The challenge of an emergency in a world in flux

With the effects of the tsunami, malnutrition in Niger and cholera in DRC, among many others, MSF has continued to focus on responding to those most in need.

As a medical-humanitarian organisation, emergencies within crisis situations have always been at the heart of our action, and our response has focused on medical interventions. With time and experience, our technical capacity to respond to urgent medical needs has improved.

Our inflatable hospital in Mansehra, Pakistan, an earthquake setting where pre-existing infrastructure had collapsed, is but one example of the evolution of emergency medical action and resulting capacity to implement highly developed medical, surgical, and intensive care services.

Although these types of emergencies continue, the character and complexity of our contexts places new demands on us. To a large extent, more conventional wars between states have been replaced by internationally influenced guerrilla wars fought within countries.

Underlying these conf licts, ideological motivations or territorial gains are more the exception, with economic motivations becoming more the rule. Civilians, normally seen as those to be protected in conf licts, are often used as commodities of war and become trapped or targeted as a result.

The violence against civilians is frequently used as a means of diminishing opposing elements, meanwhile abduction or looting of civilians - sometimes children, as in Uganda, where up to 20,000 children have been kidnapped and inducted into the Lord's Resistance Army - have become standard strategies in gaining strength against an enemy.

Changing perceptions

With this degradation, there has been a weakening of respect for aid and humanitarian interventions. Increasingly, belligerents of war perceive us as either feeding into or aggravating warring agendas, much the same way they view the civilians we aim to support.

With many warring actors fragmented along various lines, it has become increasingly difficult to negotiate our presence and also to maintain the security of MSF staff in areas where access is accomplished.

Added to this, there are more and more aid organisations and agencies involved in the business of aid. Many have different values, goals and strategies that confuse the perception of MSF. We have always believed that our reliance on principles such as impartiality and independence secures our capacity to safely intervene where needs are greatest.

However, the multiplicity of actors has blurred our distinction and with it, increased the risk of being erroneously seen as part of political or even military agendas. This limits our capacity to engage in unhindered action for those most in need.

Displaced within borders

Accessing populations also becomes more difficult with the changes in population movements. In the past, populations facing war would displace themselves to safer areas beyond their borders and cluster into camps. The classic situation was characterised by groupings of people in distinct locations where health risks were increased because of the stress of displacement and crowding under austere conditions. We have increased our capacity to clearly identify those in need and quickly provide needs-based responses in these situations.

But today, more and more people displace themselves within their borders, integrating into cities, smaller communities or other open settings so their locations are not as evident, making needs identification and response more difficult. In Colombia, for example, ongoing conf lict has caused the displacement of over two million people and many are in need of medical and psychological care; however, these people are scattered and sometimes hidden within urban centres, requiring us to seek out those needing assistance and launch multiple projects to reach a more diffuse population.

More recent global developments have also impacted on needs and our capacity to respond. As polarisation between various fundamentalist western elements and extremist Islamic groups intensifies, the capacity for organisations such as MSF to independently respond to any humanitarian needs, free from any falsely based accusations of political alliances, becomes increasingly limited and poses greater security risks. Aid workers are not in these contexts to choose sides or to die, rather they are there to save others' lives, and as global polarisation becomes more entrenched, overcoming these barriers in order to respond to emergencies becomes increasingly difficult.

Assisting in middle-income countries

As major humanitarian crises occur more in middle-income countries, the type of our emergency response has required adaptation.

Historically, MSF has mostly responded to situations in sub- Saharan Africa, where infrastructure collapse has meant few staff were available and disease patterns typically included tropical illnesses such as malaria, diarrhoea and many other infectious diseases.

Within middle-income countries such as Lebanon and Iraq, our classic emergency response has been tested with the presence of sufficient numbers of capable staff and epidemiological patterns that are more typical of western countries, with chronic diseases being among the most urgent. Our medical policies, supplies and protocols need to encompass chronic diseases such as cardiac disease, diabetes, asthma and epilepsy, among others.

