This paper is concerned with the tension between what it describes as “pure” humanitarianism and the increasing pressures on relief workers to become politically engaged by adopting developmental approaches and by seeking to actively resolve disaster-producing conflicts. Combining theory with case studies concerning the delivery of health and food aid in war zones, it argues that while seductive, attempts to use relief aid as a tool for political engagement are fraught with practical and ethical difficulties. Not only are developmental goals elusive in conflict environments, but abandoning principles of neutrality and impartiality to determine the allocation of scarce resources increases the risk of aid being manipulated by warring parties and by donor governments. While not unproblematic, the paper concludes that neutrality and impartiality remain the best principles currently available to organise humanitarian action.

1.0 Introduction

1.1 Trends in war and international responses to complex emergencies

Since about 1700 there have been 471 wars, resulting in an estimated 101-187 million deaths. More than 90% of these deaths have occurred in the twentieth century (Sivard, 1986, quoted in Zwi and Ugalde, 1989; Brzezinski, 1993). The unparalleled levels of violence which have characterised the last century, have coincided with the evolution of an equally unparalleled complex of international institutions, legal instruments and specialist agencies concerned to contain and regulate the conduct of war and to mitigate its human costs. The increasing economic and social costs of war have also taken place in a context of increasing aggregate global wealth, and in overall levels of literacy, nutrition and health.

However, within this aggregated picture of increasing wealth are significant populations for whom the quality of life has actually been eroded since the mid-1940s. To the concept of “Fourth World”, created to convey the reality of an increasingly diverse “Third World”, might be added a Fifth, whose population, in addition to suffering the effects of worsening economic, health and food security indicators, are acutely vulnerable politically. Worldwide, some 40 million refugees and internally-displaced people occupy this Fifth World; Africa’s 15 million displaced people outnumber the population of all but six of the countries on the continent (IFRC, 1996: 35-36). The particular vulnerability of this group has been well-documented: in Africa, infant and child mortality is at least ten times higher among displaced populations than elsewhere on the continent, accounting for a fifth of its total child deaths (ibid; see also Neiburg et al, 1992; Toole and Waldeman, 1990).

In the 1990s, protracted, complex political emergencies which threaten the welfare of conflict-affected have provoked a massive expansion in the international relief system. In 1980, emergency relief accounted for $353 million or 2 per cent of total official development assistance (oda); by 1994 this had increased to over 10 per cent, equivalent to more than $3 billion (Development Assistance Committee, 1995)(2).

The steady rise in relief expenditure reflects the increasing impact of violent conflict on populations’ health and food security, rather than an increase in natural disasters. The World Food Programme (WFP) reports that in 1995, its spent roughly $19 million worldwide on meeting the effects of natural disasters; this compares with more than $1.5 billion on conflict-related emergencies (Webb, 1996)(3). Similarly, Randel (1994) reports that in 1993 the European Community Humanitarian Office (ECHO), the world’s largest humanitarian aid donor, spent over 95 per cent of its aid responding to conflict-related emergencies.

The rate of expansion in relief expenditures has resulted in greater scrutiny of the international relief system in conflict situations. Hard questions are being asked: Does relief aid actually intensify conflict? Is humanitarian aid undermining long-term development opportunities? This debate is prompting greater interest in reforming relief to include developmental strategies and objectives. In addition, a wider discussion is underway concerning the role of both relief and development assistance in conflict management (see, for example, Boutros-Ghali, 1992; 1994; European Commission, 1996; Overseas Development Administration, 1996).

1.2 Structure of the paper

This paper examines the extent to which international relief can and should go beyond what Hathaway (1995) has described as its essentially palliative function. Focussing on food and medical aid in protracted complex emergencies, it highlights the practical and conceptual implications of moving beyond a “pure” relief model, in other words a model designed to save lives and which operates according to the principles of neutrality and impartiality, towards one which explicitly engages in wider political and developmental processes.

In doing so it asks, what are food and health interventions for? Should health and food interventions strive to be neutral in their relation to conflict; or should they rather aim to influence its course? Equally, should the aim be to prioritise rapid and impartial delivery of effective services, or rather to contribute to long-term capacity building? It concludes that while relief should be delivered in a manner which is politically informed it should not be politically driven. In other words, it argues that the core principles of humanitarian action – neutrality and impartiality should be safeguarded.

The remainder of the paper comprises three parts. The first provides an overview of the dynamics of conflict, and its impact on food security, health status and health systems. Second, two major issues arising from relief interventions are explored: the implications of different choice of implementing partners; and those raised by working in prolonged conflict. The paper concludes by identifying key challenges for future policy in protracted political emergencies.

2.0 Food and health insecurity in war-time: A framework for analysis

Stewart (1993), analysing the economic impact of war, distinguishes between its effects on market entitlements and on public entitlements. The former comprise of individuals’ capacity to command resources, including food, through production, market and exchange relations. The latter is concerned with access to publicly supplied goods such as water, health and education services. While public entitlements may also include access to free or subsidized food, the distinction between market and public entitlements offered by Stewart provides a useful basis from which to look at food and health insecurity respectively.

2.1 Food and War

2.1.1 The origins of food insecurity: structural vulnerability to famine

Sogge (1994) and Duffield (1990) have described vividly the origins of vulnerability to food insecurity in Africa. Focussing on Angola and Sudan respectively, these authors place contemporary food insecurity in historical context. They point to the negative impact of the colonial legacy; the effects of post-independence government policies; and the incorporation of African economies into the global trade system on agricultural production and food security. Both analyze the transformation of subsistence production, and rural populations’ growing reliance on the cash economy and wage labour; and the impact of land appropriation by the colonial power (Angola) and by successive governments (Sudan) in order to expand production of primary commodities for export.

These case studies reflect wider international trends in the political economy of food. The emergence of a structural deficit in food supply in the Third World in the early 1970s, coincided with the wider economic pressures during this period, following the oil shocks of 1971-1974, the devaluation of the dollar in 1971 and its subsequent impact on interest rates and Third World debt . Between 1949 and 1951, 12 million tonnes of grain were imported by the South from northern supplies; by 1972, this had increased to 36 million tonnes per year (Sparo, 1977). Since the 1970s, the volume of cereal imports has continued to rise in Africa in particular, trebling in the period 1970 to 1994, while national production has remained relatively static (FAO, database).

