April 19, 2017, Stuttgart Germany
Speech by Dr. Joanne Liu
International President, Doctors Without Borders/Médecins Sans Frontières (MSF)
African Chiefs of Defense Conference
I wish to express my appreciation to General Waldhauser for the opportunity to participate in this discussion with African defense chiefs. We very much value this dialogue.
There are 35,000 MSF staff working across the world today, and we find it increasingly difficult to operate in conflict settings. Indeed, we question if there is a future for independent humanitarian actors such as MSF.
We urgently need to expand our dialogue with you, so that we can expand the spaces we work in.
Negotiating directly with armed actors—whether state or non-state—is a pre-condition to securing the safe space needed by our medical teams to provide care to victims of armed conflict.
Our teams are operating across every armed conflict—be it international or non-international—on the African continent. They are deployed on the front lines of the very battlefields where forces under your command are conducting combat and peacekeeping operations.
MSF is a self-mandated, international, independent, humanitarian, and medical organization.
It delivers emergency aid to people affected by armed conflict, epidemics, natural disasters, and exclusion from health care. The scope of our action goes beyond medical aid and includes providing water to displaced communities, shelter to those in need, and more.
And while I stand here before you today, MSF is not alone in the frontlines. Please consider the other humanitarian organizations who share the same space with all of us.
Its humanitarian action is guided by medical ethics and the fundamental operational principles of international humanitarian law (IHL): humanity, neutrality, impartiality, and independence.
From Nigeria, Mali, and South Sudan—to Sudan, the Democratic Republic of Congo, Chad, Libya, and the Central African Republic—we humanitarians are also present.
Indeed, much of MSF’s work takes place in Africa, so I am especially grateful to be here with you today.
We have worked amidst numerous African civil conflicts, from Angola and Mozambique, to Liberia and DRC. We treat the wounded and sick on all sides, including those who perhaps once opposed governments, and today sit in power.
Our work in 25 African countries today accounts for 45 percent of our global activities, and 48 percent of our total operations budget.
We spend well over half a billion dollars on our operations in Africa. More than 90 percent of that expenditure is funded by millions of private individual donors.
In one year MSF will on average:
- Vaccinate more than two million people;
- Perform nearly six million outpatient consultations;
- Carry out almost 40,000 surgical operations;
- Treat 164,000 children for severe acute malnutrition;
- Treat more than two million people for malaria.
We achieve these significant numbers because we insist on being in close proximity to populations and communities in need.
Yet, we are at a critical juncture.
We see massive humanitarian needs going unmet, especially in conflict areas.
We appreciate the complexity of modern conflicts, which is why we seek more dialogue to find ways to overcome the challenge of reaching those in need.
The ability of health workers to safely care for the wounded and sick across numerous war zones is increasingly compromised and under threat. As is the ability of populations trapped in these conflicts to access humanitarian aid.
So the stakes today are high, with huge populations at risk.
For example, 800,000-plus South Sudanese refugees have fled into Uganda, forced to escape indiscriminate violence in their home country.
Within South Sudan itself, communities suffer looting, the destruction of their villages, and loss of hope—because they lack protection from militaries and authorities.
Some military forces and non-state actors routinely and flagrantly disregard the protection of civilians, and the norms and laws governing humanitarian operations.
The national security interests of states are used to justify wars without limits. Humanitarian aid is welcomed when it serves security objectives, and is often restricted or attacked when it does not.
Civilians, of course, suffer the consequences.
So we must have dialogue with you—African defense leaders—to ensure our limits are defined not by national strategies, but by our own capacity to deploy, negotiate, and scale up.
And we must discuss what binds our respective work in these areas.
What binds us—and restrains us—is international humanitarian law, or IHL.
IHL obligates MSF to assist victims of conflict and to abide by the fundamental principles of neutrality and impartiality when providing assistance.
And it obligates your forces and non-state groups to protect civilians and facilitate aid to them.
But these principles are tested day in and day out.
They are tested by non-state armed groups, of course. But also increasingly by states engaged in combined non-international armed conflict and counterterrorism situations.
