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


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

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).

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.

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 Lancet, NEJM, Vaccine, Health Affairs, BMJ, Science, and Nature.

Russia’s invasion of Ukraine last February initiated a brutal conflict between the armed forces of the two countries, with devastating consequences for the Ukrainian population. The numbers are staggering: along with the thousands killed or injured, 5.9 million Ukrainians have been internally displaced, 7.9 million have fled into neighboring countries, and many others have sought refuge by living underground. Relief organizations estimate that 17.7 million people in Ukraine are in urgent need of humanitarian assistance.1 In the closing months of 2022, Russia began bombarding the country’s power grid, water supply, and other key facilities with the aim of turning the cold and dark of winter into another weapon of war. For humanitarian actors on the ground, this was but another grim episode in a conflict that had already witnessed blatant violation of basic principles of international humanitarian law through denial of access to imperiled civilians or indiscriminate attacks on both populations and critical infrastructure, including (at the time of writing) seven hundred attacks on health care.2

In truth, however, the massive wave of air and missile attacks launched on Ukrainian cities in late autumn of 2022, along with the continuing systematic assault on health care, was an extension of the war strategy already employed by the Russians and their Syrian allies during Syria’s protracted civil war. During the final battle over Syria’s second largest city, Aleppo, in the latter half of 2016, more than 31,000 Syrian civilians died through the combined effects of explosions, barrel bombs, field executions, and chemical attacks. As aid convoys were attacked in the Aleppo countryside—denying humanitarian assistance to thousands in need—and hospitals and marketplaces were routinely hit during the siege of the city, former UN Secretary General Ban Ki-Moon declared that Aleppo had become a “synonym for hell.”3

Moreover, whereas the conflict waged in Ukraine has attracted intense diplomatic and media attention, there are many forgotten crises unfolding outside the glare of the spotlight, where populations suffer systematic violence or are denied life-saving humanitarian assistance. In November 2022, vital medical supplies finally began arriving in Tigray—the first delivery of aid to Ethiopia since fighting resumed in late summer between the current Ethiopian federal government and the former ruling party in the country, the Tigray People’s Liberation Front. The humanitarian crisis facing the Tigray region is of epic proportions, with five million people currently at imminent risk of starvation. Elsewhere, the sociopolitical and economic crisis in Venezuela continues, as mass migration, hyperinflation, and the impact of COVID-19 have exacerbated the conditions for the most vulnerable, including women and girls. This case, along with other Latin American contexts with high rates of violent death and sexual and gender-based violence, demonstrates that many of the world’s deadliest places are not in fact zones of formal armed conflict, as defined by international lawyers. Instead, they are “situations other than war,” as the International Committee of the Red Cross refers to them, featuring extreme political and criminal violence that is in many cases both organized and deliberate.4 These situations pose additional challenges for humanitarian actors, including which international legal frameworks are applicable and what responsibilities should be exercised by international organizations such as the United Nations.

These snapshots of contemporary violent conflict point to the enormous strain being placed on traditional humanitarian strategies and actors, and particularly on the delivery of effective health responses. Much of global humanitarian action has been rooted in international humanitarian law, which contains obligations to distinguish between civilian populations and combatants, and to verify that objects to be attacked are neither civilians nor civilian objects, including sites subject to special protection, such as medical and humanitarian personnel, their means of transport and equipment, and their facilities. Yet today’s warring parties—whether nonstate armed groups or state militaries—routinely dismiss or override this normative framework through strategies and day-to-day battlefield decisions that put both civilian populations and humanitarian health workers at risk.

Adding to these pressures are two worrying trends: First, the increasing rollback of political commitments to upholding humanitarian principles by UN member states and signatories of the Geneva Conventions in a context of growing geopolitical rivalry. And second, the ongoing impact of counterterrorism policies developed by governments and international organizations that have inadvertently created new obstacles for humanitarian health by constraining the provision of services in areas controlled by nonstate armed groups. There are also new constraints and challenges more specific to the humanitarian health field that call for further reflection and examination, including the increasing attention on fostering local ownership in humanitarian health delivery, the need to consider the impact of digital technology and data in caring for victims of violent conflict, and the immediate and long-term effects of infectious disease in conflict zones. While pandemics have featured in conflict settings for some time, the global scale of COVID-19 and its impact on both deeper conflict dynamics and civilian populations (including migrants) are likely to shape broader policy discussions of humanitarian health in the coming decades.

