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HUMANITARIAN STAKES N°1
MSF Switzerland's Review on
Humanitarian Stakes and Practices
HUMANITARIAN BORDERS:
INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS:
AN ETHICAL DILEMMA FOR MEDICAL STAFF
HUMANITARIANS VS. HUMAN RIGHTS:
TWO ANTAGONISTIC AGENDAS?
POST-9/11 WARS: NEW TYPES OF CONFLICT,
NEW BORDERS FOR HUMANITARIANS?
Edited by Jean-Marc Biquet
HUMANITARIAN STAKES N°1
MSF Switzerland's Review on
Humanitarian Stakes and Practices
HUMANITARIAN BORDERS:
POST-9/11 WARS: NEW TYPES OF CONFLICT,
NEW BORDERS FOR HUMANITARIANS?
Credits:
Graphic Design: Daniel Jaquet
Translation: Simon Beswetherick
Proofreading: Kimberley Plaxton
3
Contents
7
Infection control measures and individual rights:
An ethical dilemma for medical staff
9
Philippe Calain, Andrei Slavuckij
Public Health driven restrictions versus individual patients’ rights:
Is it the role of MSF to enforce public health regulations?
12
Jerome Amir Singh
Humanitarian Work and Infection Control:
Legal, Ethical, Human Rights, and Social Considerations
23
Vital Mondonge Makuma
Controlling infection during the Ebola VHF epidemic in the province of
Kasaï Occidental (DR Congo) and ethical dilemma.
25
Alain Epelboin, Pierre Formenty, Julienne Anoko and Yokouid Allarangar
Humanisation and informed consent for people and populations during responses
to VHF in central Africa (2003-2008)
39
Humanitarians vs. human rights: Two antagonistic agendas?
40
David Rieff
A False Compatibility: Humanitarian Action and Human Rights
44
Rony Brauman
The danger of a conciliatory approach
48
James Darcy
Humanitarianism and human rights
53
Post-9/11 wars:
New types of conflict, new borders for humanitarians?
54
Alain Délétroz
An unarmed international community
57
Bruno Jochum
The “War on Terror”: consequences for civilian populations
and positioning of humanitarian organisations
61
Peter J. Hoffman
The Global War on Terrorism’s Impact on Humanitarian Action
70
Jérôme Larché
Humanitarian action caught in a vice between guerrillas and the war on terror
5
Humanitarian Stakes N°1 is a compilation of articles prepared by the panelists
who participated in a day of conferences debates on “Humanitarian Borders” in
Geneva on 13 December 2007. The articles are organized by topic to reflect
the original program of the day. MSF Switzerland also has also produced a DVD
of the day containing panelists’ presentations and the debate portion of the
sessions, in addition to the electronic versions of the articles published in
Humanitarian Stakes and their French translations. The DVD may be ordered
on our Web site www.msf.ch.
Jean-Marc Biquet, Senior Researcher with MSF Switzerland’s Reflection Unit on
Humanitarian Stakes and Practices (UREPH), was the general coordinator for
the conferences and was responsible for selecting the topics and the panelists. He
is also the publishing editor of this compilation.
MSF Switzerland would like to express its appreciation to all the panelists who
were invited to participate to the conferences and who made it possible for
UREPH to produce its second publication in the “Humanitarian Stakes” series.
We would also like to thank all the individuals who attended the conferences and
made it a success, as well as all those who contributed to organizing the event.
Last but not least, we would like to express our gratitude to the donors/supporters who allow us to assist people in distress around the world.
For more information about UREPH and Humanitarian Stakes, contact JeanMarc Biquet, Senior Researcher, at [email protected].
INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF
7
With many public health activities tensions arise between personal liberties and
individual autonomy, and public health perspectives. Public health activities are
grounded in moral considerations that reflect the population-based risks and
benefits that humanitarians and other stakeholders are bound to pursue. Such
grand objectives and actions lead to relatively minor infringements on individual
rights, such as routine data collection disclosures about communicable diseases,
and others measures that infringe on privacy and confidentiality as has been
often discussed in the past.
However, a more rapidly growing concern relates to the infringement of individual
liberty and self-determination, given the power accorded to public health officials
to enact any measure necessary to contain a disease. Of particular concern today is
the continued emergence of communicable diseases with high fatality rates such as
Ebola; diseases with pandemic potential such as avian flu; and virtually indestructible or non-curable communicable diseases such as XDR-TB. Addressing these
diseases may require non-voluntary steps such as isolation or quarantine as part of
the main strategy. Such measures challenge medical and individual human rights
by placing an unfair burden on individuals who are exposed to heath problems for
the benefit of people who do not have the problem. Is there a role for humanitarian
organizations in enforcing or participating in such measures? What are the implications for subsequent medical programs?
While it is easy to say these dilemmas are governed by ethical principles, public
health ethics may not necessarily align with the medical or biomedical ethics that
govern today’s medical practices. Nowadays there is (arguably) a loose consensus
about the idea that interventions in the name of public health can be reasonably
justified, provided a number of principles are respected. These principles,
however, fall short when it comes to the practical solutions for implementing
such measures; the logic of prioritization; and the role of humanitarian organizations in actions that involve non-voluntary and autonomy-limiting compliance from the patient.
8
HUMANITARIAN STAKES
Humanitarian, non-governmental medical actors fall at a unique juncture along
the spectrum: they are not supposed to be part of the coercive policies of governmental bodies; however, they are expected to operate based on public health
principles that target populations in crisis rather than on individual needs.
Public health ethics and bioethics—where are the similarities and differences?
Where do we draw the line on actions that infringe on individual liberty? What
can and must be done for people whose individual rights have been infringed?
Above all, is it safe to assume that our public health-oriented actions are effective if they infringe on individual liberty?
9
Public Health driven restrictions versus individual
patients’ rights: Is it the role of MSF to enforce
public health regulations?
Philippe Calain, MD1; Andrei Slavuckij, MD2
In public health practice, some circumstances may lead to a clash between individual patients’ rights and measures aimed at safeguarding the security of populations. The dilemma is classically illustrated by a number of severe communicable
diseases with high potential of transmission, such as SARS, viral haemorrhagic
fevers (VHF) and pneumonic plague. National public health regulations are
expected to provide legal and technical guidance over intrusive or restrictive measures applied to communicable diseases control. These can range from public
health observation to quarantine (for suspect persons), and from isolation to
detention (for overt cases). There is however no universal template for such regulations, as applied within sovereign states. The quality, applicability or scope of
national public health laws – if any available - varies from country to country. The
current International Health Regulations2 (voted by the World Health Assembly
in 2005 and entered into force in 2007) provide legal guidance about public
health emergencies, but only to such extent that they represent a threat of international spread, or a risk to travel or trade.
The recent emergence of XDR-TB had already raised difficult ethical and technical questions about the use of compulsory isolation or forcible detention4 of
identified cases. Later, in May 2007 an incident involved a traveler with alleged
XDR-TB who circulated without restriction between Europe to the USA. This
1
2
3
4
Medical advisor, Médecins Sans Frontières – Switzerland
Programme manager, Médecins Sans Frontières – Switzerland
World Health Organization, “Fifty-eight World Health Assembly Resolution WHA58.3: Revision of the International
Health Regulations,” May 23, 2005, http://www.who.int/gb/ebwha/pdf_files/WHA58/A58_4-en.pdf.
Jerome Amir Singh, Ross Upshur, and Nesri Padayatchi, “XDR-TB in South Africa: No Time for Denial or
Complacency,” PLoS Medicine (2007); 4(1),
http://medicine.plosjournals.org/perlserv/?request=getdocument&doi=10.1371%2Fjournal.pmed.0040050
10
HUMANITARIAN STAKES
event attracted broad media coverage and it revealed blatant weaknesses in legal
and public health processes for isolation and quarantine among involved countries5. On the other hand, considering human rights and XDR-TB control,
WHO has issued recommendations6, referring essentially to the Siracusa Principles.
Médecins Sans Frontières (MSF) is an international medical and humanitarian
organization, whose specific expertise and operating environments expose its field
medical members to face possible dilemmas between patients’ rights and public
health constraints.
Firstly, MSF has gained over the years a considerable expertise in the control and
management of prominent epidemic diseases, including cholera, viral haemorrhagic fevers, plague or multi-resistant tuberculosis. These are precisely among the
conditions that would classically call for enforcement of restrictive public health
measures.
Secondly, MSF operates frequently in conflict zones or complex emergencies,
whereby public health laws are inexistent, obsolete, inapplicable or simply not
enforceable. As mentioned above, this legal limbo is not compensated by the
availability of international frameworks regulating public health within countries.
Thirdly, MSF is often in the unique position of single provider of health care,
under circumstances where local resources are insufficient to offer humane, safe
and efficient care beyond compulsory isolation. The case is typically exemplified
by outbreaks of VHF, where individual patients’ care requires costly protective
equipment, technical expertise and a surge in medical workforce.
Fourthly, MSF volunteers are often (by circumstances as much as by institutional
choice) in a position to witness and testify to the compliance, ignorance or abuse
of human rights. Illegitimate enforcement of coercive public health measures
would be no exception for us to exercise our privilege to testify and advocate to
the benefit of victims. The same can be said about overt diversion of public health
measures for research agendas, when the latter conflict with patients’ interest and
priorities for optimal care. MSF itself has neither the legitimacy, nor the mandate
to impose administrative regulations. Even if imposed by authorities under public
5
6
Howard Markel, Lawrence O. Gostin, and David P. Fidler, “Extensively drug-resistant tuberculosis: an isolation order,
public health powers, and a global crisis” JAMA (2007); 298(1): 83-86.
World Health Organization, “WHO Guidance on Human Rights and Involuntary Detention for XDR-TB Control,” January
24, 2007, http://www.who.int/tb/xdr/involuntary_treatment/en/index.html.
11
health regulations, restrictions of movement might interfere with usual patterns
of life and maintenance of livelihoods in affected areas, when access to care or
community support is limited. Thus, unnecessary restrictions can significantly
impact on the fragile socio-economic conditions of populations to which MSF
typically offer temporary assistance.
Finally, there are quite unique circumstances encountered by MSF, where public
health measures add further restrictions to an already constrained environment.
This is the case of public health isolation wards for drug resistant TB patients
inside of detention facilities. In Kyrgyzstan for example, the co-existence of
patients with different patterns of resistance to multi-drug antibiotic treatments
imply the need for segmentation of patients groups over long periods, in order to
avoid cross-contamination within treatment facilities. “Ideally”, for the sake of
safeguarding the efficiency of 2nd line treatment (often of last resort) and
preventing acquisition of incurable TB forms with further risk of spread among
prisoners and “spill-over” to civil society, this would mean separation of patients
with different resistance pattern using barbed-wire fence, thus imposing even
harsher (and, probably, longer) detention conditions on prisoners than the ones
assigned by criminal law. Nevertheless, in respect of individuals and in balancing
potential harm on the society, MSF has arbitrarily opted to advocate for implementation of rather “soft” public health measures, such as separation of patients
using “normal” wire fence and, most importantly and before all, intense patient
education and individualized follow up in case patient released before treatment
completion.
In conclusion, in the areas of its intervention, while involved into epidemic
control activities and for the sake of preventing the spread of infectious diseases
within and outside the communities, MSF is taking active part in enforcing
public health regulations. However, MSF should constantly question the appropriateness of public health measures being enforced and do not hesitate to put, or
advocate for, additional resources, if needed, to alleviate restrictions on individuals. MSF has to be prone to denounce malpractices in epidemic control related
measures of national and international actors involved if such occur.
12
HUMANITARIAN STAKES
Humanitarian Work and Infection Control:
Legal, Ethical, Human Rights, and Social Considerations
Jerome Amir Singh1
Introduction
Public health officials are usually charged with containing deadly outbreaks of
infectious diseases. However, in some settings public health infrastructure and
legislative frameworks to control disease outbreaks may be unknown, weak, or
even absent. In such settings the emergence and rapid spread of deadly airborne
diseases such as drug-resistant tuberculosis (TB) and the Ebola virus, or even
pandemic flu, raise profound questions about how humanitarian organizations
working in these settings ought to manage these kinds of crises. Uncertainty
about the distinction between different containment measures may also paralyze
relief efforts. Although the WHO has released a set of guidelines for humanitarian agencies on preparedness and mitigation with respect to pandemic flu,2
which is somewhat applicable to other deadly airborne diseases, the guidelines
surprisingly do not offer guidance on the legal, ethical, human rights, and social
implications of infection control. This paper attempts to offer such guidance by
clarifying the nature of different public health infection control containment
measures and outlining the ethical, human rights, and social implications of such
strategies. It concludes by offering guidance to humanitarian organizations
confronting outbreaks of airborne diseases in settings where the legality of infection control containment strategies is unknown or nonexistent.
1
2
Jerome A. Singh is Head of Ethics and Health Law at the Centre for the AIDS Programme of Research in Africa
(CAPRISA), Durban, South Africa; Adjunct Professor in the School of Public Health Sciences and Joint Centre for
Bioethics, University of Toronto, Toronto, Canada; and Honorary Research Fellow, Howard College School of Law,
University of KwaZulu-Natal, Durban, South Africa.
World Health Organisation Programme on Disease Control in Humanitarian Emergencies Communicable Diseases
Cluster. Pandemic influenza preparedness and mitigation in refugee and displaced populations. WHO guidelines for
humanitarian agencies. April 2006. Accessible:
http://www.who.int/csr/disease/avian_influenza/guidelines/avian2006-04-9a.pdf. Accessed 5 February 2008.
13
1. Public Health Containment Strategies and the Law
Public health officials rely on a variety of strategies to contain outbreaks of
airborne diseases. The most effective nonpharmaceutical intervention strategy is
“social distancing,” the practice of “increasing the physical space between individuals or infected populations with the aim of delaying spread of disease.”3
Social distancing strategies constitute the backbone of public health law in many
countries, allowing officials to act decisively in the face of health threats to the
wider public, even if doing so infringes on an individual’s rights. The most
common forms of social distancing are isolation, detention, incarceration, and
quarantine.4 While these strategies have in common the confinement of individuals or the restriction of their mobility rights, and are commonly used interchangeably, each is subtly distinct. It will thus be important to outline their
respective natures.
1.1. Isolation
Isolation refers to the separation of persons who have a specific infectious illness
from those who are healthy, and the restriction of the movement of the sick to
stop them from spreading the illness.5 Isolation allows for the focused delivery of
specialized health care to people who are ill, and it protects healthy people from
getting sick.6 The infected may be isolated and treated in designated health care
facilities or even in their homes; they may be subject to solitary confinement or
to group confinement. Isolation is a standard procedure used in hospitals today
for patients with TB or with certain other infectious diseases. Isolation may take
various forms.
1.1.1. Voluntary Isolation
Voluntary isolation occurs when, after appropriate counseling (if necessary), an
3
4
5
6
World Health Organisation Programme on Disease Control in Humanitarian Emergencies Communicable Diseases
Cluster. Pandemic influenza preparedness and mitigation in refugee and displaced populations. WHO guidelines for
humanitarian agencies. April 2006. Accessible: http://www.who.int/csr/disease/avian_influenza/guidelines/
avian2006-04-9a.pdf. Accessed 5 February 2008.
Centers for Disease Control (United States). Isolation and quarantine fact sheet. September 2004. Accessible:
http://www.cdc.gov/ncidod/dq/sars_facts/isolationquarantine.pdf. Accessed 6 February 2008.
14
HUMANITARIAN STAKES
infected individual voluntarily isolates himself/herself from others who are not
infected to prevent the infection from spreading to the latter. Voluntary isolation
may take the form of solitary confinement (where the infected individual has no
unprotected physical contact with others) or group confinement (where the
infected individual cohabits, shares facilities, and intermingles with others
afflicted with the same infection).
