Bearing witness: Departing MSF president reflects on three years

This article first appeared in the BMJ Feb 20, 2004 edition

Morten Rostrup, pictured last year with a child in Libya, thinks that humanitarian aid is being increasingly frustrated by a rise in "politicisation and militarisation"

When Norwegian doctor Morten Rostrup told the world that President George Bush was wrong - that Baghdad's hospitals were not operating normally after the city fell to US soldiers - he was adopting the outspoken approach that has long characterised the aid agency Médecins Sans Frontières.

As president of the agency's international committee, Rostrup, 45, had witnessed the power vacuum in Baghdad and the looting as staff fled Al Kindi Hospital, leaving their patients unattended.

As a specialist in internal medicine and intensive care he led a team that entered Baghdad days before the bombs started to fall. Once US forces entered the city he reminded the occupying powers of their "responsibilities" for civilians under the Geneva Conventions. The United States, he said, had "totally failed" to foresee the health problems.

The agency's confrontational approach is summed up by Rostrup as "to act, provoke, challenge." It means going beyond providing medicine, shelter, and care to bearing witness and pointing to the cause of problems. The agency leaves solutions to others. "We provoke political change by stating what we see in the field. It is a spontaneous action when you see misery and how politics is failing."

His three year tenure as international president has been at a time when outspokenness has been particularly necessary. Last year he marked the birthday of a Dutch field worker for the agency, Arjan Erkel, who was kidnapped 18 months ago in the Russian Caucasian republic of Dagestan, by demanding that Russian authorities take "responsibility" to secure his release, describing their investigation as a "complete fiasco." Earlier he had described the scenes at Al Kindi Hospital after a rocket had struck a residential area with the memorable quotation: "We had kids dying just before we started to operate."

He sees independent humanitarian aid as being increasingly frustrated by a rise in "politicisation and militarisation." Comments by politicians that the fight against terrorism operates on "military, political, and humanitarian fronts" increase the danger. This co-option of aid "into the war on terror" simply confirms some people's suspicions that humanitarian aid is part of the strategy of the Western powers, he argues. While working at Kandahar Hospital after the fall of the Taliban he himself was asked by local people whether he was an American soldier. This was in spite of his visible MSF vest.

This politicisation of aid may contribute to what he sees as a new trend: the targeting of aid workers, such as the bombing of the headquarters of the International Committee of the Red Cross in Baghdad last October.

Rostrup stresses the "strict humanitarian" role of Médecins Sans Frontières, which, he says, is independent of "longer term political agendas" or "peace-making processes."

He believes the agency has also provoked change through example, establishing effective treatment of HIV and AIDS in rural Malawi and the shanty-towns of Cape Town, where others may have felt that these desperately poor communities were helpless.

Médecins Sans Frontières, he argues, is taken seriously and is not just "a barking dog in the corner." "My experience is that, because we are purely humanitarian, we are respected."

Rostrup's career with the charity began in 1996. He had worked for 12 years at Oslo University Hospital and had contacted the organisation offering his services. Suddenly a message came through that he was needed. With only a day's notice Rostrup, who is unmarried and does not have children, had to fly to a field hospital in Goma on the border between Rwanda and Zaire, where thousands of refugees had fled genocide. It was only later from there that he faxed his Norwegian employers asking permission to leave.

Before joining Médecins Sans Frontières he had travelled extensively in his 20s, visiting east Africa and taking part in numerous climbing expeditions to the Himalayas and other mountainous regions. In 1996 he undertook a particularly difficult expedition to the Himalayas (his sixth expedition in that region), which he recounted in a personal view in the BMJ (1998;316: 81-2). His team had tried to save the life of a climber they encountered who had severe high altitude cerebral oedema. It meant risking an extra night below the summit. The sick climber died, but Rostrup felt that his team had had no choice but to try to save him, and he attacked the "lack of humanity" of some people who pushed for the summit regardless.

The assessment of risk, team spirit, and primitive conditions that are necessary for mountaineering prepared him well for the agency's missions. The difference today is that risks have a moral purpose: to help others.

During moments of danger, such as in Baghdad with the front line of the allied forces approaching and having had members of his team kidnapped by the Iraqi authorities, he had asked himself, "What am I doing here? Is it really possible to assist people?" The answer for Rostrup lies in the doctor-patient relationship. "In the field I am trying to be a doctor. This is my patient, I can assist this individual, give them a new life. If you concentrate on that you can function, even though the broader perspective seems helpless."

Yet Rostrup is at pains to stress that most of the 77 countries where the agency operates are relatively stable ceasefire zones. As an example he charts his own career with the agency: Rwanda and Congo in 1996, the famine in southern Sudan in 1998, Angola during the 1998 ceasefire, and Liberia in 1999-2000.

He says the reality is that although the agency's staff have to accept risk, they don't choose conflict. "We go to where the needs are, where the most vulnerable are, to try to help people totally neglected by others. We find those people in conflict areas but not exclusively."

Now after three years as president of the organisation and of "having nowhere to call home" he is handing over to his successor, Dr Rowan Gillies, an Australian. He is planning to return to the normality of part time clinical practice in Oslo. He says it is "impossible" to turn his back fully on humanitarian work, and so he will continue to do field work for Médecins Sans Frontières.

When he returns to Oslo he will have to adjust to the high tech character of a European hospital, but he knows that he will still be part of the universal doctor-patient relationship. In fact the plentiful resources of a Western country hold some attractions for him. "In Africa you are frustrated because you can't do so much. In Norway with such diagnostic equipment and drugs you can do a really good job."

And sharing his experiences with old friends from the agency will help. "I can't expect my colleagues to understand what I have done, but so long as someone does that's OK."