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Global health diplomacy and humanitarian assistance: understanding the intentional divide between military and non-military actors
  1. Sheena M Eagan
  1. Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine, East Carolina University, Greenville, NC 27858, USA
  1. Correspondence to Dr Sheena M Eagan, Department of Bioethics and Interdisciplinary Studies, Brody School of Medicine, East Carolina University, Greenville, NC 27858, USA; eagansh17{at}ecu.edu

Abstract

Often known as global health diplomacy , the provision of medical care to accomplish strategic objectives, advance public diplomacy goals and enhance soft power is increasingly emphasised in international affairs and military policies. Despite this emergent trend, there has been little critical analysis and examination of the ethics of military actors engaging in this type of work. This type of mission represents the most common form of military medical deployment within the International Security Assistance Force in Afghanistan and is now explicitly emphasised in many militaries’ defence doctrine. The growth of these programmes has occurred with little analysis, examination or critique. This paper examines the history of global health diplomacy as directly related to humanitarian assistance, focusing on the difference in intention to highlight ethical dilemmas related to military involvement in the humanitarian sphere. The relationship between non-military humanitarian actors and military actors will be a focal point of discussion, as this relationship has been historically complicated and continues to shift. Relevant differences between these two groups of actors, their motivations and work will be highlighted. In order to examine the morally important differences between these groups, analysis will draw on relevant international doctrine and codes that attempt to provide ethical guidance within the humanitarian sphere.

  • military medicine
  • humanitarian assistance
  • health diplomacy
  • civic action
  • medical ethics
  • military ethics

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Key messages
  • Global health diplomacy (GHD) has grown out of humanitarian assistance and disaster relief (HADR) but represents an ethically significant departure in terms of motivation, and intention.

  • GHD is the provision of medical care to accomplish strategic or political objectives.

  • HADR is built on foundational principles of neutrality and impariality, as well as other apolitical priorities.

  • Historically, NGOs and other humanitarian organizations have purposefully seperated themselves from military actors doing seemingly similar work due to an understood difference in foundational intention.

  • The world’s militaries are increasingly involved in GHD and HADR activities making it important to examine their role within the humanitatian sphere.

Introduction

Within our globalised world, the distinction between domestic and foreign affairs has become increasingly blurred. This reality is particularly apparent in the domain of health. The era of global health diplomacy (GHD) has arrived, building on notions of medical diplomacy and humanitarian assistance and disaster relief (HADR).1 The value of providing medical care to accomplish strategic objectives, advance public diplomacy goals and enhance soft power has long been understood by government agencies and defence assets, with the last half-century marked by increasing emphasis on this work. This type of mission represented the most common form of military medical deployment within the International Security Assistance Force in Afghanistan and is now explicitly emphasised in defence doctrine. The growth of these programmes has occurred with little analysis, examination or critique. This paper remedies this gap in knowledge by analysing this category of military medical missions in comparison with similar work done by non-military actors. We will begin by exploring the concept of GHD before looking to the broader field of HADR. The relationship between military and non-military humanitarian actors will be discussed, as this relationship has been historically complicated and continues to change. Relevant differences between these two groups of actors, their motivations and work will be highlighted. In an attempt to examine the morally important differences between these groups of actors, analysis will draw on relevant international doctrine and codes of ethics that attempt to provide guidance within the humanitarian sphere.

Humanitarian assistance and health diplomacy

Peter Bourne2 first introduced the concept of medical diplomacy in the 1970s. Bourne2 acted as a special assistant to President Carter and wrote, …certain humanitarian issues, especially health, can be the basis for establishing a dialogue and bridging diplomatic barriers because they transcend traditional and more volatile and emotional concerns… 2 In the last few decades, the ideas advanced by Bourne2 have shifted towards the broader and more inclusive goals of GHD. This type of diplomacy recognises that:

…better global health promotes stability and growth, which can deter the spread of extremism, ease pressure for migration, reduce the need for humanitarian and development assistance and create opportunities for stronger political alliances and economic relations.3

While this type of work is not entirely new, it is becoming increasingly emphasised by governments and international organisations that have embraced public health and healthcare as tools that can accomplish twin goals: improving health status along with improving international relations.4 The history of militaries and governments providing healthcare and public health resources as a way of accomplishing global diplomatic goals is bound tightly to the world of humanitarian assistance. Within the humanitarian sphere, the coexistence of military and non-military actors has long been contentious. This history, based on a strict delineation between humanitarians and militaries, is due to a foundational philosophical difference in the two groups’ motivations for providing aid. It is within this conversation that we see the seeds sown for the ethical debate concerning military involvement in this arena.

Humanitarian assistance has been defined by the World Health Organization (WHO) as aid to an affected population that seeks, as its primary purpose, to save lives and alleviate suffering of a crisis-affected population . 5 Definitions of humanitarian assistance are important as they lead to a discussion of the actors involved; who are humanitarians? Who should do humanitarian work? Who should not, and why? These questions concerning the appropriate roles for different actors in the humanitarian sphere lay at the heart of the ethical dilemmas arising from military participation in humanitarian assistance activities, dilemmas that purposefully separate humanitarianism from politics or diplomacy.

