Doctors Without Borders
Nobel Lecture by James Orbinski, Médecins Sans Frontières, Oslo, December 10, 1999
Your Majesties, Your Royal Highness, Members of the Norwegian Nobel Committee, Excellencies, Ladies and Gentlemen:
The people of Chechyna – and the people of Grozny – today and for more than three months, are enduring indiscriminate bombing by the Russian army. For them humanitarian assistance is virtually unknown. It is the sick, the old and the infirm who cannot escape Grozny. While the dignity of people in crisis is so central to the honor you give today, what you acknowledge in us is our particular response to it. I appeal here today to his excellency the Ambassador of Russia and through him, to President Yeltsin, to stop the bombing of defenseless civilians in Chechnya. If conflicts and wars are an affair of the state, violations of humanitarian law, war crimes and crimes against humanity apply to all of us.
Let me say immediately that the extraordinary distinction that the Nobel Committee has given Médecins Sans Frontières is one that we accept with sincere gratitude. But also a profound discomfort in knowing that the dignity of the excluded is assaulted daily. These are the forgotten populations in danger, like the street children who struggle each grinding hour to live off the waste of those who are «included» in the social and economic order. These too are the illegal refugees that we work with in Europe, denied political status, and afraid to seek health care, lest this contact leads to their expulsion.
Our action is to help people in situations of crisis. And ours is not a contented action. Bringing medical aid to people in distress is an attempt to defend them against what is aggressive to them as human beings. Humanitarian action is more than simple generosity, simple charity. It aims to build spaces of normalcy in the midst of what is abnormal. More than offering material assistance, we aim to enable individuals to regain their rights and dignity as human beings. As an independent volunteer association, we are committed to bringing direct medical aid to people in need. But we act not in a vacuum, and we speak not into the wind, but with a clear intent to assist, to provoke change, or to reveal injustice. Our action and our voice is an act of indignation, a refusal to accept an active or passive assault on the other.
The honor you give us today could so easily go to so many organizations, or worthy individuals, who struggle in their own society. But clearly, you have made a choice to recognize MSF. We began formally in 1971 as a group of French doctors and journalists who decided to make themselves available to assist. This meant sometimes a rejection of the practices of states that directly assault the dignity of people. Silence has long been confused with neutrality, and has been presented as a necessary condition for humanitarian action. From its beginning, MSF was created in opposition to this assumption. We are not sure that words can always save lives, but we know that silence can certainly kill. Over our 28 years we have been – and are today – firmly and irrevocably committed to this ethic of refusal. This is the proud genesis of our identity, and today we struggle as an imperfect movement, but strong in thousands of volunteers and national staff, and with millions of donors who support both financially and morally, the project that is MSF. This honor is shared with all who in one way or another, have struggled and do struggle every day to make live the fragile reality that is MSF.
Humanitarianism occurs where the political has failed or is in crisis. We act not to assume political responsibility, but firstly to relieve the inhuman suffering of failure. The act must be free of political influence, and the political must recognize its responsibility to ensure that the humanitarian can exist. Humanitarian action requires a framework in which to act.
In conflict, this framework is international humanitarian law. It establishes rights for victims and humanitarian organisations and fixes the responsibility of states to ensure respect of these rights and to sanction their violation as war crimes. Today this framework is clearly dysfuntional. Access to victims of conflict is often refused. Humanitarian assistance is even used as a tool of war by belligerents. And more seriously, we are seeing the militarisation of humanitarian action by the international community.
In this dysfunction, we will speak-out to push the political to assume its inescapable responsibility. Humanitarianism is not a tool to end war or to create peace. It is a citizen’s response to political failure. It is an immediate, short term act that cannot erase the long term necessity of political responsibility.
And ours is an ethic of refusal. It will not allow any moral political failure or injustice to be sanitized or cleansed of its meaning. The 1992 crimes against humanity in Bosnia-Herzegovina. The 1994 genocide in Rwanda. The 1997 massacres in Zaire. The 1999 actual attacks on civilians in Chechyna. These cannot be masked by terms like «Complex Humanitarian Emergency», or «Internal Security Crisis». Or by any other such euphemism – as though they are some random, politically undetermined event. Language is determinant. It frames the problem and defines response, rights and therefore responsibilities. It defines whether a medical or humanitarian response is adequate. And it defines whether a political response is inadequate. No one calls a rape a complex gynecologic emergency. A rape is a rape, just as a genocide is a genocide. And both are a crime. For MSF, this is the humanitarian act: to seek to relieve suffering, to seek to restore autonomy, to witness to the truth of injustice, and to insist on political responsibility.
