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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: 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? 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 INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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? INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. 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. 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. 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. 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 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. 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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? INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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 INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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, INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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, INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 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 Written bibliography Moulin A.M. Medical ethics and cultures of the World. Bull Soc Pathol Exot, 2008, 101, 3, 227-231 Desclaux A. L’éthique médicale appliquée aux sciences humaines et sociales: pertinence, limites, enjeux et ajustements 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. 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Bull Soc Pathol Exot, 2005, 98, 237-244. http://64.233.183.104/search?q=cache:d0UEbGPK5DMJ:www.pathexo.fr/pdf/Articles-bull/2005/2005n3/T98-32761-2-7p.pdf+epelboin&hl=fr&ct=clnk&cd=38&gl=fr 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. INFECTION CONTROL MEASURES AND INDIVIDUAL RIGHTS: AN ETHICAL DILEMMA FOR MEDICAL STAFF 37 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 HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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 HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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- HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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) HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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. HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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 HUMANITARIANS VS. HUMAN RIGHTS: TWO ANTAGONISTIC AGENDAS? 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. 50 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? 54 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 POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. 56 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. POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. 58 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. POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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 60 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… POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. 62 HUMANITARIAN STAKES 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). POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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- 64 HUMANITARIAN STAKES 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). POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. 66 HUMANITARIAN STAKES 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). POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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. POST-9/11 WARS: NEW TYPES OF CONFLICT, NEW BORDERS FOR HUMANITARIANS? 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