 All right, well, good morning and thank you all for being here today. My name is Talia Dubovie and I am the Associate Director of the Global Health Policy Center here at CSIS. Before joining CSIS, I spent several years on Capitol Hill handling national security and foreign affairs work where this question of the protection of health and humanitarian workers was a theme that ran through much of what I did. So I'm very happy to be here moderating this panel this morning. Before we start, I want to note that this is the first of two panels this morning focused on health. The second will be next door at 11, focused on the U.S. response to the Ebola crisis in West Africa. We are here this morning for a discussion on health and security in fragile states and dangerous places. In 2013, 155 humanitarian aid workers were killed, 171 were injured and 134 were kidnapped. These numbers represent a 66% increase over 2012. Our panelists here today will discuss what this means for governments, international organizations and NGOs' ability to effectively carry out humanitarian responses. What does this increase in violence mean for recruitment, training, protection, retention and care of humanitarian and health workers? And what more can or should be done to provide adequate protection for this critical work? We have a terrific group of panelists with us today. I want to note that Gail Smith from the National Security Council sends her regrets. She was called away at the last minute, so even though she is listed in your program, she unfortunately will not be here this morning. I will give a brief introduction of our three panelists, and then I will turn it over to them for opening, brief opening remarks. We will follow that by a short discussion up here, and then I'm going to open it up to the audience for questions. Nancy Lindborg is the Assistant Administrator for the Democracy Conflict and Humanitarian Assistance Bureau at USAID. In that role, she has led the Bureau's response to the Arab Spring, the war in Syria, the droughts in the Sahel and the Horn of Africa, and numerous other global crises. Before joining USAID, Nancy spent 14 years as the head of Mercy Corps, where she was instrumental in building a globally respected organization known for innovative programs in the most challenging environments. Ruse Shaya Chauvet is a physician with broad experience and expertise in international public health and humanitarian action. He is the former head of the Health Division of the International Committee of the Red Cross, and former head of the Health Department of the International Federation of the Red Cross and Red Crescent Societies, the only person to have held both those positions. He is currently the Medical Advisor for the ICRC's Health Care and Danger Project. And Jason Cohn is Communication Director for Doctors Without Borders, or MSF. He has overseen crisis and advocacy communications campaigns for MSF ranging from the Haiti earthquake and cholera epidemic to global childhood malnutrition and HIV-AIDS. He recently conducted a risk assessment analysis in South Sudan and Myanmar for MSF's Medical Care Under Fire campaign. As I mentioned, I have asked each of our panelists to provide brief opening remarks, three to five minutes. And once they've all spoken, we will turn to the discussion. And with that, I will turn things over to Nancy to get started. Great. Thanks, Talia. And great to see everybody. And I can tell by looking out that there are a number of you who have your own deep experience in working in insecure environments. And this is a conversation that has been going on for certainly the 20 years that I've been doing this work. And for a number of those years, we used to comfort ourselves by saying, but yes, in fact, car accidents still account for the greatest number of deaths among aid workers working around the world. And I think what we've seen, at least in my experience, and I think the data suggests that the last couple of years we have seen a qualitative shift, probably both in the intensity and the scope and the complexity of the crises where humanitarian and health workers are called upon to provide assistance. And as I look across the globe and see a roster of crises that include South Sudan, Central Africa, Republic, Syria, Iraq, Somalia, Myanmar, and in a different sort of threat environment, West Africa, Ebola crisis, we are seeing an uptick in not just working in dangerous environments, but absolute targeted attacks on health care workers. And Syria, I think, really hit a high water mark in terms of the way in which, first the regime, and now we're seeing, with some of the terrorist actors, health care workers and humanitarian aid workers are absolutely targeted. And the numbers of those who are killed continue to rise. And we're seeing a lot of unmistakable evidence of clinics being targeted by bombs so that both the health care workers and the people that they're treating become immediate victims. We also have seen in the past 12 months in the Central Africa Republic, there have been about 50 specifically targeted attacks on humanitarian workers. And so what used to be the kind of more negotiable crisis environment where there was always a threat of kidnapping and one needed to be able to negotiate among various armed actors has shifted so that, in fact, sometimes health care workers, humanitarian workers are, in fact, the specific target. And this is something that we, I think, all of us need to pay very close attention to. I want to note just two things. The first is the way in which at AID, we are shifting how we think about the cadre, the people who go out there. And there's been a year long effort inside AID to have a much closer look at the kind of training that we provide our people. And actually not just the humanitarian side of the house, but even the development actors who are increasingly called to work in environments that are more dangerous, you know, think Libya or Somalia or DRC, and provide a heightened level of training so that they have the tools, they have what they need to be able to stay safer, and also for the care component for when people come back from very high threat environments. We've put a lot of investment into staff care and to the kind of counseling that helps people better prepare, be better prepared and better counseled upon their return. On the program side, we're increasingly looking at the kind of programs that we need to be able to do in high threat environments that have a different kind of footprint and a different kind of profile. And I would just flag Somalia was a really important example of that. And we saw during that famine when you still had El Shabaab holding large swaths of territory that in many cases, people just could not get in, very few internationals could penetrate very far into that country. And yet we were seeing famine indications on the rise. So we really pivoted to an approach that relied heavily on use of market forces, both in terms of using traders to bring food in and so providing increased supply into the markets while we also enabled through cash vouchers to create the ability for people to purchase from the market. So it really modeled a very different approach for how to provide a market-based humanitarian assistance where you had such constrained access. And then, and we're also having to look at all the ways in which you can do monitoring and evaluation in environments where you do not necessarily have access. And we've seen a number of our partners really push the frontier in places like Syria using barcodes, for example, to track where items go so that there's some understanding of the aid is in fact reaching the people you need it to, greater reliance on technologies. However, I would say that I am struck by, and it may