By now, it is well known that the world is struggling with unequal access to vaccines. In high-income countries, roughly 75 percent of people are now fully vaccinated. But in low- and lower-middle-income countries, logistical troubles continue to plague the rollout of vaccines, and less than 35 percent of people have received a complete set of shots.

To try to close this gap, wealthy countries and international institutions have focused on partnering with less affluent states. They have funded and donated doses to the COVID-19 Vaccines Global Access program, or COVAX, which allocates shots to poorer countries. Sometimes, they’ve given out vaccines and aid directly. But although such efforts are important, the current system’s focus on working with and through states overlooks some of the world’s most vulnerable people: the 60–80 million people who live in areas outside of formal governmental control.

To reach these people is a daunting task—and not just because it requires dealing with violent actors and moving vaccines through conflict zones. Current counterterrorism restrictions in the United States and many other leading donor countries bar international aid agencies from providing any group designated as a terrorist organization with “material support.” This broad definition means that aid organizations cannot easily get doses into areas governed by such groups. To truly vaccinate the world against COVID-19 and prevent the outbreak of deadly new variants, the United States and other governments will need to do more than just donate shots and finance efforts to distribute them. They will need to understand that their laws regarding terrorist groups are making it more difficult to end the pandemic.


The millions of people who live in areas not under formal governmental control are, not surprisingly, among the populations least protected from the pandemic. In the 22 countries experiencing high- or medium-intensity conflict, according to a 2022 World Bank list (including many that are lower-middle income, rather than just low income), less than 15 percent of the population has been fully vaccinated against COVID-19. Although subnational data on vaccine distribution within conflict-affected countries is not publicly available, it is likely that vaccination rates are higher in areas controlled by government forces than in those controlled by nonstate armed groups.

International organizations are aware of this problem. COVAX has established a program that allocates approximately five percent of its doses to international aid organizations that vaccinate populations in places that national governments cannot access. But these efforts have been haphazard and constrained. Aid groups working in areas outside of formal governmental control have to navigate both the logistical challenges inherent to all immunization campaigns, such as ensuring that the vaccines are continuously refrigerated, and the demands of cooperating with nonstate armed groups, including those designated as terrorist organizations.

It is impossible to vaccinate the world against COVID-19 without engaging such groups. Whoever provides health and security services in a region has to be involved in facilitating the delivery of vaccines. In many places, such as Myanmar, Syria, and the Democratic Republic of the Congo, nonstate groups often assume these responsibilities or facilitate the delivery of international assistance. Across Ukraine, public health responsibilities are largely conducted by the two warring states—Russia and Ukraine—but in parts of Ukraine’s east, vaccination campaigns have fallen to the Dontesk and Luhansk’s “People’s Republics”: armed, Russian-backed breakaway organizations. Local communities also must be willing to get immunized, and they may need encouragement from trusted leaders. Often, such leaders aren’t part of the national government—especially in states riddled by civil war.

Many of the places that most need help from aid organizations are not receiving it.

Not all nonstate armed groups are well placed to help implement vaccination campaigns, and not all of them will be useful partners. For example, the Islamic State’s West African Province, the West Africa Islamist militant outfit previously known as Boko Haram, previously undermined efforts to contain the spread of COVID-19 by declaring that pandemic restrictions on large gatherings were a means to persecute Muslims. But a variety of other nonstate armed actors have responded favorably to the UN secretary-general’s 2020 global cease-fire call and may be effective partners. Some groups, such as Southern Cameroon’s Defence Forces, the Syrian Democratic Forces, the National Liberation Army in Colombia, the National Revolutionary Front in Thailand, and the New People’s Army in the Philippines, have declared cease-fires explicitly to facilitate COVID-19 treatment and support public health measures intended to halt the disease. Al Shabab established treatment centers for COVID-19 patients in Somalia, while the Taliban distributed personal protective equipment to health-care workers in many areas (before taking over the Afghan state). In Myanmar, the Kachin Independence Army and the Arakan Army, both nonstate armed groups, reportedly distributed vaccines to populations in the areas they controlled.

But armed groups have generally struggled to get doses to the people they govern, something that, in theory, humanitarian organizations should help address. The guiding principles of humanitarianism require that humanitarians provide assistance based solely on the population’s need—regardless of what entity recipients live under. But a variety of regulations have made that extraordinarily difficult. After the September 11 attacks, the United States, along with many of its allies, adopted far-reaching sanctions and regulations that barred aid agencies from engaging with nonstate armed groups designated as terrorists. President George W. Bush issued an executive order revoking an existing humanitarian exemption in the International Emergency Economic Powers Act, thereby making it illegal to “to assist in, sponsor, or provide financial, material, or technological support for, or financial or other services to” designated terrorist organizations. The revocation also allowed for punitive actions to be taken against organizations “otherwise associated with certain individuals or entities” designated as terrorists by the U.S. government, a far-reaching category that is not clearly defined. In 2010, the U.S. Supreme Court ruled that just providing peaceful conflict resolution training to groups deemed terrorist organizations violated the law, a prohibition that extends to providing even the kind of basic medical training necessary for a vaccination campaign.

