Collateral Damage — Médecins sans Frontières Leaves Afghanistan and Iraq
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《新英格兰医药杂志》
On November 4, 2004, the Nobel Prize–winning humanitarian-aid organization Médecins sans Frontières (MSF, or Doctors without Borders) announced that it was discontinuing operations in Iraq, owing to escalating violence against humanitarian-aid workers. This was MSF's second major departure from a war zone in four months. On July 28, the organization pulled out of Afghanistan after five of its workers were ambushed and murdered. The attack in Afghanistan was unprecedented for MSF, which has worked in some of the most dangerous war zones throughout the world for the past 33 years. The organization's decision to leave both countries was a dramatic break from its history of being the first in and the last out of war-torn regions — and from its 24-year commitment to Afghanistan in particular. Although the organization had previously shut down operations in Ethiopia, North Korea, and Rwandan camps in Zaire, each of these withdrawals had been motivated by the fear that its aid was being used against the people it was trying to help — not by security concerns. MSF's recent departures signal a larger crisis within the humanitarian-aid community, forcing many to question whether nonpartisan relief is still possible in the current political climate.
(Figure)
A Mobile Clinic in the Pasroia Valley, Bamiyan Province, Afghanistan.
An MSF doctor listens to the lungs of a patient at a clinic that was set up weekly in an old Shiite mosque.
Photograph by Jean-Marc Giboux.
Many argue that aid workers have become part of the collateral damage in the "war on terrorism" in Iraq and Afghanistan. In both regions, humanitarian-aid workers fear being kidnapped or murdered, but they also face the threat of being coopted by the coalition forces. For MSF, one crucial distinction between the two countries is the depth and duration of the organization's commitment: MSF worked in Iraq for a total of four years over two separate periods but spent more than two decades in Afghanistan — throughout the Soviet occupation, the Taliban regime, and the military action led by the United States.
In the months leading up to the murders in Afghanistan, tensions were mounting, as growing numbers of humanitarian-aid workers were being targeted and killed, often by unknown and unidentifiable fighters; more than 30 such workers had been murdered by the time MSF pulled out. Nongovernmental organizations (NGOs) received daily warnings about unsafe regions, introducing new terms such as VBIEDs (vehicle-borne informal explosive devices) and BBIEDs (body-borne informal explosive devices). Afghanistan's southern border became a large red zone where it was considered too dangerous to work (see map), but there were signs of growing violence outside these areas as well. In this new type of warfare, the laws of the Geneva Convention no longer held. As in Iraq, where the International Red Cross headquarters were bombed in 2003, insignias of humanitarian-aid organizations became targets instead of protective symbols of neutrality.
Afghanistan.
Security map from the World Food Program. Red indicates areas where it was considered too dangerous for humanitarian-aid organizations to work.
At the same time, many NGOs argued that the work of humanitarian-aid groups was being coopted by the coalition forces to serve as part of its campaign to win "hearts and minds" in both Afghanistan and Iraq. Throughout the reconstruction period in Afghanistan, MSF objected to the blurring of boundaries between the military and humanitarian-aid communities, criticizing the coalition government's strategy of deploying provincial reconstruction teams that placed soldiers and civilians side by side when delivering food, medical care, and economic assistance to the Afghanis. They argued that nationals were unable to distinguish between MSF clinics and clinics built by the military.
(Figure)
An MSF Clinic in Kandahar, Afghanistan.
A young boy receives a six-month dose of vitamin A, which is given during vaccination campaigns to reduce the severity of measles and the likelihood of measles-related complications.
Photograph by Sebastian Bolesch.
