An MSF doctor checks the pulse of a girl wounded by shelling moments before in Monrovia, Liberia. The girl was pronounced dead. A fresh round of shelling terrorized Monrovia early in the morning (July 25, 2003), as government forces and rebel troops battled for control of the Liberian capital. Photo © Chris Hondros/Getty Images

When the families in Maimu camp in Liberia hastily packed their belongings in August this year, it was their fourth time fleeing the devastating civil war that has consumed Liberia for more than a decade, with particular intensity the last three years. These families were not only escaping a combat zone, they were fleeing from violence directed specifically at them. They were trying to avoid being looted again, being raped again – or being killed.

Further south in the camps in Salala, the displaced families were also frightened. They were trying to decide what would be their "best" option: the risk of fleeing or the risk of staying. A cholera outbreak and increasing malnutrition made the situation even more desperate. They had been without food assistance for months.

Once more this year, we witnessed how civilians became deliberate targets of war in Liberia, and how control over the civilian population was one of the main objectives of combatants.

We have seen the same in Democratic Republic of the Congo (DRC), where in May in the city of Bunia (capital of the Ituri region in the northeast), civilians were deliberately raped and massacred. We have seen it in Afghanistan, Sudan, Colombia, Chechnya...

In many places where we are working, war is not just fighting with guns between rivals for power. It is a deliberate onslaught on civilians. It is rape of women and girls; it is all-out assault on the physical and emotional integrity of thousands and thousands of men, women and children.

Although it is not war or direct violence, sheer inaction in the face of disease emergencies – HIV/AIDS, malaria, sleeping sickness, to name only a few – is also causing millions of very violent deaths of each year.

The failure to respond immediately – or to respond at all – to crises borne of conflict and disease has led over time to a perception that they are normal. The longer the response takes, the more people are deceived by this notion of "normalcy," and the more inertia prevails. As a result, we are tolerating the intolerable. Concerted action to protect civilians and treat their diseases has in so many cases been sorely lacking; it is as if governments and international actors are accepting as normal what is a terrifying, deadly, daily reality for so many people. Humanitarian action is crucial to alleviate the suffering of those affected, and to point to those responsible for these crimes. Humanitarian action must constantly fly in the face of accepting the status quo. It must struggle against "normal" becoming either a criminal excuse used by governments to avoid real responsibility or a way to make millions of broken lives palatable to donor countries and rich-country publics who would like to think they are "doing everything they can," even as people halfway around the world die invisible, anonymous deaths that we would never consider normal in our own communities.


A camp for displaced people in DRC. Photo ©Copyright Eva Van Beek/MSF


In DRC, 30km away from Bunia, across Lake Albert, or 100km down to the southeast in Beni or north in Mambasa, there are people who have survived unspeakable events this year and who are telling their stories, sometimes. But move beyond this, thousands of kilometres to the north in Europe, or across a continent and an ocean in the United States, or far to the east in Japan, the idea of what is happening in DRC has not even begun to take form. This lack of knowledge and interest was clear in Bunia itself, where since May MSF has been running a small hospital right next to a camp for displaced people. Between the end of May and the end of July, 20% of the patients admitted to our clinic in Bunia suffered from war wounds. One-third of the war-wounded were women. One-fourth of the war wounds were on children under five. Rape and sexual assault in the next-door camp were frequent reasons for visits to the MSF clinic. The same grim statistics remain as this report goes to press.

Again in the Great Lakes region there has been a clear absence of political will on the part of the government and international agencies, and on the part of the warring factions themselves, to protect and assist people in danger. This has spanned years of conflict and millions of deaths. Perhaps this hesitation is because the international community of states persists in seeing fighting in DRC as a "tribal" conflict. However, we feel that this is just another way of avoiding the responsibility to address it: the conflict has been perpetuated by the surrounding countries and needs to be addressed internationally and politically. While some response was offered to the fighting in eastern DRC in the face of the failure of UN peacekeeping battalion, with the deployment of a European force led by France and with an extended UN mandate to protect civilians, the action was essentially inadequate (the European force was on the ground only a few months with limited territorial reach). Many people, especially those in the countryside outside of Bunia, were left with no protection or assistance, while in the city of Bunia, security during the day turned to ongoing violence at night. It seems that the deployment of these forces was based more on the needs of the politicians than on those of the people needing protection.

Also insufficient was the response to the intense fighting in Liberia in spring 2003 that left 75% of the country inaccessible to humanitarian aid and hundreds of thousands of displaced people crowding in and around Monrovia even as mortars and bullets were flying. This was simply a continuation of the international neglect of Liberia that has been the norm for the last decade or so. MSF teams worked during the height of the hostilities in Monrovia, providing care to civilians caught in the fighting.

