Small Wars Journal

Be Wise, Not Foolish: Medical NGO Deterrence Through an Insurgent Lens

Be Wise, Not Foolish: Medical NGO Deterrence Through an Insurgent Lens

LTC Ramey L. Wilson, MD, FACP


The use of medical care to connect with a civilian population and provide an essential service firmly resonates with counterinsurgency doctrine and the indirect approach. Often provided by nongovernmental organizations (NGOs) in unstable or conflict-inflicted areas, medical care can be influenced by the insurgent, as well as counterinsurgency forces, to increase legitimacy and control over the population. While attempting to find the slippery summit of neutrality, NGOs attempt to help those in need while feeling pressure to conform from both sides of a conflict.  This article is written as a letter from an insurgent commander to a sub-commander in Afghanistan to illuminate the perspective and tools used by insurgent forces to influence and control medical NGOs.


Asalaam Alaikum.  Greeting to you in the name of the One who will bring us ultimate victory against the foreign invaders. I write to you hastily, anxious to get this message to you before you act in a manner unworthy of your calling and detrimental to our efforts.  My prayer is that this letter arrives before you have taken any irreversible actions, Insha’Allah.

I hear from the brothers that infidels are moving into your area, and you are preparing your response.  While these foreigners come under the flag of neutrality, bringing medical supplies and care, you must proceed carefully. Their arrival presents both a risk and an opportunity to our cause. Let me offer you some guidance on how to proceed. 

I am sure that you know the risks associated with this group of foreigners claiming to be a medical nongovernmental organization (NGO). While they claim humanitarian principles and interests, you must be wise and discover their real motives. If they truly believe the tenants of their espoused neutrality and humanitarian principles, you will be able to manipulate them to our advantage.  If they are here for other purposes, e.g. the physician traitor in Pakistan who ran a vaccination program in order to find the Lion Sheik, you must expose their lies so we can exploit it internationally.[1] You must not act rashly but watch and study them. You must not underestimate the importance of learning everything you can about them, both as an organization and as individuals. I will speak more of this later.

Let’s assume, for now, that this group is not an undercover intelligence organization and the group’s claim of being a medical NGO is legitimate.  Remember that we are fighting for the hearts and loyalty of our Pashtun brothers, and we must carefully counteract any attempts of the corrupt central government to divide us from our holy brothers.  The forces of the great Satan corrupt everything they touch and, together with the Zionists, are working throughout the world to smite Allah and the words of his prophet.  They now know that they cannot defeat us as long as the people support us. Instead of fighting us directly, our enemy seeks to divide us from the population by providing essential services to the people, services that are difficult for us to provide.  Remember that this NGO, even if they claim no direct allegiance to the corrupt government, operates with the government’s knowledge and consent. Additionally, many NGOs receive their funding from the Great Satan or, if not directly from the United States government, from Americans wishing to spread Christianity in our Muslim lands. These NGOs are rarely willing to accept or embrace our values.

If you decide to let them operate in your area, you must insure that the people perceive the NGO presence as evidence of our authority, not the corrupt government’s.  More importantly, you must make it very clear to the NGO that we determine their access to the population.  Without access to the people, the NGO will be unable to perform their work and will be perceived by their donors as ineffective and a failure.

You must communicate to the NGO that their personal safety and access to the sick are dependent upon two things.  First, the NGOs must give us credit for all of the care they are providing, not the corrupt government. Secondly, they must have no contact with the foreign invaders or intelligence agencies of the corrupt government.  The NGO must know that if any information about you or your fighters is passed to our enemies, either by their workers or their patients, it will be on their heads. We cannot allow the enemy to infiltrate this area and use a ruse of medical care to obtain information on us; the Great Satan will use this information to conduct night raids to kill you and our fellow brothers.

Don’t be ignorant, however, of the risks you face if you prevent them from entering your area.  If they have legitimacy in the international community as true humanitarians, you will be perceived as a backward extremist who is preventing the delivery of health services to the region.  If you or your holy warriors injure or kill any of these health workers, the Great Satan will likely brand you a war criminal. If this happens, don’t be surprised when you are promptly martyred in a night raid or predator strike. 

Let me now outline the basics of the strategy you must pursue.  While I detest the American influence on our society, they have developed a strategy we can use against them.  The deterrence strategy used by the Americans against the Soviets (who should have informed the Americans of the futility of invading Afghanistan) provides a model for the actions we must take to respond to the NGO. Deterrence is “the persuasion of one’s opponent that the costs and/or risks of a given course of action he might take outweigh its benefits.”[2] You must employ a carefully considered deterrence plan in order to reap the benefits of claiming credit for the care the NGO provides while minimizing the risks of having them in your area.  At the most basic level, you must deter the NGO from both being a visible sign of government legitimacy and being an intelligence-gathering platform. You must develop your deterrence strategy with the following elements: understanding your opponent, managing how the NGO perceives you, communicating your threat, defending your reputation, and maintaining the capability to carry out your threat.