1.1.2. Involuntary Detention
Involuntary detention or “therapeutic detention” applies to infected individuals
who refuse to voluntarily isolate themselves to prevent their infection from
spreading to others. In these instances, the noncooperative individual may be
forcibly confined to a designated setting. Involuntary detention should never be
the first option for officials. Instead, highly infectious individuals should be
counseled about the risk they pose to others and they should be encouraged to
voluntarily isolate themselves. Only if the infectious individual refuses to agree
to voluntary isolation and poses a risk to others should involuntary detention/
enforced hospitalization be considered as a last resort.
Involuntary detention also takes two forms: involuntary solitary detention
(where the infected individual is forcibly kept isolated from others),7 and involuntary group detention (where noncooperative infectious patients share facilities
and have contact with others infected with the same disease).
While solitary confinement of an infected patient is probably the most effective
strategy for ensuring that his or her infection does not spread to others, available
infrastructure, human resource constraints, and the nature of the infectious
disease in question may mitigate against such an approach. This is true in many
developing countries where patients with the same infectious disease (such as
multi-drug resistant tuberculosis [MDR-TB] or extensively drug-resistant tuberculosis [XDR-TB] usually share a common ward because of resource constraints
but are collectively isolated from noninfected patients. The involuntary detention of patients in such instances is usually managed by hospital officials.
However, because mentally competent adult patients generally have the right to
discharge themselves from hospital facilities on demand, hospital officials usually
approach the courts to secure a detention order to deter or reverse patients
7
Democracy Now! “Is Sickness a Crime? Arizona Man with TB Locked Up Indefinitely in Solitary Confinement.” 6 April
2007. Accessible: http://www.democracynow.org/2007/4/6/is_sickness_a_crime_arizona_man. Accessed 5
February 2008.
15
absconding from treatment, and rely on state security officials to enforce the
order. Such actions, though, depend on several factors: (1) the existence of pertinent public health laws that allow for the involuntary detention of infectious
patients in the interests of public health; (2) financial resources on the part of
hospital officials to secure professional legal services to obtain the court-issued
detention order; (3) functional and competent courts to make such an order;
and (4) the availability of security services (such as the police) to enforce the
order.
It is important to note that confinement as a result of a court order does not
necessarily result in the imprisonment of the noncompliant patient. Instead, as
in the case of noncompliant XDR-TB patients in South Africa, such patients are
detained in hospital wards with other such patients where they are monitored
and receive treatment for their condition (although the efficacy of the treatment
is sometimes questionable).8 As stressed earlier, involuntary detention should
only be considered as a last resort and must be preceded by relevant counseling
by hospital officials, including education about the condition in question, and
the provision of necessary social support (for example, the patient may be the
primary care giver and/or income earner of his or her household). Addressing
these cumulative factors may induce patients to voluntarily comply with the
orders of health officials.
1.2. Incarceration
Public health officials have sometimes referred to the involuntary detention of
noncooperative infectious patients as “incarceration.”9 10 However, from a legal
and lay person’s perspective, incarceration conventionally refers to the imprisonment of individuals who have been tried and convicted of a crime, or to those
who violate a court order. In such instances, the incarcerated are usually
sentenced to a specified period in a correctional facility (such as a prison).
Although published studies have reported that short-term “incarceration” for the
management of noncompliance with tuberculosis treatment, followed by outpa-
8
9
10
Le Roux, M. “Dilemma as SA faces drug-resistant TB epidemic.” 27 January 2008. Accessible: http://www.mg.co.za/
articlePage.aspx?articleid=330723&area=/breaking_news/breaking_news__national/. Accessed 5 February 2008.
Burman, W. J., Cohn, D. L., Rietmeijer, C. A., Judson, F. N., Sbarbaro, J. A., and Reves, R. R. “Short-term incarceration for the management of noncompliance with tuberculosis treatment.” Chest, 1997 Jul 112(1):5–6.
Democracy Now! “Is Sickness a Crime? Arizona Man with TB Locked Up Indefinitely in Solitary Confinement. 6 April
2007. Accessible: http://www.democracynow.org/2007/4/6/is_sickness_a_crime_arizona_man. Accessed 5
February 2008.
16
HUMANITARIAN STAKES
tient, directly observed therapy, is relatively successful in managing difficult
patient populations (such as those with a history of homelessness or alcohol
abuse), the studies in question appear to refer to involuntary confinements of
patients in a clinical setting, not in a prison context. According to the definitions
outlined in this paper, such containment strategies are more aptly described as
“involuntary detentions” rather than “incarcerations.”11
Unfortunately, the misappropriate use of infection control containment terminology can give rise to concerns among human rights activists who justifiably
fear that the criminalization of infection may stigmatize and drive diseases
underground.12 However, even if extreme circumstances justified authorities
incarcerating defaulters or noncompliant patients in correctional facilities (for
example, if a dangerous convicted prisoner was highly likely to harm others or
to escape from a hospital detention environment and thus needed to be incarcerated in a prison environment), such patients should be placed in solitary
confinement where they would not put other inmates at risk of infection. Even
such individuals ought to be provided with appropriate health care as state
authorities are morally obliged (and in some instances, legally obliged,
depending on a country’s laws) to provide minimum levels of health care,
accommodation, and diet for every prisoner. These principles are laid out in the
United Nations Standard Minimum Rules for the Treatment of Prisoners13
although this instrument is not legally binding on countries. From a public
health perspective, however, the imprisonment of noncooperative infectious
patients who violate detention orders (for example, those who leave hospital
wards despite being ordered by authorities not to do so) is an unwise infection
control strategy as incarceration facilities (such as prisons) are typically overcrowded and such conditions will likely spur an infection’s spread in that setting.
1.3. Quarantine
Quarantine refers to the separation and restriction of the movement of persons
who, while not yet ill, have been exposed to an infectious agent and therefore
11
12
13
Burman, W. J., Cohn, D. L., Rietmeijer, C. A., Judson, F. N., Sbarbaro, J. A., and Reves, R. R. “Short-term incarceration for the management of noncompliance with tuberculosis treatment.” Chest, 1997 Jul 112(1):5–6.
Colb, S. F. “Resistant Tuberculosis and the Return of Quarantine: Justifications and Accompanying Risks.” 25 June
2007. Accessible: http://writ.news.findlaw.com/colb/20070625.html. Accessed 5 February 2008.
UN General Assembly (1977). Resolution 663 C (XXIV): Standard Minimum Rules for the Treatment of Prisoners.
Accessible: http://www.unhchr.ch/html/menu3/b/h_comp34.htm. Accessed 6 February 2008.
17
may become infectious.14 Quarantine measures originated as early as the fourteenth century15 and because of this long history most countries have quarantine
laws. South Africa, a country with a high incidence of TB and drug-resistant TB,
has enacted quarantine laws and defines quarantine as “…the restriction of the
free movement of healthy people…that have been exposed to a communicable
disease in order to prevent such disease from spreading.16
2. Ethical, Human Rights, and Social Implications
of Public Health Containment Strategies
While the above-mentioned containment strategies are arguably effective and
have been incorporated into domestic public health law frameworks, they raise
numerous ethical, human rights, and social concerns.
2.1. Confinement and Ethics
Since the early 1970s the principles of biomedical ethics have been touted as the
essential benchmarks of good clinical practice and health research. According to
these principles, health practitioners are expected to uphold, among other rights,
the patient’s right to autonomy (which stresses that mentally competent patients
have the right to determine the course of their own health) and to nonmaleficence (which stresses that patients have the right to not be harmed). However,
both these principles are violated if authorities forcibly confine noncooperative
infected patients to designated facilities to prevent their infection from spreading
to others. Such an outcome is untenable as it will mean that while a containment
measure may be legal, it would be unethical according to the biomedical ethics
paradigm. Accordingly, the last decade has seen the emergence of various
proposed principles of public health ethics.17 18 19 20 The following is an attempted
14
15
16
17
18
19
20
Centers for Disease Control and Prevention (United States). Isolation and quarantine fact sheet. September 2004.
Accessible: http://www.cdc.gov/ncidod/dq/sars_facts/isolationquarantine.pdf. Accessed 6 February 2008.
Centers for Disease Control and Prevention (United States). History of quarantine. Undated. Accessible:
http://www.cdc.gov/NCIDOD/DQ/history.htm.
Republic of South Africa Government Notice R.2438, 30 October 1987. Accessible: http://web.capetown.gov.za/
eDocuments/Regulations_-_Relating_To_Communicable_Diseases_and_the_Notification_of_Notifiable_
Medical_Conditions_-_R_2438_of_1987_411200712442_245.pdf. Accessed 6 February 2008.
Kass, N. “An ethics framework for public health.” American Journal of Public Health, 2001, 91(11):1776–82.
Uphsur, R. “Principles for the justification of public health intervention.” Canadian Journal of Public Health, 2002,
93:101–3.
Childress, J. F., Faden, R. R., Gaare, R. D., Goshin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J.
D. and Nieburg, P. “Public Health Ethics: Mapping the Terrain.” Journal of Law, Medicine and Ethics, 2002, 30:170–8.
Gostin, L. O. “Public health ethics: traditions, profession, and values.” Acta Bioethica, 2003, 9(2):177–88.
18
HUMANITARIAN STAKES
synthesis of these proposed principles:
1. What are the public health goals of the proposed intervention?
(the principle of harm prevention and necessity)
2. How effective is the intervention known to be in achieving its stated goals?
(the principle of effectiveness)
3. What are the known or potential burdens of the intervention?
(the principle of burden identification)
4. Can the burdens be minimized? Are there alternative approaches?
(the principle of least infringement/restriction/coercion)
5. Is the intervention implemented fairly?
(the principle of proportionality)
6. Can the benefits and burdens of the project be fairly balanced?
(the principle of public justification and transparency)
7. Reciprocity (individuals who are affected by public health initiatives should
be adequately supported or fairly compensated)
The above principles offer guidelines for evaluating and ethically justifying, if
applicable, proposed public health containment strategies. However, infection
control confinement strategies also raise human rights concerns.
2.2. Confinement and Human Rights
Human rights refers to an internationally agreed-upon set of principles and
norms that are contained in treaties, conventions, declarations, resolutions,
guidelines, and recommendations at the international and regional levels.21
Modern human rights instruments have their source in the 1948 Universal
Declaration of Human Rights.22 Although this instrument is not legally binding
on countries, it carries considerable moral authority. At first sight, infection
control containment strategies appear to potentially violate several rights in this
instrument, including Article 3 (Everyone has the right to life, liberty, and security of person), Article 5 (No one shall be subjected to torture or to cruel,
inhuman or degrading treatment or punishment), Article 9 (No one shall be
subjected to arbitrary arrest, detention or exile), Article 12 (No one shall be
subjected to arbitrary interference with his privacy, family, home….), and Article
21
22
World Health Organisation. A human rights approach to TB. Stop TB Guidelines for Social Mobilization 2001.
UN General Assembly (1948). Resolution 217 A (III): Universal Declaration of Human Rights. New York: United
Nations. Accessible: http://www.un.org/Overview/rights.html. Accessed 6 February 2008.
19
25 (Everyone has the right to a standard of living adequate for the health and
well being of himself and his family, including…medical care and the necessary
social services, and the right to security in the event of…sickness). However,
human rights doctrine also recognizes the limitation of many rights in a public
health emergency, provided the measures employed are legitimate, non-arbitrary,
publicly rendered, and necessary.23 In this regard, Section 25 of the Siracusa Principles on the Limitation and Derogation of Provisions in the International
Covenant on Civil and Political Rights holds: “Public health may be invoked as
a ground for limiting certain rights in order to allow a state to take measures
dealing with a serious threat to the health of the population or individual
members of the population. These measures must be specifically aimed at
preventing disease or injury or providing care for the sick and injured.”24 At
particular issue from a human rights perspective is whether the containment
strategy in question represents the least restrictive means to achieve effective
infection control and the extent of the belief in the severity of the threat.25 The
restrictions imposed by authorities should also be of limited duration and subject
to review.
While the curtailment of rights on the grounds of public health is endorsed by
human rights instruments, health workers should also be cognizant of the social
implications of such measures.
2.3. Confinement and Social Factors
As noted earlier, public health officials usually focus primarily on the public
health aspects of infection control and rely on judicial and law enforcement
authorities for assistance in this regard. However, social factors often lead to individuals resisting confinement measures; meaningfully addressing their concerns
often holds the key to effective infection control.
23
24
25
Singh, J. A., Upshur, R., and Padayatchi, N. “XDR-TB in South Africa: No time for denial or complacency.” PLoS Med
2007, 4(1): e50. doi:10.1371/journal.pmed.0040050. Accessible: http://medicine.plosjournals.org/archive/15491676/4/1/pdf/10.1371_journal.pmed.0040050-S.pdf. Accessed 6 February 2008.
United Nations, Economic and Social Council, U.N. Sub-Commission on Prevention of Discrimination and Protection
of Minorities (1984), Siracusa Principles on the Limitation and Derogation of Provisions in the International Covenant
on Civil and Political Rights, Annex. Available: http://hei.unige.ch/~clapham/hrdoc/docs/siracusa.html. Accessed 6
February 2008.
20
HUMANITARIAN STAKES
For example, in the case of drug-resistant TB, health officials may deem isolation
of the infected individual to be the most effective containment strategy.
However, the individual may be the primary or sole breadwinner of his or her
family and confinement in a health facility for up to 24 months (in the case of
MDR-TB) or indefinitely (in the case of XDR-TB) will effectively mean that the
individual’s family will likely be deprived of his or her means of livelihood during
this period. Similar factors would apply to infected single heads of households
with dependents: a prolonged or indefinite confinement in a health facility
would likely mean that such dependents would be deprived of their caregiver
during that period. Such factors have been blamed on dozens of drug-resistant
TB patients absconding from health facilities in South Africa26 and on why
court-issued detention orders have had to be obtained for their return to these
facilities (such orders have not proven effective in all cases). The South African
experience has demonstrated that merely having the lawful authority to forcibly
confine an individual against his or her will on the grounds of public health, and
exercising this authority without taking into account the social factors that could
give rise to confinement defaults, is a deficit policy. Instead, public health officials must, by necessity, consider what social support services they can offer to
facilitate patient compliance. This approach resonates with the aforementioned
public health ethics principle of “reciprocity,” which dictates that members of
the public who make a sacrifice for the benefit of others (for example, being
isolated for up to two years or longer, and foregoing their income during this
period) should be fairly compensated for doing so. Compensation in such
instances could come from both within and outside the hospital context. For
instance, hospital officials could begin by addressing internal factors, such as
making confinement conditions as comfortable and accommodating as possible,
and making counseling services available to confined patients given that many
will become depressed because of their potentially indefinite stay at confinement
facilities. In South Africa, officials at one hospital where XDR-TB patients are
being treated have created a recreational area for such patients and equipped it
with basic gym equipment, a pool table, a dart board, a television, and reading
materials.27 However, compensation or reciprocity of any kind is likely to prove
challenging in most resource-poor settings.
26
27
Le Roux, M. “Dilemma as SA faces drug-resistant TB epidemic.” 27 January 2008. Accessible: http://www.mg.co.za/
articlePage.aspx?articleid=330723&area=/breaking_news/breaking_news__national/. Accessed 5 February 2008.
21
Implementing infection control confinement measures is usually the responsibility of state officials. However, in some settings, humanitarian aid agencies
supplement government health services or are even the sole providers of such
services. These contexts raise challenging ethical and legal issues for such organizations when they encounter noncooperative infectious patients.
