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-3&S RESPONSE INCLUDED PROVIDING MEDICAL STAFF AND MATERIALS TO
EXISTING HEALTH FACILITIES RUNNING MOBILE CLINICS WHERE NO HEALTH
CARE WAS AVAILABLE SETTING UP EMERGENCY WATER AND SANITATION SYSTEMS WHERE DISPLACED PEOPLE WERE GATHERING DISTRIBUTING ESSENTIAL
RELIEF ITEMS AND ONCE INITIAL MEDICAL NEEDS HAD BEEN MET GIVINGPSYCHOSOCIAL ASSISTANCE TO THOSE TRAUMATIZED BY THE EVENT AND ITSCONSEQUENCES
)N SHARP CONTRAST TO VIRTUALLY EVERY OTHER CATASTROPHE THAT HUMANITARIAN ORGANIZATIONS ADDRESSED IN THE PAST YEAR THE TSUNAMI GENER
ATED AN EXCEPTIONAL OUTPOURING OF GOODWILL SOLIDARITY AND GENEROSITY ON AN INTERNATIONAL LEVEL ,ESS THAN A WEEK AFTER THE TSUNAMI-3& ESTIMATED THAT IT HAD RECEIVED MORE THAN SUFFICIENT FUNDS FORITS FORESEEN EMERGENCY MEDICAL ACTIVITIES IN THE REGION AND ASKED
DONORS TO CONTRIBUTE TO OUR WORK IN OTHER EMERGENCIES INSTEAD /N
PAGE  OF THIS REPORT WE EXPLAIN WHY -3& TOOK THIS n AT THE TIME n
RADICAL STANCE AND HOW IT REINFORCES OUR IDEAS ABOUT FINANCIAL TRANS
PARENCY AND OUR OWN PARTICULAR ROLE IN THIS TYPE OF CRISISEXPECT TO TREAT AS MANY AS   SEVERELY MALNOURISHED CHILDREN
AND WHERE AN ADEQUATE INTERNATIONAL RESPONSE TO THE NUTRITIONALAND MEDICAL CRISIS HAS FAILED TO MATERIALIZE)T IS THE ONGOING SUPPORT OF THOUSANDS OF INDIVIDUALS THAT MAKES IT
POSSIBLE FOR -3& TO ASSESS NEEDS AND PROVIDE MEDICAL RELIEF WITHIN
HOURS OF A DISASTER OR A CRISIS -3& CAN START WORKING WITHOUT
HAVING TO WAIT FOR THE INTERNATIONAL COMMUNITY TO WAKE UP TO THE
CRISIS OR FOR INSTITUTIONAL DONORS TO RELEASE FUNDS 4HANKS TO ITSSUPPORTERS -3& CAN RETAIN ITS INDEPENDENCE AND INTERVENE WHEN
AND WHERE OUR ASSISTANCE IS MOST NEEDED 4HIS IMPARTIALITY AND
INDEPENDENCE OF ANALYSIS AND ACTION ARE CRUCIAL ELEMENTS OF -3&S
IDENTITY THAT MUST BE UPHELD DESPITE THE CHANGING LANDSCAPE OF
HUMANITARIAN AID !S DESCRIBED IN AN ESSAY INCLUDED IN THIS REPORT-3&S IDENTITY AND PRINCIPLES ARE WHAT ENABLES THE ORGANIZATION TO
WORK IN COMPLICATED CONTEXTS IN WHICH THE EFFECTS OF MAN MADE
CRISES ARE DEVASTATING FOR INDIVIDUALS

8PSLJOHJODPOGMJDU[POFT)N ADDITION -3& APPROACHED ITS DONORS WORLDWIDE TO REQUEST THEIRPERMISSION TO USE THEIR DONATIONS IN OTHER CRISIS SITUATIONS SUCH AS.IGER 5GANDA 3OMALIA #OLOMBIA OR THE $EMOCRATIC 2EPUBLIC OF
THE #ONGO $2# WHERE HUGE NUMBERS OF PEOPLE CONTINUE TO SUFFERYEAR AFTER YEAR IN DEAFENING SILENCE /UR SUPPORTERS WERE OVER
WHELMINGLY POSITIVE AND THEIR DONATIONS ARE NOW BEING USED IN
PLACES LIKE SOUTHWEST .IGER WHERE BY THE END OF  -3& TEAMS/NE CONF LICT IN WHICH -3&S NEUTRALITY HAS BEEN CRUCIAL IS IN THE$2# WHERE FOR THE MAJORITY OF THE PEOPLE THE SO CALLED TRANSITIONFROM WAR TO PEACE REMAINED LITTLE MORE THAN A MIRAGE IN  AND 4HOUSANDS CONTINUED TO DIE FROM TREATABLE DISEASES SUCH AS
MALARIA AND MEASLES 6IOLENCE CONTINUED TO F LARE TRAPPING THOSE
LIVING IN THE PROVINCES OF )TURI .ORTH AND 3OUTH +IVU AND +ATANGA)N *UNE  THE ABDUCTION OF TWO -3& STAFF MEMBERS BY ARMED

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MILITIAMEN FORCED -3& TO WITHDRAW ITS TEAMS FROM THE OUTSKIRTS OF
THE TOWN OF "UNIA LEAVING THOUSANDS WITHOUT MEDICAL CARE 9ET-3& CONTINUED ITS WORK IN THE CITY HOSPITAL WHERE SURGEONS OPER
ATED ON ADULTS AND CHILDREN WHO HAD SURVIVED GUNSHOT WOUNDSMACHETE ATTACKS BURNING OR SEXUAL VIOLENCE %LSEWHERE IN THE $2#-3& TEAMS PROVIDED HOSPITAL AND BASIC CARE TO LOCAL POPULATIONSAND PEOPLE DISPLACED BY VIOLENCE
)N #OLOMBIA PEOPLE HAVE BEEN FORCED FOR DECADES TO LIVE AMID VIO
LENT CONFRONTATIONS AMONG GOVERNMENT FORCES PARAMILITARY GROUPS
AND ARMED GUERRILLAS WHICH HAVE TERRORIZED AND TARGETED CIVILIANS
IN BOTH RURAL AND URBAN AREAS )N ITS PROJECTS AROUND THE COUNTRY-3& TRIES TO ALLEVIATE SOME OF THE SUFFERING BY BRINGING MEDICALSERVICES INCLUDING PSYCHOLOGICAL CARE TO VULNERABLE AND DISPLACEDCIVILIANS 3IMILARLY IN THE (AITIAN CAPITAL OF 0ORT AU 0RINCE CIVIL
IANS HAVE ALSO BEEN CAUGHT IN THE CROSSFIRE OF POLITICAL AND CRIMINALVIOLENCE THAT HAS WRACKED THEIR CITY IN WAVES SINCE 3EPTEMBER 
7HILE LIVING CONDITIONS IN SEVERAL OF THE POOREST NEIGHBORHOODS
DETERIORATE AND BRUTAL ATTACKS INTENSIFY THE NUMBER OF PEOPLE WHOHAVE BEEN INJURED BY VIOLENT ACTS n AND WHO HAVE RECEIVED EMERGENCY MEDICAL AND SURGICAL CARE FROM -3& n CONTINUES TO GROW )N *ULY -3& SPOKE OUT ABOUT THE WORSENING SECURITY SITUATION AND
PUBLICLY CALLED ON ALL ARMED GROUPS TO RESPECT THE SAFETY OF CIVILIANS
AND TO ALLOW THE WOUNDED TO OBTAIN EMERGENCY MEDICAL CARE$BMMJOHBUUFOUJPOUP%BSGVSTPOHPJOHWJPMFODF
4ODAY APPROXIMATELY TWO YEARS AFTER VIOLENCE BROKE OUT IN 3UDANSWESTERN REGION OF $ARFUR THE CONF LICT HAS FADED FROM THE MEDIA"UT THE TERROR IT INF LICTS ON CIVILIANS REMAINS EVER PRESENT -ANY OF
THOSE GATHERED IN CAMPS WITHIN 3UDAN OR JUST ACROSS THE BORDER IN
EASTERN #HAD SEE NO END IN SIGHT TO THEIR PLIGHT AND REPEATED VIL
LAGE BURNINGS SEXUAL VIOLENCE AND ATTACKS HAVE MADE RETURNING
HOME AN UNREALISTIC OPTION FOR MOST 9ET THE CAMPS OR VILLAGES IN
WHICH THEY HAVE GATHERED ARE FAR FROM SECURE 0EOPLE LIVING IN THESE
AREAS CONTINUE TO BE SUBJECTED TO REPEATED AGGRESSION AND RECURRINGDISPLACEMENT $URING  -3& CONTINUED TO ASSIST MORE THAN ONEMILLION PEOPLE FORCED TO F LEE THEIR HOMES OR OTHERWISE AFFECTED BY
THE VIOLENCE AND ITS CONSEQUENCES)N ADDITION TO THE MEDICAL CARE PROVIDED -3& SPOKE OUT ON A
NUMBER OF OCCASIONS INCLUDING BEFORE THE 5. 3ECURITY #OUNCIL ON
WHAT OUR TEAMS HAVE WITNESSED IN $ARFUR !FTER HAVING PROVIDEDMEDICAL CARE TO HUNDREDS OF WOMEN AND GIRLS WHO HAD SURVIVED
RAPES OR OTHER SEXUAL VIOLENCE IN $ARFUR -3& SPOKE OUT ON VIO
LENCE AGAINST WOMEN IN A -ARCH  REPORT 4HE REPORTS STARKFINDINGS LED THE 3UDANESE GOVERNMENT TO ARREST TWO -3& INTERNATIONAL VOLUNTEERS WHO DIRECTED -3&S WORK IN $ARFUR )NTERNATIONALOUTCRY FINALLY LED TO THE MENS EVENTUAL RELEASE -3& STAFF MEMBERS
SEE IT AS A RESPONSIBILITY TO MAKE PEOPLE AND GOVERNMENTS AWARE OF
THE ABUSES THEY WITNESS 4O REMAIN SILENT IS IMPOSSIBLE (OW -3&
CAN BEST ASSIST VICTIMS OF SEXUAL VIOLENCE REMAINS A PRESSING ISSUE
AND IS HIGHLIGHTED IN AN ESSAY WITHIN THESE PAGES-EANWHILE THE INHABITANTS OF WIDE AREAS OF SOUTHERN 3UDAN HAVESTARTED TO SUFFER FROM MALNUTRITION DUE TO FOOD SCARCITY -3& TEAMSWORKING THERE ARE TREATING A GROWING NUMBER OF CHILDREN SUFFERINGFROM SEVERE MALNUTRITION AS THE PRECARIOUS NUTRITIONAL SITUATION
HAS BEEN AGGRAVATED BY THE RETURN OF DISPLACED PEOPLE AND REFUGEESNOW THAT THE PEACE AGREEMENT IS IN PLACE*NQSPWJOHDBSFGPSUIPTFXJUIOFHMFDUFEEJTFBTFT%VERY DAY IN COUNTRIES AROUND THE WORLD -3& CONFRONTS ANOTHER
FORM OF VIOLENCE THAT TOUCHES MILLIONS 0ATIENTS LIVING WITH DISEASESSUCH AS MALARIA TUBERCULOSIS 4" ()6!)$3 SLEEPING SICKNESS
AND #HAGAS DISEASE TO NAME ONLY A FEW DIE SIMPLY BECAUSE THE
MEDICINES NEEDED TO TREAT THEM ARE NOT AVAILABLE IN SUFFICIENT QUAN
TITIES ARE TOO EXPENSIVE OR DO NOT EVEN EXIST !N ESSAY ON MALARIAINCLUDED HERE SUGGESTS THAT BECAUSE THESE DISEASES MAINLY AFFECTPOOR PEOPLE LIVING IN DEVELOPING NATIONS THERE IS LITTLE URGENCY TO
INCREASE THE SUPPLY OF CRUCIAL MEDICINES FIND NEW TREATMENTS OR
DEVELOP BETTER DIAGNOSTIC TOOLS )N RECENT YEARS THERE HAS BEEN A
TIMID RESURGENCE OF RESEARCH ON THESE DISEASES HOWEVER CONSIDERING THE DECADES OF NEGLECT THESE IMPROVEMENTS ARE PRECARIOUS ANDDISPROPORTIONATELY MINOR FOR PATIENTS AWAITING DIAGNOSIS AND TREAT
MENT TODAY
7HILE -3& AND MANY OTHERS HAVE SHOWN THAT IT IS POSSIBLE TO TREAT()6 POSITIVE ADULTS n EVEN THOSE LIVING IN VERY RESOURCE POOR SET
TINGS n THE SAME HAS NOT BEEN TRUE FOR THE DISEASES YOUNGEST VIC
TIMS 4ODAY OUR EFFORTS TO TREAT CHILDREN INFECTED WITH ()6!)$3
ARE SEVERELY HAMPERED BY A LACK OF APPROPRIATE DRUG FORMULATIONSAND DIAGNOSTIC TOOLS $ESPITE THE FACT THAT -3& IS NOW SUCCESSFULLYTREATING MORE THAN   PATIENTS IN  COUNTRIES OUR FIELD TEAMSARE FORCED TO DEVISE MAKESHIFT SOLUTIONS SUCH AS BREAKING ADULTPILLS IN TWO OR STRUGGLING TO GET YOUNG CHILDREN TO SWALLOW SYRUPSFREQUENTLY TO TREAT THEM &OR ()6!)$3 PATIENTS WHO ARE ALSOINFECTED WITH 4" THE MOST COMMON OPPORTUNISTIC INFECTIONACCOMPANYING ()6!)$3 THE OBSTACLES ARE JUST AS BIG 0ROBLEMSIN DIAGNOSING 4" HIGH PILL LOADS DRUG INTERACTIONS AND THE LACK OF
COORDINATED CARE ARE SOME OF THE DIFFICULTIES FACING OUR MEDICALTEAMS IN VARIOUS COUNTRIES ESPECIALLY IN PARTS OF SOUTHERN !FRICA
WHERE BOTH DISEASES KILL THOUSANDS EVERY YEAR (OWEVER AS A FEATURE STORY IN THIS REPORT SHOWS IT IS POSSIBLE TO SUCCESSFULLY INTE
GRATE ()6!)$3 AND 4" CARE )N COUNTRIES SUCH AS 3OUTH !FRICASOME IMPORTANT HEADWAY HAS ENABLED EXTREMELY ILL PATIENTS TOREGAIN THEIR HEALTH AND RESTART THEIR LIVES'VMGJMMJOHPVSDPNNJUNFOUT
7HETHER CARING FOR AN ()6!)$3 PATIENT CO INFECTED WITH 4" A
GUNSHOT VICTIM IN $2# OR (AITI OR A MALNOURISHED CHILD IN .IGER-3& CONTINUES TO STRIVE TO BRING MEDICAL ASSISTANCE TO THOSE WHO
MOST NEED IT 9ET OUR ABILITY TO GAIN ACCESS TO PEOPLE IN NEED IS CHALLENGED BY THE ABUSE OF HUMANITARIAN SYMBOLS FOR POLITICAL PURPOSESAND THE CONCURRENT VIOLENCE AGAINST HUMANITARIAN AID WORKERSTHEMSELVES 4HE RESPONSIBILITY OF STATES IN RESPECTING THE ROLE OF
IMPARTIAL HUMANITARIAN ACTION IS SOMETHING EXPLORED IN ANOTHER
ESSAY INCLUDED IN THIS REPORT 4HIS ESSAY DISCUSSES THE NEED FOR
ACTION BASED ON PRINCIPLES -3& HAS BEEN ACCUSED AT TIMES OF BEINGhOLD FASHIONEDv AND EVEN EXTREMIST FOR REAFFIRMING ITS BASIC PRINCI
PLES IN AN EVOLVING WORLD (OWEVER IT IS THE USE OF THESE VERY PRIN
CIPLES TO INTERPRET AND RESPOND TO A CHANGING ENVIRONMENT THATALLOWS US TO CARRY OUT PRAGMATIC ACTIONS UNDER SUCH CONDITIONS 7E
HOPE THIS REPORT PROVIDES INSIGHT INTO THE WORK -3& DOES MERGING
PRINCIPLES AND PRAGMATISM IN MANY DIFFERENT CONTEXTS AND DIFFERENT
WAYS (OWEVER WE ALWAYS HAVE ONE GOAL IN MIND TO PROVIDE MEDI
CAL ASSISTANCE TO THOSE WHO NEED IT WHATEVER THE CIRCUMSTANCES
2OWAN 'ILLIES 0RESIDENT -3& )NTERNATIONAL #OUNCIL-ARINE "UISSONNIÞRE -3& 3ECRETARY 'ENERAL