be given how many crises we have going on right now, that we have, I believe, a shrinking cadre of both organizations and people who are willing and able to go into these very tough environments. And those who do have the skill set and the systems, the familiarity with working in high-threat environments right now are pretty stretched. The Ebola crisis has added to that, particularly given the pull on healthcare workers and the threat specifically to healthcare workers in that environment. I'm seeing that we don't have the pipeline of humanitarian workers that we really need to meet global demand. And I believe all of us will need to have a continued focus on how to ensure that we have not just enough healthcare and humanitarian workers, but the kind who are trained and ready and willing to work in those environments and do so with different approaches and in close partnership with those who are really on the front lines, which are usually the community members, local NGOs, leaders of those countries. So, thank you. Thank you. So, thank you very much for inviting the ICRC to this important event. As described, the pattern of attacks on healthcare workers became such an issue that the ICRC decided to have a big study called the 16-Country Study, which took place between 2008 and 2010, at the end of which the International Conference of the Red Cross and States, which have signed the Geneva Convention, gave the mandate to the ICRC to lead a project called Healthcare in Danger. With a very simple objective, improve delivery and security of effective and impartial health in situation of conflict and other emergencies. But this very simple objective, as we know, has different components that are quite intricate and complicated. The fact that we have problems is obvious. We know all of that. And even if we don't have a baseline that can prove and give a trend, no one today will contest the fact that it's a very important problem. Violence against healthcare workers has to stop and to be well understood, we don't need any set of new laws. We just need to implement what exists already. In 2012, I was based in Beirut and I was receiving regularly visits from doctors coming from Damascus and one of them told me that for him it was more dangerous to be arrested with Kalashnikov in his car compared to a dressing kit because Kalashnikov, everybody will understand that he's trying to defend himself. With the dressing kit, he will be maybe treating someone from the opposition. I think this as such is quite a worry trend. More recently, we've seen that during the Ebola crisis, healthcare providers coming to help people have been killed and lack of information at the community level was obviously at stake. We gather evidence, we continue gathering incidents, but I just want to say that ICRC publishes on the yearly base incidents that are coming from 23 different delegations, but we know that this is not representative as such as the reality, but at least it helps people to understand what are the different patterns happening in the field. We've got military, politicians, health professionals, volunteers from national societies, gathering in 11 workshops, came out with a lot of recommendations, all of them are now available. A few examples, we cannot prevent military entering into a health facility. This, by experience, we know that's not possible. But what we can do is make sure that in the standard operational procedures of military, that they bring medical people with them just to make sure that they are not going to disturb everything inside the hospital. We know that fighting can also happen around hospital. We've been talking to military people to see how we could, with their support, trying to limit the consequences for healthcare providers. Sometimes, also, we know that families, armed groups are trying to push for their own patients. They don't care about who is treated already. They want their patients to be treated. And we are also working with, in different contexts, to see how we can adjust the perimeter around the hospital to avoid such incidents. The question we see more and more is the difficulty to balance access and security. You know, we need to access the victims, but also there are places in which the second blast is a current practice. So how do you balance the security of healthcare providers coming to support and help if you know that the second blast is possible? We've seen also and had a lot of discussions on perception and acceptance from the communities themselves. I gave the example of Ebola, but not only for Ebola, how communities are accepting the people to come and help. In this perspective, religious leaders have been, we've had interesting discussions with religious leaders in West Africa, trying to put healthcare in danger in between the Islamic jurisprudence and international humanitarian law. To conclude this short presentation, I just want to give you three key messages. We've been working through this project with a large variety of interlocutors. We've been working with MSF, we've been working with safeguarding health in conflict, World Medical Association, International Council of Nurses, and many more, all of them keen to work together to change the reality in the field, because at the end of the day, if we want to make a change, it's not going to be in this room, it's going to be at the country level, just to make sure that the people we bring interested to this process work together at the field level. My second point will be to say, let's avoid to concentrate only on hopeless cases. We know them, we know how difficult they are, and we have to bear in mind that there are several countries today that have managed to have a real change. I usually mentioned the example of Colombia, but Colombia is not alone. Afghanistan, Central African Republic, there are places in which people are trying to make a difference, so don't go only for the hopeless cases. And finally, in the set of recommendations we have, we see that a lot of the recommendations are on prevention, training, universities, research. No one has a magic bullet to solve the problems we have today in the field. We need to look at them together and develop evidence for decision makers to show that violence and health, they don't work together. If we want to make a change, we need to work together on that. Thank you very much. So thank you to CSIS for having MSF here today. Trying to repeat some of the very good points that both Nancy and Bruce have made so far. We had the same sort of questions as an organization operating conflict, operating crisis zones, and we expect that this is the environment we work in. It's gonna be dangerous. We need to accept levels of risk. We need to measure them. We need to respond to them and adapt to them. And we couldn't empirically state are things worse today than they were before, but certainly. I think the key thing that we have to recognize is in those of most acute crises, the Central African Republics, the South Sudan, the Syrians, there's a huge lack of assistance reaching the people that need it most. In our case, we feel very strongly also about the provision of direct medical care. To those victims of violence in those conflict zones. And really our aim in sort of carrying out our own work under the umbrella of medical care under fire, which has been really helped by the discussions with ICRC, was to understand, not just sort of really quantitatively speaking, how many incidents were happening, where were those threats coming from in the different places that we're working, but how at the end of the day, how is that influencing and affecting access to medical care for patients? If you have a hospital that's still being able to run, but patients aren't able to access it, are you really fulfilling