3. Humanitarian Agencies and Confinement
While international intervention in “failed states” on the grounds of an infectious outbreak of disease has been conjectured and legally justified,28 relatively
few countries in which humanitarian organizations work meet the definition of
a “failed state.” Regardless, humanitarian bodies confronting or managing infectious diseases should familiarize themselves with the domestic health laws of the
settings in which they work. However, the absence of relevant domestic confinement laws should not bar humanitarian organizations from acting in the interest
of public health. In such instances, they should attempt to ascertain whether the
country in which they are based is a signatory to, or has ratified, relevant international law, such as the Siracusa Principles. If the country in question has ratified this instrument, aid workers could then base their confinement strategy
thereon. Even if the country has not ratified the Siracusa Principles, humanitarian personnel may arguably be ethically justified in temporarily confining
uncooperative infectious individuals who pose a risk to others on utilitarian
grounds, at least until such time as the relevant authorities can be notified about
the infected person in question and can take over his or her management. This
may be difficult to do in settings where there is no government authority (such
as in Somalia) or where government authority is disputed (such as in rebelcontrolled territories). Moreover, humanitarian organizations adopting such a
stance should only do so as a last resort; they should be mindful that such actions
could be construed as the organization assuming a policing role, which, in turn,
could impact the group’s reputation and undermine its future work in that
setting. It is recommended that humanitarian organizations proactively engage
with authorities, if applicable, and with local community members on these
issues prior to, or as early into an infectious outbreak as possible so that they have
the cooperation and understanding of these stakeholders. In such instances,
humanitarian personnel should, in addition, proactively justify the ethics of their
28
El-Gendi, L. “Epidemics in Failed States: The Legality of Quarantine and International Intervention.” Fall 2007.
Accessible: http://www.kentlaw.edu/perritt/courses/seminar/lubna-el-gendi-final-Epidemics%20in%20Failed%20States.htm.
Accessed 6 February 2008.
22
HUMANITARIAN STAKES
possible actions from a public health ethics perspective and be cognizant of the
social implications of a confinement policy.
Humanitarian bodies are best placed to act as a voice for marginalized groups,
including infectious individuals. Accordingly, if authorities already have infection control measures in place or are considering drafting them in response to an
infectious disease outbreak, humanitarian organizations have a moral responsibility to critically evaluate the proposed measures in light of human rights and
public health ethics frameworks, and/or to lobby for such a policy or law if one
does not already exist. If a proposed confinement policy or intervention satisfies
these benchmarks and also caters to the social needs of those who stand to be
affected by it, humanitarian organizations should lend their support to the
policy.
Conclusion
Humanitarian organizations can play an important infection control role in
settings where they are active. However, to do so they must be cognizant of
different confinement strategies and their respective legal, ethical, human rights,
and social implications. Such knowledge will undoubtedly facilitate relief efforts,
save lives, and be in the interest of public health.
23
Controlling infection during the Ebola VHF epidemic in the
province of Kasaï Occidental (DR Congo) and ethical dilemma.
Dr Vital Mondonge Makuma 1
The province of Kasaï Occidental is home to
6,365,555 of the Democratic Republic of Congo’s
60,000,000 inhabitants. The province has 43 health
zones.
From April to mid-October 2007, the Ebola VHF
epidemic raged in the health zones of Mweka, Bulape
and Luebo. The village of Kampungu, the epicentre of the epidemic, is located
in the Mweka health zone, 240 km from the town of Kananga, to which it is
connected by a railway and a dirt road.
During this epidemic, of 264 cases 187 deaths were recorded, giving a mortality
rate of 70%. The management of this epidemic encountered the following major
problems:
Insufficient application of hygiene and infection control measures in health facilities. Running water, electricity and protective equipment were almost non-existent at the start of the epidemic. Health workers did not comply with
hand-washing guidelines and did not organise the systematic disposal of waste.
Ministry of Health experts and partners reinforced these hygiene and sanitation
measures and took other complementary measures to control the epidemic. These
additional measures included raising awareness among the population, monitoring
people who had come into contact with the disease and isolating the sick.
All these measures were essential to control the epidemic and benefited the
communities hit by it. However, the majority of the measures, particularly isola-
1
Minister of Health/DR Congo Department of Disease Control Director
24
HUMANITARIAN STAKES
tion of the sick and limiting the movements of people who had been in contact
with the disease for monitoring purposes, had a restrictive effect.
During the epidemic, several conflicts between health personnel and both
patients and family members, were overcome. Family members did not often
accept the decision to isolate or restrict the movements of people who had been
in contact with the sick. Thorough explanations and great efforts of persuasion
were required from the health workers to obtain the agreement of the people
concerned by the measures. Sometimes, staff were forced to submit the will of
the patients and isolate them at home.
What does medical ethics recommend in this situation? Always seeking the
consent of the patient before implementing actions in the interest of the wider
community? Can this dilemma be resolved by existing laws or should specific
laws be introduced to cover medical practice in this type of situation.
25
Humanisation and informed consent for people and
populations during responses to VHF 1 in central Africa
(2003-2008)
Alain Epelboin 2, Pierre Formenty 3, Julienne Anoko 4 and Yokouid Allarangar 5
Introduction
Whether from the point of view of the people directly concerned, the general
public or health professionals, Ebola and Marburg viral haemorrhagic fever
epidemics are particularly dramatic ‘spectacular’, and receive extensive media
coverage, due to the following factors:
- Extraordinary mortality (30% to 90% of sufferers, depending on the type of virus);
- Extreme infectivity by direct contact with contaminated (animal or human)
body fluids, with poorly estimated risk rates (many automatically assume it is
100%, though in reality the percentage of exposed subjects that develop the
disease varies depending on the type of exposure:
- Contact with infected animal body fluids: 30% to 100% of exposed subjects
become infected,
- Contact with infected human body fluids through dirty injections: up to
75% of exposed subjects can develop the disease,
- Contact with infected human body fluids during funerals: 5% to 15%,
- Contact with infected human body fluids during home care: 1% to 10% of
exposed subjects become infected);
- Clinical severity, marked by multiple haemorrhagic signs, the intensity of
fevers and aches and the speed of fatal evolution;
- The death of doctors, midwifes, nurses and healers, which paralyses health
structures and dampens good will.
1
2
3
4
5
VHF = viral haemorrhagic fever.
Medical Anthropologist, CNRS-MNHN Paris, WHO CDS/EPR consultant, Geneva.
Epidemiologist, Department of Epidemic and Pandemic Alert and Response (CDS/EPR), World Health Organisation, Geneva.
Anthropologist, WHO consultant.
Epidemic Preparedness and Response Officer, CSR Programme, DDC, WHO/AFRO Brazzaville.
26
HUMANITARIAN STAKES
There is no vaccine or specific treatment against these viruses, just drastic sanitary measures that affect individual and collective freedoms:
- Identification of those infected (“suspect” cases and probable cases) and
exposed subjects;
- Criminological-style epidemiological surveys designed to shed light on family
secrets, as well as individual and collective unconscious beliefs and unspoken
assumptions;
- Bans on the hunting and consumption of game, a key source of food,
disrupting ordinary eating habits and local economies both materially and
symbolically;
- Imposed isolation of the sick in controlled areas, perceived as places of death
and/or contamination;
- Daily monitoring of the temperature and state of health of exposed subjects,
who are immediately isolated if they fall sick and are considered “suspect” cases
by clinicians;
- Supervision and/or banning of gatherings and travel;
- Disruption of funerary rituals, hindering the mourning process;
- Compulsory blood or tissue sampling for virological diagnosis, perceived as
witchcraft; and so on.
The epidemic, a challenge of knowledge and power
Humanitarian mission, said the visa officer at the embassy in Paris (and therefore
a priority, she thought), when told that the purpose of the trip was to participate
in the fight against viral haemorrhagic fever.
Humanitarian, certainly, but from what point of view?
That of the indigenous populations in contact with epizootic outbreaks, which
actually serve as sentinel observatories for viral haemorrhagic fevers and other
diseases emerging from the depths of African forest ecosystems?
That of humanity, which (in reality or phantasmagorically) is threatened by a
catastrophic spreading of viruses that it does not know how to treat, and which
envisages various accidental, spontaneous or provoked epidemic scenarios at the
urban and therefore the global level?
Providing protection and health cover for some also involves protecting others.
However, the quality and resources of public medical and social structures in the
remote, forgotten regions where these types of animal and human epidemics
strike are often mediocre, indeed sometimes totally lacking.
27
Care for the health (and consequently the misfortune) of these populations is
also provided by private medical structures (lay, denominational, charitable
and/or profit-making, etc.) and local practitioners (traditional healers, religious
leaders, neo-healers, traditional authorities, popular medicines). Numerous
varied and often antagonistic divinatory techniques, phytopharmacopeia, incantations and prayers, amulets and rituals are accessible and hold great credibility.
They help make sense of the misfortune of the epidemic, if not for the individual
or society, at least in terms of the metaphysical order of the world. And in one
way or another, they are constantly operating, for better or worse, at a psychological, economic, political or even epidemiological level.
Indeed, statistical and genetic explanations do not answer the fundamental questions of the individual and society: why now, why me and not someone else?
What relationship is there between the various events that affect me, my friends
and family, and my enemies?
Even with treatments and vaccines, let alone without, the biomedical model is
just another explanatory model, leaving the field open to any psychological,
social, economic or political interpretation of conscious or unconscious, spoken
or unspoken misfortune.
During the Ebola and Marburg VHF epidemics that have been ‘anthropologically’ monitored since 2003, numerous explanatory models of the epidemics
have co-existed. Each one has specific features that focus not on the type of
supernatural explanation proposed but the social use it serves: paying for ancestral sins, settlements of account between old and young or with in-laws, between
neighbourhoods or villages, between ethnic or religious groups, between natives
and foreigners, between locals and the national authorities, between ‘Westerners’
and Africans, between political parties and economic groups…
The management of misfortune – whether biological or not – always boils down
to a challenge of knowledge and power between the supporters of a world based
on the existence of viruses, microbes and other molecules, and the supporters of
worlds based on inherited or acquired mystical powers, supernatural beings,
murderous sorcerers, divine interventions, etc. There is a conflict between “the
science of scientists” and “indigenous sciences”, against a backdrop of globalisation, shaken up by clashes between antagonistic interests.
28
HUMANITARIAN STAKES
Whether or not to believe in the virus
The existence of the virus, or its animal origin, is readily denied by “negationists”, creationists, proponents of pan-African ideologies, challengers of the world
order or xenophobes, both learned and ignorant.
They view support for the biomedical model of the response to epidemics as allegiance to the selfish interests of industrialised countries, which have crushed or
are in the process of crushing (or turning into folklore) local cultures, scorning
indigenous sciences and “beliefs”, and imposing an atheistic, or even diabolical,
ideological order. Those industrialised countries also quick to exploit anything
that might make them some money, for example the pharmacologically active
qualities of certain plants, or vaccine or drug trials on local populations.
Therefore, in the eyes of those same people, the teams implementing responses
to epidemics (local and national personnel, international experts, NGO volunteers, etc.) in the name of global public health and Western science are no longer
conscientious professionals or respectable humanitarian workers, but mercenaries, agents of a national and/or international health police, charged with
imposing a despised political order. Moreover, they are accused of taking advantage of epidemics for personal financial gain. This last point sometimes proves to
be true; rather than actual embezzlement, national and international funding,
which is considerable at the source, melts like snow in the sun and, assuming it
has not completely evaporated, seems pretty meagre by the time it reaches its
destination: bereaved families and the ground staff of the epidemic response
teams.
And so doubt reigns, over both the existence of the virus and the real intentions
of the humanitarian workers, who locals confuse with the foreigners who are
only interested in election campaigns, forest and mine prospecting, trade, war or
religious proselytism.
On top of that, the safety protocols made necessary by the risk of transmission
of the virus oblige humanitarian workers to keep a physical distance, which
makes personal contact difficult. Normal spontaneous gestures such as shaking
hands, touching the person spoken to, sharing drinks and food or transportation
in the same vehicle are prohibited. Consequently, it is extremely difficult to
convey empathy.
What can be done to build trust? How can the informed consent of individuals
be obtained when the proposed measures are highly coercive and restrict individual and collective liberties?
29
What is the best way to manage people’s beliefs, and their simultaneous support
for the epidemiological model and other models for interpreting the disease and
the misfortune of the epidemic? What measures can be taken to encourage the
adoption of behaviours that help stop propagation of the virus, irrespective of
any controversy about its existence?
Coercion and understanding
Historically, the approach to tackling epidemics of diseases for which there is no
vaccine or effective treatment – whether attributed to miasmas, jinxes, curses or
viruses – has consisted of a succession of infringements of people’s liberties, and
totalitarian measures. They are applied in the name of higher interests, are often
confused with public health, and sacrifice individuals and groups. In any given
situation, there is always confusion between knowledge and power, protection of
some and exposure of others, stigmatisation and the search for scapegoats: witch
doctors, immigrants, the sick, often the lower social classes or socially marginalised groups.
It was not until the second half of the 20th century, with the criticism of scientific triumphalism, the loss of hope in “health for all by the year 2000” and
particularly the HIV epidemic, that we realised the limits of the coercive
approach in public health and switched to an approach based on understanding.
The response to Ebola and Marburg VHF epidemics must involve coercion. It
must be based on the application of coercive hygiene measures designed to break
the chains of transmission, but only after a multi-disciplinary critical analysis of
the proposed measures.
The response to Ebola and Marburg VHF epidemics must involve understanding and should:
- Ensure historic, cultural, linguistic and psychological understanding of the
populations concerned;
- Be pragmatic and didactic, whether in dealings with opinion leaders or children, taking into account the specific characteristics of each region and
working in line with local and national practices, know-how, customs, beliefs
and religions;
- Involve the people concerned in all phases of operations that affect them;
- Combat – effectively and with full knowledge of the facts – those same
“regional characteristics” when they contribute to the spread of the epidemic.
30
HUMANITARIAN STAKES
In a context in which urgency overshadows the individual and the measures
imposed risk adding destitution to death, the prescribing doctor must constantly
strive to ensure the validity, feasibility and implementation of his proposals:
would they be acceptable if he were in the shoes of the patient, or if his nearest
and dearest were under threat? An anthropologist or a clinical psychologist
would recommend working on the social distance and ethnocentrism of both
carers and patients.
The message must be conveyed that if individual and collective liberties are
violated by the responses to Ebola and Marburg VHF epidemics, that is not an
effect of exercising imperialistic medical power, but rather of carefully thoughtout knowledge, which is constantly revalidated by critical and technical revisions, and adapted to each situation.
The informed consent of individuals and societies during such epidemics cannot
be summarised as obtaining a hand-written signature at the bottom of a supposedly comprehensible, ethical and “legally sound” document. In fact, that is
merely a bureaucratic act that arouses distrust, and is only carried out when
taking biological samples. Moreover, in the societies in question, writing – like
human fluid or tissue samples ante or post mortem – is often accused of being
used for evil practices!
Rather than instruction manuals and guidelines (each of the institutions
involved has its own “guide” or endeavours to draft one), measures adapted to
each context must be devised for each situation to thoroughly manage coercive
needs and mesological constraints relating to the specific indigenous, ecological,
economic, political, cultural, psychological, historic and religious characteristics
of the region.
In other words, the treatment of the living and the dead must be “humanised”,
with social mobilisation and awareness raising, i.e. treating people and not only
bodies or infected cohorts. This is what must be done if we want to start
obtaining real informed consent, from both individuals and entire populations,
even if only by ad hoc and informal means.