The work that MSF chooses does not occur in a vacuum, but in a social order that both includes and excludes, that both affirms and denies, and that both protects and attacks. Our daily work is a struggle, and it is intensely medical, and it is intensely personal. MSF is not a formal institution, and with any luck at all, it never will be. It is a civil society organization, and today civil society has a new global role, a new informal legitimacy that is rooted in its action and in its support from public opinion. It is also rooted in the maturity of its intent, in for example the human rights, the environmental and the humanitarian movements, and of course, the movement for equitable trade. Conflict and violence are not the only subjects of concern. We, as members of civil society, will maintain our role and our power if we remain lucid in our intent and independence.
As civil society we exist relative to the state, to its institutions and its power. We also exist relative to other non-state actors such as the private sector. Ours is not to displace the responsibility of the state. Ours is not to allow a humanitarian alibi to mask the state responsibility to ensure justice and security. And ours is not to be co-managers of misery with the state. If civil society identifies a problem, it is not theirs to provide a solution, but it is theirs to expect that states will translate this into concrete and just solutions. Only the state has the legitimacy and power to do this. Today, a growing injustice confronts us. More than 90% of all death and suffering from infectious diseases occurs in the developing world. Some of the reasons that people die from diseases like AIDS, TB, Sleeping Sickness and other tropical diseases is that life saving essential medicines are either too expensive, are not available because they are not seen as financially viable, or because there is virtually no new research and development for priority tropical diseases. This market failure is our next challenge. The challenge however, is not ours alone. It is also for governments, International Government Institutions, the Pharmaceutical Industry and other NGOs to confront this injustice. What we as a civil society movement demand is change, not charity.
We affirm the independence of the humanitarian from the political, but this is not to polarize the «good» NGO against «bad» governments, or the «virtue» of civil society against the «vice» of political power. Such a polemic is false and dangerous. As with slavery and welfare rights, history has shown that humanitarian preoccupations born in civil society have gained influence until they reach the political agenda. But these convergences should not mask the distinctions that exist between the political and the humanitarian. Humanitarian action takes place in the short term, for limited groups and for limited objectives. This is at the same time both its strength and its limitation. The political can only be conceived in the long term, which itself is the movement of societies. Humanitarian action is by definition universal, or it is not. Humanitarian responsibility has no frontiers. Wherever in the world there is manifest distress, the humanitarian by vocation must respond. By contrast, the political knows borders, and where crisis occurs, political response will vary because historical relations, balance of power, and the interests of one or the other must be considered. The time and space of the humanitarian are not those of the political. These vary in opposing ways, and this is another way to locate the founding principles of humanitarian action: the refusal of all forms of problem solving through sacrifice of the weak and vulnerable. No victim can be intentionally discriminated against, OR neglected to the advantage of another. One life today cannot be measured by its value tomorrow: and the relief of suffering «here», cannot legitimize the abandoning of relief «over there». The limitation of means naturally must mean the making of choice, but the context and the constraints of action do not alter the fundamentals of this humanitarian vision. It is a vision that by definition must ignore political choices.
Today there is a confusion and inherent ambiguity in the development of so-called ‘military humanitarian operations’. We must reaffirm with vigor and clarity the principle of an independent civilian humanitarianism. And we must criticize those interventions called «military-humanitarian». Humanitarian action exists only to preserve life, not to eliminate it. Our weapons are our transparency, the clarity of our intentions, as much as our medicines and our surgical instruments. Our weapons cannot be fighter jets and tanks, even if sometimes we think their use may respond to a necessity. We are not the same, we cannot be seen to be the same, and we cannot be made to be the same. Concretely, this is why we refused any funding from NATO member states for our work in Kosovo. And this is why we were critical then and are critical now of the humanitarian discourse of NATO. It is also why on the ground, we can work side by side with the presence of armed forces, but certainly not under their authority.