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-3& HAS ANOTHER UNIQUE QUALITY THAT SEPARATES IT FROM MANY OTHER hHUMANITARIANv
GROUPS )T IS BEST DESCRIBED BY THE &RENCH
WORD T£MOIGNAGE MEANING TO SPEAK OUT AND
BEAR WITNESS TO THE SUFFERING ONE SEES -3&
SEEKS TO BEAR WITNESS TO THE FATE OF POPULATIONS AS PRECISELY AS POSSIBLE NOT AS DEFENDERS OF HUMAN RIGHTS BUT SIMPLY AS DIRECTWITNESSES TO THE SUFFERING OF THE SICK AND
INJURED AND TO THE STOLEN DIGNITY OF SO MANY
MEN WOMEN AND CHILDREN ALL OVER THE
WORLD 7E BEAR WITNESS BECAUSE IT IS PART OF
OUR UNDERSTANDING OF HUMANITARIAN RESPONSIBILITY AND OUR DESIRE NOT TO REDUCE OUR
ACTS TO THE MERELY CHARITABLE OR LOGISTICAL
7E BEAR WITNESS BECAUSE FOR MANY VICTIMSFROM #HECHNYA TO 3OMALIA TO .ORTH +OREA

THERE IS NOTHING WORSE THAN NEGLECT OR
INDIFFERENCE
4HIS INTERPLAY BETWEEN MEDICAL ETHICSBENEFICENCE DOING NO HARM AUTONOMY
AND JUSTICE AND HUMANITARIAN PRINCIPLES IS
THE TRADEMARK OF AND THE DRIVING FORCEBEHIND -3&S DUAL IDENTITY !ND TODAY
BOTH OF THESE FORCES ARE BEING SEVERELY CHALLENGED BECAUSE OF CHANGES IN OUR ENVIRONMENT AND -3&S OWN DEVELOPMENT
4HE ETHICAL FOUNDATION ON WHICH -3& OPER
ATES DATES BACK MORE THAN A DECADE TO WHEN
THE MOVEMENTS LEADERS CREATED A DOCUMENTTO GUIDE -3&S GOVERNANCE )TS KEY PRINCI
PLES WERE AND REMAIN AT THE HEART OF A BROAD
INTERNATIONAL AND ASSOCIATIVE PROCESS OF

REF LECTION AND RENEWAL WITHIN -3& 4HERE IS
NO DOUBT THAT THIS PROCESS WILL SERVE TO
REAFFIRM THE ETHICAL DIMENSION OF OUR WORK
IN THIS CHANGING ENVIRONMENT

5IFDPSSVQUJPOPGIVNBOJUBSJBOBDUJPO&ACED WITH THE ALMOST COMPLETE FAILURE OF
THE DEVELOPMENT AID SYSTEM THE TRANSFORMATION OF NATION STATES AND THE EMERGENCE
OF NEW INTERNATIONAL ACTORS OF ALL KINDS
.'/S MULTINATIONAL CORPORATIONS AND
PRIVATE SECURITY COMPANIES ETC  AND FACED
WITH THE SHOCKS BROUGHT ABOUT BY GLOBALIZATION AND THE GROWING hMARKETIZATIONv OF THE
WORLD hHUMANITARIANv ISSUES FIND THEMSELVES PUSHED MORE AND MORE TO THE FORE

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GROUND ! VICTIM OF ITS OWN SUCCESSHUMANITARIAN ACTION HAS BECOME A POLITICAL ECONOMIC AND SOCIAL STAKE IN COUNTRIESIN CRISIS AS WELL AS IN OUR OWN hDEVELOPEDv
SOCIETIES &ROM ITS ROLE AS A SMOKESCREEN TO
HIDE POLITICAL INACTION AS IN "OSNIA(ERZEGOVINA TO ITS ROLE AS A PSEUDO CATA
LYST FOR MILITARY INTERVENTION AS IN+OSOVO THE CURRENT THINKING AMONG
MANY NATIONS THE 5. AND MANY NONGOVERNMENTAL ORGANIZATIONS IS THATHUMANITARIAN ACTION SHOULD FORM AN INTEGRAL PART OF A hCOHERENT SYSTEMv n AN INTE
GRATED HUMANITARIAN SYSTEM "UT INTEGRATED INTO WHAT )NTEGRATED INTO POLICY IN THE
SAME WAY AS ARE THE USE OF FORCE ECONOMIC
DEVELOPMENT OR EVEN JUSTICE IN A GLOBALQUEST FOR CONSISTENCY AND EFFECTIVENESS!LTHOUGH THIS VISION HAS SEDUCED MORE
THAN ONE PERSON IN HUMANITARIAN CIRCLESWHETHER BECAUSE OF CONVICTION LACK OFFINANCIAL OR POLITICAL INDEPENDENCE OR SIM
PLE PRAGMATISM WE SHOULD BE CLEAR THAT
THE INTEGRATION OF HUMANITARIAN ACTION
INTO A SYSTEM IS TANTAMOUNT TO THE DISINTEGRATION OF ITS VERY HUMANITARIAN VALUES
4HE TRAP IS SET "Y INTEGRATING HUMANITAR
IAN ACTION WE TRANSFORM IT TO THE POINT OFREMOVING ITS SUBSTANCE EVEN TO THE POINT
OF DESTROYING IT !ND THAT WOULD NOT FOR
ONE MINUTE TROUBLE THOSE WHO WANT TO
MAKE HUMANITARIAN ACTION INTO A SIMPLE
TOOL AT THE DISPOSAL OF POLITICS OR OF MILITARY OBJECTIVES IN THE WAR AGAINST TERRORISM
OR THOSE WHO SEE HUMANITARIAN ACTION ONLY
THROUGH THE PRISM OF TECHNICAL STANDARDSAND COST BENEFIT RATIOS*TPMBUJPOBTUIFQSJDFPGSFKFDUJPO&ACED WITH THIS DYNAMIC -3&S REJECTION
OF THIS TYPE OF COOPERATION HAS LEFT IT
INCREASINGLY ISOLATED BOTH IN THE PLUSH
MEETING ROOMS OF THE HUMANITARIAN JET SET
n EVEN TO THE EXTENT THAT WE HAVE BEEN
CALLED hHUMANITARIAN EXTREMISTSv AT SOMERECENT MEETINGS -ORE TRAGICALLY -3& HAS
BEEN ISOLATED IN THE FIELD FIRST IN !NGOLA
THEN IN $ARFUR 3UDAN AND NOW DRAMATICALLY IN .IGER WHERE -3& TEAMS HAVE FOR
FAR TOO LONG FOUND THEMSELVES ALONE AND
LARGELY POWERLESS IN THE FACE OF A POPULA
TIONS SUFFERING
3OMEHOW UNLIKE THE )NTERNATIONAL#OMMITTEE OF THE 2ED #ROSS WHOSE ISOLA
TION IS LARGELY ACCEPTED AND RECOGNIZEDBECAUSE OF ITS MANDATE AND ITS FUNCTION IN
THE INTERNATIONAL SYSTEM -3& IS REQUIREDTO EXPLAIN ITS POSITION 4O SOME EXTENT-3& HAS PROBABLY CONTRIBUTED TO ITS OWNISOLATION THROUGH ITS OWN ATTITUDE WHICH
HAS TOO OFTEN BEEN INWARD LOOKING "UT LET
US MAKE NO MISTAKE THE FUNDAMENTAL CAUSE
OF THIS ISOLATION CAN BE FOUND ABOVE ALL IN
THE FACT THAT THE HUMANITARIAN VALUES OF
INDEPENDENCE AND IMPARTIALITY THAT WE
DEFEND ARE THEMSELVES ISOLATED OR EVEN
UNDERMINED 4HIS IS DONE NOT ONLY BY POLI
TICS BUT ALSO BY A SECTION OF THE hHUMANITARIAN COMMUNITYv)T IS PART OF EVERYONES RESPONSIBILITY TO
COMBAT THIS EROSION OF RESPECT FOR HUMANDIGNITY STARTING AT NATIONAL LEVEL WHERE
THERE IS AT LEAST A LEGAL COMMITMENT TORESPECT AND ENSURE RESPECT FOR INTERNATIONALHUMANITARIAN LAW /N THAT COUNT THE FACTTHAT THE GOVERNMENT OF 4HE .ETHERLANDSCONTINUES TO SUE -3& FOR THE REPAYMENT OF
THE RANSOM WHICH THE $UTCH GOVERNMENTNEGOTIATED AND PAID FOR THE LIBERATION OF
ONE OF OUR VOLUNTEERS WHO WAS DETAINED FOR
 MONTHS IN THE .ORTH #AUCASUS IS MOREEVIDENCE THAT STATES INCLUDING 7ESTERNSTATES PREFER TO CONTINUE TO DECEIVE THEIRCONSTITUENTS RATHER THAN SHOULDER THEIR OWNRESPONSIBILITIES.ATIONS REFUSAL TO ACT CAN ALSO BE SEEN IN
THE MANY MONTHS OF EFFORT AND PRESSURE ITTOOK TO GET THE !FGHAN GOVERNMENT TO START
TAKING ACTION TO FIND AND PROSECUTE THE
CRIMINALS WHO MURDERED FIVE OF OUR COL
LEAGUES ON A DESERTED ROAD IN !FGHANISTANIN *UNE  )N MANY COUNTRIES AT MANYTIMES POPULATIONS HAVE BEEN LITTLE MORE
THAN CONSUMABLES TO BE DISPOSED OF AT THE
WHIM OF POLITICAL AND ECONOMIC INTERESTS
(UMANITARIAN ACTION THAT TRIES TO BE CLOSE
TO SUCH POPULATIONS IS NOT IMMUNE TO THISSAME RISK 4HE QUESTION OF HOW TO DEAL WITH
SUCH VIOLENT ACTORS HAS BECOME A MATTER OF
LIFE OR DEATH (OW CAN WE TALK TO AND CON
VINCE PEOPLE WHO TAKE THEIR OWN POPULATIONS HOSTAGE THAT -3& IS NOT JUST ANOTHER

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PUPPET CONTROLLED BY THE MILITARY HUMANITARIAN ACTIONS DEPLOYED BY CERTAIN STATES(OW CAN WE BE CONVINCING ENOUGH TO BE
ACCEPTED BY ALL ACTORS )N ANY GIVEN SITUATION HOW FAR SHOULD WE GO IN THIS APPROACH
AND UP TO WHAT POINT SHOULD WE TAKE THE
RISKS INHERENT IN WORKING INDEPENDENTLY IN
PHYSICAL PROXIMITY TO THE VICTIMS OF CON
F LICTS 3OMETIMES WE CANNOT 7E RESPONDED
TO SUCH A SITUATION IN !FGHANISTAN BY STOPPING OUR ACTIVITIES AND WITHDRAWING OURTEAMS IN *ULY  AND AGAIN BY LEAVING)RAQ IN .OVEMBER  &ACED WITH THIS
POLARIZATION OF EXTREMES WHICH LEAVES NO
ROOM FOR HUMANITY WE CAN ONLY RESPONDWITH INCREASED ENGAGEMENT TEMPERED WITH
CAUTION TO REAFFIRM OUR PRINCIPLES OF INTER
VENTION,ET US NOT DENY THIS ISOLATION /N THE CON
TRARY LET US ACCEPT IT AS PART OF OUR RIGHT TO
BE DIFFERENT WHILE PROVIDING FURTHER EXPLANATION TO THOSE WHO SUPPORT US INCLUDINGOUR PRIVATE DONORS OR WITH WHOM WE HAVECONTACT IN THE FIELD 7ITH NO CONCESSIONS0EACE DEMOCRACY ECONOMIC DEVELOPMENT
AND JUSTICE ARE THE UNDERLYING ISSUES IN OR
THE BACKDROP TO MANY DRAMAS WITH
HUMANITARIAN CONSEQUENCES "UT THEY ARENOT OUR FIGHTS 7E MUST KEEP OUR ACTION
INDEPENDENT OF THESE PROCESSES WHILE STILL
MAINTAINING AN AWARENESS OF THE MANY
INTERDEPENDENCIES AND FRICTIONS THAT STEMFROM THEM 4HIS IS WHY WE REFUSE TO BE
INVOLVED IN THE INTEGRATED SYSTEM 7E REJECT
THE REDUCTION OF HUMANITARIAN ASSISTANCE TO
A ROLE OF ARMY AFTER SALES SERVICE WHETHERFOR THE 5NITED 3TATES GOVERNMENT IN )RAQ OR
THE 2USSIANS IN THE .ORTH #AUCASUS 4HIS IS
WHY WE ARE AGAINST THE 5.S CONCEPT OFINTEGRATION WHICH MAY ULTIMATELY SACRIFICEPART OF THE POPULATION AS HAPPENED IN
3IERRA ,EONE WHEN THE CHOICE WAS MADE NOTTO INTERVENE IN REBEL HELD AREAS CONTROLLED
BY THE 25& AND IN !FGHANISTAN UNDER THE
4ALIBANS RULE 3ADLY EVEN THE 5.S IMPARTIALITY IS OF VARIABLE GEOMETRY DEPENDING ON
THE POLITICAL INTERESTS OF THE MEMBERS OF THE
3ECURITY #OUNCIL AND CANNOT BE CONFUSEDWITH THE HUMANITARIAN IMPARTIALITY
DEMANDED BY -3&
4HIS IMPARTIALITY IS VITAL TO CONTINUE PRO
VIDING MEDICAL ASSISTANCE TO VULNERABLE
POPULATIONS IN NEED 3O IF WE ARE FORCED TOCHOOSE BETWEEN OPERATING IN AN INTEGRATEDSYSTEM CHOOSING WHO SHALL BE SAVED AS A