Recommendations to promote understanding
To clarify these proposals for humanisation, we have prepared a few specific
recommendations, both from the field and from multi-disciplinary workshops
with those implementing the responses to epidemics (Brazzaville 2004, Paris
2004, Versoix 2005, Winnipeg 2006, Libreville 2008). They combine simple
31
recommendations based on plain good sense and functional medicine and other
more sophisticated recommendations based on applied anthropology. Obviously, they are not exhaustive and must be used in conjunction with the recommendations of the current instruction manuals. Like these guidelines, they must
not be applied dogmatically, but assessed in light of the specificities of the field
and new scientific discoveries, then revalidated, supplemented, revised and
updated in an ongoing process.
Recommendations concerning travel by response teams
- Drive slowly in vehicles with the windows open;
- Smile and greet people confidently, do not show your fear;
- Use local forms of greeting from a distance, a wave of the hand and/or bow of
the head or upper body, with the thumbs raised, the hands together, clicking
the fingers, etc.;
- Systematically take time to explain your actions at every step, encouraging
those concerned to ask questions and express their thoughts;
- Try, as often as possible, to establish a direct dialogue with people expressing
hostility;
- Discourage anonymous personnel dressed in personal protective clothing from
driving in cars, as this may unnecessarily alarm the population and prompt
reactions of fear or violence.
Recommendations concerning home treatment and aftercare of patients
- Encourage the putting on and taking off of personal protective clothing on the
site where the action is carried out;
- Use field activities as an awareness-raising opportunity, with the handing out
of illustrated documents and, where possible, the generous distribution of
gloves;
- Systematically explain the actions to be carried out to the persons concerned,
before commencing;
- Invite a member of the family to oversee the action, providing him or her with
personal protective clothing;
- Obtain the consent of families before taking biological samples (blood, saliva,
urine, or organs in the event of an autopsy);
- Use saliva or urine samples when blood samples create problems;
- Ensure that there is always a “monitor” for staff in personal protective clothing,
positioned at the edge of the infected area, wearing civilian clothing, equipped
32
-
-
-
HUMANITARIAN STAKES
with gloves and a hand spray, to help staff get dressed, point out and rectify
any hygiene mistakes and act as an intermediary between the team in uniform
and any third parties (family, neighbours);
Try to limit the number of contact persons for families;
Constantly strive to prevent the accumulation of excessive protective layers or
symbolic over-protection, obscuring the real health risks;
Provide scrapers to thoroughly clean boots, and avoid merely rinsing soles
superficially;
Allow the treatment at home of suspects and/or sick patients who refuse hospitalisation, with the provision of personal protective materials and medicines, as
a second resort to build trust with the patient and/or the patient’s family;
During disinfection, take into account local use of the habitat, such as the
wiping of nasal discharge on posts, places that are often touched by dirty
hands, etc.;
Systematically advise exposed subjects to avoid attending gatherings (school,
sports events, etc.), when such events are not forbidden;
Give the patient or representative lab results in the form of a printed and
signed document.
Recommendations concerning the isolation centre
- Remove opaque barriers and put up thorough, clear signs, demarcating areas
reserved for staff and those potentially contaminated;
- Provide permanent night-time lighting in patient accommodation;
- Inform families of the condition of sick family members and the treatments
carried out, on a very regular basis;
- Organise secure visits of relatives to sick family members;
- Authorise, under medical supervision, deliveries of food prepared at home;
- Include local flavours and foods in the meals and drinks given to patients;
- On a case-by-case basis, consider allowing the secure access of priests or traditional healers to hospitalised patients, at the express request of patients, but
prohibiting intrarectal injections, scarification and the prescription of emetic
and purgative products.
When treating patients suffering from VHF, the medical team must comply with
the Patient Care Charter, namely:
- Quality of care must be a priority for care staff,
- Hospital staff must give patients and their families psychological support,
- The information given to patients and their families must be honest,
33
- Informed consent must be the rule for any intervention,
- Consent forms written in the national language must be the rule for specific
research,
- Patients’ beliefs and religions must be respected,
- Patient privacy must be protected,
- The medical team must give patients the chance to express their views on the
way their cases are managed.
Recommendations concerning funeral rites
- Systematically offer your condolences to the family of the deceased;
- Inform the family in advance of the different phases of the operation;
- Do not prevent local forms of expression of grief, such as weeping and wailing,
however loud and upsetting they may be;
- Supervise the putting on and taking off of personal protective clothing of the
team on the site of the operation;
- Organise the presence, in personal protective clothing, of a member of the
family, when placing the corpse in a (opaque) body bag and coffin;
- Handle corpses gently and without knocking them, showing due respect;
- If possible, avoid burials without a coffin and make provision to organise or
pay for them;
- Systematically invite the families to place any personal belongings that the
deceased “may need on the other side” in the body bag or coffin;
- At the home of the deceased, only burn contaminated objects that cannot be
salvaged and have no value for close family: do this in a remote place of the
plot designated by the family;
- Thoroughly disinfect contaminated objects that the family wishes to keep,
even if they seem worthless to the response team;
- Ensure that the operation is performed by a single team, on a single occasion,
including removal of the body, placing in the body bag and coffin and disinfection of the areas of the home (bedroom, toilet) likely to have been contaminated;
- Organise the carrying of the disinfected coffin, and burial by members of the
family equipped with gloves, under the supervision of the sanitary teams in
civilian clothing;
- Transport coffins to the cemetery in convoys, driving very slowly, with the
hazard warning lights on and observing other local signs of mourning (such as
bunches of palm leaves);
- Systematically ensure that members of the family are present during the burial;
- Provide the family with a vehicle with enough room to transport the coffin and
34
HUMANITARIAN STAKES
accompanying relatives to the cemetery;
- Take care with the positioning of the head of the corpse in the coffin, the transportation vehicle and the grave; where no coffin is used, arrange for the body
bag to be carefully lowered into the grave, without dropping it, and ensuring
that the corpse is positioned appropriately;
- Systematically arrange nameplates for graves;
- Systematically suggest that the participants wash their hands and feet using a
spray containing appropriately diluted bleach after the different stages of the
funeral (collection of the body, burial);
- If families express the wish to keep a photograph of the deceased or the ceremony to show absent friends or family that the funeral was carried out properly, offer to take a photo with a digital camera and give it to them promptly;
- Provide a death certificate, signed by a local authority.
Recommendations concerning social awareness-raising and mobilisation
- Compile relevant scientific articles and articles accessible to lay readers, guidelines and documents (pamphlets, photos, drawings, posters, video, audio) used
during earlier epidemics on copiable CDs or DVDs (that can be read on a
computer and/or DVD player);
- Make this “collection” available to the teams implementing responses to
epidemics to assist with their (re)training and allow them to choose the materials
that will be useful for their own social mobilisation and awareness-raising actions;
- Add to this collection, throughout the epidemic, with new media specific to
the situation in question;
- Clearly identify the target groups and social actors (opinion leaders), taking
care not to overlook women, marginal groups or illegal groups (medicine
hawkers, poachers, gold washers, illegal aliens, etc.);
- Anticipate risks related to scapegoating, stigmatisation of survivors, people
exposed to the disease and the families of the deceased;
- Rather than totally banning the consumption of game, which would be unrealistic, focus messages on the danger of touching and consuming animals
found dead or sick: stress the need to be able to trace the origin of meat, from
the forest to the village;
- Raise the awareness of hunters, particularly to the danger of animals found
dead, which should not be perceived as “a divine gift”, and the need to avoid
animals that are sick and/or behaving strangely;
- Avoid blurring messages specific to VHF (contact with body fluids) by
combining them with general public health messages (environmental health,
35
vector control);
- Stress the need to avoid contact with body fluids, especially in cases of fever, as
the absence of airborne contamination;
- Systematically provide the families of the sick, exposed subjects and biomedical and traditional practitioners exposed to the sick with gloves;
- Where gloves and chlorinated water are not available, recommend the use of
detergent, soap and plastic bags;
- Provide information about the risks of domestic accidents related to the presence of chlorinated water in the home;
- Raise the awareness of professionals and the population about the risks of
infection linked to using old injection equipment and shared rectal bulb
syringes;
- Produce and widely circulate health messages in the form of songs sung in local
languages by popular local musicians, in addition to wide use of the usual
media (leaflets, posters, meetings, radio discussions, TV adverts, etc.);
- Show ethnographic videos to health personnel and the general public,
explaining the various actions of the response teams (treatment of the sick,
funerals, testimonies, etc.).
Recommendations concerning awareness-raising among opinion leaders
- Carry out individual and collective awareness-raising and mobilisation actions
by providing them with educational materials (paper, audio, video) and, where
possible, gloves and bleach;
- Counter the often xenophobic ambivalence that aims to implicate “outsiders”
in the introduction and spread of the epidemic;
- Skilfully manage or fight negationists and creationists on the issue of the existence of the virus, and promoters of “miracle cures” related to indigenous religions and sciences.
36
HUMANITARIAN STAKES
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nécessaires Bull Soc Pathol Exot 2008 T101-2 pp. 77-84.
Chippaux J.P. Defining an ethics for preventive trials. Bull Soc Pathol Exot 2008 T101-2 pp. 85-89.
Formenty P, Leroy E, Epelboin A, Libama F. & col Detection of Ebola Virus in Oral Fluid Specimens during Outbreaks of
Ebola Virus Hemorrhagic Fever in the Republic of Congo. Clin Infect Dis. June 1 2006;42:1521-1526 16652308.
http://lib.bioinfo.pl/pmid:16652308
Hewlett BS, Epelboin A, Hewlett BL & Formenty P - Medical anthropology and Ebola in Congo: cultural models and
humanistic care. Bull Soc Pathol Exot, 2005, 98, 237-244.
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Boumandouki P, Formenty P, Epelboin A, Campbell P, Allarangar Y, et al. - Prise en charge des malades et des défunts
lors de l’épidémie de fièvre hémorragique due au virus Ebola d’octobre à décembre 2003 Bull Soc Pathol Exot, 2005,
98, 218-223.
http://64.233.183.104/search?q=cache:lrMnNK1-xJ4J:www.pathexo.fr/pdf/Articles-bull/2005/2005n3/T98-32770-6p.pdf+epelboin&hl=fr&ct=clnk&cd=13&gl=fr
Formenty P, Epelboin A, Allarangar Y, Libama F, Boumandouki P, et al. - Séminaire de formation des formateurs et
d'analyse des épidémies de fièvre hémorragique due au virus Ebola en Afrique centrale de 2001 à 2003. (Brazzaville,
Republic of Congo, 6-8 April 2004). Bull Soc Pathol Exot, 2005, 98, 244-254.
http://64.233.183.104/search?q=cache:qR9On7xX7icJ:www.pathexo.fr/pdf/Articles-bull/2005/2005n3/T98-3-seminaire-11p.pdf+epelboin&hl=fr&ct=clnk&cd=22&gl=fr
Formenty P., Libama F., Epelboin A, Allarangar Y., Leroy E., Moudzeo H., Tarangonia P., Molamou A., Lenzi M., Ait-Ikhlef,
Hewlett B., Roth C., Grein T., L’épidémie de fièvre hémorragique à virus Ebola en République du Congo, 2003: une nouvelle stratégie. Méd. trop. 2003 – 63-3 pp. 291-295
Epelboin A, Formenty P, Bahuchet S., Du virus au sorcier: approche anthropologique de l’épidémie de fièvre hémorragique à virus Ebola sévissant dans le district de Kéllé (Congo) 6 / = The social impact of Ebola: the case of Kellé district, Congo Canopée No. 24 July 2003 pg. 5.
http://www.ecofac.org/Canopee/N24/Sommaire.htm
http://www.open-earth.org/document/readNature_main.php?natureId=228
Balinska M. A. La Pologne : du choléra au typhus, 1831-1950. Bull Soc Pathol exot 1999 T92-5 pp. 349-354.
Formenty P, Hatz C, Le Guenno B, Stoll A, Rogenmoser P, et al. (1999) Human infection due to Ebola virus, subtype Côte
d'Ivoire: clinical and biologic presentation. J Infect Dis 179: S48-S53.
Georges AJ, Leroy EM, Renaut AA, Tevi Benissan C, Nabias RJ, et al. (1999) Ebola hemorrhagic fever outbreaks in
Gabon, 1994-1997: Epidemiologic and Health control issues. J Infect Dis 179: S65-S75.
Khan AS, Tshioko FK, Heymann DL, Le Guenno B, Nabeth P, et al. (1999) The reemergence of Ebola hemorrhagic fever,
Democratic Republic of the Congo, 1995. J Infect Dis 179: S76-S86.
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Video bibliography
Brunnquell F., Epelboin A. & Formenty P Ebola: No Laughing Matter, (Congo), 2007, 51 mn 28, Prod. CAPA
http://video.rap.prd.fr/video/mnhn/smm/0640CGebolarirre1vf.rm
http://video.rap.prd.fr/video/mnhn/smm/0640_CGebolarireangl.rm
Epelboin A., Anoko J N, Formenty P, Marx A., Lestage D., Marburg en Angola 2005 Production 2005, SMM/CNRS/MNHN &
WHO
- O trio contra Marburg 18 mn
http://video.rap.prd.fr/video/mnhn/smm/new_Trio_Marburg_00.rm
- Mise en bière d’un bébé 25 mn
http://video.rap.prd.fr/video/mnhn/smm/Miseenbiere_00.rm
- Funérailles de crise, le tailleur et les siens 37 mn
http://video.rap.prd.fr/video/mnhn/smm/Le_Tailleur_et_les_siens_00.rm
Epelboin A., Marx A., Durand J.L., Ebola au Congo 2003 Production 2004, SMM/CNRS/MNHN & WHO
- Virus, sorciers & politique, February 2003, Kéllé, 35 mn,
http://video.rap.prd.fr/video/mnhn/sm/20040211_00_ebola_au_congo_fevrier_2003.rm
- Virus paroles et vidéo, June 2003, Kéllé, Mbomo, 30 mn
http://video.rap.prd.fr/video/mnhn/smm/20040614_00_ebola_au_congo_juin_2003.rm
- Virus, braconnier et fétiche, December 2003, Mbomo, 40 mn
http://video.rap.prd.fr/video/mnhn/smm/20040617_00_ebola_au_congo_decembre_2003.rm
Website bibliography
Public health agency of Canada
http://www.phac-aspc.gc.ca
Centers for Disease Control and Prevention, Atlanta, U.S.A.
http://www.cdc.gov/
Institut de recherche pour le développement, Paris
http://www.ird.fr/
Institut Pasteur, Fance
http://www.pasteur.fr/ip/index.jsp
Médecins sans Frontières
http://www.msf.org/
Société de pathologie exotique, Paris France
http://www.pathexo.fr/
Vidéothèque "santé, maladie, malheur " SMM CNRS MNHN, Paris, France
http://www.rap.prd.fr/ressources/vod.php?videotheque=mnhn/smm
World Health Organisation, Geneva, Switzerland
http://www.who.int/en/
HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS?
39
When the Talibans exerted a terrible segregation policy towards Afghan women,
denying them health care, education, and other services, human rights activists
preached for an embargo against the regime. They went as far as to recommend
the withdrawal of any assistance to civilians that could have been perceived as
supporting the regime.
Some humanitarians refused what was considered a double punishment: the first
being the regime, the second being the denial of solidarity through assistance.
After years of conflict in Darfur, humanitarians have developed a vast network
to aid the hundreds of thousands of displaced people. Human rights activists,
supported by Western governments, have developed a campaign to save Darfur
that promotes a fly ban and a possible military intervention to stop the
massacres. Humanitarians predict civilian suffering will increase since a fly ban
would end humanitarian flights and deprive populations of assistance, while a
military intervention is said to be impossible. While some humanitarian organizations proclaim that their modes of action are equal parts assistance and advocacy for the victims of disasters, aren’t these groups blurring the lines and
creating confusion themselves?