The debate on the «Droit d’Ingerence» – the right of state intervention for so called humanitarian purposes – is further evidence of this ambiguity. It seeks to put at the level of the humanitarian, the political question of the abuse of power, and to seek a humanitarian legitimacy for a security action through military means. When one mixes the humanitarian with the need for public security, then one inevitably tars the humanitarian with the security brush. It must be recalled that the UN Charter obliges states to intervene sometimes by force to stop threats to international peace and security. There is no need, and indeed a danger, in using a humanitarian justification for this. In Helsinki this weekend governments will sit down to establish the makings of a European army, but to be available for humanitarian purposes. We appeal to governments to go no further down this path of dangerous ambiguity. But we also encourage states to seek ways to enforce public security so that international humanitarian and human rights law can be respected.
Humanitarian action comes with limitations. It cannot be a substitute for political action. In Rwanda, early in the genocide, MSF spoke out to the world to demand that genocide be stopped by the use of force. And, so did the Red Cross. It was however, a cry that met with institutional paralysis; with acquiescence to self-interest, and with a denial of political responsibility to stop a crime that was «never again» to go unchallenged. The genocide was over before the UN Operation Turquoise was launched.
I would like for a moment to acknowledge among our invited guests Chantal Ndagijimana. She lost 40 members of her family in Rwanda’s genocide in 1994. Today she is a part of our team in Brussels. She survived the genocide, but like a million others, her mother and father, brothers and sisters did not. And nor did many hundreds of our national staff. I was Head of Mission in Kigali during that time. No words can describe the sheer courage with which they worked. No words can describe the horror that they died in. And no words can describe the deepest sorrow that I and all in MSF will carry always.
I remember what one of my patients said to me in Kigali: «Ummera, Ummera-sha». It is a Rwandan saying that loosely translated, means «courage, courage, my friend – find and let live your courage». It was said to me in Kigali at our hospital, by a woman who was not just attacked with a machete, but her entire body rationally and systematically mutilated. Her ears had been cut off. And her face had been so carefully disfigured, that a pattern was obvious in the slashes. There were hundreds of women, children and men brought to the hospital that day, so many that we had to lay them out on the street. And in many cases, we operated on them then and there, as the gutters around the hospital literally ran red with blood. She was one among many – living an inhuman and simply indescribable suffering. We could do little more for her at that moment than stop the bleeding with a few necessary sutures. We were completely overwhelmed, and she knew that there were so many others. She knew and I knew. She released me from my own inescapable hell. She said to me in the clearest voice I have ever heard «allez, allez … ummera, ummera-sha» – «go, go… my friend; find and let live your courage».
There are limits to humanitarianism. No doctor can stop a genocide. No humanitarian can stop ethnic cleansing, just as no humanitarian can make war. And no humanitarian can make peace. These are political responsibilities, not humanitarian imperatives. Let me say this very clearly: the humanitarian act is the most apolitical of all acts, but if it actions and its morality are taken seriously, it has the most profound of political implications. And the fight against impunity is one of these implications.
This is exactly what has been affirmed with the creation of the international criminal courts for both the Former Yugoslavia and Rwanda. It is also what has been affirmed with the adoption of statutes for an International Criminal Court. These are significant steps. But today on the 51th anniversary of the Universal Declaration of Human Rights, the court does not yet exist, and the principles have only been ratified by three states in the last year. At this rate it will take 20 years before the court comes into being. Must we wait this long? Whatever the political costs of creating justice for states, MSF can and will testify that the human costs of impunity are impossible to bear.
Only states can impose respect for humanitarian law and that effort cannot be purely symbolic. Srebrenica was apparently a safe haven in which we were present. The UN was also present. It said it would protect. It had Blue Helmets on the ground. And the UN stood silent and present – as the people of Srebrenica were massacred.
After the deadly attempts of UN intervention in Former Yugoslavia and Rwanda, which led to the death of thousands. MSF objects to the principle of military intervention which do not stipulate clear frameworks of responsibility and transparency. MSF does not want military forces to show that they can put up refugee tents faster than NGOs. Armies should be at the service of governments and policies which seek to protect the rights of victims.