Understanding Your Opponent

As the Prophet told us, “[acquire] knowledge, it enables its possessor to distinguish right from wrong….”[3] You must begin to develop your deterrence strategy by acquiring and maintaining a complete understanding of your opponent. Start simply and expand your understanding and knowledge over time. I recommend finding a trusted family with a sick child and have him take the child to the NGO for care. Make sure he reports back to you all that he discovers during his visit.  Details such as the name of the NGO, the names of the physicians, the names of their interpreters, their location, their equipment, and the care they are giving will provide some initial information. A thorough Internet search on these facts should reveal a bounty of information.  If the NGO has no organizational website or web presence, I would strongly suspect the organization is a ruse. If this is the case, notify me immediately and I will come to assist in dealing with this extreme threat. If there is a website and it appears legitimate (it will likely have a .org address), you should be able to determine its funding sources, read its mission statement, and see where it has been operating.  Most importantly, verify that the NGO has signed the International Red Cross Red Crescent (ICRC) Code of Conduct.[4] If the NGO is not a signatory to the ICRC Code of Conduct, they are not a legitimate NGO in the eyes of the humanitarian community. More significantly, if the NGO has signed the Code, thereby promising to operate according to its tenants, the Code provides us ammunition to deter the NGO from working with the government, foreign military or intelligence agencies.  Continue your Internet search to learn all you can about the individuals who work in the organization. If they are foreigners, which I am sure they will be, knowledge of their hometowns, previous professional exploits, professional organizations, home phone numbers, and family members (all so easy to find or buy on the Internet) provides us the upper hand when you interact with them.  I still relish the fear I saw in a foreign doctor’s eyes when I rattled off his college daughter’s cell phone number and told him I knew what college and sorority she attended, but I get ahead of myself. The more you can learn about this organization and the people in it, the better prepared you will be when you interact with them. Use the population to help you collect information, either voluntarily or through coercion, to maintain a current understanding of what the NGO is doing, who they are seeing, who they are treating, and who is observing the care.  Intelligence gathering is a critical component of your strategy to both monitor for compliance and provide early warning of new individuals to the organization.  This information will also assist you in predicting how they will respond to your threats and whether you can count on them to act rationally. Above all, though, it is critical that you make intelligence collection your first and continuing priority while the NGO operates is in your area.

Managing How the NGO Perceives You

Managing the NGO’s understanding and perception of you is the second key to a successful deterrence strategy.  Your goal is to solidify your reputation as the de facto leader of the area with the ability to exert your authority without constraints.  Send those impious or treasonous brothers you have had to discipline to the NGOs for care as examples; make sure the patients tell the doctors that they were disciplined under your authority.  This will serve to communicate your control over the population. Establish, at your whim, days that civilians are forbidden to go to the NGO for care (this must be ruthlessly enforced). Nothing will get the NGO’s attention faster than your ability to deny them access to patients in need.  Once your authority has been established, NGOs will usually do whatever they must to maintain their access to the patient population.

I am assuming the foreign doctors will be infidels and will rely on local interpreters to interact with the patients. While it might be tempting to condemn these misguided brothers, you must include them in your intelligence collection. Discover their loyalties and their background in order to use use them to collect intelligence and establish your reputation and capabilities.  Use whatever means are necessary to gain control over these brothers, if needed, as they will be essential to your communication with the doctors.  Avoid any appearance of ineptitude, hesitancy, impotence or a weak resolve.  The NGOs must know your reputation and your ability and willingness to do what you threaten.

Defending Your Reputation

 While establishing your reputation is critical, it must be reestablished from time to time in order to be effective.  In our current struggle, often in the shadows, it may be easy for the NGO to forget your authority and capabilities. Any visit by foreign military personnel, security forces, or representatives of the corrupt government must be immediately followed by a visit by one of your soldiers to remind the NGOs of your authority and capabilities. Confiscate any supplies or equipment outsiders provide the NGO, and consider returning parts of these supplies if the NGO behaves properly. If you discover that a government official is coming for a visit, you might consider forbidding the population from going to the NGOs for a day or two before the official’s visit, just as a reminder to the NGO of your power in the region.