Is it a question of semantics, or the expression of real confusion within the
framework of the sacred union of goodwill for a better world? The motivations
of humanitarians and human rights activists, both of which focus on the good
of the “victims,” seem, at least in some cases, to be antagonistic. How can we
communicate these differences to the public, the media, and more fundamentally, local actors?
40
HUMANITARIAN STAKES
A False Compatibility:
Humanitarian Action and Human Rights
David Rieff 1
To think seriously about the relationship between aid workers and human rights
activists --- the overlap between the two movements, as well as the ways in which
they may be at least partly incompatible --- it is essential to go back to unfashionable sociological basics. Instead of talking about ideals, admirable as they may
be, or leaning hard on the moral bona fides of both traditions, it is better to
begin by talking about class --- the one subject, in this bizarre time of global
savagery, ideological sclerosis, and political correctness, which almost no one
seems to want to think about.
We might start with a question: what are the social matrices out of which come
most humanitarian relief workers and most of the people interested in Human
Rights come out of? If you spoke in strictly recruiting terms, you will be talking
about human rights groups and relief organizations most profitably looking for
personnel, and, perhaps more importantly, for individual donors in a rather
narrow stratum of society. There is a disproportionate number of educated
people; people who place themselves left of the political center; people who are
critical of their own societies’ complacencies; and people who are young --- that
is whose lack of family obligations permit them to go into the field more easily,
stay longer, and earn less, than they are likely to be able to do at a later point in
their lives.
These common origins --- in the cultural, generational, economic, and political
senses of the term --- is of central importance when one is trying to sort out the
ways in which the humanitarian project and the human rights project can be
separated, to what extent they overlap, and to what extent they are two facets of
the same project. After all, neither movement exists in a historical vacuum,
1
Journaliste
41
which is why movements in the broader culture cannot help but affecting how
humanitarians and human rights activists construe their roles. An example: in
Italy, where the pacifist tradition on the left is dominant, relief workers have
tended to believe they should align themselves with various post-9/11 anti-war
campaigns, whereas in France, where pacifism is a minority view, relief workers
have been somewhat less drawn to such engagements.
That said, on the broader level, relief workers and human rights campaigners are
idealists. In both movements, people want to ‘do something,’ whether it is to
right wrongs or alleviate suffering. That much joins them. But I would suggest
that actually in terms of what the “doing” actually is, there is a fundamental
distinction to be made. Here, I am less interested in the questions of rivalry
between an MSF and a Human Rights Watch (though institutional self-interest
is an under-estimated part of both the humanitarian story), than I am in the
question of whether the project of bringing humanitarian relief and that of
campaigning for human rights can ever be completely reconciled. A Bernard
Kouchner or Amnesty International’s Irene Kahn would doubtless insist there is
no problem, just as both the main current within the ICRC and within the
French section of MSF would view the matter far more sceptically.
Of course, there is a problem, and the question should not be whether it exists
but rather whether it can or, probably more importantly, should be overcome.
But to answer that, it is necessary to look at what the ‘ur’ narrative of each movement consists of.
Fundamentally, the Human Rights project is a fairly typical Western progress
narrative. Its master idea is that slowly but surely, with great difficulty and with
many setbacks and defeats, humanity is making its collective way towards a
world where different and more humane legal and political norms will prevail.
One way of describing this is to claim that over the past half-century what the
Canadian writer and politician, Michael Ignatieff, has dubbed a “revolution of
moral concern” has taken place. In fairness, there is considerable evidence of
changing norms, though not, of course, changing facts on the ground, as illustrated by the recent discussion about whether the doctrine of a ‘Responsibility
to Protect’ obliged states to intervene in Burma when the dictatorship there
failed to respond adequately to the effects of Cyclone Nargis. The debate led
nowhere, in the sense that there was no intervention. But the fact that there was
a debate at all --- something that would have been unheard of even a decade ago
--- is taken by human rights activists as a proof of the change that is taking place.
42
HUMANITARIAN STAKES
But if, both historically and operationally, the Human Rights project, is an
utopian project, positing that, in the end, the great scourges of human history -- war and human cruelty --- can one way or another be brought to an end in
the foreseeable future, humanitarian action has not been utopian, at least
nowhere near to the same degree. This does not mean that, in an era when
human rights is the official ideology of Western progressives (and, to a considerable extent, of Western governments, whether or not they are sincere in this),
that humanitarian aid workers are immune from utopian thinking. And
Kouchner’s career demonstrates how important that thinking has been within
the movement. Nonetheless, the first duty of the humanitarian is the alleviation
of suffering, not social transformation, whatever Kouchner, the authors of ‘The
Responsibility to Protect,’ and many others may claim.
One can illustrate this with a medical analogy. Fundamentally, there are two
distinct views of what physicians can accomplish: according to one model, it is
realistic to attempt over the very long run to cure most if not all diseases; in the
other, what dominates is the public health model, the triage model. It proceeds
from the assumption that for the most part all that physicians can do is alleviate
to the extent that they can. Cure remains a possibility in some cases at some
times, but it is less of a priority from a perspective that is based on the norms of
public health, and of triage, rather than that of technologically sophisticated,
heroic medicine. Of course, there are overlaps. But when all is said and done, the
two visions are incompatible in terms of their deontology.
This does not mean that there is or at least that there need to be hostility in an
operational sense. But, again from a deontological point of view, one is utopian,
while the other is not. The same can be said of humanitarianism and human
rights activism. For humanitarians, the fundamental goal is palliation, not social
transformation. In order to get their work done, they must compromise with
human rights abusers, whether these be governments or guerrillas (the only realistic alternative is to have their own army, or, more likely that of a well-disposed
outside power to allow them to work without the agreement of local authorities;
we saw where that led to in Somalia, would probably have led to in Burma, and
is leading to in Afghanistan). It is in no sense a defeat for humanitarians not to
be able to transform the societies in which they operate. Bernard Kouchner may
construe humanitarian action as an Archimedean lever for bringing about
democracy and social justice. But humanitarian action can be entirely coherent
without such a conviction, as the work of both the ICRC and MSF/France have
demonstrated. Indeed, the greatest example of anti utopian Humanitarian is the
International Committee of the Red Cross. The ICRC is actually explicitly anti-
43
utopian in the sense for example that while Human Rights activists will spoke
about impunity, about authorising intervention when there are grave breaches of
humanitarian law, war crimes or genocide, the ICRC starts by saying, in effect,
‘we work within the context of war, and one’s views or hopes as a private person
for an end to war have nothing to do with one’s analysis of the world in which
one lives in, let alone of one’s own power to alter those realities.’
In contrast, Human Rights campaigners are absolutists or they are nothing. They
cannot compromise their principles, which are fundamentally law-based, nor
can they say, for example, that a war crime committed by a group whose cause
is just is excusable whereas one committed by an oppressive government is not.
To put it another way, human rights is a zero sum game, while humanitarian
action is not. What means in the most immediate sense is that no matter what
happens at headquarters, on the ground relief workers and Human Rights officials have very different priorities, and whether they can ever be reconciled
successfully is for me at least an open question.
That said, whatever the clash of assumptions between humanitarians and Human
Rights workers, it was probably inevitable that a blurring of boundaries between
the two movements has taken place --- that, for example, Oxfam, once the
premiere water and sanitation relief agency in the world now seems far more
concerned with expanding its lobbying capacities than its operational ones. The
Human Rights movement has been in many ways the most influential movement
of Western liberalism in recent times. It is anything but simply black letter law, as
some of its more naïve apologists like to claim. To the contrary, Human Rights -- it would be closer to the mark to say, ‘Human Rightsism’ --- is an ideology like
any other and needs to be judged according to the same criteria that are applied
to any other ideology, whether Communism, free-market capitalism, etc.
But essential as it is to remain critical, it is also important to keep in mind that
Human Rights is an ideology with immense power and that, in the West at least,
it has had an immense influence. To imagine that the Humanitarian world
would be immune to it is absurd. Whether humanitarianism will be able to
remain viable operationally if it succumbs completely to the idea that its project
and that of the Human Rights movement are more similar than dissimilar is, of
course, another matter entirely.
44
HUMANITARIAN STAKES
The danger of a conciliatory approach
Rony Brauman1
The debate over the role of human rights in humanitarian action recurs within
MSF as it does elsewhere. Are we guided by this ideal? Are there tensions or
contradictions? Is there complementarity?
I will approach this topic by looking at the meaning of each of the terms used
before discussing the relationship between them, as neither humanitarian action
nor human rights are clearly defined concepts. If we take Amnesty International
as an example, we are struck by the evolution of the organization’s philosophy,
which has shifted from focusing exclusively on defending prisoners of conscience
to defending economic, social, and cultural rights (ESCRs). This is a radical
transformation. The aim of this simple observation is to illustrate that fundamentally different activities can be lumped together under the heading of
“human rights.”
For example, the notion that torture is inadmissible and intolerable can be easily
understood and accepted throughout the world. It does not necessarily require a
budget. It is “simply” a case of strictly limiting the prerogatives of those in power:
political authorities, governments, and other structures, as it is not only governments that torture. There are also militias, rebel groups, and other organizations
that hold power. The point I am trying to make is that the abolition of torture
does not require a budget, an administration, or a particular cultural reference,
but simply the decision to restrict a power.
When discussing the right to health or gender equality, we are immediately faced
with entirely different economic, psychological, and social issues. When we talk
about human rights nowadays, we lump these different categories under one
umbrella, as they have been gradually gathered together like the cumulative
1
Director of Research. CRASH (Centre de recherche sur l’action et les savoirs humanitaires)
45
rights of successive generations. They form a set of rights that NGOs assume to
be coherent, which is far from being the case. We should also remember that the
so-called “Universal” Declaration of Human Rights was signed in 1948 by a
mere quarter of today’s nations; moreover, at the time it was the result of a
compromise between a liberal concept and a socialist concept of human rights
made possible by the still-smoldering memory of the war that had just ended.
That is why many of the articles conflict and, in practice, any reference to them
is necessarily biased. The declaration allows individuals to make their own ideological selection by introducing their own hierarchy and including only those
articles of political interest. Although this eclecticism weakens the declaration, it
also allows it to exist. Despite being its merit, this compromise cannot be taken
as a coherent structure. Therefore, when humanitarian organizations base their
work on human rights, they are building on a shaky foundation, to say the least,
as opposing courses of action can be drawn from the same reference.
Let us recall the problems during the Taliban regime in Afghanistan. The attitudes of NGOs were split between protesting against the lot of women in relation to gender equality on the one hand and, on the other, a policy of tolerating
the regime to enable organizations to get aid to women, a perspective that could
also be based on the right to health. The Taliban did not prohibit the setting up
of health centers and hospitals to treat women, and MSF believed that appropriate working conditions were provided and that the disastrous situation in the
country justified working there. Beyond any reference to rights, and according
to a restrictive view of humanitarian action, the needs and context were sufficient references for us. The alternative would have been to become missionaries:
“this is what you must do, take off the veil, send the girls to school, have mixed
hospitals….” I am not anti-feminist, but I am anti-missionary, and I think that
humanitarian workers must avoid teaching morals. Indeed, what morals would
we teach? And in the name of what? As within Amnesty International, the
concept of humanitarian action upheld by MSF has also evolved considerably.
Today’s concept has reached a point where it conflicts in many aspects with that
of the past, even if the core remains unchanged. For example, the concept of
humanitarian interference put forward by Bernard Kouchner, one of the cofounders of MSF, prevailed long after his departure. The concept of humanitarian interference stems from a vision in which humanitarian action and human
rights are viewed as an inseparable whole. It is in the name of that concept that
humanitarian action, and human rights, can become a vehicle of war.
It is worth remembering that what we now term “intervention humanitaire” in
French denotes the work of humanitarian organizations, whereas the English
46
HUMANITARIAN STAKES
“humanitarian intervention” refers to military intervention. With humanitarian
interference, these two types of interventions form a kind of sequence in which
humanitarian organizations can only be the vanguard, armed exclusively with
syringes and bags of rice, and preceding the arrival of troops. This was the
scenario in Somalia, where one form of intervention and then the other swept in
with impeccable continuity. We all know what happened next.
The ancestors of “humanitarian action” were “acts of humanity,” a term with a
more glowing and appealing ring to it. Humanity is the most beautiful dimension of humankind; it is what enables us to live side by side and what prevents
us from killing one another. This is our idea of humanity; however, the other
more realistic, more concrete name for “acts of humanity” is “gunboat diplomacy.” All too often we forget that this kind of diplomacy consisted of sending
troops either to take control of a territory where Western expatriates were under
threat or to save the barbarians from their own barbarism. One of the reasons
France gave in 1830 for conquering Algeria was to save the Algerians from
slavery. The colonial discourse about the Congo or any other discussion of
colonies from that time (“The White Man’s Burden”) was characterized by
moral, civilizing notions that took human rights, or what were regarded as such,
as their driving force.
In NGO jargon, basing humanitarian action on human rights constitutes a
“rights-based approach,” as opposed to a “needs-based approach.” Thus, the
action to be taken by humanitarian organizations is determined by the rights
that can be legitimately claimed by the victims: the right to food, shelter, health,
etc. The defenders of “humanitarian interference” are strongly influenced by this
approach, which is why at least two main schools of thought can be identified:
one that sees the human rights argument as the main driver of humanitarian
action, and another that distances itself from this approach. Nonetheless,
humanitarian organizations and human rights defenders share the same aspirations and ideals. It is not a question of artificially pitting notions or people
against one another when they are not in opposition, but of maintaining a
certain distance between these two approaches.
It is interesting to note that in Darfur the supporters of interference/defenders
of human rights are calling for an armed international intervention to protect
civilians and humanitarian workers, while the others oppose such an intervention. The right to life, the right to assistance, the right of insurrection, the rights
to all sorts of positive things inevitably clash. Here again each party refers to its
preferred approach to justify choices that have already been made.
47
In more general terms, my question is: are humanitarian organizations bearers of
values? Are we responsible for spreading fundamental values, that is the values
that prompt us to act (because each person thinks that the fundamental values
are those that he or she has in mind)? If the answer is yes, we must be consistent
and say the attack on Iraq, although rather heavy-handed, careless, and incompetent, was basically justified. That is not my opinion, as I have long held that
we are not the knights of universal values. For a time I did believe that we were,
but I have since come to my senses, which proves that we are not condemned to
chronicity.
In conclusion, humanitarian workers and defenders of human rights must not
seek to reconcile approaches that have their own different logic. After all, an
MSF team has never started shooting rounds at an Amnesty International team.
There is no need to declare cease-fires and seek reconciliation. There is public
debate and there are different types of action; let them exist as they are. We can
try to influence or simply better understand one another, but let us not try to
reconcile what cannot be reconciled. This approach would be doomed to failure
and would demonstrate a lack of respect for reality. Instead, we must value a
certain diversity of viewpoints, stances, and actions. In conciliatory discourse,
everything revolves around the idea of arranging different kinds of action into a
superior system—that of absolute good, the march toward progress. Such a
process would be the equivalent of “falling in line” and would mark the end of
any serious action for humanitarian organizations.
48
HUMANITARIAN STAKES
Humanitarianism and human rights
James Darcy 1
The relationship between humanitarian action and human rights is a subject
where theory and practice can lead to very different conclusions. It is something
I have struggled with in my own professional life: I started as a commercial
lawyer, re-trained in human rights law and subsequently joined Oxfam as a coordinator of humanitarian operations in various parts of the world: Central Africa,
the Balkans, Central America, the Middle East, South and East Asia. Along the
way, I have witnessed tensions and contradictions in the application of laws and
norms to situations of armed conflict or political upheaval. It is not just that
applying rules in such contexts is problematic – it is that the rules themselves
seem to point to competing priorities and sometimes (apparently) irreconcilable
courses of action.
