The BMJ Appeal 2024-25: David Miliband on hospital attacks, Trump, and the International Rescue Committee in a “flammable world”

What is the International Rescue Committee?

It was founded at the behest of Albert Einstein, who was a refugee in New York in the 1930s. He wrote these pained letters to Eleanor Roosevelt, then first lady, saying that there was an unspeakable trauma that was going to hit Europe and that persecuted minorities—Jews, intellectuals—needed haven in the United States. But the US did not open its doors in the 1930s, so Einstein, along with 50 of his friends, created the Emergency Rescue Committee—which became the International Rescue Committee—to help get people out of Nazi occupied Europe.

Our first employee worked in Marseille in Nazi occupied France. He issued fake passports to over 2000 people. People like Marc Chagall, the painter, escaped from Nazi death camps thanks to the Emergency Rescue Committee. Our mission today is to help people whose lives are shattered by conflict, persecution, or disaster to survive, recover, and gain control of their futures. About 40% of our international work is in the health field, because it is a basic human need. And in emergency situations, it’s especially compromised.

We help people who are trapped in war zones—Gaza, Sudan, Ukraine. People who are displaced owing to conflict—that might be internally displaced in Syria or in Ethiopia or in Latin America. We help people who cross borders, refugees, and asylum seekers.

We have programmes in Bangladesh, Jordan, and Lebanon but also in the US, Germany, and the UK to span what we call the “arc of crisis.” We’re trying to support people in extreme poverty from vulnerability and danger, with the cause being the conflict and disaster that is sadly growing in our flammable world.

What drew you to working with the IRC?

Both of my parents were refugees from conflict. My mum came to the UK as a 12 year old girl on her own in 1946. She’d lost her father in the Holocaust, and her mother put her on a boat to the UK. My dad was a refugee to the UK in 1940 when the Germans invaded Belgium. Both came from Jewish families. When the Germans invaded Belgium, my dad and his dad took the last boat out of Ostend and came to the UK. I felt that, in a small way, I could close a circle because I would be helping people who shared the same fear for their lives that my parents had.

I’d worked as foreign secretary, of course. But this was foreign policy from the other end of the telescope. It was not starting with the politics and then looking at the people. It was starting with the people and then looking at the politics—whether getting medical aid into war torn Syria or tackling sexual violence in the Democratic Republic of the Congo.

IRC is, unusually, big on research. Why?

People say that research in those conflict settings and with refugees is difficult to do, but to me that’s just an excuse. People used to say that, because it’s a matter of life and death, we can’t do impact evaluation.

Our position is that, because it’s a matter of life and death, you must do research. On malnutrition, on violence against women, on immunisation, on maternal health, we’ve really been proud to say that you can do randomised control trials and impact evaluations. You’ve got to be ethically careful—we’re not going to deny people food as a way of testing what happens if people are hungry—but you can do serious work. My approach has always been to go to donors with proven programmes, because that’s a more powerful way of generating action than just empathy.

We’ve just done a randomised control trial in a conflict ridden part of northern Nigeria. One side of a valley distributed cash to farmers before a flood hit—as determined by predictive analysis—the other side of the valley received it after. We’ll see what the evidence base is for either approach and where the evidence base is lacking. Firstly, we want to be able to say to our donors that we’re investing in programmes that either we know work or we’re testing. And secondly, we’ve done the cost effectiveness and cost efficiency studies as well to make sure that we’re using the money well.

A good example is malnutrition, which is linked to about half of all deaths among children under 5 years old. Efforts to combat it tend to divide between severe acute malnutrition and moderate acute malnutrition, which we think makes no sense because they’re the same disease—anyone who’s severely acutely malnourished will have previously been moderately acutely malnourished.

We tested out a combined and simplified protocol for the treatment of moderate and severe acute malnutrition together, instead of separately. The results showed that the combined protocol is equally effective in facilitating recovery in malnourished children, more cost effective, and easier to scale than the standard, more complex protocol. There were also important learnings about protocols for the way to work and delivery methods.

We’re also working on immunisation in East African states supported by GAVI, the Vaccine Alliance. We’re getting striking results about how to deliver healthcare in conflict zones, particularly in maternal health where there’s massive problems of maternal mortality; the rate in South Sudan is 135 times that in the US. One of our programmes, focused on unintended pregnancies, reduces the death rate by 30%.

How do you decide where and what to act on?

We’re guided by our Emergency Watchlist, an annual study that identifies the 20 countries at greatest risk of humanitarian deterioration for the forthcoming year. It’s not a straitjacket for us, but it’s a good way of prioritising.

