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Health Care in Danger: Violence Against Medical Assistance in Armed Conflict

Health Care in Danger: Violence Against Medical Assistance in Armed Conflict

American Red Cross of Greater New York

520 West 49th St. New York, NY 10019

March 23, 2017

The following transcript has been lightly edited for clarity.

Sandra Paunksniene, SIPA: Good evening ladies and gentlemen, guests and panelists. Tonight we gather to discuss, as mentioned, a timely and very important topic, health care in danger: the continuing violence against medical assistance in armed conflict. My name is Sandra Paunksniene. I work with the School of International and Public Affairs (SIPA) at Columbia University. I will be moderating this discussion tonight.

Our panelists are all accomplished experts in the field. Mr. Philip Spoerri, Head of the Delegation to the United Nations, International Committee of the Red Cross, also otherwise known as ICRC, Mr. Fabien Dubuet, Representative to the United Nations, Doctors without Borders, also known as MSF, Ms. Fatima Khan, External Relations Officer at the World Health Organization, also known as WHO, Mr. Julien Piacibello, Humanitarian Affairs Officer at the United Nations Office for the Coordination of Humanitarian Affairs, otherwise known as OCHA. A warm welcome to everyone tonight. Thank you for the American Red Cross and the International Committee of the Red Cross for organizing and hosting this event. We’re delighted to see such interest in this topic.

As many of us made our way to this event tonight, we saw emergency vehicles dancing through the streets of New York to deliver patients to hospitals where they would be guaranteed adequate care and safety. There are many areas around the world where safety is a reality; however, there are also many areas around the world where health care personnel are threatened, vehicles attacked, facilities bombed, and wounded and sick patients violated. This is the reality of medical assistance in armed conflict.

We need to be aware of the deliberate destruction of health care facilities in certain armed conflict zones. But public debate often doesn’t go to the true extent of the problem, which is compliance with universal International Humanitarian Law. International Humanitarian Law applies only to armed conflict. The need to reaffirm the postulates of the obligations by International Humanitarian Law is a necessity today—particularly because the violence against medical assistance in armed conflict is on the rise.

For this diverse audience today, panelists may want to address the following questions: Why is there a need for better protection of medical care in armed conflict? What is the existing legal or ethical framework for addressing attacks on medical care in armed conflict, including accountability for violations? How does each of the panelists’ organization face the challenges of protecting health care in armed conflict? We have a great panel tonight.

Each panelist will present for approximately 10 minutes. Later we will invite the audience for short questions, comments and debates, also online. Now I would like to invite Mr. Philip Spoerri to present the perspective of the International Committee of Red Cross.

Philip Spoerri, ICRC: Thank you, Sandra. Thank you to the New York Chapter. Happy to start, as ICRC, sort of an original Red Cross-er, being here with the Red Cross tonight is a true pleasure. As you mentioned, I think I will say a few words from the International Committee of the Red Cross, possibly related to the legal framework, some words on the initiative, and I’ll be leading over to some of what the other speakers will be saying.

A thought I had this morning on the topic—every day we follow what happens in various contexts. I was seeing that MSF has the Head of Delegation from Yemen with us here today. I was seeing how our teams down at the coast in Hodeida were beefing up their support, sending in medical teams to help them and support the ongoing need to protect the wounded in ongoing fighting in Yemen. We have similar situations where we’re just having more and more of our colleagues, our medical colleagues, working to help the victims in conflicts, such as South Sudan. We could go on and on with the list. It will be interesting also to address questions related to that.

I’m just mentioning that it’s a daily issue, a huge phenomenon of the need to secure and help the wounded and the sick. As a Red Cross-er of course I will start with International Humanitarian Law because it’s really down to the first hour of who we are.

The creation of national societies starting onwards from 1863 with the first treaty of International Humanitarian Law, formerly called the law of war, or armed conflict, which has the purpose to protect different types of vulnerable groups in conflict war, whether the wounded, the sick, detainees, the civilian population. This also includes rules over certain means and ways the war is fought. To instill these limits in the way wars are conducted.

The first Geneva Convention that was written in 1864 was precisely a convention dealing to respond to the question of the wounded laying there in the field unattended. That’s where for the Red Cross, important to know, that’s the first time the protective emblems were there. That’s where it was said the doctor who was wearing such an emblem cannot be attacked and where the notion stems from that aid to victims has to be delivered in an impartial and non-discriminatory way.

This is really the true foundation going to the most core principles that are there, referring to the ambulance drivers. I mean, I think for any Red Cross-er and any ambulance driver, the important thing to know is that when you see somebody in trouble on the road, you go and help. You do not discriminate, you have to help, according to the needs, pick up the person in a non-discriminatory way. It is really basics that are there.

I think it’s important to know, when speaking about the law, obviously in 1864, we already have the first convention. Technically it only applied to the armies in international conflicts. These norms developed over the time, over the past 150 years, up to after the Second World War, Four Geneva Conventions altogether are there, which enlarge to different groups: sea warfare, prisoners of war, civilian population. Additional protocols which were established and all of these, particularly in these protocols also established in in 1977, you have additional rules that have been put in place.

If I list some fundamentals, health care must be made available in a nondiscriminatory manner. That’s just what I mention, only on the basis of the need—to help the wounded and the sick. You also have very strong protections regarding the protection of hospitals, medical facilities that are not allowed to be attacked. Also, access to health care facilities, the running of the necessary services for health care, as well. Of course, also the fact that health care personnel should not be harmed and harassed.

These rules in the conventions are universally recognized, and I would say, these are rules that you would find applicable even in what we would call non-international armed conflicts. Thus the mass of conflicts we see today, which are not between states, but between states and non-state armed groups, or even between these groups fighting, everybody, even those non-state parties, technically should be respecting all these rules.

Now, obviously, I’ll be quickly coming to the point and say, “where’s the problem?” You know there are problems. We see this now for years and years and in more and more contexts. These constant numbers of attacks that we see against health care workers and facilities. To the same point, we even had a theme that was coming up strongly: Is there a type of erosion really of the respect of these really fundamental achievements that we have seen through these treaties?

Interestingly, very recently the ICRC published a study, collected a survey among 17,000 people in 16 countries to have their views, and particularly, to ask the question: “Wrong or right to attack hospitals, ambulances, health care?” Good news, the view is overwhelmingly 82% of all respondents did respond, that’s cross-culturally, cross-context, “No.” A strong, strong confirmation in that recent survey is there.

The survey went on to other themes, which were less reassuring in many ways, but on this one, one can at least see that there’s a perception at least of a broad public on this note. Again, coming back, the realities that we have been seeing are worrying. Our colleagues from MSF will certainly dwell also more on it. The number of attacks we have seen over the years in conflicts like Syria. Nowadays we see it in Yemen. I was citing figures a few days ago in a meeting where we were referring to the past year – over 160 attacks on medical facilities in Yemen. If you look at the conflict, we’re now only 45% of the medical facilities are actually still functional in that country, a huge phenomenon.

This doesn’t go just to those contexts. You could go to South Sudan, Afghanistan, to many other conflicts where we see this phenomenon. Looking at this dire situation or this fact, actually the International Committee of the Red Cross, even before the launch of its campaign in 2011, shortly before, there were deliberations coming really from the findings of our colleagues in the field.

