Applying the policy in practice: Case studies

How closely humanitarian actors should interact with militaries was an open question during the 2016–2017 Mosul military operation in Iraq. To care for civilians injured during the nine month-long campaign by the Government of Iraq and Coalition forces to retake the city of Mosul from ISIS, the World Health Organization (WHO) coordinated a trauma response that included establishing trauma care pathways by which military forces transferred injured civilians to mobile trauma stabilization points (TSPs) near the frontlines before transporting them to field hospitals approximately one hour away.

Principles in Practice 

One of the most controversial elements of WHO’s plan was setting the TSPs as close to the frontlines as possible by “co-locating” or “embedding” them with specific Iraqi military divisions and moving the TSPs with these divisions as the frontlines shifted. WHO made this decision for security reasons (to protect civilian medical practitioners) and logistical in the reasons (it took too long to send wounded Iraqi soldiers to the Iraqi military’s equivalent of TSPs and wounded civilians to separate, NGO-run TSPs).

WHO asked the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF), two actors known for their expertise in emergency medicine, to provide services at the TSPs. But both actors declined, citing security concerns and the need for them to maintain independence from the Iraqi military and Coalition forces. Moving nearer the frontlines made it difficult not to “co-embed” and increased the chances that the organizations would be perceived as working in service of the military.

The WHO’s plan was controversial because of the close ties between humanitarians and civilian medical practitioners and the military. WHO, prioritizing the humanitarian imperative and the principle of humanity, saw this as an acceptable trade-off to concerns regarding the principles of independence and neutrality. Other humanitarians felt that any short-term benefits (i.e., saving civilian lives) were outweighed by longer-term concerns about how civilian populations would view the organizations and whether their access to people in need, in Iraq or in other contexts, would suffer.


The Mosul trauma response raises challenging questions about how aid organizations should apply the humanitarian principles during conflict.


Humanitarian organizations should provide aid where it is needed, in a manner that respects individuals’ rights and dignity. Doing so requires humanitarians to consider the short- and long-term consequences (whether positive or negative) of their actions on the people they seek to assist and on their own and other organizations. During the Mosul military operation, some humanitarian organizations determined that the principle of humanity outweighed the principles of independence and neutrality. This decision, and the conflicting opinions of organizations such as ICRC and MSF, highlights the tension (whether real or perceived) between the principles and the choices that organizations must make in order to preserve their humanitarian identity.

Questions to consider 

  • How can your team balance our mandate to provide assistance with the principles of neutrality and independence? Can you find a balance in this context?
  • How might prioritizing the humanitarian imperative affect how CARE is perceived and could it negatively affect your work (understanding that perceptions may change over time)?
  • If it appears (in actuality or perception) that you are co-located or embedded with armed actors, what other actions can you take to elevate your independence and neutrality in order to protect your program participants, partners, and selves now and in the future?
  • What role could advocacy play in ensuring that all actors are held accountable for their actions and thereby help highlight CARE’s independence and neutrality?


Humanitarian organizations should provide assistance without engaging in hostilities or taking sides in ideological, political, or religious controversies. Neutrality helps humanitarian actors secure the access and operational space they need to assist as many people as possible. How armed actors and program participants perceive humanitarians’ neutrality—or whether they perceive them to be neutral at all—is just as important as how humanitarians perceive their own neutrality or whether they are neutral in reality. In the Mosul context, some humanitarians were concerned that working closely with the Iraqi military and Coalition forces required them to compromise their neutrality, harming their reputations and complicating other relief operations.

Questions to consider

  • What might be the impact if your team chooses to remain neutral, or not, in a situation—might it ultimately help or hurt your efforts and those that need aid?
  • Who are the other armed actors involved in a given context and what is the potential risk if you are perceived as too “close” with one or several of those actors?
  • Might compromising on the principle of neutrality save lives? At what cost?


