in Emergencies Issue 8
by Jon M. Ebersole
Militarised violence presents what is perhaps the most vexing challenge to the achievement of the goal of health for all. While not a member of the UN's Executive Committee on Peace and Security, WHO is nonetheless positioned to play a crucial peacemaking role in some of the world's most difficult trouble spots.
Health interventions, such as national immunisation days (NIDs) have been undertaken successfully in war-prone societies and have even served to open avenues for peacebuilding.1 The positive impact NIDs can have in societies experiencing militarised violence by opening avenues for peacebuilding is also recognised. NIDs have been successfully carried out in the midst of armed conflict in numerous countries through short humanitarian cease-fires agreed to by armed combatants to allow health workers access to children.
The impressive successes of the polio eradication campaign illustrate that the achievement of its goal is possible, even in the midst of violent conflict. Polio eradication in the Americas could only have been achieved through immunisation campaigns carried out during armed conflict. In 1985 UNICEF, in co-operation with the Roman Catholic Church, ICRC and others, organised three «days of tranquillity» in El Salvador to implement an immunisation campaign targeting some 400,000 children in war affected regions of the country. Since that time, such temporary cease-fires for humanitarian purposes have been held in Afghanistan, Angola, Democratic Republic of the Congo, Lebanon, Liberia, Nicaragua, Sierra Leone and Sudan. While such initiatives have had positive and measurable health impacts, the full value of these cease-fires goes well beyond the specific health interventions they make possible.
Trust may be seen as the social norm most damaged in armed conflict. Erosion of trust is evident not only between the warring parties, but also infects civil organisations, commerce, and even families. But how do trust depleting social conditions affect public health? At least one commentator makes the point that societies with the lowest levels of trust tend also to be those with the least economic development. Trust, he claims, «has a large and measurable economic value»2 as the basic foundation upon which people are able to work together. Economic well-being, which is dependent on the «social capital» of diverse trusting relationships, enables populations to enjoy healthy environments, and good healthcare.
Humanitarians have long pinned their hopes for impacting peace processes through their humanitarian efforts by bringing a minimum of trust and a sense of common humanity to the most inhuman circumstances.3 Humanitarian cease-fires are seen as turning points for building the trust upon which peace can be built at both local 4 and national 5 levels. Richard Reed, who negotiated some of the earliest humanitarian cease-fires for UNICEF, suggested that cease-fires break the «habit» of fighting, and that the combatants may find that they like the pause more than returning to their war efforts.6
Some observers claim that humanitarian interventions prolong wars, and create opportunities for armed forces to abuse the naive good will of others. It is possible to view the professed willingness of an army leader to participate in the fight against polio as either a step towards a peace process, or as a tactic to gain time and military advantage. Perhaps it is both. Clearly closer examination and a more nuanced understanding are necessary.
Cease-fires, both those negotiated on purely military terms and short humanitarian ones, are based on the interest combatants have in stopping their military efforts. Militarily defined cease-fires usually occur when the parties want to stop the fighting due to the domination of one side, or when there is a stalemate. Common obstacles to reaching a cease-fire agreement include wanting to appear strong rather than weak, and aggressive public statements from leaders.7
Humanitarian cease-fires, on the other hand, can occur at any stage in a war, even when neither side wants to permanently stop fighting. In a humanitarian cease-fire, neither side has to look weak. There is a clear need - and opportunity - for a pause in the fighting that is unrelated to the military struggle. Opposing sides have an interest in presenting a positive image of themselves both at home and abroad, and leaders can wear a mantle of moral statesmanship by making public statements about their humanitarian concerns. Indeed, it is even possible that the leaders of opposing military factions can openly recognise a shared interest in the health and well being of the populations within territory under their control.
Many of the major remaining pockets of wild polio virus are in areas of active armed conflict such as Sierra Leone, Democratic Republic of Congo and Angola. In gaining access to remote and conflict ridden areas, health workers will tread familiar territory such as lack of communications and transportation, short time-lines for their cold-chains, and generally rough conditions. In addition, they will face heightened threats to their personal safety and uncertainty regarding how well some military elements have been informed of, or have agreed to, their safe passage. Indeed, some combatants may not be controlled by a central authority, have no interest in projecting a positive image of their forces, and may see only a financial or military opportunity created by the presence of unarmed civilians and their equipment.
If the goal of eradicating polio by 2005 is to be reached, it will require manoeuvring through some of the most dangerous and tricky political and geographic terrain imaginable. Flexible strategies must be developed that will enable the well co-ordinated use of opportunities in unpredictable circumstances. Gaining agreements from the combatants and mounting NIDs in countries where the infrastructure may be largely destroyed by the conflict requires mobilisation of political will at a national and international level. In facing these obstacles, WHO co-operates with a range of other actors, from UN and other peacekeeping forces to local and national health organisations.
In war zones, the main health need is for war to end. Therefore a cease-fire's political impact, if positive, may be more important for health improvement than the actual healthcare delivered. We in the humanitarian community should feel challenged to improve our methods for instituting humanitarian cease-fires both to reach populations in need of immunisation and other assistance, and to maximise the peacemaking benefits. Impartiality, neutrality and high repute remain strengths that WHO and its humanitarian partners project in their work, and these strengths should be used to maximum effect.
1 Bush, Kenneth, «Polio, War and Peace», Bulletin of the World Health Organization, 2000, 78 (3), Pp. 181-2.
2 Fukuyaya, Francis, Trust: The Social Virtues and the Creation of Prosperity, Penguin Books, London, 1995.
3 Berry, Nicholas O., War and the Red Cross: The Unspoken Mission, St. Martin's Press, New York, 1997.
4 as illustrated in Sri Lanka and Somalia by Kenneth Bush, «Polio, war and peace», Bulletin of the World Health Organization, 2000, 78 (3).
5 as illustrated in El Salvador and Lebanon by Richard Reed, «Lifelines to the Innocent: Children Caught in War», A Framework for Survival, Kevin Cahill, Ed, Basic Books, New York, 1993.
6 Hay, Robin, «Humanitarian Cease-fires: An Examination of their Potential Contribution to the Resolution of Conflict», Working Paper 28, Canadian Institute for International Peace and Security, 17 July 1990.
7 Smith, James D.D., Stopping Wars: Defining the Obstacles to Cease-fire, Westview Press, Boulder, 1995.
Mr Jon Ebersole (firstname.lastname@example.org) is a consultant working with WHO's Department of Emergency and Humanitarian Action and the Polio Eradication Programme on the Humanitarian Cease-fires Project.