By the mid-1980s, the structural vulnerability of large populations to food deficits had intensified, forcing a diversification in strategies to protect access to food and other basic commodities. In countries such as Uganda and Angola, this was marked by a withdrawal from participation in state-led markets for critical staple and export commodities, a retreat either to subsistence production, and/or to increased reliance on parallel markets (Green, 1981; Sogge, 1994; Duffield, 1994a).

In light of this structural vulnerability, Green (1986) has argued that the early stages of famine are not easily distinguishable from endemic poverty. He suggests that the interaction of drought, poor transport systems and war has left only a narrow margin between “normal” food supply and famine, leaving communities especially vulnerable to even minor shocks.

2.1.2 War and Hunger: An overview of famine theory in war-time

It is not only or primarily the absolute food deficit in Africa which has determined its vulnerability to famine. Sen (1986) has argued that rather than being determined by scarcity of food, famines occur because of a failure of entitlement. He reflected on the economic relationships which determine access to food. “Endowment bundles” provide access to food either through one’s own production or through the market. These bundles divided between “assets” (investments and stores) and “claims” (patronage and kinship ties), enable the individual to procure or produce adequate food. In periods of scarcity, entitlement is threatened since prices for staples grains are characteristically high, while the value of assets diminishes as the market becomes swamped with crisis sales. Famine occurs when there is a collapse of entitlement, restricting access to food, leading to a decline of nutritional status, and culminating in starvation.

This economistic model of famine has been critiqued by writers such as Rangasami (1985) and de Waal (1990). They challenge Sen’s focus on individual entitlements and the implication that populations are passive victims of external shocks. They dispute a definition of famine which identifies famine with widespread starvation, and which conceptualises famine as primarily an enviro-economic event culminating in an individual biological crisis (death). Rather, they advocate a definition of famine which is relative rather than absolute; active rather than passive; political and social rather than economistic.

De Waal’s work in particular has contributed to and expanded upon analysis of the coping strategies employed by populations under conditions of stress. “Coping” or “survival” strategies enable individual biological survival, but also seek to protect future livelihood, in other words to protect a particular social way of life (see, for example, de Waal, 1989). Coping strategies often entail considerable risks which are evaluated with respect to the survival of the household, group or community, rather than with reference exclusively to the individual(4). Importantly, coping strategies as usually defined are employed only temporarily pending a resumption of normal production activities.

A modified version of entitlement theory has been proposed by de Waal (1990), whereby the relationship between collapse of entitlement and famine is mediated by the implementation of coping strategies (see figure 1a). It is this active response to external shocks such as drought or increase in the price of staple food, which can avert starvation. Importantly, de Waal’s analysis suggests that famine is not identical to widespread starvation. Rather it is a social and economic phenomenon which exerts acute pressures on existing modes of production and social relations, but which does not necessarily result in death.

In recent history, all “famines that kill”, have been associated with violence and the destitution it causes (de Waal, 1989; 1990). Organised violence affects food security directly by reducing absolute availability of food produced and by undermining the asset base of opposition parties and the communities they represent. Importantly, violence is also used to block or undermine coping strategies usually used to respond to situations of acute stress. As described in more detail below, conflict hastens the pace at which entitlements collapse, resulting in widespread destitution, and heightening the risk of death through disease and hunger (see figure 1b).

The negative impact of conflict on food security is not simply an unfortunate, unintentional consequence of war, it is a deliberate strategy (Keen, 1991). It is this intentionality of disaster-creation and obstruction of response which differentiates conflict-related disasters from “natural disasters”. To denote this deliberateness of disaster-creation, and the political obstacles to mitigating conflict-induced disasters, Duffield (1994b) has proposed the term complex political emergency. As such, war-related humanitarian crises are symptomatic of strategies of warfare which seek to inflict not simply a military defeat, but to disempower the opposition, to deny it an identity, and to undermine its ability to maintain political and economic integrity (Summerfield, 1991).

In this respect Rangasami (1985) and Keen (1991) have argued that famine, like war, is functional; not only are there losers, but there are also political and economic winners. In addition to the obvious political and military victors, important commercial interests benefit from famine-creation in wartime. Merchants profit from inflated prices and distress sales. These commercial interests are frequently allied to military and political groups, themselves concerned to maximise their control over territory and to exert their hegemony over opposition groups.

Strategies of famine creation

Attacks on food security, in effect the use of food as a weapon, may be categorised under three headings: omission, commission and provision (Macrae and Zwi, 1994)(5).

Omission includes instances of food misuse where governments fail to monitor adequately and plan for food security for all sections of the population; it therefore includes both failure to manage national food reserves and to instigate and facilitate appropriate measures, including the mobilisation of available international resources for famine prevention and mitigation.

By commission, is meant attacks on the means of producing and procuring food. This category includes actions which undermine production, such as burning of standing crops or raiding of cattle. It also includes actions which hinder populations from implementing coping strategies, such as migration or accessing food aid. Thus, besieging populations and attacking relief convoys are both examples of using food as an instrument of war by commission. So too are strategies which undermine the functioning of markets; in Eritrea for example, the Ethiopian airforce regularly bombed rural markets, undermining the agricultural economy and reducing populations’ capacity to access sufficient food and other goods.

Provision is perhaps the most difficult category to define. By it, is meant selective provision of food goods in order to attract populations into particular areas and to mobilise popular support. There is a thin line here. An indicator of the political commitment of governments and opposition movements is the degree to which they are willing to meet the needs of citizens living in territory under their control. The factor which differentiates appropriate provision of food from situations where it is used as a deliberate instrument of war is the extent to which international humanitarian law is respected. Particularly important is the degree to which access to food, including access to relief aid is provided in an impartial manner, in other words is provided on the basis of need rather than selectively to populations on the basis of their political or ethic affiliation.

Tomasevski (1994) reviews the multiple instruments which exist in international humanitarian and human rights law which prohibit the use of food as a weapon. She points out, however that since the framework which defines international law relies upon the definition of substantive norms specifying what governments should and should not do, it does not articulate the rights of victims of deliberate starvation (p93). There is currently no mechanism which supervises governments’ adherence to the patchwork of legal instruments which nominally protect civilians in war-time, nor which can enforce other governments’ obligations to enforce international law where second states are guilty of its violations. This applies in particular to the genocide conventions which place particular obligations on third parties to intervene to prevent or mitigate systematic, genocidal killings (Adelman and Suhrke, 1996).

