Historically, we have witnessed a decline in the absolute number of deaths from conflicts since 1946, often attributed to the values, laws, and democratic institutions that flourished after WWII (World War II). However, we are now witnessing a marked change in the number and the nature of major conflicts that threaten our collective efforts to ensure global peace and save democracy.Reference Khorram-Manesh ¹ Critical are the warning signs that historical humanitarian assistance efforts we have worked under have markedly changed or are disappearing.

Although the link between democracy and effective humanitarian assistance is not always straightforward due to slow or politically influenced democratic processes, competing national interests, foreign policy agendas, and systemic challenges such as corruption and bureaucratic inefficiencies, the fundamental values and principles inherent in democratic systems generally create a more conducive environment for establishing and sustaining robust humanitarian assistance efforts in response to conflicts and disasters. The emphasis on human rights, accountability, civil society engagement, and international cooperation provides a strong foundation for effective and principled humanitarian action.Reference Green ²

Today, there is an emerging consensus globally that threats “to the stability of the current international order are rising” leading to a “specter of widespread democratic decline.”Reference Kendall-Taylor ³ Factors contributing to these changes are the decreasing numbers of people living in democracies, changes in the extent of democratic rights, and an increase in autocratizing countries.Reference Herre ⁴ In 2021, fewer than a fifth of the world’s population lived in “fully free countries.” ⁵ The US is considered a “flawed democracy.”Reference Azpuru and Hall ⁶ Autocratic regimes create a hostile environment for independent organizations, including non-governmental organizations (NGOs), and often neglect or mismanage their health care systems. The suppression of civil society and the weakening of health care are mutually reinforcing, leading to a decline in the overall well-being of the population.Reference Santos ⁷

A 2021 Richard Horton Lancet Editorial cautions that while liberal democracy has wavered during complex crises facing the world today, the public “might lose faith in its efficacy and, over time, be susceptible to the attractions of more authoritarian rule.”Reference Horton ⁸ However, evidence is clear that “autocratic regimes have characteristically failed to adopt investments in public health, education, and prevention measures to keep pace with population growth and density.” A year before the Lancet Editorial, in 2020, Burkle argued that public health emergencies of international concern, such as infectious disease outbreaks, climate change, epidemics, and pandemics, represent an increasing risk to the world’s population.Reference Burkle ⁹ It is safe to assert that globally we will not adequately manage a major pandemic or the consequences of climate change without the coordination of all countries despite their political preferences. Autocratic regimes are “seriously handicapped by sociopathic narcissistic leaders who are incapable of understanding the health consequences of their populations or their responsibility to their global neighbors, as illustrated in their lack of ability to manage the COVID-19 pandemic, placing the rest of the world at increasing risk.”Reference Burkle ^{9 ,} Reference Khorram-Manesh and Burkle ¹⁰ Increasingly, hours of debates among disaster medicine colleagues ask, "Are we using our global health resources appropriately or are those efforts in vain?”

Within autocracies, varied levels of religious restriction exert effects dangerous enough to spark a civil war.Reference Kim and Choi ¹¹ Prolonged conflicts, such as the enduring conflict between Israel and Palestine, can transform religious beliefs into ideologies that fuel the quest for survival and justice. These ideologies make political resolutions difficult to achieve and result in decades of occupation, forced displacements, expulsions, significant loss of life, economic stagnation, and global health crises.Reference Khorram-Manesh and Burkle ¹² Autocrats are both envious and fearful of organized religion’s ability to mobilize the citizenry. Melanie Sauter describes that the “paradox of humanitarian neutrality occurs when humanitarians adhere to neutrality resulting in being perceived as less neutral by conflicting parties. Providing aid to all, including perceived enemies, especially non-state armed groups, becomes a primary obstacle to humanitarian access.Reference Sauter ¹³ Autocratic governments and foreign military interventions pose greater threats to the neutrality of humanitarian workers, often resulting in severe repercussions. To quash domestic opposition, autocrats worldwide are not only learning from each other but also increasingly working together.Reference Ghattas ¹⁴

Somewhat unexpectedly, certain autocracies, for example, China, have acknowledged their limitations and allowed a growing presence of international non-governmental organizations (NGOs), but only if closely monitored and overseen by a government ministry or a government-run (NGO).Reference Ghattas ¹⁴ Many scholars and policymakers can pursue development goals (often called “bypass aid”) in this manner. Some international NGOs operate in authoritarian regimes, “even in countries that have become more hostile.” One author concluded his writings with the quote: “It’s complicated. Dictators love NGOs, but they don’t.”Reference Heiss and Davies ^{15 – 16}

