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Humanitarianism...in the Meantime
Christopher Stokes, Secretary General, MSF International
Humanitarian aid saves lives today, until peace, until reconstruction, until development, maybe. But humanitarian action never builds much; it concentrates on saving lives now until they can be rebuilt tomorrow. It is not hopeful, it is immediate and it has to be judged on its capacity to be with victims in their hour of need and to help them survive the crisis, the war or the epidemic. On this count, Iraq more than any other conflict today shows-up the limits of humanitarian assistance.
With conflict at the heart of MSF’s self-determined mandate, we constantly have to assess the effectiveness of our assistance, methods of intervention, and the need for improvement. For MSF, this year was marked by a return, of sorts, to the Iraq war with teams from several MSF sections. After the attacks on the International Committee of the Red Cross (ICRC) and UN compounds, the assassination of British aid worker Margaret Hassan, and the growing number of security incidents in Baghdad, we withdrew all international teams at the end of 2004, while assisting some of our most threatened Iraqi colleagues to leave the country. The option to continue running minimal aid programs from the safety of neighboring countries was quickly dropped, though there was a heated internal debate among those in favor of keeping an "external" support and those favoring a clear break because of the seemingly impossible security environment. Iraq triggered a wider debate about the risks the MSF movement was or was not prepared to take. Though risk-taking was acknowledged to be an inevitable part of humanitarian work given the environments in which the association operates, there was a willingness to set a limit: loss of life of MSF staff was unacceptable, it was not a sacrifice - presumably for the greater imperative of saving lives in an extreme conflict situation - that the movement was prepared to accept. Given the associative nature of MSF, this is perhaps not surprising: each part of the movement is accountable to a series of distinct national associations that are fundamentally egalitarian in their membership and way of deliberating and making decisions.
The problem is the spread of the conflict in the last three years, and particularly since 2006, across central and southern Iraq and gaining ground in the north around Kirkuk and Mosul. In cold statistical terms - the number of deaths directly caused by armed conflict - Iraq is the most ferocious conflict in the world today, including Darfur. While meeting Iraqi refugees this summer in Jordan, Lebanon, and Syria to assess health needs, I was struck by how their families had been scattered by the war and the heavy casualties they had suffered. The international reporting of the suicide bombings masks the heavy toll of daily assassinations, the almost casual execution at checkpoints that disappear as quickly as they were set-up in many parts of the country, the continued kidnappings, and disappearances of relatives. These crimes are committed against patients in hospitals. There are no sanctuaries for civilians in Iraq.
Yet the war has also been marked by the stark absence of international humanitarian aid agencies delivering effective assistance on the ground. MSF is certainly not one of those delivering effective humanitarian assistance in Iraq.
Insecurity is the cause of our absence. The principle of acceptance by the population and local authorities is the foundation of MSF field teams’ security. But there are other ways to ensure the delivery of aid, such as protection: bullet-proof jackets, cars, and even deterrence, the use of armed escorts. The deterrence option would require MSF to work under heavily armed, close protection of, say, the coalition forces, an option chosen by some a few years ago but abandoned by practically all today. In our view, mounting a heavily armed response in order to provide medical assistance is very hard to reconcile with the fundamental principles of humanitarian assistance such as neutrality and independence. Further, the ability to provide assistance in the long term is compromised by the use of deterrence that alienates local communities and authorities.
The alternative, working thanks to a widespread acceptance of our medical assistance, is very hard to put in place and difficult to sustain in this war. For independent humanitarian aid to work, a minimum level of acceptance is needed, people on the ground have to support the basic objectives. Security assurances by those with the public monopoly of violence have to be forthcoming. In wars where there are no clear front lines, where no single force establishes a public monopoly of violence over a set territory, the negotiated circulation of aid supplies and aid workers is compromised. To make things worse, the subsequent absence of effective visible aid agencies working side by side with Iraqis, has reinforced the mistrust towards foreigners and western organizations in general. The multiple layers of violence in Iraq today prevent effective assistance to civilians. Conversely in Somalia, where the minimum conditions necessary for a real humanitarian space are also not very high, MSF has been able to work across large swaths of the country for the past decade, deploying numerous medical teams to deliver lifesaving assistance. The country is fractured along clan lines and alliances, but there is a precarious space within each area of clan control that allows the careful organization and implementation of aid programs. "Humanitarian space" – the space required to assess needs, deliver aid, and control its use – is never a given, it is something we have learned, sometimes painfully, to negotiate and maintain in unsafe places from Palestine to Liberia, from Ivory Coast to Colombia.