2.2 Health and health systems in war-time

Conflict exerts direct and indirect effects on health and health systems (Zwi and Ugalde, 1993); many of these effects endure long after the guns have been silenced.

Direct effects are broadly related to the impact of military action and include death and injury – physical and psychological. In terms of health systems, military attacks kill health workers, while health infrastructure and supplies are often looted. Of much greater magnitude, however, are the indirect effects of political, economic and social changes which both underlie conflict and are precipitated by it. For example, the risks of rape by military personnel, the increased levels of prostitution which may occur as female heads of household seek cash income in the absence of other productive activities and the breakdown in health services and reduced opportunities for treating sexually transmitted disease may all increase the vulnerability of conflict-affected communities to HIV infection (Zwi and Cabral, 1991; Smallman-Raynor and Cliff, 1991; Bond and Vincent, 1990).

In the case of health systems, conflict tends to exacerbate pre-existing structural weaknesses. Many of the features illustrated in Figure 1 are common to health systems experiencing other forms of structural stress in developing and non-conflict-affected transitional societies. Thus, although the intensity of the financial, human resource, management and organisational difficulties in conflict-affected countries is often much more extreme, the nature of the problems are similar to those of many of the poorest countries.

Health systems adjust to these changed environments; some of these may be positive developments. In Zaire, as the capacity of the state to finance and provide services has declined, so community involvement in health management and finance has increased (J. Lambouray, pers. comm.) In the revolutionary conflicts in Mozambique, Nicaragua and Eritrea, new strategies for health, based on the principles of primary health care, have emerged (Walt and Melamed, 1988; Cliff and Noormahomed, 1989; Garfield and Williams, 1992; Sabo and Kibirige, 1989).

In other countries health systems have not been able to adjust to the stresses of war and economic decline. In many situations there has been a decline in the availability of health care in rural areas as health workers seek sanctuary in more secure urban areas and drug supplies diminish (see, for example, Macrae et al, 1993). As the capacity of public health care systems breaks down, so may there be a rapid and uncontrolled expansion of private care. The rate and nature of privatization may threaten both the quality of health care delivery and the longer-term sustainability of national health care systems. This trend for rapid privatization reflects a broader process of acute decentralization which accompanies the disruption of central state power during periods of instability.

2.3 Health and food security in war-time: common features

Analysis of food security and health systems during conflict reveals a number of similarities.

First, the underlying vulnerability of populations to food and health insecurity. Conflict exacerbates structural vulnerabilities in food security and health systems. So, for example, household’s capacity to access sufficient food either through employment or through their own production is often severely compromised even prior to conflict. Similarly, in many countries the structure and financing of health systems prior to conflict is often such as to limit effective coverage and to raise sufficient financial resources to sustain health services. What this implies is that even once a solution to the “bullets and bombs” problems of war have been resolved, the structural obstacles to food and health security will need to be confronted.

Second, both food security and health systems are affected by the breakdown in political institutions associated with war and political violence. In particular, where governments are no longer willing or able to defend property rights and so provide a secure legal environment to protect production and to regulate markets, populations will become more vulnerable to acute food insecurity. Where a government is no longer working to protect their citizens, but is rather belligerent party in the war, then a key pre-condition for economic and social relations breaks down. In terms of entitlement to food this manifests itself in terms of a (often deliberate) failure to maintain a legal basis for transactions – for example, the effective sanctioning of violent asset stripping, forced removal from land and discriminatory employment policies. In terms of health services, the breakdown in state institutions has implications for equitable provision of services, if for example, government forces discriminate in terms of different populations’ access to health services, and/or are attacking health facilities in opposition territory. As described below, this has important implications for international humanitarian interventions in terms of identifying appropriate partners for the delivery of aid in war-time. It also implies that a precondition for ‘post’-conflict rehabilitation of food security and health systems will be the establishment of an effective legal and political framework.

A third related but distinct point is the deliberateness of strategies which undermine food and health security in war-time. Attacks on food and health systems are intentional, designed to disempower the opposition, not simply unfortunate consequences of military strategy. This implies that establishing a framework for the protection of civilians from violence is a pre-condition for effective measures designed to improve health and nutritional status in war-time.

3.0 Terms of Engagement: International interventions in complex political emergencies

As Edgell (1975) suggests:

“….it may be best to begin with the not-always-remembered truism that political goals and military targets will always be the supreme priorities to the warring parties in a civil conflict” (p71)

Davis (1975) in a later chapter in the same volume continues:

“…..the intercession of relief agencies in war is akin to spectators in a stadium running down on the field while a football game is in progress so as to reduce the incidence and severity of the tackling.” (p 81)

What both these authors highlight is that the objectives of humanitarian interventions frequently run counter to the logic of war. For belligerents, undermining the capacity of opposition military and political actors to sustain and protect populations under their control is critical. Conversely, capturing relief can serve an important function for warring parties, enhancing their own political legitimacy and their military capacity. Thus, while international actors may seek to portray their interventions as essentially neutral in intent, in other words designed only to respond to suffering of civilians, for warring parties, relief is anything but neutral.

In this context, securing access and devising strategies for the delivery of humanitarian supplies which are resilient to the counter-prevailing interests of belligerents is a critical issue. In the following sections issues of access and implementing institutions and strategies are explored. In section 3.2 the particular issues raised working in protracted complex political emergencies are examined.

3.1 Securing Access

The trend towards increasing international intervention in complex political emergencies was established in the early 1990s, but had waned quickly by the middle of the decade. In conflicts as diverse as those in Bosnia, Rwanda, Somalia and Iraqi Kurdistan, these interventions have coincided with the use of third party military force. The increasing use of third party military forces under United Nations, regional and bilateral banners has been justified frequently in terms of increasing humanitarian access, rather than in terms of confronting the root or proximate causes of conflict and associated humanitarian crises (Tomasevski, 1994; see also Hurd, 1993(6)).

The scope for greater humanitarian interventions in conflict zones has expanded considerably since the end of the Cold War. Until the mid-1980s, humanitarian intervention was limited by consideration of sovereignty. International actors, including the UN, could work only with the consent of national governments, effectively limiting their engagement to government-held territory, or to working with refugees who had sought safe haven in a second country (Duffield, 1994b). Only the ICRC could and would work on both sides of a conflict: their engagement was also subject to the condition of mutual consent.