your mission of what you're trying to do in terms of providing access to medical care? So we've taken sort of a qualitative approach of looking at a number, a wide range of diverse cases of countries that we work in. So everything from cars, I just mentioned, South Sudan, Honduras, city inside Tripoli in Lebanon, somewhat divided city. We're also looking at Myanmar, as well as the Congo, Kibera, Slum in Kenya, and really just trying to understand where are these threats coming from? How are they manifesting and how at the end of the day, are they impacting the medical care we're able to provide? I've done some of that work myself in South Sudan and Myanmar recently in the last year. It's been carried out by other members of our teams across some of those different countries that I mentioned. And I think what's interesting that we've learned so far and we're still very much in the processing part of this reflection, this analysis, is that the severity of incidents isn't necessarily correlated directly with the loss of access to healthcare. The level of violence that our teams deal with on a day in and day out basis in the Central African Republic we're able to still operate, albeit under very difficult conditions. Military personnel, state non-state actors entering facilities with weapons threatening staff threatening to take out and sometimes killing patients inside facilities. The same has been sort of happened over the last 10 or 11 months in South Sudan since the restart of the conflict there. But even before that, before the conflict started we had issues of trying to ensure the access to impartial medical care in an environment where you had inter-communal violence unfolding. And medical facilities not necessarily respected and a very difficult and fast sort of moving environment. Jux deposed that with a place like Yemen where of course there's always gonna be difficulties and challenges dealing with different armed groups there but also principally what we found is that there is a lot of tension around sort of the respect for the medical profession itself and how families view whether or not the quality of care that's being provided to their family members and that oftentimes leading to violence taking place inside hospitals or issues with ambulances. And in some ways that spilling over to a really an impact on how medical care is provided in terms of the ideas of treating people based on need or medical triage trying to influence who gets treated first. And also just playing out as a fear amongst doctors and so our national staff colleagues about do we take this patient, do we treat this patient, do we refer them to another structure and sort of almost absurd situation where no one wants to declare a patient dead because of the ramifications of what that would mean and what level of care you're able to provide. Then Jux deposed that with some of the issues that many of you may be aware of in Myanmar where we are trying to as an organization have not been able to work in a Rockhine state since February when we were expelled by the government in that part of the country and we're still working to try and try and get back in there. But even in the lead up even before that expulsion took place we faced a lot of challenges from the community which stem from a lack of acceptance of providing medical care to one side or the other. And that doesn't necessarily manifest itself in direct physical violence towards international staff for say but more arguably sinister ways of undermining the ability to provide medical care. Drivers are being threatened so we can't maintain referral services. Landlords being threatened so you can't maintain teams in the areas where you need to provide care. All sorts of the infrastructure underneath it and which eventually leads to and combined with certain policies that are put in place not being able to provide medical care to the people who you're trying to provide. So I can't go, I can tell you a laundry list of security incidents in South Sander car yet we're still able to operate in those environments. Yet in Myanmar you juxtapose that where arguably the level of violence has been less with the ability to provide healthcare has been diminished significantly in the places where we want to provide it. So I think it's interesting to understand these environments because at the end of the day aid agencies they work in specific environments. Global trends are interesting but they don't tell us that much about what we need to do to be adaptable to what the changing environment is. And also I think you've given some nice examples Nancy of how organizations are trying to sort of adapt and provide assistance in some of these areas. It's tricky I think for us as a medical organization trying to provide that direct hands-on care which we think is so core to our identity of providing care and that's how we see our accountability is that we know who we're treating and the patients that we're treating and we're treating them as partially as possible based on need. So that requires really talking to everyone talking to low level commanders and checkpoints all the way up the chain of the command and what I think we've learned and we've known this isn't something recent this has been true for as long as we've been working in these environments is that the guarantees you get at a local level or a very high level even obviously at the very highest level of a state or an opposition group doesn't necessarily translate into what happens on the field. You need to be able to have good level contacts and networking all the way up the chain of command and with communities as well. I think it's out Sudan it's been interesting for us to understand some of the most interesting things that I learned were through from anthropologists understanding the different dynamics around who controls and who has some sense of control on a monopoly on violence that happens in communities and environments. That manifests very differently sometimes between one ethnic group or tribe to another understanding those dynamics. They're not always hierarchical and they're oftentimes very different social structures that you need to engage with. I'll just end with so I think in many ways what we're looking at is it's really not necessarily innovation per se but back to the basics of what trying to do. All these places that we're talking about here there's a huge disconnect between the amount of need and aid provided. And we really strongly think, I think as MSF is that emergency response that's our core business and that's what we really need aid agencies to be working on and trying to focus most of their efforts on. And that requires that networking, that understanding, that dialogue, continued effort to reach and talk to all different levels of the different people that we have to deal with those environments. At a state level I think as what Bruce was alluding to is it requires the states recognize that all the sort of principles are there. They're in an international humanitarian law. They're in the Geneva Conventions. We don't necessarily need new treaties, new protocols, new things. Those basics are there. They're on paper. Governments have agreed to adhere to them. We need other actors to respect them. We also need to just respect the independent and impartial care aspects and nature of medical care, regardless who it's provided to and in what environments. And that's really important that we get sort of back to basics and acknowledgement of that. So I'll just leave it there. Great. Thank you all. You've given us a lot to discuss. I wanna pick up on one of the last points you made, Jason, is the point that risk mitigation is a very location specific activity. And I'm wondering if you could each talk a little bit about