Multiple and shifting layers of violence require different strategies. One challenge will require ensuring that our strengths do not turn into weaknesses. The high turnover of committed international staff, the doctors, nurses and logisticians who question and challenge and shape new interventions across the many emergency operations MSF launches across the world, should not prevent the creation of strong networks of local Iraqis in war zones. Without them, assistance is impossible because to work in Iraq is to work blind: we can assist only with and through local counterparts, without MSF staff going to the field to discuss with beneficiaries, measure in person and subsequently adjust how the aid is organized. In effect, the first step on the road back to assistance is remote-controlled operations where MSF teams are based in neighboring countries. Only later, and in the best of cases, will assessment visits be possible. The effective deployment of aid teams will come at a much later stage. MSF’s important logistical and organizational capacities also count for less in an environment where aid is to be supplied piecemeal and often in a secretive manner, using local truck companies who can get through the numerous official, unofficial, insurgent, and neighborhood checkpoints. The clandestine supply of aid is requested by local counterparts such as hospital directors and surgical teams, who risk assassination if any link between them and a foreign entity, such as an international aid organization, comes to light. Saving lives is a deadly occupation for Iraqis and foreign aid workers alike. Hundreds of doctors have been killed in this conflict.
More surprising still, independence, a fundamental principle to MSF, is not a clear-cut operational asset in this setting. For some countries in the region where we aim to assist refugees fleeing the fighting, there is a preference for aid agencies with strong ties to particular states through funding – use of institutional government funds – and close backing from their respective governments. A country isolated by the label "axis of evil" can well consider that an NGO with close foreign-state backing acts as a bridge to that country. Further, close state ties, even with a foreign state, are seen as an indication of the controllability of the so-called nongovernmental organization, especially in countries where the concept of a genuine, independent nongovernmental agency is alien and suspicious.
To dilute basic principles is not an option. They are deeply embedded in the identity of MSF and there is no willingness to renegotiate them. In practice, the long-term benefits of a strong principled approach towards independence, impartiality, and neutrality could outweigh the immediate gains of compromise. MSF will need to maintain the principles that have guided the movement and apply adapted and innovative operational strategies.
MSF teams have managed to get a foothold through remote-controlled operations, providing much needed medical supplies to hospitals inside the war-torn provinces via Jordan or Kurdistan. Additionally, along the lines of “doing what we can to help until we can go in,” patients requiring reconstructive and orthopedic surgery, often as a result of the bombings, are painstakingly brought, thanks to networks of Iraqi doctors, to an MSF surgery project in Jordan. Here they can get the specialized medical care they cannot get in Iraq. A similar strategy will be established in Kurdistan. Both activities, supply and evacuation of patients, are useful in and of themselves, but they are also necessary steps to having teams on the ground and closer to where needs are most acute. The necessity of bringing in teams has become greater over the past year, as doctors working in overrun emergency departments have described the impact of the growing exodus of medical professionals and the consistently high patient caseload as a result of the fighting. The reversal of our questionable earlier decision not to attempt remote-controlled operations in 2005 is a result of this deterioration inside Iraq.
In the worst war-zone of the new century, international assistance is absent on the ground. In contrast, the deployment - albeit fragile and often threatened - of over one hundred MSF international aid workers in Darfur, compared to the sum total of zero in central and southern Iraq where the war rages, is a painful reminder of the impotence of humanitarian aid agencies.
The struggle to assist victims of conflict is not one MSF can abandon, but it will be a long, hard struggle to achieve a real operational space in Iraq. Humanitarian action here is not effectively saving lives today, in the meantime, until peace, until development. It is deploying in the periphery, on the margins of the main needs, until new strategies open the way back into the war-zones.