Rabin Torbay - International Medical Corps

Mr. Rabih Torbay
Senior Vice President for Programs, International Medical Corps

Preparing and Working Together to Save Lives

Over the past two days, we have discussed how to make the world a safer, more secure place. This is an obvious priority from a humanitarian perspective, especially for an organization like mine that all too frequently finds itself delivering assistance in highly unstable environments. International Medical Corps today implements relief programs in some of the most volatile provinces of Afghanistan, in the western governorates of Iraq, in the Darfur region of Sudan and the unsettled eastern provinces of Democratic Republic of Congo.

I believe it is generally understood that defense and diplomacy alone cannot create a safe and stable environment on their own. As essential as these are, they only create optimal conditions for the most important component of a society’s long-term security and stability: Development.

It is also obvious that to deliver this package of defense, diplomacy and development, civilian agencies such as mine and military organizations such as those represented by so many of you here today must work together. It is in our common interest to do so.

Consider this data prepared by Tuft’s University’s Feinstein International Center: Driven by factors, including climate change and population growth, the number of natural disasters reported globally has steadily grown over the past half century, from around 50 per year in the early 1960s to the neighborhood of 500 annually in the early years of the 21st Century.

Such prospects demand a new effort to reduce tensions that have long separated two of the most important, yet culturally opposite, actors that respond to major natural disasters-international non-government humanitarian groups like my own, and the military. With more and bigger natural disasters forecast for the future, our only choice is to find ways to ease the allergic reaction each has historically triggered in the other. Like it or not, the hard realities are these: In today’s world, we increasingly need each other; in tomorrow’s world we will only need each other more.

For the military, natural disasters in today’s world pose a new kind of security challenge. In countries where such events can overwhelm weak governments, threaten social and political stability and quickly raise broader regional security concerns, the job of containing their impact has become a military priority as well as a humanitarian one. Even if our reasons may differ, NGOs and the military share a common goal of helping victims and creating a stable environment.

Airlifts of food, medical supplies and emergency international relief personnel into Banda Aceh following the 2004 Asian tsunami by the U.S. Navy and Marines and the armed forces of Australia, Japan, India and others, exemplified this nexus. It is a perfect example of how the military’s unique strengths can help ease a major humanitarian crisis.
Non-government humanitarian aid groups also face daunting new challenges, including deteriorating security conditions, tougher access to remote disaster areas and a real-time need for basic information about the disaster itself—all areas where the military has the potential to help.

Against this backdrop, it is not surprising that civil-military relations have been a highly visible, hotly-debated, topic in the past few years. Many scholarly papers have been written about the issue. There have been more interaction between some NGOs and the military, but so far, only a few have gone beyond the” getting to know each other” phase.

Today, to highlight the importance of preparedness, I want to explore two very different kinds of civil-military interaction: Those that occur in more secure, permissive environments and those that unfold in unstable, often tense, non-permissive surroundings. The two examples I have chosen are Haiti and Afghanistan.


Haiti is the second oldest independent country in the Western Hemisphere. It was established in 1804. However, after gaining its independence from France, Haiti was badly misruled by a succession of dictators, who seemed to achieve little aside from accumulating vast personal wealth. From one of the richest agricultural lands in the Americas during its colonial era, Haiti became the poorest country in the Western Hemisphere, with a per capita income just a fraction of its Latin American neighbors. Today, it is unable to produce enough food to feed itself and malnutrition is visible, especially among children. Life expectancy is short and infant mortality is high. About 12% of children die before their first birthday. One third of all children perish before their 5th birthday. The population of Haiti today is about 8.3 million people. Just under half are illiterate and even before the recent earthquake, about 80% lived below the poverty line.

The seeds of Haiti’s poverty and disease lie in a culture of political ineptitude and corruption. As it has in other failed nations around the world, the inability to provide such basic needs as food, medicine and education has bred contempt for the government, cynicism about its motives and a sense of hopelessness about the future. It is a potent recipe for instability.

It was against this backdrop that last January 12th, an earthquake measuring 7.0 on the Richter scale hit the Haitian capital of Port-au-Prince. It was a shallow quake and caused massive destruction in the capital and surrounding areas. It terrified the country and directly affected about 3 million people. More than 230,000 died and an estimated two million others were displaced. These are people that did not have much to begin with.

The local response was non-existent, but the international community responded quickly. Governments, aid organizations, the United Nations and militaries from several countries sent personnel and material to assist. Search and rescue teams poured in from all over the world. The U.S. Southern Command sent troops. The hospital ship, USNS Comfort, was dispatched.

My organization, International Medical Corps, was on the ground treating patients just 22 hours after the quake struck. Among emergency relief groups, we were the first to arrive from the “outside world”. Why? Because we had prepared for events like that and we knew what needed to be done.

The needs in those chaotic initial days clearly overwhelmed the response. Haitians went hungry and thirsty. Then they became agitated and upset. Sporadic riots and anti-government demonstrations broke out in the capital. However, the arrival of the U.S. troops brought calm and the arrival of additional aid and the provision of essential services stabilized the situation further.