how you get the knowledge you need to go into each of those communities. And it's not just each country. It's each area. It's each village. It's each town. It's each tribe. And whether or not you need, now that you're seeing possibly these shifts in targeting of workers, do you need different partners? Do you need better information? And do you have the ability to get what you need to do your work? So I think you really need both. You need the generalized information and you need the ability to apply it. And I absolutely agree with Jason, very, very specific situations. And I think what we've seen over and over again is that oftentimes in these big conflicts, and I'm thinking of Iraq, Afghanistan, Syria, you have opportunities to more deeply engage at the community level before the violence becomes more difficult to get more people in, more international. And it's critical that you form those community networks to get that community acceptance that is really the backbone of being able to operate in some of these areas, even if you're not able to be there at the same levels of personnel. It is very different when you're trying to provide care using some of the models that I think MSF does versus a model that is supporting local actors. And so you do have to differentiate the kind of assistance that you're providing. But that local knowledge, that really specific understanding of individuals and dynamics is key. One of the things that we've been doing for about a decade, if not more, is supporting the NGO security networks. And these are the networks, there's one in Afghanistan, there's one in Syria, I think there's one in a lot of these high-threat environments where it's an opportunity to share that level of localized, highly contextual information real-time among all the actors. And I've seen personally how this works where, say you're driving from one city to the next, you check through this network of everybody's security officers so that you can see exactly what's happening on the road ahead or you can check on who the key actors are in a particular community. And I think that's been a very important development that brings additional sophistication to the operations, both of local knowledge but also of at any moment, the security environment. I think we can spend the whole day talking about risk mitigation. But I think maybe what will be interesting to say is, first of all, because the patterns of conflict have changed. You have also a different set of interlocutors and in some parts of the world, it became very complicated. You, as, you know, I think as all of us, you want to make sure that, first of all, you don't risk anything for the people you send to the field, as well as for the patients you're trying to treat. And to get there, you need to work on the image. So people need to understand what means independence, what means impartiality, what means the fact that you're not there to be, you know, sited. And so it is sometimes also a bit complicated. I agree that we have to work with local NGOs, but some of them will be felt as part of one side and so, you know, we have, through the project, we have a book on responsibilities of health personnel in which we try to explain very simply to health care providers, you know, what are your rights and responsibilities in case of a conflict, in case of an emergency? And this alone, I think, helps people to provide a positive image of health care providers in the sense of the needed impartiality. And I think this is really, to me, a key element of whatever happens in the field to develop risk education. If I may, just, we know a lot in the field, you know, talking to people at the ground level that not necessarily well known at the global level. Sometimes, all of us, we are a kind of link in the information that is provided at the global level from what we understand at the local level. Yeah, I mean, I think it's in terms of the risk mitigation, it's really a really open and transparent dialogue of what your intentions are as an aid organization for MSF. It's, you know, how that we're gonna offer care to everyone, we're gonna treat people in many environments, it requires a real explanation of keeping weapons out of the hospital and that will treat people based on need through a strict adherence to sort of medical triage. And I think it's sort of making sure that your operations and your rhetoric are aligned, right? That you're doing everything you can to reach populations on however many sides of a conflict they may be. I think, and also just from a personnel from a training standpoint is, at least for us, I think it's really been a reaffirmation of that while obviously there is a command and control in terms of who makes decisions about when teams are reduced, operations suspended, teams evacuated in certain cases, that everyone in the team has a responsibility around the question of security, that this isn't just something we delegate to somebody else or a specialist within a coordination team, that everyone plays a role and obviously the link with our national staff is absolutely so critical to that, understanding the environment and whether or not what the risks are, whether we're accepted in that community. So it's talking at all levels. It could be religious leaders, it could be local community leaders. It's also understanding sometimes how the fact that MSFs and organizations are gonna come into an area, provide free medical care. What are the economic implications of that, right? Because there are sometimes we have seen threats that have come as a result of displacing services that have otherwise been a means of the economy, the health economy for people. And that contributing to some of the dangers that we might face, we've seen that sometimes in Afghanistan and other countries as well. So it's really understanding what your, while your purity of your intentions might be, are very clear. There are implications that you don't necessarily see from the outset in terms of what risks you may or may not face, I think, in an environment. Just to pull this back a little bit. I mean, risk is an inherent part of these jobs. And so we talk about risk mitigation as opposed to risk elimination. How is that, how do you communicate that both to potential employees? And you mentioned the pipeline of trained and willing and able people to go into these environments. But then how do you also communicate that to your donors and your funders, particularly when your funders may be the US Congress, and how does that conversation play out? Well, I'm continually struck by the lack of focus and awareness of the risks that humanitarians face. That there isn't the kind, we just celebrated quite importantly Veterans Day yesterday. But we really need, we have a Humanitarians Day, I think it's August 8th. But it's not very well known. I'm even having trouble remembering the date. But this really needs to be amplified and celebrated. And we saw a version of this just two weeks ago with this sudden hysteria around the returning healthcare workers from West Africa. And President Obama made a big effort to hold an event at the White House to honor the healthcare workers, to try to change the narrative from one of stigma that these are possible disease carriers to really celebrating and recognizing and destroying your risk that they willingly took, that they volunteered to take. And this is true whether you're fighting Ebola or whether you are providing assistance in Syria or Somalia or any number of the places that we've all named. And so part of that I think is that all of us have a duty and a need to elevate that narrative that it is risky and not to pretend that we can mitigate or eliminate and prevent the risk. Secondly, and I think this is no secret to anyone in this town, the risk