Humanitarianism: personal ideologies and institutional culture

Aid workers represent a diverse, international community of medical, public and allied health, social and political experts, whose values and beliefs are unique and personal but also strongly shaped by the shared experiences in humanitarian settings. Despite the variety of personal histories, by and large our participants identified a strong personal responsibility to serve others and shared feelings of altruism as overriding motivational values. This is consistent with limited existing sociological research on aid workers and military medical personnel.3 ,11 Early sensitisation to these values—through education, media, international travel and family experiences (particularly those dealing with exposure to trauma, displacement or discrimination)—and early politicisation to forms of social inequality and injustice, seem to have instilled and reinforced a rights and responsibility discourse, with central focus on solidarity, community participation and agency, and a rejection of paternalism, colonialism and other asymmetrical social–political relationships. Accordingly, our participants did not positively identify with ideologies of philanthropy or charity, likely because of negative historical connotations attached to these concepts.18 Possibly, early life exposures (via family, travel and education) contributed to the cultivation of these values, which subsequently evolve into concepts of solidarity and rights through a better understanding of culture, society and international politics. Importantly, this shared sense of personal responsibility may reflect a selection bias within the humanitarian industry, as those who commit to a career in humanitarian aid work may self-select for the above qualities, which they perceive as effective philosophies for engaging in the challenges of the humanitarian aid profession.

The perspectives and experience of career medical aid workers are closely tied to personal ideologies, and the sense of mission, directive and purpose of the aid organisations they represent. Humanitarian philosophies seem to be derived from intensive interactions between aid workers, their INGOs and the overall humanitarian community. These interactions create strong, frequently shared personal and institutional identities, as well as personal value systems that are reflected in institutional mission statements and programming; this particularly applies to the concepts of responsibility, solidarity, accountability and sustainability, which represent both a strong unifying value system as well as a source of conflict between individuals and organisations. Perceived discrepancies in an organisation's theoretical mandate and its treatment/application of these values, was a major cause of aid worker dissatisfaction, turnover and burnout. This suggests that the humanitarian aid industry could benefit from a clarification of goals and values in the area of programme mandates and project missions, as well as worker recruitment and retention; this represents a unique opportunity to strengthen and reform the humanitarian aid industry, thereby improving not only aid provision itself, but also worker satisfaction, health and performance.

Despite clear critical assessments of the INGO community, the strong belief in the positive reception and impact of INGO programming on impacted communities and stakeholders is promising, and is strongly linked to the dedication, motivation and collective will of the staff. The sense of collectiveness, synergy and shared values with the respective organisation likely contributes to a culture of continuous debate and reflection, further nurturing the evolution of motivations and ideological maturation. In return, this helps to retain humanitarian workers beyond their early assignments. The need for collaboration and compromise in a dynamic aid system is universally recognised, and is frequently achieved through active contribution by aid workers to their organisational programmes and directives. Interestingly, this observation was most prominent with participants from MSF, who emphasised active internal and external debate on humanitarian issues and transparency as part of the organisation's culture. In general, these feelings translated to a sense of agency on the part of experienced aid workers as active decision-makers, which contrasted with their appraisal of the UN and governmental organisations’ cultures as lacking, both in the spirit of volunteerism and ‘true’ humanitarian response, based on the needs of populations and representation of its constituents (employees and recipient populations).

Conflicts, criticisms and accountability dilemmas in aid work

Career humanitarians are deeply aware of the limitations, shortcomings and negative consequences of their aid operation and its inefficiencies and ineffectiveness. Not every aid is good aid.19 These shortcomings and consequences include failure to reach intended beneficiaries; perpetuation of corrupt governments; depletion of limited local material and human resources; and negative impacts on local capacity-building, infrastructure and sociopolitical institutions through financial dependence, mismanagement of resources, and a neglect of cultural norms or local priorities and expectations.8 ,18–23 While the immediate goal of saving lives is a fundamental objective of medical humanitarian interventions, humanitarian aid often fails to address overwhelming needs, and is ineffective in the long term if mechanisms to address underlying sociopolitical causes of human suffering are not available. Success and sustainability of programmes require the collaboration of multiple stakeholders, as well as the recognition and addressing of power dynamics based on finances, political allegiance, citizenship status, etc.

