The Long Shadow of Violence Against Humanitarian Workers

On a recent Saturday morning, a helicopter hovered over the town of Zafarana in Syria's western Homs province, where it dropped barrel bombs on a Doctors Without Borders-supported hospital, killing seven and injuring dozens more. Directed by an unidentified perpetrator, the attack came in two waves, first hitting the town, then the nearby hospital, both targeting the injured and medical personnel caring for them. The incident is the third attack on Doctors Without Borders hospitals in only two months, following earlier strikes against facilities in Afghanistan and Yemen by U.S. and Saudi-led forces.

Humanitarian organizations can be powerful agents of health and stability, particularly during military conflicts or other situations where no one else is able to provide essential services such as housing, food, and emergency medical care. But increasingly, as the sanctity of humanitarian work is undermined, the ability of groups like Doctors Without Borders is threatened in the places they are needed most.

Beyond the immediate carnage and questions about how the recent attacks happened, the result will severely impair the capacity to treat people living in these war-torn regions. According to Les Roberts, professor of Population and Family Health at the Mailman School, the loss of the hospitals like these and the groups that support them can weaken entire health systems.

To understand Roberts’ ominous projection, consider diarrhea, a potentially life-threatening condition for people in developing countries. Not only would severe cases be denied care, he says, but the ripple effect from closed hospitals could diminish the availability of front-line interventions like oral rehydration therapy and the construction of sanitation systems.

Doctors Without Borders operates in areas of the world with some of the worst health problems and fewest services available to meet them, and the group often empowers local allies to provide those services. At the same time, the organization provides an important message of good will. “The more desperate the place,” Roberts says, “the more important it is that people there feel that the world still cares about them.”

That good will is being steadily eroded. According to a report by Aid Workers Security, attacks on humanitarian workers have more than tripled in the last ten years, from 63 attacks in 2004 to 190 last year. Today, in parts of the world like Iraq and Syria, humanitarian actors are not just caught in the crossfire; they are being actively targeted. Only 20 years ago, the climate was very different.

Roberts recalls working in Rwanda during the bloody 1994 genocide: “I would get caught in a firefight and Rwandans would see my WHO vehicle and dash out to help me because they knew I was neutral.” He experienced a similar phenomenon six years later in the Congo. But since 9/11, he has seen aid groups become much more cautious about putting their workers in harm’s way, and populations less prone to default to positive assumptions about outside aid workers.

“A Fanatic Level of Neutrality”

The biggest exception to this trend is Doctors Without Borders, which, Roberts says, upholds “a fanatic level of neutrality.” One way they do this is by refusing money from governments. This reputation for independence allows them to set up hospitals in countries like Afghanistan, Somalia, and the Central African Republic, and to treat civilians and combatants on both sides of a conflict.

Roberts says this stance of extreme neutrality was increasingly necessary as U.S. policy blurred humanitarian and military missions with the goal to “win hearts and minds.” He gives the example of Afghanistan, where an NGO delivered food on one day, and intentionally, the following day, military personnel in civilian clothing would provide the same service.

Trust toward health workers was wounded when American psychologists took part in the torture of detainees at Guantanamo Bay and the CIA sponsored a sham vaccination campaign in Pakistan in the hunt for Osama Bin Laden. After the CIA program came to light, there was a severe backlash against vaccination programs, culminating in the murder of eight polio workers and the suspension of the United Nations vaccination program in Pakistan. Today, polio remains endemic to Afghanistan and Pakistan.

In 2013, twelve deans of public health schools, including Mailman Dean Linda P. Fried, wrote a letter to President Obama to condemn the sham vaccination program, writing, “as a general principal, public health programs should not be used as a cover for covert operations.” The White House responded and agreed with the deans, saying the CIA had pledged to “make no operational use of vaccination programs.”

How to Restore Trust

In an October 7 apology for the destruction of the Doctors Without Borders hospital in Kunduz, Afghanistan, President Obama expressed his “deepest condolences.” Since then, a U.S. military investigation found the airstrike occurred due to a series of errors, including mistaking the hospital for a nearby Taliban base. But for Doctors Without Borders, the report was insufficient; the group is demanding an independent investigation into potential war crimes, claiming they repeatedly shared the hospital’s coordinates with military forces.

Article 18 of the Geneva Convention states, “Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the parties to the conflict.” This sentence “gives very little latitude for misunderstanding,” says Roberts. “It was great and uncommon for the Pentagon to so openly and honestly critique the miscommunications that allowed for the hospital bombing. But we would be a stronger country for allowing an outside investigation to go forward.”

Non-governmental organizations depend on an atmosphere of trust and respect. When Doctors Without Borders or the Red Cross is present in a crisis, they minimize disruption and keep people from fleeing in vast numbers across borders. Roberts recalls how during, and in the aftermath of the Rwandan genocide, outside groups stepped in to provide many of the services to keep people alive until those services could be established locally.

“These NGOs, treated shigella and malaria cases, chlorinated Kigali’s water supply, fed children in orphanages, and allowed the government to grow into these roles again,” Roberts says. “That seems to me the ideal solution to addressing collapsed governments. Acceptance of violence toward [Doctors Without Borders hospitals] or other neutral facilities will curtail an already cautious humanitarian community from showing up where they are most needed.”