The barrier of sovereignty has been eased over the past decade, both de facto and de jure. The phenomenon of “failed states” where no clear government authority exists has effectively challenged the concept of state sovereignty. In selected cases such as Kurdistan in 1991 where a government was in place, the international community, particularly the Western powers have shown greater willingness to intervene without the government’s consent. Duffield (1994b) highlights the precedent set by the illicit, NGO-led cross-border operation from Sudan into Eritrea and Tigray in challenging the primacy of sovereignty, and how this and subsequent experiments have effectively expanded massively the extent of “humanitarian space”, unconstrained by sovereignty. Importantly, he points out this humanitarian space is being established in conflict zones: the militarization of humanitarian relief is a reflection of the fact that humanitarian aid is being delivered under highly insecure conditions. (7)

Greater interventionism in conflict zones has a number of implications for those concerned with health and food security for war-affected populations. First, the proximity of the intervention to the conflict increases the risks of manipulation of supplies by warring parties. Second, the politicisation of humanitarian relief, through its association with third party military forces and with institutions who also serve a political role, such as the United Nations, the European Union and regional political organisations such as ECOWAS and NATO, also entails risks in relation to the actual and perceived neutrality of relief. What follows from this is the importance of careful analysis of the design, implementation and monitoring of relief delivery strategies in a war zone.

3.2 Implementing food and health care programmes – institutions and delivery strategies

Depending on how objectives are defined, international interventions to mitigate the impact of complex political emergencies are likely to differ in terms of who is involved in the delivery of resources and services, and in terms of what is provided. The institutional framework selected to manage these emergencies is central: as described above, it is political institutions which are both disaster-producing and which are trying to obstruct disaster-mitigating activities. In this context, defining the relationship between the humanitarian agency, the belligerents and the intended recipients of aid is crucial.

During the 1980s the proportion of official emergency aid channelled through governments declined markedly. For example, the proportion of emergency aid allocated to governments by the European Commission fell from over 95 per cent in 1976 to only 6 per cent in 1990 (Borton, 1994). Official donors, the primary source of relief finance, no longer automatically accord governments with having either the legitimacy or capacity to respond to emergencies; indeed, increasingly they are seen as being part of the problem.

Donors have diversified their implementing strategies in order to meet the perceived need to work impartially in conflict-related emergencies. By channelling resources through the United Nations and through NGOs, donors have been able to sustain relief interventions while maintaining political distance. As the UN emergency specialised agencies are themselves rarely operational, they too have become more dependent on NGO capacity to provide services and delivery resources in complex political emergencies. NGOs have become seen, therefore, as a means of maintaining humanitarian engagement in war-affected countries, providing a political buffer between donor and recipient governments, while maintaining the operationality of the international relief system.

In delegating implementing authority to the UN and ultimately to NGOs, the donor community has quietly eroded the sovereignty of recipient countries, seeking solutions to complex political emergencies, at least in the short-term, outside conventional public state structures. Duffield (1991) commenting on this privatization of welfare provision in war-time, notes that the shift from public to private institutions as a vehicle for the delivery of relief aid has important implications for the existing and future role of the state. In particular, it effectively postpones defining the political and social role of the state in conflict-affected countries. However, by reducing the availability of resources available to existing governments, typically state structures are weakened further, so indirectly strengthening opposition forces. Furthermore, by avoiding the state, it might be argued that donors are limiting opportunities to negotiate its reform.

3.2.1 Modes of engagement for health service provision

In relation to the health sector, this shift in donor support from national, public institutions to international, private agencies has particularly obvious and potentially insidious effects. As described above, health systems which produce services are the outcome of a complex series of economic, social and political relations. National public health systems, however financed, rely upon the presence of a coherent policy framework, organised training, accreditation and remuneration of health workers, and mechanisms for regulating the distribution and quality of services (Cassels, 1992). In this sense, public health systems as conventionally conceptualised rely upon the presence of strong centralized state structures (ibid; Macrae et al, 1994). This should not be seen to imply that international actors ought to support violent and illegitimate state structures. Rather, in the absence of state structures or in the absence of state structures seen to be legitimate or competent, there are no obvious alternative mechanisms available to provide an authoritative basis for raising public revenues for health nor to make decisions regarding the allocation of international resources.

In complex political emergencies where donors are reluctant to support the provision of health services directly through central governments there are two basic strategies which can be used to increase access to health services and so help to reduce mortality and morbidity. Either the provision of basic supplies – drugs and vaccines to existing public health institutions, delivered through a third party such as the UN or an NGO, or the direct provision of services by an NGO. Each has their advantages and disadvantages in terms of the extent to which they represent a “pure” relief model or strive to achieve longer-term engagement.

By delivering medical supplies to existing public health facilities, the aim is to maintain utilization rates and to increase the capacity of health services. The availability of basic supplies, particularly drugs, is an important determinant of the functioning of health services. Put simply, people are unlikely to seek medical advice if they don’t think that there are likely to be drugs available. Channelling drugs through existing public health structures has the advantage of being relatively cheap, and there may be opportunities for the UN and NGOs to provide additional training and support, and so contribute to capacity-building for the future.

However, while the provision of material supplies is a necessary condition of effective health services functioning, it is not sufficient. As described above (section 2.2.2) health services are the result of complex system, and the availability of resources is only one component: others, for example, financial resources to pay health workers are also crucial. Often, international agencies are not allowed to use relief resources to provide additional incentives to government staff as this could be seen to be effectively engaging with state structures. So public health workers are likely to be less motivated, and perhaps to leave public service to work elsewhere, including working as health professionals with NGOs.

Relief aid cannot therefore address the major structural obstacles to effective health service functioning; to do so, would imply engaging with central state administration, at least to provide an effective regulatory and financing framework. In this sense, relief is necessarily limited to the provision of material supplies, but this alone can only achieve limited impact on health services functioning.

In addition, simply delivering material inputs does not imply that these can be easily translated into effective services. In a province of South Darfur Sudan, for example, drugs targeted at a group of 70,000 internally displaced people were supplied to existing public health facilities by UNICEF and NGOs. The public health facilities, were used predominantly by the host population, comprising largely Rizegat and Maalia; the displaced Dinka faced a series of cultural, linguistic and political obstacles to accessing the facilities. The host population was itself suffering the effects of a recently introduced national cost-recovery scheme for drugs, which had increased the burden on local councils to finance the scheme. Relief resources, targeted towards the displaced, were thus managed and controlled by the host community, themselves experiencing a decline in their access to basic services. It is unsurprising, therefore that they claim priority access. In this environment, health workers were under considerable pressure not to allocate resources on the basis of need, but rather in terms of ethnic and political priorities; in the absence of monitoring and support, the entitlements of the displaced to basic drugs and vaccines were eroded.

