Identifying Contemporary Civil Wars’ Effects on Humanitarian Needs, Responses & Outcomes

The destruction of a maternity hospital in the besieged city of Mariupol on March 9, 2022, drew the world’s attention to Russia’s increasing attacks on medical facilities, confirmed by the World Health Organization (WHO), since the Russian invasion of Ukraine on February 24, 2022.1 As “the hospital was clearly identifiable and operational at the time it was hit . . . [and n]o effective warning was given [or] time-limit set,” the Organization for Security and Co-operation in Europe (OSCE) determined this attack and others to be in clear violation of international humanitarian law (IHL), despite Russia’s claims that Ukraine staged the attack in what was called “fake news” and, later, that the building was used by the Ukrainian far-right Azov battalion.2 The Russian armed forces also blocked humanitarian aid from the besieged city, obstructing “humanitarian corridors” and seizing food and medical supplies set for Mariupol.3 Reports from a makeshift hospital in the city’s last site of Ukrainian defense, the Azovstal steelworks plant, indicated Russia’s continued attacks and the lack of medication to treat the wounded.4 Because local supply chains were damaged and the war displaced both patients and health care providers, delivery of aid, including emergency contraception amidst rising reports of sexual violence, not least from Bucha, faced challenges elsewhere in Ukraine.5 In the meantime, millions of refugees forced to flee Ukraine sought access to health care in the neighboring countries.6

Russia’s war in Ukraine is an interstate war, a rare event in the landscape of contemporary armed conflict, which has been dominated by intrastate or civil wars since World War II.7 However, its impact on humanitarian health care provision bears a resemblance to the challenges posed by wars in which “armed combat [takes place] within the boundaries of a recognized sovereign entity between parties subject to a common authority at the outset of the hostilities”8 but where “other states have [increasingly] intervene[d] militarily on one or both sides.”9 In these contexts, researchers have identified attacks on medical facilities and personnel, impediments to health care reaching patients, and displacement of patients and health care providers as among the challenges also evident in Russia’s war in Ukraine.10 These common challenges manifest differently across specific armed conflict contexts, and change over time.11 Researchers have also identified similarities in justifications used by perpetrators of violations of IHL—including those related to health care—across inter- and intrastate wars, such as blame-shifting, denial of facts, misinformation, and colonial representations of the enemy, which Russian explanations of the attack on Mariupol’s hospital exemplify.12 Elements of the analytical framework that this essay advances to better understand the effects of contemporary civil wars on humanitarian activities in general, and health care provision in particular, can thus be applicable beyond internal armed conflicts.

How do we make sense of the contemporary violent contexts in which humanitarian actors operate?13 I argue that civil wars are highly complex, social processes that involve a myriad of actors and their evolving relationships, which humanitarian actors are an integral part of.14 The evolution of these relationships as a result of the different actors’ concurrent activities, their transformation in response to internal and external pressures, and the emergence of new actors all serve to underpin the “changing conflict environment . . . [that] the provision of humanitarian services must continually adapt to.”15 Understanding the effects of civil wars on humanitarian activities therefore requires mapping these relationships and their evolution and drawing the implications of these changes for the operation of humanitarian actors. This mapping entails not simply identifying the different actors and their interests that are central to specific contexts at any given moment in the conflict, but also analyzing what relationships exist between conflict actors and charting the dynamics their evolving interactions produce over time. These dynamics range from internal politics within these actors to violent and nonviolent conflict and cooperation between them.

In this essay, I briefly outline the actors involved in civil wars and delve into the social systems that these actors’ relations generate. This discussion demonstrates that humanitarian actors are not isolated from but are both constituted by and constitutive of the interactions between the internal and external actors engaged in contemporary civil wars. Placing humanitarians in the context of these social systems can help us to understand how the relationships they establish evolve—sometimes for reasons outside of their control. Humanitarian health care provision is contingent on this evolution and requires locally informed, adaptive practices in order for humanitarian organizations to be able to negotiate access, protect medical facilities and personnel, and deliver vital assistance in an ongoing way in response to changing circumstances.