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PRODUCT OF THE POLITICAL IMPORTANCE OF THE
POPULATION AND OF WORKING AMID hORGANIZEDCHAOS v OUR CHOICE IS CLEAR !ND THE CHOICE IS
NOT MADE TO DOGMATICALLY DEFEND OUR INDEPENDENCE BUT BECAUSE WE ARE CONVINCED
THAT THE CO EXISTENCE OF INDEPENDENT ACTORSIS THE BEST OPTION FOR POPULATIONS IN DANGERTO HAVE A CHANCE TO OBTAIN NEEDED CARE AND
ASSISTANCE $ID THIS FAMOUS INTEGRATED SYS
TEM RESPOND IN $ARFUR .O $ID IT WORK IN A
PEACEFUL COUNTRY LIKE .IGER THAT WAS EDGINGTOWARD HIGH LEVELS OF STARVATION !GAIN NO
"Y CONTRAST THIS FAMOUS SYSTEM WORKED
PERFECTLY EVEN TO THE POINT OF GETTING CARRIED AWAY AFTER THE TSUNAMI HIT 3OUTH !SIA
IN $ECEMBER  THANKS TO THE COMPLICITY
OF THE MEDIA WHICH CONVERTED THE DISASTER
INTO EMOTIONAL ENTERTAINMENT )F HUMANITARIAN ACTION CONTINUES TO BE TRANSFORMEDINTO A SYSTEM IN WHICH GOVERNMENT AND
HUMANITARIAN ACTION IS INTERMINGLED -3&
WILL PROBABLY HAVE NO CHOICE OTHER THAN TOACCEPT EVEN FURTHER ISOLATION TO MAINTAIN ACERTAIN TENSION AT THE RISK OF BECOMING A
KIND OF STOWAWAY IN A SYSTEM GOING INCREASINGLY AROUND AND AROUND IN CIRCLES

VIEWS AND EFFECTIVENESS 7E MUST MAKE THE
EFFORT TO CHANGE THE WAY WE WORK AND THINKTO ADAPT TO THAT ENVIRONMENT /UR ISOLATIONMUST NOT LEAD TO CONFINEMENT ON THE CON
TRARY IT MUST PUSH US TO OPEN UP TOWARD
OTHER ACTORS IN ORDER TO BETTER UNDERSTAND
THEM SO THAT WE CAN COOPERATE MORE EASILY
WHERE POSSIBLE OR CONFRONT THEM WHEN NEC
ESSARY !CCEPTING THIS DIFFERENCE IMPLIES AN
EVER GROWING DEGREE OF TRANSPARENCY ON THE
PART OF -3& AND INCREASINGLY SUBSTANTIALACCOUNTABILITY MECHANISMS

6TJOHPVSJTPMBUJPO"DBUBMZTUGPSQSPHSFTT)N THAT LIGHT THE MAIN ISSUE TO BE EXAMINED
BY -3& IS OUR CAPACITY TO EMERGE FROM OUR
HUMANITARIAN MICROCOSM IN ORDER FOR POPULATIONS TO BETTER ACCEPT OUR ACTIONS)NDEED ABOVE AND BEYOND OUR CERTITUDE IN
OUR PRINCIPLES WE MUST MAKE THE EFFORT TO
UNDERSTAND HOW WE ARE PERCEIVED IN THE
FIELD ON ACCOUNT OF OUR ATTITUDES ACTIONS/UR IDENTITY IS ALSO LINKED TO THE WAY WE
SEEK CREATIVE SOLUTIONS TO THE MEDICAL CHALLENGES FACING US ) WILL FINISH WITH JUST ONE
OF THESE THE FIGHT TO ENSURE ACCESS TO CARE
FOR THOSE LIVING WITH ()6!)$3 BECAUSE ITLEADS TO ANOTHER SITUATION THAT IS ALSO ABOUTTO CONFRONT -3& )N THIS AREA -3& IN ITSROLE OF PIONEER AND THORN IN THE SIDE OF

4HIS NOTION OF ACCOUNTABILITY ALSO INCLUDES
TRANSCENDING ANOTHER PARADOX RELATED TO-3&S IDENTITY THE FACT THAT ALTHOUGH WE
ARE PERCEIVED AS A GLOBAL ACTOR WE IN FACTREMAIN A MOVEMENT COMPRISED OF NATIONALASSOCIATIONS COMPOSED OF MEMBERS )T IS
ESSENTIAL THAT WE SUCCEED IN PRESERVING THE
ASSOCIATIVE ASPECT OF THE MOVEMENT WHICH
IS A GENUINE ANCHOR IN OUR RESPECTIVE SOCIETIES AND WHICH SERVES AS A REAL SAFEGUARDAGAINST THE TECHNOCRATIC AND BUREAUCRATICSHIFTS FACING SO MANY ORGANIZATIONS OF-3&S SIZEPUBLIC INSTITUTIONS AND PRIVATE ACTORS CANNOT WORK ALONE TO ACHIEVE ITS OBJECTIVES /UR
ROLE AS A CATALYST FOR CHANGE FORCES US TOENGAGE WITH OTHERS WHETHER IN A COOPERA
TIVE WAY n THROUGH PARTNERSHIPS n OR IN A
CONFRONTATIONAL WAY THAT FORCES THOSE IN
POWER TO ACCEPT THEIR RESPONSIBILITIES TO HELPMILLIONS OF PEOPLE DEPRIVED OF TREATMENT 4O
PROMOTE ACCESS A FEW YEARS AGO -3& CRE
ATED ITS INTERNATIONAL #AMPAIGN FOR !CCESS
TO %SSENTIAL -EDICINES WHICH HAS CONTRIBUTED TO A DRASTIC FALL IN THE PRICE OF LIFE
EXTENDING ANTIRETROVIRAL MEDICINES $RUG
PRICES HAVE PLUMMETED FROM ABOUT 53  PER PATIENT PER YEAR IN  TO LESS
THAN 53  PER PATIENT PER YEAR IN 
&ACED WITH NEEDS BEYOND ITS OWN SCOPE OF
WORK AND WANTING TO SAFEGUARD ITS FOUNDATION IN THE FIELD -3& LATER SUPPORTED THE
CREATION OF A SEPARATE ORGANIZATION THE$RUGS FOR .EGLECTED $ISEASES INITIATIVE
$.$I  $.$I IS A LOGICAL NEXT STEP THATAIMS TO STIMULATE THE BARREN FIELD OF FUNDA
MENTAL MEDICAL RESEARCH FOR NEGLECTED DISEASES INCLUDING SLEEPING SICKNESS KALA AZAR
AND #HAGAS DISEASE &OR EVERY STEP FORWARD
HOWEVER NEW DILEMMAS ARISE FOR US AND FOR
OUR TEAMS IN THE FIELD SUCH AS FINANCIAL
CONSTRAINTS AND THE CRISIS IN AVAILABLE
HUMAN RESOURCES THAT REPRESENT THE NEWBARRIERS TO ACCESS TO CARE IN MANY SUB
3AHARAN COUNTRIES 4HESE PROBLEMS GO FAR
BEYOND THE hTRADITIONALv RESPONSIBILITIES OF-3& AND THE SITUATION CREATES ANOTHER FORM
OF PRESSURE ON OUR IDENTITY AND OUR PRINCI
PLES OF ACTION 7E CONTINUE TO ASK (OW
FAR SHOULD WE GO IN OUR COOPERATION WITH
OTHERS OR WITH CONFRONTATION (OW CAN WE
SET LIMITS FOR OURSELVES AS A CATALYST WHEN
THERE IS SO MUCH STILL TO BE DONE

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"ETWEEN THE TEMPTATION OF THE ALTER GLO
BALIST ILLUSION AND THE TRAP OF BECOMINGNOTHING MORE THAN AN ASPIRIN TO PREVENTHEADACHES IN OUR OWN SOCIETIES -3& MUST
REAFFIRM ITS OWN MEDICAL AND HUMANITARIAN
IDENTITY 4HE CURRENT DEBATES WITHIN -3&
ARE SIGNS OF THESE TENSIONS AND OF OUR WILL TO
TAKE ON THESE SITUATIONS AS A MOVEMENT IN
ORDER TO PRESERVE THE REAL MEANING OF OUR
NAME

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7E KNOW FROM EXPERIENCE THAT HUMANITAR
IAN ASSISTANCE IS BOTH MOST NEEDED AND
MOST THREATENED IN AREAS WHERE PEOPLE ARE
SUFFERING BECAUSE OF ARMED CONF LICT n NOT
BECAUSE OF NATURAL DISASTER OR DISEASE "Y
DEFINITION THEREFORE PART OF THE TERRITORY IN
WHICH -3& ATTEMPTS TO DELIVER ASSISTANCE IS
OUTSIDE OF ANY GOVERNMENTS CONTROL 4HISREALITY MAKES IT SOMEWHAT OF AN EMPTY GESTURE TO CALL ON NATIONS TO PROTECT HUMANITARIAN AID WORKERS OR TO URGE OTHER GOVERN
MENTS TO PRESSURE THOSE COUNTRIES IN WHICHASSAULTS ON AID WORKERS OCCUR
4HE 'ENEVA #ONVENTIONS MAKE CLEAR THATSTATES AND NON STATE ACTORS INVOLVED IN
ARMED CONF LICT HAVE A RESPONSIBILITY TO
MAKE SURE THAT ALL hPERSONS TAKING NO ACTIVE
PART IN THE HOSTILITIESv AND THIS INCLUDESHUMANITARIAN AID WORKERS ARE TREATED
HUMANELY 4HE 5. 3ECURITY #OUNCIL HAS
EVEN PASSED A RESOLUTION URGING hx3TATES TO
ENSURE THAT CRIMES AGAINST SUCH PERSONNEL;PARTICIPATING IN HUMANITARIAN OPERATIONS=DO NOT REMAIN UNPUNISHEDxv   7ITH THESE
PRECEDENTS IN MIND SHOULD A HUMANITARIAN
ORGANIZATION LIKE -3& TAKE IT UPON ITSELF TO
REMIND STATES OF THEIR RESPONSIBILITY TO PROTECT HUMANITARIAN ASSISTANCE
7E HAVE TO CONSIDER THE ARGUMENT THAT CALLING ON GOVERNMENTS TO PROTECT HUMANITAR
IAN ASSISTANCE COULD IN FACT UNDERMINE THE
IMPARTIALITY AND THE INDEPENDENCE OF

HUMANITARIAN ORGANIZATIONS THAT ARE PRO
VIDING AID)PXGBSUPQVTI )F WE EXTEND TOO FAR THE ARGUMENT THATNATIONS HAVE A RESPONSIBILITY TO PROTECTHUMANITARIAN ASSISTANCE WHEREVER IT IS
DELIVERED AND REGARDLESS OF WHETHER THE GOVERNMENT HAS CONTROL OVER A REGION THEN WE
RISK GETTING A RESPONSE THAT SAYS h7E
ASSUME OUR RESPONSIBILITY BUT THE ONLY WAY
WE CAN ASSUME IT IS BY PROHIBITING HUMANITARIAN WORKERS FROM GOING THEREv 4HIS TYPE
OF REPLY IS MORE OR LESS WHAT -3& HEARDFROM THE $UTCH GOVERNMENT WHEN -3&
CHALLENGED IT TO ACT IN THE CASE OF ITS KID
NAPPED STAFF MEMBER !RJAN %RKEL h4HE
$UTCH GOVERNMENT BEARS A GENERAL RESPONSIBILITY FOR THE SAFETY OF ITS CITIZENS 4HE-INISTRY ADVISES $UTCH CITIZENS TRAVELINGABROAD AND DRAWS THEIR ATTENTION TO POSSIBLE DANGERS )N ITS ADVICE TO TRAVELERS TO THE
2USSIAN &EDERATION IT POINTS TO THE DANGERS
OF CONF LICT IN THE NORTHERN #AUCASUSv
#AN WE BLAME THE $UTCH GOVERNMENT FOR
THIS REPLY .O INSTITUTION CAN BE OBLIGED TO
DO THE IMPOSSIBLE )F A GOVERNMENT HAS AN
OBLIGATION TO PROTECT ITS CIVILIANS BUT KNOWSn OR PRETENDS n THAT IT CANT EXERT ANY INF LUENCE ON CRIMES HAPPENING IN CERTAIN AREAS
THEN THE ONLY PROTECTION IT CAN OFFER IS A hNO
GOv ORDER !T THE SAME TIME BECAUSE IT HAS
BECOME FASHIONABLE IN 5. AND DIPLOMATIC

CIRCLES TO MIX HUMANITARIAN OBJECTIVES WITH
POLITICAL OBJECTIVES n IN OTHER WORDS TO TRY
TO TURN HUMANITARIAN ASSISTANCE INTO A CON
VENIENT TOOL TO BUILD PEACE OR TO FIGHT TERRORISM n SOME NATIONAL ACTORS MIGHT BE VERYKEEN TO EMBRACE OR EVEN HIGHLIGHT THEIRRESPONSIBILITY TO PROTECT HUMANITARIANASSISTANCE 4HIS ASSUMPTION OF RESPONSIBILITY WOULD GIVE THEM AN ALIBI TO STEERHUMANITARIAN ASSISTANCE AWAY FROM TROUBLESOME REGIONS )F WE ACCEPT THAT WE NEEDSOME KIND OF hGREEN LIGHTv FROM GOVERN
MENTS FOR OUR INTERNATIONAL AID WORKERS TO
BE ALLOWED TO WORK IN CERTAIN REGIONS IN
ORDER FOR THEM TO ENJOY THE PROTECTION OF
THOSE GOVERNMENTS THEN WE LOSE OUR INDEPENDENCE AND IN MANY CASES OUR NEUTRALITY AS WELL IN THE EVENT THAT THOSE GOVERN
MENTS ARE NOT PERCEIVED AS NEUTRAL IN THE
CONF LICT 7E COULD ACCEPT THE PRINCIPLE
THEN ARGUE THAT THE REFUSAL OF THE GREEN
LIGHT IS WRONG THAT THE ALIBI IS FALSE THAT THE
GOVERNMENT REFUSING THE GREEN LIGHT DOESHAVE SOME INF LUENCE IN THE CONCERNEDREGION BUT REFUSES TO USE IT FOR POLITICALDIPLOMATIC OR ECONOMIC REASONS "UT
WOULDNT THIS LEAD US TO DISCUSSIONS IN
WHICH WE DONT WANT TO BE INVOLVED