Where we have seen an expressed interest in the well-being of civilians it has often been used to promote other goals, such as peace-building, nation-building and reconstruction. Yet these goals, however positive and worthy they may be in and of themselves, should be kept distinct from provision of humanitarian assistance. Unfortunately, we see exactly the opposite happening: politicians are using humanitarian language as a "rationale" or "cover" for war (Iraq); international agencies are incorporating humanitarian work into broader political goals such as peace-building and reconstruction (Angola, Afghanistan, Iraq). Distinctions between humanitarian and political goals are fading. In Liberia, UN peacekeepers continue to work closely with the UN's humanitarian agencies.


An MSF national staff vaccinates a child in Zhare Dasht Camp, Afghanistan. Photo ©Copyright Sebastian Bolesch


In Afghanistan, coalition forces are adopting a "humanitarian" agenda as a way to achieve military goals and extend the Afghan government's reach. However, we believe that the very different roles and responsibilities of peace-enforcers and those charged with assisting civilians in an impartial fashion cannot be mixed. Confusion leads to increased insecurity for aid workers and decreased ability to provide independent aid to people who need it.

The humanitarian idea that must prevail is one of assistance given according to needs alone. It is time to destroy the idea that humanitarian work should be used to build peace – or pacify a country – or establish democracy – or anything else, other than assist people who are in need regardless of their nationality, origin, skin color, political affiliation or religious belief. These other goals can be legitimate political goals, but they are based on political analysis and political commitment. Humanitarian action, on the other hand, is based only on an analysis of needs. It is easy to confuse relief aid with humanitarian aid. Relief aid can be very valuable assistance, given to people in different contexts. However, when it is not given solely on the basis of needs and the principles of independence, neutrality and impartiality, it is not humanitarian aid. There has been much confusion about these two kinds of assistance during the recent war in Iraq.

In the run-up to the war in Iraq, the humanitarian idea was used by the belligerents as a justification for going to war and by opponents of the war as a justification for peace and pacifism. After the main hostilities ceased, we concluded that at that time there was no humanitarian crisis: no mass displacement of people, no epidemics, no famine. What we did see was an abrogation of responsibility on the part of the occupying power, the United States. The coalition did not plan any kind of emergency intervention for the post-war period; in terms of the health care sector, hospitals were looted, their management disintegrated, and the result was that many people who needed care could not get it. At the same time, humanitarian actors had great difficulty carving out a space for truly independent assistance in the country.

The bad consequences of this are clear. Security is a constant concern and has deteriorated enormously in Iraq, for Iraqis certainly, and for those trying to assist them. Security is compromised not only by local actors but by outside forces, as local and global interests vie for a stake in the future there. The bombings of UN headquarters there in August, and International Committee of the Red Cross (ICRC) headquarters in October, were heinous assaults on innocent civilians and show how continuing violence is severely limiting the ability of international agencies and humanitarian organizations to assist the Iraqi people. Statements on the part of officials in the US government (that if NGOs pull out of Iraq the "terrorists win"; or in Afghanistan that NGOs are "force multipliers") only contribute to the vulnerability of organizations to attacks by associating them with the political agenda. Our own team in Iraq withdrew shortly after the ICRC bombing to evaluate the continuation of our work.

Far away from Iraq, in the North Caucasus, conditions for civilians are very difficult and humanitarian assistance is not easy to provide. Chechens living in Chechnya and displaced to neighboring Russian republics of Dagestan and Ingushetia live in an environment of terror and coercion. In Chechnya, conflict marks the daily lives of ordinary civilians; at the same time, independent witnesses are forced out because all actors, including the authorities, have created an environment of hostility, harassment, kidnapping and killing, where hundreds of people disappear, without a trace. The principal victims are Chechen; yet more and more, independent humanitarian aid workers cannot escape the terror and violence.

In August 2002, Arjan Erkel, MSF's Head of Mission in the North Caucasus, was kidnapped in Dagestan, where MSF was assisting displaced Chechens. Well over one year later, Arjan is still missing. MSF has worked tirelessly to secure his freedom. We have also repeatedly called on the Russian authorities to press their investigation into his kidnapping, which so far has been a complete failure. We believe they could be doing much more to find and free Arjan, and that it is their responsibility to do so immediately. In August 2003, the United Nations Security Council passed a resolution on the need to protect humanitarian workers. How can the Russian government vote for this resolution when it is not working sufficiently for Arjan's release? Is there a double-standard here for Security Council members and others?

Inaction by governments and international actors who could be putting pressure on Russia is slowly crushing Chechens in the region. Shouldn't we question the rationale of the Russian government which states that there is no reason for Chechens to be outside Chechnya because conditions are "normal" there? The fact that Arjan Erkel is still missing is really a symbol of the Russian government's success at glossing over what is really happening in Chechnya and selling it to the international community of states, which is all too happy to take refuge in its own inertia and give carte blanche to what is happening on the ground.