While early studies of civil war focused on “dyadic” relationships between states and insurgencies, recent work has sought to disaggregate these actors, recognizing their various origins and multidimensional nature, and to incorporate a broader range of violent and nonviolent actors in the analysis.16 These actors include civilian populations, traditional leaders, religious groups, rival militias, humanitarian agencies, international organizations, neighboring states, and private corporations, each of which, as civil war scholars have noted, is driven by its own “distinct logic.”17 To this set, we can add “extralegal groups” that, unlike politically driven insurgents, do not seek to take over the state or part of its territory to implement political projects but rather to provide basic “governance functions” to sustain their profit-driven activities.18 Humanitarians, themselves driven by a distinct technocratic logic defined by neutrality, impartiality, and independence and the guidelines that stem from these principles,19 have to navigate the terrain where these actors’ identities, interests, and activities “coexist and coevolve.”20 For the purposes of this essay, I group these actors into nonstate, state, civilian, and external categories to explore their relationships.

Nonstate armed groups or insurgents that challenge the state’s authority and control over territory lie at the center of dynamic systems of relationships that define contemporary civil wars. Insurgents typically mobilize and organize before the war and are therefore embedded in broader populations to a different extent.21 They emerge from distinct origins in clandestine groups, social movements, and elite splinters within the regime, which condition their relationships with other actors.22 For example, as political scientist Janet Lewis has shown, clandestine groups made up of a core of dedicated recruits rely on local networks for their survival in their early days due to the asymmetry of power in their relationship to the state.23 As a result, these groups tend not to engage in indiscriminate violence against the communities that they depend on, at least initially, leaving these communities off the radar for humanitarians until the armed groups become viable and turn against them. This was the case with the Lord’s Resistance Army in Uganda. On the other hand, as political scientist Theodore McLauchlin has argued, splinters of existing armies that rebel against the state emerge from within the regime and rely on intra-regime networks.24 These groups are not necessarily weaker vis-à-vis the state and do not initially depend on the population to recruit fighters, but their preexisting military capacity means that the wars they initiate are shorter and bloodier and attract humanitarian action early on in the fighting. The First Liberian Civil War is an example.

Regardless of these distinct origins, in order to sustain their opposition to the state, insurgents ultimately need to generate support from civilians and develop concrete organizational forms to work toward their goals.25 This approach involves the establishment of leadership structures and institutions that can govern behaviors within the organization, thereby socializing members through training, disciplinary practices, and political education.26 While these efforts are aimed, in part, at fostering cohesion, internal politics and external influence can nonetheless produce divisions within insurgent organizations, leading to fragmentation and infighting between factions competing for leadership and influence.27 These dynamics reduce the capacity of leaders to control their organizations and multiply the number of actors within a conflict context, with direct implications for humanitarians seeking to engage with nonstate armed groups on the ground.28 For example, a group that is initially cohesive, with identifiable leaders who can negotiate from a unified position and induce members to deliver on given commitments, can later fragment, renege on prior commitments, and make continued engagement challenging due to internal splits and factional competition. In practice, this means that sustained dialogue with armed groups may not be possible. Humanitarian organizations will thus have to engage multiple groups to obtain the necessary security guarantees for their activities.29

But nonstate armed groups’ transformations, and the implications that they may have for humanitarian actors and their work, are not simply a feature of internal politics. These groups also have to constantly adapt to other nonstate, state, civilian, and external actors’ activities. As a result, we cannot merely analyze nonstate armed groups’ organizational dynamics to understand the challenges civil wars pose to humanitarian health care provision. In addition, we should place the evolving relationships they have with other actors at the center of analysis, ranging from competition and alliance formation with other nonstate armed groups to violent and nonviolent conflict and cooperation with the state, the different civilian responses to these groups’ activities, as well as varied forms of international intervention. The social systems that emerge from these dynamics are critical for our understanding of the ever-changing environment in which humanitarian actors operate during civil wars.