MSF health facilities have come under aerial attack in Afghanistan, Sudan, Syria, and Yemen. MSF medical staff have been threatened or harassed by combatants in the Democratic Republic of Congo, Central African Republic, Lebanon, Honduras, Myanmar, and South Sudan.
Combatants demand, even threaten doctors—that their comrades be treated ahead of others, or they deny care to patients based on ethnic, religious, or political grounds.
These abuses violate the fundamental principle of impartial medical care: the prioritization and treatment of patients based only on health needs.
Warring parties do not always adhere to their own obligations to the rules of war.
Worse, aid providers—and their civilian recipients—are mercilessly attacked.
Today, we see the provision of humanitarian aid based on the needs of warring parties, rather than on the needs of patients and populations. Aid has been co-opted by counter-insurgency and counter-terrorism campaigns.
And ongoing attacks on humanitarians and civilians are often described as mere mistakes or “collateral damage.”
Hospitals are raided, attacked, looted, and bombed—especially in areas considered to be opposition- or insurgent-controlled.
We have witnessed people killed in their hospital beds.
Soldiers raid hospitals to hunt wanted enemies and seize patient records.
Hospitals have become places of fear and death, rather than of safety and healing.
The impartial provision of aid to anyone in need—including wounded and sick combatants —has become criminalized in some places, and we worry this is an increasing trend.
We must find convergence in understanding how we can expand assistance to the maximum number of people in need.
Doctors risk being criminalized and arrested for treating, quote, “terrorists” or criminals. And patients risk their lives by seeking care.
As MSF, we will not accept a logic that the “doctor of my enemy is my enemy.”
While our modus operandi is peaceful, we are not pacifist. So it is not war itself that is the problem. It is about how you allow wars to be conducted.
Our ability to gain the trust of vulnerable communities is undermined when aid becomes a symbol of authority, rather than remain an independent and neutral act to alleviate acute suffering.
This, for example, is why we don’t want armed escorts. We want access to populations based on trust.
The co-optation of aid only leads to attacks on aid, which then lead to the forced closure of health facilities, often where others don’t exist.
The loss of health services at the precise moment care is most needed means that expectant mothers die in child birth. Children go unvaccinated, or perish from treatable diseases like malaria or diarrhea. Others lose all access to the treatments they need to survive.
We do not deny the role of governments and militaries in alleviating suffering. But a distinction must be drawn between epidemics or natural disasters and conflicts. The difference lies in our respective objectives.
In medical or natural disasters, both humanitarians and militaries deploy to save lives.
For example, while our call for the deployment of military biohazard assets to west Africa during the recent Ebola epidemic may appear inconsistent with our principles, we see a basic coherence.
Militaries possess capacities and skill sets ideally suited for response in certain settings and contexts. We believe that as long as a military aid response is community- and patient-focused and not implemented through a national security or political lens it can contribute greatly in major disasters and epidemics.
And indeed, MSF was cautious about the primary motivations behind the eventual military mobilization to West Africa. Nonetheless, it was the absence of a conflict that contributed to our ability to work alongside the military responders.
Because while we share the same operational space in conflict settings, we certainly do not share the same goals.
So cooperation is indeed required. We must interact, if only so our medical teams can pass your checkpoints, and so that populations maintain access to assistance.
We should indeed have one thing in common in conflict settings: a shared, practical understanding of our respective roles and responsibilities, to which we are mutually obligated and accountable.
For you as military leaders, this implies a responsibility to protect civilians, facilitate treatment of the sick and wounded, ensure the smooth functioning of humanitarian staff and medical structures, and adhere to the principles of military necessity, distinction, precaution, and proportionality in your use of deadly force.
For MSF, IHL imposes a responsibility to conduct medical and humanitarian activities without taking sides, while ensuring that our medical structures provide treatment impartially—to all sick and wounded, no matter who they are.
The reality on the ground, however, is often very different to the common understanding we can reach in this room.
It is indeed at the intersection of IHL and domestic criminal and counterterrorism laws where we encounter difficulty securing the neutrality and safety of the medical mission.
You are obligated to grant the space to save lives and alleviate suffering, including of individuals who oppose you.