There are many other people who are equally ignored, and for whom inaction can be equally mortal. These people don't die the "spectacular" deaths of violent combat. These are the people who die every day because of infectious diseases that are, in many cases, treatable. Nearly 15 million people each year succumb to infectious diseases, especially malaria, tuberculosis (TB) and HIV/AIDS. Curative treatments exist for malaria and TB; life-prolonging antiretroviral (ARV) therapy exists for HIV/AIDS. Why aren't these treatments being given to the millions of people who need them?

Out of the six million people with AIDS in developing countries who are so sick they need ARVs today in order to survive, only about 300,000 have access to treatment, and in Africa (where 29 of the world's 42 million infected people live) only 50,000. What about the others? Has this urgent situation become so big that we just cannot see it anymore for what it is – an emergency that deserves an emergency response? Until now a real emergency response, characterized by rapid reaction backed by sufficient commitment and money, has been an illusion. There is no generally accepted focus on treatment; even prevention policies often do no more than pay lip service to real action. This lack of urgency in addressing the AIDS crisis has persisted for so long that it has become the status quo; it has become normal. The immediate desperation of millions of people, which should have prompted rapid action, has instead turned into fatalism and hopelessness. Millions of sick people are ready to give up because of our inaction. People with malaria do not fare much better: most of the hundreds of millions of people who get malaria every year don't have access to effective treatments, even though they exist. Is deliberately withholding life-saving medicine from someone who needs it any different from waging war on that person, or failing to protect him in times of conflict?

The AIDS crisis is probably one of the largest humanitarian catastrophes in human history, if measured by the number of affected people, the quality of their lives and the (unused) capacity we have to ease their suffering. In the face of this avoidable suffering, we must offer life-saving treatment to people most in need. Today we can only bear witness to the political vacuum surrounding this crisis. Neglecting treatment for people in need and failing to respond to this emergency should be considered nothing less than a criminal attitude.

Even MSF is not doing enough. We are providing ARV treatment to people in developing countries around the world, with over 10,000 people expected to be under treatment by the end of 2003. We are showing that treatment is possible in places where people are poor and where health infrastructure is not what we would always like it to be. From our experience, when ARV treatment is provided for free, people are as consistent in taking their medicine as people in richer corners of the world.

The World Health Organization's goal of providing 3 million people in developing countries with antiretroviral treatment by the end of 2005 will need political commitment and money from donor countries and local governments in order to succeed. But we need to emphasize that 3 million by 2005 must begin with three, five, thirty, one hundred or one thousand patients today. We need to start now. MSF needs to do more to increase the number of people we are treating, and governments and other organizations need to start providing treatment. Every life is valuable.

Public-private partnerships encompassing governments, UN agencies, NGOs, civil society organizations and private enterprises are increasingly seen as mechanisms to find solutions to the AIDS epidemic and other global problems. But in our opinion, politicians have the sole responsibility to solve these problems. Even though partnerships may be useful, politicians must not use partnerships to shirk or dilute their own responsibility, or use partnerships as an excuse for slow action. For some diseases, there are not even adequate drugs available as treatment. To change this, MSF has joined public health and research institutions in Kenya, India, Brazil, France and Malaysia to become a founding partner in the new Drugs for Neglected Diseases initiative (DNDi) which is working on research and drug development for medicines for diseases such as sleeping sickness, leishmaniasis, malaria and others. DNDi is also trying to provoke local governments and donor countries to take up their responsibilities to address these diseases; we hope that DNDi will put the responsibility – and the response – on the public sector and governments.

We can provide aid based on needs and speak out about the criminal response to civilian suffering due to war and disease emergencies because we are independent. To remain effective in our mission we must safeguard this independence. We must continually work to distinguish ourselves from the everexpanding pool of relief actors and service providers who do not strictly adhere to humanitarian principles. This is becoming increasingly difficult.

Thanks to the over 2 million private donors who fund us around the world, over 80% of our income comes from private sources. This guarantees our financial independence. For them, but especially for the people we assist around the world, we are working ceaselessly to safeguard our independence of action and spirit.

Pretending that humanitarian action is a way to meet political goals is as erroneous as pretending that humanitarian actors can provide political solutions. At MSF, this is why we define ourselves as confronting power, not becoming part of it. Our aim is to save lives threatened by political interests that leave little room for considering people in need for what they really are: human beings. Our role is to cast ourselves against a reality which ignores this simple idea.

Dr. Morten Rostrup, President, MSF International Council
Rafael Vilasanjuan, MSF Secretary General

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