NGOs have the potential to undermine autocracies and bolster democracy. While many autocracies may harbor uncomfortable feelings toward NGO work, others argue that they still “remain a powerful force for democracy.” ¹⁶ Yet, in December 2024, the Taliban in Afghanistan, in one of many crackdowns on women’s rights since they took power in 2021, stated they would close all NGOs employing Afghan women allegedly because they didn’t wear the Islamic headscarf correctly. ¹⁷

NGOs increasingly experience widespread crackdowns globally primarily because they still have the potential to undermine authoritarian governance. However, those responding to worldwide public health emergencies must be increasingly cautious regarding their individual and collective security, ability, and capacity to launch and maintain serviceable humanitarian responses. The “dangers of kidnapping, sexual assault, robbery, severe injury, and death are commonly acknowledged,” yet remain significant threats that NGOs frequently overlook.Reference Quereshi ¹⁸ Recommendations currently focus on “comprehensive security awareness training and building robust capabilities for crisis management.”Reference Quereshi ^{18 – 20}

In 2023, Abby Stoddard and others reported that more aid workers died by violence than in any previous year on record, with 280 fatalities reported in 33 countries. More than half of these deaths (163) were aid workers killed in the first 3 months of the conflict in Gaza, mostly by airstrikes. ^{22 –}Reference Stoddard ²³ As of August 7, 2024, the provisional global fatality counts of aid workers reached 172, the highest rate ever in recent years. Major armed conflicts in Gaza, Sudan, and Ukraine have accounted for the highest proportion of aid worker attacks and killings by state actors, suggesting a further erosion of international humanitarian law and a shrinking of security within humanitarian operations. ^{22 –}Reference Stoddard ²³ In Gaza, Sudan, and other conflicts, concerted humanitarian advocacy efforts with governments – both public and behind the scenes – have resulted in little change in policy and tactics. Far from protecting and facilitating humanitarian aid, militaries have repeatedly obstructed and endangered aid programs. Global efforts to address the problem of violence against aid workers through UN resolutions and international media campaigns like “#NotATarget” have also not managed to slow the continued upward trend of global casualty numbers. ²¹ NGO Security Risk Management programs attempt to “unpack the changing environments, practices, discussions, and technical considerations impacting the safety and security of aid workers and operations.” ^{22 –}Reference Stoddard ²³

Regarding the increase in security issues affecting aid workers, it is also strongly argued that “much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteer’s grasp of the damage caused.”Reference Bauer ²⁴ Without greater coordination, global aid groups must improve coordination with host and local governments and institutions.Reference Deserranno, Nansamba and Qien ²⁵ Ethical considerations serve concerns with international volunteering, recommending that all volunteers must ask: “What are your motivations, are you confident that your presence will not cause harm to the community, can you ensure that your volunteering truly benefits the community, and whether the local community will feel respected and benefited from one’s actions?”Reference Roth ²⁶ The development of WHO’s new strategies regarding EMT work, “Emergency Medical Teams 2030 strategy,” lays a strong foundation, but its sufficiency will be determined by its successful and sustained implementation. It’s a roadmap, and the journey requires dedicated effort and resources. ²⁷

Multiple NGOs faced closure and security threats during COVID-19 as NGO security, finances, and operations collapsed.Reference Worthington ²⁸ Finding a match between volunteer competencies and the host country’s needs is a high priority. In addition, health care and health security go hand in hand, necessitating minimum health security and infrastructure to protect health care providers.Reference Khorram-Manesh and Burkle ²⁹ Given the direction that global health crisis risks are taking today, it is crucial that these questions be asked and solutions sought for pandemics and climate change crises. These questions must be addressed in the context of a potential global crisis for every country where NGOs work.Reference Lough, Tiessen and Lasker ³⁰ How NGO resources and personnel will be used, managed, and protected in climate change and global pandemic crisis management is increasingly critical. A logistical field mantra followed by one of the authors (FMB) over many years: “Send the right people, with the right training, for the right purpose.”

While the spread of autocracies poses a major global concern, the specific impacts of one nation’s actions are contingent on the potential for a sudden scarcity of international resources and the resulting vulnerability of health care workers. The notion that withdrawing resources in an increasingly violent world enhances security or national greatness dangerously ignores a hidden, yet growing, threat.