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POMZBOTXFS 
3OME HAVE SUGGESTED THAT STATES SHOULD
EXERCISE THEIR RESPONSIBILITY TO PROTECTHUMANITARIAN ASSISTANCE EFFORTS BY OFFERING

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DIRECT MILITARY PROTECTION TO NONGOVERNMENTAL ORGANIZATIONS PROVIDING AID !
SCHOLAR FROM A 53 BASED CONSERVATIVE THINKTANK CALLED THE 2AND #ORPORATION WHO ALSO
HAPPENED TO BE THE WIFE OF THE 53 AMBASSADOR TO !FGHANISTAN WROTE IN 4HE 7ALL
3TREET *OURNAL IN !UGUST  THAT  AID
WORKERS HAD BEEN KILLED IN !FGHANISTAN IN
THE PAST TWO YEARS ALL OF THEM UNARMED AND
WORKING IN CIVILIAN PROJECTS 3HE SUGGESTEDTHAT THEIR LACK OF WEAPONS AND SOLDIERSESCORTS DID NOT PROTECT THEM BUT RATHER ONLY
MADE THEM EASIER TO KILL 3HE CONCLUDED
THAT IN THE LIGHT OF TODAYS REALITY SECURITY
DEVELOPMENT AND AID WERE ALL PART OF THE
SAME WHOLE AND THAT HUMANITARIANS WOULD
HAVE TO OPERATE UNDER THE COVER OF ARMS n OR
NOT AT ALL "UT OBVIOUSLY THE ARMED FORCES
THAT COULD OFFER SUCH PROTECTION ARE SELDOMNEUTRAL IN THE CONF LICT !CCEPTING SUCH PROTECTION WOULD UNDERMINE BOTH OUR NEUTRALITY AND OUR INDEPENDENCEFOR THE PROTECTION OF HUMANITARIAN WORKERSIS FOR THEM TO GIVE UP THEIR INDEPENDENCE OR
THEIR NEUTRALITY THEN HUMANITARIAN ASSISTANCE IS NO LONGER BEING PROTECTED IT IS BEING
DESTROYED )N SUCH SITUATIONS THERE IS NOTENOUGH WATER BETWEEN THE 3CYLLA OF BEINGEMBRACED AND EMBEDDED WITH MILITARY
POWERS AND THE #HARYBDIS OF BEING CAUGHT
IN A GENERAL CLIMATE OF LAWLESSNESS )N SUCHSITUATIONS THE ONLY REMAINING OPTION COULD
BE TO WITHDRAW n WHICH -3& WAS FORCED TO
DO RECENTLY IN BOTH !FGHANISTAN AND )RAQ
7HEN WE DEMAND THAT STATES PROTECT OUR
HUMANITARIAN ASSISTANCE WERE MERELY ASKING THEM TO ATTEMPT TO END THOSE 3CYLLA OR#HARYBDIS SITUATIONS 7ERE ASKING THEM TO
LIVE UP TO THEIR COMMITMENT TO CREATE ASPACE IN WHICH HUMANITARIAN ASSISTANCE CANOPERATE WITHOUT HAVING TO RELY ON MILITARY
PROTECTION AND WITHOUT OFFERING UP ITS
WORKERS AS MARTYRS )S THAT SUCH AN IMPOS
SIBLE DEMAND#FIBWJOHMJLFTQPJMFEDBUT )N AN INTERNAL -3& DEBATE A PARTICIPANT
COMPARED -3&S ATTITUDE TOWARD PROTECTION
WITH THE BEHAVIOR OF A SPOILED CAT THAT IS A
CAT THAT LIKES TO SIT NEAR THE FEET OF THE MISTRESS OF THE HOUSE BUT STARTS TO HISS AS SOON
AS SHE ATTEMPTS TO CARESS IT )N OTHER WORDSWE WANT PROTECTION BUT WE DONT WANT TO BE
SEEN AS NEEDING OR RECEIVING IT
4HIS COMPARISON ILLUSTRATES THE CONFUSIONTHAT HAS BEEN CREATED BY OUR REPEATED CALLSFOR NATIONS TO ASSUME THEIR RESPONSIBILITIESTO PROTECT HUMANITARIAN ASSISTANCE 4HE
CONFUSION LIES BETWEEN THE PROTECTION OF
HUMANITARIAN ASSISTANCE AND THE PROTECTION
OF HUMANITARIAN WORKERS /RGANIZATIONSLIKE -3& DONT MIND BEING CARESSED BUT WE
DONT WANT TO BE HUGGED TO THE POINT OF SUF
FOCATION !LLOWING GOVERNMENT ACTORS TO
DECIDE WHERE HUMANITARIANS CAN OR CANNOT
GO AND ALLOWING GOVERNMENTS TO IMPOSE
MILITARY ESCORTS AS A CONDITION FOR PROTECTION MIGHT WELL PROTECT HUMANITARIAN WORKERS BUT KILLS THE PRINCIPLES OF HUMANITARIANASSISTANCE7HAT -3& AND OTHERS ARE DEMANDING ISRESPECT AND NON AGGRESSION TOWARD HUMAN
ITARIAN ASSISTANCE NOT SO MUCH IN THE SENSE
OF PHYSICAL PROTECTION FOR HUMANITARIAN
WORKERS THROUGH INTERNATIONAL MILITARYBODYGUARDS /BVIOUSLY HUMANITARIAN AIDWORKERS ARE NOT VOLUNTEERING FOR MARTYR
DOM 4HEY CANNOT GIVE ASSISTANCE WHERE
THEY ARE TARGETED BY WARRING PARTIES OR
CRIMINALS (OWEVER IF THE PRICE TO BE PAID

4HE 5. 3ECURITY #OUNCIL DOESNT ASK FOR
THAT MUCH EFFORT ON THE PART OF STATES 7HATIT DOES URGE IS THAT STATES DO NOT ALLOWCRIMES AGAINST HUMANITARIAN WORKERS TO GO
UNPUNISHED /NE COULD DEBATE WHETHER THISIS SUFFICIENT )F ALL STATES ENSURED THAT THOSECOMMITTING CRIMES AGAINST HUMANITARIAN
WORKERS WERE FOUND AND PUNISHED WOULD IT
BE ENOUGH TO PROTECT HUMANITARIAN ASSISTANCE 0ROBABLY NOT (OWEVER SUCH A COM
MITMENT WOULD BE A SOLID START ONE FOR
WHICH WE ARE STILL WAITING$SJNJOBMTHPVOQVOJTIFE
!FTER  MONTHS OF CAPTIVITY -3& HEAD OFMISSION !RJAN %RKEL WAS RELEASED IN !PRIL BY HIS KIDNAPPERS )MMEDIATELY AFTER
THE RELEASE THE MEDIA REPORTED THAT $UTCH&OREIGN !FFAIRS -INISTER "ERNARD "OT HAD
SAID %RKELS RELEASE WAS THE RESULT OF NEGOTIATIONS AND THAT HE KNEW WHO WAS RESPONSIBLE FOR THE KIDNAPPING (E ALSO SAID THAT
THE $UTCH GOVERNMENT WAS INVOLVED IN
SECURING !RJANS RELEASE
4HE QUESTION OF TO WHAT EXTENT THE $UTCH-INISTRY OF &OREIGN !FFAIRS WAS INVOLVED IN
SECURING !RJANS RELEASE IS THE SUBJECT OF A
COURT CASE ON WHICH WE WILL NOT COMMENT
HERE &AR MORE IMPORTANT FOR THIS ARTICLE n
AND FOR THE FUTURE PROTECTION OF HUMANITAR
IAN ASSISTANCE n IS THE FOREIGN AFFAIRS MINISTERS ADMISSION THAT HE KNEW WHO WASRESPONSIBLE FOR THE KIDNAPPING

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!S EXPLAINED -3& DOESNT ASK MUCH FROMSTATES WHEN IT COMES TO PROTECTING HUMANITARIAN ASSISTANCE 7E DONT ASK STATES TO TELL
US WHERE WE CAN OR CANNOT WORK WE DONTASK STATES TO GIVE US MILITARY ESCORTS "UT WE
DO DEMAND THAT STATES DO WHATEVER THEY CANTO ENSURE THAT CRIMES AGAINST HUMANITARIAN
WORKERS DONT REMAIN UNPUNISHED/F COURSE THIS RESPONSIBILITY CANNOT START
ONCE THE SUSPECTS ARE KNOWN IT MUST START
MUCH EARLIER )F THE SUSPECTS ARE KNOWN IT
BECOMES EVEN MORE UNACCEPTABLE THAT THE
GOVERNMENT OF A VICTIM OF A CRIME AGAINST A
HUMANITARIAN WORKER DOESNT EVEN TRY TO
hENSURE THAT CRIMES AGAINST SUCH PERSONNEL
DO NOT REMAIN UNPUNISHEDv 7HAT HAS THE$UTCH GOVERNMENT DONE TO ENSURE THAT THE
CRIME COMMITTED AGAINST !RJAN %RKEL DOESNOT REMAIN UNPUNISHED
7HAT ABOUT THE MURDERERS OF -3& STAFF
MEMBERS (£LÞNE DE "EIR "ELGIAN CITIZEN
7ILLEM +WINT $UTCH CITIZEN %GIL 4YNAES
.ORWEGIAN CITIZEN &ASIL !HMAD AND"ESMILLAH !FGHAN CITIZENS IN !FGHANISTANDURING *UNE  )T WAS THE !FGHANAUTHORITIES WHO INDICATED THAT THEY HAD
IDENTIFIED A SUSPECT 4HEIR PRIME SUSPECTWAS A LOCAL POLICE COMMANDER WHO HAD
BEEN FIRED BEFORE THE MURDERS AND REINSTATED AFTERWARD )T SEEMS THAT HIS INTENTIONWAS TO DEMONSTRATE THAT HE IS A KEY ELEMENT
IN THE SECURITY OF THE AREA  )RONICALLY THE
GOVERNMENTS OF "ELGIUM .ORWAY AND 4HE.ETHERLANDS ARE ALL DONORS TO THE ,AW AND/RDER 4RUST &UND FOR !FGHANISTAN WHICH
HAS AS ITS FIRST OBJECTIVE TO ENSURE THE
hNATIONWIDE PAYMENT OF POLICE STAFF SALARIESv &OR A WHOLE YEAR RATHER THAN ENSUR
ING THAT THESE MURDERS WOULD NOT GOUNPUNISHED THESE GOVERNMENTS UNKNOWINGLY CONTRIBUTED TO THE SALARY OF THE PRIMESUSPECT )T TOOK AN INTENSE LOBBYING CAM
PAIGN ON THE PART OF -3& AND OTHERS BEFORE
THE PRIME SUSPECT WAS JAILED AND A CASE WASBROUGHT AGAINST HIM(UMANITARIAN AID ORGANIZATIONS ARE NOTASKING FOR SO MUCH 7E ARE NOT DEMANDING
SAFETY GUARANTEES FOR OUR WORKERS 7E ARE
ASKING STATES NOT TO COMMIT CRIMES AGAINSTHUMANITARIAN WORKERS AND IF OTHERS DO TO
DO EVERYTHING IN THEIR POWER TO ENSURE THATTHESE CRIMES DONT GO UNPUNISHED )TS AN
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-3& TEAMS REGULARLY WITNESS THE RESULTS OF LARGE SCALE AND DIVERSE
TYPES OF VIOLENCE STATE PERPETRATED VIOLENCE MASSACRES TORTURE
SYSTEMATIC RAPE AND SO ON $ESPITE THIS WE HAVE HAD TROUBLE FINDING SUITABLE RESPONSES TO THESE SENSITIVE AND COMPLEX ISSUES ONLYFRAGMENTS OF WHICH ARE EVEN VISIBLE TO US 4HESE ISSUES ARE ONLY
MADE MORE DIFFICULT BECAUSE OUR RESPONSE CAN COMPROMISE THE
SAFETY OF OUR NATIONAL AND INTERNATIONAL STAFF
4HERE ARE MANY REASONS WHY IT IS SOMETIMES DIFFICULT FOR -3& TO
RESPOND TO VICTIMS OF SEXUAL VIOLENCE 4HERE ARE DIFFERENCES OF
OPINION ON WHAT CONSTITUTES SEXUAL VIOLENCE AND CULTURAL OBSTACLES
LINKED TO THE GENERAL STIGMA SURROUNDING RAPE MAKE THE IDENTIFICA
TION OF VICTIMS DIFFICULT )T IS HARD TO PROVIDE STAFF SENSITIVITY TRAINING ON THESE ISSUES IN AN EXTREME EMERGENCY SITUATION WHERE MANYNEEDS MUST BE MET QUICKLY !ND VICTIMS OF SEXUAL VIOLENCE SOMETIMES REFUSE TO COME FOR HELP 4HOSE WHO ARE STRONGLY INF LUENCED BYRELIGIOUS IDEOLOGY OR ARE DEPENDENT UPON OTHERS MAY FEAR OSTRA
CISM ESPECIALLY BY MALE PARTNERS WHO COULD ABANDON THEM IF IT
BECAME KNOWN THAT THEY HAD BEEN RAPED