Given the existence of multiple nonstate armed groups in contemporary violent contexts, humanitarians rarely operate in relation to a single armed group, even that which appears to be the dominant actor in the broader civil war or any subnational locale.30 Different armed groups compete for population support and scarce resources and ally for strategic and ideological reasons. These actors can be driven by political goals, even if they engage in criminal activities to finance their operations, or by profit, even if they establish governance structures to protect their business, as conflict scholar Christine Cheng has demonstrated in the case of “extralegal groups,” or by a combination of both.31 Their patterns of relationships as well as their identities and interests therefore vary and can change over time. This in turn shapes how they perceive humanitarian activities.32 For example, research has shown that groups seeking domestic and international legitimacy are less likely to undermine humanitarian health care provision compared with those that do not seek legitimacy or those whose legitimacy does not depend on the population’s support or abiding by international rules that govern humanitarian action.33 However, their struggles with each other and the state can create challenges for humanitarian actors. Humanitarian health care provision in an area controlled by an armed group can preclude health care providers’ access to territory controlled by that group’s enemies. Moreover, engagement with some but not other armed groups that share control over an area can compromise health care provision there. Finally, changes in territorial control can undermine previous agreements and require renegotiation. Humanitarian efforts in Syria exemplify each of these challenges.34 Understanding changing relationships between nonstate armed groups can help “humanitarian actors to keep up with the pace of fragmentation, splitting and alliances that forms the rhythm of the life of armed actors” and thereby adapt to the challenges that result from these dynamics.35

Nonstate armed groups’ relationships with each other and their effect on humanitarian action cannot be understood outside of the activities of the state. Researchers have found that state counterinsurgency strategies are one of the key determinants of nonstate armed groups’ internal cohesion and intergroup relationships.36 Shifts in state counterinsurgency policy, for example, can interact with different groups’ organizational features to make some groups more vulnerable to fragmentation than others, with trickle-down effects on humanitarian activities.37 These shifts can be motivated by changing political realities, but are rooted in the government’s preferences, institutions, and coalitions with various actors that underpin its political vision or, as political scientist Paul Staniland has put it, its “ideological project.”38 Changes in intra- and intergroup dynamics that are generated by state policy are thus a further crucial part of the systems of relationships in which humanitarian actors are embedded. The stable relationships they build with some nonstate armed groups—to facilitate the delivery of humanitarian assistance—can subsequently be impeded by the changing pressures these groups face from the state.

Yet governments engage not only in violent relationships with nonstate armed groups, but also in nonviolent conflict and even forms of cooperation.39 In fact, relationships between states and nonstate armed groups can be placed on a continuum of “armed orders” that ranges from “total war,” characterized by military interactions, to containment, cooperation, and alliance over mutually beneficial goals, such as attacks on shared enemies or population governance.40 State and nonstate forces can therefore restrain violence to receive medical care alongside each other and make arrangements to enable health care provision to their members and the populations they control. In Nepal, for example, the Communist Party of Nepal-Maoist (CPN-M) relied on access to existing health facilities for treatment of their members and allowed health service delivery to meet civilian needs in the areas under their control, including through humanitarian organizations. As analysts have demonstrated, humanitarians established operating principles and organized IHL training for warring parties to help protect health care provision from the kind of politicization that marked other services, such as education.41

Nevertheless, even humanitarian health care provision can be “weaponized” by state and nonstate armed actors, especially when these actors find themselves in a relationship of “total war” and interpret humanitarian health care assistance as advancing the other side’s position.42 Arrest, detention, and in extreme cases execution of health workers for treating wounded enemy combatants is the most basic form of such weaponization, recorded in contexts as diverse as Colombia, Chechnya, and East Timor.43 State and nonstate armed actors also militarize health facilities—for example, by using these facilities as bases for their operations or places to store arms—and they politicize aid by denying access to certain populations, such as those controlled by their opponents.44

Humanitarian actors thus operate in dramatically different contexts within the broad rubric of contemporary civil war that constrain and enable their activities in distinct ways and that can change unpredictably. In some situations, this means that the provision of humanitarian health assistance can backfire in what conflict scholar Reed Wood and statistician Emily Molfino have called “unintended negative externalities,” whereby such aid can intensify violence between insurgent and counterinsurgent forces.45 These negative externalities depend on whether assistance is perceived by the warring parties as advancing one or the other actor’s military capabilities or resources (defense infrastructure, for example).46 Where they are seen to undermine the state’s position, such as in the areas outside of its control, especially with regard to nonstate armed groups that are categorized as “terrorist organizations,” humanitarian activities can be obstructed by the state. One clear illustration is in the Nigerian government’s restrictions on humanitarian health care provision to areas controlled by Boko Haram.47 Similarly, insurgent retaliation is more likely when humanitarian aid provided by organizations allied with the state is used in an attempt to win the “hearts and minds” of the population and facilitate government control over the contested or insurgent-controlled areas, as in the case of Afghanistan.48 Forms of retaliation range from intentionally targeting humanitarian personnel and civilians receiving assistance, to predation and looting of medical supplies and facilities, to seeking to extend control into the areas where humanitarian assistance is concentrated.

