Picture the situation in Haiti: families living on top of sewage-contaminated rubbish dumps, with no reliable sources of food and water and virtually no access to health care. This scenario depicts the situation in Haiti before the earthquake that catapulted this impoverished and conflict-ridden country into the international headlines. Now the latest target of humanitarian relief, international organisations, national governments, and non-governmental organisations (NGOs) are rightly mobilising, but also jostling for position, each claiming that they are doing the most for earthquake survivors. Some agencies even claim that they are “spearheading” the relief effort. In fact, as we only too clearly see, the situation in Haiti is chaotic, devastating, and anything but coordinated.

Much is being said elsewhere about the performance and progress of relief efforts in Haiti. It is crucial that the immediate needs of the Haitian people are urgently met. But it is scandalous that it took a seismic shift in tectonic plates for Haiti to earn its place in the international spotlight. Political rhetoric is familiar: domestic and international point-scoring during times of crisis and disaster is a common game played by many governments and politicians. But this dangerous and immoral play has many losers, especially since the rules include judging the needs of desperate people according to subjective perceptions of worth.

For example, just think back 5 years to the dismal international response to the catastrophic earthquake in Pakistan. Additionally, over the past 2 weeks alone, flooding has displaced 30 000 people in Kenya and 4000 people in Albania, and in Yemen, the Democratic Republic of the Congo, and Somalia hundreds of thousands of people have been displaced by further fighting. All international agencies, including the World Food Programme, have recently withdrawn from Somalia—one of the most violent countries in the world with a population size similar to Haiti. It is unimaginable that international agencies and national governments might one day compete for attention in leading a Somali humanitarian relief effort. The reasons for their current inaction are most un-humanitarian.

We have repeatedly drawn attention to the fact that when viewed through the distorted lens of politics, economics, religion, and history, some lives are judged more important than others—a situation not helped by the influence of news media, including ourselves. This regrettable situation has resulted in an implicit hierarchy of crisis situations further influenced by artificial criteria, such as whether disasters are natural or man-made. As this week's special issue on violent conflict and health shows,* the health needs of people affected by conflict are repeatedly neglected.

Politicians and the media make easy targets for criticism. But there is another group involved in disaster relief, which has largely escaped public scrutiny—the aid sector, now undoubtedly an industry in its own right. Aid agencies and humanitarian organisations do exceptional work in difficult circumstances. But some large charities could make their good work even better. The Lancet has been observing aid agencies and NGOs for several years and has also spoken with staff members working for major charities. Several themes have emerged from these conversations. Large aid agencies and humanitarian organisations are often highly competitive with each other. Polluted by the internal power politics and the unsavoury characteristics seen in many big corporations, large aid agencies can be obsessed with raising money through their own appeal efforts. Media coverage as an end in itself is too often an aim of their activities. Marketing and branding have too high a profile. Perhaps worst of all, relief efforts in the field are sometimes competitive with little collaboration between agencies, including smaller, grass-roots charities that may have have better networks in affected counties and so are well placed to immediately implement emergency relief.

Given the ongoing crisis in Haiti, it may seem unpalatable to scrutinise and criticise the motives and activities of humanitarian organisations. But just like any other industry, the aid industry must be examined, not just financially as is current practice, but also in how it operates from headquarter level to field level. It seems increasingly obvious that many aid agencies sometimes act according to their own best interests rather than in the interests of individuals whom they claim to help. Although many aid agencies do important work, humanitarianism is no longer the ethos for many organisations within the aid industry. For the people of Haiti and those living in parallel situations of destruction, humanitarianism remains the most crucial motivation and means for intervention.

*This special issue of The Lancet is published to coincide with the international conference Violent conflict and health in a globalized world as part of a collaborative effort with The Journal of the Danish Medical Association and Social Science and Medicine, both of which have published their own theme issues on conflict