Ensuring Public Health Neutrality Les F

The NEW ENGLAND JOURNAL of MEDICINE

Perspective march 21, 2013

Ensuring Public Health Neutrality Les F. Roberts, Ph.D., M.P.H., and Michael J. VanRooyen, M.D., M.P.H.

n June 1968, a clearly marked Swedish Red Cross der to analyze the DNA of the plane flying relief supplies into the breakaway household members. The ploy I appears not to have worked in 1 state of Biafra was shot down by Nigerian fighters. the bin Laden compound, since Before the war was over, many relief planes would Afridi’s team was kicked out. Nonetheless, in a 60 Minutes inter- be shot down and far more would recipients, and provided a blan- view last June, Defense Secretary crash because the Nigerian gov- ket of impunity for the future Leon Panetta said that Afridi was ernment’s shoot-to-kill order criminal actions of the Nigerian helpful in finding bin Laden.5 In forced them to fly at night. The government. May 2012, Afridi was convicted of brazen targeting of Red Cross To underscore the necessity of treason and sentenced to 33 years relief flights on civilian humani- humanitarian neutrality, 12 deans in prison. tarian missions was hard to imag- from prominent U.S. schools of Because of these events, Paki- ine. In the minds of some people, public health sent a letter to Pres- stan expelled the foreign staff of however, these attacks were justi- ident Barack Obama on January 6, the international aid agency Save fied by another clear violation of 2013, protesting the conduct of a the Children from the country in humanitarian neutrality: on at sham vaccination campaign as September 2012 — a move that least one occasion, a plane paint- part of the hunt for Osama bin threatened the network of health ed with the Red Cross insignia Laden.4 In the lead-up to the May and development services that the was actually carrying weapons.2,3 1, 2011, targeting of Osama bin organization had established over That rare instance of military ac- Laden in Abbottabad, Pakistan, the past 30 years. In December, tion masquerading as humanitar- the Central Intelligence Agency eight polio vaccination workers ian relief completely undermined (CIA) reportedly hired a Pakistani were killed in an apparently coor- the neutrality of everyone who surgeon named Shakil Afridi to dinated set of attacks (see photo), operated by the accepted rules of go house to house vaccinating and the United Nations has sus- humanitarian assistance, cost the children but also drawing back a pended its polio-eradication ef- lives of both aid workers and aid little blood in the syringe in or- forts in Pakistan, where 150,000

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humanitarian assistance for those in need; that the provision of services be based not on nationality, race, religion, or political point of view, but on need alone; and that aid organizations implement their interventions independently, without the influence of national political agendas. Whereas the articles of the Geneva Conven- tions compel governments to abide by international humanitarian law, the code of conduct com- pels the civilian aid community to protect recipients from exploi- tation and to serve without bias. Protests after the Killing of Vaccination Workers in Pakistan. This code, which virtually all major U.S. nongovernmental organizations have pledged to adhere children die of vaccine-prevent- closed to them because of politi- to, serves as a barometer for ap- able illnesses each year. After cal and/or security interests that propriate interventions; it also, at decades of a global campaign ignore the type of unintended least ideally, assures the access funded largely by the U.S. gov- negative public health impacts we and safety of aid workers in con- ernment and recently by the Bill are witnessing in Pakistan.” flict situations. Today, in virtual- and Melinda Gates Foundation, For physicians who have taken ly all crises, lifesaving aid in the polio has been eradicated from the Hippocratic Oath, the wisdom form of water, food, and medi- all but three countries: Afghani- of the 2000-year-old pledge is evi- cine is provided by unarmed peo- stan, Nigeria, and Pakistan. It dent: “Whatever houses I may ple protected by the image that has taken many years and hun- visit, I will come for the benefit they are humanitarians first and dreds of millions of dollars to of the sick, remaining free of all foremost, working for the health bring us to the brink of global intentional injustice.” For those of people in need. The fact that eradication of polio, an achieve- of us who work in politically un- their protection is the trust and ment that appears to have been stable settings where armed con- common purpose of the commu- made much more difficult by flicts are under way, the pledge of nities in which they work enables the CIA’s actions. humanitarian neutrality is equally public health campaigns to tran- The deans of the schools of essential. This pledge is codified scend nationalism, race, and eth- public health asked the President in the Geneva Conventions, which nicity. It also permits public health to commit the United States to are also U.S. law, and the Red endeavors to save millions of lives refraining from disguising mili- Cross Code of Conduct under every year. tary or intelligence actions as which the United Nations and Although some U.S. policy- public health activities. Defend- major aid agencies operate. This makers consider immediate na- ing the interests of global public code of conduct provides operat- tional security concerns a higher health workers, they wrote, “Inter- ing parameters within which Unit- priority than long-term global national public health work ed Nations and nongovernmental health efforts, the CIA’s false builds peace and is one of the organizations engage communi- vaccination campaign in Pakistan most constructive means by ties in crisis. The codified prin- may cause collateral damage with which our past, present, and fu- ciples of humanity, impartiality, profound long-term implications ture public health students can and independence require that for national security. If every aid pursue a life of fulfillment and all people be treated humanely in worker with a syringe is suspect- service. Please do not allow that all circumstances and that the ed of being a spy, the children, outlet of common good to be international community provide families, and communities of the