That’s where it always comes from, if you ask our field delegation, our doctors, our medics say that there is just a staggering number of these attacks. Difficult then to calculate how much this phenomenon has become worse or not. We said this is an issue. We have to flag it. That’s why thinking about it and meeting together with our friends in the Red Cross and Red Crescent Movement, the 190 national societies. Also of course the International Federation of the Red Cross, we all sort of sat together and designed this campaign together.

It was launched at the International Conference of the Red Cross and the Red Crescent, when all of this large Movement meets with the States, the signatories to the Geneva Conventions, every four years, this one was launched. But it’s also fair to remember, and I’ll have WHO or MSF watching carefully, it was designed very early on as a campaign of an unnatural nature in the sense that we really wanted to reach out to a huge community of concern and have partners. We partnered up very early, for example, with MSF on this campaign to study the topic further but also to see where the issues are and raise awareness among the public.

There was a study, which ICRC conducted from 2012 to 2014, in 11 countries. That one looked into 2,400 attacks on health care personnel, facilities, patients, and highlighted already there the direct and indirect consequences of it. I know there are other studies. I’m sure our colleagues from the WHO have more recent facts and data.

The interesting thing was the important numbers of these direct attacks. We also learned, for example, on findings of direct effects and indirect impacts. I remember at the time and I was thinking today, what I was fixing to say, I didn’t have all the figures there, but one of the examples in the report was an attack on a health center in Somalia where a number of young physicians were killed. I think they were neurosurgeons, very specialized doctors and we know how long this education takes, 10 or 15 years to build this expertise. In a country where few doctors were present, the number of young doctors killed at the time, thinking of the number of patients they would have treated and the impact that had, it went into hundreds of thousands of patients who would not be treated. So that was the first thinking of looking also into the long-term effect of that.

This led all the way up to 2015 when we had the next International Conference with a very strong resolution passed. When I say these resolutions, it’s not something that innocent because they are passed with the Red Cross and all the States parties. That is a very special thing. In these resolutions, measures were taken to work on strengthening domestic legislation, for example for stronger measures in training of forces and medical personnel on this issue. Even going into things like making armed groups aware of this matter and finding creative ways to seek better respect for them.

At the time when that happened in 2015, and looking even after that, we realized of course how timely this initiative had been. Because in the years coming, it just became worse. Hard to empirically always prove, but I mean the phenomena we have seen and many of our organizations. The stuff we’re seeing now is very sad—direct attacks even on our institutions and our medical facilities. This predominantly, at least feels, even without going into all the figures, as something that has become an exponentially growing phenomenon.

That is the campaign that was there. It of course continues. It didn’t stop with 2015. It has to be followed up also for the next conference so it is a continued approach. I will not dwell too much on one step that took place last year, here in New York in May. We had the adoption of the resolution of the Security Council. All of us here are able to recite the number, 2286, that was the resolution. The highest deciding body at the United Nations, adopted a resolution unanimously. This resolution re-affirmed all those rules I was referring to in a very strong way. Also it delegated a number of follow-up proposals. I just want to say from a Red Cross perspective in seeing our part of this all, it was also a good resolution in terms of content.

Thanks to a lot of the work that we had done together over the years, the resolution covered a lot of the groundwork that was already done, in terms of content, needed to support the work of such resolutions. For us the Red Cross and Red Crescent, ICRC of course, we will have to continue to engage with states and with all partners who can help to push this topic further and manage to make a difference. Because even after that resolution, that was the sad part, is that we had one of the worst three months just coming after that resolution.

It’s not that something like that happens and the situation changes. Sometimes it gets even worse for the moment. It feels like that. Although, probably I can also refer to some examples of the colleagues in the field that can capitalize on this strong notion that there is this note at the highest level and one has at least a consensus on this aspect. I take a very positive stance on the fact that as an international community, one can reach such results.

Now, I will just also want to draw attention to you and your packets. You have this document “Time to Act”. This should give you also the opportunity to act and, at the last page, you can even see how because there’s a little box which says, “What can you do?” There you will see the toolkit that we have to see how one can engage and the material available to act on this initiative “Stop the violence, safeguard healthcare.” Looking forward to the discussion. Thank you very much.

Sandra Paunksniene, SIPA: Thank you, Philip. Thank you for refreshing our knowledge about the International Humanitarian Law and about various campaigns you are leading and resolutions at the UN, especially of the Security Council. Next speaker is Mr. Julien Piacibello, from the United Nations Office for the Coordination of Humanitarian Affairs.

Julien Piacibello, OCHA: Thank you very much, Sandra. Philip has talked very eloquently about the legal framework about the situation prompting us to be here, where we are today. I’m going to try to complement that by giving the perspective from my office from the UN Office for the Coordination of Humanitarian Affairs or OCHA on these very important issues of the protection of medical care in conflict. Maybe just a little bit of background of what we do.

Part of OCHA’s role is to provide UN decision-making bodies with information on humanitarian issues and share a humanitarian point of view on the topics that are on the agenda of these institutions. One of these topics is the protection of civilians in armed conflicts, which the Security Council put on its agenda in 1999. It’s in the context of its responsibilities for the protection of civilians that the Security Council adopted last year Resolution 2286, which is a very important text. It’s the first resolution that the Security Council has adopted specifically dedicated to the protection of our subject today, to the protection of medical care in conflict.

It doesn’t mean, of course, that the UN, the Security Council, or the UN denied or ignored the issue before. That doesn’t mean that the UN or the Security Council ignored the issue before the adoption of 2286. Actually, it has always been part, although maybe implicitly, of the protection of civilians that I just referred to. For example, you have the Office of the Special Representative on Children in Conflict, which has been monitoring attacks against hospitals since 2011. And you have other UN bodies that have long addressed some aspects of the issue at least.

For example, the General Assembly or the Human Rights Council. Resolution 2286 is really a turning point, because it can be seen as the first UN reference framework that is completely dedicated to the protection of medical care and also addresses the protection of medical care in a comprehensive manner, in all its aspects, basically. It’s a very important document. It’s important and it’s very significant that the Security Council adopted this resolution. You all know that the Security Council is the most important body in the UN and it’s the only one, which has the power to adopt resolutions that are binding on states. 2286, of course, is binding on states.

One might ask if the Council has been dealing with the protection of civilians since 1999, why has it adopted 2286 only one year ago? I would like to caution you against an explanation that I have been hearing here and there. Some say that is because of the unprecedented extent that the issue has taken, which would have prompted a Security Council reaction.

First, I’m not really sure that one can say with certainty that the impact of conflict on medical care is today much worse or even worse than what it was 10 years ago. I don’t know if someone can say that and be 100% sure. But maybe more fundamentally, there’s something that is wrong with this idea that there will be a threshold, quantitative threshold, above which suffering or wrong doing will become unbearable. Because that implies that when you don’t reach that threshold, there’s no problem and there’s no need for action. So we lose every moral or every principled approach. I would really caution against that rationale.

What we see is that conflict has devastating impact on medical care. We see that in some instances, there are reasonable reasons to believe that this impact was intentional or at least could have been easily avoided. That goes against norms that states agreed upon. So, if there is an issue it calls for a response.

