International Activity Report 2003
Iraq

International staff (as of July, 2003): 20 National staff (as of July, 2003): 108

This simple question reveals one of the legacies of the war in Iraq: an erosion of the meaning of the word "humanitarian." Invoked by the United States and the United Kingdom as one motivation behind the war (ridding the country of a tyrant), ignored or manipulated by Saddam Hussein, used as an argument for paci. sm by NGOs (the disastrous humanitarian consequences of war would be too great), the essence of the "humanitarian" idea took quite a blow, to the ultimate detriment of those who may have needed assistance.

MSF understands humanitarian action to be a response to conflict. Aid or relief for humanitarian reasons is assistance given independently and impartially, based on need alone, not tied to political agenda, ethnic identity or religious affiliation. It is not tied to being "liberated" or being on one side or another of a conflict.

In Iraq, the concept of humanitarian action was put to the forefront to either justify, prevent, or "spin" hostilities. Humanitarian aid became just another instrument of war, blurring the lines between independent humanitarian aid, military obligation and propaganda. In terms of the way it was fought, the war was also packaged as a "humane" war; yet the circumstances of some civilian deaths in Iraq require investigation.

Declining to comment on the possibility of a humanitarian emergency in the event of war in Iraq, MSF chose instead to do everything to be present when war hit, to be in a position to better understand the suffering of the people in the event of war and provide medical assistance if any were needed. Active in the country in the early 1990s, MSF left in June 1992 because of inability to work independently under Saddam Hussein's regime. MSF was prevented by the Iraqi government from establishing a presence in the intervening years. Finally, as war loomed in late 2002 and early 2003, MSF was able to restart negotiations and was granted permission to begin work in March 2003.

As the US-led coalition began bombing Iraq, a team of six expatriates, including a surgical team, was on the ground in Baghdad, hoping to assist already highly trained Iraqi medical workers who could possibly need support in event of war. There was not much possibility to bring independent assistance in the run-up and opening days of the war. Nonetheless, the team began assisting Iraqi staff at al-Kindi hospital in northeast Baghdad. MSF teams in Jordan, Kuwait, Syria and Iran prepared for possible out. ows of refugees.

At the beginning of April, just as increasing numbers of wounded people were arriving at al-Kindi hospital, two MSF expatriates and one local staff member were taken by the Iraqi secret police. All activities were suspended until their release by their captors nine days later, just after the fall of Baghdad. Ultimately, the main hostilities of the war lasted a little over . ve weeks. Real needs – but no humanitarian crisis With the team safely reunited, MSF began a general assessment of the health situation, visiting hospitals and clinics in many areas of the country. During April and May, expanded MSF teams conducted brief assessments of health facilities in 25 cities, donating supplies and equipment and assisting medical staff as needed. In visits to more than 70 health facilities, MSF teams witnessed none of the characteristics of a major humanitarian crisis, such as massive displacements of people, famine or widespread epidemics. There were no large refugee flows. MSF did, however, assist a group of about 1,000 refugees from Iran (in Iraq since 1980) caught in the no-man's land between Iraq and Jordan in precarious conditions.

An unacceptable number of lives

Despite the lack of acute humanitarian needs, MSF was nevertheless alarmed. The most urgent medical problem in Iraq was the lack of leadership in the highly centralized health system, which had slipped into chaos in the aftermath of the war. With no central organization, the medical infrastructure in Iraq had begun to deteriorate. MSF spoke out about the situation, calling on the occupying power to address the health needs of the Iraqi people and to establish some sort of order within the health system, in compliance with international humanitarian law. According to the Geneva Conventions it is the responsibility of the occupying power to meet the basic needs, including health care, of civilians in an occupied area. "The lack of leadership and lack of intervention," said MSF International Council President Morten Rostrup, a doctor on the MSF team in Baghdad during the war, "has cost an unacceptable amount of lives." Many patients had been discharged from hospitals during the bombing and were afraid to return for secondary surgery or follow-up treatment. Widespread looting stripped many public hospitals of all equipment and drugs; insecure streets prevented the medical staff in some areas from coming to work. Iraqis with chronic diseases such as diabetes no longer had access to life-saving medicines, and limited water and electricity in parts of the country were also contributing to the health problems.

MSF's efforts to support principal hospitals in Baghdad and elsewhere were at first impeded, however. When the main hostilities ended, hospitals quickly became coveted prizes in tense political struggles between hospital administrators and directors, coalition members, and local religious leaders. Such conditions made it virtually impossible to provide meaningful added value through these structures at the time. In May, however, MSF was able to begin work in al-Thawra hospital in Sadr City, Baghdad.

MSF opens primary health centers in Baghdad slums

"Many people get their water from wells that are so filthy that when you look down into them you see layers of garbage" – Pierre Boulet-Desbareau, Head of Mission for Iraq, June 2003

By June 2003, the medical infrastructure in Iraq had deteriorated even further, with shortages of drugs caused by the collapse of the distribution system and widespread looting. MSF responded by supporting the fragile medical structure in several parts of the country. In Basra and Missan, MSF began assistance to 16 health centers, providing essential drugs and supplies and rehabilitating buildings destroyed during the bombing.

MSF also began a primary health care project in the slums of al-Ma'amil and al-Muntadhr in Sadr City, one of the poorest areas of Baghdad. An estimated 300,000 people live in shantytowns in the area, many in metallic shacks on garbage dumps. With no access to medical care, clean water or sanitation, the health situation is critical and the potential for outbreaks of disease is enormous. The people living here are desperate for medical services: MSF teams carried out 138 consultations in one day when the first of three clinics opened; by early September, teams were carrying out an average of 2,500 consultations each week. At al-Thawra hospital, also in Sadr City, MSF is working on the emergency ward. MSF is also focusing on safer nursing techniques, organizing practical training sessions, and supervising nurses and junior doctors on the wards.

In addition to providing direct medical services, MSF is working together with the Iraqi Ministry of Health to improve the health situation of the people in Sadr City. Activities include creating a surveillance system to track infectious diseases and provide an early warning system for outbreaks, and improving access to water and sanitation facilities.

Uncertain future

By late summer 2003, basic services such as health care – and water and electricity – were still not being ensured by the Coalition Provisional Authority or the Iraqi Governing Council. The security situation was deteriorating, with stepped-up attacks not only on Coalition forces but on symbols of the western presence in Iraq, including aid workers. MSF teams in Basra were evacuated in August as the situation in that city became increasingly unstable (national staff completed the distribution of drugs to health centers and hospitals).

Perhaps the most visible reminders of the lingering problems are the brutal bombings of the United Nations headquarters in Baghdad in August and the International Committee of the Red Cross headquarters in October. MSF was shocked by the deaths of large numbers of Iraqi and international staff. These assaults were a tragic illustration of how continuing violence is severely limiting the ability of humanitarian organizations and international agencies to assist the Iraqi people.

Ironically, if war as such didn't create a humanitarian emergency, the failure of the victors to ensure basic security and provide essential services for civilians ultimately created many more needs than would have otherwise been the case.