Before I go into what worked on the ground in Haiti, I would like to talk first about what did not work well in the early days:
Aid poured in—both people and supplies-but much of it was based more on availability and an understandable desire to do something to help than on precise, targeted needs.

There was a serious lack of coordination across the board, specifically: Many countries sent search and rescue teams, but there was little coordination and teams failed to communicate with each other once on the ground; little, if any, communication existed between search and rescue teams and medical assistance groups supporting hospitals and other critical emergency services; there was little communications or coordination between the different militaries that came to help.
- A limited number of NGOs—I stress a limited number— decided not to cooperate with the military.
- There were too many VIP trips.

Now, the positives---and there were many.
- Overall, civil-military cooperation was good—some described it as excellent—compared to earlier disaster response operations.
- Troops on the ground immediately assumed a valuable support role. They secured hospitals, settlements and other essential locations. The very presence of uniformed soldiers from the 82nd Airborne Division patrolling the city center area of the capital, Port-au-Prince, had an immediate calming effect on the hundreds of thousands of frightened victims made homeless by the disaster, who were forced to sleep on the streets or in flimsy shelters erected in local parks or other open areas. These Haitians had lost everything, but they drew comfort that there would at least be order as long as the soldiers remained.
- In the confusion and desperation that characterized those early post-quake days, emergency medical teams, including those working with International Medical Corps at the Haitian National University Hospital (HUEH), also breathed a visible sigh of relief when the 82nd Airborne first showed up. With little fanfare, the soldiers established order. They calmed the anxious and unruly crowds of loved ones and passersby that had milled around the hospital’s main gate and organized access to the hospital grounds.
When the soldiers of the 82nd handed back the hospital’s security responsibilities to local authorities in late February, there was a sense of loss on both sides.
“We could not have achieved what we did without them,” summed up Dr. Neil Joyce, International Medical Corps medical director during those initial hectic weeks.
But the soldiers did far more than security. They helped distribute water and food. At the hospital, they transferred patients, set up tents and generators. It was military planes that airlifted in critically-needed supplies and it was soldiers on the ground that brought water and MREs to our doctors and nurses working at the university hospital and at mobile clinics elsewhere in and around the capital. Military doctors and medics treated patients alongside NGO doctors and nurses. “The soldiers’ presence was an altogether positive development for the medical teams,” concluded a recent article in the New England Journal of Medicine (www.nejm.org) signed by nine medical professionals who were among the first to arrive at the hospital after the quake. “By maintaining order and limiting the crowds of onlookers, they gave us more ready access to our patients.” Most importantly, the military reopened both the airport and the port of Port-au-Prince, which was critical for everyone’s success. The leadership of the U.S. 98th Civil Affairs Battalion (airborne) on the ground in Port-au-Prince clearly understood how to work with NGOs and the United Nations. They immediately dispatched a senior liaison officer to the UN Joint Operations and Tasking Center with the mission to provide support to NGOs and the UN based on needs and requests.

The initial response to the Haiti earthquake had an enormous impact. Countless lives were saved, essential services were restored and a fragile, yet tangible, stability settled over the capital. But the response also achieved something beyond that by proving two points: (1) that humanitarian organizations and the military can work together effectively in permissive environments, and (2) the impact of that cooperation can be far greater than if we each work on our own without coordination or collaboration.
The response also taught us that there is still room for improvement. For example:

- Serious joint civil-military planning needs to take place. We always react well, but we need to be proactive and prepare together for different scenarios.
- Communications and coordination between the NGOs and the military needs to be improved.
- A respected body or institution is needed that can act as a buffer or intermediary between the military and those NGOs that are still hesitant to work or cooperate with the military, even in permissive environments.

What should we take from the Haiti response?

This is a promising experience that should encourage us to do more. At one level, it has proven that a joint civil-military response can be effective and can have a favorable impact on humanitarian conditions following a major natural disaster. It can create or sustain the kind of stability essential to begin the journey to recovery. In short: It affirmed that NGOs and the military can work well together. However, we should not be content to leave it at that. We need to be proactive. Haiti must become a case study from which we draw positive lessons, then use those lessons to plan—together—for such situations so that next time we can be more effective. And as the Tufts University study I mentioned at the beginning of my remarks underscores, it is certain there will be a next time.


From the feel-good-about-ourselves response in Haiti, I want to focus briefly on a more complex issue half a world away from the Caribbean: Afghanistan, where international aid groups and the military work together—or at least are trying to work together—in a far more challenging, non-permissive environment.
It is a truism that the Sept. 11th attacks changed the world for us all. Before 9/11, Afghanistan was just one more far-off place and NGOs were mostly still seen as “angels of mercy”neutral, impartial, independent and hardly ever targeted. Even when they were thrown together in the same geographical space, the NGO and military worlds tended to remain separate. They rarely interacted with each other, let alone considered cooperation. There were occasional exceptions—Kosovo was one—but the norm was an uneasy co-existence.

