In August 2013, Doctors Without Borders/Médecins Sans Frontières (MSF) pulled out of Somalia after working in the country continuously for 22 years.
The last year has been one of exceptional circumstances, decisions, and compromises, particularly with regards to Somalia and Syria. We have again seen profiteering from humanitarian organizations, in the form of robberies and the looting of medical structures, but the most striking thing we have witnessed is the failure of the global humanitarian aid system in countries such as Central African Republic (CAR) and South Sudan.
Since its founding, MSF has faced different forms of violence against its patients, staff, health facilities, and medical vehicles, and has also witnessed targeting of health systems in general. The situation in Somalia, however, became untenable in 2013 as the balance could no longer be found between the risks involved, the compromises we had to make – such as hiring armed guards and implementing remote management to support national staff – and our ability to provide medical care to the Somali people. Staff members had been threatened, attacked, kidnapped, and even killed during our time in Somalia, but it was when it became apparent that the parties with whom we were negotiating were in some cases actively involved in, or complacent towards, violent actions directed against MSF that we had no choice but to draw the line. A lack of respect and deliberate violations of medical humanitarianism for political and financial profit were putting the lives of our patients and staff at risk. We withdrew with heavy hearts.
In Syria, the civil war continued into its third year, and it is estimated at present that nine million people are internally displaced in the country or have fled abroad as a result of the violence. This means that over 40 percent of Syrians have been forced from their homes. Those remaining in Syria have had to endure ongoing and incessant violence, and entire cities have been decimated. The healthcare system has collapsed, resulting in outbreaks of preventable diseases such as measles and polio. Countless Syrians are desperate to access medical treatment, and are without services for everyday requirements like antenatal care, immunizations, and the management of infections or chronic diseases. MSF operated aid programs where working agreements could be negotiated, namely in opposition-held areas where instability was a constant challenge, and support was given to Syrian medical networks. Inpatient wards, outpatient consultations, surgery, and maternal and obstetric care were provided by MSF and vaccinations were undertaken. However, in a country where we should have been running some of our largest medical programs, the opportunities to reach people and to respond in a timely manner to the enormous needs remained extremely limited; a forceful reminder of how access to medical care was by and large not respected and in many cases directly targeted by those involved in the conflict and used for political purposes. In Lebanon, Iraq, Turkey, and Jordan, MSF continued to provide healthcare for Syrians inside and outside the refugee camps.
The year was punctuated by numerous acute crises that left entire communities vulnerable, with little skilled medical help. In some cases, external assistance was their only lifeline and yet MSF often found itself alone tackling not just the medical but also the other humanitarian needs of the people affected.
Political events marked a descent into instability and brutal violence in both South Sudan and CAR, displacing thousands. In CAR, there was a presidential coup in March and subsequent political clashes spread throughout the country and inflamed religious divisions. By January 2014, it was estimated that over one million people had fled their homes, 245,000 of whom crossed the border into neighboring countries such as Chad and Cameroon. Hundreds of thousands of people were sheltering in the bush and others were living in displacement sites. By the end of 2013, nine MSF emergency projects were delivering healthcare in CAR alongside seven ongoing programs, and over 800,000 medical consultations had been provided to people throughout the country.
In South Sudan, where people have come to rely in large part on MSF for healthcare, violence in Jonglei early in the year caused displacement, and in December, fighting between different factions of the army quickly spread throughout five states, causing people to flee their homes and destroying hopes of stability for the nascent country. More than 3,000 MSF staff continued to operate 16 programs in nine states, and three emergency projects were opened to care for the displaced and war-wounded; further emergency programs opened in neighboring countries such as Uganda to provide aid to the refugees. December was only the beginning of what was to become a grave crisis of violence, civil war and human suffering in South Sudan.
Once again this year, MSF’s largest program expenditure was a response to the repeated displacement of people and the appalling lack of healthcare in Democratic Republic of Congo (DRC). While there is a large aid community in DRC, much of it is focused in Goma and areas of the country considered stable, the more remote areas of eastern DRC, where people are subjected to increasing conflict, banditry, widespread abuse, and sexual violence, are largely neglected. In 2013, heavy fighting caused massive displacement and inadequate living conditions meant diseases such as malaria, cholera, and measles were rampant. MSF undertook a number of emergency projects and vaccination campaigns in the country and in total, more than 1.2 million children aged between six months and 15 years were vaccinated against measles.
Responding in the Philippines
This year we were shown once again that public sympathy for the plight of others is never as strong as in the wake of a natural disaster. While fundraisers continue to struggle to raise financial support for victims of war, individuals worldwide quickly dug into their pockets to assist survivors of the Philippines’ Typhoon Haiyan in November. The great force of the storm, and the storm surge that followed, destroyed public health facilities, but due to the experience of local health workers and the preparedness of the Department of Health, medical needs were much smaller than feared. MSF sought to assist the Filipinos by providing medical care and relief supplies, while also rebuilding healthcare capacity. Numerous logistical challenges were encountered within the first days; even so, by the two-week mark MSF had a fast-growing team of international and local staff in four hospitals and eight health centers, and was running mobile clinics in 37 locations.