Civilian populations are at the core of this contestation. It is widely accepted that armed actors require civilian support to achieve their wartime objectives.49 They seek to establish control over territories with not only armed force but also institutions in what is broadly known as rebel governance. These institutions vary widely, even within the same contexts, and structure rebel-civilian relationships in different ways.50 Provision of health care, among other basic services, is one of the goals that insurgents undertake when they come to control territory.51 Hindering health care provision, which entails significant human costs that are not comparable to those associated with not providing other services, such as education, can jeopardize insurgents’ attempts to secure civilian support in the short term as well as with regard to the longer-term political and social goals that many of these groups have. Interfering with the provision of health services may also jeopardize their efforts to establish themselves as legitimate actors beyond the territories that they control. As a result, while some armed actors weaponize health care, others explicitly decide not to and actively protect health care for various strategic reasons, including to bolster their legitimacy among the civilian populations they govern and more generally. The case of the CPN-M in Nepal is illustrative of this search for legitimacy.

While humanitarian health care provision was relatively unrestricted by the CPN-M, coercion typically plays a role in insurgent relationships with humanitarians, with implications for co-optation of health care activities.52 Because of the importance of being perceived as health service providers for civilians, insurgents seek to control and manipulate humanitarian actors delivering health care where they have capacity to do so, appropriate medical facilities and supplies, and even attack humanitarian actors and civilians when these services do not advance their social, political, and military goals. As political scientist Zachariah Mampilly has found in South Sudan, insurgents are then able “to siphon material and financial resources that enrich rebel coffers by inserting themselves between international aid efforts and the civilian populations they claim to serve.”53

Civilian inhabitants of the areas armed groups govern, however, are not simply on the receiving end of the arrangements that these groups make with humanitarian actors and the institutions that they build. Some cooperate with insurgents, whereas others refuse to, with a range of associated responses, from leaving the areas insurgents control to obeying the rules they impose, and from supporting or even enlisting in their organizations to resisting their rule.54 Equally, civilians can support humanitarian aid provision, particularly health care, because it is essential to survival in contexts where few medical services and facilities may have existed before the war or where access to existing health care is dangerous or no longer possible, such as in urban areas where medical services and facilities have increasingly come under attack.55 But they can also reject it, especially when humanitarian assistance in fact puts them at greater risk, for example, by leaving the areas where assistance is concentrated to avoid retaliation from armed actors. Finally, civilians can use humanitarians to navigate complex conflict contexts, for example, by identifying as victims to be eligible for aid or drawing on humanitarian actors’ standing and capacity to help lobby on their behalf or protest armed actors’ activities.56 In these and other ways, civilians in contemporary civil wars exercise agency and engage in forms of self-protection that can be missed when focusing solely on nonstate, state, and external actors.57 Civilian responses to armed actors and humanitarians, among others, are therefore a major part of systems of relationships that emerge in civil wars. Civilians influence the ways in which other actors engage in these contexts by remaining neutral, variously supporting or resisting their activities. The knowledge of these local dynamics is critical for the ability of humanitarian organizations to facilitate rather than hinder civilian efforts to navigate these contexts.

Local actors, such as religious organizations, provide and support the delivery of health care and develop their own relationships with nonstate, state, civilian, and external actors in these contexts. In fact, the distinction between the local and the international is not clear-cut, as demonstrated by the practices of remote management in which international humanitarian organizations rely on local staff and partners for the delivery of health care.58 However, humanitarians can be broadly seen as part of the category of external actors. They can operate as individual organizations or in collaboration with local and international partners, including private actors. They can also be embedded within broader international coalitions, for example, progovernment forces delivering counterinsurgency aid. Indeed, internationalization is a common feature of contemporary civil wars, and different forms of international intervention have been shown to shift the dynamics of conflict.59 For example, armed intervention by external states clearly changed the balance of power between state and nonstate forces in Syria.