The establishment of parallel, often internationally NGO-run services suffers from different constraints. It is relatively expensive, particularly in terms of expatriate salary payments, and the establishment of such parallel services are seen to run counter to developmental principles of building national and local capacity for public health. In Mozambique, for example, the extreme decentralization of health services which emerged as numerous NGOs established different services in different areas, was seen to constitute a primary threat to national capacity to design and implement a coherent and sustainable national health programmes (Hanlon, 1991). Nor are such internationally-led welfare services necessarily neutral in their activities and impact. The establishment of health services to serve populations who have been forcibly relocated into camps, for example, may serve to attract other populations and effectively serve to legitimise relocation strategies in the eyes of displaced communities and others (Keen and Wilson, 1994; Karim et al, 1996).

In choosing implementing partners in complex political emergences there are a number of dilemmas. On the one hand international agencies may have greater capacity to respond quickly and effectively, having financial, human and communications resources, and may provide greater political distance between the donor and the belligerent party, so potentially maximising impact in favour of the target group. However, the neutrality and impartiality of NGOs may also be compromised, and it comes at a cost. The price tag attached is that maximising political distance, is often (intentionally) decapacitating for national and local institutions, since it relies on a transfer of resources and power from national to international institutions, and from the public to the private sector.

3.2.2 Terms of engagement: food aid and food security interventions

Similar dilemmas emerge regarding the institutional framework for the management of food aid. Jaspars and Young (1995) provide a useful breakdown of the stages of allocation and distribution of food aid, from the donor to the individual recipient, charting at each stage respective institutional roles and responsibilities. A process of delegation and decentralization of institutional responsibility occurs as food moves through the system. Donors pass food aid through one of three channels: bilaterally government to government; multilaterally through WFP and through NGOs. The International Committee of the Red Cross (ICRC) is also a major provider of food aid, most of which it procures through its own funds (Jaspars and Young, 1995: 10).

At field level, it is primarily NGOs and the ICRC who are responsible for the management of food aid, since bilateral government to government food transfers are extremely limited in war situations, and the major multilateral agencies, such as WFP and UNHCR are not usually operational themselves. At field-level the international relief system has to meet with national and local authorities, and, of course with the intended beneficiaries. It is therefore NGOs and specialised agencies of the UN which are involved most directly in making decisions about strategies for managing distribution of food aid resources take place, not the donor community nor necessarily national authorities.

As with health sector interventions, strategies for food distribution entail deciding whether the intention is to strengthen or undermine existing institutional structures within the beneficiary population (Jaspars and Young, 1995). Jaspars (1994), Shoham (1996) and Pottier (1996) analysing food aid during the Rwanda crisis in 1994, have highlighted the importance of choice of distribution strategies in determining the nutritional and political impact of food aid. In the early stages of the refugee influx into Zaire, for example, NGOs provided food through the existing political leadership, much of which had been implicated in the genocide.

While using NGOs can provide donors with political distance between themselves and belligerent governments and local authorities by reducing their physical access to food resources, since NGOs also rely upon community-level institutions, such as churches or civil groups, for access and for distribution of resources, the “chain of neutrality” is easily broken. The encroachment of political and military actors onto aid resources may be more or less visible at the local level. At night or once aid workers have left, households may be required to “redistribute” a proportion of their rations to the predominant political leadership. The reallocation of resources may also occur through the process of negotiation for access, so for example, armed militia may demand a share of the resources in return for refraining from attacking a convoy. Achieving access may therefore come at a price, and in exercising “fieldcraft”, decisions are made regarding the extent to which maintaining operationality entails a compromise of humanitarian principles (African Rights, 1994; Jaspars and Young, 1995).

In both Rwanda and Sudan, recent reports have highlighted the implications of the failure to conduct careful political analysis of power relations within conflict-affected populations and of monitoring of the impact of food aid (Jaspars, 1994; Shoham, 1996; Pottier, 1996; Karim et al, 1996). For example, Jaspars (1994) and Shoham (1996) conclude in the Rwanda case that inequalities resulting from intra-camp political structures which were the primary determinant of poor nutritional outcome, rather than the overall availability of food aid. What this suggests is that effective management of relief resources is contingent upon a clear analysis of existing political structures and the capacity of relief agencies to manage relief in such a manner as to ensure that resources are distributed on the basis of need. The capacity of relief agencies to confront existing power structures to ensure effective distribution of supplies is limited to their negotiating power, with the only sanction available being that of withdrawal. In other words, ultimately the effectiveness of relief interventions is dependent more on national political military actors than on international relief agencies. Where negotiation by relief agencies is not yielding access, confronting existing power structures, through political and even military intervention, is a pre-condition for effective humanitarian operations.

3.2.3 Implications of institutional choice: common themes

What emerges from analysis of the institutional framework for the delivery of relief, is that for donors and major multilateral providers of food and medical aid, neutrality tends to be identified primarily at the macro level, rather than at the meso- and micro-level. In other words, achieving neutrality is associated with not using bilateral – government to government instruments, but ignores how other institutions -NGOs and UN agencies interact with national and local government authorities, and how decisions regarding distribution strategies function at the community level. Responsibility for neutrality is thus effectively delegated downwards through the system, but is not regularly monitored.

The failure to identify the political processes which determine the effective impact of distributions of food and medical aid derives in part from mistaken assumptions about the nature of complex political emergencies and of relief responses. In particular, it is testimony to the persistence of an analysis which focuses primarily on the delivery of supplies (Duffield, 1994a; Macrae et al, 1993). It is a noticeable feature of relief aid assessment, reporting and monitoring systems that they predominantly quantify need in terms of deliveries of resources such as food aid or essential drugs, and only very rarely analyze these figures in terms of impact or amount of supplies actually received by individuals or households (Karim et al, 1996; Apthorpe et al, 1996; IFRC, 1995, p42-45). In this sense, the process by which material inputs translate into specific outcomes and impact is ignored; measurement of impact is frequently assumed to be identical with measurement of logistical performance.