It seems to me there are essentially two kinds of questions here. One concerns
the overlap of agendas and goals: are humanitarians and human rights activists
concerned with the same things, trying to achieve the same ends? The second
concerns the issue of compatibility and tensions between the approaches that
each group adopts. Even if there is a substantial overlap of agendas of concern,
experience tells us that the ways in which they are being pursued can be in
tension or even incompatible.
On the first question, I think there is an increasing overlap in the agendas of
concern. This has become more apparent as the international human rights
agencies have become so much more engaged than they used to be in situations
of armed conflict and mass violations. At a rhetorical level at least, many of the
pronouncements of Human Rights Watch (for example on Darfur) could have
been drafted by the ICRC. Of course, they are more prescriptive – and lay a
1
Director, Humanitarian Policy Group, ODI
49
greater emphasis on issues of justice and the imperative of bringing abusers to
trial. This has never been comfortable territory for humanitarians, whose need
to maintain access and open channels of communication tends to lead to a less
adversarial approach. This is one of the areas of tension between the two camps.
It is not just a clash of approaches, I think: justice per se has never been core
humanitarian concern.
Because of my legal background, I was involved with the Sphere Project in the
early days, specifically in drafting the Humanitarian Charter. This was (roughly)
an attempt to establish a right to humanitarian assistance, and then to say what
must be the minimum content of such a right if it was to mean anything in practice. In a way, the Sphere standards are a working out of that idea, based on the
agencies’ collective experience of providing relief and drawing on many existing
standards, protocols etc. This seems to me to have been an important and worthwhile endeavour, not least because it maintained a focus on the relationship
between the individual (and community) and the state as the primary duty-bearer.
The idea of a ‘rights-based’ approach to humanitarianism was particularly attractive to the multi-mandate agencies in the 1990s. It seemed to offer the prospect
of a unifying theory for their humanitarian and development work, and to some
extent it did (and still does). There seemed to be a close relationship between
human rights ideas of non-discrimination and humanitarian notions of impartiality; and the idea of shared humanity and the equal value of all human life
underpinned both. For the most part, there is a good ‘fit’ between the two codes.
On the issues of substance, the civil and political rights frame much of what fell
within the humanitarian ‘protection’ agenda; and together with the right to life,
the economic and social rights can be taken as a basis (or at least supporting
evidence) for a right to humanitarian assistance.
Where I am more sceptical about a rights-based approach is in the conflation of
humanitarian and all other rights-related issues, and the assumption that these
are (in rights language) ‘indivisible and inter-dependent’. If they truly were, then
we might as well give up on humanitarian action. Although rights language can
be used in crisis contexts, it is often more appropriate to talk of a duty to act in
the face of human suffering. (Anyone who reads the Geneva Conventions will
realise that humanitarianism is more a duty-based code than a rights-based one).
The point about the humanitarian imperative is that it puts a moral priority on
this duty such that it overrides other considerations. In the terms of Kant’s moral
philosophy, it is a categorical imperative.
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HUMANITARIAN STAKES
The related problem with rights-based approaches, I think, is that the idea of
‘protecting rights’ involves an agenda that goes well beyond the capacity and
remit of humanitarian agencies, particularly given the contexts in which they are
operating. Human rights provide the template for a ‘decent’ political settlement
between the state and those living in it. Where the political contract is severely
strained or disrupted – as it is almost by definition in many of the contexts we
are concerned with – then focussing on what ought to be is inevitably in tension
with what is. Humanitarianism is primarily a response to the messy status quo
rather than a reforming agenda. Putting the relationship between state and
people back together is a political agenda, with developmental implications. But
making the relationship work today for the benefit (or least harm) to the civil
population is part of the humanitarian agenda. As any field worker knows,
creating the political space (locally, nationally) for people to find safety and
access assistance is part of the job, what we tend to refer to as creating ‘humanitarian space’. Here the political actors may be state or non-state, a point of
divergence from human rights theory.
Though there is a fair degree of overlap in theory, the tensions in practice
between rights and humanitarian agendas are much more serious I think. One
of my memories from working with Oxfam in Indonesia (in Aceh, pre-tsunami)
was of two of our local (humanitarian) staff being arrested by roving police and
severely beaten up for associating with a human rights group that was deemed to
be in league with the Free Aceh Movement. Human rights activism is almost by
definition politically sensitive in such contexts. Humanitarianism, in theory, is
not – it is politically neutral. But of course, we know that (whether by association or otherwise) it is often perceived as being anything but neutral. The multimandate agencies have arguably muddied the waters here: they want to be
perceived as neutral humanitarian actors while pursuing advocacy on rights and
justice. Mind you, MSF is also vocal on these issues, as its origins and identity
require it to be. So perhaps we are all guilty of blurring these distinctions.
What to conclude from this? That it is vital to find a viable modus operandi
between human rights and humanitarian agencies, whose concern with civilian
protection (at least) is a shared one. That there can be complementary action, but
we should not pretend that our agendas are the same. That we should be alive to
the potential for clashes of approach and try to minimise them; and here the
human rights agencies must take very seriously the potential for jeopardising access
and staff safety. I think that the idea of a right to humanitarian assistance (close
cousin of the droit d’ingerence) constitutes a meeting point between rights and
humanitarian agendas, and it is something that we should all be prepared to assert.
POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS?
53
POST-9/11 WARS:
NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS?
Nobody can deny the impact of 9/11 on international relations. Whether
through the eyes of journalists, analysts, or politicians, the Global War on
Terrorism (GWOT) and its aftermath have become the lens through which to
explain and interpret the world today.
Even for humanitarians the impact, or supposed impact, of 9/11 fuels discussions, writings, and perceptions of how to understand the conflicts, roles, and
motivations of the world’s actors. However, beyond the conflicts and the
tensions, has the emergence of what has been called, not without controversy,
the new war of civilizations had an impact on humanitarian assistance?
Does the GWOT explain the global shift in the discourse and concerns of some
agencies from actors who uphold and act in accordance with universal values to
actors who are profoundly Western in their values, modes of action, and identity? Terrible crises are impacting millions of people in places where humanitarian actors cannot work, including large portions of Afghanistan and Ethiopia,
and regroupment zones for IDPs in Iraq and Somalia. Is the nature of the
conflicts in some parts of the world imposing the absence of all external assistance to victims of violence and displacement? Should it incite change, if not
revolution, in the way humanitarians plan their responses to needs and interact
with their environment? Is the GWOT inciting a global revolution in humanitarian practices, or is it simply imposing new criteria for interpreting international relations until the next set of benchmarks emerges?
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HUMANITARIAN STAKES
An unarmed international community
Alain Délétroz 1
Did the major change that we are seeing today in the humanitarian field come
about as a result of 9/11, as suggested by the theme of the debate in which MSF
invites us to engage this year, or rather during the wars that shook Europe during
the 1990s?
During the Balkan wars, humanitarian organisations saw themselves plunged
into a widespread state of confusion, in which the populations concerned often
had trouble differentiating between military action that considered itself to be
humanitarian and humanitarian work in the strict sense. For the victims of war
and the populations concerned, it is difficult to make a clear distinction between
soldiers sent by the United Nations, the African Union, the European Union or
other institutions, whose mission to protect civilians directly involves the use of
force, and the strictly humanitarian action carried out by organisations such as
Médecins Sans Frontières (MSF), Médecins du Monde (MdM) or the International Committee of the Red Cross (ICRC). This confusion seems to have
become firmly rooted in the humanitarian landscape.
What has changed since 11 September 2001, what has emerged from the
remains of the World Trade Center in New York, is a new feeling of vulnerability,
not only in the US but throughout the West, faced with the determination of
individuals who are prepared to commit suicide in order to wreak death. The allpowerful USA, that was increasingly being referred to as a “hyperpower”, was
suddenly attacked on its own soil, in an operation that was relatively easy to carry
out. The 9/11 attacks struck the heart of the US’s economic centre, Wall Street,
and more precisely, the heart of its symbolic strength, the Twin Towers, which
were among the tallest buildings in the world.
1
Vice President (Europe), International Crisis Group
55
To a degree, the US government’s reaction to those attacks marks a turning point
in the history of the United States of America. The current government is
extremely ideology driven and has a messianic view of its role in history. Its president sees the world in black and white, while the former secretary of defence
came across as rather smug about his military power. This government’s reaction
to the attack of 9/11 plunged us into the world that we know today, because it
completely blurred the understanding of humanitarian action: in the US, but
also in Europe, the whole language and discourse surrounding the defence of the
human element – whether it be the humanitarian discourse, the discourse about
human rights or, worse still, about democratisation and freedom – has lost all
credibility.
George Bush does not yet seem to understand that when the words “freedom” or
“democracy” come out of his mouth, they are heard in three-quarters of the
world, in much the same way as when the Bosnians heard Mr Milosevic say the
word “peace”.
Last week, one of my colleagues returned from a private meeting with a group
of Buddhists in Asia (he is Buddhist himself ). He was struck by the extent to
which the participants at that meeting, who usually try to share pacifist ideals,
rejected the whole Western discourse about human rights, because they sense
that it conceals what they believe to be the real motivation: bringing about
changes of regime.
This notion of change of regime is viewed pretty much throughout the world as
the real aim of the West. Worse still, many leaders use the spectre of a Western
hidden agenda in an extremely cynical way to justify the massacre of their own
people, as the Khartoum regime has clearly illustrated for years.
What is to be done in such a context? We are heading towards a world in which
conflicts will be increasingly diluted. The demands of actors in conflicts are
becoming ever-more specific and local, which makes negotiation more difficult.
At the same time, easy access to the most sophisticated weapons of war can transform any old warlord into a force to be reckoned with, whose political
programme often boils down to its control of a few Land Cruisers topped with
formidable weapons. Somalia, Darfur and the Horn of Africa are obvious examples. Today, for example, I heard a negotiator who has been a member of delegations to Abuja, Machakos and Arusha say in public: “I no longer know where to
start negotiations with the 18 armed groups in Darfur!” To negotiate, one must
have an agenda and demands. The sphere of power of small-scale warlords is
limited to a space in which not much can be built.
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HUMANITARIAN STAKES
A second major challenge will probably lie in what I would call a “de-Westernisation” of our international organisations, whether they be humanitarian organisations, conflict prevention organisations, or even – and here we are touching
on a central, extremely complex issue – the United Nations Security Council.
This organ has a very clear mission: to maintain peace in the world. However, it
is completely incapable of achieving this mission, because the governments of
the only five countries that have permanent member status have a right of veto
that they use indiscriminately to decide the affairs of the whole world. The
discussions that took place during the 2005 General Assembly in relation to
reforming the use of this right of veto in cases where populations are in danger,
came to nothing. The even more fundamental discussions that should have led
to a reform of the Security Council, about granting certain countries in Africa,
Asia and Latin America a permanent seat in this global authority, also came to
nothing.
Consequently, we have a situation where the resolutions of the Security Council
are becoming progressively less effective because the governments at which they
are directed can easily find an ally in the Council who will support them, usually
for economic or simply political or geostrategic reasons, regardless of the number
of massacres they may be committing within their territories. Therefore, the
challenge of the future will probably be to form a sort of global alliance between
all those who care about the human aspect. In most countries that are at war,
there are people who think, get involved, risk their lives to improve the situation
and are immediate allies. In our organisations, we must find visible leadership
positions for those people. They must be the ones who, increasingly, speak out
and take decisions in their geographical regions and fields of expertise.
However, that alone will not suffice. In my view, there are no ready-made solutions to meet these challenges. The conflicts around the world seem to be
increasingly difficult to get to grips with. Conflicts are moving away from the
classic interstate war and now involve a growing number of actors who, thanks
to increasingly easy access to ever-more destructive arms, wage wars only to end
up with a ministerial position in a given government. If we throw in the added
problem of access to resources, we fall into the trap of wars of territorial control.
Faced with this type of conflict, at present, the international community is
largely unarmed. Once it recognises this, it should be able to create the institutions it needs. A security council that better represents the weight of the different
countries and regions of the world is an immediate necessity.
57
The “War on Terror”: consequences for civilian populations
and positioning of humanitarian organisations
Bruno Jochum1
Nearly 6 years since it began after the attack on the World Trade Centre in
September 2001, the “Global War on Terror” (GWOT) is the main driver of
several conflicts that have traditionally been viewed as separate: Iraq, Afghanistan
and the tribal areas of Pakistan, Somalia since early 2006, as well as, to a lesser
degree, the Philippines and Yemen2 . Although each of these conflicts has specific
local and regional characteristics, they share the fact that they were started, or
entered a new phase, in the name of the armed struggle of the American administration against Al-Qaeda.
Given the prolongation of this international war and the increase in the number
of open fronts, it has become essential to globally assess its consequences for
civilian populations and humanitarian work in general. In large parts of the
world, the credibility of major humanitarian organisations and their perception
as an impartial actor rests on their ability to fully assume this critical responsibility.
For us, the GWOT is currently the single political and military event responsible
for the greatest population movement, as well as the greatest numbers of
wounded and dead. Just by adding up the numbers of displaced people and
refugees from Iraq, Somalia and Afghanistan, the figure exceeds 5 million, which
is almost double that of Darfur. The number of direct victims of violence totals
several hundred thousand dead and probably 3 to 4 times more injured. The fact
that no global count is being kept makes it all the more necessary to prepare and
publish documentation about this war and its effects.
1
2
Director of Operations MSF-Switzerland
The fight against terrorism has also been used to justify certain other conflicts, which have now died down: the fighting of the LRA in northern Uganda and the war in Chechnya, for example. Thus, the GWOT has become justification
for the belligerents of the ‘righteous camp’ to commit all sorts of acts of violence against the ‘terrorists’ and those
who support them.
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HUMANITARIAN STAKES
This unobjective reality relayed to the general public forces us to question, coolheadedly, why some political crises and the resulting human tragedies prompt
mobilisation while others do not. Indeed, in 2007, why did the Darfur conflict
attract so much media attention when the violence there had subsided considerably, yet at the same time half of the inhabitants of the Somali capital were
leaving their homes because of the deadly fighting taking place in the name of
the fight against terrorism?
To attempt to answer this, we must look beyond the classic dichotomy between
“good” and “bad” victims. Of course, this distinction is clearly evident when
relating developments in the GWOT: the societies to which the victims belong
are often perceived as a hotbed of terrorist activity. Therefore, they are seen to be
responsible for their fate, and the act of showing the human consequences of the
war could detract from the political and military objectives of that war. A prime
example is Somalia: forgetting that the conflict was internationalised in 2006
with the American administration’s decision to use military force against the
Islamists; forgetting that that decision, taken up by the Ethiopian army, led to
the worst violence in 15 years and the displacement of hundreds of thousands of
people; the prevailing opinion is that the Somalis are fighting among themselves,
as they always have.
Another characteristic of the conflicts in question is the wish to limit or prevent,
for security or geo-political reasons, the movement of those fleeing the violence.
The Jordanian, Syrian and Kenyan borders are closed, forcing most of the families affected to remain in their societies of origin, near the most dangerous areas.
The Geneva Convention on Refugees is barely applied, and this contributes to
keeping a lid on the situation and obliging any assistance to be organised from
within the conflict.
However, the majority of these contexts are largely closed to classic humanitarian
assistance. At the border between Afghanistan and Pakistan, where NATO military operations are taking place, there is hardly any assistance for the populations
affected. Meanwhile, in Somalia, the internationalisation of the conflict that
began in 2006 has sparked fears of Iraqisation, at a time when the humanitarian
situation is the worst it has been since the early 1990s.
In recent years, the inveiglement of private humanitarian action into the political missions of the United Nations has considerably weakened, throughout the
world, the perception of NGOs as autonomous, neutral and impartial actors.
The United Nations integrated missions are an attempt to develop a more effective global political response to crises, but suffers from two fundamental pitfalls.