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)NITIAL DATA FROM VARIOUS CONTEXTS IN WHICH WE WORK SHOW THE HUGE
RANGE AND UNPREDICTABILITY OF VIOLENCE IN GENERAL AND OF SEXUAL VIO
LENCE IN PARTICULAR &OR EXAMPLE IN RECENT YEARS -3& TEAMS IN THE)TURI REGION OF THE $EMOCRATIC 2EPUBLIC OF THE #ONGO $2# HAVEBEEN TOLD OF THE KIDNAPPINGS OF YOUNG GIRLS WHICH HAVE BEEN LINKED
TO ACTS OF EXTREME CRUELTY 7E HAVE SEEN HOW RAPE AND THE THREAT OF
RAPE ARE USED TO TERRORIZE AND CONTROL CIVILIANS IN $ARFURS DISPLACE
MENT CAMPS 4EAMS HAVE SEEN THE CONSEQUENCES OF A RISE IN CIVILIANAND DOMESTIC VIOLENCE IN ,IBERIA FOLLOWING THE WAVES OF ARMED CON
F LICT THAT HAVE CROSSED THAT COUNTRY.FEJDBMSFTQPOTJCJMJUZJTOPUQPMJDFXPSL(OWEVER WHEN IT COMES TO RESPONDING TO THE CONSEQUENCES OF SEXUAL VIOLENCE OUR MEDICAL PRACTICES SOMETIMES MEET RESISTANCE OR
WE FIND THAT OUR TEAMS ARE LIMITED BY THE REALITY OF CERTAIN SITUATIONS 9ET OUR MEDICAL RESPONSIBILITY COMPELS US TO AVOID MAKINGJUDGMENTS ABOUT THOSE WHO NEED OUR HELP AND TO OVERCOME ANY
hREF LEXESv n BOTH CONSCIOUS OR UNCONSCIOUS n THAT MIGHT PREVENT USFROM DOING AS MUCH AS WE CAN FOR VICTIMS OF SEXUAL VIOLENCE-EDICAL RESPONSIBILITY IMPLIES AMONG OTHER THINGS AN OBLIGATIONTO PROVIDE NEEDED RESOURCES 4HAT IS A DOCTOR NEEDS TO MAKE EVERYPOSSIBLE UP TO DATE MEDICAL RESOURCE AVAILABLE TO THE PATIENT 9ET
PUTTING THIS IMPERATIVE INTO ACTION IN THE FIELD SOMETIMES CAN PROVETO BE VERY COMPLICATED 6IOLENCE IS COMPOSED OF INTENT AND HARM
THE AGGRESSOR AND THE AGGRIEVED n AND ALTHOUGH THE NOTION IS OFTENCOLORED BY CULTURE AND MAY HAVE POLITICAL ECONOMIC OR RELIGIOUS
DESIGNS CONTEXTUALIZING OUR INDIVIDUAL AND COLLECTIVE RESPONSIBILITY TO PEOPLE AND SOCIETIES BESET BY THIS KIND OF VIOLENCE MAKES THE
EXERCISE OF MEDICAL RESPONSIBILITY PARTICULARLY DELICATE

-3& WORKERS THEMSELVES ARE NOT IMMUNE FROM THE MISCONCEPTIONSABOUT RAPE THAT EXIST IN LARGER SOCIETY )NDEED THERE MAY BE A TEMPTATION TO RESORT TO CULTURAL RELATIVISM PERHAPS MAKING ASSUMPTIONSABOUT THE SEXUAL PROPENSITIES OF A BENEFICIARY POPULATION TO HIDEOUR OWN DISTRESS WHEN FACED WITH PHENOMENA FOR WHICH OUR ASSISTANCE IS AND MUST BE LIMITED /NE MIGHT EVEN HEAR A COMMENTSUCH AS h$OES RAPE REALLY HAPPEN IN !FRICAv OR h9OU KNOW SOMEPEOPLE JUST HAVE A VIOLENT SEXUALITYv 3UCH COMMENTS IMPLY THAT ALL
VALUES ARE RELATIVE DEPENDING ON THE CULTURAL CONTEXT IN WHICH THEY
ARE FOUND )RONICALLY THE ONLY OPINIONS CONTINUALLY MISSING FROM
THE DEBATE ARE THOSE OF THE PEOPLE THEMSELVES )N THIS KIND OF DISCUSSION WE TAKE AWAY THEIR RIGHT OF SELF DETERMINATION AND THE
VALUES THAT CONCERN THEM
)N THE FIELD AND IN THE HEADQUARTERS OFFICES ONE CAN HEAR SNIPPETSOF CONVERSATIONS THAT RAISE DOUBTS ABOUT THE VICTIM STATUS OF SOMEFEMALE PATIENTS 0ERHAPS THEY WANT TO CONCEAL CONSENSUAL RELATIONSWITH A PARTNER OR MAYBE THEIR REAL MOTIVE FOR SEEKING TREATMENT
AFTER A RAPE IS TO GET FREE SOAP OR CLOTHING 3UCH SUSPICIONS ALSO GETTANGLED IN A DIALOGUE ABOUT WHETHER OR NOT CONSENSUAL SEX BETWEENOLDER MEN AND PRE PUBESCENT GIRLS CONSTITUTES RAPE OR A FORM OF
SEXUAL EXPLOITATION(OWEVER WE MUST REMEMBER MEDICAL RESPONSIBILITY IS NOT POLICE
WORK )T IS NOT OUR JOB TO TEST THE VERACITY OF CASES NOR IS IT OUR WORKTO EXPLORE ASPECTS OF ANTHROPOLOGY OR THE SOCIAL SCIENCES TO BETTERUNDERSTAND THE CONTEXT n EVEN THOUGH CULTURAL ASPECTS MUST OF
COURSE BE CONSIDERED 4HIS IS TRUE NOT ONLY IN CASES OF RAPE BUT
ALSO IN BROADER TERMS WHEN DEALING WITH A LOCAL POPULATIONS CON
CEPTS OF HEALTH BODY IMAGE VIOLENCE AND SEXUALITY

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SFTQPOEUPWJDUJNTPGTFYVBMWJPMFODFw/UR MEDICAL RESPONSIBILITY COULD THEREFORE BEGIN WITH EASING ACCESSTO CARE FOR THESE FEMALE PATIENTS FOR WHOM SUCH ACCESS IS OFTEN VERYLIMITED RELATIVE TO THE GENERAL POPULATION 4HIS CAN COME DOWN TO
WORKING WITH THE INVISIBLE LEAVING THE RESPONSIBILITY FOR ESTABLISH
ING THESE ACTIVITIES ENTIRELY UP TO THE WILL AND hMILITANCYv OF ONE OR
MORE OF OUR STAFF MEMBERS)N EMERGENCY SITUATIONS MAKING THIS KIND OF CARE AVAILABLE CANSOMETIMES SPARK COMPETITION WITH OTHER HEALTH IMPERATIVES THATMUST BE ADDRESSED )N SUCH CASES WE ARE FORCED TO CARRY OUT A KIND
OF TRIAGE THAT THREATENS TO CREATE A FORM OF COMPETITION AMONG OURPATIENTS /UR PRIORITIES OFTEN DICTATED BY INDIVIDUAL OR PUBLICHEALTH ISSUES EG CHOLERA WHICH CAN KILL WITHIN HOURS REMAINSOLIDLY ANCHORED IN AN IDEOLOGICAL FRAMEWORK THAT WE SOMETIMESFORGET TO QUESTION

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7HILE TRYING TO AVOID ACCEPTING ALL DIFFERENCES FROM OUR NORMS AS
hCULTURAL v WE ALSO FACE THE POTENTIAL FOR TAKING ON AN hIMPERIALISTv
ATTITUDE THAT CONSISTS OF DICTATING THE POPULATIONS BEST INTERESTS n
PARTICULARLY WHEN WE ARE DENOUNCING AND BEARING WITNESS TO PRAC
TICES WE OPPOSE AND WHEN WE ARE ESTABLISHING MEDICAL CARE WHERE IT
IS LIMITED OR COMPLETELY LACKING -EDICAL RESPONSIBILITY IS PRIMARILY
A MATTER BETWEEN PATIENT AND PRACTITIONER 4HE OBLIGATION TO GIVERESOURCES n EVEN WHEN OPERATING IN DANGEROUS SITUATIONS n IS ABOVE
ALL THE OBLIGATION TO PROVIDE CARE AND TO ENSURE ITS QUALITY )N CASES
OF SEXUAL VIOLENCE IT COULD BE A MATTER OF GIVING ANTIBIOTIC TREAT
MENT TO COMBAT A SEXUALLY TRANSMITTED INFECTION GIVING PROPHYLAXIS TREATMENT TO PREVENT ()6 INFECTION PROVIDING MEDICINE TO
AVOID PREGNANCY PERFORMING AN ABORTION OR RECONSTRUCTIVE SURGERY
OR OF COURSE ADDRESSING PSYCHOSOCIAL ISSUES!LTHOUGH THERE IS INSUFFICIENT SCIENTIFIC CAUSAL EVIDENCE TO DESCRIBEA DIRECT LINK BETWEEN SEXUAL VIOLENCE AND ()6 TRANSMISSION OURACTION IN EMERGENCY SITUATIONS MUST BE GUIDED BY THE TIME IMPERA
TIVE FOR EFFICIENT PROPHYLACTIC TREATMENT OF ()6 DESPITE THE FACT THATTHESE MEASURES SOMETIMES INTERFERE WITH THE MANAGEMENT OF OTHER
PUBLIC HEALTH PROBLEMS !PART FROM PURE PROPHYLACTIC ACTION POSTEXPOSURE PROPHYLAXIS 0%0 IS ONE OF THE ONLY TOOLS WE HAVE AVAILABLE IN THE FIELD TO HOLD BACK ()6 TRANSMISSION IN ENDEMIC CONTEXTS ,OOKING BACK WE KNOW THAT IN 2WANDA THOUSANDS OF WOMENWERE INFECTED WITH ()6!)$3 THROUGH WIDESPREAD SYSTEMATIC RAPE
DURING THE GENOCIDE OF  !T THE TIME -3& WAS NOT FOCUSING ON
VICTIMS OF SEXUAL VIOLENCE WHILE BEING CONFRONTED WITH SO MANY
TYPES OF VIOLENCE AND ENORMOUS INSECURITY INCLUDING HARM TO ITSOWN TEAMS (OWEVER SHOULDNT WE LET THE CONSEQUENCES OF THATEVENT SERVE AS A GUIDE FOR OUR FUTURE ACTION ON THE ISSUE 3HOULDNT
CARE FOR VICTIMS OF SEXUAL VIOLENCE AND RAPE BE ONE OF OUR FIRSTPRIORITIES IN CONF LICT SETTINGS ESPECIALLY KNOWING THE SUFFERING IT
CAUSES ITS VICTIMS AND THE LONG TERM HEALTH CONSEQUENCES IT CANHAVE ON A WHOLE GROUP

*TEPJOHTPNFUIJOHFOPVHI%XPERIENCE HAS SHOWN THAT IT IS SOMETIMES DIFFICULT FOR -3& TEAMSTO ADDRESS THE CONSEQUENCES OF VIOLENCE WITHOUT BEING ABLE TO ACT ON
THE CAUSES .ONETHELESS WE SHOULD NOT DISCOUNT THE CARE THAT WE
MUST AND CAN PROVIDE TO PEOPLE EVEN IF IT MAY SEEM INADEQUATE GIV

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EN THE CHRONIC STRUCTURAL OR POLITICAL NATURE OF THE SITUATION 4HE
RESPONSIBILITY THAT MEDICAL PRACTITIONERS AND ORGANIZATIONS CARRY
IN THESE EMERGENCY SITUATIONS GOES FAR BEYOND A LEGAL CONCEPT )T
ALSO TOUCHES ON AREAS OF POLITICAL ETHICAL AND CIVIL RESPONSIBILITY/UR ABILITY TO PROVIDE COMPREHENSIVE CARE TO VICTIMS OF SEXUAL VIO
LENCE AND RAPE IS LIMITED 9ET WHEN ONE OF OUR DOCTORS SIGNS A MEDICAL CERTIFICATE AND HANDS IT TO THE PATIENT THIS ACT TO SOME EXTENTSYMBOLIZES THE UNIQUE RESPONSIBILITY THAT THE DOCTOR HAS TO PROVIDEASSISTANCE AFTER AN EPISODE OF SEXUAL VIOLENCE "Y SIGNING THE DOCU
MENT THE DOCTOR IS COMMITTING HIM OR HERSELF PERSONALLY AND TAK
ING PART IN THE PRACTICE OF INDIVIDUAL MEDICINE WITHIN GROUP AND
PUBLIC HEALTH CARE SYSTEMS 4HIS CAN BE A HEALTHY EXERCISE FOR BOTH
THE DOCTOR AND THE PATIENT WHEN THE SUFFERING OF SO MANY VICTIMSOF SEXUAL VIOLENCE IS OFTEN REDUCED TO STATISTICS LACKING ANY NAMESOR FACES !ND IT SHOULD CONTINUE TO BE THE ETHICAL FOUNDATION ON
WHICH OUR MEDICAL PRACTICES ARE BASED

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/VER THE LAST FEW DECADES -3& DOCTORSALONG WITH OTHER HEALTH WORKERS IN THE
DEVELOPING WORLD HAVE BEEN DISMAYED TO
SEE THE STRUGGLE WITH MALARIA BECOME MORE
AND MORE DIFFICULT %RADICATION EFFORTS IN
THE 5NITED 3TATES AND %UROPE WIPED OUT
MALARIA BY THE S "UT IN MOST PARTS OF!SIA !FRICA AND ,ATIN !MERICA THE RAPID
DEVELOPMENT OF PARASITE RESISTANCE TO MEDI
CINES AND GROWING RESISTANCE OF THE MOS
QUITO VECTOR TO INSECTICIDES HAVE COMBINEDWITH WANING 7ESTERN INTEREST IN THE FORMERCOLONIAL WORLD TO DEFEAT ERADICATION EFFORTS

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4ODAY   MILLION PEOPLE DEVELOP MALARIA EACH YEAR n FAR MORE THAN IN THE S
/F THE ESTIMATED ONE MILLION PEOPLE WHO
DIE FROM THE DISEASE EACH YEAR  PERCENT
ARE !FRICAN CHILDREN UNDER THE AGE OF FIVE
-ALARIA CONTINUES TO BE THE NUMBER ONE
CAUSE OF ILLNESS ADDRESSED BY OUR PROGRAMS,AST YEAR ALONE MORE THAN A MILLION PEOPLE
WERE TREATED BY -3& FOR THE DEADLY FORM OF
THE DISEASE FALCIPARUM MALARIA

