in the Syrian Conflict. 6
As global connectivity allows for the space of humanitarian work to open up to non-traditional groups, outside perceptions of humanitarian work restrict the space within which these groups operate. Both military and humanitarian organisations continue to view each other with mutual mistrust, borne of years of intra-organisational clashes and incompatibility. Non-governmental organisation representatives frequently speak of the worry that employees will be perceived as military actors further placing them at risk. The perceived effect of military involvement on medical aid is immediately apparent in Mosul, for example, where hospitals set up by foreign humanitarian organisations were colloquially named by nationality – ‘the French hospital’ and ‘the American hospital’ – thus, allying them with national military forces.
The importance of novel forms of data collection and surveillance provokes questions regarding the way in which relationships between actors are negotiated. Information asymmetry further cements mistrust between involved parties. Debates over data gathering assure the need to resolve further complex issues within the humanitarian space relating to data ownership, privacy and sourcing. 7 This capacity or incapacity to exchange information mediates on the ground decisions often leading to devastating outcomes such as the case of Kunduz Hospital airstrike.
Conclusions
Connecting the health community of academics, military and humanitarian personnel is vital for increasing collaboration across disciplines and political allegiances in order to better negotiate the various contestations of the humanitarian space. In the face of a growing burden of displaced and vulnerable populations, there remain vitally underexplored dynamics in this realm, including the implementation of protection mechanisms for healthcare in conflict, civil–military associations in humanitarian settings and intelligence sharing in violent contexts. The need for more research and action on humanitarian intervention in violent contexts is imperative to ensure effective responses to future public health emergencies.