Modern armed conflicts require profound transformation of the humanitarian system with strong global leadership

Young boy and small child behind barbed wire in Mosul

"In her final annual report as England’s Chief Medical Officer and UK Chief Medical Advisor, Professor Dame Sally Davies outlines the UK’s leading role in global health and highlights the need to share international knowledge and experience.

The report makes clear that by focusing purely on domestic health, we risk failing to control the shifting tide of global threats. Diseases and their determinants do not respect international borders. Ebola, antimicrobial resistance, and widening health inequalities are already presenting significant challenges..."

A collection of letters from key world health leaders to the CMO are presented in the report, making a series of recommendations to secure a prospering health system and population both at home and across the world. Within this collection is a letter from Centre Co-Director Prof Karl Blanchet alongside Co-Directer Dr Jennifer Palmer, Centre members Prof Bayard Roberts, Prof Francesco Checchi, and colleagues at other institutions, reproduced below.

Dear Dame Sally,

Failing to keep pace with modern conflicts

Contemporary conflicts, driven by access and control over natural resources (water and land), state failure and connectedness of the global world continue in low-income countries and increasingly in middle-income countries with the rise in non-state armed groups. This is accompanied by increasing violation of the rules-based international order such as the Geneva Conventions and International Humanitarian Law, which used to help shape behavior of states and non-state actors during conflicts and resolve violent disputes through a set of common rules and agreements (1).

Armed conflicts have had tremendous impact on the social development and economy of countries, by reducing the availability of basic services, creating food insecurity, and high inflation. This reduces the gross domestic product (GDP) growth of a country in conflict by an average of 2% per year. Unfortunately, conflicts are often endemic in most fragile states, trapped in a cycle of violence and economic under-development, with 90% of countries experiencing civil war being more likely to experience similar violence within a period of 30 years.

The impact of conflict is staggering when looking at human cost. The number of people who have lost their lives or experienced traumatic situations, leaving durable physical and psychological scars, has increased. Health professionals have now become a target. In 2018 alone, at least 973 attacks on health workers, health facilities, ambulances and patients were reported in 23 countries in conflict (2). Armed conflicts have forced populations to leave their homes, abandoning everything behind them. At the end of 2018, 68.5 million people were reported as forcibly displaced, almost doubling in 10 years, with half of refugees being children (3).

Humanitarian crisis requires an aid response. International donors spend about $25 billion a year on humanitarian aid; however, there is a global annual shortfall of at least $15 billion. Following the World Humanitarian Summit in 2016, the humanitarian system has been described as broken (4) and characterized by an absence of global leadership, the marginalizing of frontline local organizations who are being siloed from development initiatives, and a weak evidence base for effective interventions (5).

The way forward for the UK

The UK is at the forefront of humanitarian assistance, spending over £1.4 billion annually in the last two fiscal years on humanitarian assistance, including providing the second largest bilateral funding to the Syrian response since 2012. The UK has also provided leadership through development of the UK Public Health Rapid Support Team in 2017 to respond to global health emergencies, including humanitarian crisis and conflict situations.

However, the scale and cost of the humanitarian and public health response in emergencies will continue to challenge donor countries, and there is more the UK can do. It is important to mitigate the risks of these crises and the scale of the response by properly investing in fragile states’ health systems to build long-term health system capacity. Forced migration has been a growing issue for health systems, humanitarian agencies and donors. Area-based approaches where all vulnerable populations are provided assistance according to transparent and simple vulnerability criteria are needed, while respecting their legal rights according to status (e.g. refugee) – be it overseas or in the UK.

Rapid mobilisation of human resources to respond to critical crises is also essential, as demonstrated during the Ebola outbreak in West Africa in 2014. We call for an NHS England strategy facilitating NHS staff deployment in humanitarian settings to provide support to global health emergencies and a drive to embed humanitarian medicine across training pathways and Royal Colleges.

Global accountability and transparency in terms of allocation of Official Development Assistance spending are urgently required. The UK should become the champion for improving performance and accountability in humanitarian response by supporting and investing in strengthened performance standards and monitoring and evaluation capacity. This should go hand in hand with the promotion of evidence-based interventions for humanitarian response. The UK could become a lead in funding and promoting high quality global humanitarian research and creating a global evidence-based movement for humanitarian response. To achieve this, humanitarian medicine and public health in humanitarian crises should be considered as a key part of NIHR strategy for global health and for UK Research and Innovation (UKRI) as a whole. This would ensure dedicated, sustainable long-term funding for research alongside capability building in humanitarian crises.

Local organisations are the first responders in an increasingly insecure environment for health professionals in conflict affected countries; however, they are only currently eligible for UK funding if they have an approved ‘Rapid Response Facility’ partner. The UK should collaborate with other international donors to create specific funding mechanisms to ensure local organisations can be funded directly to deliver humanitarian assistance and not only through international NGOs.

The UK has demonstrated strong commitment to humanitarian response through sustained funding and support to international relief agencies. It is now time for the UK to show leadership in global humanitarian response to champion evidence-based interventions, transparency and accountability.

Yours sincerely,

Karl Blanchet on behalf of the co-authors:

Prof. Francesco Checchi - LSHTM
Dr Fouad M. Fouad - American University of Beirut
Dr Jennifer Palmer- Co-Director of the Health in Humanitarian Crises, LSHTM
Prof. Bayard Roberts - LSHTM
Prof. Paul Spiegel, Director of the Hopkins Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health
Prof. Richard Sullivan, Co-Director of Conflict & Health Research Group at King’s College

1 HM Government. 2015. National Security Strategy and Strategic Defence and Security Review 2015 – A Secure and Prosperous United Kingdom. London
2 The Safeguarding Health in Conflict Coalition. 2019. Impunity Remains: Attacks on Health Care in 23 Countries in Conflict. Geneva.
3 UNHCR. 2019. Figures at Glance. (Accessed on 05/06/2019
4 Paul B Spiegel. 2017. The humanitarian system is not just broke, but broken: recommendations for future humanitarian action. The Lancet. June 08 2017.
5 Blanchet K., Roberts B, et al. 2017. Evidence on public health interventions in humanitarian crises. The Lancet.

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