Communicating Your Threat

Communicating your threat will be one of the most difficult aspects of your deterrence strategy.  While its effectiveness will depend upon your reputation and the NGO’s impression of your capability and intent, the threat must be communicated unambiguously and coherently.  This can sometimes pose a challenge when there is a language and cultural divide.  Your intelligence and research should allow you the ability to consider the NGOs response to any communication, but you must insure that all of those involved in the struggle understand the threat and how to communicate it. There must be no confusion or the possibility of misinterpreting the threat.  The essence of your message to the NGO must be simple and easy to understand: if the NGO wants to operate in this area, they must acknowledge your authority and refrain from providing any intelligence any government, military or outside organization.  If the NGO fails to comply with these behaviors, either as a group or as individuals, the entire organization will be forced to leave the area, and they will not be allowed to have access to the population.

I recommend using the ICRC Code of Conduct, which the NGOs should have signed, as a common point of departure for your communication.  Point three and four of the Code state that “[aid] will not be used to further a particular political or religious standpoint,” and “[we] shall endeavour not to act as instruments of government foreign policy.”[5]  More specifically, take special care to understand the implications of the expansion of point four:

      [we] will never knowingly – or through negligence – allow ourselves, or our employees, to be used to gather information of a political, military or economically sensitive nature for governments or other bodies that may serve purposes other than those which are strictly humanitarian, nor will we act as instruments of foreign policy of donor governments.[6]

We couldn’t have asked for a better tool than the ICRC Code of Conduct to deter the NGO from giving credit to the government or pass information to the intelligence or military organizations. We only have to get the NGO to do what they have already promised. This will be much easier than getting them to do something against their convictions.  Your job is to “help” them keep their promise and make sure they understand the consequences of breaking their word.

Let me offer, however, one word of caution.  You must be subtle in communicating the specific actions you will take if the NGO defies your threat. It is possible the NGO could feel so threatened by your threat that they might feel they have no choice but to report you to the government.  Avoid this at all cost. Let your reputation and capabilities speak to your resolve to carry out your threat.  

Maintaining the Capability to Carry Out Your Threat

Finally, you must remain vigilant.  Your ability to leverage this NGO for your benefit will be based on your ability to carry out your threat.  Maintaining this capability demands continued intelligence of the clinic’s personnel and activities and maintaining your control over the populace.  If it appears that you are unable to deliver on your threat, the NGO could switch their behavior and allow their clinic to be used to collect intelligence. Enemy intelligence gathering of our activities would be catastrophic to your area and our cause.

In conclusion, the arrival of this medical NGO caries both risk and opportunity.  I pray that you understand the importance in dealing with this situation deftly and with great care. Read these principles to your subordinates and make sure they understand what we are trying to accomplish. It is unlikely that the NGO understands that by operating under their “humanitarian” principles and pledging to abstain from reporting us, they are providing us passive support by allowing us to operate undetected and in the shadows.[7] Take personal supervision of this endeavor. As I mention previously, you must be of one mind so there is no doubt or confusion of your intentions. The principles of deterrence theory greatly educate the actions you must take to turn the presence of this NGO to our advantage. We shall prevail and outlast the Great Satan’s presence on our soil—his resolve is already growing thin as shown by America’s planned departure. Once he is gone, we shall destroy this puppet government and establish a true Islamic State and prepare for the future Caliphate, Insha’Allah.

“Obey Allah and his messenger…”[8]

-Sher Dil

This article was adapted from a paper written for Deterrence, Coercion and Crisis Management, a course taught by Dr. Robert O’Connell during the summer of 2012 at the Naval Postgraduate School.

The views expressed in this document are those of the author and do not reflect the official policy or position of the Department of Defense or the U.S. Government.


[1]. Ibrahim Shinwari and Jibran Ahmad, “Pakistani doctor jailed for helping CIA find bin Laden,” Reuters News, posted May 23, 2012, (accessed May 8, 2013).

[2]. Alexander George and Richard Smoke, Deterrence in American Foreign Policy. (New York: Columbia University Press, 1974), p.11.

[3]. Missi Inchyra, “Islamic Concept of Knowledge,” International Islamic University Malaysia, (accessed May 8, 2013).

[4].  International Federation of Red Cross and Red Crescent Societies, “Code of Conduct Signatories,”, (accessed May 8, 2013).

[5]. International Red Cross and Red Crescent Society, “Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief,” (accessed May 8, 2013).

[6]. Ibid.

[7]. Gordon H. McCormick, "Seminar in Guerrilla Warfare (class lecture)." Monterey, CA: Naval Postgraduate School, Winter Quarter 2012.

[8]. Quran 3:32


About the Author(s)

Dr. Wilson is an Army physician studying in the Defense Analysis Department of the Naval Postgraduate School in Monterey, California.