Humanitarian organizations should provide aid in a manner that is autonomous from the economic, military, political, or other objectives of actors present in the operational area. Being independent helps humanitarians remain impartial and neutral. The principle of independence should not imply no or few contacts with authorities or less openness to activities; on the contrary, it should help aid workers develop, safeguard, and explain their autonomy. One challenge to the principle of independence in Mosul was the colocation or embedding of medical practitioners with the Iraqi military and Coalition forces, which made it appear that humanitarians were not autonomous from military or political objectives.

Questions to consider

  • How can you maintain a dialogue with armed actors while maintaining your independence?
  • What types of information should you share—or not or never share—with armed actors to ensure your independence?
  • What might be the impact if you do or do not engage with armed actors?

Maintaining our humanitarian identity depends upon using the principles to guide strategies and operations, which, in turn, involves making difficult decisions. The principles serve as guides in decision-making, but they do not always point in the same direction. Asking questions and thinking through challenging situations and potential benefits or consequences as a team is important.

The role that militaries should play in preparing for and responding to disease outbreaks was a crucial question in the 2014–2016 West African Ebola virus disease (EVD) outbreak. The response to the outbreak—which primarily affected Guinea, Liberia, and Sierra Leone, and resulted in more than 28,600 suspected, probable, and confirmed cases—involved unprecedented calls for military intervention due to the need for healthcare personnel and technical support.[1]

Principles in Practice

Health actors recorded the first EVD cases in Guinea in March 2014.[2] From there, the disease spread quickly, outstripping in-country response capacities and the ability of any one entity to respond. Médecins Sans Frontières (MSF) estimated that it would take approximately three months for donors, governments, health and humanitarian actors, and NGOs to scale up their efforts, during which time EVD would continue to spread.[3]

On 2 September 2014, International President of MSF Dr. Joanne Liu urgently requested that UN member states deploy biohazard containment teams to support the EVD response.[4] This was an unprecedented call for MSF, since states’ biohazard response capacities are typically a military capability developed to respond to biological or chemical warfare, rather than public health crises.[5] Given MSF’s concerns about the spread of the virus, the request was essentially a plea of last resort to bring about rapid, concrete action. The request carried operational and reputational risks: development and humanitarian organizations were concerned that the deployment of foreign troops would militarize the response, negatively affect community perceptions of health and aid workers, and impede humanitarian independence.[6]

Following requests by MSF, the Government of Liberia, and others, the United States and the United Kingdom announced that they would provide military assets to support the response.[7] Ultimately, these assets came in the form of coordination and logistics support for governments and INGOs, rather than biohazard response teams. The deployment of military assets was not without value or meaning, however. The engagement of foreign militaries marked the symbolic beginning of a substantial international response and in some instances reassured people in the most-affected countries that an intervention was underway. By late February 2015, transmission rates were decreasing.[8]


The severity and novelty of the outbreak led some humanitarian organizations, such as MSF, to request global support to contain the virus through military-led biocontainment teams. These organizations contended that the time-limited and defined scope of foreign militaries’ involvement was critical to the containment of the virus and upheld the humanitarian principle of humanity. Others felt that it challenged the principle of independence.


The severity of the EVD outbreak led many organizations to prioritize humanity, which likely influenced their decision to request foreign military involvement in the response—a request that might have been surprising in other contexts. The humanitarian imperative is to save lives and alleviate human suffering, which is part and parcel of the role; in contrast, militaries’ roles tend to be more task focused. Here, then, militaries’ role was to contain the outbreak and—unbounded by the humanitarian principles—to do so regardless of cost.

Questions to Consider:

  • At what point might my or my team’s mandate to save lives and alleviate human suffering begin to outweigh our concerns about upholding the other humanitarian principles?
  • What am I and my team willing to do to uphold the principle of humanity? Is this acceptable to CARE more broadly? More importantly, is it acceptable to the people we are aiming to assist?