These weaknesses in the information base used to design, implement and monitor food and health interventions in emergencies derive in part from the particular culture of relief operations(8). Emphasis placed on speed of response, is seen by some to preclude extensive data-gathering and analysis. More significant, however, are the risks associated with developing information systems which are conflict-sensitive (IFRC, 1995:41-48). Collection of information regarding political structures is extremely difficult; for UN specialised agencies, for example, the collection of such information might prove embarrassing and complicate their relations with local and national authorities. At field level, explicit collection and reporting of political processes may be risky for both aid personnel and for individual beneficiaries.

In addition to the logistics of political analysis is something more powerful still: the collective imperative of portraying humanitarian aid as essentially technical and apolitical. This imperative, frequently sustained by the media which links the donor community with specialised UN agencies and NGOs, may also serve national political interests if it serves to divert humanitarian actors’ attention from violence and human rights abuses (IFRC, 1995: 46; Duffield, 1996(9)). In this way, the myth of the neutrality of relief assistance goes unchallenged, while accountability for the political and technical impact of relief interventions remains opaque.

3.2 Working in chronic political emergencies

The protracted and chronic nature of complex political emergencies is an important factor in promoting debates promoting more developmental approaches to relief. Increasing interest is being shown in how the concept of the relief-development continuum can be applied in complex emergencies (see, for example, European Commission, 1996; Boutros-Ghali, 1992; 1994).

The origins of the relief-development continuum lie in approaches to natural disasters. Underpinning the concept of the continuum is that good development practice can prevent disasters, or at least mitigate their impact; equally, well designed relief programmes can contribute to future development, so in turn reducing vulnerability to future hazard. In complex political emergencies the primary hazard is conflict: adapting the concept of the continuum to these contexts implies identifying relief strategies which reduce future vulnerability to conflict. Equally, it implies identifying development strategies which are likely to prevent conflict

Importantly, the concept of the relief-development continuum is premised on the assumption that once the hazard has passed, populations will be able to resume ‘normal’ development activities. Reflecting this model of disasters, relief programmes including those in complex political emergencies, are designed as short-term interventions, and aim to address the final stages of a disaster – the risk of widespread starvation (Keen and Wilson, 1994; Duffield, 1994a). By providing relief aid, the aim is to enable populations to survive what are seen as temporary interruptions to what is seen as an otherwise progressive developmental process (Duffield, 1994b).

This model suffers from a number of serious flaws in relation to complex emergencies which are inherently political and typically protracted, extending over a number of years or even decades. Uncritical application of the continuum concept by international aid actors risks increasing the vulnerability of conflict-affected populations. For example, a common feature of relief programmes is that the amount of free food aid distributed declines over time (Jaspars and Young, 1996). It is assumed that over time, populations will be able to diversify their sources of income and to resume some level of production: maintaining free food distribution is commonly seen to risk the creation of aid dependency and to distort agricultural production and markets (Karim et al, 1996; Apthorpe et al, 1996).

While such a strategy may be appropriate in some contexts, in protracted conflicts there is a risk that the duration of humanitarian crisis may be confused with their chronicity. In other words, the fact that a conflict-affected population has been receiving relief aid for a prolonged period, does not necessarily imply that they will have become any less vulnerable over time, nor that alternative sources of income will necessarily have arisen.

For example, in South Darfur a relief programme was established to provide nutritional support to displaced Dinka in 1992. It was assumed that this population would quickly be able to become self-sufficient in food, and during the following four years, distributions of free food were steadily reduced. The objective for the provision of food aid was changed from that of nutritional support to agricultural support. The provision of a small quantity of food aid was seen to enhance populations’ ability to cultivate and to participate in income-generating activities, so ultimately reducing dependency on relief food.

Reduction in rations led displaced people to diversify their “coping strategies”, away from relief aid to an increased reliance on working as share-croppers and casual labour on land owned by the host community. Intensification of these income-generating strategies this context can be seen as indicating greater integration of the displaced with the host community and greater self-reliance. This was the view of the local authorities in the area, and of many personnel in the specialised agencies of the United Nations and some donors.

However from the point of view of the displaced, far from representing a progressive trend, increased participation in the agricultural economy was seen as being disadvantageous. The terms under which share-cropping arrangements were established were disadvantageous, leaving the displaced indebted when the harvest was brought in(10) (Karim et al, 1996). Lacking access to adequate land and agricultural inputs, their capacity to cultivate was limited, and yields remained very low.

Physiological evidence testifies to the deterioration in the status of the population as the international relief system sought to reduce “dependency” on relief aid and to encourage “self-sufficiency” among the displaced by reducing the flow of free relief aid. Nutritional indicators actually deteriorated over time, rather than improved. In May 1992, 22.4 per cent of children were less than 80 per cent weight for height. These figures were seen to indicate a situation of sufficient gravity to warrant a major relief intervention, with a full general ration. In each subsequent year rations were cut, and in May 1994, it was recommended that free relief aid should be finally phased out, despite the fact that nutritional indicators were actually worse than those two years earlier (29.4 per cent, less than 80 per cent weight for height) (Karim et al, 1996).

It is important to emphasise that as well as losers, the policy to reduce rations also yields benefits. According to the Commissioner of Ed Da’ein, the displaced constituted 85 per cent of the labour force in the province. Because of the limited extent of food aid, the displaced became increasing dependent on local labour markets to survive. This has had clear commercial benefits to the host community. The same group exercises considerable control over the allocation and distribution of relief resources. The capacity of local authorities to capacity to influence relief strategies is considerable, while the displaced lack any representation on key committees charged with policy and programming on relief matters (Karim et al, 1996).

A similar dynamic can be seen in relation to the health sector. Under an international relief label, populations are usually entitled to receive free drugs and health consultations from aid-supported services. Once the situation is redefined as constituting a development phase, donors frequently advocate that cost-recovery schemes be introduced (see, for example, European Commission, 1996). This despite the fact that actual change in the health and economic status of the population may be extremely marginal. In this sense, moving from relief to development, far from being progressive may, in the short-term at least, result in a reduction of populations’ entitlements to basic goods and services (Stockton, 1996).