posture that is able to be taken by official Americans has become increasingly constrained. And so therefore it's even more important to have partners who are willing and able to get out there. I mean, I often say that if I hadn't been to a lot of these places prior to taking the position I have now, I would not have a very clear view of what some of these dynamics are because you just as an official part of the administration you don't have the opportunity to get out because of the risk inversion that we have right now. But without getting out and without taking those risks we cannot do the job. You cannot make the difference that it's absolutely imperative to be made. And so we need to really, really need to celebrate the people who do it, provide all the training that's possible, look at all the ways and I'm really struck, Bruce you're absolutely right, we don't need new conventions or need new laws but these are so not understood or respected by a lot of the critical actors who represent the risk these days. So it's really about what are the strategies, what are the ways in which we can make those more universally understood, respected and applied. And we keep whacking at it in different ways. AID signed a partnership with OIC about a year and a half ago and have worked very hard to bring all of the Islamic NGOs into a dialogue to really elevate and celebrate these laws. And I know that ICRC regularly provides human rights training for any actor that wishes to receive it. So Ambassador Mitchell has been relentless in his negotiations with the government of Burma to enable humanitarian actors to get back to work in Burkine State. But there's no easy answer to this and this will just take relentless effort. I think what we've discovered with the healthcare and danger project, I thought at the beginning it will be well defined, conflict and other emergencies. But more and more people are telling me we have the same problem at home. And when I say home, I'm talking about Spain, France, UK, that there are lots of countries in which the non-respect for healthcare providers is a real problem. So what I want to say is that I think the problem we are dealing with today are not only for the others. I think we need really to start to look at home what we can do. And maybe this helps also people, as you said, to understand what are rights, responsibilities, existing laws, what has to be applicable. I think we need also, fortunately for the ICRC, in most of the context in which we work, we have Red Cross and Red Crescent National Societies. They are strongly based on the ground and they can help us sometimes to really understand and contribute to limit the risk. Very often I make the comparison between what we do for healthcare in danger and what we do in the prisons. You know, when ICRC visits the prison, we have to talk to the health people in the prison as well as the health director. And of course the health people, they don't have the same problems as the health director. The director or the government has one objective which is about security. So you need to find ways to bridge the gap between the two. And maybe one way to do it is that to convince the health prison director that to invest in health and impartial health will contribute to security. Yeah, I think one of the things that we've been trying to do with our work on these different countries is really just to practically kind of give examples of what works or doesn't work in these different kinds of environments. To train our own staff and sort of improve the sort of institutional memory and lessons learned from these places and also share those lessons learned, I think, publicly as well with the rest of the medical and aid community. I think one of the things that some of the things we're seeing and we're learning practically speaking is is that there are strategies where we can maintain medical facilities in areas where it is safe. Oftentimes the cost of that is that those hospitals are serving one segment of the community or one ethnicity, let's say, because they're divided communities and they're actually geographically divided. So like a city like Tripoli in Lebanon where we have clinics that are in the Sunni and Shiite neighborhoods. And the ability for people to cross that and get health care is not really accepted or they themselves don't feel safe. You could say the same thing in South Sudan. You could say the same thing probably in Yemen in a lot of places. So there is sometimes a sort of a trade-off between safety and security and being able to provide care and your ability to actually serve everyone. And I think that's just, that's just in some ways the reality in the trade-off that we've seen play out time and again. Regardless of the context and where the threats may come and that's, I think that's very tricky. I think as you also alluded to the problems at home, well, is in situations of sort of political unrest, how we've seen in a place like Bahrain several years ago where basically healthcare facilities became also, in some ways prisons are places of interrogation as opposed to places of care. And the spillover impact of that of having to clandestine clinics being set up where so people could go if they were injured and get treatment. And no longer seeing those facilities as a place to go for care and what that sort of knock-on effect of that is. But I think we have a lot to learn, a lot to process and a lot, I think, to share. So bringing different people around the table is something we've tried to do in a number of these different countries we've been looking at. So whether they're ministries of health, whether they're medical associations, whether they're people in the security service, the military, et cetera. I think you guys have been doing a lot of that much more than we have proactively engaging members of the different militaries in different countries that you've worked in sensitizing them. We also have to expect that in a lot of the places that we're working in, as much as we would wish, that things like IHL are really not viewed necessarily as that legitimate. And so we need to figure out ways to explain our need to provide care and how we provide it in different language because those are policies accepted at the state or an international level, but they don't necessarily resonate when you're talking to a tribal chief of the Neware in Northern Zhongli State and South Sudan. I mean, we have to be honest. And they are sort of accepted to a certain degree a very high level, maybe at opposition or government levels, but when you get down to the brass tacks of implementation on the field, they don't mean much. And it really comes down to the fact that medical care, in some cases, is viewed as aiding the enemy. And that's something that we have a very difficult time overcoming that reality. Well, let's open it up for questions. I think we have a couple of folks running microphones. We'll do two or three at a time. And if you can speak into the microphone and say who you are and where you're from before you ask your question. Let's start in the middle here and then come up to the front. Len Rubenstein, I'm from Johns Hopkins. Today I chair the Safeguarding Health and Conflict Coalition. And I thank all of you for speaking on all the work you're doing on risk mitigation and protection. But the discussion tends to leave out a different element, which is that we know that indigenous health workers, not necessarily those who are affiliated as local staff of humanitarian groups are the principal victims. And a lot of these risk mitigation strategies won't work. So we have to look at other ways. And in the discussion, one approach is often left out and that is the monitoring, reporting, accountability mechanisms of the human rights community. Those