Aid agencies are tightening security measures in the Middle East and increasingly outsourcing work to local organizations to limit their exposure to multiplying risks across the region.
Most if not all international NGOs had already stopped sending expatriate staff into Syria by the time footage emerged 10 days ago of a British aid worker being beheaded by Islamic State militants who control around one third of the country.
But the killing has brought into focus the increasing dangers faced by aid workers across the region just as they are also facing huge risks in their work dealing with the Ebola outbreak in West Africa.
Those dangers are making it hard for NGOs to deal with some of the most acute humanitarian crises of the century.
“The severity of the risk, but also the targeted nature makes it very hard for any humanitarian organization to operate in these areas,” said a representative of one aid organization working in the Middle East, who did not want to be named.
“Humanitarian activity is very limited at the moment; everyone is very much constrained by the security situation.”
International aid agencies are relying increasingly on local organizations to get access to communities in need both in Syria and Iraq.
In Syria alone, some 3.5 million people have been internally displaced by the conflict with more than 800,000 forced from their homes since IS overran the north's largest city in June.
“The basis of our security in a context like Iraq...is acceptance, so the people on the ground, all parties to the conflict, know who you are,” said one NGO security director. “We are trying to approach everybody that is playing a part in the conflict.”
In footage showing the beheading of aid worker David Haines, his masked executioner said it was in revenge for Britain's decision to arm Kurdish forces, which have been regaining ground from IS militants in northern Iraq since the United States began a campaign of air strikes last month.
Another British aid worker, was shown at the end of the video, and the masked man said he too would be killed unless British Prime Minister David Cameron changed his policies.
“Humanitarian activities are being more and more manipulated in order to serve goals and objectives that don't have anything to do with the humanitarian assistance that we strive to provide,” said Fabio Forgione, Head of Iraq Mission for Doctors without Borders (MSF).
“That...completely undermines our capacity to reach those populations that are in the most dire need in Iraq.”
A new record for violence against civilian aid operations was set in 2013 with 251 separate attacks affecting 460 aid workers of which 155 were killed, according the Aid Worker Security Report which is supported by USAID.
The increase was driven mainly by Syria and South Sudan but Afghanistan was the most dangerous country.
The governments of kidnapped expatriates often impose media blackouts whilst they try to negotiate their release so the number of aid workers being held by militant groups including Islamic State is not known, but the United Nations estimates 200-300 Syrian aid workers were abducted in August.
“The kidnapping of local workers has become a phenomenon and it's happening a lot - especially in the last 2 months. It's all anecdotal because negotiations are ongoing,” an aid worker in southern Turkey said of the situation in Syria.
Security risks pose a series of problems for aid agencies. The cost of insurance in the region is on the rise.
Insurance contracts are normally renewed only on an annual basis, but insurers say premiums are rising in kidnap and ransom products even if they have already been renewed, with estimates of as much as a 100 percent increase over the past 18 months.
Those policies cover oil and construction workers as well as aid workers who are often closer to the action.
“In the Iraq business, we are seeing higher demand than we were a year ago, our premiums have to adjust to the risk,” said Henry MacHale, head of accident and speciality risks at insurer Aspen, on kidnap and ransom insurance.
“We have seen (Syria and Iraq) as a real problem over the last two years but we have had to review premiums further in light of the increase in activity in the region during the last 6 months.”
Oxfam, which does not work in IS-controlled areas, said it could not reveal details of its insurance premiums but a spokeswoman said: “We have robust, specialized and detailed security procedures firmly in place to protect our staff and partners, and to make use of a range of different insurance policies to ensure our teams are able to effectively, and safely, deliver desperately needed aid.”
A spokesman for MSF said it had not had to change its global insurance cover in the past few years due to “perceived increased exposure to risks”.
With budgets driven in large part by donations, NGOs can little afford the kind of insurance premiums that oil companies are used to paying.
Reports of beheadings or kidnappings could also impact on donations to aid charities although the Oxfam spokeswoman said: “We have not seen donations rise or fall as a result of the recent high-profile advance of IS forces in Syria and Iraq. Our supporters gave generously to appeals we have run for both Syria and Gaza to support Oxfam's response to these crises.”
The worsening situation in the Middle East comes as pressure increases on NGOs to do more to help people in West Africa affected by the Ebola virus which has killed over 2,811 people.
NGOS are on the ground but face serious risks. Three local MSF staff have died of the disease and an infected French staffer was evacuated to Paris. In Guinea, eight people trying to raise awareness of Ebola were killed by a hostile crowd.
Nevertheless, some NGOs have started to focus their resources on Ebola, making it harder to recruit expatriate staff to the Middle East.
A security director for one NGO working in Iraq said although expatriates were still travelling to areas outside the relatively safe Kurdistan region, only staff from countries that are not involved in the conflict were sent.
Many international NGOs have suspended their activities in areas proclaimed a caliphate by Islamic State, but some agencies continue to provide assistance via “remote control” -- as they refer to working through local partners.
“It's a process that we do when we decide that a country is getting too dangerous to work in: like Somalia, some parts of Afghanistan, Libya,” said Laurent Hamida of ACTED, for which Haines also worked when he was kidnapped.
Hamida said ACTED had pulled its staff out of Libya after an armed group took over the capital last month and set up its own government, plunging the country into violent chaos. “We're trying to still keep running through local partners.”
The World Health Organization (WHO) is still supplying medicine to parts of Iraq under Islamic State control, and recently conducted a nationwide polio immunization campaign.
“It's a mixture of using the local NGOs and local authorities local mayors and communities,” said WHO's country representative and head of Iraq mission Syed Jaffar Hussein.
“We use local contractors to deliver medicine: they are local people and they already have some agreement with the occupation forces. They also will be paying something to them to let their consignment go ahead.”
Hussein said they had taught volunteers how to administer the polio vaccine in areas too dangerous for its own staff.
WHO said while sabotage could not be ruled out, human error was likely to blame for the deaths of 15 children vaccinated against measles in Syria, a program done by another NGO.
“In these very violent, polarized contexts (working through local relief networks) means some loss of control and accountability,” an aid agency representative said.