Left to Ponder
‘If we hadn’t been there, they might not have gotten along but they wouldn’t have been killing each other either.’ With those words, a member of staff working with Médecins Sans Frontières (MSF) summarised what he thought was a direct, albeit unintended, effect of MSF’s presence on the conflict affecting the town of Agok. Located in the disputed Abyei Special Administrative Area (ASAA) on the border between Sudan and South Sudan, Agok was hit by intercommunal fighting in February 2022. No longer able to operate the 185-bed secondary care facility with surgical capacity, MSF was forced to suspend and relocate its activities. In the wake of the initial shock of having to leave unexpectedly after nearly fourteen years of uninterrupted presence, came questions about the organisation’s possible share of responsibility in the trail of events which escalated into full-blown violence. In agreement with the above comment, many in MSF pointed to what the literature posits, namely the fact that humanitarian assistance delivered in conflict settings affects local patterns of violence and can sometimes fuel conflict by spurring mechanisms of predation,1 or by reinforcing local grievances.
It is rare (though not unheard of) for MSF as for other humanitarian actors to try to document the long-term, unintended impact of their presence on the local political economy, as they oscillate between a vow to ‘do no harm’ and the realisation that there are distortive effects and negative externalities to their action which they do not and cannot control. Without detracting from the project’s achievements in terms of providing high-quality secondary healthcare in a context where there was none, this article intends to investigate whether MSF’s presence in Agok represented a factor of destabilisation for local balances and in what way. It builds on an internal capitalisation exercise conducted for the purpose of documenting the history of the MSF project in Agok from its opening in May 2008 until its official closure in April 2023, with a goal to critically reflect on the risk of humanitarian aid resources being siphoned to finance war or instrumentalised to escalate intercommunal resentment.
Three key questions will be addressed. First, in what way could MSF have disrupted local balances? Second, to what extent was the organisation aware of the adverse consequences of its presence? And third, would more awareness have led to different operational choices and mitigation measures? A brief literature review will look at how aid influences patterns of violence. Then after a short introduction to the context, the piece will focus on MSF’s experience in Agok. Whenever possible, quantitative data will be relied upon but the analysis will be largely based on field research: formal and informal discussions with MSF staff, community members, leaders and authorities. Therefore, the objective is not to present findings as undisputable truths but to suggest avenues for further reflection.
Greed and Grievance
It is sometimes said that the potential of humanitarian assistance to produce negative externalities has received only limited attention compared to the large volumes of aid devoted to conflict zones (Wood and Sullivan, 2015). Nevertheless, a number of qualitative and quantitative studies conducted as early as in the 1990s highlighted some of the unintentional adverse consequences of humanitarian assistance, including the risk of aid becoming a resource in interstate and civil wars (Keen, 1998; Anderson, 1999). Around that time, talk about ‘war economy’ revived old debates about belligerents’ diversion of the humanitarian windfall for war purposes leading to the prolongation of conflicts (Jean and Rufin, 1996; Brauman, 2016).
A significant strand within more recent literature uses political economy research as an analytical lens to better understand how economic interests shape conflict dynamics (Wennmann, 2019), emphasising the fact that ‘crises are powerful vectors of change that produce winners and losers over space and time’ (Carbonnier, 2016). While much of this research focuses on the nature of conflict economies or on conflict financing, another sub-body of literature is more specifically concerned with the role of greed and grievance in conflict onset. In that regard, seminal work by Paul Collier and Anke Hoeffler challenged the then prevailing narrative about ethnic conflict being grounded in some form of identity struggle. Instead, they argued that economic motivations are more important than cultural grievances to explain the occurrence of civil war (Collier and Hoeffler, 1998, 2004; Collier and Sambanis, 2005). Some authors rejected Collier and Hoeffler’s somewhat caricatural opposition of greed and grievance as competing explanations of conflict, and rather emphasised the interaction of multiple socioeconomic and political factors in triggering the outbreak of warfare (Ballentine and Sherman, 2003; Bannon, 2003; Arnson and Zartman, 2005; Berdal, 2005).
Nowadays, there is a consensus that much ethnic conflict is at least fed by (if not rooted in) competition for resources (Milton and Herring, 2003) and that aid represents a source of revenue that creates rent-seeking and predatory behaviours (Djankov et al., 2008). Aid can benefit one party or one group over another through mechanisms of extortion or diversion by warring parties, including through the kidnap-and-ransom industry (Carbonnier, 2016; McLean, 2021). Yet, depending on how aid regenerates or undermines local business, or how its economic fallouts are distributed, it can also reinforce grievances in a less direct and visible way. Thus, revenue drawn from property rentals, logistics, transport, taxes and, of course, employment, are all potential avenues for humanitarian funds to fuel violent conflict (Idris, 2016).
