A key debate in the field of humanitarian assistance is the question of who should pro-vide health care and other humanitarian aid to the civilian population. If the special case of an occupying power is not considered, and one instead focuses on the role of civilian and military actors in peace-keeping, peace-building or complex emergency scenarios, there are basically four possible approaches:
The “involved NGO”: Humanitarian actors explicitly take sides in a conflict.
1.
The “clean hands”: Humanitarian actors do not interact with military forces in any 2. way, and operate independently of them.
The “protected humanitarian”: Humanitarian actors operate independently from 3. military forces in their service provision, but are protected by military forces, as
needed.
The “engaged military”: Based on an expanded security concept, military forces 4. engage in humanitarian action, such as distribution food, providing health care.
There are convincing – and not so convincing – arguments for all positions.
The “clean hands” approach may rest on the assumption that humanitarian action is fundamentally different from the activities of the military. Humanitarian action is not about security or establishing peace, but serving a population in need. That is a philosophical and moral argument, rather than an empirical one. It is based on an assumption that the military role is to provide security through the use or potential use of violence.
Another more practical argument for the “clean hands” is that a sharp distinction between the humanitarian and the military may be conducive to the security of the hu-manitarian workers, as those workers then can be clearly identified as non-combatants.
Then, it is argued, combatants, in accordance with humanitarian law, common decency as well as to avoid alienating their potential supporters among the civilians, will refrain from attacking humanitarian workers.
Another practical argument for the “clean hands” approach is that military pro-tection may in fact both endanger humanitarian workers, particularly through the mechanism that “legitimate targets”, i.e. military personnel and illegitimate ones, i.e.
humanitarian workers may be confused. Thus, even security provision to humanitar-ians by military may make delivery of humanitarian aid more difficult as Oxfam has argued (Oxfam International, 2003).
The “Involved NGO” approach is also based on a moral or political argument, i.e. that one of the parties to the conflict is right. This may be more clear cut in some conflicts than others. The position may have security consequences for staff, since the
favored party may chose to protect the humanitarian workers, while the other party may still respect humanitarian aid workers.
Arguments for military intervention in humanitarian aid, either through provi-sion of security for humanitarian workers or direct proviprovi-sion of aid, may rest both on practical considerations, and tactical and strategic ones. The practical one of security is quite obvious, in the sense some environments are extremely unsecure. Court makes the contention that the practical argument also entails that coordination should be military, because they are the only ones that possess and overview of the threats and have the skills to evaluate them(Court, 2004).
On the more tactical or strategic level, the military may consider aid as a integral and necessary part of their operations, for example in a wider counter-insurgency context. That is, as a part of the effort to win “hearts and minds”. In their new national Health plan, the UK government establishes as a policy option to use “military sup-port to create the right conditions for overall success is a key function of stabilization and improving health outcomes” (HM Government, 2008, s. Annex: 20). During the Vietnam war what started out as altruistic actions by American soldiers providing health care to Vietnamese civilians later became American policy to “win hearts”. It was, perhaps needless to say, far from successful. As the Israeli general Moshe Dyan remarked during a tour of Vietnam “foreign troops never win the hearts of the people”
and held that – echoing the discussion on legitimacy above – that it would have to be the government that supplied help(Wilensky, 2004).
While both proponents and critics of direct involvement between humanitarians and military employ security arguments, the evidence for how and when combatants attack humanitarian workers is mixed. It is fairly clear that in general, humanitarian workers are able to operate in war zones, without being attacked, but it is also clear that a significant number of aid workers are attacked.
