An open access publication of the American Academy of Arts & Sciences
Spring 2023


Paul H. Wise, Jennifer M. Welsh, and Jaime Sepúlveda
View PDF

Paul H. Wise, a Fellow of the American Academy since 2018 and cochair of the Academy’s project on Rethinking the Humanitarian Health Response to Violent Conflict, is the Richard E. Behrman, MD, Professor of Child Health and Society, Professor of Pediatrics, Co-Director of the March of Dimes Center for Prematurity Research, and a Senior Fellow at the Freeman Spogli Institute for International Studies at Stanford University. He participated in two other projects at the American Academy: Civil Wars, Violence, and International Responses; and New Dilemmas in Ethics, Technology, and War.

Jennifer M. Welsh, a Fellow of the American Academy since 2021 and cochair of the Academy’s project on Rethinking the Humanitarian Health Response to Violent Conflict, is the Canada 150 Research Chair in Global Governance and Security at McGill University. Her most recent books include The Return of History: Conflict, Migration and Geopolitics in the 21st Century (2016) and The Responsibility to Prevent: Overcoming the Challenges of Atrocity Prevention (2015).

Jaime Sepúlveda, a Fellow of the American Academy since 2014 and cochair of the Academy’s project on Rethinking the Humanitarian Health Response to Violent Conflict, is the Haile T. Debas Distinguished Professor of Global Health and the Executive Director of the Institute for Global Health Sciences at the University of California, San Francisco. He is also a member of the U.S. National Academy of Medicine. He has published in journals such as The LancetNEJMVaccineHealth AffairsBMJScience, and Nature.

This collection of essays raises the fundamental question of whether the current infrastructure and practices of humanitarian health provision are increasingly out of step with the nature and scale of human needs generated by new forms of violence and a political context increasingly hostile to humanitarian values. The introductory essay by David Miliband and Ken Sofer articulates this challenge with clarity and power.1 It outlines in sharp relief a failed global commitment to the humanitarian mission and provides important, pragmatic opportunities for urgent ameliorative action. Each of the essays in this volume focuses on a different dimension of the challenge, some more attentive to conceptual issues, others to operational realities. Together, they provide a coherent mosaic of critical scrutiny, and lay an essential foundation for understanding both the obstacles and opportunities for strengthening current practices and implementing needed reforms.

In her essay, Anastasia Shesterinina examines the evolving character of contemporary civil conflicts and its implications for an effective humanitarian response.2 She underscores the dynamic character of current humanitarian challenges and details the growing diversity of combatants and constantly changing, adaptive relationships between them. While Shesterinina provides a cogent, conceptual analysis, she also emphasizes the contingent nature of service provision in these areas and how the shifting identities and often veiled interests of violent actors can obscure the boundaries between threat and safety for humanitarian operators on the ground. Shesterinina also reminds us that humanitarian services themselves can become just one more coercive tool in these complex settings, by which those who control access to needy populations vie for resources, legitimacy, and power. These emerging challenges can become especially complex when a variety of nonstate armed groups (NSAGs) control access to humanitarian supply routes and populations in need. In their essay, Ann-Kristin Sjöberg and Mehmet Balci explore the role of these groups in detail and outline strategies humanitarian health providers can employ to navigate this often labyrinthine terrain.3 Of particular concern has been the institution of global restrictions on engaging with NSAGs considered “terrorist” or included on sanctions lists at the international, regional, or domestic level. These restrictions can take the form of financial or even criminal penalties and have hindered necessary humanitarian services in a variety of conflict settings.