According to the WHO, humanitarian assistance can be divided into three categories based on the degree of contact HADR actors have with the affected population. These categories are key to our discussion as they help define which types of humanitarian activities are considered appropriate for military actors/resources and which are not. Humanitarian assistance activities are first differentiated as being either proactive or reactive. Generally, this distinction is made by separating disaster relief/response from other forms of humanitarian aid, the latter being reactive and the former proactive. HADR then fall into three general categories:

  1. Direct assistance: activities involving the face-to-face distribution of goods and services to the affected population, such as direct medical care.

  2. Indirect assistance: activities that are at least one step removed from the affected population, to include the transportation of relief goods or relief personnel.

  3. Infrastructure support: activities providing general services, such as road repair, airspace management and power generation that facilitate relief, but are not necessarily visible to or solely for the benefit of the affected population.

Each of these categorised types of HADR involve different sets of actors with different skill-sets and capabilities. Specifically, the humanitarian landscape has long been populated by governmental bodies, non-governmental organisations (NGOs) and militaries. The relationships between these groups has historically been contentious, as non-military actors strive to appear apolitical and neutral, thus requiring purposeful separation from the political sphere. The international humanitarian community permits military actor participation in only two types of HADR: infrastructure support and indirect assistance.6 Historically, NGOs and other humanitarian organisations have sought military involvement for security and logistical support. This involvement has been driven by the desire for HADR activities in unstable areas or active conflict zones, leading to a recognition that the military is uniquely able to provide the security necessary for the HADR to take place. Despite these limitations on military involvement, the world of GHD has made way for a change in the humanitarian landscape.

Importantly, militaries have not remained contained within the categories outlined above. The majority of developed nations have progressively made HADR a significant part of military goals and operations, recognising the strategic and diplomatic value of this work, in line with the birth of medical or global health diplomacy discussed earlier. As an example: after the withdrawal of British troops from Afghanistan, the UK military began to plan specifically for a future of humanitarian deployments.6 Additionally, according to the US Department of Defense Instruction 3000.05, military stability operations are a core U.S. military mission that shall be given priority comparable to combat operations… 7 Stability operations often involve the provision of medical resources. These plans and policies highlight the reality that health and medical care have been ever more recognised as a powerful tool for diplomacy and strategy to bring safety, security and stability to populations and nations that lack medical infrastructure and healthcare.

However, it must be recognised that military involvement in HADR is a political act, driven by strategic goals that include diplomacy. As we will discuss next, it is because of this non -humanitarian motivation that non-military actors in HADR have sought to keep the military out of the fold. Additionally, these differing motivations help shed light on the fact that GHD is a significant departure from HADR that may make room for increasing military presence. The next section of this paper will draw on accepted international doctrine and codes of conduct to explore the morally important differences in this work; why is HADR work different when done by military actors as compared with civilians? What sets these missions apart? Moreover, do these differences matter to ethical analysis? This analysis highlights ethical dilemmas in GHD, and also serves to explain the contentious nature of the relationships between military and civilian actors in HADR.

International doctrine, codes of conduct and debates

To examine the morally relevant differences between civilian and military actors in HADR, we can look to the code of conduct as published and supported by the International Red Cross and Red Crescent Movement and other NGOs. Codes of conduct, such as this one, are useful to ethical analysis and worthy of examination because they are representations of normative morality, or expectations, as conceptualised and promulgated by the specific group of actors themselves. We can gain useful insights and understanding of group or professional, morality and identity by examining such codes as they are arguably an expression or representation of their collective morality. Examination of these codes also makes apparent the philosophical differences between HADR and GHD.

The Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief was jointly prepared by the International Federation of Red Cross and Red Crescent Societies along with the International Committee of the Red Cross (ICRC). According to the ICRC, the code seeks to guard standards for behaviour in the delivery of HADR, outlining ten points. Of these ten, four points are particularly relevant to understanding the perceived problems with military involvement as well as the separation of HADR from GHD. They are as follows:

  1. The humanitarian mission comes first.

  2. Aid priorities are calculated on the basis of need alone.

  3. Aid will not be used to further a particular political or religious standpoint.

  4. We shall endeavour not to act as an instrument of government foreign policy.

While there is variation between HADR organisations, these foundational precepts lay the groundwork on which these organisations are built. As is evident, the goals of GHD and military involvement in HADR are seen as expressly forbidden due to a foundational conflict in intention. Military HADR is politically driven and thus not in line with this civilian code of conduct. Since GHD and militaries themselves are instruments of government foreign policy, the provision of humanitarian assistance is often bound by other priorities that promote political motives.8

The division between military and non-military actors in HADR is further underscored by the Oslo Guidelines promulgated by the United Nations Office for the Coordination of Humanitarian Affairs. These guidelines were the result of a collaborative effort that culminated in an international conference in Oslo, Norway, in January 1994.9 These guidelines were revised in 2007 after the unprecedented 2005 deployment of military forces and assets in support of HADR. The 2007 Oslo Guidelines expressly articulate an agenda for GHD and HADR.10 This version offers increased specificity concerning military involvement and reinforces the principles laid out in the ICRC’s Code of Conduct (discussed above).