have expanded recently. WHO is required now to collect data. Security council has an accountability mechanism under the children armed conflict mechanism. But it seems to me that that needs to be part of this. We even need criminal accountability like in Syria. But that's very rarely talked about. Now I understand the constraints of humanitarian groups in sharing data or in calling for those kinds of approaches. But I think leaving it out of the conversation is a huge mistake because that's got to be part of the solution. So I welcome your response. Hi, good morning. I had a question about a country that we haven't discussed this morning on Pakistan. Everyone knows that the KPK province is sort of a black box. And I was just wondering what advice you would provide to humanitarian donors and donors working in that country and specifically in that province. All right, why don't we start with those two? Jason, you wanted to jump in on that first one? Yeah, so I think that's a very good point. I mean, these strategies you talk about risk mitigation, yes, they absolutely, we can't, there's not a lot we can do for our national staff colleagues and many of the Ministry of Health or other workers that are affected by this violence. And a subset of our research that we're doing is specifically directed at trying to understand strategies that we could employ that would help improve the security management for our national staff at MSF. That's work that we've just sort of started in the last few months and involves interviewing numerous staff across a number of countries to sort of understand that. Because I think one of the big ethical and moral sort of hazards of all of this is how much of that risk do we devolve to those staff in a place like Syria where it's almost impossible to have international staff? How much do we put on their shoulders and at what point do you cross a line at the risk that you're allowing them to accept to do that work and the commitment in that? And it's challenging and I absolutely agree. We really haven't figured out how to do that better. Outside of the fact that in some places we're bringing so-called impacts from different parts of the countries and the responsibility we have to kind of bring them back to where they live in the country. But there's huge limitations and a lot of research that needs to be done to understand those thoughts more accurately. Yeah, Len, thank you for your question. I thought maybe I haven't been clear enough but the healthcare in danger project is not about humanitarian people. The healthcare in danger project is about all healthcare providers. And so we know from the data we collect that most of the people affected have nothing to do with ICRC, Red Cross or even MSF. They are affecting local people. So just to say that the set of recommendations we have are of course useful for us and the humanitarian family but they go far beyond this family. Concerning your second point and I agree on the importance of data collection. And I know of the importance to being able to quantify what happens on the ground, especially in Syria. But as I said also, I think Syria should not be a case that is so desperate that we don't look at the rest of the world. So that's the message. It's important to stress what's happening there but not to forget that there are many places in the world in which we can make also a difference. And just to your question about Pakistan. ICRC has been a few years ago brutally affected as you know. And since then we have sharply reduced what we've been able to do in Pakistan. Even if we know that Pakistan is definitely a healthcare and danger priority in many sense. I just want to say that nowadays we've had as a follow up of the discussions we had with Islamic circles, with Islamic relief organizations. We had recently in Islamabad a big meeting with scholars and that's what we can do today. Unfortunately, not enough. So I wanted to just respond quickly to Len. I think you raised a really important point and this of course is an age old issue in terms of how to, I mean a lot of humanitarian organizations have access to a lot of data. But we saw in Darfur what happened about seven years ago when a number of groups were kicked out because of suspicion that they were providing information that was relevant to the Hague. I think that the question also is it, it can act as a deterrent more usefully or more frequently. It becomes an after the fact tool. I think we haven't seen in Syria that it's useful as a protection device because there are lots of good reports that are coming out on a regular basis that chronicle exactly how many healthcare workers have been killed, the clinics bombed. That data's available and hasn't detoured either the regime or ISIL. I think it's critical to collect that and to know that, to publish that. I'm not sure it's actually protecting the lives of the very, very courageous medical people who are bearing the brunt of a lot of that targeting. But this is the ongoing conversation that we all have and will continue to have. Just to jump a little bit off of the Pakistan question, one of the things that I think we've seen over the last decade is a little bit of a blurring of the lines between national security priorities, humanitarian priorities, development priorities. And the kind of example that comes to mind very quickly is the vaccination campaign in Pakistan that led to the Bin Laden raid and what the fallout was from that for all of your organizations. But Jason, we were talking before this about the lines between development and humanitarian response. And I'm wondering if each of you could talk a little bit about how you respond, how your organizations are responding to both the mixing of these activities and kind of what you see as the way forward as a lot of these, as you see a lot of these lines continuing to blur and mix together. So on the relief and development mixing, I think we need to be just very clear about the environment in which we're working. Because I have been a significant proponent for the whole concept of resilience, which is fundamentally the idea that when possible, one needs to connect up the relief and development in environments where you want to promote a more durable and a faster recovery and enable communities to be able to bounce back. And that involves investing at the community at the regional, at the systemic level, and use those humanitarian dollars to set the stage for future success. And you need to blur it. I think that communities are not segmented into, okay, now I want emergency help and now I want development help. And so these are false categories that we have developed over the last 50 years as we perfect how we deliver assistance. That's very different, however, than when you're in a hot conflict zone when you're trying to navigate armed actors to deliver essential assistance. And there's no possibility of moving into a situation of recovery. You're just, it's just a keeping people alive. And that's a very, very different kind of environment. And you don't may need different actors who specialize in doing that. But we, at our peril, continue to wall off relief from development in all environments over long periods of time. Then you have the Hades where the NGOs were accused of creating separate systems for 50 years that didn't lead to any tangible progress. I will also say, since we're titled Fragile States, I take great part in the framework that's developed by the G7 Plus for a new deal for engagement with Fragile States. And it does require that one understands that to move out of conflict, you need to think about investment in things like legitimate politics and insecurity. And there are often countries where there's, maybe the political will, but not the political