The primary challenge to independence came from the close coordination between foreign military units and humanitarian organizations—for example, U.S. Department of Defense (DoD) personnel were embedded into USAID’s Disaster Assistance Response Team (DART). Humanitarians’ requests for military support, coordination with foreign militaries, and close operational proximity to said armed actors can affect community perceptions of humanitarian organizations.

Questions to Consider:

  • What objectives did foreign militaries have in responding to the EVD outbreak in West Africa? How did those align with or differ from the objectives of people in the affected countries, their governments, and local, national, or international responders?
  • What effect, if any, does the type of emergency have on questions of operational independence? Do you think that it mattered to humanitarian organizations like MSF that they were requesting military support to a disease outbreak in countries not at the time involved in conflicts?

The greatest concern in the West Africa Ebola case in regard to engaging with military units included community perception and independence to accomplish mission goals without external intervention. In some cases, the support of the military is necessary to prevent further extremities from occurring. This case study demonstrates that military operations can be necessary to control a situation, and while there are many concerns in regard to the principles in practice, exceptions and hard decisions must be made to prioritize humanity. Recognizing that military operatives have resources and skills needed in extreme situations is important, and coordination will look and be executed differently in each situation. In that recognition, you will have to reconcile and balance the measures needed to prioritize human life.


[1] Reid, Katheryn et al., “2014 Ebola Virus Outbreak: Facts, Symptoms, and How to Help,” World Vision, March 24, 2020,‌/‌health-news-stories/2014-ebola-virus-outbreak-facts.

[2] Coltart, Cordelia E. M. et al., “The Ebola Outbreak, 2013-2016: Old Lessons for New Epidemics.” Philosophical Transactions of the Royal Society of London, Series B, Biological Sciences vol. 372,1721 (2017): 20160297,

[3]  O’Callaghan, Sorcha. “COVID-19: Five Lessons from Ebola.” Overseas Development Institute, March 20, 2020,

[4] Bosely, Sarah, “Ebola Outbreak: Call to Send in Military to West Africa to Help Curb Epidemic.” The Guardian, September 2, 2014,

[5]  Pérache, André Heller, “‘To put out this fire, we must run into the burning building’: A Review of MSF’s Call for Biological Containment Teams in West Africa.” Humanitarian Practice Network 64, June 2015,

[6] Ibid.

[7] Kamradt-Scott, Adam, et al., “Civil–military Cooperation in Ebola and Beyond.” The Lancet 387, no. 10014 (2016): 104-105, https://www.thelancet‌.com‌/journals/lancet/article/PIIS0140-6736(15)01128-9/fulltext.

[8]  UN Development Group, Western and Central Africa, “Socio-economic Impact of Ebola Virus Disease in West African Countries: A Call for National and Regional Containment, Recovery, and Prevention.” February 2015,

Armed actors—particularly militaries—can provide unique assets and capabilities that humanitarians cannot. The Nepal 2015 earthquake response provides an example of when a government, humanitarian agencies, and militaries coordinated efforts for a largely successful response.

Principles in Practice

A 7.8 magnitude earthquake struck Nepal on April 25, 2015, causing severe damage in 14 of the country’s 75 districts.[1] The earthquake resulted in nearly 8,900 confirmed deaths, destroyed 605,300 houses, and damaged an additional 288,300 houses, and temporarily displaced 188,900 people.[2]

While the earthquake caused harm in some already hard-to-reach areas, it also damaged infrastructure, such as roads, and caused landslides that complicated responders’ access to affected populations.[3] This meant that air transport was the only way to reach certain areas, but there was a dearth of civilian aircraft in the country and of space from which to fly them: Nepal has only one, relatively small, international airport that can only accommodate eight large aircraft at any given time.[4]

