The Middle East is an atypical context for Médecins Sans Frontières (MSF). The increasing complexity of humanitarian action, particularly the blurring of the lines between humanitarian and military actors and the increasing use of humanitarian language to justify wars, have made it even more difficult for MSF to negotiate independent operational space. This is especially so in some countries in the Middle East. Moreover, we are unaccustomed to working in middle-income countries where addressing non-communicable diseases is the priority. Although MSF is used to responding to acute crises, the Middle East suffers mostly from the chronic consequences of conflict.
In Iraq, for example, the health system considered one of the best in the Middle East started to deteriorate during the 19801988 war with Iran, and continued to decline following the 1991 Gulf war. Sanctions imposed in 1990 by the UN Security Council, followed by the 2003 invasion, disrupted the Iraqi medical system at all levels. Since 1990, a progressive loss of qualified and experienced health workers has led to a serious shortfall in the coverage and quality of healthcare services. Laboratory services are poor due to a lack of equipment and chemicals. Essential medical equipment has not been maintained, and health facilities are in poor condition. Medical care is not available in remote areas and there are problems in ensuring regular and adequate supplies of electricity and clean water.
Iraq, like other middle-income countries, is undergoing an epidemiological transition. Before 2003, communicable diseases such as malaria, respiratory tract infections and diarrhoeal diseases accounted for most deaths. Now, noncommunicable diseases are more common.+Chronic Non-Communicable Diseases Risk Factors Survey in Iraq, WHO, 2006, www.who.int/chp/steps/IraqSTEPSReport2006.pdf. Meanwhile, two decades of conflict have created a third category of patients, namely war victims. Violence has been one of the leading causes of death in Iraq, reaching its peak in 2006, with more than 27,000 civilian deaths according to one estimate.+This estimate is from Iraq Body Count: www.iraqbodycount.org. Since 2003, the Ministry of Health has prioritised war victims, diverting resources from other parts of the health system to meet their needs. Although the number of war victims has diminished in recent years, this category of patient remains the first priority, not only for the government but also for national and international NGOs.
Gaza is also experiencing a protracted political and socioeconomic crisis. It has a population of 1.44 million, with the sixth-highest population density in the world. A fifth of the population (18%) are under five years of age, and 45% are under 15. Three-quarters of the population are registered as refugees, and supported by the United Nations Relief and Works Agency (UNRWA). Around 50% are unemployed and the proportion of people living under the poverty line is increasing (48% in 2006; 79.4% in 2011).+See Fast Facts: Programme of Assistance to the Palestinian People, UNDP, http://www.ps.undp.org/. In 2009, four-fifths of the population were dependent on humanitarian aid. Morbidity and mortality patterns are similar to other middle- and high-income countries. Chronic diseases such as diabetes and hypertension are increasing, according to the World Health Organisation (WHO). Less than 5% of mortality is related to infections. In 2007 the leading causes of mortality were heart and cerebro-vascular diseases, accounting for 32% of all deaths in Gaza; the second highest cause was trauma/accidents (17.8%), most of which were war-related. There are almost 4,000 physicians, 4,200 nurses and 24 hospitals in the Gaza Strip (12 Ministry of Health, ten NGO-run and two small private hospitals). In total there are 13.6 hospital beds per 10,000 people in Gaza.+This compares with 17 per 10,000 in Jordan, 22 in Egypt, 36 in Lebanon and 63 in Israel. Of the 2,000 hospital beds available, only 164 are designated for specialised and intensive care. UNRWA runs 18 of the 130 Primary Health Care clinics, while NGOs and the Ministry of Health run 57 and 55, respectively.
A change in approach?
MSF has been working in the Middle East for more than 20 years. Unlike Sub-Saharan Africa, where MSF has traditionally focused on emergency vaccination programmes, epidemic control, reducing malnutrition and support for primary healthcare centres, in the radically different health landscape of the Middle East MSF has concentrated on filling health gaps or niches, such as support for a dialysis unit in Iraq, reconstructive surgery in Jordan for Iraqi patients and innovative medical approaches in Lebanon, rather than providing basic healthcare. Changes in the health profiles of Iraq, Gaza and other countries in the Middle East suggest that the number of war victims in these countries is decreasing, and that addressing non-communicable diseases is becoming a greater priority. MSFs experience and expertise, however, lies in responding to emergency medical needs (traumatic injury and communicable diseases) arising from humanitarian crises. As such, MSF has had to change its approach to working in these areas.