As noted before in this paper, it is often contended that wars are becoming more brutal. A corollary is that aid workers are increasingly targeted (Sheik, Gutierrez, Bol-ton, Spiegel, & Burnham, 2000). The UN High level Panel on Threats, Challenges and Change holds that UN Staff security “has been eroding since the mid-1990s”(United Nations, 2004, p. 63). Deaths among humanitarian workers have certainly increased, from only a few per year in the 1980s to several tens of workers in the late 1990s. During this period, being caught in or, being target of violent conflict was the most common cause of death for humanitarian workers, surpassing traffic deaths (Sheik, Gutierrez, Bolton, Spiegel, & Burnham, 2000). A study from 2002 indicates levels in 1998–2001 on basically a similar level, i.e. around 40–50 deaths per year(King, 2008). A study by Center for Humanitarian Dialogue from 2005 finds similar levels, documenting 291 deaths in the years 1997 to 2003, or an average death rate of 42 per year(Buchanan &
Muggah, 2006) and holds that while the risk of death may not have increased, the fear
Nevertheless, when then increase in the number of aid workers is taken into considera-tion, the picture becomes less clear. While there has been an absolute increase in the number of deaths, the evidence for an increase in the risk is much more uncertain. One study finds that the risk of being a victim of violence among aid workers in increased from 4.1 per 10,000 aid workers per year in 1997 to 6.1 per 10,000 in 2005 (Stoddard, Harmer, & Haver, 2006). Deaths alone accounted for a risk of about 2.6 per 10,000 aid workers. A recent paper finds that the total risk of violence related deaths, medical evacuations and hospitalizations is about 6 per 10,000 humanitarian worker per year (Rowley, Crape, & Burnham, 2008). To bring these figures into context, the mortality from violence in Norway is 0.09 per 10,000 per year(Statistics Norway, 2008)
A clear finding from all studies is that deaths among humanitarian workers to a large extent are caused by intentional violence. That car accidents should kill more aid workers than violence is not borne out by any of the studies.
The operational environment of the aid workers, such as presence of integrated missions, presence of the great powers etc appears to have little correlation with the number of deaths or victims (Stoddard, Harmer, & Haver, 2006). However, specific countries, such as Afghanistan and Iraq, account for a large proportion of the deaths.
Thus, wars in general may not have become more brutal, but a few particular wars have turned out to be very much so.
Taken together, the information available of aid workers as victims of violence does not enable us to draw clear conclusions regarding their involvement with military. In particular, reports on who actually perpetrated the violence, as well as their motives, are generally poor. In reality perpetrators may span a range from more or less well disciplined national armies, to rebel forces, militias and bandits with more or less
“social”2characteristics. The support or understanding that the perpetrators enjoy with their communities has been little studied. Arguments on the security of humanitarian personnel that rests on an undiscerning view of the actors are unlikely to be valid.
Thus, at the current state of knowledge, arguments based on empirically based considerations of how security may be improved or not improved by various forms of involvement between humanitarian workers and military cannot be substantiated, simply because the empirical knowledge does not exist.
2 “Social bandits” is what Hobsbawm term the Robin Hood type bandits who at least to some extent serve their communities of origin(Hobsbawm, 1981).
Conclusion
As was noted at the outset, there are many conclusions that cannot be made, simply because lack of data, and also because of lack of systematic reviews of data that actu-ally exist. A problem that emerges time and time again is that of selection effects and comparison. For example, those that actually have been available for study, are present in refugee camps or survived ordeals are different from those that were not observed.
When all observations are from refugee camps, it is a logical fallacy to state that char-acteristics are due to the fact that people live in camps. Comparison is necessary.
The literature and the outlook that it represents have perhaps one main failing, namely the notion that good things go together, and conversely, that bad things also go together. As many examples in this review have shown, while the notion may be generally true, there are sufficient counter examples to make it a bad guideline for policy. There is, in general, a need for thorough reviews of existing data, as well as data collection within a broad range of fields.
There is no reason to underestimate the complexity of data collection and analysis of public health related data from conflict zones. For example, while the lack of good data on gender based violence is certainly a reflection on the lack of importance often attached to “women’s issues”, especially in war, it is also a reflection of the fact that data collection in this field is very difficult and ethically challenging.
One issue that has emerged in various guises at various points in the text is the need for data, standardization and dispassionate measurement. For example, the debate about mortality following the studies of mortality in Iraq referred to above has led to a reconsideration of methodologies; calls for standardization; and that organizations independent of both belligerents and humanitarian aid providers should carry out assessments (Checchi & Roberts, 2008). While American General Tommy Franks, referring to the invasion of Iraq is justly (in)famous for the statement “We don’t do body counts” apparently absolving himself of the need to keep track of civilian casualties, there is a strong argument that those that may have self interest in what the numbers turn out to be should not collect the data. Such interests may be to portray an oppos-ing party as vile, belittle transgression perpetrated by one’s own military forces, or, in the case of aid organizations secure funding.
Similar discussions are currently underway when it comes to standardization of measurement of morbidity, malnutrition and general health status in complex
emer-for improved communication between academia, policy makers and practitioners of humanitarian aid is also clear, as shown for example by the evolution of the understand-ing of malnutrition, where policy makers and practitioners have, in some cases, been far behind the development of the science, to the detriment of those that suffered from malnutrition (Golden, 2002).
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