The Government of Nepal immediately launched a large-scale operation to respond to the effects of the earthquake, relying on a natural disaster response framework they had developed with support from the UN.[5] From the outset, the Nepali Army—as the national disaster management lead—was involved along with humanitarian organizations and foreign militaries.[6] The UN Civil-Military Coordination (McCord) team developed a coordination strategy that facilitated information sharing between civilian and military actors and helped the humanitarian community submit rapid requests for assistance to military forces involved in the response.[7]  In some instances, the militaries served as first responders—for example, by conducting search-and-rescue operations—and in others amplified civilian efforts with logistics support, such as by transporting aid supplies and workers via helicopter.[8] Humanitarian organizations were able to quickly access relief commodities, conduct aid distributions, and mobilize services such as health care and protection.


Given context-specific elements, such as that the disaster occurred during peacetime, the 2015 earthquake demonstrates how humanitarians and armed actors might coordinate in distinct-but-complementary ways to achieve a beneficial, minimally harmful outcome and help meet the humanitarian imperative.


Humanitarians worked closely with various foreign militaries, who transported humanitarian goods and personnel to hard-to-reach areas of Nepal.

Questions to consider

  • In your opinion, did the humanitarian community’s decision to use military assets satisfy the conditions laid out in this policy? Why or why not?
  • In this scenario, how were the humanitarian community’s objectives similar to those of the Nepali military and foreign militaries? How were they different? Would your answer change if Nepal had been experiencing a conflict?
  • If your team has no other option but to engage with armed actor(s), what steps could you take to ensure that the actor(s) understands and respects your objectives?


Although the emergency in Nepal was due to a natural disaster and did not occur during active conflict, there were still some tensions between the Nepali military and civilians, the lingering effects of a Maoist insurgency that began in 1995– and lasted until 2006.[9] Aid workers relied on the military for access, however, there still needed to be considerations to neutrality in the response because of the historical background because the community still had perceptions of the military.

Questions to consider

  • The earthquake and coordinated government-humanitarian-military response took place in a largely peaceful context. How might the response have looked different if Nepal were experiencing a large-scale conflict?
  • Given the country’s fairly recent history of conflict, why wasn’t neutrality prioritized more during the earthquake response? In similar situations, where a crisis occurs during a peaceful period but where there is a history of tension between civilians and armed actor(s), is it possible for humanitarians to coordinate with the armed actor? What steps might humanitarians take to demonstrate neutrality?

The unique circumstances of any disaster and the context in which it occurs help determine the possible extent of humanitarian–military coordination. The specific facts of the 2015 Nepal earthquake led to a successful joint operation between humanitarian and military actors, where each understood their roles, adhered to their respective mandates, and cooperated where possible.

[1] Reid, Kathryn, “2015 Nepal Earthquake: Facts, FAQs, and How to Help.” World Vision, April 3, 2018, https://www.worldvision‌.org/‌disaster-relief-news-stories/2015-nepal-earthquake-facts#:~:text=A%20magnitude%207.8%20earthquake%20struck‌,more‌%20than%2022%2C000%20suffered%20injuries.

[2] OCHA, “Nepal Earthquake Humanitarian Response, April to September 2015.” 2015,‌/sites/

[3] Cook, Alistair, et al., “International Response to 2015 Nepal Earthquake: Lessons and Observations.” S. Rajaratnam School of International Studies, October 2006,‌04Oct2016.‌pdf.

[4] Ibid.

[5] Ovesen, Puk and Stine Heiselberg. “The Humanitarian Response to the 2015 Nepal Earthquake.” UN Chronicle.

[6] USAID, “Nepal Earthquake – Fact Sheet #7.” May 3, 2015.

[7] OCHA, “Humanitarian Civil-Military Coordination in the Nepal Earthquake Response,” Issue 5, May 2015, https://‌

[8] Robson, Seth, “Military Delivering Supplies as U.S. Promises More Aid to Nepal,” Stars and Stripes, May 6, 2015,

[9] BBC, “Nepal Profile – Timeline.” February 19, 2018,