A panel of practitioners explored the complex relationship between UN peacekeeping and medical services at an IPI panel, “Healing or Harming? United Nations Peacekeeping and Health.” The November 12^th event also marked the launch of an IPI report of the same name.

Health emergencies, like the Ebola outbreak in West Africa, present particular challenges for UN peace operations. The panel assessed the contribution that peacekeepers make to improve health outcomes, as well as the unanticipated negative effects that they can have.

Peacekeepers can contribute to a host population’s health by facilitating access for humanitarian aid agencies or delivering health assistance directly.

But they can also present a health threat to the host population, face health risks themselves in challenging environments and actually aggravate the problem by confusing the responsibilities of military and humanitarian actors in the delivery of medical assistance.

Simon Rushton of Chatham House, a co-author of the report, outlined the key differences between “what peacekeepers do in theory and what they do in practice.” This difference “raises some real challenges both in terms of pre-deployment planning, identifying the resources that are needed for a mission, and effective oversight of what missions are actually doing in the field,” Mr. Rushton said.

Sara E. Davies of Australia’s Griffith University, the report’s other co-author, said the “primary function of peacekeepers is the delivery of the missions’ military and political objectives.” However, she said, in areas where humanitarian access is “difficult, dangerous, or sparse,” and in emergency situations, peacekeepers often take on humanitarian responsibilities, especially the provision of medical assistance.

A comprehensive review of the mandates of current peace operations worldwide by the authors found language ranging from peacekeepers being formally mandated to provide direct humanitarian assistance, to mandates that, by contrast, made no reference to their humanitarian role, she said.

In that vein, Mr. Rushton said that this spectrum of mandates leads inevitably to situations in which “individual military medics will provide services even when they are not supposed to, in extreme cases, even in direct contravention of their orders. And this they do for good professional ethics reasons, they do for good humanitarian reason.”

The challenge for the UN and its partners will be finding a balance that “doesn’t necessarily restrict what well-meaning medics are able to do,” he said, while still raising awareness for peacekeepers to some of the “potential inadvertent harm” that could be caused by providing medical assistance.

Military medics are already grappling with criticism from NGOs caused by one such consequence—increased attacks on humanitarians. This has partly been due to medical assistance provided by the US, UK and the national militaries of the coalition in Afghanistan and Iraq, as part of a strategy to “win the hearts and minds” of local populations.

With the lines between military and humanitarian actors blurred, Mr. Rushton acknowledged that an “erosion of humanitarian space” is a problem. “Explicit use by peacekeeping missions of this ‘winning hearts and minds’ language to describe their provision of medical service to civilians—that’s something which at the very least should raise some concerns,” he said.

Anthony Banbury, Assistant Secretary-General of the UN Peacekeeping Department of Field Support, agreed with Mr. Rushton that there are political dimensions to problems often characterized as purely techincal. This, he said, is “one of the mistakes the Secretarait has made.”

“These are technical issues, but they are political, policy issues, that have implications that go well beyond the healthcare community, and I think that is a really important point to take away, and we in the Secretariat probably spend too much time looking at it from a technical perspective,” he said.

Mr. Banbury also raised the question of what should be UN peacekeeping’s role when a health crisis arises where there is already a political mission on the ground, citing the examples of cholera for the United Nations Stabilization Mission in Haiti (MINUSTAH), and Ebola for the United Nations Mission in Liberia (UNMIL.)

A health challenge that has plagued several UN peacekeeping missions has been the spread of HIV/AIDs. Mr. Banbury detailed the UN’s shift in strategy to stop the virus’ spread to either host populations or peacekeepers.

“There was a very conscious decision to put condoms everywhere in all the UN peacekeeping offices—all the restrooms, offices, they’re everywhere and you can get them by the fistful, if you look at some of the numbers at how many condoms we bring into Liberia—I mean, millions—you really, really wonder, ‘what on earth?’ he said.

Mr. Banbury recognized a tension between the “signal” bringing millions of condoms to a mission could convey, and the intention of the UN behind it, for an agency with a persistent problem of sexual abuse and exploitation.

That is why, he said, “We’re working very hard to prevent that, telling our personnel, particularly uniformed personnel, but not only, that they should not be fraternizing, even in a consensual way, with the local population.”

He said another challenge for peacekeeping operations was a lack of consensus on responsibilities amongst the UN Security Council, host governments, humanitarian actors, and UN Peacekeeping. “What is it that we are trying to achieve in that country and who is doing what? Is it a peace and security agenda, is it a development agenda, is it a human rights agenda, is it all of it?” he asked.

“Unless we have clarity on what exactly the objectives are and who is responsible for pursuing it, we end up with the types of situations, far from desirable, that Sarah and Simon point to, where you have UN peacekeeping personnel providing services where it may or may not be related to their mandate. They certainly aren’t resourced to do it,” he said.

The Assistant Secretary-General also raised concerns about the adverse impact on locals systems when a peacekeeping mission provides health services without building up a sustainable national system.

“If the UN doctor or nurse are there, and are going to provide good care, does that impede the development of national healthcare systems?” he asked. “If we’re in a country and 10 years later the UN provided a lot of medical care, and they can tick off the tens of thousands of people they assisted, or maybe they can’t because data is not there, but is the local clinic in any better shape than it was than when the UN Peacekeeping mission arrived 10 years earlier, and it would be a real shame if the local healthcare system is not in any better shape at the end of the 10 years than it was at the beginning.”

Mr. Banbury said that the range of opinions among Troop Contributing Countries (TCCs) about peacekeeper relations with the host populations, including methods for providing healthcare, mean “it’s hard for us in the secretariat to develop a single approach, even differentiated for different conflict situations, because of the varied views of our TCCs that we have to take into account.”

He mentioned favorably that the UN Supervision Mission in Syria (UNMIS) was the first peacekeeping mission to provide mental health services to peacekeepers.

Ms. Davies lamented the scant existing information on peacekeeping and health. “Most the literature that we found tended to focus on peacekeepers deployed from Europe, Australia, Asia, and to a lesser extent South America,” she said. Noticeably absent from the list, was research on peacekeeping missions in Africa.

Dr. Adarsh Tiwathia is UN Peacekeeping’s Senior Medical Officer. She disagreed with the report’s authors that the UN should bear the brunt of responsibility—and cost—of pre-deployment medical checks for peacekeepers. National militaries, she said, are already conducting similar screenings annually. “We want to move away from the UN taking responsibility for this —we can’t—with 125,000 soldiers rotating every year, it is an onerous task, we can’t really do it,” she said.

She concluded the panel by reminding the audience that while the term “standard of care” is often evoked at the UN, it does not have a universal definition. The UN medical services are currently establishing guidelines for all member states to follow in areas including hygiene, safety, and surgeries in the field, she said.

“A standard of care in New York is going to be different from standard of care in Mali, and different in India—my country—and it is going to be totally different from a field hospital,” she said. “I have a military background, what standard of care we give, what is acceptable in a military environment, in a warzone, is not what would be acceptable in Cornell or NYU [hospital], so medical services are playing catch-up, trying to put in place standards of care,” she said.

Warren Hoge, IPI Senior Adviser for External Relations, moderated the conversation.

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