capacity. And there's a different kind of engagement that we need. So in my mind, what it comes down to is having a very clear understanding of the context in which you're working and the ability to make the appropriate choices based on that. Syria is still in a very hot crisis zone. However, there are communities in the North that are trying hard to not just, to not lose all of their market capacities and ability to have some kind of normal life for their families. Again, a question on which we can spend quite some time. Maybe, as you mentioned, the Fragile States, I think the definition of Fragile States goes very easily with the Fragile system, with the Fragile health system. And we know by definition that whenever we have to work, and this is what we do usually in most of the places in which we are together, is that the lack of investment in health that has a consequence on the capacity of the state to react when there is a problem like Ebola or a conflict. So this permanent distinction between relief and development I think has also been quite a big pain for all of us in the field, because I think the urgency to develop and to get a resilient system is sometimes much more important than just to respond to emergencies. As far as the ICRC is concerned, I just want to say that I think the ICRC wasn't part of the MDG's move in the 2000s. But it's certainly now much better position to contribute to what will be the post MDG's, the post 2015. And we see that what we developed through the healthcare endanger or whatever we developed as an activities can be a positive contribution to this process. Yeah, I think for us as MSF is an emergency medical organization, we're very focused on the emergency response. And I think the tricky thing for us is that we've seen sort of time and again, the inability to shift from sort of this interim and a post-conflict development programming, say in the South Sudan, back into very quickly into an emergency response mode. And I think there's a very tricky balance to strike between trying to understand that societies need to develop, they need to move on beyond conflict and the fact that most of the places in some of those countries like South Sudan or Qatar, arguably there isn't really a state functioning in the vast majority of the country to respond, particularly at least from our view to the health needs. And how can we sort of strike a balance between what the work of some organizations are doing with the state when all of a sudden that state becomes an active member of the conflict. And how do we balance that and how does that have implications for how those organizations are perceived, their response capacity? I think there's also a question of, from the donor side, institutional and government donor side, is where's the flexibility in sort of trying to strike a balance between the need to be accountable for the dollars provided to organizations to do what they said they're supposed to do in their grants and their contracts and what the needs of the situation at hand require. And that, we've seen that, I mean, we've seen that in Haiti in the cholera epidemic after the earthquake and the inability of groups to be able to shift and reprioritize as needs. We're actually seeing that unfolding a bit now, even though there's a very large machine moving in response to the Ebola outbreak, is that what we thought maybe a few weeks ago maybe isn't what we need today. And so how can organizations who are being funded less from private sources, let's say, and are more locked in and understandably, publics wanna know what those organizations are doing, what they're say they're doing, so there's that contractional accountability notion, but if it's not needed as the situation evolves, how do you adjust? And I think, you know, for MSF as an organization who largely depends on private sources, we have some of that flexibility in dependence and I think it's a tricky balance for other organizations. The place like Afghanistan, we had a lot of concerns, you know, where we were trying to operate, obviously in areas that were controlled by, largely controlled by the Taliban, at the same time, how do you balance that against working with the state who's viewed and being a part of developing that state for which another side is opposing that same development? Say what you want about the values and the principles of that development, there's still that question of neutrality, independence and partiality becomes quite difficult, I think, when you get down to implementation of programs and providing assistance in areas that are not controlled by the government, you're helping to develop. So I think it poses a lot of very difficult practical dilemmas. I think you raise really, really important points and just a quick response is that, through USAID's Office of Foreign Disaster Assistance, we have a great deal of flexibility and in the Ebola response, for example, those grants are as flexible as they need to be to enable the shift in the response. Where we have had less flexible ability is in our longer-term mission funding. And so part of the process that AID has been going through for the last year is how to bring that greater flexibility into the longer-term funding and have experimented with things like this idea of a crisis modifier that you can inject in the middle of a longer-term grant, the ability to do pivots or even a full-on emergency response as the situation changes. Because I think, Jason, you're absolutely right, that one critical piece of this is having the adaptability and the flexibility. Because when South Sudan went from being on a development course to all of a sudden the state being a part of the conflict, everything needed to shift and needed to shift quickly. And so there is definitely, I think, the requirement for the donor side to be as flexible as these environments require. There's a question in the back. Wait for the, we've got a webcast, so let's wait for the microphone. Greetings, I'm Thomas Ward. I used to work at the World Bank and I'm heavily involved in healthcare and other aspects. But my biggest concern is the corruption side of it. Especially in the grants and the flexibility. If you look, there's a history of corruption and corruption and corruption in my area in particular. And my concern is if you just throw a bunch of money in it, are you just creating a bigger problem afterwards? The World Bank is unnoticed of corruption projects where they've hit one person, but now they just go ahead and continue to disperse on new ones. There's a hand in the front here. Hi, my name is Sheila Murray. I'm with World Vision. And I actually wanted to go back to the comments that you made about the transition from relief to resilience to development in the context of health system strengthening. Just trying to work through that process myself recently and working on what those strategies really look like. And I was wondering if you had any strategies that you would recommend that really do promote sort of that transition. I mean, we have the World Health Organization's six building blocks for health system strengthening. I was wondering if you had any strategies that you've seen that really are effective when you're trying to bridge that gap and work on transitioning from a relief healthcare system to something that's more resilient. Thank you. I will take a spin on that question before I turn it to you guys. But in terms of the ability to respond to emergency situations, are you seeing an impact on where you already have health systems that are strong for the ability of local folks to respond to crises and to be able to keep the lines between what the medical missions might be and the other political and crisis environment that's swirling around. And whether or not that underlying