Our participants had difficulty describing local populations with disempowered terminology and highlighted their strength, coping strategies and significant contribution to overall aid,19 and asserted that their rights to assistance and protection should be guaranteed as it is in disaster survivors in the Northern countries.24 Several factors likely contribute to such pervasive views among career humanitarians, including the recognition of power imbalance between aid workers and recipients, a forward moving ‘rights concept’ rooted in the civil rights movement of the 1960s, and human rights and women's rights movements of recent years. The concept of rights-based versus need-based care provision was a particular source of critical concern for some participants, and recognised as a key area of divisiveness between individual values and institutional realities. Popularly, there is a distinction between rights to health as a general human right and broader rights to humanitarian assistance, including rights to protection and representation25 ,26; the unique position of medicine as separate from ‘contested rights discourse’ was pronounced among our study population, especially among participants from MSF, even as concepts of solidarity, agency, and community empowerment were touched on as driving personal and institutional values. The tendency to try to separate these rights may represent an attempt to depoliticise medicine as a historically independent and politically neutral field. The intersection of medicine and politics represents a key area of discomfort, conflict and debate for medical humanitarians, many of whom support politicised approaches to culture and power while at the same time eschewing the political components of medicine. Our study population expressed doubt about the benefit and field practicality of a theoretical rights-based approach, especially in the absence of an effective accountability mechanism. There is also considerable tension between the conceptual idea of accountability towards intended beneficiaries and its practicality; the tripartite accountability structure identified by participants, while considered ideologically appropriate, was in reality difficult to maintain, with the common result being the marginalisation of beneficiary voices. This is in stark contrast to participants’ abstract or personal consideration of beneficiary populations, which was viewed through a strongly rights-based lens. Reasons for the impracticality of accountability mechanisms are generally theoretical, including but not limited to difficulty adjusting programme management to reflect existing local skills and customs, dysfunctional or chaotic local institutional settings and attempts by powerful local actors to divert resources from those most in need.27 Additionally, aid organisations might have to convince larger donors to accept the sharing of accountability with aid recipients. Although mechanisms exist and are proposed to improve accountability,28 such as integrating the community in operational or programmatic decision-making via true partnership, when it comes to funding and financial accountability, the issue is particularly complex.28 ,29 Could beneficiaries be effectively involved in financial decision-making, allocation of resources, and programming? Is there space for a rights-based approach in aid provision, and can these conflicting views be reconciled? What does this mean for reform within the aid industry? These questions require renewed consideration from the humanitarian field. Giving the voice to aid recipients to exercise their health rights is a critical social justice issue to address, and a way to assure, capacity-building, but the focus may need to be on specific approaches for increasing accountability that lead to meaningful improvements of aid operation and effectiveness.28 ,29–31 The mind-set and structure of operations in major INGOs may need significant institutional reforms to absorb this sharing process and there is a dire need to transform the current dynamic from merely connecting resources to brokering better governance, true collaboration and cooperation among community, government and international actors.28 ,29

Finally, the friction between governmental organisation and NGOs was an important and central theme that cannot be ignored if future humanitarian interventions are to be successful. Member states’ politically motivated foreign policy agendas on aid direction and distribution, and the history of military involvement in decision-making processes in the UN, have contributed to a hesitancy on the part of INGOs to consider them as true humanitarian agencies, or as desirable partners. At the same time, there is recognition among many humanitarians that organisations such as the UN play an important role in strategic movement, coordination, and relationship-building with local governments and authorities. Advocacy resources and diplomatic channels could be extremely helpful if they are consensus based, need based, and free of political agendas when it relates to health and other basic humanitarian needs; however, in the view of our participants, this has been difficult to achieve, with the exception of a very few agencies such as UNHCR and Unicef, and even among participants the success of these groups was seen as widely variable. It is unclear whether the current UN structure allows for its agencies to effectively apply a need-based approach to humanitarian situations in collaboration with INGOs. This parallels a similar concern participants shared over the mission, role and scope of practise of fledgling INGOs that have blossomed out of the recent trend in global volunteerism. Although INGOs are generally considered critical to providing needed services and effective in alleviating suffering, there are concerns over quality of work and services generally, and especially among those NGOs that have limited resources and expertise, are newly conceived, or that cater to the global medical volunteerism for trainees or the lay population.8 For the UN as well as for these new organisations, a clarification of roles and responsibilities is essential, and strong internal discussion must be held to define values and organisational philosophies, especially regarding the critical concepts of rights-based and need-based care provision. Our participants drew a slight distinction between the work of major INGOs with significant experience and smaller or newly formed NGOs, but communicated factors that could define better service, including INGO specialisation, improved logistical expertise, communication, collaborative approaches with local partners, and critical assessment of cultural and institutional identity.

Humanitarian access

Humanitarian aid provision has undergone considerable changes in the past 20 years. A substantial body of literature discusses issues of ethics and accountability in humanitarian aid provision, as well as the idea of ‘neo-humanitarianism’, which addresses the embedded nature and appropriation of humanitarian principles for political and military operations.32–38 Recently, the post–9/11 wars in Afghanistan, Iraq, Libya and Syria have contributed to and reinforced the ‘blurring’ of lines between military operations and humanitarian aid, further narrowing the humanitarian space and creating dangerous situations for aid workers and for target populations.28 ,33 ,38 The concerns over conceptual and practical access to populations in humanitarian situations have important implications for training, debriefing and retention of employees, as well as their physical safety and emotional health. While negotiating at the local level with different parties to ensure short-term access has always been an important component of facilitating access to populations,39 broader and more proactive sociopolitical approaches are desperately needed to counter the shrinking humanitarian space. Clearly, there is a need for broad range reform, reflection and restrategising for approaches within INGOs and the broader humanitarian aid community, in addition to the UN and other governmental structures. This includes addressing the overarching political forces that limit humanitarian access based on foreign policy agendas, and emphasising a more need-based approach in aid evaluation and provision. Successful advocacy initiatives against the interests of powerful pharmaceutical industry such as MSF's access campaign for generic HIV medications, and the drugs for neglected diseases initiative (DNDi), could serve as models for pushing targeted, need-based agendas in aid work, and could be replicated at the policy level to address humanitarian access internationally.40 ,41 Finally, the profession of medicine itself is uniquely positioned to play a proactive and important role in international humanitarian aid work, resisting political and social coercion and maintaining a strong commitment to the core principles and concepts of independency, impartiality and neutrality.