&RUSTRATED BY THE POOR AVAILABILITY OF EFFEC
TIVE MEDICINES AND DIAGNOSTIC TOOLS -3&
BEGAN THREE YEARS AGO TO DRAW ON ITS FIELD
EXPERIENCE TO PRESS THE INTERNATIONAL COM
MUNITY TO TAKE GREATER RESPONSIBILITY FOR
INCREASING ACCESS TO MALARIA TREATMENT"ECAUSE MANY OF THE OLDER MALARIA TREAT
MENTS SUCH AS CHLOROQUINE AND FANSIDARHAVE BECOME ALMOST COMPLETELY INEFFECTIVE
A NEW LINE OF MEDICINES KNOWN AS ARTEMISININ BASED COMBINATION THERAPY !#4
HAS BEEN DEVELOPED RECENTLY 4REATMENT
WITH !#4 TAKES JUST THREE DAYS AND COSTS AS
LITTLE AS 53  PER CHILD AND 53 PER ADULT
-3& HAS DEMONSTRATED THE EFFECTIVENESS OF
THESE NEW TREATMENTS )N A HIGH TRANSMISSION AREA IN !NGOLA FOR EXAMPLE ADMISSIONS FOR SEVERE MALARIA WERE REDUCED BY PERCENT IN THE YEAR FOLLOWING THE INTRODUCTION OF !#4 /VER THE SAME PERIOD MORTALITY WAS REDUCED BY  PERCENT COMPARED TO
THE PREVIOUS YEAR .&%&$*/44"/4'30/5*&3&4"$5*7*5:3&1035

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THE WORLD n TO PROVIDE TREATMENT FOR FREE )N
ADDITION WHILE DEMAND WORLDWIDE FOR !#4
HAS INCREASED PHARMACEUTICAL COMPANIESTHAT HAD PROMISED TO INCREASE PRODUCTION TO
MEET THE NEED HAVE FAILED TO DO SO

)N PART BECAUSE OF SUCH EVIDENCE THERE IS
NOW WIDESPREAD RECOGNITION BY DONORS 5.
AGENCIES AND AFFECTED COUNTRIES THAT !#4S
MUST BE MADE AVAILABLE AS SOON AS POSSIBLE
TO HALT MALARIA DEATHS MAINLY OF YOUNG
CHILDREN WHO ARE NOT TREATED ADEQUATELY-OST COUNTRIES IN SUB 3AHARAN !FRICA HAVESWITCHED THEIR NATIONAL TREATMENT POLICIESFROM USE OF OLDER INADEQUATE TREATMENTS TO!#4 BASED THERAPY

3ECOND THERE IS NOT ENOUGH MONEY TO ALLOW
MALARIA BURDENED COUNTRIES TO PROVIDETREATMENT FOR FREE )N "URUNDI FOR EXAMPLE
THE MAIN PROBLEM WITH TREATMENT IS THE
COST )N THE LAST FEW YEARS THE GOVERNMENTCHANGED ITS MALARIA TREATMENT POLICY TO!#4 FUNDING WAS PROCURED TRAINING WAS
IMPLEMENTED AND THE OLD INEFFECTIVE DRUGSWERE REMOVED FROM CLINICS "UT LIKE MANYCOUNTRIES "URUNDI HAS BEEN PERSUADED BY
THE 7ORLD "ANK THAT IT NEEDS TO CHARGE A
SMALL FEE FOR A MEDICAL CONSULTATION ,ARGELY
AS A CONSEQUENCE OF THIS DECISION PATIENTSARE BEING DENIED EFFECTIVE TREATMENT /NE-3& SURVEY CONDUCTED IN THE COUNTRYS-AKAMBA PROVINCE FOUND THAT FEWER THAN
 PERCENT OF PATIENTS WITH MALARIA WERE
TREATED WITH !#44HIS PAYMENT POLICY HAS BEEN PROMOTED IN
THE HOPE THAT hCOST SHARINGv OR hCOST RE
COVERYv SCHEMES WILL MAKE HEALTH SYSTEMSIN POOR COUNTRIES MORE SUSTAINABLE 4HIS ISA FALSE HOPE IN THESE VERY POOR COUNTRIES2ATHER THAN ADDING INCOME TO THE HEALTHSYSTEM COST SHARING HAS PROVEN TO BE A VERYEFFECTIVE WAY OF KEEPING THE POOREST FROMRECEIVING TREATMENT-3& STUDIES HAVE SHOWN THAT THE DEATH
RATE FROM MALARIA GOES UP WITH INCREAS
ING HEALTH SERVICE CHARGES /NE STUDYCONDUCTED EARLIER THIS YEAR IN #HAD FOUND
THAT THE COST OF !#4 WAS A HEAVY FINANCIAL
BURDEN FOR MOST &OR HALF OF THE PEOPLESURVEYED THE PRICE PAID AT THE HEALTH CENTERWAS EQUIVALENT TO AT LEAST  DAYS OF INCOME
FOR THE POOREST  PERCENT IT EXCEEDED THEIRMONTHLY REVENUE 3EVENTY PERCENT OF THOSEWHO SOUGHT MEDICAL ASSISTANCE NEEDED TO
SELL GOODS OR BORROW MONEY TO PAY FOR IT
4HESE POLICIES ALSO HAVE BEEN FOUND TOPREVENT EFFECTIVE DIAGNOSIS #ONFIRMATION
OF CLINICALLY SUSPECTED MALARIA BY EITHER MICROSCOPY OR RAPID DIAGNOSTIC TEST IS A CRUCIALPART OF TACKLING MALARIA EFFECTIVELY 4HESE
TESTS ARE NEEDED FOR TWO IMPORTANT REASONSTO CONFIRM THAT A PATIENT HAS MALARIA SO
THAT !#4S ARE NOT MISUSED AND TO ENCOURAGE CORRECT DIAGNOSIS SO THAT OTHER CAUSESOF FEVER CAN BE TREATED OFTEN ALL FEVERS ARE
ASSUMED TO BE MALARIAL  -3& TEAMS HAVEFOUND THAT THE AVAILABILITY OF MICROSCOPYIS LIMITED BY LACK OF SUFFICIENT NUMBERS OF
TRAINED TECHNICIANS AND THE USE OF RAPIDDIAGNOSTIC TESTING IS LIKE !#4 LIMITED BYSHORT SIGHTED POLICIES THAT DEEM THEM TOO
EXPENSIVE"QPMJUJDBM OPUBNFEJDBMQSPCMFN
&OR -3& IT IS CLEAR THAT THE MAJOR PROBLEMS INVOLVED IN TACKLING MALARIA ARE NOTTECHNICAL MEDICAL OR SCIENTIFIC )T IS ENTIRELYFEASIBLE TO PRODUCE ENOUGH !#4S AND TO
ENSURE THEIR DISTRIBUTION SO THAT TREATMENTCAN REACH PEOPLE IN NEED "UT THAT WILL ONLY
HAPPEN IF THERE IS URGENT AND SUFFICIENT PO
LITICAL ACTION 4HE RESPONSIBILITY FOR CURING
MALARIA CANNOT LIE WITH A CHILDS POVERTYSTRICKEN FAMILY 4HE RESPONSIBILITY LIES WITH
THE INTERNATIONAL COMMUNITY WHICH CAN
AND MUST PROVIDE THE FUNDS TO TREAT EVERY
CHILD AND ADULT SUFFERING FROM THIS ENTIRELYCURABLE DISEASE%FOJFEFGGFDUJWFUSFBUNFOU

!T THE INTERNATIONAL LEVEL TWO MAJOR ISSUESPERSIST THERE IS A CRITICAL SHORTAGE OF !#4S
AND NOT ENOUGH MONEY TO ALLOW MALARIABURDENED COUNTRIES n AMONG THE POOREST INª+VMJF3ÏNZ

(OWEVER THE PROBLEM IS FAR FROM SOLVED
%VEN WHERE NEW POLICIES ARE IN PLACE -3&
HAS OBSERVED THAT EFFECTIVE DIAGNOSIS AND
TREATMENT REMAINS AVAILABLE TO ONLY A TINYPROPORTION OF THOSE WHO NEED IT !LTHOUGH
 !FRICAN COUNTRIES HAVE AGREED TO USE!#4S ONLY  HAVE BEGUN TO DO SO ANDONLY A HANDFUL HAVE DONE SO NATIONALLY

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JO4PVUI"GSJDB4HE SHAPE OF THE 4" EPIDEMIC HAS BEEN DRAMATICALLY AFFECTED
BY ()6 4" IS ONE OF THE WORLDS LEADING CAUSES OF DEATH
ESPECIALLY IN DEVELOPING COUNTRIES 4HE 7ORLD (EALTH/RGANIZATION 7(/ ESTIMATES IT KILLS TWO MILLION PEOPLE
EACH YEAR AND ANOTHER EIGHT MILLION BECOME ILL 7HILE ONE
THIRD OF THE WORLDS POPULATION IS INFECTED WITH THE MYCOBACTERIUM MOST PEOPLE DO NOT BECOME SICK UNLESS THEIR IMMUNESYSTEM IS COMPROMISED !ND THAT IS EXACTLY WHAT THE ()6
VIRUS DOES 4ODAY 4" IS THE LEADING CAUSE OF DEATH AMONGPEOPLE LIVING WITH ()6 $ESPITE THIS FACT FEW COUNTRIES HAVEPROGRAMS THAT PROVIDE 4" TREATMENT ALONGSIDE ()6 CARE
-3& HAS BEEN SPEARHEADING EFFORTS TO INTEGRATE CARE FOR PEO
PLE LIVING WITH 4" AND ()6!)$3 IN +HAYELITSHA 3OUTH!FRICA A POOR URBAN TOWNSHIP NEAR #APE 4OWN )N  IN
COOPERATION WITH THE 0ROVINCIAL !DMINISTRATION OF THE
7ESTERN #APE AND THE CITY OF #APE 4OWN -3& STARTED A PILOTPROJECT AT +HAYELITSHAS 3ITE " 5BUNTU CLINIC +HAYELITSHA HAS
THE HIGHEST 4" INCIDENCE   NEW CASES FOR EVERY  
PEOPLE PER YEAR AND ONE OF THE HIGHEST ()6 PREVALENCE RATES PERCENT IN THE METROPOLITAN AREA 4HE CLINICS hONE STOPv
SERVICES QUICK REFERRALS AND CAREFUL MONITORING OF BOTH 4"
AND ()6 PATIENTS HAVE MADE IT THE BUSIEST CLINIC IN THE
7ESTERN #APE FOR BOTH 4" AND !26 TREATMENT

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7ORD HAS TRAVELED QUICKLY THAT PATIENTS CAN NOW GET CARE FOR
BOTH ILLNESSES AT THE SAME PLACE AND THE WAITING ROOM IS FULL
EVERY MORNING AT  h4HE PATIENTS ARE COMING v SAYS 'ILLES
VAN #UTSEM AN -3& PHYSICIAN WORKING AT THE 5BUNTU CLINICh4HIS CLINIC IS SEEING MORE PATIENTS THAN OTHERS )NTEGRATIONIS WORKING FOR PATIENTS 4HEY KNOW IT MAKES IT EASIER TO GETCAREv)NTEGRATING 4" AND ()6!)$3 CARE HAS NOT BEEN EASY AS
TREATMENT FOR BOTH ILLNESSES HAVE HISTORICALLY BEEN PROVIDED
THROUGH SEPARATE PROGRAMS IN THE 7ESTERN #APE REGION RUN

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BY DIFFERENT HEALTH AUTHORITIES 7HILE MEDICAL TEAMS ON THE
GROUND SEE THE OBVIOUS NEED AT A HIGHER LEVEL PROTECTING EXISTINGPROGRAMS AND AREAS OF CONTROL OFTEN SEEM TO HAVE PRIORITY OVER
IMPROVED MORE EFFICIENT PATIENT CARE

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4" IS MORE DIFFICULT TO DETECT IN ()6 POSITIVE PATIENTS AS THEY TENDTO CONTRACT LESS COMMON MORE DIFFICULT TO DIAGNOSE TYPES OF THE
DISEASE 4HE FACT THAT IN MANY COUNTRIES DIFFERENT HEALTH STAFFS AND
DEPARTMENTS HANDLE DIAGNOSIS AND TREATMENT FOR THESE TWO ILLNESSESMEANS THAT MANY PATIENTS FOUND TO HAVE ONE DISEASE MAY NOT BE
TREATED OR EVEN TESTED FOR THE OTHER %VEN WHEN THEY ARE REFERRED FORTESTING OR CARE MANY PATIENTS MUST VISIT MULTIPLE HEALTH CENTERS TO
GET THE CARE THEY NEED (EALTH CARE PROVIDERS ALSO FACE FRUSTRATINGOBSTACLES IN GETTING SICK PATIENTS TESTED AND STARTED ON TREATMENTBECAUSE OF THE SEPARATE SYSTEMS

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0LUS THE 7(/S COMMITMENT TO DAILY DIRECTLY OBSERVED 4" TREAT
MENT HAMPERS EFFORTS TO INTRODUCE MORE F LEXIBLE AND ADAPTED TREAT
MENTS h-3& IS ONE OF THE FEW ORGANIZATIONS WORKING TO MAKE INTEGRATION A REALITY IN 3OUTH !FRICA v SAYS -ARTA $ARDER COORDINATOR
OF -3&S !CCESS TO %SSENTIAL -EDICINES #AMPAIGN IN 3OUTH !FRICA
0LACES LIKE THE 5BUNTU CLINIC SHOW THAT ON A SMALL SCALE INTEGRATIONIS WORKING BUT A LOT STILL NEEDS TO HAPPEN 5BUNTU IS ONE OF ONLY A
HANDFUL OF 3OUTH !FRICAN HEALTH CENTERS THAT ARE OFFERING INTEGRATEDCARE FOR 4" AND ()6 PATIENTS AND ALL OF THESE EFFORTS PALE IN COM
PARISON TO THE IMMENSE NEED FOR THEM