With 2286, the Council brought a strong response. I mentioned that it was adopted with protection of civilians’ agenda. Actually, the expression “protection of civilians” is a bit misleading. It’s not only about civilians. It’s about the norms and activities that, in situations of foreign conflicts, contribute to the protection of all those who do not participate in hostilities or no longer participate in hostilities. When you look at 2286, it includes the protection of non-civilians, members of military medical units, persons who are out of combat. I mean fighters who can no longer participate in hostilities because they are wounded or sick. That is important to keep in mind.

Maybe two additional comments on the scope of our subject and of 2286: First there is a tendency to call this resolution, a resolution on the protection of hospitals and medical personnel. Let’s not forget the wounded and the sick. Let’s not forget them. Parties to conflict have an obligation to respect and protect, to care for the wounded and sick. 2286 records this obligation. Actually IHL protects specifically medical personnel. In a sense it is because of their function, which is to contribute to this protection, so let’s not forget the wounded and sick.

Secondly, protecting medical care in conflicts. It’s not only protecting from acts of physical violence. There’s a lot of less visible acts that seriously impair the provision of medical care in conflicts. For example, the occupation of hospitals by parties to conflict, blocking medical convoys’ access to areas that are held by the enemy, or passing legislation that criminalizes the provision of health care, for example to groups that are considered as terrorists.

OCHA provides for an obligation on the parties to conflict to care for wounded and sick, without any other distinction than based on purely medical grounds. OCHA protects the ability to perform medical functions impartially, in line with medical ethics. It’s interesting that Resolution 2286 recalls these rules and addresses programs of obstructions to medical care. That’s very important, I think.

Now beyond recalling the rules, what actions does Resolution 2286 call for? Here, that’s also why it’s a reference document. It outlines a road map for action for all actors, principally states and parties to conflict. It calls on states, and when relevant, parties to conflict to develop domestic frameworks that guarantee respect for international law; to correct the armed obstructions to medical care; to share challenges and good practices; to implement precautionary measures in the planning and conduct of hostilities; to conduct investigations with human rights standards into potential violations affecting medical care; and to adopt some reputable measures, including ensuring accountability and providing reparations. That’s a very comprehensive road map.

Interestingly, Resolution 2286 doesn’t stop here. It requests that the Secretary General submits recommendations on how to implement this method in practice. These recommendations were published in September 2016. For OCHA, it’s really a reference document going forward. First it’s a collective document. It’s a document that reflects the views of various humanitarian entities, of the ICRC, of MSF, of the WHO. It was elaborated in consultation with the all the key partners on this issue.

Secondly, I think it’s an ambitious document in the sense that it doesn’t repeat 2286. It doesn’t just repeat or restate international law. It provides some concrete, very concrete, options to rationalize existing norms. Sometimes these options go beyond strictly legal obligations on states and parties to conflict.

Third, I would say it’s a pragmatic document because the measures that it proposes are very concrete. Often they rely on existing mechanisms, for example, on fact-finding or accountability.

Finally, my analysis is that it is a moral document in the sense that it puts each type of actor in front of its responsibilities. States and parties to conflict have definitely the primary responsibility to take action. Quite frankly, on a number of issues, if they don’t take action, no significant progress is likely to happen.

Now when states fail to act, the recommendations underline that the Security Council has to take action on a number of issues, including fact-finding and accountability. Then of course the recommendations address what the UN and humanitarian organizations should do to incite, inform, and support these efforts.

The recommendations outline three types of measures. Some preventive measures, which are measures that states should principally take to promote respect for medical care, both within their own jurisdiction and the external relationships, and both in times of peace and in times of conflict.

Second type of recommendations: practical precautions that parties to conflict should take to prevent and minimize civilian harm in the conduct of hostilities. Then there’s a third group of recommendations, which consist of corrective measures to ensure accountability, the provision of preparations and the continuous improvement of existing measures. To inform such efforts, the recommendations show a need for regular specific monitoring and analysis.

Basically, we have now a UN reference framework. We have a roadmap, and we have a toolbox to implement this roadmap. So how do we go forward with that? For my office at least, I would see three priorities. The first is we need to promote the effective implementation of 2286, along the lines of the Secretary General’s recommendations, by using every relevant forum. We must continue to go to the council. We must go to the General Assembly. We must choose every forum that allows us to talk about this issue and promote its implementation.

Secondly, the council asks for the Secretary General to brief every 12 months on the implementation of 2286. It’s our responsibility. It would be very important, I think, that these briefings are not just business as usual. We must be able to bring some constructive information, not only to highlight the gaps, but to highlight the good practices. What is being done to give ideas, and put states in front of their responsibilities. That will depend largely on our ability to improve systematic data collection and analysis. I think that Fatima is going to say a few words about that. That will depend also on the willingness of different stakeholders to share information with us.

Lastly, from the point of view of OCHA, it will be very important to connect the protection of medical care to the broader protection of civilians’ agenda. The Security Council has multiplied category-specific discussions on this agenda these last years on UN personnel and humanitarian personnel, on journalists and now on medical personnel. There are very good reasons for this. I think that overall this is a positive trend. This is a positive evolution. But there are also good reasons why we should not lose sight of the broader protection of civilians’ perspective. I will just name two of these reasons.

First, the fundamental issues that affect medical care in conflict are the same fundamental issues that affect all civilians and all categories of public persons. Basically lack of compliance with international norms, lack of accountability for non-compliance with international norms. There is something a bit artificial to fragment the way we address these issues for different categories of personnel.

The second reason is that we should not neglect those who are trapped in conflict and do not fall within any specific category. Who is it? Basically, adult males who are not wounded or sick, who are not medical or UN humanitarian personnel or journalists. I think it’s a lot of people. I will stop here, thank you.

Sandra Paunksniene, SIPA: Thank you, Julien, for this explanation of how Resolution 2286 came to be, and for dissecting the most important issues, and how it is right now for most people working in this field, and for explaining obviously the protection of medical care and the protection of civilians and how they fare in the relationship with the Security Council. Now I will give the floor to our next speaker who is Mr. Fabien Dubuet, MSF.

Fabien Dubuet, MSF: First of all, I would like to thank the ICRC and the American Red Cross for organizing this event and for inviting MSF. It is indeed a very timely conversation. We are among friends. I see a number of known faces. I’ll try to be as candid as I can.

I would like to make two preliminary observations. One, I do not want to feed the sort of narrative that we are hearing a lot that it is far more dangerous for humanitarian organizations, especially for medical actors, these days in conflict situations. I think at MSF we’re very careful about such assumption because we, in fact, lack some solid and scientific data. This said, there is no doubt that we are dealing with a very deplorable trend recently.

There’s no doubt when you look at the number of conflicts and crises, Syria and Yemen, against South Sudan, even Nigeria, there are a number of worrying attacks and trends. We do need to react. But I also want to remind that the sort of attacks we’ve seen against the medical mission are part of a broader trend, in terms of the conduct of hostilities and definitely we are seeing a bit of a race to the bottom when it comes to the respect or lack of respect of humanitarians. That is my first observation.