A Political Impasse Rooted in Three Decades of War
The idea that relief efforts can fuel or prolong conflict has become somewhat commonplace despite the difficulty to gauge the valuation of aid relative to other sources of revenue within a given economy. Some have argued that the adverse impacts of aid may in fact be overstated, and that, aside from extreme circumstances, aid is likely to represent only a small fraction of war economies (Persichino, 2003). How aid compares with other resource avenues for funding conflicts therefore depends on the context, and the impact of MSF’s presence in Agok cannot be understood without making reference to the ASAA.
The 1972 Addis Ababa peace accord which ended the first Sudanese civil war gave Abyei the right to hold a referendum to decide whether the area should remain in Southern Kordofan or join Bahr Al Ghazal. However, in 1983, when the second Sudanese civil war broke out, the planned referendum still had not taken place. In 2005, Abyei was not included in the Comprehensive Peace Agreement (CPA) signed between the North and the South of Sudan. Instead, separate protocols were negotiated and agreed on for the ‘three areas’ – Abyei, South Kordofan and Blue Nile states. The current impasse over the status of Abyei centres on border demarcation and who should have the right to vote in a referendum to determine the future of the area, between remaining in the North or being integrated into the territory of South Sudan (Figure 1). Motivating each party’s territorial claims are distinct issues of control over coveted oil reserves, competing claims for access to the cattle grazing pastures between the Arab Misseriya and the Ngok Dinka ethnic groups, as well as internal national political stakes. To this day, none of the CPA’s key milestones have been satisfactorily met, and the failure of the parties to implement the Abyei Protocol has resulted in large-scale fighting between the Sudanese Armed Forces (SAF) and the Sudan People’s Liberation Army (SPLA) in 2008 and in 2011, followed by an enduring stalemate.
In terms of demographics, it is estimated that 4–5,000 people were living in and around Agok originally. In 2008, that figure rose to 55,000 after most of the people living in Abyei fled South. Then in 2010, as the vote for independence approached, an estimated 40,000 Ngok Dinka who had fled outside of the box came back, fearing retaliation from the North if the South voted for secession. Additionally, another major contextual element to factor in the demographic equation is the stability brought to the ASAA after independence with the deployment of the United Nations Interim Security Force for Abyei (UNISFA) in June 2011. Affected by large-scale violence from December 2013 onwards, surrounding communities from Warrap and Unity States took refuge in the ASAA and increased its overall population to around 120–125,000 – though it is unknown how many concentrated in and around Agok, as opposed to scattering elsewhere in the box.
These demographic changes brought their share of disruption, one of which was growing resentment between two Dinka sub-tribes. For years, the Ngok and Twic communities have claimed to be the rightful owners of Agok and its Aneet market. Historically, the large-scale displacement of the Ngok south of river Kiir was tolerated by the Twic but considered to be temporary. Over time, the burden placed on the latter to support the former and to offer them access to their lands, partly due to existing intermarriages between the two tribes, caused mounting resentments and jealousies between both communities. When, in 2017, the Ngok Dinka Abyei Administration initiated a demarcation survey, the move was perceived by the Twic as an intrusion into their ancestral land. A series of incidents reported throughout 2020 and 2021 further ignited tensions, to the point that when the demarcation process reached the area of Aneet market in December 2021, it was probably the last straw that triggered the violence.
Territorial claims in Abyei.
Citation: Journal of Humanitarian Affairs 5, 2; 10.7227/JHA.110
MSF’s Footprint in Agok
When MSF started supporting the Ministry of Health (MoH) in the Abyei Hospital in 2006 after long negotiations with both the North and the South, the initial rationale was to respond to the needs of a highly vulnerable population trapped by decades of conflict. In 2008, armed confrontations between the SAF and the SPLA caused almost the entire population of Abyei town to flee and MSF to resettle in Turalei and in Agok, while temporarily maintaining activities in Abyei. Again, in May 2011, MSF teams were forced to evacuate Abyei after the invasion and destruction of the town by the SAF and MSF remained the only emergency medical organisation working in Agok. Following a phase of uncertainty leading up to the 2011 referendum, MSF gradually renounced transferring activities back to Abyei. Subject to much internal discussion at the time, this decision was motivated by the low number of returnees and a reluctance to signal to the population that it was safe to return, as well as the fear that any large investment in Abyei would be risky for MSF teams and uncertain financially.