The Pentagon repeatedly denied allegations that the provincial reconstruction teams endangered aid workers, but the U.S. government continued to refer to NGOs as partners in the war effort. Secretary of State Colin Powell referred to them as "force multipliers" and members of the "combat team" in a speech delivered before NGO community leaders.1 In May 2004, one month before the murders, coalition forces distributed leaflets in southern Afghanistan showing a man carrying provisions with this message: "In order to continue the humanitarian aid, pass over any information related to Taliban or Al-Qaida to the coalition forces."2
MSF was one of the few NGOs that would not collaborate with provincial reconstruction teams in Afghanistan or negotiate with the coalition forces in either country. Since its formation in 1971, MSF has remained staunchly independent, disavowing any political or religious affiliations. The organization was founded by a group of French physicians who had split from the International Red Cross because they believed it was unethical to provide medical care without exposing the human-rights abuses they saw during a civil war in Nigeria. This secession defined the organization and its mission: to alleviate suffering and "bear witness," speaking out against the atrocities its representatives encounter in their work.3
On June 2, 2004, however, MSF's tenuous safety zone in Afghanistan was shattered when three European and two Afghan officers were individually gunned down while driving in their trademark white Land Rover in the northwest corner of the country, a region that had previously been considered safe. The Taliban claimed responsibility for the attack, accusing MSF of working for U.S. interests, and threatened the organization with more attacks in the future. Senior Afghan security officials acknowledged, however, that a former local police chief was responsible, citing his recent dismissal and his desire to damage the reputation of his successor. A few low-level officials were subsequently detained, but none were arrested. Six weeks later, at the press conference at which MSF representatives announced their decision to leave, they cited the Afghan government's failure to protect medical aid workers as mandated by international humanitarian law.
Until the assassinations, MSF provided health care in 13 provinces with 80 international volunteers and 1400 Afghan staff members. Their projects offered basic and hospital-level health care, treatment for tuberculosis, and programs to reduce maternal mortality in a country where roughly one in four infants dies before his or her first birthday, between one in six and one in nine women dies from complications of childbearing, and the average life expectancy is 42.6 years. MSF's departure necessitated a rapid handover of its clinics both to the Afghan Ministry of Health and, ironically, to many NGOs funded by the U.S. Agency for International Development (USAID). By early August, USAID projected that 9 to 12 former MSF health facilities would require additional funding in order to stay open. Simultaneously, the Afghan Ministry of Health issued a position paper that was sent to the commanders of the provincial reconstruction teams, embassies, and President Hamid Karzai, condemning the conflation of military operations with humanitarian aid. As the document noted, "The distinction between aid workers and soldiers/reconstruction teams has become fatally blurred."4
In Iraq, MSF has struggled to develop a meaningful presence since the first Gulf War. In 1991, the organization assisted Iraqi Kurds fleeing government repression and provided medical aid in the southern part of the country, but it was later forced to leave by Saddam Hussein. In December 2002, MSF workers reentered Iraq, in advance of the U.S.-led invasion, establishing three health care clinics in Sadr City that employed a total of 90 Iraqis and 2 international aid workers. Despite U.S. sanctions, Iraq's health care needs were starkly different from Afghanistan's. In 2002, the average life expectancy in Iraq was 61 years, and roughly one fifth as many women died in childbirth as in Afghanistan. Most of Iraq's infrastructure was still intact before the invasion, and the majority of Iraqis received monthly food rations under the United Nations oil-for-food program, which was established in 1997.
After the invasion and as the violence escalated, MSF workers were caring for an increasing number of injured and wounded Iraqis; by the organization's departure in November 2004, they had provided approximately 100,000 medical consultations since January 2004. In addition, threats against aid workers were increasing: by the time MSF withdrew, more than 170 foreigners had been kidnapped, and 30 had been murdered.
Whereas MSF was one of many humanitarian organizations leaving Iraq, its departure from Afghanistan was much more controversial. Some NGOs protested the timing of MSF's departure during a politically sensitive period, a few months before the Afghan presidential election. Others thought the pullout was long overdue. One thing is certain: MSF's withdrawal caused many NGOs to reexamine their reasons for being in Afghanistan and to reconsider the safety of their aid workers. Despite MSF's departure from both countries, senior leaders still maintain that it is possible to bring nonpartisan humanitarian aid to communities in crisis. For now, however, MSF has no plans to return to either Iraq or Afghanistan. Its reason is clear: violence predominates. There is a deeper issue, however, that lingers in the minds of those who run the organization. The impact of humanitarian-aid work has political consequences for both sides. Caring for an individual patient or setting up clinics to help decrease maternal mortality is increasingly equated with a political victory or loss. "Humanitarian aid has become politicized," according to Nicolas de Torrente, executive director of MSF USA. "We could not push back these forces — the people who attacked us and those who assimilated us. We had no other choice."
Source Information
From Brigham and Women's Hospital, Boston.
References
Powell CL. Remarks to the National Foreign Policy Conference for Leaders of Nongovernmental Organizations. Washington, D.C.: State Department, October 26, 2001. (Accessed November 24, 2004, at http://www.state.gov/secretary/rm/2001/5762.htm.)
