© Zohra Bensemra/REUTERS

In July 2006, amid intensifying armed conflict between Israeli Defense Forces (IDF) and Lebanese Hezbollah fighters, MSF launched an emergency intervention to help address medical-humanitarian needs. Assistance was offered on the Israeli side dealing with civilian deaths and injured from rocket attacks; however the nature of the conflict was such that there were greater needs and less available assistance in Lebanon.

With a high intensity bombardment cutting major roads and bridges throughout the country, transportation was difficult and dangerous, compelling MSF to make public statements reminding those engaged in the conflict that they had a responsibility to allow assistance to reach civilians caught in the fighting. Though vociferous in such demands, MSF retained its neutrality by refraining from commenting on specific military decisions of either side. This independent and impartial approach to the provision of aid allowed us to move and assist in a context where almost all movement was prevented.

Many of the people we help are trapped within highly charged and complex social and political contexts that create significant barriers to the provision of aid.

The difficulties reaching people in need in Lebanon are illustrative of a growing problem of access that MSF has confronted over the past year.

Despite the relative simplicity of our mission — to provide impartial medical-humanitarian assistance to those in need and prevent loss of life — our ability to obtain access to patients can rarely be assumed. Many of the people we help are trapped within highly charged and complex social and political contexts that create significant barriers to the provision of aid.

Security Concerns

At the time of writing, humanitarian organizations have been reducing activities or pulling out of Darfur, Sudan. Over a million people have been living a survival existence with 'adequate' health parameters for over two years in camps in Sudan and Chad, disguising an utter lack of hope and despair that pervades these islands of assistance. These are the lucky ones who manage to have sustained contact with the diminishing and underfunded aid made available to them. Outside the camps, especially in West and North Darfur, violence against civilians continues, accompanied by a significant increase in targeted attacks against aid workers including MSF staff, making land travel and logistical assistance close to impossible.

MSF has been working in Darfur since early 2004 and intends to stay as long as we are able to be effective, although the situation is becoming increasingly precarious. Serious security incidents have forced us to reduce activities in the Jebel Marra region, despite an ongoing cholera outbreak, and we can no longer send surgical referrals by road for emergency care. This reduction in the ability to provide basic assistance is likely to have a critical impact on an already fragile health situation.

Numbers mean little without reflecting on the relevance of the assistance and the quality of our work.

Likewise in Sri Lanka, a country where we worked for many years during the conflict, seventeen aid workers from the NGO Action Contre la Faim were executed in July 2006. The perpetrators of this outrage have not been identified. With such attacks on clearly identified aid workers, there is a grave concern for the future of assistance in this country. MSF is struggling to get access to areas where there is no humanitarian assistance at all in this brutal civil war.

An unhealthy mix

Over the past year, there has been a mounting distrust toward aid organizations by those who have the power to grant us access. This mistrust is not always misplaced. The practice of some nongovernmental organizations (NGOs), private contractors and many governments doing 'humanitarian' work with a specific political aim causes confusion, and reduces the acceptance of the universal nature of humanitarian assistance. This contributes to a climate where groups opposed to any underlying political aim use confusion as an excuse to attack aid workers.

This mounting distrust is just one of the ongoing challenges of providing emergency assistance discussed in an article in these pages by Marilyn McHarg, who underscores our need to adapt to and anticipate not only a changing humanitarian landscape, but also dynamic social, political and even geographical environments in order to identify where and how we can best provide effective assistance. Addressing the problem of access, she proposes that new strategies must necessarily be developed to carry out our work. As this report goes to press, we are launching a new project to provide reconstructive surgery for wounded Iraqis in Jordan and working with Iraqi medical groups to assist them in responding to the effects of daily violence in that country.

