Humanitarian aid: some political realitiesBMJ 2006; 333 doi: http://dx.doi.org/10.1136/bmj.39002.408808.80 (Published 19 October 2006) Cite this as: BMJ 2006;333:817
- Richard J Brennan (), health director,
- Egbert Sondorp, senior lecturer
- International Rescue Committee, New York, NY 100168, USA
- Conflict and Health Programme, London School of Hygiene and Tropical Medicine, London
The scale of current humanitarian crises in the World Health Organization Eastern Mediterranean Region (EMRO) is vast and the legacy of past wars persists. Around 60% of the world's refugee population have fled EMRO countries,1 and the region is host to half of the world's refugees. The Palestinian territories, Afghanistan, Iraq, and Sudan are four of the five main sources of refugees globally, while the Palestinian territories, Pakistan, Iran, and Syria are the world's major hosts of refugees. Many of these people have been “warehoused” for decades in long term camps. In addition, over a third of the 21 million “internally displaced persons”—people who have been forced from their homes but have not crossed national borders—are in EMRO countries. These are startling statistics for a region that contains only 8% of the world's population.
Recent crises have highlighted problems faced by the global humanitarian aid community. These include the difficulty of achieving interagency coordination, poor documentation of humanitarian need, and the lack of security for aid workers. Each illustrates the close link between politics and humanitarian action.
In 1991 the United Nations set up the Office for the Coordination of Humanitarian Affairs (OCHA) to improve interagency cooperation. After a review of its work the “cluster approach” was introduced in 2005 to improve humanitarian outcomes.2 Lead agencies have been identified for key areas of humanitarian intervention and play a major coordination role (box). The WHO is the lead agency for the health cluster. It is responsible for forming partnerships with ministries of health and helping them conduct baseline assessments, develop response plans, and build the capacity of local health services. Early assessments of the impact of this approach have been mixed.3
Recent events in Lebanon have shown just how challenging humanitarian coordination can be. The Lebanese Ministry of Public Health has limited reach and authority. Hezbollah, the agency widely considered to be the most efficient and accountable, was not only belligerent in the recent conflict but is considered to be a terrorist organisation by many Western governments. Hezbollah had a good reputation as a provider of social services before the war and operated a network of clinics and hospitals at lower cost than other providers. Its reputation has improved since the ceasefire, because it provided cash grants quickly, restarted water supplies, and extended health care to the internally displaced population.
Western governments, the United States in particular, have clear rules that restrict their grantees from supporting alleged terrorist organisations. Yet international non-governmental organisations prefer to work through local agencies, especially when they are effective at national level. UN agencies and international non-governmental organisations need to step delicately in Lebanon to ensure that gaps in services are dealt with, duplication of effort is minimised, and constructive partnerships with local communities are established. Some coordination with Hezbollah or its partners is inevitable, although it is essential to avoid strengthening or legitimising the organisation.4 Aid disbursements should be channelled only through groups who are not associated with militias or military activity.
Over the past 30 years civilians have been disproportionately affected by conflict, as an article in this issue by Musani and colleagues underlines.56 Documenting the humanitarian needs of civilians is difficult. Excess mortality is the most useful measure, and data are usually collected through population based surveys, which are useful for documenting the impact of humanitarian relief, mobilising resources, and influencing policy.7
Problems with security and access can make consistent collection of accurate data hard, but political obstacles can pose greater problems. Despite several surveys there is considerable controversy over the death toll in Darfur,8 in part because the Sudanese government seems to have little interest in allowing large scale surveys. In Iraq, the high mortality documented in a methodologically sound survey, which was far higher than that found in previous reports,9 ran into political opposition in the US and United Kingdom.10 Government officials' desire to refute or ignore uncomfortable findings must be countered by a determined effort to show the scale of humanitarian need by using objective and valid data.
Recent events in several EMRO countries highlight a third area of concern. Violence towards humanitarian staff has increased, making it hard to provide humanitarian assistance. In Darfur—for example, only half of the people who need assistance are now receiving it.11 The bombings of the UN and Red Cross headquarters in Baghdad in 2003 were dramatic examples of this problem. Since the signing of the Darfur peace agreement in May this year, more humanitarian workers have been killed there than in the previous two years. In Afghanistan, 27 aid workers were killed in the first eight months of 2006.
Recent research confirms the trend of increasing attacks on humanitarian workers, in particular of national staff.12 These attacks form a breach of the Geneva Conventions. The reasons for this are complex and the solutions challenging. Deploying peacekeeping troops to troubled areas has proved difficult; the Sudanese government has refused deployment of a UN force in Sudan and the North Atlantic Treaty Organisation has struggled to convince its members to commit troops to Afghanistan. Further efforts to improve security to allow national and humanitarian agencies must be made, however, for without it, aid agencies are hamstrung. UN members and regional bodies, such as the African Union and Arab League, must end impunity for violators of international law, and those guilty of crimes should be brought to justice.11
Humanitarian aid has become more politicised. Humanitarian workers cannot reverse this alone but they can reduce its impact. They need to affirm humanitarian principles, commit to doing no harm, document the scale and nature of crises accurately, and hold decision makers accountable for their policies and actions.