Article 25

Dying to Treat the Sick

In Uncategorized on 07/22/2013 at 8:54 am

Doctors Without Borders IA child in a war zone receives treatment. Scene from “Access to the Danger Zone.” Courtesy of Doctors Without Borders/Médecins Sans Frontières (MSF).

Doctors without Borders and the politics of aid

By Margo Pierce

Doctors in the United States are familiar with stress but it doesn’t usually take the form of having bullets and bombs aimed at them. But those are some of the risks faced by Médecins Sans Frontières (MSF), or Doctors without Borders, who take health care to people in war zones.

The organization believes medical care is a fundamental human right, without regard to ability to pay, race, religion or political persuasion.

At the Esquire Theater in Clifton last month MSF offered a free screening of Access to the Danger Zone. The film, directed by Peter Caesar, featured MSF and other non-governmental organizations working in Afghanistan, Somalia and the Democratic Republic of Congo.

Daniel Day-Lewis narrates the film. His opening lines set the tone: “Forced to bear the unbearable consequences of violence, they flee their homes, are shot at, bombed, maimed, raped, tortured and killed. If infrastructure and health-care services then collapse, their chances of survival are even more drastically reduced. This is the moment when humanitarian aid is most vital. Yet reaching the victims of conflict is a difficult and dangerous endeavor in which humanitarian organizations take enormous risks to alleviate suffering and to save lives.”

For MSF, this aid begins with negotiating with all sides in a conflict to gain safe access to areas where people need them. This frequently means working with an existing medical facility – sometimes a hospital, other times a clinic – or setting up a new location that people can walk to. They go in armed only with medical supplies, equipment and whatever materials they can’t purchase locally.

Jan Egeland, former U.N. under-secretary-general for humanitarian affairs, appears in the film and explains it this way.

“I remember, as a very young relief worker, there was a veteran relief worker who told me that of course you have to negotiate with the devil if you’re seeking access to the depths of hell. That’s what we have to do in certain situations. And we have to be allowed to do that.” he says. “Too often humanitarian organizations, doctors and others are prevented access to civilians, and the civilians die, while we, the international community, are passive observers. For two reasons: there is no access, we are blocked from getting there; or the other one, there is no security – the humanitarian workers lose their lives in trying to reach the victims. And that’s not a natural disaster preventing that. It’s people. It’s generals, it’s military people, it’s politicians preventing us from having access to those in greatest need.”

Picking sides

The process of negotiating is slow, the work involved in maintaining ongoing communications with warring parties is time-consuming; and when allegiances change or new splinter groups form, it’s difficult to keep track of all the sides in a conflict.

Some NGOs get around this by picking a side and leveraging the protection they offer to get to civilians in need. A United Nations official in the film explains that greater access and therefore more assistance are provided when armed escorts are used.

But Stephane Hauser, an MSF field coordinator, vehemently disagrees.

“That is a total distortion of the role of humanitarian aid workers,” he says. “Humanitarians will be shot at because there is a total confusion. I feel safer wearing this thin MSF T-shirt than a bulletproof vest.”

To avoid being associated with one side or another, MSF believes developing good faith and proving their neutrality means operating facilities where anyone can get medical care at no cost. No weapons of any kind are allowed into the facilities. Afghanistan is a case in point. Another MSF filed coordinator, Stefand Argenziand, explains how it works in that country.

“The hospital where MSF is working is a weapon-free area, where no armed person is allowed to enter unless they leave their weapons at the entrance in the weapons locker,” he says. “This creates a place where people who are being traumatized by war can access health care without the presence of armed people around. Hospitals do not have any weapons carriers inside and provide thereby an environment where patients, irrespective of their background, feel fine and are entitled to receiving health care.”

Even though all possible precautions are taken to safeguard staff and patients, there are no illusions at an MSF medical site about the danger the staff face. While MSF doesn’t promise safety or security on the ground, they have learned over time how to manage crisis situations. Within the first few minutes of the film, an assessment is underway to address the kidnapping of aid workers just moments earlier.