MacAskill E. Pentagon forced to withdraw leaflet linking aid to information on Taliban. Guardian. May 6, 2004. (Accessed December 1, 2004, at http://www.guardian.co.uk/afghanistan/story/0,1284,1210400,00.html.)
Fox RC. Medical humanitarianism and human rights: reflections on Doctors without Borders and Doctors of the World. Soc Sci Med 1995;41:1607-1616.
Office of Minister of Health. Position paper: security and access to health care. Kabul, Afghanistan: Transitional Islamic State Afghanistan Ministry of Health, August 7, 2004.(Ingrid T. Katz, M.D., M.H)
(Figure)
A Mobile Clinic in the Pasroia Valley, Bamiyan Province, Afghanistan.
An MSF doctor listens to the lungs of a patient at a clinic that was set up weekly in an old Shiite mosque.
Photograph by Jean-Marc Giboux.
Many argue that aid workers have become part of the collateral damage in the "war on terrorism" in Iraq and Afghanistan. In both regions, humanitarian-aid workers fear being kidnapped or murdered, but they also face the threat of being coopted by the coalition forces. For MSF, one crucial distinction between the two countries is the depth and duration of the organization's commitment: MSF worked in Iraq for a total of four years over two separate periods but spent more than two decades in Afghanistan — throughout the Soviet occupation, the Taliban regime, and the military action led by the United States.
In the months leading up to the murders in Afghanistan, tensions were mounting, as growing numbers of humanitarian-aid workers were being targeted and killed, often by unknown and unidentifiable fighters; more than 30 such workers had been murdered by the time MSF pulled out. Nongovernmental organizations (NGOs) received daily warnings about unsafe regions, introducing new terms such as VBIEDs (vehicle-borne informal explosive devices) and BBIEDs (body-borne informal explosive devices). Afghanistan's southern border became a large red zone where it was considered too dangerous to work (see map), but there were signs of growing violence outside these areas as well. In this new type of warfare, the laws of the Geneva Convention no longer held. As in Iraq, where the International Red Cross headquarters were bombed in 2003, insignias of humanitarian-aid organizations became targets instead of protective symbols of neutrality.
Afghanistan.
Security map from the World Food Program. Red indicates areas where it was considered too dangerous for humanitarian-aid organizations to work.
At the same time, many NGOs argued that the work of humanitarian-aid groups was being coopted by the coalition forces to serve as part of its campaign to win "hearts and minds" in both Afghanistan and Iraq. Throughout the reconstruction period in Afghanistan, MSF objected to the blurring of boundaries between the military and humanitarian-aid communities, criticizing the coalition government's strategy of deploying provincial reconstruction teams that placed soldiers and civilians side by side when delivering food, medical care, and economic assistance to the Afghanis. They argued that nationals were unable to distinguish between MSF clinics and clinics built by the military.
(Figure)
An MSF Clinic in Kandahar, Afghanistan.
A young boy receives a six-month dose of vitamin A, which is given during vaccination campaigns to reduce the severity of measles and the likelihood of measles-related complications.
Photograph by Sebastian Bolesch.
The Pentagon repeatedly denied allegations that the provincial reconstruction teams endangered aid workers, but the U.S. government continued to refer to NGOs as partners in the war effort. Secretary of State Colin Powell referred to them as "force multipliers" and members of the "combat team" in a speech delivered before NGO community leaders.1 In May 2004, one month before the murders, coalition forces distributed leaflets in southern Afghanistan showing a man carrying provisions with this message: "In order to continue the humanitarian aid, pass over any information related to Taliban or Al-Qaida to the coalition forces."2
MSF was one of the few NGOs that would not collaborate with provincial reconstruction teams in Afghanistan or negotiate with the coalition forces in either country. Since its formation in 1971, MSF has remained staunchly independent, disavowing any political or religious affiliations. The organization was founded by a group of French physicians who had split from the International Red Cross because they believed it was unethical to provide medical care without exposing the human-rights abuses they saw during a civil war in Nigeria. This secession defined the organization and its mission: to alleviate suffering and "bear witness," speaking out against the atrocities its representatives encounter in their work.3
On June 2, 2004, however, MSF's tenuous safety zone in Afghanistan was shattered when three European and two Afghan officers were individually gunned down while driving in their trademark white Land Rover in the northwest corner of the country, a region that had previously been considered safe. The Taliban claimed responsibility for the attack, accusing MSF of working for U.S. interests, and threatened the organization with more attacks in the future. Senior Afghan security officials acknowledged, however, that a former local police chief was responsible, citing his recent dismissal and his desire to damage the reputation of his successor. A few low-level officials were subsequently detained, but none were arrested. Six weeks later, at the press conference at which MSF representatives announced their decision to leave, they cited the Afghan government's failure to protect medical aid workers as mandated by international humanitarian law.
