For decades, the medical aid group Doctors Without Borders has been known for going places many other aid groups won't. But several times over the past two years its facilities have been hit by airstrikes in Syria, Yemen and Afghanistan. And now the group must adapt to a more threatening world.
Michiel Hofman began working with Doctors Without Borders, known internationally as Médecins Sans Frontières (MSF), in 1992 in Liberia. Over the years, whether it's been in Bosnia, Chechnya or South Sudan, the senior adviser for security and operations says its clinics and staff have come under small-scale attack, such as looting and burning. Hofman says that's part and parcel of working in a conflict zone.
But he says over the last few years there's been a dramatic increase of aerial attacks on its clinics or hospitals it supports. Those have been in Yemen, Syria and Afghanistan, on civilian medical facilities that should be untouchable under international humanitarian law.
"The figures are just astounding," he says. "If you take this year alone, we're already at the count of seven, I think — including the last one in Aleppo, and we're not even halfway through the year."
Hofman says when there are ground attacks, MSF officials usually know who is responsible and can negotiate with local commanders.
"With these aerial attacks ... it's much more difficult to know who we actually [need to] talk to about this," he says.
Take Syria, for example. With so many nations involved in the fight, it's hard to know for sure who is responsible for a particular attack. Hofman says his organization is pushing all countries to adhere to international law protecting health facilities. He says it's hard to keep staff if they don't know they're protected.
"A lot of our ability to operate is based on trust — the trust of the medical staff that we ask to work there, but also trust by the patients that these hospitals are safe places," he says.
He points to staff at the MSF hospital in Kunduz, Afghanistan, which agreed to continue to work even after the town was captured by Islamist militants. In October 2015, the facility was hit by U.S. forces conducting an airstrike. MSF says at least 42 people were killed in the attack, including 14 staff members. Hofman says employees felt their trust had been violated.
He says there has also been a recent demonstration in a neighborhood in southern Syria against MSF reopening a facility destroyed by airstrikes.
"The population didn't want a hospital to be reopened because they were afraid their town would be targeted if there was a hospital in that location," he says.
Airstrikes aren't the only threat that has increased. Hofman says in almost every ongoing conflict in the world, abduction has become a routine strategy of warring parties. Security measures that didn't exist before are now actually related to mitigating or preventing the risk of abduction.
As MSF has expanded its operations, it's become better known worldwide, says Hofman. Kidnappers looking for money or headlines target the group's medical workers from the international community.
"Because they tend to have, to say it very crudely, the highest market value ... It's actually mostly Western staff," says Hofman of those who have been kidnapped. "And if I dare say so, [it's the] white Western staff who is most at risk."
To mitigate the risk, sometimes MSF uses just local workers, he says. But he says there are certain programs that can't be done without international staff.
The aid agency also restricts its workers' movements with things like curfews, or it might even pull out of a country. What it still won't do is use armed security.
"Those people who can provide you with armed protection are always connected to one or the other party in a conflict. Which means as soon as you accept an armed party, you become a legitimate target for the other side of that conflict," he says.
Hofman says it's critical that MSF — like all humanitarian aid agencies — remain impartial. That includes never turning away a patient, no matter which side he or she is on.