AJN REPORTS

Counterterrorism or Humanitarian Aid? Worsening situations around the world up the risks to providers.

O

n the evening of May 2, 2011, President Barack Obama attended the annual White House Correspondents’ dinner. Only hours before, he had given the okay for U.S. Navy SEAL Team Six to helicopter into a walled compound in the Pakistani city of Abbottabad to find and kill Osama bin Laden. The SEAL team succeeded, but while some people around the world celebrated, not everyone was happy. Officials in Pakistan were livid that the United States had conducted the operation without their knowledge, and their investigation into how it was pulled off revealed another surprise: part of the ruse had involved a fake, CIA-orchestrated hepatitis B– vaccination campaign involving at least one hired local surgeon and many health care workers who were unaware of the real nature of their operation. Great anger and distrust followed: since the raid, more than 60 polio vaccine workers—mostly women—have been murdered by Pakistani Taliban. When it comes to humanitarian relief work, physicians usually make the headlines, but it’s nurses, often working with local health aides, who provide “at least 80% of hands-on care—maybe more in underdeveloped countries,” according to Jennifer E. Dohrn, DNP, FAAN, assistant professor of nursing at the Columbia University School of Nursing and director of the Office of Global Initiatives and its World Health Organization (WHO) Collaborating Center for Advanced Practice. According to the May–June Hastings Center Report, health care professionals are increasingly providing care in nations where counterterrorism-related activities jeopardize the delivery of care to local populations; increase global health disparities; threaten funding of relief programs; and cause ethical distress for nurses, whether they’re with a humanitarian organization or part of a military operation. Those providing care are often in situations in which they “feel [unable] to do anything,” a result of “policies that restrict them, their place in the hierarchy of decision making, or psychological barriers,” the report’s coauthor, Lisa Eckenwiler, PhD, associate professor of philosophy and health administration and policy at George Mason University, told AJN. [email protected]



A Pakistani health worker marks the finger of an Afghan refugee child after giving her a polio vaccine. Photo by Muhammed Muheisen / Associated Press.

THE CURRENT LANDSCAPE

Humanitarian aid is no longer only being delivered to those hit by cataclysmic natural disasters or borderjumping pandemics. It’s also increasingly going to people whose lives have been displaced by politically and economically destabilizing armed conflicts or civil wars. “About half of all humanitarian aid goes to Muslim nations . . . and there is suspicion of the [West’s] motives for the aid,” said Gerald Martone, MS, RN, former director of humanitarian affairs at the International Rescue Committee and the former cochairman of the Disaster Response Committee of InterAction, a coalition of U.S.-based humanitarian agencies. That suspicion isn’t exactly unfounded, as the CIA-led campaign to bring down bin Laden proved.

HEALTH CARE PROVIDERS CAUGHT IN THE MIDDLE

In this landscape, codes, protocols, and laws protecting the neutrality of those providing humanitarian aid get compromised. And humanitarian aid, as one of many civil activities that fall at least partially under the purview of U.S. forces, can become—according to Tactics in Counterinsurgency from the U.S. Department of the AJN ▼ November 2014



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AJN REPORTS

Army (2009)—“a central counterinsurgency activity, not an afterthought.” The militarization of humanitarian aid might further policy goals, as it did in the killing of bin Laden. However, said Martone, it “blurs the lines between military and civilian humanitarian personnel [and makes the latter] vulnerable to accusations that they are agents of the government’s global war on terror.” Those lines may well continue to blur. For instance, some project that in the near future low-flying unmanned drones, currently used for spying and bombing, will be used to deliver medical supplies, such as vaccines and other medicines, even fresh water. And Americans may be increasingly receptive to these gray areas. Many Americans have become more accepting of the use of torture and other illegal activities to gain information or strategic advantage in the war on terror, according to a December 2011 Red Cross report, What Americans Think of International Humanitarian Law. America’s growing acceptance of illegal tactics, write the authors, hints at how difficult it could become for nurses to uphold the profession’s code of ethics.

RAISING AWARENESS

More people providing humanitarian aid were injured, kidnapped, or killed in 2013 than in any year since record keeping began, according to the 2014 Aid Worker Security Report from Humanitarian Outcomes. And in 2012 the International Committee of the Red Cross (ICRC) called violence against health care workers “one of the most serious humanitarian challenges in the world today.” To address that challenge, major health care and humanitarian organizations—including the WHO, the ICRC, Doctors Without Borders, the Safeguarding Health in Conflict coalition, and the International Council of Nurses—have launched initiatives, individually and collaboratively, in efforts to • raise awareness of the challenges faced by those providing humanitarian health care and services. • push for the development and enforcement of principles, policies, and practices that ensure safe and secure access to health care for all who need it, especially those in conflict zones. • ensure the safety (and neutrality) of those providing health care. • better understand the interpretation and practice of Islamic law as it applies to the provision of health care. In addition, many nursing and public health schools and nursing organizations have revised or added programming that introduces students, often in interprofessional classes, to the kinds of physical, psychological, and ethical challenges they’re likely to 22

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encounter in these settings. Curricula are being developed to teach nurses to recognize morally ambiguous situations and resolve or at least blunt the tensions they may encounter in situations in which real-world practice and professional ethics collide. Many Red Cross chapters also offer programs— often free—to those considering or doing international disaster or humanitarian work. According to a recently published report from Rand Europe, Handling Ethical Problems in Counterterrorism: An Inventory of Methods to Support Ethical Decisionmaking (http://bit. ly/1ryOc6e), this kind of real-world education and training has “a consistently positive effect.”

SELF-PROTECTION AND RISK MINIMIZATION

What practical steps can nurses doing international relief work take to protect themselves (and their patients) and minimize the risk that their care and services will be restrained or controlled—or co-opted—to advance objectives not related to health care? There are several things nurses can do. Know as much as possible about where they’re going. To get up to speed, said Dohrn, who’s been involved in overseas relief work as a teacher, participant, and coordinator for 20 years, nurses must gather information about a region’s culture, physical landscape, and political climate. What are its larger national and international issues? What are the health care needs of the populace, and what resources will be available to help meet those needs? Know the group they’re working for. “Wellknown organizations, such as the International Rescue Committee, have a lot more ability to [provide necessary] pushback on the restraints health care providers might run into,” said Martone, who has been involved in humanitarian work for more than 30 years. Self-care. “In humanitarian work, nurses tend to overwork and overperform and subordinate selfcare because it seems selfish and extravagant,” said Martone, “but they need to pay attention to it and take breaks and recharge.” Understand local laws and policies affecting nurses. Around the globe, said Eckenwiler, counterterrorism laws have been passed that restrict the provision of material support—including health care—to groups designated as terrorists. Such laws sometimes criminalize the provision of that support, even in situations of humanitarian need. “[Such laws and policies] put a lot of stress on nurses because nurses take an oath to put patients first,” said Eckenwiler. Clarify goals. It’s important to remember, said Dohrn, “you are going there to be of use, not to be a martyr. The site must provide stability. You must be able to do the work you go there to do. And there must be an exit strategy.”—Eileen Beal ▼ ajnonline.com

Counterterrorism or humanitarian aid?

Worsening situations around the world up the risks to providers...
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