Moving forward: building and maintaining a healthy workforce in a changing aid environment

Substantial emotional responses to extreme humanitarian experiences are common, especially among aid workers, and may present as burnout, depression, post-traumatic stress disorder (PTSD) and excessive or unhealthy alcohol use or cigarette smoking during or on returning from mission trips.42–47 A limited number of aid organisations provide formal debriefing for their returning volunteers,44 ,45 and aid workers are generally expected to develop personal management skills to deal with their emotional stress.44 ,47 ,48 Many institutions, especially those engaged in short-term volunteerism, provide no psychosocial support.44–49 Overwhelming emotional exposure, lack of self-care and personal management skills, lack of social support, pre-existing emotional conditions, and ineffective and dissatisfying aid programmes are contributing factors, according to our study population. The emotional effects of field hardship could be minimised with clearer communication and transparency about cumulative emotional burden, potential emotional situations and ethical scenarios volunteers may encounter, stress management techniques and training, clarification of expectations, and debriefing on returning.42 ,49–52 The INGO community is beginning to recognise the need for institutional support and reform in this area. Notably, balancing work and personal life, as well as taking time off, are important, actionable habits that are increasingly encouraged within larger INGOs. Skills can also be developed to successfully alleviate some of the burden of emotional and physical isolation.44 ,47 ,49 ,53

Despite a continued commitment to medical aid work, experienced aid workers are unclear about the scope or details of their future commitment. Significant physical and emotional challenges in the field influence decisions to seek more headquarters or coordination positions, or to take regular breaks between positions. Lack of job security, environmental challenges for raising children or having a family, other family obligations, a need for more normal social life, changing career or educational goals, and financial constraints are issues that need to be systematically addressed by the INGOs to assure continuing commitment by experienced medical aid workers. In addition to personal needs, barriers in institutional hierarchies are contributing factors to work dissatisfaction. Decision-making processes for field projects differ widely among INGOs, and tensions often develop when decisions are made without input from key stakeholders within organisations. As a result, aid workers may feel disenfranchised by their organisation, or feel their talents, knowledge and field expertise are not properly accounted for in decision-making processes. This disjunction is problematic and can compromise effectiveness.

Despite important concerns regarding the scope, success and sustainability of their work, job satisfaction remained high among our participants, and early motivations and personal philosophies were by-and-large reinforced through a career in the humanitarian field. The positive emotional impact of delivering effective aid could not be overemphasised. Career humanitarians asserted personal growth, and indicated becoming more understanding, reflective, compassionate and socially conscious. They demonstrate a trend of strong, sensitive, and fundamentally political foundations as a self-selected and highly motivated subgroup; this may contrast with prevailing ideologies among short-term humanitarian aid workers, charity, or philanthropic organisations, many of which employ more traditional, paternalistic or non-accountable views and approaches.8 ,18 ,32 ,33 ,54 Exploration of the personal values of humanitarians is helpful when cultivating the next generation of aid worker. Specifically, it may help identify goals, values and beliefs that correlate with emotional resilience and positive personal growth among humanitarian recruits. Alternative rubrics and complementary approaches to evaluate and transparently communicate the impact of aid operations and projects’ outcomes should be systematically explored.

Limitations

Our study is not without limitations. Many of these topics were explored in the absence of any prior systematic assessment, and were meant as tools to shed light onto important topics identified by aid workers and to generate ideas for future research. Our study survey was not designed to provide a comprehensive look at the psychological, moral and ideological beliefs of overall aid workers, or to fully capture the issues within the overall humanitarian operations, governance, or the future of humanitarian movement. We applied a qualitative descriptive approach to begin a dialogue and provide a forum for debate, with a research-based advocacy approach that explores many aspects of medical aid provision and operation from the perspective of international career medical aid workers. Most of our participants worked in more than one organisation over a period of 5–20 years, bringing in broader perspective and experience as a result. However, while our sample population represented a variety of humanitarian INGOs, the opinions and ideas of the participants may not fully represent the diversity of opinions in the humanitarian field; further exploration of the experiences of non-medical humanitarian aid workers, local, community-based and host-country aid workers, and short-term or mid-term medical aid workers is warranted. Finally, our study did not explore the perspectives of aid workers who had left the field of aid work.