Against this backdrop, we have co-led a multiyear initiative through the American Academy of Arts and Sciences to critically interrogate and creatively reimagine strategies for preventing civilian harm and delivering critical health services in areas plagued by violent conflict.5 As co-editors with diverse scholarly backgrounds and varied policy experience, our work has been based on a central premise: that innovative approaches are best derived from a deeper, transdisciplinary understanding of the changing political, military, legal, and health dimensions that are dramatically redefining humanitarian action across the globe. Our collaborative work has brought together legal and security experts, health professionals, policy-makers, artists, leaders of humanitarian organizations, and representatives of conflict-affected communities to address a range of pressing challenges. Our in-depth research projects have included examination of the political and security dimensions of pandemic response in areas of weak governance and violent conflict (drawing lessons from the Ebola outbreaks in West Africa and the Democratic Republic of the Congo), as well as the humanitarian health challenges related to major migrant flows, with a particular focus on those seeking relief from criminal and political violence in Mexico and the countries of the Northern Triangle of Central America.6

All our activities have been organized around a set of interrelated principles: 1) interdisciplinarity, with an emphasis on integrating long-siloed scholarship and deliberations; 2) ongoing, substantive dialogue with practitioners and victimized communities in the field; and 3) sustained engagement with disciplines that help shape local and global norms, including the arts and other arenas of talent and expertise beyond traditional academic spaces.

In developing this issue of Dædalus, we convened authors and relevant experts in small workshops organized around specific themes to both enhance the quality of their essays and generate ideas and momentum for broader policy changes in humanitarian health delivery. The volume reflects the most significant cross-cutting issues that have emerged from our collaboration with the contributors, as well as our consultations with humanitarian health practitioners over the last four years. The collection also illustrates our belief in the fundamental role that the arts play in shaping norms and public understanding of humanitarian needs. By leveraging the American Academy’s network and connecting with artists in conflict-affected areas, we have included a series of artistic works within the volume.

The essays and artistic expressions that follow are designed to illuminate and examine the key features of the complex challenges facing humanitarian actors today, but also to provide forward-looking ideas for rethinking strategies to deliver humanitarian health assistance in a rapidly changing conflict environment. We begin with an introduction by International Rescue Committee (IRC) President David Miliband and IRC Director of Policy Communications Ken Sofer, who vividly depict the stark realities that give rise to the widespread need for humanitarian assistance, and particularly health services, in today’s zones of conflict.7 Our contributors to the first half of the volume build on this foundation, with an analysis of how the nature of contemporary civil wars shapes humanitarian needs, responses, and outcomes, and a discussion of how the shift of major powers away from counter­insurgency, and back toward peer or “near-peer” conflict, is likely to affect the context for humanitarian health delivery.

Our authors then revisit the ethical and legal principles that have long guided humanitarian action and deliberate on how the changing character of war—including fast-moving technological developments—is undermining compliance with these traditional norms. At the same time, they ask how a set of prominent justice-related claims, such as the imperative to decolonize humanitarian assistance, demand reconsideration of what it means for humanitarians to act ethically. We round out the first section with a discussion of two particularly challenging contexts for humanitarian health delivery: situations of urban conflict, such as those in Iraq, Syria, and Yemen, where humanitarian missions have struggled to access and meet the needs of civilian populations; and situations of intense political and criminal violence, which create ambiguity regarding the appropriateness of different legal frameworks for regulating efforts to protect and assist populations under threat.