My second observation is that, by definition, humanitarian action is about deploying operations and personnel in violent situations, characterized by insecurity and the presence and sometimes the heavy presence of armed actors. There is no magic wand. There is no guideline, no pre-established roles to really guarantee the safety and security of your staff 100%. Humanitarian action is about taking risks. Of course calculated risks, as much as you can. It’s about re-learning how to mitigate those risks. Such measures are really profoundly context-specific and also very much multi-dimensional. This being said, I was trying to identify some key ingredients which we think at MSF are very instrumental to deploy our medical or humanitarian operations while preserving the security and safety of our staff.

I would like to mention two main elements. One is really the clarity and even the modesty of your mission, of your mandate. I think it’s an opportunity for me to remind that while humanitarian action is a very important endeavor, it is a very modest one, in fact. If you look at IHL, even the definition of what humanitarian action is and their international role, there is a decision from the International Court of Justice, it’s really just about alleviating human suffering. And you have to stick to the strictly humanitarian character of what you do and of your mission.

So you have to be very independent from any sort of political, military, economic, security agenda. I just feel like this because we are dealing with a bit of a growing confusion between the role and the responsibility of humanitarian organizations and the responsibility of political actors. Also, we’ve been seeing more and more the kind of increasing incorporation of the humanitarian agenda into broader framework; whether it is political, counter-terrorism, development or even economic. I just want to insist on the need to really better defend and restore the integrity of the humanitarian agenda.

We need to be seen for what we are in the field by the belligerents. This is really one important criterion for the safety and security of our staff. The second element I want to mention is a dialogue with the belligerents. Probably the most important and here I just want to remind also that all conception of interaction is based on acceptance by the parties to a conflict, it is peaceful by nature.

Our presence is always the result of negotiations with belligerents. These negotiations are a constant process. It’s time-consuming. It evolves constantly. Not everything is, of course, negotiable. This is where IHL and humanitarian principles are very useful benchmarks. For instance, the way we translate neutrality or impartiality as operational principles is through very concrete benchmarks. The fact that we don’t accept weapons in our facilities. The fact that we really insist on being able to respond and to provide our assistance based on needs that we have assessed ourselves. Also that we provide this assistance on the basis of the non-discrimination principle.

Humanitarian space is always a fight, and lately it’s true that a lot of our conversations with belligerents, state and non-state actors, that the core of the conversation has been on the conflict arrangements. It’s a very broad topic so I will not elaborate. Maybe we can come back to that in the conversation. It is really about how do we notify our movements to the belligerents? How do we provide GPS coordinates to the parties? How do we secure working conditions through a very consistent and constant engagement with the parties?

I would just want to add and flag a few challenges here. First of all, there is a bit of tension between the emergency nature of what we do, the human imperative. You want to go fast because you want to save lives, and the need to build confidence with the belligerents sometimes takes time. Sometimes they’re reluctant. There’s a tension here.

The second challenge would be the importance to not criminalize the dialogue between humanitarian organizations and non-state actors. I think here we have a number of belligerents today, which are listed as terrorists. I think sometimes the national and international legislation is a bit of an obstacle for us.

Sometimes we lack access to these belligerents and sometimes the groups are extremely fragmented. Those are two situations that we don’t really like at MSF. They are right now some crises where we do have operations, and we have no or limited contact with the parties. Luckily, these are more exceptions than the rule, but we are in that situation in a number of countries, and we don’t really like this.

Then, at the end of the day, the acceptance by the belligerents of our work really is based on multiple criteria, on their military objectives, their agenda. Sometimes their military objectives can be totally antagonistic, totally opposed to our work, and the sort of activities that we are deploying or we want to build. Most of the time, we succeed to find mutual interests. Sometimes it’s not the case.

The perception of MSF by the belligerents is a very complicated topic because how do you control your perception as much as you can? How do you even know how you are perceived by some of the parties? I mentioned the access, sometimes the challenge of accessing the parties to talk to them in a very consistent way. Very important is the quality of our operations. Very often, we don’t even talk about this when it comes to security and safety, but what you do and how you do it, and the quality of what you do is a very important criterion for the safety and security of your team. We think we need to be very hands on. We think we need to be present, a real presence, so not a remote presence. Sometimes we do have to build operations remotely. We don’t like this. We feel it’s a big challenge. We think also that there’s a bit of a loss of know-how in the humanitarian community, in terms of deploying operations with a real presence and having real doers on the ground.

Then lastly, it’s also how your activities sell themselves in the economy environment. It’s also a very complicated topic, but I just wanted to mention. I want to finish on one thing, since we’re in New York. It’s really the sort of external pressure, the diplomatic pressure, the role [of] the diplomatic community. Since we are here in New York, there is the UN. One is the UN headquarters. We have almost all states and even regional organizations are represented to the UN.

The dialogue we have with the belligerents and the construction of our operations in conflict situations sometimes has to involve public communication and diplomatic pressure. This is really what we call advocacy or humanitarian diplomacy. I think it’s a reminder that negotiating a safe environment for your teams on the ground is really about having multiple transactions, sometimes at the same time. Of course, always first in the field, but more and more, we find ourselves having to leave these transactions or these negotiations at different locations. Of course, in the country, but also regionally and internationally. Sometimes, even here in New York.

The reason why Eric, our Head of Mission in Yemen, is here is because we are having a series of conversations with a number of actors in New York about our operations in Yemen. As you know, Yemen is an awfully challenging working environment. This is just to say that sometimes you can be as independent as you want, but at the end of the day, you need some diplomatic support. Sometimes you also need to use the political cost or the reputational cost. That is a calculation for some of the parties, some of the belligerents we are dealing with. It’s always very tricky because you want to keep your operations on the ground. But sometimes you have no choice when your negotiations, or what you’ve tried to achieve, have failed. You have to use some leverages and some of these leverages are about public communication and behind-the-scenes diplomatic work.

I will finish on this. This is also why we ended up actually jointly with the ICRC and five member states asking and negotiating Security Council Resolution 2286. We felt that after a series of incidents, some of them very serious, we needed a bit of a physical reassurance. We needed a strong political signal from the Security Council, but in fact, I think 80 member states also co-sponsored the resolution.

Now it’s about really making it happen—operationalizing the resolution. Which in fact, more or less, reminds existing obligations under IHL. This is a difficult challenge, but I think we need to re-secure some diplomatic unity on the basics of humanitarian action and I’ll finish on this. This is a very important challenge, but it is a challenge for which the civil society really has a role to play. I think it’s also very reassuring to see all of you on a Thursday evening, attending an event on this topic.

Sandra Paunksniene, SIPA: Thank you, Fabien. We heard how multi-dimensional the issue is, from your point of view. Especially we heard what difficulties you have and your employees have, because of the emergency nature of your work, because of dialogue between non-state and state actors, also lack of access, military objectives, quality of preparations and political advocacy or humanitarian diplomacy. Next I will give the floor to Miss Fatima Khan from the World Health Organization. You have the floor.

Fatima Khan, WHO: Thank you. I want to thank the American Red Cross for organizing this panel and as Fabien said, everyone for coming out on this evening to join us. I will focus my remarks to three specific areas, and I will try to build on what my colleagues so eloquently and thoughtfully put out.