Coordination: not a panacea

With an ever-growing number of aid organizations, there are now increasing attempts to coordinate humanitarian assistance to control and direct this assistance in a certain direction. Superficially coordination can have positive results allowing various agencies to use their strengths within a comprehensive response; however, "lack of coordination" is currently used as a blanket excuse for every failing of aid assistance. In some cases, it is not a failure of aid but rather a deliberate and politically motivated lack of access to aid for people in need. The intricacies and potential dangers of coordination being provided as a sole response to the failures of aid in the past is discussed in this report by Fabien Dubuet and Emmanuel Tronc, who outline MSF's position whilst the UN implements changes in its system of aid assessment and delivery. MSF remains careful to separate itself from these processes, instead relying on independence of assessment and action to respond to specific needs of specific populations, rather than contributing to a global framework of dubious origins and effectiveness. Independent and impartial assessment is not only a principled, but also a practical approach that allows us safe and rapid access to people in need.

Effective responses

Despite our concerns around these issues, our records over the past year show a massive volume of medical care to individuals and families around the world: this includes doing more life-saving surgery, treating more malaria, and offering mental health support to more people than ever before. MSF in 2005 provided medicalhumanitarian assistance to over 10 million people, including assistance in major emergency responses following an October earthquake in Asia, and treatment for 26,000 people with cholera in Angola in the spring of 2006, the largest outbreak of this disease in that country in over a decade. But these numbers mean little without reflecting on the relevance of the assistance and the quality of our work: each patient is much more than a statistic and we must be sure that if we treat someone for malaria, for example, that they get a humane consultation, the right diagnosis and treatment.

Particularly when we have access to fieldappropriate medical and logistical tools, we are able to adopt new methods of treatment to provide relevant and quality care. A novel approach to an old problem of treating malnourished children, mobile feeding centers and the availability of an effective, portable nutritional rehabilitation product helped MSF carry out its largest and most successful response to child malnutrition in Niger in 2005. 63,000 severely malnourished children were admitted to programs, where record cure rates were achieved. Dr. Milton Tectonidis explains this intervention and its importance in an essay within this report — an undertaking that allowed us to demonstrate that death by malnutrition is not necessarily inevitable and can more and more be equated with death by neglect.

Similarly, as we continue to provide a full package of HIV/AIDS prevention and treatment to people and communities in 32 countries, our developing strategy is to decentralise care and increase the number of sites where treatment is available — an approach described in this report by our team in Thyolo, Malawi. The size of scaleup that is truly needed, however, continues to be limited by a shortage of human resources and the state of health systems in many countries. It is unrealistic to believe that these issues will be solved sufficiently to treat everyone with HIV/AIDS. A comprehensive response to this epidemic is precluded by a disgraceful lack of drugs, diagnostics and monitoring tools developed for resource-poor countries, who instead must make do with the detritus of westernfocused research. More appropriate tools are urgently needed to address this crisis head-on, to treat many more people despite the human resources and structural crises. While we are buoyed by the outcomes of our interventions in 2005/2006, we also recognize that MSF can only offer immediate and time-limited solutions. It must be clear that the modest improvements we can make should be viewed neither as an opportunity for governments and international organizations to abdicate their responsibilities, nor an alibi for political inaction. Speaking out and raising awareness of this neglect is how we avoid covering up the problem. This year, we include in this report a selection of photos of people from the Democratic Republic of Congo — where human needs have largely been ignored by the international community.

Self-criticism is an essential element of MSF and the 19 sections of MSF went through an internal process this past year aimed at improving our operations and governance structure. Developing from this is a commitment to maintain the transparency of our actions and concretely increase the accountability we display to those we assist and the donors that generously assist our work, for it is reliance on individual donors that allows us to act quickly and independently and in response to human needs.

We see this accountability as a potent tool to ref lect openly on our operations and improve them significantly as we meet new challenges and obstacles. MSF will continue to look for new ways to manoeuvre past whatever barriers may arise, logistical, security or political and assist those who are being neglected — firmly grounded in our identity, and our intention to provide quality medical care for people who would otherwise have none.

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

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