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0OFTUPQTFSWJDFT'OOD VENTILATION FOR THE NEW CLINIC IS ESSENTIAL TO DISCOURAGE TRANSMISSION OF 4" AS MORE THAN  PATIENTS COME THROUGH THE CLINIC
EACH DAY !LL NEEDED 4" AND ()6 SERVICES ARE AVAILABLE AROUND THE
PERIMETER OF THE NEW CLINIC 4HE CLOSE PROXIMITY REDUCES WAITING
AND TRAVELING TIME FOR PATIENTS AND MAKES REFERRALS MUCH EASIER
h"EFORE IT WAS ALWAYS FRUSTRATING WHEN YOUD KNOW A PATIENT HAS 4"
CLINICALLY BUT YOU HAD TO SEND THE PATIENT TO ANOTHER PLACE TO BETESTED v SAYS 3HAHEED -ATEE THE PRINCIPAL MEDICAL OFFICER OF THE
5BUNTU CLINIC WORKING FOR THE 0ROVINCIAL !DMINISTRATION OF THE
7ESTERN #APE h)NVARIABLY PATIENTS GET LOST IN THE SYSTEM 3O NOWTHAT WEVE MOVED OVER TO THE ()6 SITE WITH THE 4" CLINIC HERE IT IS
MUCH EASIER FOR ME TO SAY @9OUVE GOT 4" ,ETS GET YOU STARTED ON
4" TREATMENT )T MAKES IT EASIER FOR THE PATIENTS 9OU KNOW YOURPATIENT DOESNT HAVE TO GO IN YOUR QUEUE AND TOMORROW STAND IN
ANOTHER ONEv"ECAUSE THE SAME PATIENTS OFTEN FACE BOTH ILLNESSES MEDICAL STAFF
NEED TO BE ALERT TO SIGNS OF CO INFECTION AND POSSIBLE DRUG INTERACTIONS AND SIDE EFFECTS 2EGULAR CONSULTATIONS WITH A DOCTOR OR NURSE
ARE A CRUCIAL PART OF FOLLOW UP CARE FOR ALL ()6 POSITIVE PATIENTS
4HEY TAKE PLACE EVERY FEW MONTHS n MORE OFTEN IF THERE ARE COMPLICATIONS 4HE MEDICAL STAFF CHECK THE PATIENTS IMMUNE SYSTEMWEIGHT ADVERSE REACTIONS AND ADHERENCE TO TREATMENT()6!)$3 PATIENTS DISPLAYING SIGNS OF 4" ARE QUICKLY REFERRED FORTESTING )N THE SAME WAY 4" PATIENTS ARE ENCOURAGED TO BE TESTED
FOR ()6 ONCE THEY HAVE BEEN ON 4" TREATMENT FOR TWO MONTHS IF
THEY HAVENT DONE SO ALREADY !PPROXIMATELY  PERCENT OF THE CLIN
ICS 4" PATIENTS TESTED HAVE BEEN FOUND TO BE CO INFECTED WITH ()6)F THEY ARE FOUND TO BE POSITIVE THEY ARE SENT TO SEE ONE OF THE ()6
NURSES 4HEY HAVE BLOOD TAKEN TO CHECK THEIR IMMUNE SYSTEM AND
RECEIVE COUNSELING &ROM THEN ON THEIR CASE WILL BE JOINTLY MAN
AGED 7HILE TAKING THEIR 4" MEDICINE THEY WILL BE PREPARED TO
START LIFE EXTENDING ANTIRETROVIRAL !26 TREATMENT IF NEEDED 
4HEY WILL ALSO BE EXAMINED BY THE MEDICAL STAFF FOR OTHER OPPORTUNISTIC INFECTIONS 4HOSE WHO REFUSE TO BE TESTED ARE REGULARLYENCOURAGED BY THE STAFF TO CHANGE THEIR MIND

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4HE MAJORITY OF THE CLINICS PATIENTS ARE WOMEN )N 3OUTH !FRICA
THE CLINICS DOCTORS SAY THE AVERAGE 4" AND ()6 PATIENT IS A WOMANIN HER S WHO OFTEN HAS CHILDREN SOME OF WHOM ARE ALSO ()6
POSITIVE h)TS EASIER FOR A WOMAN TO BECOME INFECTED WITH ()6 v
EXPLAINS $R 3ARANCHUK h0LUS WOMEN ALSO TEND TO COME FOR HELPEARLY WHEREAS MEN HERE WAIT UNTIL THEYRE ALMOST DEAD BEFORE THEY
COME INv

0ROMOTING SELF RESPONSIBILITY THROUGH COUNSELING HAS BEEN A KEY
ELEMENT TO TREATMENT COMPLIANCE FOR THOSE TAKING !26S "EFORE
TREATMENT IS STARTED AT THE 5BUNTU CLINIC PATIENTS ARE EDUCATEDABOUT THE DISEASE AND HOW !26 TREATMENT WORKS 4HEY MUST ALSOMEET CERTAIN CONDITIONS BEFORE IT CAN BEGIN 4HESE INCLUDE DISCLOSING THEIR ()6 POSITIVE STATUS TO AT LEAST ONE PERSON SELECTING A
hTREATMENT ASSISTANTv TO HELP THEM COMPLY WITH DAILY TREATMENTREQUIREMENTS AND PROMISING TO KEEP NECESSARY MEDICAL AND COUN
SELING APPOINTMENTS AT THE CLINIC /NCE PATIENTS ON !26S HAVE BEEN
ON TREATMENT FOR A FEW MONTHS AND SHOW GOOD ADHERENCE THEY ARE
GIVEN MONTHLY OR EVEN BIMONTHLY SUPPLIES OF THE MEDICINE TO SIM
PLIFY THEIR OWN LIVES .EW 4" PATIENTS ARE ALSO EDUCATED ABOUT THEIRDISEASE ITS TREATMENT AND THE IMPORTANCE OF COMING TO THE CLINICFOR REGULAR MONITORING

-OST PREGNANT WOMEN  PERCENT IN +HAYELITSHA AGREE TO BE TESTED FOR ()6 4HOSE MOTHERS FOUND TO BE POSITIVE ARE OFFERED TREAT
MENT TO HELP REDUCE THE RISK OF TRANSMISSION OF THE VIRUS TO THEIRNEWBORN )N  -3& SAW APPROXIMATELY  CHILDREN IN ITS CLINIC
AND ABOUT HALF OF THEM WERE TAKING !26S
/NCE A DIAGNOSIS OF 4" AND ()6 IS CONFIRMED OTHER PROBLEMS SUR
FACE IN PROVIDING TREATMENT TO CHILDREN 3OME ()6 DRUGS ONLY EXISTIN TABLET FORM OR IN FOUL TASTING SYRUPS REQUIRING REFRIGERATION
/THERS CALL FOR FREQUENT ADMINISTRATION AN EMPTY STOMACH AND LOTS
OF CLEAN WATER "ECAUSE OF DRUG INTERACTIONS BETWEEN SOME COMMON
4" AND ()6!)$3 DRUGS CHILDREN MAY NEED MORE EXPENSIVE DRUGSOR SECOND LINE !26 MEDICINES THAT MAY NOT BE AVAILABLE /THERDRUGS HAVE NOT BEEN STUDIED IN CHILDREN AND THEREFORE CANNOT BE
USED WITH VERY YOUNG PATIENTS 4HE PROBLEM OF LACK OF TREATMENT FOR
CO INFECTED INFANTS AND CHILDREN WILL BE FACED MORE AND MORE OFTENBY HEALTH CARE STAFF TRYING TO TREAT THEM

5IFEJGGJDVMUJFTPGEJBHOPTJOH5#0ATIENTS THOUGHT TO HAVE 4" ARE GIVEN A hSPUTUM TESTv 4HIS TESTRELIES ON FINDING SIGNS OF 4" IN THE MATERIAL AN INFECTED PATIENT CAN
COUGH UP FROM THEIR LUNGS (OWEVER MANY ()6 POSITIVE PATIENTSDEVELOP TYPES OF 4" THAT ARE DIFFICULT TO DIAGNOSE WITH THIS TEST/FTEN THE BACTERIA ARENT FOUND IN THE SPUTUM OF ()6 POSITIVEPATIENTS h4HE MATURATION OF THE ()6 EPIDEMIC HAS MEANT MORE
SPUTUM NEGATIVE CASES v SAYS $R #HRISTINE 6ILLIER A 4" SPECIALISTWORKING FOR THE CITY OF #APE 4OWN AT THE +HAYELITSHA CLINICS h"UT
THE MESSAGE DIDNT GET ACROSS THAT THE PATIENT NEEDED FURTHER ASSESSMENT IF THEY WERE SPUTUM NEGATIVE 3O THEY WOULD JUST COME BACKLATER SICKERv

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NATIONAL 4" PROGRAMS THAT FOCUS ON hSPUTUM POSITIVEv PATIENTS AS
RECOMMENDED IN THE PRE ()6 ERA )N THE PAST THE TYPICAL PATIENTWAS CONSUMPTIVE COUGHING AND LOSING WEIGHT !LTHOUGH THATPATIENT PROFILE IS STILL THE MOST PREVALENT ONE MANY OTHERS HAVEATYPICAL SYMPTOMS OF 4" 4HE NUMBER OF PEOPLE WITH EXTRAPULMONARY 4" 4" OUTSIDE OF THE LUNGS IS GOING UP AND THAT IS LINKED TO()6 0ATIENTS AT THE 5BUNTU CLINIC WHO SEEM TO HAVE SIGNS OF 4"
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TREATMENT MAY BE STARTED THE SAME DAY BEFORE A CLEAR CONFIRMATIONIS MADE

4O BE CURED OF 4" A PATIENT MUST TAKE FIVE OR SIX PILLS EVERY DAY FOR
SIX TO EIGHT MONTHS 4HE 7(/ HAS ADOPTED A STRATEGY ONE PART OF
WHICH CALLS FOR PATIENTS TO TAKE DAILY MEDICINE IN FRONT OF A HEALTH
WORKER OR TRAINED COMMUNITY WORKER OR FAMILY MEMBER TO ENSURE
THAT THEY FOLLOW THE PRESCRIBED TREATMENT SCHEDULE 7HEN STRICTLYFOLLOWED THIS $IRECTLY /BSERVED 4REATMENT BETTER KNOWN AS $/4
PLACES A HEAVY BURDEN ON PATIENTS WHO MUST TAKE THE TIME AND
MONEY TO TRAVEL TO GET THEIR MEDICINE AND BE WATCHED TAKING IT )T
ALSO PUTS DEMANDS ON HEALTH STAFF WHO MUST OBSERVE TREATMENT FOR
MANY PATIENTS EACH DAY 7(/ RECOGNIZES MANY OF THESE CONCERNSAND IS NOW IN THE PROCESS OF ADAPTING ITS GLOBAL 4" POLICY TO ADDRESSTHEM -3& AND SOME OTHER ORGANIZATIONS ADVOCATE A LESS RIGID
APPROACH TO $/4 BASED ON PATIENTS NEEDS AND THE REALITIES OF WHATCARE PROVIDERS ARE SEEING "ASED ON ITS EXPERIENCE -3& PROMOTESMODIFIED $/4 A SYSTEM IN WHICH PATIENTS TAKE THEIR 4" MEDICATION

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TO THE CLINIC AND THE DOCTOR TESTED ME FOR ()6 AND IT WAS YES )HAD TO CRY AND CRY ) TALKED TO THE COUNSELORS AND THEY SAID
h.O ITS NO GOOD $ONT CRY YOU MUST LIVEv 3O THEY TALKED TO
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AND THEY FOUND IT
3O ) HAD 4" AND ()6 ) HAD TO TAKE TABLETS FOR 4" AND ) WAS VERYVERY WEAK !ND ) HAD TO GO TO THE HOSPITAL AND WAS NOT FEELINGWELL AT HOME ) THOUGHT WITH THIS ()6 ) MUST GO THERE TO DIE )HAD TO TAKE THE TABLETS FOR EIGHT MONTHS FOR 4" !FTER EIGHTMONTHS ) WAS FEELING ALL RIGHT FEELING BETTER
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) STARTED VERY LOW ) WAS FEELING VERY BAD 3O )VE BEEN TAKEN
THEM SINCE  ) MUST STILL GO TO THE CLINIC) STARTED WORKING FOR -3& IN  )NSIDE )M FEELING SO GOOD
4HE 4" IS GONE .OW WHILE )M WORKING ) SEE PEOPLE WHO ARE
VERY SICK WHO HAVE THE SAME PROBLEMS ) TALK TO THESE PEOPLE )TELL THEM THAT ) WAS SICK TOO !ND NOW )M WORKING EVERY DAYn .ONKULULO +ILI A 4"()6 PATIENT IN +HAYELITSHA WHO NOWWORKS AS A CLEANER AT THE 5BUNTU CLINICOBSERVED BY A $/4 PROVIDER DURING THE FIRST FEW WEEKS OF TREAT
MENT INSTEAD OF DURING THE FULL TREATMENT TIME AND THEREAFTER BERESPONSIBLE FOR TAKING THEIR PILLS AT HOME 4HIS GIVES PATIENTS MUCH
MORE FREEDOM WHILE ENABLING HEALTH STAFF TO EXPLAIN TREATMENT AND
PROVIDE SUPPORT IF PATIENTS EXPERIENCE SIDE EFFORTS IN THE EARLY
PHASE OF TREATMENT 4O BOOST ADHERENCE TOOLS USED IN !)$3 TREAT
MENT HAVE BEEN DUPLICATED TO 4" PROGRAMS SUCH AS ADHERENCECOUNSELING AND DESIGNATING A hBUDDYv FOR EACH PATIENT

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LY /NCE A PATIENT IS CURED THERE IS NO GUARANTEE THAT HE OR SHE WILLNOT BE RE INFECTED ESPECIALLY THOSE WHOSE IMMUNE SYSTEM IS
ALREADY WEAKENED BY ()6!)$3
4HE FACT THAT -3& AND ITS PARTNERS CAN TREAT PEOPLE WITH 4" BUT
CANNOT ADDRESS THE REAL CAUSES FOR THE CONTINUED HIGH SPREAD OF THE
DISEASE IS FRUSTRATING h7E TREAT OUR PATIENTS FOR SIX MONTHS AND
THEN WE HAVE TO SEND THEM BACK TO THE SAME CONDITIONS WHERE THEY
GOT IT THE FIRST TIME v SAYS $R -ATEE h4HEY GO BACK TO THE OVER
CROWDING THE LACK OF SANITATION NO WATER NO ELECTRICITY THAT TYPE
OF THING 3O THERE ARE SOCIAL ISSUES THAT HAVE TO BE LOOKED AT BEFOREWE CAN EVEN SAY WE ARE GOING TO GET 4" UNDER CONTROLv
7ITH BOTH DISEASES AFFECTING SO MANY PEOPLE -3& BELIEVES 3OUTH!FRICA AND OTHER COUNTRIES HIT BY THE DUAL EPIDEMIC WILL HAVE TO
PUSH FOR INTEGRATION BASED ON THEIR OWN NATIONAL HEALTH SITUATION
AND POLITICAL CLIMATE h0EOPLE KEEP TRYING TO BLOCK INTEGRATION v
CONCLUDES $ARDER hBUT -3& KEEPS PUSHING BECAUSE MEDICALLY IT
MAKES SENSEv
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WHO ARE SUFFERING FROM 4" !S HERDERS THE !FARS MOVE THEIR ANI
MALS EVERY THREE OR FOUR MONTHS IN SEARCH OF GOOD GRAZING AREAS
AND ADEQUATE WATER 4HE REGIONS ONLY HEALTH FACILITIES ARE FOUND
MOSTLY IN TOWNS ALONG THE MAIN ROADS FAR FROM THE !FARS PASTURELAND AND WATER SITES 4HE AREAS REMOTENESS MAKES IT DIFFICULT FOR
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STAY IN ONE PLACE FOR A LENGTH OF TIME IF EFFECTIVE TREATMENT IS AVAILABLE AND FOOD AND HOUSING ARE SUPPLIED -3& ALSO HAS STAFF THATSPEAK THE NOMADS NATIVE LANGUAGE SOMETHING OFTEN LACKING IN
OTHER HEALTH FACILITIES-OST PATIENTS DIAGNOSED WITH 4" MUST TRAVEL DAILY TO A HEALTH CLIN
IC TO RECEIVE AND BE OBSERVED TAKING THEIR MEDICINES 4HIS IS PART OF
THE 7(/ STRATEGY TO CONTROL 4" CALLED $IRECTLY /BSERVED
4REATMENT 3HORT COURSE BETTER KNOWN AS $/43 3UPERVISINGPATIENTS TAKING THEIR MEDICATION IS DONE TO AVOID HAVING THEM MISSTREATMENTS WHICH CAN LEAD TO TREATMENT FAILURE AND TO THE EMER
GENCE OF RESISTANCE TO 4" DRUGS