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world will no longer have protec- Mailman School of Public Health, New York paign — a word of advice. Nigerian Village tion against our greatest killers. (L.F.R.); and the Department of Emergency Square. December 19, 2012 (http://www Medicine, Brigham and Women’s Hospital, .nigeriavillagesquare.com/forum/main-square/ Ultimately, if the neutrality of pub- Boston (M.J.V.). 74397-chinamanda-achebe-hate-campaign lic health efforts is undermined, -word-advice-2.html). This article was published on February 27, 4. Deans’ letter to President Obama (http:// the world will become a more vio- 2013, at NEJM.org. www.jhsph.edu/news/news-releases/2013/ lent and unhealthy place. Klag%20letter%20to%20President%20 Disclosure forms provided by the authors 1. Aid flight reported downed by Nigeria. Obama.pdf). are available with the full text of this article New York Times. June 7, 1969. 5. 60 Minutes. A source in Abbottabad at NEJM.org. 2. Galeota WR. Conversation in a L.I. bar with helped U.S. find bin Laden. June 10, 2012 a soldier of fortune: he flew food to Biafra. (transcript) (http://www.cbsnews.com/video/ Harvard Crimson. August 16, 1968 (http:// watch/?id=7396619n). From the Program on Forced Migration and www.thecrimson.com/article/1968/8/16/ Health, Heilbrunn Department of Popula- conversation-in-a-li-bar-with/). DOI: 10.1056/NEJMp1300197 tion and Family Health, Columbia University 3. Re: Chinamanda and Achebe hate cam- Copyright © 2013 Massachusetts Medical Society.

Security of Health Care and Global Health Robin Coupland, F.R.C.S.

y introduction to “global spread insecurity resulted in the companying insecurity makes it Mhealth” was rude. In the late termination of health care pro- most difficult to address them. 1980s and early 1990s, I worked grams, which left entire already- Even providing prehospital care as a surgeon in field hospitals of vulnerable populations without for the wounded, including first the International Committee of health care. aid and transport by ambulance, the Red Cross (ICRC). I treated Among all the constraints fac- becomes dangerous, since health hundreds of wounded people in ing health care delivery in such care personnel, ambulances, and eight different countries in Africa settings, the most difficult one health care facilities may be open and Asia, where I visited many to address is a lack of security.1 to attack. local health care facilities, the One of our head nurses put it The uprisings in North Africa majority of which were hopeless- quite simply: “We can’t do any- and the Middle East in the past ly understaffed or undersupplied thing without security.” In the big- 2 years have taken place largely because of armed conflicts. Our ger picture, the success or failure in urban environments, where the surgical actions were just one part of our efforts to provide health preexisting facilities on which of a wide array of health care ac- care rested less on impeccable wounded people — whether civil- tivities, and the ICRC is only one program planning and execution ian, police, or military — would of many organizations attempt- than in the hands of the people normally depend for health care ing to support or deliver health who were responsible for our se- suffer a range of security prob- care in contexts of violence. The curity (or lack thereof), and it be- lems, in part because these facili- security of facilities, patients, and came clear to me that the relation- ties and the people who staff staff was an everyday working ships among security, insecurity, them become integrated into the consideration, and the problems health, and health care are ex- events. Ambulances may be at- we faced were common to all tremely complex. Moreover, armed tacked, and their staff harassed, health care providers. Certain conflict generates immediate and because of the patients they are roads could not be traveled, am- additional health care require- carrying. Health care providers bulances were attacked, supplies ments for wounded and sick peo- may be prevented from treating were looted, staff and patients ple that exceed peacetime needs. members of one side of the dis- were subject to a variety of threats, Hospitals may fill rapidly with pute or the other. Hospitals may and worst of all, patients and my wounded people, both military be seen as a place where enemies colleagues were sometimes target- and civilian, and the additional or “terrorists” can be arrested, in- ed directly and kidnapped or killed. health care requirements arise at terrogated, or even killed. Again, Often such violence or wide- precisely the time when the ac- insecurity may be the factor de-

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