 Perhaps the most potentially catastrophic humanitarian challenge is the prospect of armed conflict between great powers. Over the past decade, the U.S. and allied militaries have pivoted from a preoccupation with waging counterinsurgency to intense preparation for conducting large-scale military operations against peer or near-peer militaries. It is not clear that the humanitarian health community has responded accordingly and expanded its planning and capabilities to meet the potential humanitarian demands of such a conflict. Sir Lawrence Freedman’s contribution to this volume provides an acute and disturbing analysis of the Russian invasion of Ukraine, a war that has provided a preview of what large-scale combat operations might look like.4 This interstate war departs from the far more prevalent civil conflicts of the past three decades and offers a graphic illustration of the humanitarian impacts of massive artillery, missile, and drone attacks on urban populations. Russia has focused these attacks not only on military targets but also against civilians and civic infrastructure. In so doing, it has not only violated the laws of war but done so strategically to undermine the Ukrainian capacity and will to fight. As Freedman observes, this strategy to target civilians and civilian infrastructure has yet to result in any major military advantages, but it has tragically and likely criminally generated a humanitarian catastrophe and large-scale refugee flows. Freedman’s essay also recognizes the potential for a protracted stalemate, as well as a rapid escalation involving a cascade of reciprocal actions that could lead to a widening of the war, and possibly the use of nuclear weapons.

Several of the contributors also address emerging trends and challenges to modern humanitarian action. Keith Stanski examines the unique requirements of providing humanitarian services in urban areas. Urban warfare is not new. However, the recent use of explosive and chemical weapons in densely populated areas has raised significant legal and operational challenges for humanitarian efforts.5 Of special concern is the interdependence of urban infrastructure and social norms that make civilian life and humanitarian operations particularly vulnerable to attack. Damage to any one of these systems can have powerful reverberating effects. Recent Russian air assaults on the Ukrainian energy grid have affected the delivery of essential services, including food and water supply, sanitation, transportation, and health care at public facilities. Stanski draws on his varied field experience to outline constructive steps to mitigate the destruction of urban communities and protect particularly important civilian structures, such as hospitals, and focused humanitarian initiatives, such as relief convoys.

Technical innovation is also transforming the capabilities and vulnerabilities of the humanitarian mission. Larissa Fast assesses the rapidly expanding requirements of the digital environment in conflict and the humanitarian response.6 Modern humanitarian activities demand coordination, and modern coordination requires the sharing of data. However, as Fast points out, the ethics and governance of data collection, sharing, and use require urgent attention. This is because the collection, sharing, and use of data, regardless of intention, inevitably involves the negotiation of power. The issue of consent in humanitarian settings will often require a dialogue between those in desperate need and those who control the resources essential to meeting this need, a dialogue that must be rooted in trust, but a trust that must navigate profound differentials in power. Moreover, in humanitarian settings, data can function not only as an empowering tool but also as a potential vulnerability and ruinous weapon. Data can be used to advance a variety of harmful objectives, including the identification of individuals or communities for targeting, and to mount harmful attacks on social media. Fast outlines the requisite technical and governance protections for data involved with humanitarian efforts, all of which must marry technical sophistication with an unwavering respect for the interests and voices of the communities at risk.

While the evolving nature of conflict and combatants has generated new humanitarian challenges, so too have new political and moral understandings of what effective and just humanitarian services require. The essays by Amanda Murdie and Morgan Barney and by Dima M. Toukan articulate the requirements of localization, a general commitment to respect the role of local communities in shaping the objectives and machinery of humanitarian provision.7 The diverse representation of affected populations is fundamental to this commitment, especially those long excluded from humanitarian leadership, including women, ethnic and religious minorities, and socially marginalized groups. The authors also note the difficulties that humanitarian actors have encountered in fully meeting the requirements of localization, requirements that raise serious questions about the viability of long-standing humanitarian practices.

The essay by Sergio Aguayo also confronts traditional humanitarian health perceptions by arguing that some of the most protracted humanitarian challenges are being generated by political and criminal violence in areas not formally considered to be at war.8 Aguayo uses the case of Mexico to argue that humanitarian crises associated with modern mass migrations are best understood as part of an illicit ecosystem of human trafficking governed by organized criminal enterprises and corrupt government officials. This is an important challenge to conventional legal and operational humanitarian frameworks that have been constructed for interstate and civil wars. More broadly, his essay serves as an important reminder that in settings of extreme violence, the boundaries between political grievance and criminal greed can be blurred, a reality of veiled menace that can threaten even the most benevolent of humanitarian actors.

