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Ethics and legitimacy

Ethical dilemmas and moral suffering are frequent in the practice of humanitarian medicine. The allocation of resources, triage, rationing and interference with local health systems represent sources of dilemmas which are frequently encountered. It is important to anticipate and recognize these dilemmas, particularly as part of disaster management. Humanitarian medical action also raises a number of controversies on medical practices, effects on health systems and global health policies. Given these controversies, it is necessary to examine the exact field of humanitarian medicine and its sources of legitimacy.

 

Extractive industries

In developing countries, extractive industries (artisanal and industrial) have far reaching consequences on health through environmental pollution, some communicable diseases, violence, destitution, and compromised food security. The rapid expansion of these industries will inevitably engage humanitarian medical organizations towards affected populations, whether at the level of public health and diseases, geopolitical environments affecting access to health or the confrontation of “moral” and operational values endorsed by the mining and oil-extracting sector.

 

Medical care under fire

Since its foundation, MSF has faced different forms of violence against its patients, staff, health facilities and medical vehicles, as well as against national health systems in general. Medical practice can thus be perverted for political and martial purposes. This violence deprives entire populations of vital assistance and is a means for the parties to the conflict to exert, both symbolically and practically, their power over people’s lives...

 

Middle East

MSF has been working in several countries of the Middle East (Bahrain, Egypt, Iraq, Jordan, Lebanon, Libya, Palestine, Syria, and Yemen) for more than 20 years. This region poses specific challenges for the organization. As health systems are often functional, but degraded, MSF focuses its assistance on specialized medical activities, such as support for a dialysis unit, emergency services or reconstructive surgery. Since the beginning of the conflict in Syria, MSF has also provided emergency, medical and surgical care to Syrian refugees. MSF’s added value also lies in responding to emergency medical needs during humanitarian crises: in Iraq, Syria or in Gaza, for example, in so-called middle-income countries which suffer mainly from the chronic consequences of conflicts and where the treatment of non-communicable diseases constitutes the priority. MSF has had to adapt its work to this specific context. The negotiation of an independent operational space is particularly complex due to the multiplication of the number of actors.

 

Perception of MSF and humanitarian action

The way a humanitarian organization is perceived depends on both context-independent factors (e.g. the organization’s activities in other parts of the world, its reputation, its visibility on the international stage, and the consistency of its principles and activities) as well as context-specific factors (the way the organization implements its operations in the country, the relevance of its activities to needs, its communication strategy, its relationship with public structures, its position with regard to national political issues, the management of local human resources, its integration into the pre-existing social fabric). Perception has a considerable impact on both the quality of operations and the safety of staff and beneficiaries and therefore requires special consideration. In order to understand the ways that patients, populations, and authorities perceive its principles and medical practices, MSF launched the Perception Project. During the study, which lasted four years and was conducted in more than ten countries, close to 7,000 people were interviewed. Since September 2001, the world has been characterized by the redefinition of power relations and the emergence of new actors challenging the foundations of humanitarian action or its use for military purposes. In light of this, it seemed important to conduct the study and to share its results in order to offer some keys to understanding perception.

 

Military-humanitarian relationships

In their actions and words, humanitarians need to prove de facto their identity in accordance with the principles of humanity, impartiality, independence and neutrality, at the risk of legitimately being suspected of acting as opposing forces’ accomplices or having agendas other than providing assistance to those in need. It is on this basis that humanitarians negotiate – with more or less success – a workspace with armed forces for an exclusively humanitarian purpose, a "humanitarian space", which must be acquired and confirmed on a daily basis. The evolution of conflicts, as well as the way armed groups use aid and interact with aid actors, require monitoring of the problem. In this way, the adjustment – if necessary – of the modus operandi of humanitarian staff can be implemented, in order to achieve operational objectives without compromising present and future relations with all actors.

 

Sexual violence

From Greek mythology to the Democratic Republic of Congo, sexual violence has often been a component of conflict. Its strategies and goals are numerous: compensation/payment for armies, initiation ritual for child soldiers, torture to obtain information, tool of terror to humiliate people considered to be enemies, etc. This violence affects entire populations, that is, not only women and children but also men, whatever their generational or socio-cultural belonging. Beyond the moral and physical consequences, victims sometimes have to face the fear of being rejected by their relatives or community. The response to sexual violence is not only medical (HIV prophylaxis, treatment of sexually transmitted infections, emergency contraception, etc.); it is also psychological (mental health care, social care). Finally, it should be noted that this problem remains an essentially political one, especially in the preventive aspects of this violence and the coercive aspects with regards to the fate of attackers.

 

Forced displacement

At the end of 2012, over 45.2 million people in the world were living in situations of displacement. This figure, which increased in 2013 mainly because of the Syrian crisis, includes refugees and asylum seekers, but also persons displaced within their own country. Although war and situations of violence are the main cause of displacement, notably in situations such as Afghanistan, Somalia, Iraq, Syria and Sudan, other causes of displacement also exist: natural disasters, displacement induced by development, poverty, the consequences of climate change, the lack of resources, etc. In recent years, Médecins Sans Frontieres (MSF) has invested heavily in forced displacement situations, whether in the Democratic Republic of Congo, Somalia, Kenya or the Middle East.

 

Global public health surveillance

Threats posed by new, emerging or re-emerging communicable diseases are taking a global dimension. The concept of global public health surveillance, an essential component of the global strategy for tackling epidemics across borders, has been expanded and formalized through a number of recently developed instruments and initiatives. These notably include the International Health Regulations (IHR), whose origins can be traced back to the adoption by World Health Organization (WHO) Member States of the International Sanitary Regulations in 1951. The legally-binding agreement, revised by the World Health Assembly in 2005 to include additional infectious diseases and extend regulation to other public health events of international concern, provides the legal framework for countries to link and coordinate their action through a universal network of surveillance. However, a number of external factors influence political commitment to comply with international health regulations. Low-income countries also face intrinsic difficulties when submitted to the ever-increasing pressure to upgrade their public health surveillance capacity.

 

Humanitarian action

This research topic covers a wide variety of subjects on humanitarian action: the aid system, the quality of aid, new actors, epidemics, access to health, food security, etc.