The scope for rehabilitation and restoration of livelihoods may be extremely limited in protracted emergencies because of the limited scope because of the continued effects of violence. Attempts to reconstruct health facilities, for example, in Mozambique and in northern Uganda while conflict continued served to attract further violence, as armed groups saw this as an attempt by the respective governments to enhance their legitimacy among the civilian population (Keen and Wilson, 1994; Macrae et al, 1993). Equally, in Wau, southern Sudan, the scope for expanding agricultural production to levels where it could support the town’s population remained limited by lack of key inputs, but also by insecurity, which limited the availability of land (Karim et al, 1996). Threats to livelihood restoration may persist even once relative peace has been secured: for example, landmines continue to present a major obstacle to agricultural rehabilitation in large areas of Angola, Afghanistan, Cambodia and Somalia.

These examples, and others might have been cited(11), highlight the need to examine closely whose interests are served by moving from relief to development. There is a risk that the concept of the continuum is used to provide the appearance of normalization of the position of war affected populations, and are seen as a means to rationalise the reduction in relief entitlements. While such strategies may yield budgetary savings for donors, they also risk rewarding the “winners” and further punishing those most vulnerable, politically and economically.

In the absence of improvement in political and security conditions, and in line with their humanitarian mandates a continued and rigorously monitored supply of basic relief goods may provide at least a minimum degree of protection to war-affected populations. Defining these minimum requirements and protecting populations’ entitlement to receive them is likely to become increasingly critical in the context of donor fatigue and disengagement from protracted conflicts(12).

4.0 Conclusions

4.1 Purity or Political Engagement: Conflict or complementarity?

Hathaway (1995) in a provocative paper suggests that the international relief system, particularly the international refugee regime, is becoming increasingly diffuse in its objectives, and has subsequently lost sight of its primary purpose. He argues that under pressure from the small number of countries which finance the international relief system, the essentially palliative function of relief is being dissipated, as agencies such as UNHCR adopt policies more linked to securing political objectives of donors such as containment of potentially destabilizing refugee movements.

This process of “mandate creep” is also reflected in increasing claims of NGOs and some UN specialised agencies to be engaging in the realm of conflict resolution and human rights monitoring (African Rights, 1994). It is also apparent from the extension of specialised relief agencies such as UNHCR into the domain of community development, especially in reintegration programmes of refugees, and conversely the expansion of specialised development agencies such as UNDP into conflict zones, conventionally reserved for their sister, relief agencies (Macrae et al, 1994).

In different ways, these trends represent a move away from the basic tenets of impartial and neutral relief programming. While the content of relief programmes has not changed substantially -food and medical relief remain the primary ingredients, the objectives they aim to serve, and the strategies used to achieve them, are changing in the face of increasingly numerous and protracted emergencies. Therefore the use to which the instruments of food and medical aid are put is in the process of changing: no longer is the primary aim exclusively in terms of reduction in mortality and morbidity – rather an extended series of developmental and political objectives are also presented.

In part, these shifts have evolved from increasing recognition of the very real difficulties of implementing neutral and impartial aid programming in war situations. As has been described above, attempts to provide resources in conflict situations are doubly vulnerable to manipulation: resources are scarce, and there are powerful disincentives for belligerents to allow the opposition to profit from them.

By turning neutrality on its head, it is argued: if aid can contribute to dynamics of violence, maybe it can contribute to peace-building, or at least to conflict reduction.

However, explicitly using humanitarian resources for developmental and political objectives raises a number of dilemmas and is likely to confront some formidable practical obstacles. There is a risk that rather than working to achieve more robust relief programming, in other words by working to achieve more impartial and neutral humanitarian actions, the principles are abandoned. The baby is being thrown out with the bathwater.

The first ethical and practical dilemma which will face the aid community if it abandons these key principles of neutrality and impartiality is that of defining what Meier (1993) has called a constitution for decision-making. In other words decisions need to be made about how decisions can be made. Conventionally, the state has been identified as the ultimate authority responsible for upholding the rule of law, raising public revenues and determining the distribution of a nation’s wealth, including international resources.

Where governments either no longer exist, or are not seen to constitute a legitimate authority to determine the allocation of welfare resources for a population, the international community has responded by using non-government actors: in effect, responsibility for meeting the basic needs of populations has been both globalised and privatised. In this context of globalisation and privatisation, it is no longer clear who is responsible for determining the allocation of resources, by what mechanism they should be distributed, and who will be responsible in the long-term for the provision of basic services and the maintenance of law and order.

Attempts to overcome this problem have been made by giving international bodies – the UN, Red Cross Movement and NGOs the resources to deliver services directly. This raises the question of according to what principles should relief resources be allocated: if the principles of neutrality and impartiality are abandoned, then they will have to be allocated according to some other set of political principles, set by other, political actors in either/both donor or recipient countries.

There is clearly considerable scope to ensure that the relief aid is managed more robustly by global and private bodies in order to conform to international humanitarian standards are met; whether the UN Department of Humanitarian Affairs can act as global body to monitor adherence to these standards remains open to question. What is less clear is whether if the principles of neutrality and impartiality are abandoned as the basis for relief planning how accountability for decisions regarding the distribution of relief resources can be achieved. In particular, it would provide national and international actors with considerable room for manoeuvre in determining who should and who should not gain access to public welfare.

Importantly, if humanitarian principles are to constitute the basis for decisions regarding the use of international resources in war-time, then the fundamental contradictions between relief and developmental assistance need to be recognised. Developmental programming implies the existence of an institutional framework to provide the legal and political basis for production and the provision of resources, it also implies the existence of a fiscal framework to raise and distribute public revenues. Most fundamentally, it implies engaging with existing institutions to achieve long-term sustainable development.

By definition, in complex political emergencies the pre-conditions for development and development aid programming are not in place. Existing authorities are more often the problem than the solution in terms of achieving food and health security; to engage with them to provide public welfare and to organise the means of production would imply violation of humanitarian principles and would be to ignore the role of existing governments in disaster-creation. In sum, to provide resources to such regimes would be to effectively condone political violence and to increase the risk that international resources will be used against the interests of war-affected victims.

The difficulties of mixing developmental and humanitarian objectives have been intensified by further claims that developmental assistance can be used to prevent and resolve conflicts. It is argued that in a similar way that developmental relief can be used to reduce the impact of natural hazards, so by addressing the root causes of conflict, developmental aid can reduce levels of violence and support political solutions.