Humanitarian actors, however, can have important effects of their own, including the negative externalities for insurgent and counterinsurgent violence and beyond. These actors have developed institutional procedures and policies rooted in the humanitarian principles to advocate for unrestricted access to health care to combatants and civilians with varied actual or perceived affiliations, train warring parties in IHL, and negotiate and support the delivery of health care. These advancements have been made despite the constrains on the health systems, restricted access to the populations in need, and other challenges that exist in contexts of civil war.60

But these efforts can come into tension with political projects of host states and donors, as exemplified by counterterrorism legislation that complicates engagement with armed groups listed as “terrorist organizations.”61 Politicized funding and aid allocations, poor coordination among humanitarian actors, and misalignment between their different priorities and the needs of the populations can result in insufficiently tailored, short-term responses.62 These responses can also unintentionally increase civilian insecurity, particularly when they do not account for conflict interactions involving armed actors. Political scientists Erin Baines and Emily Paddon, for example, have shown how relocation of civilians to “protected villages” in Uganda limited access to local networks and knowledge central to civilian self-protection strategies, deepened civilian dependence on state protection, and endangered those who moved to the camps as loyal to the state in the eyes of insurgents.63 Increasing civilian insecurity can also stem from the interaction of humanitarian strategies with the politics of local actors involved in health care provision. As political scientist Sarah Parkinson and anthropologist Orkideh Behrouzan have found, the procedures of refugee registration and insurance contracting that humanitarians established to facilitate care for Syrian and Palestinian refugees in Lebanon hindered access to health care and exposed refugees to structural violence in the exclusionary Lebanese health system.64 Addressing such unintended consequences of humanitarian activities requires a locally informed—and critical—understanding of the contexts humanitarians operate in.

This discussion has demonstrated that humanitarian actors are involved in complex systems of relationships where nonstate, state, civilian, and external activities, including those of humanitarians, shape health care provision in interaction with one another. Because of its universal and vital quality, health care is strategically important for armed actors whose members and the communities in which they are embedded require such services and whose internal and external legitimacy in part depends on their decisions around health care. Yet health care provision is uniquely drawn into various conflictual and cooperative relationships between nonstate, state, civilian, and external actors, which means that in some circumstances, these actors can consciously obstruct, refuse, and manipulate health care provision. Moreover, their decisions can change as they navigate a complex set of conflict relationships.

These contingent constellations of identities, interests, and activities are context-specific and result in what anthropologist Lisa Dorith Kool and her coauthors have referred to as “humanitarian micro-spaces . . . fluid, dynamic and evolving so fast that practitioners can hardly keep up.”65 By mapping not merely the different actors and their interests at any given time in a conflict but also the evolving relationships that they establish with one another in the course of conflict, humanitarian health providers can better understand and operate within such “micro-spaces.” While the systems of relationships I discuss here have long been a part of civil wars, the proliferation of actors and their activities in contemporary civil wars makes these social systems increasingly complex. To adapt to changing conflict realities, humanitarian actors involved in health care provision must come to terms with this complexity. The framework for analyzing systems of relationships developed in this essay can contribute to this goal, and to the underlying shift in mindset to viewing civil war as a social process that is necessary to make sense of contemporary conflict environments.

author's note

This research is funded by the UK Research and Innovation Future Leaders Fellowship (grant title: “Understanding Civil War from Pre- to Post-War Stages: A Comparative Approach”; Grant Reference: MR/T040653/1; start date January 1, 2021). Data availability statement: no primary data is associated with this article. I would like to thank the editors of this Dædalus issue and the participants in the workshop on Understanding 21st Century Violent Conflict’s Effects on Humanitarian Health, particularly Zachariah Cherian Mampilly, for their comments.