The result has been a climate of fear among humanitarian organizations, which are now wary of doing work in regions controlled by designated terrorist groups lest they fall afoul of U.S. restrictions. Donors are also afraid of supporting aid organizations that potentially violate these laws, making it more difficult for humanitarian organizations to raise money. And because the list of designated groups continues to grow—50 new groups have been added to the U.S. list of Foreign Terrorist Organizations since September 11, for a total of 73—humanitarian organizations have been dissuaded from dealing with even those nonstate armed groups that are not U.S.-designated FTOs.

The current framework does permit humanitarian actors to engage in negotiations focused on gaining access to vulnerable populations, but by excluding all more substantive cooperation, humanitarian actors frequently struggle to come to a mutually beneficial agreement with armed groups or to effectively distribute assistance, even if they receive access. The threat of criminal and civil liability has also incentivized aid agencies to hide interactions with nonstate groups or let national partner organizations and staff manage them, putting frontline workers at legal risk in addition to the normal security risk that they bear. As a result, many of the places that most need help from aid organizations are not receiving it.


The international community has a clear moral and public health imperative to facilitate vaccine distribution throughout the world. And to do this as well as possible, aid organizations will need to be able to work with nonstate armed groups. That means that wealthy countries in general, and the United States in particular, must allow such engagements by revising their sanctions regimes and legislative frameworks to affirmatively let humanitarian organizations engage with nonstate armed groups. This could include Congress amending the International Emergency Economic Powers Act to permit such assistance. It could also entail the president simply reinstating the humanitarian exemption via executive order.

If empowered to act, history suggests that aid groups can have tremendous success at reaching people who live beyond state control. In 2013, for instance, the Syria Polio Control Task Force—a coalition of opposition groups and NGOs with support from organizations like the WHO, UNICEF, and the Turkish Red Crescent—organized an immunization campaign in opposition-held territory to stop a polio outbreak. It was remarkably effective, reaching more than a million children by securing the cooperation of rebel groups and recruiting vaccinators that were, as one study put it, “trusted by both the community and the militants.” Evidence from effective polio campaigns in Burundi and Afghanistan in 2001 and 2007, respectively, also demonstrates that by cooperating with armed groups, health organizations can cut across conflict lines and successfully inoculate children.

Altering the current restrictions on engagement with nonstate armed groups will not make these collaborations easy. Getting consent from such organizations to operate on their territory requires continuous negotiation, particularly in situations where armed group loyalties are fluid and violence regularly breaks out. But it will make them possible. It will help safeguard the international and national staff who operate in areas governed by armed groups by allowing them to engage with the powers on the ground and get their support. (If humanitarian actors do not do engage with armed groups, they are often viewed by such organizations as either a threat or a source of lootable goods.) In the best-case scenario, loosening the current restrictions on engagement may allow international organizations to broker temporary or partial cease-fires so that they can provide critical health-care services. Such an accomplishment wouldn’t be without precedent; in 1985, Save the Children successfully negotiated a three-day cease-fire in El Salvador that allowed the organization to vaccinate 200,000 children.

Even if it can’t pause conflicts, rolling back current counterterrorism restrictions will still enable international organizations to gain access to—and the trust of—local populations in places that desperately need assistance. It will also allow aid actors to support on-the-ground partners that are central to all medical campaigns in conflict-affected regions, advancing the U.S. government’s stated desire that locals take the lead in managing their own health care rather than having foreign actors make decisions from afar. Although this process won’t always be savory—most of the organizations labeled by Washington as terrorists have done plenty to earn their designations—it is the price that governments must pay to end the pandemic, and it is entirely consistent with the humanitarian principle of helping the world’s most vulnerable people no matter the surrounding circumstances. Ultimately, to vaccinate all populations against COVID-19, the United States and its partners must deal with the world as it is, not as they want it to be.

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  • SUSANNA CAMPBELL is an Associate Professor at the School of International Service at American University.
  • JACOB KURTZER is Director and Senior Fellow with the Humanitarian Agenda at the Center for Strategic and International Studies.
  • HILARY MATFESS is an Assistant Professor at the Josef Korbel School of International Studies at the University of Denver.
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