First, I would like to touch upon the challenges faced by health care workers, some of which MSF has already discussed. Secondly, I would like to talk about the impact that attacks on health care have on longer-term health service delivery. Third, I would like to speak about data collection.

During emergencies, as we know, the delivery of health care services is vital to the survival and longer-term well-being of affected populations. Healthcare is reported to be and repeatedly identified by emergency-affected populations as one of their top priorities for humanitarian assistance. Meeting these life-saving health needs is increasingly challenging. In the current political context, the needs are unprecedented. In 2015, an estimated 125 million people were affected by emergencies, which was the largest number ever on record. This continues to grow.

Health care workers strive to deliver services to those in need of health care. In doing so, they face many challenges, including overwhelming demands, insufficient numbers, lack of trainings, supplies, medicines, ongoing conflict, heightened anxiety and fear from patients and families and sometimes communities, limited access, changing front lines, stress and exhaustion, this list can go on. We can go into this more in depth later on.

I mean, for instance, in Mosul, we see that health care workers are almost at the front lines, if not at the front line, dealing with patients who are just evacuated from Mosul. In Syria, we know they work under increasingly difficult and horrifying conditions with no relief.

During the Ebola outbreak in West Africa, they were basically trained on the spot to deal with the disease that they had never experienced before. This is just to give an idea, which you all know probably better than I do about what people have to go through every day to deliver health care services.

Then, of course, the most alarming and disturbing challenge for health care providers during emergencies is when they’re the victims of attacks. These are real attacks, threatened, targeted or just indiscriminate attacks across the board. As my colleagues already mentioned, we’re witnessing a lack of respect for the sanctity of health care, in the present time—for the right to health care and for International Humanitarian Law. Patients are shot in their hospital beds. Medical personnel are threatened and attacked and hospitals are bombed.

In Afghanistan, Palestine, Yemen, health facilities are bombed. In Turkey and Bahrain, health care workers have been denied the right to treat patients. In Pakistan and Nigeria, polio vaccinators have been shot and killed. During the Ebola outbreak, health care workers and health facilities were attacked and health care workers were killed. In South Sudan, patients have been shot in their hospital beds. Again, this list can go on and on. We don’t have the time to go through it right now.

It does bring me to my second point on the impact on health service delivery in the longer term. This is something that we’re not able to analyze just yet. We know that there’s a direct impact. They deprive people of urgently needed care where it’s needed most. While, as I said, this is largely undocumented and we don’t have the proper analysis yet, it’s presumed to be significant. Which not only impacts short-term health care, but also longer-term health needs and wellbeing of affected populations. Essentially the health system, health work force, and ultimately achieving the sustainable development goals.

An example of this is in Iraq, in Karrada, which is a town near East Mosul, which was occupied until August 2016. The hospital as you can imagine once it was no longer occupied was not functional at all. It was damaged. It was heavily mined. There was a lot of work that needed to be done to clear that hospital, to re-build the foundations, to bring in generators, to bring in eventually medical supplies, equipment, to bring back health workers.

It took over six months for it to even become partially functioning. Now, just recently, on March 7th, it was re-opened to provide trauma and obstetric services. This is just one example, and it’s probably a more positive example of the impact of health care delivery. There’s countless others. Some of them we don’t even know how it affects longer-term delivery of health care.

Which then brings me to my third point, which is data collection and WHO’s contribution. Currently, there’s no public, available source of consolidated information on attacks on health care and emergencies. Last year, WHO started consolidating and analyzing data that is available on open sources. While that data is not comprehensive, the findings shed light on the severity and frequency of the problem.

The full report can be found on our website. Initially we looked at the period from 2014 to 2016, which shows that 896 attacks were reported in 20 countries facing emergencies. As colleagues mentioned before, we don’t have the full data. We shouldn’t only require data to show that this is a problem, but sometimes the data helps to build our case when we go on to advocate for this issue.

We are now in the final stages of developing a methodology and a tool, as Julien mentioned. This tool and methodology will aim to include better and more standardized definitions and classifications for data collection to understand the problem and find solutions so that we can begin a more analytical and systematic way of looking at the impact of attacks on longer term health care, and also demonstrate the multiplier effect on attacks on workers, on facilities, on communities, long-term health goals, global public health and then so forth.

WHO commits to promoting and applying good practice and to work with member states, health cluster partners and other stakeholders to maximize our collective efforts. We are working very closely with MSF, OCHA and ICRC to implement 2286. As my colleagues have said, it’s quite a challenge to move forward on this, but we are doing what we can. We hope that together with improved information and improved advocacy, we’ll get a better understanding of this issue. Decision makers, health care providers, humanitarian organizations, parties to conflict and affected communities can work better together to ensure that health care is provided universally during emergencies to those who need it, and in a safe and unhindered way. Thank you.

Sandra Paunksniene, SIPA: Thank you, Fatima, for listing for us and explaining what WHO is doing, including the importance of delivery of health care services in emergencies, impact of attacks on health care to longer-term well-being and data collection. This concludes our introductory remarks by our panelists. We will now move on to the questions. We can take two or three questions, short questions, and we see which panelist is able to respond to those. Yes sir?

Speaker 1: Regarding 2286, it seems to me that civilian casualties should be more collateral damage. But it seems with conflicts we see now, civilian causalities are almost the intended target. So much of it becomes tribal, religious that it’s almost family against family. So, what kind of challenges are you facing on the ground to try to overcome this?

Sandra Paunksniene, SIPA: Would you like to take another question, at this point in time? Yes, sir?

Speaker 2: It seems following up on the gentleman from MSF’s comment, that we don’t know if war is actually more dangerous now for aid workers than before. I’m wondering if, reflecting on the past 30 years, we do see changes in the security architecture, infrastructure, and practices of agencies. In the sense, do we see larger budget allocations, more human resources devoted to security problems than we have in the past? Related to it, an associated question is of security tactics creating blowback for larger humanitarian strategy, in terms of the growth of the use of private security contractors by humanitarian agencies, if you could speak to that.

Philip Spoerri, ICRC: I can start. The first question is one of changing nature of warfare. There generally of course if you go a bit longer down in history and you would say that the way wars were fought—take first World War, we see the trench warfare. Many aspects where you have strong fighting just between regular armies. Then you probably say proportionally less civilians, though I’m sure there are quite a few passing through experiences where also civilians were overrun. Generally speaking, one does see a tendency that the proportion in warfare of the toll on civilians compared to those who are actually the combatants or fighters, has grown. Plus you have this phenomenon, of course, even more exaggerated by the fact that in most of these situations where we’re looking at today are not state conflicts but civil wars or very messy internal situations with an ever-growing multiplication or fragmentation of actors today.

That there is of course the problem, in the part of the law, and the challenge you have always to distinguish between who is the fighter, who is the civilian. In some of these situations, you of course have a challenge. Particularly in war, you already have these internal issues and families are associated. Who is the innocent civilian? That is of course a challenge, and I believe that is why a lot of the thinking and the discipline and on interpretations on whom you can target has become more challenging. That is something for us to work on. I would agree that in many of the situations we are facing a bigger problem that also more civilians are attacked. It will be a longer discussion—one has to now unravel that even more.