Agok was a project out of the ordinary for MSF in terms of longevity, volume of activities and scale of resources invested (88.5 million Swiss francs). For fourteen years, the MSF hospital remained the only functioning secondary health care service in the ASAA, carrying out an average of 35,500 out-patient department/emergency room consultations and 5,800 inpatient department admissions each year. Throughout the project’s duration, the scope of medical services evolved constantly, from an initial focus on primary healthcare to a comprehensive secondary healthcare package. Efforts made to improve the quality of the care provided translated into huge investments in infrastructure, sophisticated diagnostic capacities, capacity building for the staff, as well as advocacy and research.
Despite these undeniable successes, Agok was also spoken of by some inside the organisation as the remnant of a possibly outdated MSF standalone model, an alien structure in the middle of nowhere, disconnected from the local health map. In fact, the dilemma between investing in the MSF structure in Agok or working in collaboration with the MoH has been a leitmotiv throughout the history of the project. In 2013, based on the realisation that few of the displaced had returned to Abyei, MSF officially renounced transferring activities back there in any near future and reaffirmed its intention to stay in Agok mid-term. Yet, the question arose again in 2017, when important investments to rehabilitate the MSF hospital had to be made. Eventually, it was decided that making any large investment in Abyei would be both risky for MSF teams and uncertain financially, considering no progress had been made towards a settlement of the political dispute between Misseriya and Dinka or Sudan and South Sudan. What also weighed in the decision is that still only a small part of the population had returned to Abyei and MSF didn’t wish to signal to the rest of them that it was safe to return.
Between 2019 and 2021, tentative steps towards a collaboration with the newly built Ministry of Health Hospital in Abyei were hampered by an intention to reap the rewards of the millions’ worth of investments made in Agok. Consequently, in February 2022, when clashes between the Twic and Ngok Dinka communities forced MSF to move to Abyei and Mayen Abun (in Warrap State), there was a sense of missed opportunity because none of this would have happened, had MSF relocated earlier. More than the sore of ‘losing it all’, some inside the organisation expressed the belief that MSF wasn’t simply caught up in deteriorating community relations but somehow played an active role in the conflict by attracting surrounding populations to settle near the hospital and by causing them to compete for employment or business opportunities.
A Place Worth Fighting for
When MSF suspended its activities in 2022, less than half of its staff came originally from the ASAA. It is also a fact that the population of Agok and surrounding villages grew extensively over the course of MSF’s presence, although it is hard to know exactly when, why and by how much, given the absence of official census and the many other push and pull factors that played a part in these demographic changes (as described above). Consequently, it is impossible to determine the extent of MSF’s direct impact on demographic trends with any degree of certainty, or how it interplayed with people’s specific circumstances. In a country where people have endured more than fifty years of large-scale internal movement, war-induced displacement, independence-induced resettlement, labour as well as environmental migration, it would be presumptuous to think of MSF as a unique anchor factor in Agok, as if there aren’t a multitude of factors which contribute to determining where people settle, over the long run.
As a result of the war, a majority of the Dinka Ngok have not been able to live on their lands north of the river Kiir for the last 30 years. Many members of the younger generation grew up as internally displaced persons in northern or southern Sudan or as refugees in neighbouring countries (Bont, 2014). In fact, during an internal capitalisation exercise conducted by the author, several locally recruited MSF staff indicated that they never owned land in Abyei, and while proximity to MSF was without a doubt part of the reason they chose to come to Agok, the search for safety, the opportunities they found to buy land and the emotional attachment they developed to the place over the years certainly played as big a role in their decision to stay.
The evidence of MSF’s direct impact on the local economy is arguably more tangible than that on changing demographics. Salaries alone give a good idea of the economic benefits part of the population derived from MSF activities, as well as the ASAA authorities by means of taxation. In 2017, when the project team reached its maximum size (417 full-time equivalents), budget actuals for locally hired staff stood at 3.7 million Swiss francs. That same year, an additional 1.8 million Swiss francs was distributed in contributions to the National Social Insurance Fund in one day. Such considerable amounts of cash injected by MSF year after year did not only enrich those directly employed by the organisation but allowed the emergence of a local economy. In candid terms, it isn’t much of an exaggeration to say that MSF ran the local market, or at the very least is directly responsible for its exponential growth from a few stalls where only basic items could be found to around 800 shops offering ‘anything from a Christmas tree, a shirt with a picture of Tupac on it, or Air Jordans’ (interview with former MSF international staff).
Naturally, this financial manna benefited some more than others, sparking frustration with what was perceived as preferential treatment. As the second biggest direct source of wealth in the area after the cattle business (and one that paid in dollars from June 2015 onwards), MSF caused the Ngok and Twic communities to compete for jobs or to control the economic spinoffs of the market. In that sense, MSF’s presence raised the stakes of an existing, long-standing land dispute.