James Ingram, former head of WFP has sounded a note of caution in this regard, arguing that:

Dealing with causes and the long-term effects of interventions involves making judgements that one side or the other may see as politically motivated and hence unacceptable. To assume that we know the correct answers to conflicts in other countries is Western hubris. Just as politics is the art of the possible, so our humanitarian action must address what is possible; saving more civilian lives in internal conflicts is an achievable goal (Ingram, 1993, page 185).

Implicit in Ingram’s analysis is that the mixing developmental and conflict resolution objectives with humanitarian objectives is likely to diminish the ethical basis of humanitarian programming which derives from the principles of neutrality and impartiality. Importantly, Ingram also highlights that failure to achieve clear separation between developmental and humanitarian objectives is likely to result in major operational difficulties. If relief is not seen as neutral and impartial by warring parties, then they may claim that it is a legitimate target for attack.

A further operational difficulty which emerges from attempts to make relief more developmental is that there is often very little “developmental space”, indeed it is the object of warring parties to undermine the development opportunities to undermine opposition group’s development opportunities. So, for example, in Sudan, the scope for internally displaced to develop a sustainable base for subsistence production was undermined by forcible displacement and discriminatory policies regarding access to land. Similarly, it may also be questionable whether the “development” of refugee communities is desirable; for example, the idea that existing Hutu power structures should have been reinforced in the camps around Goma in Zaire is highly debatable in light of the fact that it contained a significant minority of genocidaires and was located in an inherently unsuitable location from both the public health and political points of view. Even achieving the most minimal, humanitarian objectives of saving lives and reducing morbidity and suffering is a sufficiently complex objective to realise in these difficult environments, uncritical extension the range of operations to include developmental objectives risks failure.

The pressure on humanitarian agencies to extend their range of activities into conflict resolution and developmental programming is a further indication of the trend towards delegation of responsibility from the political domain into the aid domain, and from the domain of international public action on to the privatized domain of international NGOs. The Joint Evaluation of the International Response to the Genocide and Conflict in Rwanda emphasised that aid cannot be substitute for political action (Erricksen et al, 1997). Increasingly, however, relief aid is being used explicitly as a form of political action, whereby relief actors are under pressure to take sides and to make decisions about preferred outcomes.

Maintaining the purity of the humanitarian purpose does not imply pursuing relief programming in an uncritical manner, in particular it does not imply acting in a politically ignorant manner. Maintaining the scope for humanitarian intervention will rely upon relief agencies being politically informed, but ensuring that they are not driven by the political agendas of either powerful donor countries nor of political and military actors in the affected countries. Only in this way, by rigorously defending the humanitarian imperative, can the interests of the victims of complex political emergencies be defended against the political interests of both donor governments and warring parties. Political engagement is necessary in order to address the root causes of conflict and to provide political solutions. It is not the job of health workers and food aid agencies to serve this purpose however; they have neither the mandate nor the tools to do so. Political responsibility lies in the political not the humanitarian domain.


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1. This paper draws on ideas and inspiration gathered from a number of research and writing collaborations; my debt to these colleagues, too numerous to recount, is gratefully acknowledged. Particular thanks are due to Mark Bradbury and Suzanne Jaspars, mentors and co-researchers in the Review of Operation Lifeline Sudan, who offered their perceptive and often critical comments on an earlier draft of the paper. An earlier draft of this paper was present to a meeting convened by UNU/Wider in Helsinki in October 1996.

2. It is important to note that the increase in the proportion of total oda allocated to relief reflects not only the increase in the absolute amounts allocated to relief, but is also indicative of relative stagnation in overall oda since the early 1990s.

3. This excludes the additional $46.5 million supporting economies affected by economic collapse or chronic food security.

4. These threats may be either short-term, such as the increased risk of disease due to crowding and poor environmental conditions affecting drought migrants. Or they may be long-term, for example, increased reliance on collecting wood for sale as fuel may result in long-term deterioration in the natural environment, threatening future food production.

5. This section draws heavily on Macrae and Zwi, 1994, pp11-20.

6. In this speech, the British Foreign Secretary stated: “…To impose and guarantee order in the former Yugoslavia would take huge forces and huge risks over an indefinite period – which no democracy could justify to its people. British troops there have a humanitarian not an enforcing role…”

7. In those countries such as Sudan and Zaire where humanitarian crises have occurred while a government remains in place, and where there is no willingness to violate sovereignty through third party military intervention, erosion of sovereignty has been more quietly eroded. In these environments, the major international donor countries aim to work around governments by channelling resources outside the state system through the United Nations and NGOs. The limitations of these attempts to work around, rather than confront the sovereignty problem is evidenced by the extreme vulnerability of internally displaced persons (idps) and the lack of a clear international regime for their protection (Cohen and Cuenod, 1995).

8. For a detailed and challenging analysis of the construction and utilization of information in complex political emergencies, see Disasters 20(3) for a collection of papers, edited by David Keen and John Ryle, entitled: “The Fate of Information in the Disaster Zone”.

9. Duffield has used the term “functional ignorance” to describe this phenomenon of deliberate underestimation of the political dimensions of humanitarian crisis, and the use of delivery data to sustain the “culture of success” aid agencies rely upon to maintain their financing and personal professional positions.

10. Under these share-cropping arrangements, the harvest was technically divided between the landowner and the share-cropper. Landowners provided share-croppers with an advance of food, basic agricultural inputs and cash to enable them to survive and cultivate during the rainy season. Fluctuations in grain prices during the year mean that when the crop is divided, and the value of the advance subtracted, the proportion left to the share-cropper is insufficient to meet subsistence needs. The lack of capital on the part of share-croppers, destitute following their forcible displacement from the South means that they are unable to accumulate sufficient capital and grain reserves to avoid this debt-trap.

11. For example, Apthorpe et al (1996) reviewing the work of WFP in coastal West Africa, note the relative vulnerability of internally displaced populations to ‘donor fatigue’; int his region, rations were also reduced without adequate information on the expansion and effectiveness of alternative survival strategies.

12. Aware of the need to define statutory humanitarian entitlements, some NGOs are currently seeking to formulate a “claimant’s charter”, identifying minimum nutritional and health inputs to which disaster populations should be entitled (Nick Stockton, personal communication). In common with the Right to Development, specifying and enforcing the obligations accompanying the claimant’s rights is likely to be a difficult issue. However, specifying minimum requirements would at least provide a benchmark against which the appropriateness of international humanitarian response could be measured.

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