Endnotes

• 1World Health Organization, “WHO Records 100th Attack on Health Care in Ukraine,” News Release, April 7, 2022. See also World Health Organization, “WHO Surveillance System for Attacks on Health Care,” (accessed May 1, 2022).
• 2Wolfgang Benedek, Veronika Bílková, and Marco Sassòli, Report on Violations of International Humanitarian and Human Rights Law, War Crimes and Crimes Against Humanity Committed in Ukraine since 24 February 2022 (Helsinki: OSCE Office for Democratic Institutions and Human Rights, 2022), 46–47.
• 3Bethan McKernan, “Buses Rescue 2,000 Mariupol Refugees but Russia Blocking Aid, Says Ukraine,” The Guardian, April 1, 2022.
• 4“Situation Inside Besieged Steel Plant is ‘Beyond a Humanitarian Catastrophe,’ Commander Inside Tells CNN,” CNN, April 29, 2022. For further details, see Michael Schwirtz, “Last Stand at Azovstal: Inside the Siege that Shaped the Ukraine War,” The New York Times, July 27, 2022.
• 5Weronika Strzyżyńska and Isobel Koshiw, “Rush to Get Emergency Contraception into Ukraine as Reports of Rape Rise,” The Guardian, April 28, 2022.
• 6The United Nations High Commissioner for Refugees, “Operational Portal Ukraine Refugee Situation” (accessed May 1, 2022).
• 7On the global spread of civil war, see James D. Fearon, “Civil War & the Current International System,” Dædalus 146 (4) (Fall 2017): 18–32.
• 8Stathis N. Kalyvas, The Logic of Violence in Civil War (New York: Cambridge University Press, 2006), 5.
• 9Sebastian von Einsiedel, Louise Bosetti, James Cockayne, Cale Salih, and Wilfred Wan, “Civil War Trends and the Changing Nature of Armed Conflict,” United Nations University Centre for Policy Research Occasional Paper 10 (New York: United Nations University Centre for Policy Research, 2017), 5.
• 10See, for example, Leonard S. Rubenstein and Melanie D. Bittle, “Responsibility for Protection of Medical Workers and Facilities in Armed Conflict,” The Lancet 375 (9711) (2010): 329–340.
• 11See, for example, Fiona Terry, “Violence Against Health Care: Insights from Afghanistan, Somalia, and the Democratic Republic of the Congo,” International Review of the Red Cross 95 (889) (2013): 23–39.
• 12Duncan McLean, “Medical Care in Armed Conflict: Perpetrator Discourse in Historical Perspective,” International Review of the Red Cross 101 (911) (2019): 771–803.
• 13While contemporary lethal violence does not only occur in contexts of armed conflict, in this essay, I focus on armed conflict, particularly civil war. See Keith Krause, “From Armed Conflict to Political Violence: Mapping & Explaining Conflict Trends,” Daedalus 145 (4) (Fall 2016): 113–126.
• 14Anastasia Shesterinina, “Civil War as a Social Process: Actors and Dynamics from Pre- to Post-War,” European Journal of International Relations 28 (3) (2022): 538–562.
• 15Paul H. Wise, Annie Shiel, Nicole Southard, et al., “The Political and Security Dimensions of the Humanitarian Health Response to Violent Conflict,” The Lancet 397 (10273) (2021): 511.
• 16Jessica Maves Braithwaite and Kathleen Gallagher Cunningham, “When Organizations Rebel: Introducing the Foundations of Rebel Group Emergence (FORGE) Dataset,” International Studies Quarterly 64 (1) (2020): 183–193; and Kristin M. Bakke, Kathleen Gallagher Cunningham, and Lee J. M. Seymour, “A Plague of Initials: Fragmentation, Cohesion, and Infighting in Civil Wars,” Perspectives on Politics 10 (2) (2012): 265–283.
• 17Zachariah Cherian Mampilly, Rebel Rulers: Insurgent Governance and Civilian Life During War (Ithaca, N.Y.: Cornell University Press, 2011), 16.
• 18Christine Cheng, Extralegal Groups in Post-Conflict Liberia: How Trade Makes the State (Oxford: Oxford University Press, 2018), 11.