Security in the past, that’s the same. We have many of these questions, you know. More attacks on health care than in the past. I am always just staggered if I look at the Syria context, and I don’t have the latest. I know that we’re near the 55 of our Red Crescent colleagues who have been killed. I can’t remember in the past 40, 50 years that we’ve had a context where we had direct numbers like that, but maybe I’m forgetting something. I think we’ve had a lot of that. I think in at least some of these contexts that Fabien has been referring to in this spiral down that there is definitely a massive security problem for many of those who are trying to help on the ground.

On the question of private security and others aiding, definitely the Red Cross or Red Crescent, we don’t work like that. We believe that these methods of working, at least, do not help us because they do not secure the confidence of the parties. We engage in this painstaking exercise of really building up the trust and the connections. Maybe not operating if we know that we do not have the acceptance, even by some of the most difficult lines in that area. Others operate differently. Maybe others can comment on that.

Julien Piacibello, OCHA: Thank you, maybe just to say that quickly about the security of humanitarian workers. My point was not to say that the situation was better today than it is yesterday. That was definitely not my point. My point was more to say that it’s not a question of threshold, and we shouldn’t wait for an issue to take it up. To address this issue is a small question of principle. Now I was not implying in any way that the situation is better today than yesterday. In fact, I don’t know.

Just on the very interesting question of maybe how practices of some NGOs, UN agencies have changed in terms of how we manage security. There was an interesting study that was published, I don’t know exactly when, I think it was 2011, 2012. The name of the study was “Stay and Deliver“. That was a very interesting study that basically showed that yes, a lot of NGOs, INGOs are investing more and more into security management. Or when they are delivering in areas of active conflict, it’s very often through interconnected partners. You even have some INGOs which are just basically managing funds and funding implementing partners but do not have an established presence in areas of active conflict.

There is going to be soon a follow-up study to this first study to see how things are evolved on those fronts. A little spoiler, one of the things that the study shows is that the more humanitarian organizations tend to make compromises on humanitarian principles, for example using private security companies, the more they actually have problems, and the more they are likely to be targeted by parties to conflict. I think this is really important in that it raises the issue that Fabien was talking about. How do you gain acceptance? How do you operationalize? How do you translate humanitarian principles into practical operational rules for your organization?

I think the way that MSF and ICRC work by having straight red lines and saying, “Either we operate according to our principles or we just don’t operate.” I think that’s the way to go. They are probably the two most principled organizations and they are probably the two organizations that have the highest presence—international organizations that have the highest presence in areas of active conflict. That says something.

Fabien Dubuet, MSF: I don’t think I’m able to answer your first question—are conflicts today more costly for civilians than before. I don’t know, I’m not sure actually, but again, I mean I don’t even know if we can scientifically answer this question. Because what we know is that today looks like we are in . . . and that’s good news, we are more sensitive, all of us, in general, to the price that civilians pay in conflicts.

We have social media, the coverage is easier so that I would say that’s a piece of good news. You should look at the practice in the Security Council in the past 50 years, you see the protection of civilians topic issue discussed. It is even a very official issue, discussed in the [Security] Council. You have the first report actually by the new Secretary General on the protection of civilians in May. Julien is very much working on this.

I would like to take your question with a different angle. I think for me it’s more the issue of what is your responsibility as an organization, as a medical humanitarian organization, in circumstances where you have operations where you see this sort of violence. For us, the absolute red line is that we will not maintain operations if we feel that our activities are used to contribute to a criminal enterprise. I say that, I mean this is a very heavy decision to make, for a humanitarian organization to say, “Well I’m going to stop and sometimes I’m even going to withdraw.” It’s very unique. These are very heavy decisions.

In the history of MSF, we made such decisions in a number of crises. The one I remember is the refugee camps in Congo, at the time Zaire, DRC today, just after the genocide in Rwanda. There are some conflicts right now and where we are actually seeing where some belligerents are targeting civilians. It looks like they are targeting civilians as part of their military objective. They see the targeting of civilians or some of them as an important condition to meet what they have defined as their military objectives. It’s unacceptable of course, but I think we have a number of conflicts right now where we are in that situation. That raises a lot of questions for us.

Then on the second question, actually I brought a book that’s MSF’s, I think it was last year, which is called “Saving Lives and Staying Alive“. I really encourage you to read the book. I don’t remember who asked the question, but because the book is a very critical reflection about what we’ve seen in the past 10, 15 years, sort of. It’s more security advisors, more budget for security, more guideline, policy papers. I think for us the question is, are we moving towards more professionalization or just more bureaucratization, more bureaucracy. It’s not very clear.

Fatima Khan, WHO: Thank you. I’ll just build a little bit on some of Julien’s point on managing security and the evolution of that, especially in the UN system. Because there was a time, and you might remember this, when the UN was, I guess, more free to move around and more active. Then the whole situation changed with the Canal Hotel bombing in 2003 when we started looking at our security in a very different way. Maybe that has changed how we deliver on the ground. It’s possibly changed how different actors and groups see us. But we always have that challenge of trying to assess when we have to take a calculated risk to deliver services, but in a way that we can protect our staff as well as possible. As Fabien has said it’s our work to go in there. I say this as WHO because WHO is not as operationalized as other colleagues. It’s really MSF on the front lines and our implementing partners. Also doctors and nurses who work in the Ministry of Health, those who don’t have any security at all.

One question that comes up a lot in our discussions at the UN also is how do we address that security for those that don’t fall under certain international umbrellas. I think that’s something that we struggle with now. It’s a question and a conversation that we’ll continue to have in the coming months and years.

Sandra Paunksniene, SIPA: Thank you. We’ll take other questions now.

Speaker 3: Thank you. Thank you very much to all the panelists. I just wanted to hear your thoughts on accountability mechanisms. In light of the attacks against health care, what kind of mechanisms does UN have at this time?

Sandra Paunksniene, SIPA: Perhaps one more, okay.

Speaker 4: One of the things I was kind of wondering is you were speaking obviously sort of within the context of protracted humanitarian operations where there is this increasing multitude of actors. Somebody mentioned that as the principles are compromised and the ways they might be compromised that actually tends to increase the risks or the presence of problems for those actors.

We all know what the reality is. One actor making a compromise, kind of compromises everybody. Or it has potential to do that. Just something that I’ve been thinking about recently and would love for you guys to speak to is the idea that whether it’s practical, whether it’s operational, whether it’s realistic, if there could be some convergence of how we operationalize these principles, how we prioritize them. I know each organization kind of has its own way of doing this, but it does create these risks. The more that that’s going on, the more actors there are who are operating differently, the bigger those risks get. I was just wondering realistically is there something that ever is going to happen or should be pushed for? If it were, what avenues are the one that you could see that being realistic and in what ways do you think it is not realistic?

Or to play devil’s advocate to my own question, is there strength in diversity? That it’s better that different organizations operate differently because it creates different access, depending on how they’re prioritizing their principles or operations.

Sandra Paunksniene, SIPA: Would you like to take those?

Julien Piacibello, OCHA: On the first question, on accountability mechanism: first thing I would like to say is we have to define what we mean by accountability. There’s not only legal and judicial liability. There’s also the way that each armed group or armed forces can enforce discipline in their own ranks. I know that a lot of organizations, Geneva Call, the ICRC, are working with parties to conflict in order to have that kind of mechanism system reached.