Sept. 11th changed all that, nowhere more than in Afghanistan. Foreign militaries arrived to fight the non-Afghans who had planned and launched the Sept. 11th attacks from Afghan soil as well as those Afghans who had welcomed and hosted the attackers. According to the latest available NATO figures, 102,000 troops from 46 countries are currently deployed in Afghanistan. At the same time, diplomatic initiatives to rebuild a country emerging from years of foreign occupation, civil war and oppressive Taliban rule, have brought an influx of NGOs and other international organizations to implement ambitious relief and development programs. Since 2001, the United States alone has devoted over $14 billion on humanitarian and development-related work as well as governance and democratization programs. And this does not include counter-narcotics, Afghan military training or other security-related programs.

Initially, the traditional dividing lines remained in Afghanistan and the old rules seemed to still apply. NGOs did what they do best and the military did what it does best. Interaction was limited, but mostly friendly. Yes, there were “trespassing” issues, but, they were generally well-managed.
Insurgent attacks on NGOs were rare. In the months that followed the route of Taliban forces in the fall of 2001 and the retreat of Al-Qaeda’s leadership into the mountainous tribal areas along the Afghan-Pakistan frontier, conditions seemed to improve.

Then they got worse. By 2003-2004, the security situation began to deteriorate and every year since then, it has become more difficult. Steadily, more areas of the country have become active military operation zones between the Government/Coalition forces and a budding insurgency known broadly as Anti-Government Elements (AGE). The fighting has hampered humanitarian operations, complicating our access to affected populations. The Taliban reemerged in many areas stronger than ever and the conflict has steadily escalated. Between 2008 and 2009, incident levels rose between 30 to 35%. As civilian suffering has increased, the humanitarian space in which NGOs operate has become steadily smaller. Currently, less than 40% of the country is officially described as a ‘low-risk/permissive environment.’
The creation of the Provincial Reconstruction Teams with their military-civilian mix, plus the growing involvement of the military in what traditionally was NGO work has added to tensions between the NGOs and the military.

So, where is the civil-military relationship in Afghanistan now?

Today, perspectives and attitudes towards the military differ sharply within the NGOs community working there. Some—as in Haiti—want no interaction at all with the military. Others seem undecided just how to adjust to the military’s involvement in humanitarian affairs. Then there are those who have come to realize that the realities of the post-Sept. 11th era leave us no viable option: We need each other and we must find ways to work together.

I see this mix of reactions on the part of NGOs as part of a broader evolution in thinking about the civilian-military relationship that is now underway, not just in Afghanistan, but in other non-permissive environments, such as Iraq. It is a journey that for many humanitarian groups has gone from complete denial to a gradual—if sometimes grudging—acknowledgement that both they and international organizations such as the U.N. agencies on one side, and the military on the other, need to find a way to co-exist, coordinate and, where possible, collaborate.

All too often, the question we keep asking is this: Should a relationship exist between NGOs and the military and, if so, what is the best way to develop it?
But my question is the following: Can we afford not to have that relationship? Can we afford not to find a way to work with each other? Reality dictates the answer: No, we can’t afford it anymore.

Certainly, an effective relationship between the NGOs and the military is far harder to establish in a non-permissive environment than in a permissive one. The perception by local community leaders that an NGO is working too closely with the military can easily jeopardize the NGO’s mission and place its staff in serious danger. It is sometimes difficult for the military to understand that an NGO’s only real defense in non-permissive environments is community acceptance.

However, I believe there are ways we can build an effective relationship without necessarily having to interact directly in the field or engage in routine contact. Put simply, we do not have to flaunt it. The real foundation of a strong cooperative relationship requires both the NGO and military communities to get to know, understand, appreciate, trust and respect each other. Achieving this in the pressure-cooker of a non-permissive environment I believe is asking too much. This foundation instead needs to be established through frequent interaction, discussion, training and preparing together before deploying to non-permissive environments.

So, if you accept that we can no longer ignore each other and work in isolation, I see two initial challenges. We must:
- Ensure that we focus not just on short-term results, but, on longer term impact;
- Find ways to work together effectively without compromising either’s mission.

While I do not have a magic wand to make these happen, I do offer two recommendations to share with you in the hope we can think about them and begin to move forward with them.
1. We must learn to prepare, plan and communicate and we must learn to do this early and often. We need to listen to each other and learn, first to understand, then to respect each other’s roles. We need to remind ourselves that we share the same goal. In Afghanistan, this goal includes the well-being and safety of the Afghan people, the sustainability of our actions and the long term stability of Afghanistan as a free nation. If we focus on these goals in whatever plans we make, we can have an enduring impact.
2. There are situations in non-permissive environments where open, visible coordination could compromise us. That is the reality. I believe a viable alternative in such situations could be to work through an intermediary. We call this creating a buffer. The intermediary should be a body trusted by both NGOs and the military, whose role is to facilitate dialogue and interventions. Many NGOs have found this to be critical in non-permissive environments, but also occasionally useful in permissive environments.
To summarize my remarks, I believe the military and civilian organizations such as NGOs need each other and we need to be serious about finding ways to cooperate in both permissive and non-permissive environments. Ignoring each other is no longer an option. Cooperation is the only way to maximize the impact of us both, not just on the welfare of the people, but in our efforts to bring stability and ensure the security of a country.

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