• 19I am grateful to Zachariah Mampilly for highlighting this logic in relation to the political approach of the state discussed here. See Michael Barnett and Martha Finnemore, Rules for the World: International Organizations in Global Politics (Ithaca, N.Y.: Cornell University Press, 2004).
• 20Susanna P. Campbell, Michael G. Findley, and Kyosuke Kikuta, “An Ontology of Peace: Landscapes of Conflict and Cooperation with Application to Colombia,” International Studies Review 19 (1) (2017): 92.
• 21See, for example, Anastasia Shesterinina, Mobilizing in Uncertainty: Collective Identities and War in Abkhazia (Ithaca, N.Y.: Cornell University Press, 2021).
• 22Janet I. Lewis, How Insurgency Begins: Rebel Group Formation in Uganda and Beyond (Cambridge: Cambridge University Press, 2020); Donatella Della Porta, Teije Hidde Donker, Bogumila Hall, et al., Social Movements and Civil War: When Protests for Democratization Fail (London: Routledge, 2018); Theodore McLauchlin, “State Breakdown and Army-Splinter Rebellions,” Journal of Conflict Resolution 67 (1) (2022); and Shesterinina, “Civil War as a Social Process.”
• 23Lewis, How Insurgency Begins.
• 24McLauchlin, “State Breakdown and Army-Splinter Rebellions.”
• 25Sarah E. Parkinson and Sherry Zaks, “Militant and Rebel Organization(s),” Comparative Politics 50 (2) (2018): 271–272.
• 26Amelia Hoover Green, The Commander’s Dilemma: Violence and Restraint in Wartime (Ithaca, N.Y.: Cornell University Press, 2018).
• 27Bakke, Cunningham, and Seymour, “A Plague of Initials.”
• 28On humanitarian actors’ engagement with nonstate armed groups, see Ann-Kristin Sjöberg and Mehmet Balci, “In Their Shoes: Health Care in Armed Conflict from the Perspective of a Non-State Armed Actor,” Dædalus 152 (2) (Spring 2023): 103–124.
• 29Hichem Khadhraoui, “Fragmentation of Armed Non-State Actors in Protracted Armed Conflicts: Some Practical Experiences on How to Ensure Compliance with Humanitarian Norms,” International Review of the Red Cross 101 (912) (2019): 993–1000.
• 30Multiparty civil wars are a common feature of the contemporary armed conflict landscape. See Fotini Christia, Alliance Formation in Civil Wars (Cambridge: Cambridge University Press, 2012), 14.
• 31Cheng, Extralegal Groups in Post-Conflict Liberia.
• 32Ashley Jackson, In Their Words: Perceptions of Armed Non-State Actors on Humanitarian Action (Geneva: Geneva Call, 2016) (accessed May 1, 2022).
• 33Wise, Shiel, Southard, et al., “The Political and Security Dimensions of the Humanitarian Health Response to Violent Conflict.”
• 34Kimberly Howe, No End in Sight: A Case Study of Humanitarian Action and the Syria Conflict–Component 2: The Contemporary Humanitarian Landscape: Malaise, Blockages and Game Changes (London and Boston: King’s College London, Feinstein International Center, and Humanitarian Policy Group, 2016), 19–21.
• 35Khadhraoui, “Fragmentation of Armed Non-State Actors in Protracted Armed Conflicts,” 1000.
• 36Christia, Alliance Formation in Civil Wars, 25–26.
• 37Paul Staniland, Networks of Rebellion: Explaining Insurgent Cohesion and Collapse (Ithaca, N.Y.: Cornell University Press, 2014).
• 38Paul Staniland, Ordering Violence: Explaining Armed Group-State Relations from Conflict to Cooperation (Ithaca, N.Y.: Cornell University Press, 2022), 18.
• 39Campbell, Findley, and Kikuta, “An Ontology of Peace.”
• 40Staniland, Ordering Violence.
• 41Simon Rushton and Bhimsen Devkota, “Choosing Not to Weaponize Healthcare: Politics and Health Service Delivery during Nepal’s Civil War, 1996–2006,” Medicine, Conflict and Survival 36 (3) (2020): 212–231.