According to the Oslo Guidelines, humanitarian assistance must be provided in accordance with the core principles of humanity, neutrality and impartiality and with full respect for the sovereignty of states. Additionally, assistance must be based on actual needs and delivered by actors that have no political interest or stake in the situation. The involvement of foreign military and civil defence assets can only occur as a last resort. Specifically, military actors should be requested only in cases where there is no comparable civilian alternative and only when the use of military assets can deliver a critical humanitarian need, making the military actors uniquely capable or uniquely available if time constraints are relevant. An example of this type of legitimate military involvement can be seen in the case of the 2015 Ebola virus disease epidemic in West Africa.11 During this health crisis, it was widely accepted that the world’s militaries were uniquely situated to provide rapid deployment of personnel and other resources. In this case, military-actors provided both direct and indirect assistance, as well as infrastructure support. For instance, the UK provided direct medical care to infected healthcare workers as part of Operation GRITROCK.6 Despite the WHO’s call for military involvement during the Ebola epidemic, their participation is seemingly against United Nations guidelines. The Oslo Guidelines are specific in the perceived incompatibility of military actors in HADR, unless it is a last resort.9

Based on analysis thus far, the main and morally important difference between civilian and military actors’ engagement in HADR activities lies in their underlying intent. While arguments could be made that certain non-military organisations fail to meet the normative ideals discussed thus far, it seems that military-actors inherently fail this litmus test due to their place within the political sphere. Since militaries act as an arm of politics and national interests, their participation in HADR activities is seen as complicating the core humanitarian principles of impartiality and neutrality. This normative conception of incompatibility is then reiterated through doctrine and explicitly codified. The scepticism concerning the military’s place in HADR is predicated on the assumption of strategic/political goals. This asummption will now be explored.

According to a Center for Strategic and International Studies (CSIS) report on the topic, the primary benefits of these engagements are strategic and not humanitarian.12 Military involvement in HADR is justified with appeals to concepts expressed within the model of GHD, as discussed earlier. Although based on the same history as HADR, GHD is not similarly founded on principles of neutrality and impartiality, and therefore much more analogous to military HADR work. The CSIS report describes military humanitarian assistance as having the following primary benefits:

  1. Expand the ability of governments to access, influence and improve foreign relations;

  2. Strengthen military and diplomatic ties;

  3. Enhance military understanding of people and culture in critical areas;

  4. Improve readiness and capabilities (train personnel in austere environments);

  5. Strengthen the host nation’s health system.

These benefits, or goals, are explicitly stated in the CSIS report and then underscored by the doctrine establishing HADR programmes across many nations’ militaries, including the UK and the US.12 According to Katz et al,1 the US government has explicitly supported global health initiatives as a projection of smart power . Other research has established the strategic intent behind specific programmes, contributing to evidence that the military is perhaps more prone to instrumentalising medicine and HADR for other non-humanitarian purposes.13

However, discussing intention as related to this work requires an extra step within the military context. There has been research that highlights distinctly different motivations when comparing individual military personnel as opposed to the institution as a whole. According to Draper and Jenkins,6 those involved in Operation GRITROCK regarded the mission as humanitarian. Draper and Jenkins’6 data suggest that the motivations expressed by the service members align more with NGO workers than is often suggested. A divergence between individual motivation and institutional motivations has also been shown in the US Army Medical Corps.

Conclusion

While these differences in intent, or motivation, explain the schism between military and non-military actors in the HADR domain, it does not necessarily render military HADR activities unethical. Additional research is needed to separate institutional goals from those of individual military healthcare providers in the field. It is possible that the GHD model will alter the HADR landscape sufficiently and lessen the divide between these two sets of actors. Alternatively, we will see greater separation between NGOs and governments engaging in similar work with disparate goals. Either way, militaries are continuing to increase their role in humanitarianism, nation building and diplomacy. In order to overcome these hurdles and join non-military actors in providing complementary assistance and avoiding redundancy, militaries will have to make choices about how they conceptualise military medicine, train those who will be deployed in this setting and interact with non-military actors. Understanding the history of the HADR sphere and its connection to GHD is a necessary first step that can lead to understanding and collaboration that will eventually accomplish the goals of both groups of actors more effectively.

References

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Footnotes

  • Presented at Ethics Grand Rounds: Naval Medical Center Camp LeJeune: Jacksonville North Carolina, USA.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.