These middle-income contexts have also challenged MSF to develop new strategies and play a more secondary role whilst engaging in more partnerships. In the summer of 2006 our medical activities in Lebanon were in some ways unusual for MSF, conducted alongside well-developed medical resources and included helping provide supplies and treatment for chronic diseases, kidney disease in particular.

It is likely we will be called upon to assist in this manner in the future.

Learning from natural disasters

MSF has responded to a number of natural disasters through the years, but these emergencies have not been seen as one of our main interventions. Usually, MSF has struggled to find a role, as the most urgent needs tend to be related to rescue, followed by logistical support.

Most needs are answered by armies, national actors, and through local solidarities. The incredible local response of Sri Lankans to the 2004 tsunami limited our need to intervene there.

Similarly, the Pakistani army was highly effective in its activities following the October 2005 earthquake in southern Asia.

The needs for medical response in these situations, although present, do not always amount to substantial medical interventions. Pakistan was an exception. With destruction of small buildings in remote areas, there were relatively more injured demanding a medical response, and fewer deaths. But usually this is not the case - survivors of earthquakes and other natural disasters usually present limited injuries, whilst their major needs include shelter, water, sanitation, and food. All interventions MSF can do, but usually on a small scale and in support of medical interventions.

In the future, however, factors including increasing environmental degradation and climate change may well contribute to changes in epidemiological patterns and a greater number of natural disasters such as droughts and floods. Although these events are highly unpredictable in nature, we should be aware of what exactly we are able to provide to people in distress and be ready to respond with the strengths we have developed.

By accepting our limits, but continuing to develop our core strengths, we can advance our response. It is clear there are others better able to respond in the first phase of natural disasters and intervening in the very first hours of a rescue phase requires an expertise and logistical capacity that MSF does not have.

We are better placed to direct our efforts in the survival phase - this work has synergies with interventions in other settings and facilitates the development of our specialities instead of potentially diluting them by broadening our scope. Emergency surgery is a particular activity we have identified as a focus area.

We are increasing our capacity for emergency surgery and other specialised medical services - for example we now routinely send nephrologists to the field to treat crush syndrome, a condition characterised by renal (kidney) failure and often seen in people who have survived a building collapse precipitated by earthquakes or bombings.

Mental health, nutrition and monitoring for epidemics amongst displaced persons in crowded living spaces are also areas that overlap with our medical interventions elsewhere. These are aspects we need to further build up and adapt to evolving situations.

Treating emerging diseases

Changes in epidemiological patterns are among the greatest challenges ahead for MSF. Recent increases in frequency of viral haemorrhagic diseases such as Ebola in parts of Africa have demanded highly specialised and culturally adapted responses, which so far have been limited in success due to the complexity resulting from the interplay between cultural orientations and needed medical interventions.

In Angola in 2005, an outbreak of Marburg haemorrhagic fever required us to wear bio-safety gear, which frightened local community members. Further, people with the illness had to be isolated to prevent the spread of this highly infectious disease.

Many of these patients died, so it was perceived that people separated out by MSF were meant to die, and community members became reluctant to seek help for those who were sick. Such misunderstandings underscore the need for cultural sensitivity in situations where we cannot anticipate how our tools and approaches may be received.

Likewise, a recent MSF intervention in a plague outbreak in Ituri, Democratic Republic of Congo (DRC) highlighted the need for MSF to continue in its pursuit of understanding such diseases, their spread, and necessary treatment within various contexts - in this case, an isolated war setting.

Emerging diseases such as avian flu also demand highly specialised responses. But like any intervention by MSF, choices must be made and an avian flu outbreak highlights this dilemma more than ever. Our capacity to take on such a pandemic will be limited, though it should not inhibit our preparedness to do what is possible, where it is possible.

2005 has been a demanding year for MSF in terms of emergency response. With the effects of the tsunami, malnutrition in Niger and cholera in DRC, among many others, MSF has continued to focus on responding to those most in need. Although these responses in their own right were of value and laid further foundation to whatever emergency responses are required in the future, the challenges ahead in this changing world will place further demands on us. Ours is a challenge of continued adaptation and evolution in order to ensure we are assisting those most in need on a medical basis and to the best of our abilities.