• 42Fouad M. Fouad, Annie Sparrow, Ahmad Tarakji, et al., “Health Workers and the Weaponisation of Health Care in Syria: A Preliminary Inquiry for The Lancet–American University of Beirut Commission on Syria,” The Lancet 390 (10111) (2017): 2516–2526.
• 43Rubenstein and Bittle, “Responsibility for Protection of Medical Workers and Facilities in Armed Conflict,” 333.
• 44Alice Debarre, Hard to Reach: Providing Healthcare in Armed Conflict (New York: International Peace Institute, 2018), 9–11.
• 45Reed M. Wood and Emily Molfino, “Aiding Victims, Abetting Violence: The Influence of Humanitarian Aid on Violence Patterns during Civil Conflict,” Journal of Global Security Studies 1 (3) (2016): 187.
• 46Renard Sexton, “Aid as a Tool against Insurgency: Evidence from Contested and Controlled Territory in Afghanistan,” American Political Science Review 110 (4) (2016): 731–749.
• 47Alice Debarre, Safeguarding Medical Care and Humanitarian Action in the UN Counterterrorism Framework (New York: International Peace Institute, 2018), 32–33.
• 48Sexton, “Aid as a Tool against Insurgency;” and Wood and Molfino, “Aiding Victims, Abetting Violence.”
• 49Kalyvas, The Logic of Violence in Civil War.
• 50Zachariah Cherian Mampilly and Megan A Stewart, “A Typology of Rebel Political Institutional Arrangements,” Journal of Conflict Resolution 65 (1) (2021): 15–45.
• 51Mampilly, Rebel Rulers.
• 52Rushton and Devkota, “Choosing Not to Weaponize Healthcare,” 223; and Reed M. Wood and Christopher Sullivan, “Doing Harm by Doing Good? The Negative Externalities of Humanitarian Aid Provision during Civil Conflict,” The Journal of Politics 77 (3) (2016): 739.
• 53Mampilly, Rebel Rulers, 151–152.
• 54Juan Masullo, “Refusing to Cooperate with Armed Groups: Civilian Agency and Civilian Noncooperation in Armed Conflicts,” International Studies Review 23 (3) (2021): 887–913.
• 55Wise, Shiel, Southard, et al., “The Political and Security Dimensions of the Humanitarian Health Response to Violent Conflict,” 513.
• 56Mats Utas, “Victimcy, Girlfriending, Soldiering: Tactic Agency in a Young Woman’s Social Navigation of the Liberian War Zone,” Anthropological Quarterly 78 (2) (2005): 403–430; and Oliver Kaplan, Resisting War: How Communities Protect Themselves (New York: Cambridge University Press, 2017). Note also that humanitarian workers can be perpetrators of violence against civilians. See Betcy Jose and Peace A. Medie, “Understanding Why and How Civilians Resort to Self- Protection in Armed Conflict,” International Studies Review 17 (4) (2015): 521.
• 57Jana Krause, Juan Masullo, Emily Paddon-Rhoads, and Jennifer Welsh, eds., Civilian Protective Agency in Violent Settings (Oxford: Oxford University Press, forthcoming).
• 58These practices are known as remote management. See, for example, Howe, “No End in Sight,” 23.
• 59Jeffrey T. Checkel, ed., Transnational Dynamics of Civil War (Cambridge: Cambridge University Press, 2013).
• 60Debarre, Hard to Reach.
• 61Jackson, In Their Words, 24.
• 62Debarre, Hard to Reach. See also Alice Obrecht, Dynamic Gridlock: Adaptive Humanitarian Action in the Democratic Republic of Congo, Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP) Country Study (London: Overseas Development Institute/ALNAP, 2018).
• 63Erin Baines and Emily Paddon, “‘This is How We Survived’: Civilian Agency and Humanitarian Protection,” Security Dialogue 43 (3) (2012): 231–247.
• 64Sarah E. Parkinson and Orkideh Behrouzan, “Negotiating Health and Life: Syrian Refugees and the Politics of Access in Lebanon,” Social Science & Medicine 146 (1) (2015): 324–331.
• 65Lisa Dorith Kool, Jan Pospisil, and Roanne van Voorst, “Managing the Humanitarian Micro-Space: The Practices of Relief Access in Syria,” Third World Quarterly 42 (7) (2021): 1494.