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Negotiating access to civilian populations affected by armed conflict is possibly the single most important challenge faced by humanitarian organisations today. While the principle of free access to victims enshrined in the Geneva Conventions puts the onus on warring parties to provide rapid and unimpeded access to people in need, in practice, humanitarian organisations have to carve out spaces for action through sustained engagement with States and parties to conflict. Arguably, insofar as it affects the interests of multiple parties and sometimes challenges notions of sovereignty, aid has always been vulnerable to manipulation. Concurrently, the exponential growth  of the aid sector over  the past decade and the centrality of States and donors in shaping policy, challenges both the place and relevance of independent humanitarian action.

Ethical challenges are inherent in the practice of humanitarian medicine . Some of them are universal in health care but heightened in humanitarian contexts; resource scarcity, triaging decision, quality concerns and referral pathways among others. Other challenges are specific: denial of access to health care, potential interference with local systems and communities, and the perceived independence and impartiality of humanitarian action. Recognising and addressing these challenges informs decisions about what is the right approach. Yet, that is not always possible so actions to minimise harm are equally relevant. Humanitarian medical action also raises a number of controversies on a global level; what is ethical medical practice in different cultures, how to address health system inequity and are global health policies just? Given these controversies, it is necessary to examine the exact field of humanitarian medicine and its sources of legitimacy as a differentiated working environment within biomedical ethics.

In the first half of 2022, the number of forcibly displaced people worldwide rose to over 100 million according to the UNHCR. This figure includes refugees and asylum seekers, but also the 53.2 million people displaced within their own country. Although war and situations of violence are the main cause of displacement, notably in situations such as Afghanistan, Burkina Faso, the Democratic Republic of the Congo, Ethiopia, Myanmar, Nigeria and lately Ukraine, other causes of displacement include natural disasters, poverty, as well as the impact of climate change. While refugee camps largely set the scene for humanitarian action in the 1980s, today’s challenges when it comes to providing medical care to refugees and other displaced people are not what they were then. Contemporary patterns of migration make for less traditional humanitarian settings, with the majority of the world’s displaced people now living in informal settlements in urban settings, not in identifiable camps, forcing humanitarian organisations to question their role and to redefine the limits of what they do. Growing anti-migration sentiment, deterrence policies and criminalisation are additional challenges facing organisations trying to provide assistance to people on the move.

From Greek mythology to the Democratic Republic of Congo, sexual and gender-based 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 and gender-based 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.

Populations in distress are particularly vulnerable to communicable disease outbreaks and epidemics. Prevention, containment and treatment of affected populations and communities remain a core component of humanitarian health action through vaccination, health promotion, water and sanitation activities, and case detection and management. Recent large-scale epidemics have brought to the fore many long-standing challenges such as equitable access to care, local priorities versus the global health security agenda, and indeed the disproportionate support available to fragile health systems. Meanwhile the impact of disease outbreaks goes far beyond the individuals and communities directly affected, encompassing political, economic and social sectors of territories already in crisis.

The history of humanitarian action is a burgeoning field of research, encompassing not only the post-Cold War period but key moments throughout the 20^th century and precursors from the colonial epoch. While classic methods of documentary research have not been discarded new sources have also emerged, be they from non-traditional archives or primary sources in fields of intervention. These developments have facilitated giving voice and perspective to those historically regarded as passive recipients of assistance. The resulting output can provide insights into how humanitarian action has evolved, lingering biases, and ideally less paternalistic approaches as the sector gradually moves beyond its Western origins.

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. MSF’s experience is hardly exceptional in this regard and there are numerous debates as to how such violence has evolved, what trends can be identified, the persistence of impunity irrespective of the protections enshrined in International Humanitarian Law, along with the effectiveness of related mitigation measures such as profiling. It is however indisputable that attacks on the medical mission influences not only the provision of aid but has the potential to deprive entire populations of vital assistance at times when needs are the most acute.  Meanwhile the long-term consequences of acute insecurity in conflict environments, such as the departure of medical personal or the broader collapse of health systems, has only been studied sporadically.

Public health interventions play a key role in directly protecting the health of populations in humanitarian settings, especially when living in transient, displaced, and overcrowded conditions. Equally, threats posed by new, emerging or re-emerging communicable diseases and antimicrobial resistance also take a global dimension. Following the West African Ebola outbreak and the COVID pandemic, global public health surveillance efforts are increasingly being viewed through a health security lens, including border protection measures. Formalised initiatives include the Global Health Security Agenda (GHSA), launched in 2014, and the International Health Regulations (IHR), a legal framework last revised at the World Health Assembly in 2005. These complementary frameworks recognise the extent to which global travel and trade impact population health, reinforcing the need to view social justice and health as interdependent global challenges. However, several external factors influence political commitments to comply with GHSA and IHR. Low-income countries also face intrinsic difficulties with increasing pressure to upgrade their public health surveillance capacity within existing fragile and under-resourced health systems.

The health of our planet is sharply in decline – putting historically recent, and fragile, human health gains at risk. Some climate related changes and environmental damages are already irreversible. Populations living in humanitarian contexts are disproportionately affected yet they have contributed the least to climate and environment degrading practices. The planetary health dossier is transversal and highlights the importance of interdisciplinary work. Health specific challenges include climate sensitive diseases (vector-borne, respiratory infections due to air pollution), rising food insecurity (malnutrition), one health and extreme heat crises affecting the most vulnerable (extremes of age, chronic conditions). It requires rethinking the impact of climate and environment on health, building alliances and developing partnerships across sectors, emphasising the point that we cannot address this challenge alone. MSF will also seek to reduce its environmental footprint with practical mitigation actions, such as searching for and implementing alternatives to single-use items and rethinking MSF’s supply chain to make it more sustainable.