Speaking Out for Access to Health Care
MSF is a medical organization, but our work does not stop at the delivery of care; it is also about bearing witness in extreme situations. In October, MSF launched the Speaking Out website (speakingout.msf.org), making publicly accessible MSF témoignage documents on different crises through the history of the movement. These writings offer a window into the internal debates around operational challenges faced by the movement and the foundation of MSF’s public positioning over the years.
There were many events that compelled MSF to make public statements and speak out in 2013. On August 21, information was received from MSF-supported doctors based in three locations in the Damascus governorate of Syria that they had directly cared for approximately 3,600 people displaying neurotoxic symptoms. MSF was the most direct independent witness through the reliable doctor-to-doctor link we had developed in the country and we released a statement – an action not undertaken lightly – detailing what had been seen at the MSF-supported hospitals.
On December 12, MSF published an open letter to Valerie Amos, UN Under-Secretary- General, about the situation in CAR and the UN humanitarian system’s failure to respond adequately to the emergency or ensure minimum requirements for human life. MSF’s deployment of staff and delivery of aid had shown that with principled humanitarianism, it was possible to provide widespread assistance. Less than a week later, MSF sent an open letter to member states of the ‘High Level Group on Syria’ meeting in Geneva, urging them to take action so that people blocked from receiving Damascus-controlled aid could obtain the assistance they needed through cross-border efforts.
Witnessing steady refugee flows from conflicts in Africa and the Middle East, MSF also spoke out about the restrictive and repressive migration policies in EU states. Teams have treated migrants in several overcrowded, ill-equipped detention centres that are contributing to deterioration in residents’ physical and mental health. A December press release calling for the closure and refurbishment of the Lampedusa center in Italy was heeded and MSF continued to provide healthcare for undocumented migrants in Italy, Greece, and Bulgaria, all the while urging those responsible to provide living conditions that respect human dignity.
MSF’s Access Campaign also worked tirelessly, advocating for patients in light of the Transpacific Partnership Agreement (TPP) being negotiated between the USA and 11 Pacific Rim nations, as well as the India–European Commission trade agreement, continuing the Hands Off our Medicine campaign launched in 2010. Both these trade agreements include aggressive standards for intellectual property, extending drug patents and effectively blocking access to generic medicines for diseases including HIV – drugs that MSF purchases for millions of patients and that people in the developing world depend on for their treatment and survival.
Tackling Malaria, Tuberculosis (TB) and HIV
Seasonal Malaria Chemoprevention (SMC), a WHO-recommended preventive measure which has proven effective in Chad and Mali, was used in Niger for the first time in 2013. For four months during the rainy season, children received a course of antimalarial treatment and while usual methods of mosquito bite prevention, including the use of nets and sprays remain the basis of the programs, SMC is proving useful to protect the health of children at risk from severe malaria in areas of high seasonal transmission. In collaboration with the health authorities, MSF continued to respond to drug-resistant TB in the southern Caucasus. In KwaZulu- Natal, South Africa, the Bending the Curves project was introduced to tackle the high co-incidence of HIV and TB. Viral load technology, which monitors the amount of HIV virus in a patient, was introduced in areas of Mozambique this year, and in Swaziland the ‘test early and treat early’ effort continued.
Medical Care Under Fire
The year’s events were a harsh reminder that some choose to make medical aid a target for their own benefit. Teams withstood localised security incidents in places such as Afghanistan, Nigeria, Pakistan, South Sudan, Syria, and Yemen. In DRC, four Congolese MSF staff, Chantal, Philippe, Richard, and Romy, were abducted by an armed group while on an evaluation mission in July. At the time of writing, a dedicated team is still actively searching for them. On a more positive note, our colleagues Montserrat Serra and Blanca Thiebaut were released after having been held in captivity for 21 months. They had been abducted from Kenya’s Dadaab refugee camp in 2011. The issue of incidents targeting MSF and other humanitarian organizations is of significant concern, not only for security, but also for the ultimate impact these events and their consequences – temporary suspension or revocation of medical services – have on the health and survival of the people we aim to help. In 2013, MSF began researching such incidents, their impact and our response in the Medical Care under Fire project. We hope to identify ways to improve patients’ safe access to healthcare and the security of healthcare structures and international and national medical teams.
MSF’s work in 2013 felt at times like an uphill struggle. Despite the challenges, however, and the sheer number of people caught in crises this year – many traumatised by the violence, losses, and uncertainty of conflict – our supporters and teams around the world delivered medical care to more than eight million people in their hour of need. We would like to take this opportunity to thank everyone who has made our work possible over the last year.