by Les F. Roberts, Ph.D., M.P.H., and Michael J. VanRooyen, M.D., M.P.H.
In June 1968, a clearly marked Swedish Red Cross plane flying relief supplies into the breakaway state of Biafra was shot down by Nigerian fighters.1 Before the war was over, many relief planes would be shot down and far more would crash because the Nigerian government’s shoot-to-kill order forced them to fly at night. The brazen targeting of Red Cross relief flights on civilian humanitarian missions was hard to imagine.
In the minds of some people, however, these attacks were justified by another clear violation of humanitarian neutrality: on at least one occasion, a plane painted with the Red Cross insignia was actually carrying weapons.2,3 That rare instance of military action masquerading as humanitarian relief completely undermined the neutrality of everyone who operated by the accepted rules of humanitarian assistance, cost the lives of both aid workers and aid recipients, and provided a blanket of impunity for the future criminal actions of the Nigerian government.
To underscore the necessity of humanitarian neutrality, 12 deans from prominent U.S. schools of public health sent a letter to President Barack Obama on January 6, 2013, protesting the conduct of a sham vaccination campaign as part of the hunt for Osama bin Laden.4 In the lead-up to the May 1, 2011, targeting of Osama bin Laden in Abbottabad, Pakistan, the Central Intelligence Agency (CIA) reportedly hired a Pakistani surgeon named Shakil Afridi to go house to house vaccinating children but also drawing back a little blood in the syringe in order to analyze the DNA of the household members. The ploy appears not to have worked in the bin Laden compound, since Afridi’s team was kicked out. Nonetheless, in a 60 Minutes interview last June, Defense Secretary Leon Panetta said that Afridi was helpful in finding bin Laden.5 In May 2012, Afridi was convicted of treason and sentenced to 33 years in prison.
Because of these events, Pakistan expelled the foreign staff of the international aid agency Save the Children from the country in September 2012 — a move that threatened the network of health and development services that the organization had established over the past 30 years. In December, eight polio vaccination workers were killed in an apparently coordinated set of attacks (see photo below: Protests after the Killing of Vaccination Workers in Pakistan.), and the United Nations has suspended its polio-eradication efforts in Pakistan, where 150,000 children die of vaccine-preventable illnesses each year. After decades of a global campaign funded largely by the U.S. government and recently by the Bill and Melinda Gates Foundation, polio has been eradicated from all but three countries: Afghanistan, Nigeria, and Pakistan. It has taken many years and hundreds of millions of dollars to bring us to the brink of global eradication of polio, an achievement that appears to have been made much more difficult by the CIA’s actions.
The deans of the schools of public health asked the President to commit the United States to refraining from disguising military or intelligence actions as public health activities. Defending the interests of global public health workers, they wrote, “International public health work builds peace and is one of the most constructive means by which our past, present, and future public health students can pursue a life of fulfillment and service. Please do not allow that outlet of common good to be closed to them because of political and/or security interests that ignore the type of unintended negative public health impacts we are witnessing in Pakistan.”
For physicians who have taken the Hippocratic Oath, the wisdom of the 2000-year-old pledge is evident: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice.” For those of us who work in politically unstable settings where armed conflicts are under way, the pledge of humanitarian neutrality is equally essential. This pledge is codified in the Geneva Conventions, which are also U.S. law, and the Red Cross Code of Conduct under which the United Nations and major aid agencies operate. This code of conduct provides operating parameters within which United Nations and nongovernmental organizations engage communities in crisis. The codified principles of humanity, impartiality, and independence require that all people be treated humanely in all circumstances and that the international community provide 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 Conventions compel governments to abide by international humanitarian law, the code of conduct compels the civilian aid community to protect recipients from exploitation and to serve without bias.
This code, which virtually all major U.S. nongovernmental organizations have pledged to adhere to, serves as a barometer for appropriate interventions; it also, at least ideally, assures the access and safety of aid workers in conflict situations. Today, in virtually all crises, lifesaving aid in the form of water, food, and medicine is provided by unarmed people protected by the image that they are humanitarians first and foremost, working for the health of people in need. The fact that their protection is the trust and common purpose of the communities in which they work enables public health campaigns to transcend nationalism, race, and ethnicity. It also permits public health endeavors to save millions of lives every year.
Although some U.S. policymakers consider immediate national security concerns a higher priority than long-term global health efforts, the CIA’s false vaccination campaign in Pakistan may cause collateral damage with profound long-term implications for national security. If every aid worker with a syringe is suspected of being a spy, the children, families, and communities of the world will no longer have protection against our greatest killers. Ultimately, if the neutrality of public health efforts is undermined, the world will become a more violent and unhealthy place.
New England Journal of Medicine