If UN military operations are to protect civilian populations in the future, going beyond the «mea culpa» excuses of the Secretary General over Srebrenica and Rwanda, there must be a reform of peacekeeping operations in the UN. Member States of the Security Council must be held publicly accountable for the decisions that they do or do not vote for. Their right to veto should be regulated. Member States should be bound to ensure that adequate means are made available to implement the decisions they take.
Yes, humanitarian action has limits. It also has responsibility. It is not only about rules of right conduct and technical performance. It is at first an ethic framed in a morality. The moral intention of the humanitarian act must be confronted with its actual result. And it is here where any form of moral neutrality about what is good must be rejected. The result can be the use of the humanitarian in 1985 to support forced migration in Ethiopia, or the use in 1996 of the humanitarian to support a genocidal regime in the refugee camps of Goma. Abstention is sometimes necessary so that the humanitarian is not used against a population in crisis. More recently, in North Korea, we were the first independent humanitarian organization to gain access in 1995. However, we chose to leave in the fall of 1998. Why? Because we came to the conclusion that our assistance could NOT be given freely and independent of political influence from the state authorities. We found that the most vulnerable were likely to remain so, as food aid is used to support a system that in the first instance creates vulnerability and starvation among millions. Our humanitarian action must be given independently, with a freedom to assess, to deliver and to monitor assistance so that the most vulnerable are assisted first. Aid must not mask the causes of suffering, and it cannot be simply an internal or foreign policy tool that creates rather than counters human suffering. If this is the case, we must confront the dilemma and consider abstention as the least of bad options. As MSF, we constantly call into question the limits and ambiguities of humanitarian action – particularly when it submits in silence to the interests of states and armed forces.
Last week, the United States Congress passed a bill authorizing direct food transfers to the Rebels in South Sudan. This is a misappropriation of the meaning and intent of humanitarian assistance. It makes food a fuel of war. And it is a dereliction of a state’s duty to use any and all political means to address a 17 year-long civil war that has left millions dead. Sudan’s civil war today is a human misery where millions are displaced and at risk of starvation and disease; where people are bombed, robbed, looted constantly, and even enslaved, while corporate oil interests are protected, where humanitarian space is so severely restricted that it exists only in pockets; and where we and other NGOs and UN Agencies struggle to bring humanitarian assistance and protection. Is food the only political option to curb war? Food aid or humanitarian assistance, if it is to be «humanitarian assistance» – cannot be a tool in state-craft. In this case we must denounce the perfidious use of food that confuses the meaning of humanitarian assistance. If the political masks itself in an ambulance, then it is certain that the ambulance will be fired on. As well, if food is allowed to be used as a weapon of war, then it also legitimates that populations can be starved as a weapon of war.
Independent humanitarianism is a daily struggle to assist and protect. In the vast majority of our projects it is played out away from the media spotlight, and away from the attention of the politically powerful. It is lived most deeply, most intimately in the daily grind of forgotten war and forgotten crisis. Numerous peoples of Africa literally agonise in a continent rich in natural resources and culture. Hundreds of thousands of our contemporaries are forced to leave their lands and their family to search for work, food, to educate their children and to stay alive. Men and women risk their lives to embark on clandestine journeys only to end up in a hellish immigration detention centre, or barely surviving on the periphery of our so called civilised world.
Our volunteers and staff live and work among people whose dignity is violated every day. These volunteers choose freely to use their liberty to make the world a more bearable place. Despite grand debates on world order, the act of humanitarianism comes down to one thing: individual human beings reaching out to their counterparts who find themselves in the most difficult circumstances. One bandage at a time, one suture at a time, one vaccination at a time. And, uniquely for Médecins Sans Frontières, working in around 80 countries, over 20 of which are in conflict, telling the world what they have seen. All this in the hope that the cycles of violence and destruction will not continue endlessly.
As we accept this extraordinary honor, we want again to thank the Nobel Committee for its affirmation of the right to humanitarian assistance around the globe. For its affirmation of the road MSF has chosen to take: to remain outspoken, passionate and deeply committed to its core principles of volunteerism, impartiality, and its belief that every person deserves both medical assistance and the recognition of his or her humanity. We would like to take this opportunity to state our deepest appreciation to the volunteers and national staff who have made these ambitious ideals a concrete reality, and who have, we believe, brought some peace to the world that has experienced such immense suffering and who are the living reality of MSF.
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