The ultimate challenge to the humanitarian health community is the direct threat of violence. In 2022, there were almost eleven hundred attacks on health workers or their facilities, resulting in more than two hundred deaths and four hundred forty injuries. In many ways, these figures represent a synoptic expression of the destabilizing array of challenges the essays in this collection articulate so well. There was hope that a strong global recommitment to the protection of humanitarian health would bolster the safety of health workers and facilities in areas of extreme violence. However, as Simon Bagshaw and Emily K. M. Scott describe in their essay, just such a recommitment, Resolution 2286, passed by the United Nations Security Council in 2016, has largely failed to provide any strengthened protection.9 Indeed, the failure of Resolution 2286 has only underscored the perceived erosion of humanitarian norms and the sense of vulnerability among humanitarian health workers around the world.

Together, these essays suggest that the rich, complex development of humanitarian health has reached an inflection point, a historical moment that demands a fundamental rethinking. The humanitarian mandate remains unchanged. However, the evolution of organized violence and an increasingly unstable geopolitical order have generated challenges so profound and varied that a reconsideration of humanitarian health’s most basic tenets and pragmatic practices seems imperative.

In this context, the ethical foundation of humanitarian health becomes an essential component of this rethinking. In her essay, Ana Elisa Barbar argues that the ethical principles that have guided humanitarian health for decades require purposeful reexamination and, ultimately, validation or revision.10 Perhaps the most consequential reassessment will involve the emerging tensions between the core principles themselves, tensions generated seemingly paradoxically by expanded efforts to make humanitarian health more effective, ethically responsible, and just. Localization initiatives are not only likely to enhance the effectiveness of humanitarian health services but also address justice issues that have long been ignored. However, in areas in which communities are affiliated with distinct political or combatant groups, intimate engagement with these communities can challenge the humanitarian principles of neutrality and independence. Similarly, while the purposeful inclusion of long-marginalized groups is welcome, it should be pursued with careful attention to the requirements of impartiality, which demands that medical care be provided based on medical need and not on other characteristics or claims.

Finally, innovative strategies to improve the effectiveness of humanitarian health delivery are also creating tensions among accepted humanitarian principles. For example, recent evidence-based analysis of humanitarian health delivery has emphasized the need to stabilize injured patients as quickly as possible. This led the World Health Organization during the Battle of Mosul in Iraq to embed humanitarian medical personnel with Iraqi security forces close to the front lines.11 This strategy did, in fact, save lives, thereby honoring the essence of the humanitarian principle of humanity. However, it simultaneously violated the core humanitarian principles of neutrality and independence.

These challenges reflect the reality that legitimate calls for reform, even those based on greater effectiveness or strong justice claims, may not always align or even be compatible. The rethinking of humanitarian ethics, therefore, will ultimately require careful negotiation between sometimes competing imperatives, a negotiation that may have to tolerate, if not embrace, a respect for nuance, local conditions, and humanitarian needs.

The essays in this collection recognize that humanitarian health provision depends upon compliance with ethics, international law, adequate global financing, and ultimately, the exercise of power. However, humanitarian care also depends upon humanitarian norms, broad patterns of behavior shaped by a shared appeal to succor and material relief based not on nationality or kinship, but merely on being human. Yet years of study and experience in the field have revealed that norms cannot be solely mandated; they must also be felt. Humanitarian health depends upon things that transcend rules and principles but engender a common sense of compassion, a shared commitment to protect, and the sentiments that stir people to act in the interests of others. In many ways, this is the realm of the arts—of music, paintings, photography, literature, and poetry. It is fitting, therefore, that the artistic contributions in this issue of Dædalus recognize, in some small way, the role of the arts in shaping humanitarian norms and the power of imagination when it is mobilized in service to empathy, outrage, and justice.