Once off the battlefield and under treatment, those individuals are patients, regardless of their political or military affiliation. And they are accorded the full protection of international law.
As a doctor, I cannot accept that patients will be killed, wounded, or arrested while under my care if they are perceived to pose a security threat to those in power.
My objective is simply to save lives and alleviate suffering amidst the devastation of war—to assist and protect until warring parties cease hostilities.
Our loyalty is simply to our patients. We will negotiate with whomever has the power to grant or prevent access to those in need.
We make no de facto judgement in this regard, though we always reserve the right to speak out when we witness obstructions to aid or violence inflicted on the populations we assist.
Where and how we intervene is based on our own independent assessment of health needs.
Aid must be for its own sake. It is not a tool for stabilization, reconstruction, state-building, winning hearts and minds, force protection, or generating public support back home.
But your obligations are broader.
The legal provision of aid must be vigorously maintained.
This is clearly upheld in UN Security Council Resolution 2286, which condemns attacks against medical facilities and personnel in conflict situations and reaffirms their rightful protection.
It reaffirms the international framework under which all states must abide. It supersedes national laws or doctrines that may pay less respect to the core of IHL.
But, one year since its unanimous passage, the resolution, co-sponsored by 11 African countries, has yet to be operationalized by states.
Encouragingly, the United States has reaffirmed its own obligations under international law to protect the medical mission in international and non-international armed conflict settings.
Last year, the US secretary of defense issued a statement of principles on the provision of humanitarian aid.
Among other reaffirmations, it declares the following:
“Medical care during armed conflict is an activity that is fundamentally of a neutral humanitarian and non-combatant character. Ensuring that medical care during armed conflict is protected requires that parties refrain from acts that undermine its protection and take affirmative steps to distinguish medical care from activities of a combatant character.”
It goes on to make clear that “all the wounded and sick, whether or not they have taken part in the armed conflict, shall be respected and protected. The wounded and sick are persons placed hors de combat by sickness or wounds.”
This should be a model for all military rules of engagement.
We were deeply shocked by the recent bombing of our colleagues in Rann, Nigeria. From this tragedy we have have expanded our dialogue with Nigerian authorities—just as we expanded our dialogue with the US following the attack on our hospital in Kunduz, Afghanistan.
I’m here today because we want to have these discussions before the worst happens, not after. Preventing the worst is the most compelling imperative for dialogue.
I firmly believe that amidst the complexity, chaos, and danger of war, we need to do everything possible to reinforce the rules.
As doctors and soldiers, we need to regain a sense of mutual understanding of the rules of war. The stakes are too high and the outcomes we have seen are lethal.
We therefore seek the following concrete outcomes from our dialogue, consistent with international law:
- Complete respect for weapons-free policies within health premises;
- No use of force within or against any non-militarized health or humanitarian structure, vehicle, or premises;
- No pursuit, questioning, or arrest of any person while he or she is under medical treatment in a health facility;
- Your acceptance that independent and impartial medical care to any wounded and sick is excluded from any definition of material support of terrorism—and you should make your positions publicly known;
- Established lines of communications with all levels of the military, including relevant special operations forces, and acceptance of aid group communications with non-state armed groups, even your enemies.
We measure aid by a humanitarian standard, not by any other objective.
And facilitating aid for the sake of it is your responsibility.
So we must have a shared understanding of the rules of war, and a commitment from you to implement that understanding, for the sake of your own people.
That understanding can only be established and maintained if we have permanent channels of communication at all levels of your military structures.
Despite its inherent brutality, even war has rules—rules that protect the most vulnerable, and enable the provision of assistance to them.
We do not seek special favor or dispensation. We only seek your respect for, and adherence to, well- established norms and laws.
I know it is firmly within the realm of the possible. I have experienced it.
The countless checkpoints I have crossed in places like North Kivu in the DRC prove the point.
I passed those checkpoints because the soldiers knew we were assisting everyone at our hospitals and clinics down the road—including them, if need be.
Those hospitals and clinics are the last line of defense of humanity. They are the lifelines of communities. You need them as much as your people do.
And we need you to ensure that we can work inside them.