Ensuring public health neutrality.

n engl j med 368;12 nejm.org march 21, 2013 1073 be shot down and far more would crash because the Nigerian government’s shoot-to-kill order forced them to fly at night. The brazen targeting of Red Cross relief flights on civilian humanitarian missions was hard to imagine. In the minds of some people, however, these attacks were justified by another clear violation of humanitarian neutrality: on at least one occasion, a plane painted with the Red Cross insignia was actually carrying weapons.2,3 That rare instance of military action masquerading as humanitarian relief completely undermined the neutrality of everyone who operated by the accepted rules of humanitarian assistance, cost the lives of both aid workers and aid recipients, and provided a blanket of impunity for the future criminal actions of the Nigerian government. To underscore the necessity of humanitarian neutrality, 12 deans from prominent U.S. schools of public health sent a letter to President Barack Obama on January 6, 2013, protesting the conduct of a sham vaccination campaign as part of the hunt for Osama bin Laden.4 In the lead-up to the May 1, 2011, targeting of Osama bin Laden in Abbottabad, Pakistan, the Central Intelligence Agency (CIA) reportedly hired a Pakistani surgeon named Shakil Afridi to go house to house vaccinating children but also drawing back a little blood in the syringe in order to analyze the DNA of the household members. The ploy appears not to have worked in the bin Laden compound, since Afridi’s team was kicked out. Nonetheless, in a 60 Minutes interview last June, Defense Secretary Leon Panetta said that Afridi was helpful in finding bin Laden.5 In May 2012, Afridi was convicted of treason and sentenced to 33 years in prison. Because of these events, Pakistan expelled the foreign staff of the international aid agency Save the Children from the country in September 2012 — a move that threatened the network of health and development services that the organization had established over the past 30 years. In December, eight polio vaccination workers were killed in an apparently coordinated set of attacks (see photo), and the United Nations has suspended its polio-eradication efforts in Pakistan, where 150,000 Ensuring Public Health Neutrality