We’re not only talking about immediately. Sometimes, in particular in the UN, when you hear of accountability, you know it’s ICC, criminal, etc. I think that we should start by defining what accountability is. What kind of accountability you want, what kind of accountability is appropriate and start working with parties to conflict. Then, if you’re talking about judicial accountability, I think the first way to go is to try to work with national authorities. In basically every country there is some sort of a judicial system. Some of course sometimes are not always very operational but you cannot simply say that we’re willing to pass on what happens nationally in your country. Sometimes states are willing also to enforce accountability.

It’s not always the case. When it’s not the case, when you’ve pursued those kinds of avenues, when you have discussed with governments, when you realize that there is a lack of willingness or lack of capability to enforce judicial accountability first you need to have investigations. There’s a broad range of potential mechanisms. Again, you have national mechanisms to investigate incidents. Because all incidents do not necessarily lead to judicial prosecutions.

The Security Council dispatched some fact-finding missions in view of ensuring accountability. The Security Council also has the power to mandate fact-finding commissions in order to see if there are grounds for judicial prosecutions. Secretary General, too, without the Security Council. Basically my point is once you have exhausted the national possibilities, and I think this should always be the first step, then there’s a responsibility of the international community. The international community can do things, in terms of soft investigation, you have international humanitarian fact-finding commission which has never, never been activated. The Secretary General’s recommendations on implementation of 2286 make it clear that this is one of the avenues that should be explored.

Then, when it is clear that there is need for judicial accountability, here again you have international options. They are on the table and, quite frankly, I think that the Security Council and most member states know those options. You have the ICC, of course. You have options on the table. I think they are already known, at least by those who can resort to those options. The question is of the political will.

Philip Spoerri, ICRC: I think you went through the list of the things national and what exists internationally. The only point that one should make I think is that one has to be frank that despite the fact that ideally national courts would and that’s on the international level, the international court and all these systems are still rather embryonic in their sort of outreach. In most of the situations in the conflicts to see how much you would have judicial accountability is also often very weak. There is of course a huge gap that people are not held to account. Of course, you have the other types of mechanisms where conflicts are ongoing, the ICRCs and the others try to bring forward compliance. This remains a huge challenge for all of us to address that. There is not a perfect answer to it, and many of the mechanisms that are foreseen are not working.

On the other question, I have got the point of it, but I feel that if you look at the principles, you take their origin, stepping, let’s say, from the Red Cross world to the various humanitarian principles to act, I did see that there are big efforts early 90s and throughout the 90s on the way these principles were taken onboard by the wide community of NGOs. The UN to cite not the least also incorporated these principles. I certainly think that there is an importance for dialogue that goes beyond because not everybody was necessarily part of dialogue for last 150 years for those who were discussing these issues all the way into the 90s. Nowadays, you probably have different actors of everybody onboard. It’s always important to try to bring people onboard around the number of principles that are affected in humanitarian action.

Lastly, again, that’s my personal conviction. I do also like the idea of diversity of actors and not having just one pool or one set of central actors because one does see that in certain contexts different types of actors, with different ways of operating, sometimes reach goals that others do not. There is also some beauty to the diversity, but obviously, while respecting certain number of principles.

Fabien Dubuet, MSF: Maybe briefly on accountability, first of all, I think it’s a very difficult, sensitive topic. When we negotiated 2286, obviously very quickly, this was one of the hardest and most sensitive issues in the negotiation. I think Julien mentioned that there are existing obligations if you look at IHL, it’s actually a very impressive and detailed system when it comes to accountability. Even in terms of individual criminal responsibility, the issues are very much political, as you said, rather than legal. There’s a whole set of instruments existing in the UN, outside the UN.

On accountability, for us, the most important thing when we have a serious security incident is to establish the facts. It’s not about justice. It’s not about the ICC. It’s about really understanding what happened so that we can adjust our dialogue with the belligerents, so that we can adjust our security policy, so that we can maintain a lot of operationality in the presence of usually international and national stuff.

On the second question, it’s a difficult one because on the one hand, one of the main characteristics of the international community for the past 15, 20 years is the development of the multiplication of actors. This comes with a number of positive news and less positive news.

The kind of easy answer I could provide is that we do have at the central international level the Inter Agency Standing Committee, which is the body of strategic coordination for humanitarian action, including all or most UN agencies, some NGO platforms, of course the ICRC and IFRC, etc. This body has defined and adopted a series of common standards, of common rules, on a variety of topics.

There is diversity and actually in MSF we believe in this diversity. In some crises it’s actually good to have diversity of operational strategies. Look at Syria. It’s so difficult that I think we all are doing something. It’s a bit of a puzzle. It’s not enough, but none of us are satisfied with the sort of operations we have. We don’t have the operations we should have in Syria. That’s a reality. I think at the end of the day, the diversity of actors enables also a diversity of response on the ground. We think it’s probably a positive development.

Sandra Paunksniene, SIPA: We’ll take other questions.

Speaker 5: If you were talking to the Security Council about this resolution: if you look at some of the states that we’re talking about where the acts are happening, they’re states that are either supported by Security Council members or actually a Security Council member themselves. And so with this article in trying to move things forward, how do you see that happen with Security Council agreeing to a resolution, based on what society likes? We all agree that health care workers shouldn’t be attacked and civilians. Then, on the other side, having the same problems in their own back yard.

Speaker 6: I have one question directed at the Red Cross. Two workers were abducted by ISIS. Is there any word on them, did they ever turn back up? Also, the UN resolution: what sort of enforcement can the UN do? What are their mechanisms for actually . . . You know you have the carrot and the stick—what sticks does the UN actually have?

Julien Piacibello, OCHA: OCHA was not really very involved in this resolution. But a group of states and humanitarian actors managed to get a consensus on a text which is comprehensive, which is strong, despite all the differences you might have amongst all the Security Council members. That’s the positive step. That doesn’t mean that there is a very strong consensus on the way to go from now in order to make progress. It doesn’t mean that it removes all the divergences and the internal problems that you have in the Council, honestly.

The fact that all the members of the Council were able, at this point in time, to agree on a text that is as strong as 2286 means that if we do our job in the UN that might answer, in part, one of your questions, if in the UN we do our job. We provide information on what is happening or not in implementation of 2286. If we continue to bring the issue to the Security Council consistently, if we manage to, let’s say, maintain this strong voice on the issue, then at some point, the composition of the council is not fixed. The political dynamics are what they are. They might change. I cannot tell you that there’s no challenge that is linked to those kinds of political divergences and dynamics. What I can tell you is that we have the normative basis now to try to continue to bring the issue to those who decide.

In order to respond to the question, what the UN can do, what sticks the UN have, depends on who you’re talking about. The UN, it’s the UN Secretariat? It’s the UN institutions such as the Security Council? That’s very different. The Security Council has a lot of sticks. It can even create sticks, if it wants. That’s a big stick.

All members of the Security Council are not of the same opinion on the way to go or whether to use the sticks or not. The UN Secretariat, we don’t really have a lot of sticks. It’s different. What we can do and I’ll be honest with you, in terms of concrete progress in the field, it’s not much. It’s really not much. I’m not saying nothing. I’m just saying that if you don’t have states and parties in conflict willing to engage, we can only do so much.