59
Firstly, these missions are organised by a Security Council that no longer reflects
the real balance of power in the world. Secondly, they conceptualise the humanitarian sector as a tool at the service of a political mission: Peace. A backlash of
this is that any opponent of the political process may decide to attack humanitarian workers. This trend is compounded by the organised confusion between
human rights defenders and actors providing humanitarian assistance. The amalgamation, in discourse and in practice, of the former, whose aim is social transformation, and the latter, whose sole purpose is to relieve the suffering of civilian
populations, heightens suspicion in societies that cannot accept an intrusive
discourse imposed from outside.
Taking this thinking even further, the “ideological polarisation” inherent in the
GWOT has pretty much eliminated any middle ground: on one side, Colin
Powell has publicly described humanitarian organisations as “force multipliers”
in the “fight against terror”; on the other side, the most radical jihadist movements associate humanitarian organisations with a global political and military
agenda, making them a legitimate target for attacks. The principle of neutrality
is dismissed from all sides. Consequently, all the actors involved, including
humanitarian teams, are judged first according to their society of origin, and not
necessarily the work they are trying to perform. In the past, International
Humanitarian Law (IHL) offered a useful framework for humanitarian organisations working in conflict zones. In recent years, IHL has been undermined by
the GWOT, particularly through the actions of the US, further weakening the
foundations of impartial relief operations intended to help the most vulnerable
populations.
At the end of the day, what is specific to humanitarian action in these contexts
is the absence of a means of independently assessing needs/the situation, and the
limited presence of international witnesses (as opposed to the 15,000 humanitarian workers present in Darfur). All this contributes to pushing the human
consequences of the GWOT into the background, compared with other crisis
situations: image of the “bad” victim, closing of borders, insecurity and restricted
access.
Trying to “force” humanitarian access by adopting increasingly elaborate and
visible protection and security measures is a serious mistake: ultimately, the effect
of this will be to establish NGOs more firmly in a given ‘camp’, where their role
is limited to organising the technical aspects of assistance services, and they are
identified as sub-contractors. For example in Iraq, a few rare ‘NGOs’ make this
choice, contracting the services of private security firms to provide them with
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HUMANITARIAN STAKES
armed escorts. Hiding behind protective screens will merely distance humanitarian organisations even more from the local populations and reinforce the
vicious circle of two irreconcilable worlds, especially when those screens are
provided by private operators.
At MSF, we believe that the creation, maintenance and expansion of a genuine
humanitarian space rests on respecting fundamental principles and carefully
reflecting on the way we operate, as much as the pertinence and the quality of
the aid action. Central to this is a transparent identity and a firm decision to
distance ourselves from the aid system, which is becoming increasingly subordinate to higher political aims such as the GWOT, peace or democracy. This calls
for tireless work to build links and acceptance of our work among the societies
concerned and the belligerents. We will be able to (re)build a relationship of
trust, and facilitate our humanitarian action, by more effectively analysing local
contexts and refining our operations. Finally, this approach requires us to
directly address the current asymmetry in the processing of information related
to the humanitarian consequences of the concerned war…
61
The Global War on Terrorism’s Impact
on Humanitarian Action
Peter J. Hoffman 1
The September 11, 2001 terrorist attacks (9/11) triggered a new wave of
armed conflicts around the world that have impacted humanitarian action.
Shortly after 9/11 the United States (US) initiated the “Global War on
Terrorism” (GWOT) to defeat extremist anti-American Islamic elements. In
October 2001, the US went to war in Afghanistan to oust the Taliban regime
that had harbored Al Qaeda, the terrorist group, which had perpetrated 9/11.
Since then, Western military forces have remained in Afghanistan to maintain
a search for terrorists and support the post-Taliban government under President Hamid Karzai—at present, Western troops total approximately 54,000
(26,000 from the US, and the others from North Atlantic Treaty Organization
(NATO) countries; mostly the United Kingdom (UK), the Netherlands,
Canada, Australia). In March 2003, the US invaded Iraq ostensibly as part of
the GWOT, to prevent the Saddam Hussein from using weapons of mass
destruction or handing these technologies and arms over to terrorists.
Although Hussein’s regime was rapidly defeated and dismantled, other violent
tensions have surfaced and a war (civil or otherwise) persists. As of the end of
December, Western military forces in Iraq number over 170,000 (160,000
from the US). With wars in Afghanistan and Iraq, and military operations in
Southwest Asia, the Middle East and the Arabian Peninsula, and North and
East Africa, which seemingly pit the West against Islam, there is much debate
regarding the “Clash of Civilizations.” In providing assistance in these war
zones, humanitarian agencies have become entangled in this debate. With an
upsurge in the number of Muslim war victims from the GWOT, relief work
will increasingly be forced to confront the rigors of these operating environs.
1
Peter J. Hoffman is Research Associate at the Ralph Bunche Institute for International Studies, The City University of
New York, and Adjunct Lecturer in Political Science at Hunter College.
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For aid personnel the core challenge is “how?”: How to get relief to those in
need? How to deliver aid and not appear as an agent of military forces? How
to limit the risk of violence against humanitarian workers? How to provide
assistance without offending belligerents, victims, and local populations?
This essay considers the impacts of the GWOT on humanitarian action. The
first part unpacks the phenomenon and points to the prominence of political
factors, as opposed to cultural ones, in stifling access and agencies. The second
part follows up on the issue of threats and concentrates on the microcosm of
security arrangements to argue that agencies should establish “humanitarian
intelligence” units.
I. Politics and the Erosion of Humanitarian Space
War invariably shapes humanitarian action; the political grievances, economic
interests, and security threats of armed conflicts influence the scope of humanitarian needs, the limits of international humanitarian law (IHL), and the
mechanics of humanitarian space; and, the GWOT is no exception. In the
wake of 9/11, Huntington’s “Clash of Civilization” thesis received attention
for its seeming prescience.2 But its overly simplistic argument—that
unchanging cultural characteristics fuel inevitable wars—exaggerates the influence of these factors.
The GWOT is fundamentally a political-military struggle between the US and
anti-American states and groups that aggregates several wars fought over the
control governments and resources into one—some are civil wars (with religious, tribal, and ethnic dimensions), some are independence movements and
insurgencies, and some are inter-state wars. In Afghanistan, while a central
government battles against militarized opposition and NATO forces hunt Al
Qaeda and Taliban elements, there is also the conflict between warlords (some
of who are engaged in drug trafficking). There is also often an ethnic component to factionalism in Afghanistan, with persistent rivalries between Pashtun,
Tajik, Hazara, Uzbek, and Turkmen groups. In Iraq, there is a lingering insurgency against US and UK forces—some are former members of the deposed
Hussein regime, but not all—and a war between Shiite militias (most are Arab,
but some are of Persian descent) and Sunnis groups (some of which are
2
Samuel P. Huntington, The Clash of Civilizations and the Remaking of World Order (New York: Simon & Schuster, 1996).
63
working with the US to eliminate Al Qaeda terrorists, who are also Sunni).
There are also Kurdish forces in the north that have long fought against the
government in Baghdad, as well as small minority groups, such as the Yazidis.
Although there are considerable variations between Afghanistan and Iraq, as
well as from other conflicts such as Somalia, in terms of the politics,
economics, and local customs, in the perspective of the “Clash of Civilizations” these wars share one overarching element in common: they can be interpreted as representing a culturally-driven struggle between the West and Islam.
However, concentrating exclusively on this cultural tension mischaracterizes
problems and misdirects problem solving.
Culture may affect prospects for conflict but it is politics that is decisive in
determining humanitarian action. A recent illustration of this is the December
26, 2007 expulsion of the top United Nations (UN) and European Union officials from Afghanistan by President Karzai for holding talks with anti-government forces. This demand demonstrates competition among political rivals in
Afghanistan to be gatekeepers of international assistance. It is not that culture
does not contribute to field conditions of humanitarian action but that political cleavages and bottlenecks are often more significant.
The impact of the GWOT on humanitarian affairs broadly is seen in the deviation from conventional warfare as both state militaries and armed non-state
actors have behaved in contravention to IHL. Al Qaeda and other terrorist
groups have become notorious for attacking civilians and humanitarian
workers. Some local militias participating in the GWOT have engaged in
human rights abuses. But most troubling of all is that some Western militaries
have violated the laws of war. For the US to flout the Geneva Conventions, as
typified by the continuation of interrogative practices constituting torture at
Guantanamo Bay and other “ghost” sites of detention beyond international
legal purview, suggests profound fragmentation in the political consensus
underpinning humanitarian issues.
In terms of humanitarian action, the impacts of the GWOT are that a wide
variety of belligerents have withered neutrality and independence—some
extremist militarized actors like Al Qaeda do not give consent to humanitarian
agencies, others such as the US seek to steer agencies’ efforts. Humanitarian
space was founded upon a political compromise of neutrality, independence
and consent, and although it realized action, action was truncated. This meant
not taking sides or speaking out regarding what they witnessed. For instance,
in World War II, the International Committee of the Red Cross (ICRC) deliv-
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ered assistance to prisoners of war (POWs) held by Nazi Germany, but only by
working within political constraints.
In civil wars this compromise faces greater corrosive pressures because state
sovereignty is often contested and therefore whom agencies are to hold responsible or negotiate with is uncertain. As more and more armed conflicts question the primordial compromise of humanitarian action, politics are
necessarily invoked. Consequently, regardless of the preferences or principles
of humanitarians, politics becomes an occupational hazard. Politics has been
termed the art of the possible and similar to how the political elements of other
armed conflicts have shaped subsequent humanitarian actions, the GWOT
influences what is now possible.
In previous humanitarian crises politics was contained through a general political consensus and the specific consent of belligerents. But this is not the case
with the GWOT. Whether Colin Powell’s claim that NGOs were “force multipliers” and part of the US “combat team” is true or not, his statement torpedoes any pretense of independence or neutrality.3 The politics of the GWOT
are exclusionary—a “with-us-or-against-us” mentality—and splinter political
support for humanitarian action.
Security threats are perhaps where GWOT-induced political fragmentation is
most readily witnessed. However, it should be noted that the GWOT does not
appear substantially different than other armed conflicts in one important way,
the frequency of attacks on humanitarian workers. A study by Stoddard,
Haver, and Harmer finds that the overall rate—5 to 6 per 10,000—is basically
consistent with earlier periods of humanitarian action.4 According to this study
the upsurge in the number of casualties is mostly attributable to the fact that
there are more aid workers in the field than ever before. However, whereas the
data shows that the overall frequency of this behavior has not significantly
increased, it should be noted that most of these attacks appear to be connected
to a political message of rejecting humanitarianism. With the US trying to
brand humanitarian organizations as under their command, humanitarian
personnel become targets for their political value. Humanitarian agencies have
seen this scenario before—in the 1990s UNITAF’s pursuit of Mohammed
3
4
Colin Powell, “Remarks to the National Foreign Policy Conference for Leaders of Non-governmental Organizations,” (U.S. State
Department, Washington, D.C., October 26, 2001).
Abby Stoddard, Adele Harmer, and Katherine Haver, Providing Aid in Insecure Environments: Trends in Policy and Operations
(London: Overseas Development Institute, 2006).
65
Aidid in Somalia led to danger for UN humanitarian agencies, and
UNPROFOR’s operations in Bosnia resulted in threats against UNHCR staff.
Although the total level of threat presently experienced is not much greater
than what is typically encountered in this inherently dangerous undertaking,
the chances an attack is politically-inspired is greater. The current siege on
neutrality is palpable but such security environments are not unprecedented.
The funding of humanitarian action also seems to signal that political factors
related to the GWOT are having an effect. The US has become the predominant “belligerent-donor,” being both a major participant in this armed conflict
and a top source of funds for humanitarian responses. However, while the US
has increased its financial contribution, as the Colin Powell quote above exemplifies, it has also sought to direct humanitarian action. In seeking to harness
the moral and economic assets of the international humanitarian system, the
US has often diminished the political legitimacy of agencies and thereby
furthered the divide over the role and reach of humanitarian action.
Although the GWOT often extols a macro-narrative of cultural conflict, political competition is the engine of the war and powers humanitarian challenges.
The struggle over who will govern and who will gain from governance, more
than desire to annihilate another culture, dictates the contours of relief. In
short, part of the impact of the GWOT is to misdirect the conversation about
the war and humanitarian responses into one about cultural survival, instead
of the collapse of independent humanitarian space. Since World War II
although there have been tragic departures from humanitarian norms, occurrences of widespread systematic dismissal, manipulation, or skewing have been
relatively uncommon. But in the GWOT, wholesale deviations have become
routine.
Humanitarian action has been evolving as the politics of what is possible has
changed. The GWOT questions the independence and neutrality of agencies
and sires security threats.5 However, as the history of the international humanitarian system indicates, the GWOT has accelerated, not initiated, a larger
longer-term erosion of the established politics of a neutral, independent, and
consent-based humanitarian action. Although these politics could change, at
present the GWOT propels political divisions more than protects humanitarian space. While this diagnosis of the GWOT’s impacts is distressing, it
5
Kenneth Anderson, “Humanitarian Inviolability in Crisis: The Meaning of Impartiality and Neutrality for U.N. and NGO Agencies
Following the 2003-2004 Afghanistan and Iraq Conflicts,” Harvard Human Rights Journal 17 (2004), 41-74.
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should not be defeating. That the problem lies within politics and not culture
(which tends to be slower moving) is encouraging. The next section looks at
the security implications of humanitarian action where the politics are
contentious and suggests the need to institute intelligence units.
II. Security and Humanitarian Intelligence
The divisive politics of the GWOT contribute to dangerous operating environments and information geared specifically to help agencies assess field
conditions and evaluate their options is needed. Although the rate of attacks
against humanitarians is comparable to previous armed conflicts, high profile
assaults in the context of the GWOT such as the August 2003 bombing of the
UN compound in Baghdad and the June 2005 murders of Médecins Sans
Frontières (MSF) personnel in Afghanistan have renewed attention to security
arrangements. For agencies to decide whether to stay in these war zones, and,
if so, through what means, requires “humanitarian intelligence”—methodical
data collection, analysis, and promulgation.6
Humanitarian organizations pride themselves on dedicating as much of their
funding as possible to relief services and intentionally minimize other expenditures. Investing in humanitarian intelligence would also appear to be far
down on the priority list for most agencies. For example, in the late 1990s the
UN High Commission for Refugees had a budget of about $1 billion but allocated only one-half of a statistician to compiling figures on refugee flows.
The security arrangements of an agency are a litmus test of their ethical priorities and what they think is politically possible. Neutrality or what some term
“acceptance” is the optimal solution and the approach initially deployed
because access is achieved through consent.7 If international personnel are seen
as provocative as compared to those from the war-torn area, agencies may turn
to “localization” tactics. However, this may shift the burden to local personnel
who may be even more vulnerable. Thus, where humanitarian space based on
neutrality and consent is elusive and when the UN or other multinational
forces do not provide protection, some agencies contemplate more muscular
tactics.
6
7
Peter J. Hoffman and Thomas G. Weiss, “Humanitarianism and Practitioners: Social Science Matters,” in Michael Barnett and
Thomas G. Weiss, eds., Humanitarianism in Question: Politics, Power, Ethics (Ithaca: Cornell University Press, 2008, forthcoming).
Koenraad Van Brabant, Operational Security management in Violent Environments: A Field Manual for Agencies (London:
Overseas Development Institute, 2000).
67
And this is where humanitarian intelligence is needed more than ever, in
assembling knowledge on both security threats and security providers. First,
threat assessments signal when a switch from a neutral posture should be
considered, or when to switch back if local politics change. Data on aid
delivery, mortality rates, and other key indicators is insightful into the efficacy
of tactics. Second, if agencies decide to operate in non-permissive environments documentation on which actors are tenable in terms of protective capabilities and local political perception must be readily available.