Top of our list for 2024 was Sudan. Why? Because there are 26 million people in humanitarian need in that country—12 million displaced by conflict both inside and outside the country; 3.5 million have fled to countries like South Sudan and Chad, which are incredibly poor countries.

Gaza has warranted a very significant effort. We work with Medical Aid for Palestinians, deploying 13 emergency medical teams that have been working in hospitals in Gaza. We also have water, sanitation, and hygiene services, nutrition teams, and child protection teams. It remains a very difficult, dangerous situation with huge humanitarian need among two million people there.

South Sudan, Burkina Faso, and Mali all have very significant conflicts. Myanmar is probably not on most people’s radar these days, but there is a growing conflict there. There is conflict in Somalia, the Chad Basin—so northern Nigeria, Niger, Cameroon, Chad—and Ethiopia. And in the Democratic Republic of the Congo, where the east has been roiled by unspeakable conflict for about 40 years.

A lot of those countries are rarely discussed, if ever, in the media. How can we address that?

It’s difficult. For one, there’s more conflict and disaster. That has an aversive response in people because it seems overwhelming. So, the first question is how do you make the problems a bit more granular and manageable? That’s why our watchlist is important. If you say, “300 million people in humanitarian need,” people think it is like climbing Mount Everest. But if you say there are 20 countries in which more than 70% of the people in humanitarian need are located, you can begin to get a fix on that.

Second, there is a globalisation of lack of agency. People feel that they’re disempowered. Part of our job is to show that there are things you can do. There is a difference that you can make. Third, it’s easier to get information out than ever before in human history, but the algorithms of our now digital world reverberate the negative rather than the solutions. We’re a solution focused non-governmental organisation, and we face an uphill struggle because negativity gets three times around the world before any positive response.

I haven’t got easy answers to these. But our approach involves a focus on solutions, for a diversity of voices, and the use of trusted intermediaries like The BMJ to get our message out.

There are several major wars happening right now. And in all of them—despite humanitarian laws, Geneva conventions—attacks on hospitals and other healthcare settings continue. How do we fix that?

This is incredibly distressing and incredibly dangerous. We had two IRC health workers driving an ambulance in north west Syria in 2016, and they were hit by a Russian missile that targeted their ambulance and killed. It really woke me up to this march of impunity in conflict zones.

Attacks on healthcare are increasingly a feature of the conflict zones that we work in, whether in Gaza or Sudan or Ethiopia or Ukraine. Civilian infrastructure is becoming part of the battle space in an incredibly dangerous way.

Our 2023 Emergency Watchlist was called Time to Build Back the Guardrails. The international laws and norms you mentioned—they were set up after the second world war. I think there is a march of impunity, and the obvious fear is that it coincides with a retreat of democracy. They’re related but separate trends. Larry Diamond, the Stanford professor and science writer, talks about “democratic recession”: wherever a country is or was on the spectrum between democracy and autocracy, it’s moved in a less liberal direction—not in a traditional left-right political sense, but in a classical sense of respecting human rights.

This democratic recession is separate from but related to the axis between impunity and accountability. Democratic states set standards for themselves to live up to those guardrails. And democratic states are meant to have their own house in order. In some cases, they’re retreating from that.

There is also a change in the global landscape where the power of the United Nations is being questioned in an instrumental way from all sorts of sides. That is very dangerous for the civilians who we represent and the aid workers we are. Because it’s not just health facilities that are getting targeted, it’s aid workers and health workers in particular.

This march of democratic recession is incredibly dangerous. At the moment there is more impunity than there is sanction on impunity.

Donald Trump. What are you expecting from his new presidency?

The first Trump administration reissued on its first day sweeping restrictions on funding and action around sexual and reproductive health in developing countries funded by the US government. We know that most of our clients are women and girls, that sexual and reproductive health services are fundamental to life. So, we’re bracing ourselves for that change to be repeated. We’re really fearful about our programmes supporting unintended teenage pregnancies and reducing maternal death rates.

We also know that President Trump in his first term severely reduced from about 90 000 to 12 000 the number of refugees being allowed into the country under the refugee resettlement programme. The commitments or comments so far suggest that that is also likely to be on the chopping block.

In the wake of those decisions, in 2017, we appealed to a wider donor base to support our programming. And we’ll do that again. The success of the BMJ Christmas appeal will help to fund things like sexual and reproductive health in emergency settings.

What the money [raised by readers of The BMJ] will go into is our most impactful, most cost-effective programmes. Those are programmes around malnutrition, immunisation, sexual and reproductive health, and economic empowerment. We’re about helping people to survive and to thrive.