The authors in the second half of this issue apply their deep policy-making and field experience to address a set of specific ethical and operational challenges facing those who seek to provide humanitarian health relief in twenty-first-century conflicts. We begin part two with a discussion of the ongoing dilemmas and obstacles confronting humanitarian health actors in engaging with nonstate armed groups, which leverages the most recent research on both the need for and modalities of working with these actors. The following essay examines both the opportunities and challenges posed by new capacities to gather and use data in humanitarian emergencies, and the tensions that can arise concerning the need to share data between and among humanitarians and with donor governments. Our contributors then focus in on the increased risks of violence against humanitarian health workers and facilities and assess the impact of various high-profile diplomatic efforts both to prevent such attacks and to hold perpetrators accountable.

A final set of essays takes up a prominent theme from the 2016 World Humanitarian Summit: namely, the imperative to “localize” humanitarian assistance by empowering and supporting local actors, including in the health care sector. Our first contribution on this theme explores the role of local women’s organizations in Jordan as frontline responders with the potential, if harnessed, to improve both health service quality and gender equality, while the second draws on a survey of international nongovernmental organizations to better understand what efforts they have undertaken to localize health services and build critical capacity in conflict-affected societies.

We conclude the volume with our own reflections on the key messages that emerge from the essays. We also draw out recommendations for how to pursue innovative change in humanitarian health delivery in light of the profound shifts in the nature of conflict itself, and in the normative and operational environment in which humanitarian actors operate. Taken together, the essays we have assembled show that the rich and complex tapestry of norms and practices that shapes humanitarian health delivery is now confronting a historic moment. While the humanitarian mandate remains unchanged, the evolution of organized violence and increasingly unstable geopolitical order have generated challenges so deep and varied that a reconsideration of humanitarian health’s most basic tenets and pragmatic practices seems unavoidable. Even the ethical foundation of humanitarian health responses, we argue, will become an essential component of this rethinking, as both scholars and practitioners grapple with not only the growing tensions among core humanitarian principles, but also the competing imperatives that sometimes underpin legitimate calls for reform of today’s humanitarian system.

The creation of this volume was a collaborative effort among many individuals and institutions working toward a more robust humanitarian landscape. This Dædalus issue originated with the Rethinking the Humanitarian Health Response to Violent Conflict project at the American Academy of Arts and Sciences. We are grateful to the members of the project’s advisory group for their advice in shaping the trajectory of this initiative, including Donald Berwick, Elisabeth Decrey Warner, Marian Jacobs, Arthur Kleinman, Joanne Liu, Jane Olson, Deborah Rutter, and Tamara Taraciuk-Broner; the consultants who helped lay out the foundations of this project in the preliminary and exploratory meetings, including Michael Barnett, Jocelyn Kelly, Beatriz Magaloni, J. Stephen Morrison, James Orbinski, David Polatty, Anne Patterson, Leonard Rubenstein, Fernando Travesi, Ronald Waldman, and Elisabeth Wood; and the American Academy of Arts and Sciences’ Committee on International Security Studies for their oversight of this volume. We are appreciative of Dirk Druet for his leadership and authorship of our work on pandemic and peace operations, and Ender McDuff and David Fidler for their invaluable assistance on the project’s publication on international cooperation in pandemic preparedness and response. We would also like to thank our partners at the University of California campuses in San Francisco and San Diego, and El Colegio de la Frontera Norte for their collaborative work and field research on regional humanitarian responses to pandemics in the context of forced migration. We thank our home institutions McGill University, Stanford University, and the University of California, San Francisco, for supporting us. We are grateful to Chris Merrill and James Cuno, whose insights were crucial for the inclusion of the creative writing and visual arts pieces in this volume. We thank the Academy team, especially David Oxtoby, Tania Munz, Peter Robinson, Melissa Chan, Michelle Poulin, Francesca Giovannini, Islam Qasem, Kathryn Moffat, Kathleen Torgesen, Rebecca Tiernan, Jen Smith, Phyllis Bendell, Scott Raymond, Peter Walton, and Key Bird for their support. This venture would not have been possible without the generous support of Louise Henry Bryson and John E. Bryson, the Malcolm Hewitt Wiener Foundation, and The Rockefeller Foundation.

Finally, and most important, we thank each of the writers and artists whose work appears in this volume. This edition of Dædalus would not have been possible without your extensive research, revisions, and creative contributions.