In the occupied Palestinian territories, the MSF programme deals with three areas: mental health, post-operative care and physiotherapy. In Syria, MSF is providing primary healthcare and mental health services to Iraqi refugees. In Lebanon, which has a highly privatised health system and a very low number of psychologists, MSF is providing mental health support to Lebanese and Palestinian refugees. In Tunisia, Egypt and Yemen, MSF donated medical equipment and supplies to healthcare facilities to enable health staff to treat people who were injured during the recent demonstrations in these countries. The teams also provided training to Tunisian and Egyptian medical staff on managing large caseloads of injured people and helped set up additional emergency preparedness systems (triage, medical kits, etc.). In Bahrain, MSF teams provided medical supplies and psychological support for medical staff. Importantly, it also spoke out (temoignage) regarding the governments use of medical facilities in Bahrain to crack down on protesters. This unacceptable practice made it impossible for people injured during clashes to seek treatment.+See MSF Calls for End to Bahrain Military Crackdown on Patients, 7 April 2011, www.msf.org. MSF has also provided care to people fleeing Libya.
Challenges in the Middle East
One of the main challenges for MSF is the requirement to engage in networking activities with all stakeholders, not only the most accessible, as a starting point for acceptance, acknowledgment and recognition of its humanitarian intervention. While MSF has not always prioritised this in contexts where it is already well-known, civilmilitary and security issues in the Middle East make investing time and effort in explaining its principles and approaches to stakeholders crucial to MSFs work.
Networking represents a key component in developing MSFs activities, making sure that all key stakeholders are aware of its activities and principles. In these conflict or post-conflict contexts, access to the most vulnerable people, security for MSF teams and networking are key challenges for the organisation. It requires the building of humanitarian space to enable medical teams to access those in need, as well as independent evaluations of needs and programming options. Developing and maintaining relationships also requires continuous follow-up work. This is challenging for MSF, which often engages in short-term programming, has correspondingly high staff turnover and lacks a continuous presence in some countries.
Undertaking (and updating) good context analysis is also extremely important in this complex region. For example, the Israeli occupation in Palestine and the internal conflict between Fatah and Hamas have required MSF to improve and update its context analysis. MSF had a rather simplistic understanding of the context and dealt only with the Palestinian Authority (PA) and Israel, without realising the growing importance of Hamas as a political actor. For example, MSF continued to sign operating agreements for Gaza with the Ramallah authorities almost two years after the Hamas takeover. Teams also found it very difficult to assist torture victims (especially Hamas militants tortured by Fatah security forces) in the West Bank because of MSFs longstanding bilateral relationship with Fatah. In Jordan and Iraq, non-state actors strategies had to be understood in order to negotiate with them to gain access to vulnerable populations without compromising the security of MSF teams.
Engaging elites in the Middle East in a constructive debate on the impact that humanitarian medical action can have on their societies is also important. Humanitarian principles need to be explained and demonstrated operationally. However, it is also important to explain to the wider public the reasons behind operational and programming choices. For example, some have questioned MSFs neutrality because it does not have medical activities in Israel. The reality is that MSF does not need to intervene in Israel, where medical needs are already met by a sophisticated healthcare system. This also requires improving our knowledge on how to intervene effectively in urban settings. In fact, Palestinian camps in Lebanon or in the Gaza Strip and IDPs in Northern Iraq are challenging contexts partly due to their urban settings.
In 2008, but published in 2011, MSF conducted research on perceptions of the agency in the region.+Caroline Abu-Sada, Dans loeil des autres, Perception de laction humanitaire et de MSF, MSF Suisse, Editions Antipodes, Lausanne, 2011. From the research it was clear that, while MSFs identity as a health organisation is recognised and valued, most people were not aware of the high proportion of independent funding MSF has at its disposal. In the Middle East, several criteria are used to judge the effectiveness and coherence of an organisation: its public position towards the conflicts in the region, its sources of funding and its knowledge of the various contexts involved. This is where the neutrality and the financial independence of MSF play an important role in its acceptance. In Northern Iraq, people vividly remember MSFs 1991 intervention, as it was the only organisation working in the most remote areas of the region at that time. Challenging as it may be, being in Iraq or in the occupied Palestinian territories resonates throughout the entire Arab world.
Caroline Abu-Sada is the Research Unit Coordinator for MSF Switzerland.