development is gonna be critical for future crisis situations. Sorry. So those are both really important issues. On the corruption piece, all of our emergency funding goes through partners, through UN or NGO or local actor partners. It's not going through government systems. It does beg the question, however, of how do you, without using the government systems, help them get strong? And that's really the crux of the G7 Plus Fragile States New Deal question mark. And we have at AID looked at a number of approaches that can create greater transparency and accountability through reimbursement strategies. We don't give the money to the Ministry of Health that they spend the money and we reimburse them or also greater engagement of your regular citizen. There's a great project in Burkina Faso where just by publicizing which hospitals were getting what amount of money, they suddenly increased the level of service because money had not been getting from the central budget to these hospitals. But when you put that citizen spotlight on it, there was a greater transparency and therefore it had an impact on the corruption. So I mean, it's a constant effort to look at those kinds of strategies to reduce the corruption while also enabling systems to get stronger. On the resilience piece, one of the things that I feel very passionate about is resilience is a shared goal of both relief and development. I see it less of a transition approach, but rather a shared understanding that when you have resilient systems, you are absolutely able to withstand shocks, whether it's conflict, whether it's a virus. And we're seeing in West Africa, two countries that had very, very fragile systems and were quickly overcome as opposed to what you see in Senegal and Algeria where they were able to mobilize and contain the spread of the virus. So that absolutely needs to be a shared goal and something that is thought about, again, highly contextually specific as you move through these responses. In the Ebola situation, it's a big, big challenge because that's a hugely expensive response for things that cannot be reused. The protective personal equipment, for example, is a gigantic piece of the budget. However, what I think about are three things that hopefully we'll be leaving behind. First is a population that has moved light years ahead on sanitation practices. I think that this has been a crash course in hand washing for those three countries. Secondly is a trained cadre of health workers that has been enhanced in what they've been able to do. And thirdly, we're already looking at how to revitalize the health care system as a part of the next phase of the Ebola response, particularly in Liberia. Just about corruption. I think coming back with, coming here with a strong field background, I have to say that we need to see what kind of corruption are we talking about? Are we talking about the big corruption at the government level? Or are we talking about people asking for money just because otherwise they can't survive at the hospital level, the nurses, the doctors? So I think corruption is something that we have discussed throughout the project with the angle of medical ethics, ethical principles and see what are the situations in which health care providers can be put in difficult situations. Some dilemmas are coming on the issue of corruption, so don't want to go into details, but just to tell you that the project has tried to address that too. Concerning the resilience, what you've been mentioning, I think it has to be said also that in some contexts, if we look at Afghanistan, for instance, we can't behave in Afghanistan like if it was the first day, we are there for 30 years. And they are probably within Afghanistan also zones of emergency, zones of probably good system, others that are in the development phase. It's difficult to have just one image for such a complex situation, in my opinion. Yeah, I mean, to be frank, I think we're not set up as MSF sort of to be where our expertise is in building systems or strengthening them. That said, in stable situations, we do a ton of work in HIV, drug-resistant tuberculosis, malaria, a lot of areas that are relatively stable where we're oftentimes working with ministries of health, trying to improve protocols and practice in the medical care field. So we're trying to do what we can there. I think, as I alluded to earlier, this concept of resilience is not something necessarily in the wheelhouse of MSF, let's say. And I think we kind of come back to the same point, whereas we have to acknowledge that right now we have an aid system that is highly overstretched and in many ways underperforming in a lot of aspects in the most critical crises. And we talk about resilience in the context of systems, I think, and that's very important. But we also have to acknowledge that we face a situation more refugees than we've probably had ever since World War II. We have people, individuals and communities that are arguably incredibly resilient. They're having to deal on their own for months at a time without anyone coming to assist them. And for me, that is, and I think for MSF, that is the unacceptable situation that we have right now is that as we try and build those systems, there's no functioning state in Central African Republic and there won't be for a long time. We have to acknowledge that. The mortality levels that we saw back in 2011, most of it largely from malaria, were catastrophic. There were emergency levels in an unstable environment. And I think for the aid community as such, we have to acknowledge that we need to be better at assisting those populations because they're demonstrating incredible resilience. The health workers that are staying in their communities are showing incredible resilience. I mean, we had a situation in South Sudan in Lear, in Union State, where we had to evacuate our hospital and we had, and this is our national staff, took patients in an ambulance, evacuated the hospital the sickest. That ambulance was, those ambulances were stopped. Armed groups took the ambulances. They took them by stretcher bearer into the bush for months at a time with whatever medicine they had. They tried to give the TB patients, the HIV patients who were there, medicine to last them as long as possible. I mean, this is individual acts, I think, and we see refugees surviving countless without assistance, whether they be in an Ethiopia coming over from South Sudan or a number of other places. And we just need to continue, at least from our perspective, to do that assistance better, to be there faster, to provide the needs as best as we can. And that's really, I think, is really what is in some ways lacking and frustrating for MSF as an organization right now. And we acknowledge we're not in a good place to be telling, you know, building systems ourselves. We've built ourselves to be responsive in other ways, and that can certainly be done by other organizations. We just see this critical gap right now. Well, I would love to continue the conversation, but our time has run out. I think that a couple of the points that I've taken from this conversation are we need to be working harder to make sure that everybody across the globe understands who these actors are, what they're doing, what humanitarian responses, celebrating the medical professionals and humanitarian workers who are out there doing this critically important work. And we need to continue this conversation and make sure that we're doing everything we can to build a trained, able, and willing workforce to go out and continue to do these missions throughout the globe while we continue to work on stopping the crisis. Thank you very much to Nancy, to Bruce, and to Jason for coming and being here today. And thank you all for listening. Thanks, guys.