The issue of private security providers has been lurking for some time but
became firmly entrenched in humanitarian debates of the early 1990s, especially with the use of “technicals” in Somalia. The soul-searching of Kofi
Annan in 1994, who was then head of UN peacekeeping, to find an armed
force to disarm militants in refugee camps in the Democratic Republic of the
Congo and his consideration of security contractors further stirred arguments.8
IHL has been opposed to virtually all armed non-state actors, and especially
those who fight for economic gain.9 Accordingly, among humanitarians the use
of security contractors is controversial to say the least, and though some agencies are developing protocols for engagement, others adamantly reject such
practices. The ICRC has quietly backed off its earlier stance of simply advocating the abolishment of security contractors and this fall released a policy
focused on ensuring that contractors were merely compliant with IHL.10 In
contrast MSF strictly refuses to sanction, let alone hire security contractors.
Despite ad hoc usage, the debate nevertheless rages on, particular in cases
where international politics essentially neglects humanitarian crises. For
example, proponents of contractors, such as the International Peace Operation
Association, have trumpeted their potential to bring security to Darfur.11
However, calculation the trade-offs of such arrangements, including
accounting for local views, should be thorough, evidenced-based, and inde-
8
9
10
11
Kofi Annan, Thirty-Fifth Annual Ditchley Foundation Lecture, SG/SM/6613, 26 June, 1998. www.un.og/News/Press/docs/
1998/19980626.sgsm6613.html. For more on the a turn of humanitarians to contractors see Michael Bryans, Bruce
D. Jones, ands Janice Gross Stein, “Mean Times: Humanitarian Action in Complex Political Emergencies,” Coming To Terms
1, no. 3 (January 1999); and, Tony Vaux, Chris Seiple, Greg Makano and Koenraad Van Brabant, Humanitarian action and
Private Security Companies: Opening the Debate (London: International Alert, 2001).
Article 47 of Additional Protocol I of the Geneva Conventions stipulates that mercenaries are illegal and are therefore not entitled to many of its protections and opposition is also codified in the 1989 United Nations International Convention against
the Recruitment, Use, Financing and Training of Mercenaries.
See the ICRC’s website on Privatisation of War: http://www.icrc.org/Web/Eng/siteeng0.nsf/html/pmc-fac-230506.
Doug Brooks, “Focusing on Sudan,” and Max Boot, “Send Private Security Companies into Sudan,” Journal of International
Peace Operations 2, no. 1 (2006), 4 and 9. Also, see http://ipoaonline.org/php/.
68
HUMANITARIAN STAKES
pendent.12 Moreover, even with new controls in place an adequate vetting
procedures and guidelines require knowledge about the conduct of specific
security firms.
In instances where agencies suspect a move away from neutrality may be
warranted—as belligerents and local populations may present or perceive
agencies as having taken a side—they nonetheless desire to maintain independence. The data upon which they make their judgments regarding tactics
is crucial. Information influences action, and truly independent humanitarian
action can only be predicated upon independent humanitarian intelligence.
Furthermore, intelligence must consider not only the type and degree of problems but also the nature of proposed solutions. Agencies should be vigilant in
evaluating the effects of security arrangements—do they enable access or overshadow relief work? Are there clear and legitimate rules on the use of force and
codes of conduct in place? What means of obtaining security undermine the
intended ends of humanitarian action? Under what conditions does a backlash
occur? There are no immediate, clear, or permanent answers to these questions,
but when they surface it is imperative that agencies have infrastructure that
routinely asks them to offer locally specific evaluations of security options.
Humanitarian intelligence can help to clarify complex and time-sensitive
matters such as whether or when to use security contractors, which ones to use,
and what instructions to give them.
The GWOT encompasses multiple armed conflicts with different local political cleavages and as a result there is no one-size-fits-all approach to carrying
out humanitarian action. A degree of danger has always been present in such
work, but when agencies encounter wars with dubious humanitarian space,
some are experimenting with non-traditional and potentially alienating security arrangements. In general humanitarian agencies tend to be more knowledgeable about the ethical foundations and administrative logistics of their
work than they are about the nuances of operational environments, including
tracing the feedback of whom they work with. Human and financial resources
should be dedicated to developing in-house humanitarian intelligence capacities in order to regularize the gathering of data, sharing of analyses, and
tailoring of tactics. Although agencies may not have mastery over all that feeds
into local perceptions of neutrality, they do control their own actions. Inde-
12
Peter J. Hoffman and Thomas G. Weiss, Sword & Salve: Confronting New Wars and Humanitarian Crises (Lanham, MD:
Rowman & Littlefield, 2006), 152.
69
pendent intelligence capabilities will bolster the independence of operations,
and ultimately enhance credibility. Humanitarian intelligence cannot obviate
dilemmas of security, but it can better prepare agencies to face them. While
some agencies and donors may see such efforts as a luxury that diverts scarce
resources, a greater investment in data and dissemination would pay invaluable
dividends. In the end the financial cost of humanitarian intelligence will
always be less than any human toll or political price paid from misdiagnosed
and mishandled security threats.
70
HUMANITARIAN STAKES
Humanitarian action caught in a vice
between guerrillas and the war on terror
Jérôme Larché 1
Introduction
According to some commentators, the Cold War period was the golden age of
humanitarian intervention, as there was more room for manoeuvre, both physically and politically, than there is now. The new world order, or rather “disorder”,
that emerged following the fall of the Berlin Wall, and even more noticeably after
the attacks of 9/11, has complicated the work of humanitarian actors, making it
more ambiguous, more political, and sometimes more manipulable. The
Médecins du Monde motto – “soigner et témoigner” (“provide care and bear
witness”) – illustrates both the wish to take action beyond the purely medical
sphere and the resultant dilemma.
New conflicts?
Rather than new conflicts, the collapse of the Soviet empire prompted a new
interpretation of conflicts, as it revealed the existence of local dynamics that were
already at play during the Cold War. However, although the causes and characteristics of contemporary conflicts are manifold, the currently trend is towards
radicalisation and polarisation. Hence, new actors (such as Islamic NGOs) have
become more visible, while armed guerrillas have become increasingly
autonomous and fragmented. The distinction between fighters and non-fighters
is also being blurred by the growing presence of private security and military
firms and the significant increase in civilian-military operations undertaken by
conventional armies. This confusion of roles and perceptions becomes particularly deleterious when coupled with the radicalisation of certain groups, all
within a context of technological, financial and media globalisation, which proj-
1
Jérôme Larché is an anaesthetist and international missions representative on the board of Médecins du Monde.
71
ects the new threats to the global level. The recent Arche de Zoé (Zoe’s Ark)
affair confirms the gradual shift in the “humanitarian image” in the West, as elsewhere.
The “Global War on Terror” (GWOT) launched by the US administration after
9/11 also fuelled talk about the division of values, particularly between the
western world and the Arab-Muslim world. Echoing the thesis of S Huntington’s
“The Clash of Civilizations”, this debate calls into question, now more than ever,
the belief in the universality of the paradigms advocated by western humanitarian NGOs; this affects both the way local populations and parties at conflict
perceive us, and our understanding of those populations and parties.
Consequently, the security of humanitarian missions has become a major
constraint to operating in certain regions and accessing vulnerable populations
in need of assistance. We need to develop and intensify acceptance strategies,
making them the cornerstone of our “security” approach, rather than just
digging in our heels like other actors such as the United Nations. Although the
community approach has limits that need to be recognised, the resultant proximity is essential to ensure effective, long-term operations, reduce existing risks
and respect humanitarian ethics. Moreover, it decreases the likelihood of actions
being based on overly “ethnocentric” ideas, which are out of kilter with the real
needs of the beneficiary populations.
In these complex regions, it also seems that local dynamics have more influence
than global logic. In Darfur, for example, the political map of alliances (and divisions) between the different tribes and armed groups concerns geographical areas
of 20 to 30 km2, in a constantly shifting and highly volatile context. Huntington’s simplistic theory largely overlooked the considerable heterogeneity of
each cultural region, particularly the Islamic region, forgetting that “in the
conduct of wars, local logics hold more sway than global interdependencies”2. In
this clear context of deteriorated security, national staff continue to be the first
target of deadly attacks, and alternative strategies such as ‘remote management’
are far from ideal. That is why we must continue to develop our collective
thinking on this subject, share our experiences and, in particular, establish a
procedure for our interventions (including the network upstream of the action)
in these difficult regions.
2
M A de Montclos “Guerres d’aujourd’hui. Les vérités qui dérangent” (“Wars of today. The inconvenient truth”) pg. 12.
72
HUMANITARIAN STAKES
Nonetheless, humanitarian actors themselves have sometimes contributed to this
confusion, when, faced with difficulties or dangers, they have accepted help from
the military or armed groups to transport aid and personnel or protect themselves. In order to ensure their safety, a number of NGOs and international
organisations do, however, use the services of private local or international security firms. These practices, which appear to be becoming more widespread, risk
feeding a commercial market whose main objective is the management of peacekeeping operations3. Therefore, it is now essential for humanitarian NGOs to
stress their position of impartiality and independence, both at home and in the
field. Indeed, our actions and behaviours in the field build our identity and the
image we convey. However, that image can become blurred by the proliferation
of actors setting up “humanitarian-style” programmes or working in a similar
way. The civilian-military operations advocated by many western countries are
only there to “create an environment that is favourable to force”.
Humanitarian action and the war on terror (GWOT)
Humanitarian action is governed by International Humanitarian Law (IHL),
which is talked about increasingly frequently, yet it is also increasingly threatened
by the United States, which interprets it very freely, sometimes even flouting it
completely. The various mistakes made by US soldiers in Iraq, Afghanistan or at
Guantanamo Bay illustrate this perfectly. Operation Iraqi Freedom represents a
new approach to post-conflict humanitarian action. This approach brings
together security, governance, the humanitarian response and reconstruction, all
under the direct control of the Pentagon – the US Department of Defence
(DoD) – through the Office of Reconstruction and Humanitarian Assistance4.
This links humanitarian action closely to the security agenda of the United
States. Indeed, Colin Powell has clearly stated that American NGOs should be
“facilitators of US foreign policy”, particularly within the context of the GWOT.
This strategy supposedly resolves “incoherencies in the humanitarian community” which, given its role of performing and coordinating humanitarian action,
ends up acting as an unofficial agent of the DoD. However, the limits and shortcomings of this approach quickly became apparent, even when it comes to establishing a single command for all aspects of the post-conflict response. Today,
everyone can see the major insecurity in Iraq and the extreme difficulties
3
4
See the website of the International Peace Operations Association (IPOA) – a US-based trade association for private
security and military firms - http://ipoaonline.org
Directed by an Under Secretary of Defence.
73
encountered by NGOs working there. Thus, it can be concluded that the
strategy of the direct, complete political subordination of humanitarian action
has proven to be a failure, and that a more inclusive and multilateral approach
that respects IHL is needed.
In Chechnya, the war on terror has served as a pretext for the Russian authorities to avoid describing the situation there as an armed conflict, and instead
consider all Chechnyan resistance fighters terrorists. At the European level, we
must also remain vigilant, as the draft European Constitution provided for the
creation of a corps of “humanitarian volunteers”, bringing together NGOs,
soldiers and politicians. This strategy, incorporated into the ESDP and approved
by the European Council in 2003, actually risks adding to the confusion and, on
the ground, causing those “volunteers” to be increasingly viewed as interstate
agents of the European Union rather than humanitarian actors. The reform of
the United Nations with a view to carrying out integrated missions that bring
together political, military, humanitarian and development agendas, should be
interpreted as the wish of countries to begin integrating humanitarian action
with the other tools available (particularly diplomatic and military tools) for the
management of complex crises. Therefore, it seems essential to insist on the need
for an intervention framework for NGOs, in accordance with the principles of
humanitarian action.
The GWOT is often used to justify the unjustifiable. To illustrate my point, I
will take the example of Ogaden, where Médecins du Monde is working in the
district of Kibri Dehar. This region is the scene of a chronic conflict between the
government forces (TPLF) and the Ogaden National Liberation Front (ONLF),
which is calling for the secession of the Somali region. In April 2007, the
Chinese oil installation in Obole was attacked by the ONLF, resulting in the
deaths of 9 Chinese workers and 65 Ethiopian workers. In May 2007, after
grenades were let off in the administrative capital Jijiga, the Ethiopian Prime
Minister Meles Zenawi decided to launch a large-scale political-military operation to “contain” the actions of the ONLF. In July 2007, numerous witnesses
confirmed the strategy of the Ethiopian government to step up its fight against
the ONLF – which is classed as a “terrorist” organisation – with blatant disregard for the civilian population. IHL has been violated repeatedly, with villages
being burnt, harvests destroyed, forced displacement of civilians, rape, arbitrary
detentions and an economic blockade with Somalia. During this period, the
ICRC was expelled from the region, accused of spying and misinformation,
while an NGO blacklist was circulated. Other NGOs chose to withdraw from
Ogaden. The movement of humanitarian workers (outside urban areas)
74
HUMANITARIAN STAKES
continues to be closely monitored and restricted, while the necessary drugs are
often blocked and the nutritional status of the population (particularly the
under-fives) remains precarious. The humanitarian situation of civilians in
Ogaden is extremely worrying, as are the GWOT claims used by the Ethiopian
government to justify its violence against the inhabitants of this region and the
restrictions imposed on NGOs.
The European position on the use of humanitarian action for political ends has
now been clarified. The recently published document “European Humanitarian
Consensus”, which has the broad approval of the Council and the representatives
of the member states, the European Commission and the European Parliament,
clearly stipulates that “EU humanitarian aid is not a crisis management tool”5.
Conclusion
Since 9/11, boundaries have shifted and humanitarian organisations need to
adapt, demonstrating collective intelligence and coherence, in order to effectively defend their principles and their space. Some worrying trends (military
privatisation, incorporation of humanitarian action with the political management of complex crises, increasing influence of funding agencies and companies)
are emerging in the humanitarian landscape of the future. Consequently, we
must identify and expose the blurring of perceptions caused by civilian-military
operations in certain contexts (Afghanistan, Iraq, Chad). NGOs must also
improve their inclusive, participatory approaches vis-à-vis local populations and
their capacity for analysing complex contexts. Ultimately, in view of these new
trends, it seems essential to reaffirm, through a movement of collective advocacy,
a pragmatic humanitarian identity based on adapted, responsible forms of
action, yet rooted in clear, intangible principles.
5
European Humanitarian Consensus – Part 1, Chapter 2, paragraph 15. Official Journal of the European Union
(30/01/2008).
Humanitarian Stakes N°1 is a compilation of articles prepared by panelists
who participated in a day of conferences debates on “Humanitarian
Borders” in Geneva on 13 December 2007. The articles are organized by
topic to reflect the original program of the day.
Under the theme “Humanitarian Borders,” the panelists addressed the
following topics:
- Infection control measures and individual rights: An ethical dilemma for
medical staff
- Humanitarians vs. human rights: Two antagonistic agendas?
- Post-9/11 wars: New types of conflict, new borders for humanitarians?
For more information about UREPH or this publication, contact Jean-Marc
Biquet, Senior Researcher, at [email protected].
Humanitarian Stakes is available in English and in French on our Web site
www.msf.ch
Already published:
Humanitarian Stakes N°0, March 2007
- Humanitarian Medicine: An Enemy of Public Health?
- Is Independence Still Relevant in Humanitarian Action?
MSF - 78, rue de Lausanne - CP 116 - 1211 Genève 21 Tél.: +41 (0)22 849 84 84 - Fax: +41 (0)22 849 84 88
[email protected]
ISSN 1662-5471

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