Delivering health aid to hotspots including Haiti and Afghanistan has brought together - and at times pitted against one another - humanitarians and militaries in an uneasy but increasingly necessary union.
As the military’s role in health aid is likely to grow - since the 2004 Indian Ocean tsunami, the US military has deployed 40 times to natural disasters worldwide - delineating the rules and responsibilities of each side in the field has become all the more necessary.
Even after some two decades of working more closely with militaries to deliver aid, researchers and humanitarians are still divided about such cooperation in health care.
“It is not just a case of one-off costs, but the long-term impact of a hospital not being seen as a safe or neutral space, or of it being associated with an opponent’s strategy,” said Simone Haysom, a researcher with the London-based Overseas Development Institute’s Humanitarian Practice Group, who co-authored a study on trends in coordination between humanitarian organizations and militaries.
“To have any type of weapon near a health structure makes them the target in conflict. That is why a no-weapon strategy is the best way to guarantee patients’ security,” Michiel Hofman, a UK-based operations adviser for health NGO Médecins sans Frontières (MSF), told IRIN in early 2012.
Somalia, where two of MSF’s workers were kidnapped and another two killed in late 2011, is the only country where the NGO uses armed guards (private) near its clinics. Only in Afghanistan in the 1980s and the Russian Republic of Chechnya in the 1990s has MSF been forced to use government or opposition forces for security. Notwithstanding, the no-weapons-in-clinics rule is absolute.
The Oslo Guidelines, written in 1994 and revised in 2007, give recommendations on ways humanitarians should work with armed forces, and the International Committee of the Red Cross (ICRC) has its own rules. But Haiti’s earthquake in January 2010, which killed more than 220,000 and has left more than 350,000 still displaced years later, highlighted the need for more specific guidelines, even in times of peace, say experts.
Coordinating with the military - often a last resort - largely depends on the context of the country and its disaster, such as: Is the emergency man-made, or a natural disaster? Is there a conflict? Is the government stable? While the earthquake in 2010 and ensuing cholera epidemic happened at a time of peace in Haiti, the country’s history of instability complicated the humanitarian response, said Viviana De Annuntiis, civil-military coordination officer for the UN Office for the Coordination of Humanitarian Affairs (OCHA) in Haiti’s capital, Port-au-Prince.
De Annuntiis said because Haiti’s crisis was a natural disaster, the strategy continues to be one of cooperation between the two sides, but if the political situation deteriorates, the strategy turns into one of “coexistence” in which humanitarians and militaries work separately to “minimize competition and conflict” by staying out of each other’s way.
The Oslo Guidelines and the ICRC’s rules distinguish between what is called for during peace time and conflict, with the understanding that the biggest risk, for humanitarians, to work with militaries is becoming a target. Regulations that fail to identify what to do in countries deemed fragile - like Haiti - fall short, experts say.
In Haiti coordination between the humanitarian and security community post-earthquake was largely based on “personal relationships and friendships among leaders of response entities", according to a recently published study of Haiti’s health system by Harvard Medical School and NATO.
The study is the first in a series analysing multinational military forces’ participation in health system strengthening in crisis-affected fragile states. In Haiti, this “complex web” of coordination was ultimately "underdeveloped and inefficient" to handle such a large disaster, the study concluded.
In September 2011, the UN Stabilization Mission in Haiti (MINUSTAH) published rules of engagement for aid workers and armed forces working in Haiti, with the expectation that other aid agencies and NGOs working there will draft their own rules. A first revision is scheduled for early 2013.
The Geneva-based Inter-Agency Standing Committee (IASC), which issues recommendations to improve humanitarian aid delivery, has emphasized the importance of focusing on populations in need and not allowing political agendas to influence health aid delivery.
Pros and cons
But the problem is military aid almost always has an agenda, leading to suspicion when an army provides health care. The army’s biggest motivator is self-protection, said a former officer with the UK army and now OCHA’s regional civil-military coordination officer for the Asia-Pacific region, Sebastian Rhodes Stampa.
“I don't think [military health aid] is particularly altruistic - it meets a specific need to influence potentially problematic populations at the operational level and is often linked to the military concept of `force protection' - a number of strategies to ensure the local populace don't target you,” he told IRIN.
While militaries are known for their strong, highly mobile field-based capabilities and experience in treating war-time trauma, said Rhodes Stampa, the flipside is they work independently and unilaterally, “undermining government attempts to provide health services,” added Haysom from ODI.
Setting up health care facilities in order to further political aims complicates - and compromises - their humanitarian partners, said Sandrine Tiller, MSF’s programme adviser for humanitarian issues.
“Quite a few of the armed actors in Afghanistan have set up health facilities for political objectives. It is not just the Western military forces but also other countries looking for influence,” Tiller said. “Few of these health facilities are really responding to health needs.”
Not only are these “politico-health” facilities ineffective, they may also be dangerous for patients and providers, added MSF’s Hofman. “When you link hospitals to military interventions, then hospitals become targets. If [the army] builds a hospital in the morning and fights the opposition in the afternoon, then the army is participating in the war. Then the health facility becomes a target.”
He cited a German-funded hospital the army built in Afghanistan in 2009 that was repeatedly targeted by international and opposition forces.
Five MSF workers were killed in Afghanistan in 2004. MSF blamed its compromised security on the NATO-led security coalition, which did not observe the Geneva Conventions - the core of humanitarian law that regulates armed conflict and treatment of war victims - which was, until then, a major tool MSF used to negotiate with governments security for its projects.
“That decision [to not apply the conventions] has given free rein to states to start disregarding the Geneva Conventions and to decide which part of them to abide by… It is harder to negotiate [access] agreements with states now,” said Hofman, the MSF adviser. The conventions also apply to rebel groups, known as “non-state actors”.
But the situation was not that simple, said Stuart Gordon, professor in the department of International Development at the London School of Economics. “There was a blindness on the part of the NGO community. They saw Afghanistan as being in a post-conflict phase, which led them to cooperate with NATO authorities and the Afghan government to an extent that perhaps they should not have.”
Wherever possible, using civilians to deliver aid is most often the best idea, he concluded. “Unless there is an overwhelming need, the concern is that they [military] are used before they are necessary.”
MSF withdrew from the country soon after the killings, but since 2009, has resumed healthcare services and maintains talks with the many military actors in Afghanistan, including the Afghan army and the NATO-led International Security Assistance Force (ISAF), to which the US is the number one contributor.
The need for humanitarians to cooperate with armed forces originated in the late 1980s as states began sending their militaries to help after natural disasters and manmade conflicts.
Such coordination was then novel and the presence of UN peacekeeping troops alongside combat forces in Afghanistan positioned humanitarians alongside a supposed “Western” agenda, according to some onlookers, including locals, experts say.
Though two decades have passed since humanitarians and militaries were first forced to work together in Iraq, details on how to coexist are still being sorted out. Despite the existence of some guidelines, aid groups are still struggling to carry them out in crises.
“Is it a lack of clarity, lack of awareness or lack of will?” asked ODI in a recent paper.
The institute has research under way in Afghanistan, Pakistan, South Sudan, Haiti and Timor-Leste to learn why.