Karima, an elderly woman by Sudanese standards, sat in the rain outside an MSF clinic in western Darfur, Sudan, when MSF staff first saw her. She was sitting, exhausted, in the mud and her legs were covered with her own excrement, suffering from diarrhea and subsequent dehydration. The clinic was closed. Together, with the help of a Sudanese nurse, MSF medical volunteers took her to the nearby hospital, washed and fed her, and found a relative to look after her. She stayed at the hospital for only one night, became rehydrated and left for her own shelter the next day.

Photo © Jacob Maikere Ruiz

Karima's desperate situation was not unique. Millions around the world face the same suffering and feeling of abandonment. Yet she reflects the foundation on which MSF's work is based, every day, in hundreds of projects around the world. Each patient is an individual deserving care simply because they have none and need it. Every individual deserves assistance that helps restore personal dignity.

Our work, whatever the context, can be simplified into thousands of these individual interactions taking place between MSF caregivers and our patients. Our aim is clear. Assist those who need medical help now.

The past twelve months have been turbulent by any standard. The tragedy in Darfur, Sudan unraveled before our eyes, growing worse as the months went by. Extreme violence against civilians led to a massive displacement of more than a million people. Access to this whole population was denied and then restricted for months, with only occasional but ineffective protests from the international community as their condition deteriorated. The scant attention given to the crisis until recently was due partially to a desire not to upset the North-South Sudan peace process – effectively sacrificing a group of the country's civilians for future stability. At the time of this writing, although the humanitarian response to the crisis has improved dramatically, the presence of food and medical aid has done little to end the fear and abuse that haunt the people of Darfur.

While Darfur finally started receiving public attention by mid-2004, many other crises causing immense human suffering remained hidden from view, rarely mentioned in headlines. The forgotten war taking place in the Democratic Republic of the Congo continued to claim lives, both directly through violence and more insidiously because of displacement and disease. Increasing violence in Uganda also sent thousands on the run, but made little impact on the outside world. MSF's independence makes it possible for us to go to these "neglected" crisis zones and help those who have been forgotten. While we cannot provide assistance to all of those who need it, our presence in more than 70 countries provides aid for many of the most vulnerable and allows us to speak out on what we witness there.

Neutrality under attack
The murders of our five colleagues in Afghanistan's Badghis province on June 2, 2004 were a shock to the movement and to the world. The tragedy highlighted both the dedication of our national staff and volunteers and the increasingly difficult and dangerous environment in which they work. The decision to withdraw from Afghanistan was a tragic consequence of MSF becoming a target. While MSF feels a great sense of frustration and sadness at diminishing aid to people who need it desperately, there are limits to the risks the organization can accept.

The targeting of humanitarian aid workers for political gain is, unfortunately, not a new phenomenon. However, the current "war on terror" in all of its guises makes maintaining our neutral and independent position an ongoing struggle we cannot afford to lose.

Although the entire MSF movement was relieved when volunteer Arjan Erkel was released in April 2004 after 20 months in captivity, the North Caucasus' insecurity remains a daily reality for the people of the region. Effective assistance is severely curtailed through an atmosphere of violence and intimidation, compounded by the impunity shown for attacks on humanitarian workers. The difficulties we face pale in comparison to the daily suffering of the people we try to help. Humanitarians will always be needed who will seek out and assist people in crisis, whatever the political framework of the day, regardless of the obstacles placed between them and the populations they seek to help.

When people are "sacrificed"
Today there are plenty of crises and conflict zones requiring humanitarian assistance. While a few are caused by natural disasters or epidemics sparked by natural conditions, most are man-made. The need for humanitarian action usually arises when those in power refuse to uphold commitments they have made to protect those living within their borders or to shoulder responsibilities promised under national or international law. While action can be linked to cases of violent conflict, humanitarian action can also be called for when states allow the most vulnerable to be excluded from needed protection or care. The growing use of cost-recovery programs is an illustration of this type of problem. Related user fees require payment to obtain health care in many countries – a system that has proven exclusionary and dangerous for the most vulnerable groups. Today MSF is trying to eliminate all user fee requirements involving its own programs.

When civilians are not protected or are actively harmed by governments or other actors, it is the role of humanitarians first to respond to their needs but also to expose the conditions and lives of those who are sacrificed – and to remain in solidarity with these people. Such situations not only occur in Africa, Asia and Latin America. Civilians escaping from Darfur and other crisis zones have been met with harsh treatment in Europe when they tried to gain political asylum or immigrate.

Urging expanded treatment
Humanitarian action is called for in silent wars as well. The death toll caused by treatable infectious diseases such as HIV/AIDS, malaria, and tuberculosis (TB) remains staggering, especially in the poorest countries. During the past few years there has been a paradigm shift in the "accepted" thinking on infectious diseases. Patient treatment is becoming the focus as opposed to economic or public health concerns.

The World Health Organization (WHO) and many governments and donor agencies now agree with MSF that it is unethical to keep giving chloroquine to patients suffering from highly resistant strains of malaria. In the same way, it is no longer considered ethical to allow the 30 million people currently infected with HIV/AIDS to die due to lack of treatment. Before 2002, WHO and donor governments used what could be called a "public health" approach on HIV/AIDS treatment in poor countries. They believed it was too difficult and expensive to treat people with HIV/AIDS using antiretroviral (ARV) drugs, so the focus was placed on prevention programs – essentially sentencing millions to an early death.

Civil society action during the last three years has caused the prices of ARV medications to plummet. The WHO and the US government have professed desires to treat millions of HIV-positive people and close to 500,000 people in developing countries are now getting treatment. This change is no doubt a success, but the struggle is far from over.

Major obstacles are keeping effective treatment out of reach for many who need it. Other diseases, such as TB, have not received the same strong political push to improve and expand treatment. TB diagnostic tools and treatment fail many hard-to-treat patients, often the kind we see in our own programs, because their care is considered too difficult to provide.

The Campaign for Access to Essential Medicines, which has had so much success with reducing the price of HIV/AIDS drugs, is now advocating for an urgent global approach to the lack of research and development on TB.

Whether we are working directly with patients like Karima or advocating for policy change on their behalf, principles are essential to MSF's work. Impartiality allows us to assess who are the most vulnerable, the most excluded, so that we can make practical and ethical decisions about our interventions and actions.

Independence and neutrality are tools we use to enable us to gain access to these people and create the trust essential to help those who have been betrayed, attacked or neglected by others. These principles also allow us to speak out on what our teams witness in the field, perhaps helping to bring about change, but certainly raising the question, is such suffering necessary? In the end, however, our goal is simple: to treat other humans with respect when they are at their most vulnerable and to do so in a pragmatic and palpable manner.

Rowan Gillies, M.D., President, MSF International Council
Marine Buissonnière, MSF Secretary-General

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