Awareness and Mitigation
If it is true that MSF largely made Agok worth fighting for, then the next question to ask is: to what extent was the organisation aware of its unintended impact? Both the desk in Geneva and the mission leads in Juba probably underestimated the consequences of MSF resources being predated by different communities, for instance by failing to take stock of the fact that some of its staff were actively involved in fuelling tensions. By a former desk member’s own admission, there was a sort of ‘habituation bias’ about South Sudan, causing teams to misread or underestimate red flags. MSF dealt with Abyei authorities exclusively and neglected counterparts in neighbouring Warrap State, as did every other organisation working in the box since Agok was officially made part of the ASAA in 2005. This not only narrowed the organisation’s understanding of the context but upset part of the Twic community.
At a more micro level, strikes, threats and internal pressure tactics among staff were handled as human resources issues, rather than as an indicator that something more serious was going on. Possibly because field teams were too busy running a 185-bed hospital; possibly also because humanitarian organisations have a tendency to resist or resent being pulled into community matters. An artificial line is indeed sometimes drawn between what happens inside and what happens outside the health facilities MSF runs, which can easily sour the relationship between the local community and the organisation if the former feels MSF is not holding its staff accountable. The difficulty lies, of course, in the fact that there is a very fine line between not working in a bubble and allowing community disputes to dictate managerial decisions. Would it have led to a different outcome if MSF had? And more generally, would more awareness of the adverse consequences of MSF’s presence have led to different operational choices?
In contexts where there is virtually no State and where communities are structured along clan, ethnic or religious lines, humanitarian organisations are bound to become a valued asset, which in turn attracts different groups to try to capture the income linked to their presence. One way to reduce the stakes associated with that appropriation is to reduce the amount of resources injected in the local economy. For example, by not giving preference to local purchases or by paying staff smaller salaries. Yet, doing so based on the premise that this money might fuel the wider conflict seems hardly justifiable, not to mention the obvious resentment it would have caused. Another option would be to reduce the scope of services to a minimum. But capping project size based on the precautionary principle would carry its share of drawbacks for the population. How to compare aid’s adverse consequences on local dynamics with its intended, positive impact on population’s livelihoods or health, is an impossible question to answer, even in retrospect.
It should also be made clear, at the risk of stating the obvious, that the land dispute between the Ngok and the Twic precedes and exceeds MSF. The organisation’s share of responsibility in fostering resentment and aggravating intercommunal grievances should therefore be put into perspective with how actors at local and national levels intentionally feed on those grievances to purposefully create instability and advance their own interests. For example, with how Salva Kiir’s regime maintains power by setting feuding elites against each other (Craze, 2022). Many more factors may also have had an incidental influence on what occurred in Agok. Some local actors speculate, for example, that if the former Paramount Chief of Abyei (killed in 2013) had still been alive, none of this would have happened, as he was highly respected in Twic (interview with MSF locally hired staff). Overall, assessing the relative importance of these various factors as determinants of the outbreak of war is a rather speculative enterprise. As is the attempt to summarise deeply complex local patterns of violence through the prism of an external actor’s influence.
The Cost of Saving Lives
The realisation that humanitarian aid has unintended effects, possibly displaces people, reshapes power dynamics and sometimes fuels war is frankly not earthshattering news. Without going so far as to say that the ‘do no harm’ dictum common among aid organisations is an illusion (Terry, 2003), it would be naive to pretend that humanitarian assistance can ever be provided without causing any harm. Where the State has been weakened and where livelihoods have been put at risk, aid will inevitably benefit some more than others and arouse resentment. In that sense, MSF has some responsibility in the intercommunal tensions that resulted in the outburst of violence in Agok in February 2022.
Yet, it goes without saying that a number of additional factors warrant consideration. More research is needed, for example, to distinguish the short- and long-term impact of humanitarian assistance on patterns of violence, as some authors have suggested that aid might exert a pacifying influence over time (Wood and Sullivan, 2015). One should also be realistic about the simple fact that aid organisations generally lack the skills and time to fully grasp the nature of the distortions they cause, their significance, and short- or long-term implications for people’s lives. Additionally, the near impossibility of determining how these distortions weigh in the overall balance of the positive and negative impact of aid is another reason why these distortions may be, and often are, overlooked.
Nevertheless, and while the effects of humanitarian aid on people should remain the primary lens of analysis for humanitarian action, the effects on the conflict itself must be considered. At the very least, actors need to be aware of and realistic about the relative benefits and harm of their presence. Then they can either accept the latter as a cost of ‘doing business’ and look for levers to mitigate it, or they can consciously decide not to reach such a level of influence by limiting their scope of intervention. In contexts with overwhelming needs, this will necessarily entail making some very difficult choices.
Note
In this context, predation refers to the process by which different groups compete for limited resources.
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