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As the first quarter of 2015 draws to an end the number of conflicts around the world shows no sign of abating. There are now more refugees living outside their home country than ever before in human history, according to the UN refugee agency UNHCR. The longevity and chaos of these conflicts, which are dominated by infrastructure destruction and the specific targeting of civilians, are taking an unbearable toll on health systems in the affected regions.

In this light, international medical support — especially vaccination — is becoming increasingly important as local healthcare providers struggle to deliver basic services. But foreign interference, often involving military protection and white, western doctors with little cultural and language awareness, brings its own problems.

Last week (13 March), NGO members, military personnel and aid agency staff came together at the Royal Society of Medicine in London, United Kingdom, to discuss finding innovative ways to run vaccination programmes. They heard that in 2014 alone 89 aid workers and their protectors died in Pakistan and Nigeria in the course of working to administer polio vaccinations.

Quickly, perceptions of vaccinators are open to instrumentalisation.

Marion Birch, London’s Institute of Global Health

This is a distressing development since the days of ‘corridors of peace’ agreements in the 1980s, when warring factions in Uganda and Mozambique laid down their weapons to let doctors vaccinate local children, said Marion Birch, a lecturer at University College London’s Institute of Global Health.

“How did we go from [that] to the deaths of so many vaccinators? Changes of perceptions had a significant effect,” she said.

A lot of these changes of perceptions have to do with the changing face of war. Whereas conflicts in the latter half of the 20th century had clearly defined factions, locations and time spans, modern warfare is far more muddled. It has murky divisions between friend and enemy, and flares of arbitrary violence rather than battles and ceasefires.

This kind of protracted conflict goes along with increased indoctrination of local populations. As people in remote, war-riddled areas are subject to widespread social media propaganda and conflicting messages about who is on their side, vaccinators can easily become associated with the enemy.

“Think about it — they are doing something to a child that is not sick, and its parents may not be quite sure what this is about,” Birch said. “Quickly, perceptions of vaccinators are open to instrumentalisation.”

Fortunately vaccination agencies are increasingly aware of these risks. Médécins Sans Frontières (MSF), which provides medical aid around the globe, has done research into how its presence is perceived by those on the receiving end of care.

Caroline Abu Sa’Da, who coordinate’s MSF’s research unit, said survey results show that many people see MSF workers as physically isolated, in secure compounds. Their white cars are indistinguishable from UN vehicles or those of private security firms. There are also too many expats making crucial decisions, and the organisation is not involved enough in the training of local staff, she said.

MSF is using these findings to rethink their strategy to provide vaccination and deliver medical aid. Abu Sa’Da encouraged others at the event to do the same — for the sake of giving better support and keeping health staff safe.

“We need to think about all the actors around vaccination projects, and their understanding of what we do,” she said.

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