“We accept to work in war zones and with the victims of those wars,” says Stephan Goetchebuer, an MSF head of mission. “It is an illusion to think that we can avoid security risks or be completely safe from violence. That is nonsense. But on the other hand, we can, in case of these negotiations, obtain and perhaps demand that if we become a target, these people will notify us.”

The past 10 years have been the deadliest on record for humanitarian aid workers, with more than 230 national and international aid workers killed and more than 150 wounded. Kidnapping is also a common occurrence, usually when on the road driving to or from remote locations to deliver medical services. One reason is the way humanitarian aid has been co-opted by governments trying to influence the outcome of a conflict.

“It can never be a strategic political tool for any party to any conflict to use humanitarian relief,” Egeland says. “If and when humanitarian relief – food items, medical supplies – are given in exchange for loyalty, for information, in exchange for political support, it’s wrong. It’s totally wrong. Humanitarian aid has to be given according to needs. If women, children, civilians, have a need of humanitarian assistance, they should be given that without any conditions.”

Meinie Nicolai, MSF president, acknowledges that the negotiated access isn’t foolproof.

“We’ve been fired on by the regular army during a vaccination campaign,” she says. “It upset us a lot. We were used as bait. The army, with support of the U.N. peacekeeping forces, were trying to wipe out one of the groups where we were vaccinating. And while our teams were vaccinating, the army opened fire.”

Intimidated patients

Providing humanitarian aid under such conditions requires a commitment to delivering that service first and foremost. To define the best way to deliver that aid under any circumstances, the Sphere Project prepared the Humanitarian Charter and Minimum Standards in Humanitarian Response handbook. Sphere began in 1997 with a group of NGOs, including the International Red Cross and Red Crescent Movement. Their objective was to provide the best possible service in response to a disaster. They defined two core beliefs as the foundation for their work.

“Those affected by disaster or conflict have a right to life with dignity and, therefore, a right to assistance; and … that all possible steps should be taken to alleviate human suffering arising out of disaster or conflict.”

Their principles more fully explain the reasoning behind those beliefs:

  1. All humanitarian agencies should ensure that their actions do not bring further harm to affected people;
  2. that their activities benefit in particular those who are most affected and vulnerable;
  3. that they contribute to protecting affected people from violence and other human rights abuses; and
  4. that they help affected people recover from abuses.

What quickly becomes apparent in Access to the Danger Zone is that different levels of commitment to those or similar principles vary from organization to organization. MSF works with a very high standard that, in modern warfare, can be difficult to uphold.

Founded in 1971 in France by doctors and journalists, MSF exists to provide “independent, impartial assistance … to people whose survival is threatened by violence, neglect or catastrophe, primarily due to armed conflict, epidemics, malnutrition, exclusion from health care or natural disasters,” according to its website ( “MSF provides independent, impartial assistance to those most in need. MSF also reserves the right to speak out to bring attention to neglected crises, challenge inadequacies or abuse of the aid system and to advocate for improved medical treatments and protocols.”

The film shows the experiences of the victims of wars as a way to explain why these people try to gain access to dangerous places. In one scene, a child lies listless in a bed.

“We definitely see patients that come very delayed to the emergency room because of security,” says Jomar Staverlokk, an MSF emergency room nurse. “The 15-year-old boy has been having fevers for five month, and bloody diarrhea, bloody stool. Since yesterday he started vomiting fresh blood, so it’s definitely something wrong with the upper part of the intestines. So we will take him to the ward for blood transfusion.”

Security problems take the form of military checkpoints, snipers, roadside bombs, threats and intimidation. People can’t safely get to hospitals or clinics, even if one is nearby, so non-lethal medical conditions go untreated and advance to the point that they become life-threatening. When MSF collaborates with a local hospital or sets up a location, they see patients who have treatment for weeks and months.