Until the assassinations, MSF provided health care in 13 provinces with 80 international volunteers and 1400 Afghan staff members. Their projects offered basic and hospital-level health care, treatment for tuberculosis, and programs to reduce maternal mortality in a country where roughly one in four infants dies before his or her first birthday, between one in six and one in nine women dies from complications of childbearing, and the average life expectancy is 42.6 years. MSF's departure necessitated a rapid handover of its clinics both to the Afghan Ministry of Health and, ironically, to many NGOs funded by the U.S. Agency for International Development (USAID). By early August, USAID projected that 9 to 12 former MSF health facilities would require additional funding in order to stay open. Simultaneously, the Afghan Ministry of Health issued a position paper that was sent to the commanders of the provincial reconstruction teams, embassies, and President Hamid Karzai, condemning the conflation of military operations with humanitarian aid. As the document noted, "The distinction between aid workers and soldiers/reconstruction teams has become fatally blurred."4
In Iraq, MSF has struggled to develop a meaningful presence since the first Gulf War. In 1991, the organization assisted Iraqi Kurds fleeing government repression and provided medical aid in the southern part of the country, but it was later forced to leave by Saddam Hussein. In December 2002, MSF workers reentered Iraq, in advance of the U.S.-led invasion, establishing three health care clinics in Sadr City that employed a total of 90 Iraqis and 2 international aid workers. Despite U.S. sanctions, Iraq's health care needs were starkly different from Afghanistan's. In 2002, the average life expectancy in Iraq was 61 years, and roughly one fifth as many women died in childbirth as in Afghanistan. Most of Iraq's infrastructure was still intact before the invasion, and the majority of Iraqis received monthly food rations under the United Nations oil-for-food program, which was established in 1997.
After the invasion and as the violence escalated, MSF workers were caring for an increasing number of injured and wounded Iraqis; by the organization's departure in November 2004, they had provided approximately 100,000 medical consultations since January 2004. In addition, threats against aid workers were increasing: by the time MSF withdrew, more than 170 foreigners had been kidnapped, and 30 had been murdered.
Whereas MSF was one of many humanitarian organizations leaving Iraq, its departure from Afghanistan was much more controversial. Some NGOs protested the timing of MSF's departure during a politically sensitive period, a few months before the Afghan presidential election. Others thought the pullout was long overdue. One thing is certain: MSF's withdrawal caused many NGOs to reexamine their reasons for being in Afghanistan and to reconsider the safety of their aid workers. Despite MSF's departure from both countries, senior leaders still maintain that it is possible to bring nonpartisan humanitarian aid to communities in crisis. For now, however, MSF has no plans to return to either Iraq or Afghanistan. Its reason is clear: violence predominates. There is a deeper issue, however, that lingers in the minds of those who run the organization. The impact of humanitarian-aid work has political consequences for both sides. Caring for an individual patient or setting up clinics to help decrease maternal mortality is increasingly equated with a political victory or loss. "Humanitarian aid has become politicized," according to Nicolas de Torrente, executive director of MSF USA. "We could not push back these forces — the people who attacked us and those who assimilated us. We had no other choice."
Source Information
From Brigham and Women's Hospital, Boston.
References
Powell CL. Remarks to the National Foreign Policy Conference for Leaders of Nongovernmental Organizations. Washington, D.C.: State Department, October 26, 2001. (Accessed November 24, 2004, at http://www.state.gov/secretary/rm/2001/5762.htm.)
MacAskill E. Pentagon forced to withdraw leaflet linking aid to information on Taliban. Guardian. May 6, 2004. (Accessed December 1, 2004, at http://www.guardian.co.uk/afghanistan/story/0,1284,1210400,00.html.)
Fox RC. Medical humanitarianism and human rights: reflections on Doctors without Borders and Doctors of the World. Soc Sci Med 1995;41:1607-1616.
Office of Minister of Health. Position paper: security and access to health care. Kabul, Afghanistan: Transitional Islamic State Afghanistan Ministry of Health, August 7, 2004.(Ingrid T. Katz, M.D., M.H)