Mercy Knows No Frontier

Doctors Without Borders Brings Aid to Developing, Warring Regions

Since 1998, the medical aid group Doctors Without Borders has released an annual list of the top 10 most underreported humanitarian stories of the year. Based on field reports from more than 70 countries, the list is calibrated according to the relative severity of various crises balanced against the coverage they were given by Western news organizations. In 2005, television networks in the U.S. broadcasted a total of roughly 14,000 minutes of evening news; together, the top 10 stories on the Doctors Without Borders list received a combined eight minutes of news coverage. I recently spoke with Nicolas de Torrenté, executive director of Doctors Without Borders (also known as Médecins Sans Frontières, or MSF) about the list and about MSF from his office in New York.

The Congo has appeared on your list for seven years straight. What is the situation there, and why has it been on the list for so long? The Congo does stand out. In terms of the duration and the magnitude of the war, and in terms of its effect on the civilian population, it is extremely serious by any measure. It’s the direct violence against people, including sexual violence, and then it’s the indirect violence — forced displacement, people having to leave their homes, the destruction of livelihoods, and so on. And then it’s the collapse of infrastructure. Basically, the entire public infrastructure has, after decades of war and misrule, completely collapsed. Right now we have a situation in one part of the Congo called Katanga where there’s been renewed fighting between government soldiers and militia groups that were formerly allied with the government, in opposition to the Rwandese forces that were invading the country. Now they are fighting each other, and it’s led to huge displacement — about 100,000 people in the last few months in Katanga.

Considering the enormity of the issue, why don’t we hear more about it? There are objective reasons. It’s been going on for a long time, it’s complicated — you know, you can’t generalize. [The Congo] is vast, logistically difficult, and quite insecure. … So, there are objective reasons why it’s a hard story to cover. But beyond that, I think there is a basic lack of effort by the media to develop some understanding of the issue and to transmit that to its audience, to unpack what’s happening there. I think one of the main reasons for that is the assumption that people just don’t care, that the American public doesn’t care about what’s happening. It’s a vicious cycle: You assume there’s no audience for this, you don’t invest the resources, there’s no coverage, and what coverage it does get is very superficial and doesn’t help people understand what is occurring, and, as a consequence, people aren’t interested.

Chechnya is another perennial crisis — it’s been on the list every year since 2000. This despite a ceasefire, and at least the appearance of stabilization. Normalization is the catchphrase that’s being used to describe what’s happening, but it just doesn’t do justice to what’s actually happening. There has been some movement of people back into Chechnya in the last couple years, but the main reason for that is that they have been forcibly removed from neighboring republics. Assistance was cut off for many of the refugee camps by Russian authorities. Insecurity has spread in the region, which means that it wasn’t any safer to be in Ingushetia [a neighboring republic] than to be in Chechnya. So there has been a movement of return, but it hasn’t meant that things have drastically improved inside Chechnya. Clearly, the level of services available for people who have returned is far below what is needed, and people continue to be exposed to a great deal of violence and continue to be deeply traumatized by the situation.

What about southern Sudan? A peace treaty was recently signed there, ending the 50 years of war between the Islamic Sudanese government in central Sudan and the Christian and animist rebels in the south. The common assumption is that when there is a [peace agreement], at least on paper, conditions on the ground have also improved. What we often see is that this political progress does not lead directly to improvement from a humanitarian perspective, which is certainly the case in southern Sudan. There has been less fighting, but that doesn’t mean the fighting has stopped entirely — fighting has continued in various regions in the last year. And there has been a big return of people. But the efforts of aid agencies and the efforts of the UN have not matched at all the expectations of people. In fact, we had as many emergency situations in southern Sudan in the last year as we have had in previous years. Things have not improved — we have high levels of malnutrition, high levels of people affected by violence.

Most of these crises we’re talking about occur in war zones. How do you reconcile MSF’s doctrine of neutrality with these very highly charged political situations, in which one group of people may be very clearly repressing another? For us, being neutral means not taking sides in a conflict, not aligning ourselves with one side or the other. That doesn’t mean we would not call attention to atrocities as they affect one side or another. That we will do. For us, that is compatible with neutrality. Without taking sides in a conflict, you can still denounce atrocities. For us, that is not breaching our mandate to remain neutral, even though it may be perceived that way by the parties involved.

The Hippocratic Oath requires doctors not to withhold medical care from someone in need. By operating in war zones, does that mean that MSF might end up aiding and abetting despotic regimes, or soldiers committing war crimes? The key distinction in humanitarian law — and as a consequence, in humanitarian aid — is between people who are combatants participating in fighting, and noncombatants. By far, the majority of the people we treat are civilians. The most vulnerable groups in war zones almost always are women and children and the elderly. But of course we will treat wounded combatants. Now, does that aid and abet despotic regimes, does that fuel wars? We have to be very aware of the consequences of what we do, we have to monitor ourselves very carefully. We try to limit all of the negative effects of what we do. And they do exist. Anytime you are working in a war zone, you are prone to being used or manipulated in some way. … And in some extreme cases we decided that our aid was doing more harm than good, and it was being used against the people we were trying to help, and we pulled out.

For example? We pulled out of North Korea in 1998. In North Korea, we were not convinced that our nutritional assistance was actually improving the lives of the children there, because we were not allowed to work freely. So the question was whether we were just aiding the North Korean regime. But overall, when you provide aid in Darfur today, or in Congo today, aid is not the reason people are being starved, displaced, and killed. The motivation of the belligerents is not to capture aid. Aid is not fueling war. I’m convinced of that.

One story on the Without Borders list not related to war was AIDS in the developing world. In particular, we are trying to attract attention to the issue of AIDS infections in children, which thankfully is not a big problem in America and in the industrialized countries. There were fewer than 60 children born with HIV/AIDS in the U.S. last year. But in the developing world it is a huge issue. We had 2.2 million children worldwide born with AIDS last year, and hundreds of thousands who need to be put on antiretroviral therapy. … Right now, we lack the means for diagnosing children who are less than 18 months of age, in the field. There are complicated lab tests that would be available in the U.S., but in the field we don’t have such sophisticated equipment. Half the kids born with HIV [in developing regions] die before the age of two. So, if you can’t detect whether they are HIV positive before 18 months — you are missing so many. That’s just unacceptable. When you see the devastation caused by AIDS in kids — AIDS is unacceptable, in general, but with kids it is so much more so.

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