If you have states and parties to conflict, which are willing to engage, we have a supporting capacity that can multiply their efforts and the impact of their efforts. What we can do in a manner that doesn’t depend completely on states and parties to conflict, is to continue to bring the issue, to keep the issue alive in the Security Council. To try to improve the way that we collect data, that we interpret data, that we analyze this data. We can do something, the humanitarian community can do that, but the UN is also peace operations. It’s also peacekeeping operations.

When you look at 2286, the Council expresses its intention to mandate peacekeeping operations, to where relevant, contribute to the establishment of an agreement that is conducive to the protection of medical care. These are concrete things that we can do until there is more willingness, political traction. It’s very important I think to try to do everything we can until there is a real particular convergence again on the subject.

Philip Spoerri, ICRC: On cases of abduction, I don’t really like to comment too much on such cases. I mention one fact of the realities that organizations like ours have to deal with that challenge all the time. I think MSF would have many examples. At any moment in time we are facing situations. Last year, we have constantly situations where we had to deal with abduction cases. That is something that we manage as an institution ourselves. Our security cells are on the ground, at the headquarters. The toll that takes psychologically for us, but of course the families and sometimes these cases also last over a long time.

It is really a major issue for an organization to handle. Sometimes even multiple abductions at the same time. Often and most often, these abductions, they end in a way, a good end but we’ve also had some very tragic incidents. That is also a reality for too many humanitarian operators these days and having to deal with these situations.

Fatima Khan, WHO: I won’t talk about the Security Council too much. But I do think we have to look beyond the Security Council and look at who they are and who they’re comprised of. They’re national governments and they have constituents. They have national policies. They have foreign policy that’s driven by what their citizens want. In order to make an impact or change the way Security Council members are going to vote on a situation or take a position, it really also comes from the grassroots community level in their own countries. That’s where NGOs, academic institutions, and individuals really come into play. If there’s enough noise and enough advocacy within countries, it could eventually make an impact on how members end up taking decisions.

Fabien Dubuet, MSF: I very much agree with Fatima I think on the Security Council. I don’t want to escape the question. In fact, our international president herself answered your question, in a way, in a speech she delivered in September when we came back to the Security Council in relation with 2286, to discuss the recommendation of the Security General to operationalize the resolution. It’s a very good document, by the way, which I really encourage you to read.

In a way, she said to the Council, you failed when you passed a resolution in May, last year. So she had a very strong message. I agree with Fatima that we need also to look at the members in the Council, separately. It’s no secret that on Yemen, three of them, maybe four, actually are very involved. It’s no secret on Syria, a lot of them are involved. I think for us, we’re back to what I was trying to describe earlier. When do you decide that the sort of dialogue and negotiation that you’re having is not enough. Then you look at these countries, and you try to see how they will assess the political or reputational cost. If MSF, for instance, goes public on these issues.

I think each situation is very unique. Again, you have to go back to the context, obviously. Then these member states do not necessarily react the same way to security incidents. The way, for instance, the United States reacted to what happened to us in the country of Afghanistan is very different from the sort of reaction that we’ve been experiencing with Saudi Arabia on Yemen or the sort of reactions we’ve seen or we can see from Russia on Syria. I think there is really a diversity of situations. For us, it’s a bit of a responsibility to look at that on a context-per-context basis. Also, as Fatima has said, really looking at the constituencies inside these countries.

Sandra Paunksniene, SIPA: Perhaps panelists would like to say concluding remarks for the discussion and maybe reiterate how all of us could be involved in ensuring that less violence occurs for medical assistants in armed conflict.

Philip Spoerri, ICRC: I showed the further resources how each one of you can get engaged. I am heartened just seeing how this has evolved over the years. More and more organizations are getting involved. Because this was not the case just five, six years ago. If I take it from this side of the table: WHO is now focusing on data collection and analyzing, and this parts the work that has been done by OCHA in following up with the UN yearly sort of checking how the trend is going forth, not to speak of MSF who was of course with us on this right from the start. And for many, many actors that are widely in the health community this has become an issue, and there are many practical recommendations that are there and just require a constant reminding and energy to getting a justifying call to all of us to keep this topic alive and keep pushing. Yeah, I just want to thank you. Thanks of course to all of you who have taken the time to attend this session, thanks.

Julien Piacibello, OCHA: I would just like to of course thank all of you for attending tonight. Just maybe say that I hope I didn’t give the impression that 2286 or those numbers, it’s not only bureaucracy, it’s not only something that is on paper. This is something that is on paper, but that’s also the expression of a consensus of the Security Council at one point. It’s very important to realize that it’s not just a piece of paper. It’s something that is going to drive some efforts on the ground, concretely. It’s going to make a difference from presences on the ground because there is a document that has an authority and that some of our colleagues in the field are going to be able to use in our discussions of these governments and discussions with parties to conflicts.

Of course, it doesn’t solve the issue. The real issue is the implementation of the norms from the ground, the compliance with the norms, to trying to make progress on this. But don’t underestimate the importance of the norms themselves and the significance of the adoption of Resolution 2286, because I think the way to go now is to use this to try to make real progress on the ground. Thank you.

Fabien Dubuet, MSF: Briefly, just to thank you very much for this invitation and the ICRC, the American Red Cross. I think this is part of a broader conversation that we are very much having actually, the four of us, almost on a weekly basis these days. You can be part of this conversation. I’m sure you’re all on Facebook. Some of you may even have Twitter or Instagram. I think it’s easier today to be part of it. There will never be enough people on deck to defend the values of humanity, dignity, solidarity. Please get engaged, be here, be there. It’s very important. Civil society has a real role to play. In the past and the future will continue to make sure that the number of things happen or doesn’t happen.

Fatima Khan, WHO: I just would like to say also as my colleagues have said, that this is a major achievement just having the issue of attacks on health care on the radar at the Security Council, even at the UN. The situation has changed a lot, my organization has also evolved a lot in how we advocate and deal with this. I think we’re on a positive trajectory, but it’s slow. In the UN things are always a bit slow and it takes time.

We hope that we can continue to move forward, and this discussion was very helpful to start a conversation and hopefully we will continue that conversation. I guess as we do move forward, the thing that we should always keep in mind is when we talk about norms and standards, we talk about numbers and data that the best way to make a real impact is to remember that the human face of it. That we’re actually talking about human beings, when we talk about health workers and we talk about patients and victims.

I think we have to be more creative in how we tell the story. We already have been telling this story and there’s many stories, weekly, daily about doctors in Syria, doctors in Iraq. There is an article in Time Magazine about the Ebola workers, or the Ebola nurse who tragically passed away recently. It’s these kinds of things that we have to keep on bringing to the forefront because, after all, Security Council members are people, right? We just need to connect in a human way to make a big difference. Thank you.

Sandra Paunksniene, SIPA: Just to conclude: I believe all of us believe in a thorough overview of the attacks to health care access and workers in combat zones, as well as a better understanding of each organization and different approaches that you’re taking to addressing the topic. Thank you everyone for this successful event. Thank you American Red Cross and ICRC for organizing it and have a wonderful evening.

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