“We had numerous examples of babies being lost because the checkpoint blocked for too long, delayed the passage,” says Pierre Krahenbuhl of the International Committee of the Red Cross.

Fatima Murad Ali, an MSF midwife, describes another problem.

“They don’t want to come out at nighttime, because there are a lot of mines on the road,” she says. “They don’t want to come. There are a lot of police and other stations, so it is not safe to come here.”

A number of people in the film argue that government hospitals don’t deliver humanitarian aid. They describe military intimidation of patients in their beds, unable to get away during treatment. Or treatment is only offered in exchange for information about the “enemy” or other information deemed useful by those paying for the hospital. As a result, many don’t return for follow-up care after their initial visit.

‘Not a business’

Michael Newman, a general surgeon in Miamisburg, Ohio, has seen all of this and more on missions to all of the countries shown in Access to the Danger Zone. He first learned about Doctors without Borders from a news report shortly after the tsunami in the Indian Ocean. Eight years later he serves on the board of U.S. board of MSF, and all of his assignments have been in war zones.

“The range of surgeries that I do when I’m abroad with MSF is quite different in the range of surgeries that I do in the United States,” Newman says. “The facilities and technology and instrumentation is much different. The facilities and equipment and technology that (are) available at MSF mission sites is equivalent to the same level of technology from 40 or 50 years ago in the United States.”

Medicine, bandages, water and electricity are usually in short supply in the field. Even so, the work does save lives. Newman is particularly impressed with the work MSF is doing in Syria.

“Syria’s a huge problem, and health care is targeted,” he says. “Many of the doctors have left. Hospitals have been directly targeted. The civilian population, just for basic medical needs, has no access to what prior to this war was a pretty functional and good medical system. I feel strongly that, by MSF being in Syria and providing medical care, that legitimizes them being more politically involved with advocacy. That’s a good thing.

“The wars nowadays involve everybody in the country. It seems more and more, in the wars that I’ve seen, it’s bystanders and kids and elderly people and people not in the military get harmed more than the military. I’m opposed to the military fighting, but I’m even more opposed to all of the carnage of innocent bystanders. It’s just regular people that are really being harmed. It’s very discouraging.”

Making the public aware of dire situations is a key component of MSF’s work. The organization, which received the Nobel Peace Prize in 1999, has a long record of calling attention to violent conflict.

In 1985 MSF spoke out against the Ethiopian government’s forced displacement of its own citizens. In 1994 it called for an international military response to the Rwandan genocide. In 1995 it condemned the Serbian massacre of civilians at Srebrenica. In 1999 MSF denounced the Russian military bombardment of Grozny, Chechnya. In 2004 and 2005 it asked the U.N. Security Council to pay greater attention to the crisis in Darfur, Sudan. In 2007 the organization denounced the targeting of civilians in the Democratic Republic of Congo, the Central African Republic, Chad and Somalia and criticized Thailand and Laos for threatening to forcibly return nearly 8,000 Hmong refugees to Laos.

Newman says the human connection to medical care drew him to MSF missions. In this most fundamental form of delivering care, he finds inspiration. He doesn’t believe medical care should be a luxury item.

“One of the reasons that I started working with MSF is in this country medicine is a business. Within the mission, medicine is not a business,” Newman says. “It is a right we’re trying to make available to everyone irrespective of race, religion, nationality. I find that aspect to be very attractive. I’m a little bit disappointed in this country in that we have this business model of medicine that doesn’t seem to work very well.

“Working from within MSF is reinvigorating. I find the system in humanitarian aid to be much more in line with my general ethic. That’s one of the reasons that I remain involved with the organization.”

The United States is supposed to agree with Newman, having ratified the Universal Declaration of Human Rights. Article 25 of that covenant states, “Everyone has the right to a standard of living adequate for the health and well-being of (oneself) and of (one’s) family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”



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