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0ATIENTS VISIT THE NEARBY HEALTH CENTER DAILY TO BE DIRECTLY OBSERVED
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TREATMENT UNDER CLOSE SUPERVISION FOR THE FIRST FOUR MONTHS !FTER
THAT THEY ARE DISCHARGED AND PROVIDED WITH A THREE MONTH SUPPLYOF MEDICATION WHICH THEY ADMINISTER ON THEIR OWN 4HEY AREINSTRUCTED TO RETURN TO THE CENTER AFTER FINISHING ALL OF THE DRUGS FOR
A FINAL 4" SPUTUM TEST THAT WILL SHOW WHETHER THEY ARE CURED-3& OPENED THIS 4" CENTER IN  WITH THE AIM OF PROVIDING QUALITY 4" TREATMENT ADAPTED TO THE !FAR WAY OF LIFE 'ALAHA IS A CROSSROADS FOR NOMADS BRINGING THEIR HERDS TO THE LOCAL RIVER 4O MAXIMIZE THE CHANCES THAT THE NOMADS COMPLETE THEIR TREATMENT -3&
ADAPTED A PROGRAM USED SUCCESSFULLY IN +ENYA THAT WAS DESIGNEDSPECIALLY FOR NOMADIC POPULATIONS )TS CENTRAL IDEA IS THE CONSTRUCTION OF A hPATIENT VILLAGEv CONSISTING OF HOUSES BUILT IN THE VICINITY

h&OR NOMADS THIS IS A GOOD ADAPTED APPROACH v EXPLAINS $R
!YUB THE PROGRAMS MEDICAL COORDINATOR h4HEY HAVE DIRECT OBSERVATION FOR A LONGER INTENSIVE PERIOD BUT A SHORTER TREATMENT COURSE
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-3& MEDICAL TEAMS WILL TREAT AS MANY AS   SEVERELY MALNOURISHED CHILDREN IN.IGER DURING  n THE OVERWHELMING MAJORITY ON AN OUTPATIENT BASIS 4HIS NEW
APPROACH TO TREATMENT HAS GREATLY EXPANDED -3&S CAPACITY TO RESPOND TO A LARGENUTRITIONAL CRISIS AND IS HELPING TO SAVE MANY LIVES IN SOUTHWESTERN .IGER
0REVIOUSLY ALL SEVERELY MALNOURISHED
CHILDREN WERE HOSPITALIZED FOR PERIODSOFUP TO ONE MONTH SO THAT THEY COULD
RECEIVE MEDICAL CARE AND GRADUALLY
INCREASING QUANTITIES OF THERAPEUTICMILK 7ITH THE  INTRODUCTION OF
NEW PRODUCTS WHICH ARE ESSENTIALLY THE
SOLID EQUIVALENT OF THERAPEUTIC MILK
-3& HAS LARGELY SWITCHED TO THE AMBULATORY MANAGEMENT OF ALL CHILDREN NOTREQUIRING INTENSIVE MEDICAL CARE
4HIS NEW SOLID FOOD IS A READY TO USE
FORTIFIED PEANUT BUTTER PASTE THATREQUIRES NO PREPARATION WATER OR COOK
ING "ECAUSE IT COMES IN INDIVIDUAL
PACKETS THAT ARE RESISTANT TO MICROBACTERIAL CONTAMINATION IT CAN BE STORED FOR
MONTHS 5NLIKE THERAPEUTIC MILK POW
DERS THESE QUALITIES MAKE THE PRODUCTIDEAL FOR TREATING A SEVERELY MALNOURISHED CHILD AT HOME THUS SPARING THE
MOTHER THE NEED TO LEAVE THE REST OF HER FAMILY FOR AN EXTENDED PERIOD )NSTEAD THE
MOTHER BRINGS THE SICK CHILD ONCE A WEEK TO ONE OF -3&S AMBULATORY CENTERS WHERE
THE CHILD IS EXAMINED AND GIVEN MEDICAL TREATMENT IF NECESSARY ALONG WITH A WEEKS
SUPPLY OF THE SOLID THERAPEUTIC FOOD /NLY THOSE WHO DEVELOP COMPLICATIONS OR SEVERE
ILLNESSES ARE REFERRED TO ONE OF -3&S INPATIENT UNITS

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WHO HAS WORKED IN -ARADI 4AHOUA AND !GUIE .IGER hWE WOULDNT HAVE BEEN ABLE TO
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CENTRAL .IGERIAN TOWN OF 9ELWA (OMESWERE DESTROYED AND PEOPLE WERE KILLED
RAPED AND ABDUCTED AS INTER COMMUNAL VIO
LENCE F LARED "EFORE THE MILITARY BROUGHT
THE MASSACRE TO AN END AROUND  PEOPLE
HAD BEEN KILLED -3& STARTED TO PROVIDEEMERGENCY MEDICAL AID TO THOSE WHO HAD
F LED 7HILE TREATING MANY PHYSICALLY
INJURED AND SICK ADULTS AND CHILDREN IN DISPLACED PERSONS CAMPS MEMBERS OF THE -3&
TEAM BEGAN HEARING HORRIFIC STORIES ABOUT
WHAT PEOPLE HAD EXPERIENCED 4HE TEAMREALIZED THAT MANY SURVIVORS INCLUDING A
LARGE NUMBER OF CHILDREN WERE LIVING WITH
SEVERE PSYCHOLOGICAL TRAUMA )N RESPONSE-3& STARTED A PSYCHOSOCIAL PROGRAM TO HELPADULTS AND CHILDREN AS THEY RETURNED HOME
AND TRIED TO REBUILD THEIR SHATTERED LIVES
4HE PROGRAM FOR TRAUMATIZED CHILDREN USEDCREATIVE TECHNIQUES AND COMMUNITY SUPPORTTO ACHIEVE ITS SUCCESS(FUUJOHTUBSUFE
4HE -3& TEAM VISITED SCHOOLS AND COMMUNITY LEADERS IN 9ELWA TO EXPLAIN HOW CHIL
DREN MIGHT MANIFEST THEIR TRAUMA$IFFICULTY CONCENTRATING CRYING JAGSBECOMING EASILY UPSET IN THE CLASSROOMMISSING SCHOOL OR ABUSING SUBSTANCES n ANY
OF THESE BEHAVIORS MIGHT BE SEEN AFTER SUCH
AN EVENT h-AKING THE TEACHERS AND SCHOOLS
AWARE OF THE SYMPTOMS WAS A WAY TO OFFER
THEM SUPPORT SO THE TEACHERS WERENT SO
OVERWHELMED WITH CONTAINING THE EMOTION v EXPLAINS 'WEN 6OGEL THE -3& PSY
CHOLOGIST WHO DIRECTED THE -3& PROJECTh)TS ALL A BYPRODUCT OF THE TRAUMAv

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STERS LEARNED HOW THEIR FEELINGS AND BEHAVIORS WERE LINKED TO THEIR PERSONAL EXPERIENCES -3& COUNSELORS USED DRAMADRAWING BREATHING TECHNIQUES AND MOST OF
ALL MUTUAL LISTENING TO HELP REDUCE THE PSY
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APY AND COUNSELING TO APPROXIMATELY  
CHILDREN ENROLLED IN SCHOOLS IN 9ELWA AND
THE SURROUNDING AREA
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ASKED THE CHILDREN TO DRAW WHAT THEY HAD
EXPERIENCED IN -AY 4HE YOUNGSTERS LEANEDOVER THEIR PIECES OF PAPER CONCENTRATINGINTENSELY AS HORRIFIC SCENES TOOK SHAPE MEN
WITH OVERSIZED WEAPONS PEOPLE RIDDLED
WITH BULLETS BURNING HOUSES AND PEOPLE
WITH SEVERED LIMBS
h3OME CHILDREN FIND IT HARD TO EXPRESS THEIREMOTIONS AND TRAUMATIC MEMORIES VERBAL
LY v EXPLAINS 6OGEL h4HESE CHILDREN CANOFTEN PRESENT THEIR EMOTIONS BETTER BYDRAWING AND THE PICTURES THEY DRAW SHOW
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BERS OF THE TEAM ASKED THE CHILDREN TO
EXPLAIN THEIR DRAWINGS AND LISTENED TO THE
DESCRIPTIONS A FATHER BEING SHOT UNCLE
DECAPITATED SISTER ABDUCTED HOUSE RAN
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CROPPED UP HUNDREDS OF TIMES RECOUNTED
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TRARY THE SITUATION IS NOT STABILIZING AND
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HAD BEEN DISPLACED BY THE ONGOING VIOLENCEPLAGUING THE REGION 4HIS NUMBER INCLUDES
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IANS WHICH STILL INCLUDE SPORADIC FIGHTINGBEATINGS AND SEXUAL VIOLENCE )N ALL LOCATIONS WHERE -3& PROVIDES MEDICAL CARETEAMS CONTINUE TO SEE A SIGNIFICANT NUMBER
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ACTORS TO PROVIDE MORE HELP TO THE REGIONS
CIVILIANS&OR THE MAJORITY OF THE DISPLACED PEOPLE
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STAY IN A MORE URBAN ENVIRONMENT 3OME OF
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4WO DAYS LATER -3& STARTED IN CONJUNCTION WITH NATIONAL
EFFORTS TO PROVIDE EMERGENCY ASSISTANCE TO INDIVIDUALS IN NEEDOF MEDICAL CARE FOOD CLEAN WATER SHELTER AND OTHER BASIC
NECESSITIES 4HE MAJORITY OF -3&S WORK WAS CARRIED OUT IN DEVASTATED COMMUNITIES IN )NDONESIA AND 3RI ,ANKA ALTHOUGH
STAFF ALSO PROVIDED HELP TO PEOPLE IN 4HAILAND AND )NDIA )NITIAL
EXPLORATORY TEAMS ASSESSED THE NEED FOR AID IN -ALAYSIA-YANMAR "ANGLADESH AND 3OMALIA BUT DID NOT FIND ANY SERIOUS UNMET MEDICAL NEEDS
h!T NINE IN THE MORNING ) RECEIVED A MESSAGE FROM A FORMER COL
LEAGUE IN "IREUEN ON !CEHS EAST COAST &LOODING EVERYWHERE IT
SAID 4HEN ) SAW THE FIRST REPORTS FROM OTHER COUNTRIES HIT BY THE
DISASTER AND REALIZED THIS WAS SOMETHING VERY BIG 7E PUT A TEAMON STANDBY LOOKED AT EMERGENCY STOCK IN OUR WAREHOUSE STARTEDNEGOTIATING CLEARANCE WITH THE AUTHORITIES AND OF COURSE HAD
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THREE NURSES ARRIVED IN THE HARD HIT )NDONESIAN REGIONAL CAPITAL OF "ANDA !CEH ON  $ECEMBER 4HEY BROUGHT WITH THEM
 METRIC TONS OF MEDICAL AND RELIEF MATERIALS 4HE TEAMIMMEDIATELY SET UP A CLINIC AND BEGAN ASSESSMENTS AND RELIEF
OPERATIONS IN THE CITY 3HORTLY THEREAFTER MEMBERS OF THE TEAMTOOK TO THE AIR RENTING HELICOPTERS TO BYPASS WASHED OUT ROADSTO CONDUCT ASSESSMENTS AND DELIVER AID TO ISOLATED COMMUNITIESALONG THE COUNTRYS WESTERN AND NORTHEASTERN COASTS

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STAFF INCLUDING DOCTORS NURSES PSYCHOLOGISTS LOGISTICIANS AND
WATER AND SANITATION EXPERTS WERE WORKING IN THE AREA 4EAMSFOUND MANY SURVIVORS SUFFERING FROM INJURIES AND WOUNDSMANY OF THEM INFECTED RESPIRATORY TRACT INFECTIONS SKIN DISEASES AND MENTAL TRAUMA )N VARIOUS LOCATIONS -3& RAN MOBILE
CLINICS PERFORMED SURGERY CONDUCTED VACCINATION CAMPAIGNSAGAINST MEASLES AND TETANUS DISTRIBUTED SUPPLIES EVACUATED
PATIENTS BY HELICOPTER ORGANIZED AID DELIVERIES BY BOAT AND CAR
RIED OUT COUNSELING SESSIONS 4HE ORGANIZATION ALSO DONATED
FOOD SHELTER AND MEDICAL EQUIPMENT )N A FEW WEEKS -3& WAS
SUPPORTING HOSPITALS AND DISTRIBUTING MORE HOUSEHOLD ITEMSINCLUDING TENTS KITCHEN KITS AND TOOLS
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TRAGEDY PARTICULARLY DURING HEAVY RAINS -3& STAFF TRUCKED IN
CLEAN WATER BUILT LATRINES AND CLEANED AND DISINFECTED WELLS !SPEOPLE BEGAN TO RETURN TO THEIR VILLAGES IN THE MONTHS AFTER THE
DISASTER -3& SLOWLY HANDED OVER THE MAJORITY OF ITS WATER AND
SANITATION PROJECTS TO OTHER GROUPS BUT CONTINUED TO MONITOR
THE CAMPS FOR DISEASE OUTBREAKS'PDVTJOHPOUSBVNB/NCE EMERGENCY NEEDS HAD BEEN MET -3& CLOSED MANY OF ITSTSUNAMI RELATED PROJECTS IN THE BELIEF THAT IT WAS NOT THE ORGANIZATIONS ROLE TO CONDUCT THE LONG TERM DEVELOPMENT WORK AND
RECONSTRUCTION WORK THAT WOULD BE REQUIRED IN MANY PLACES
-3& HAS NOW REORIENTED MOST OF ITS WORK TO PROVIDE MENTALHEALTH CARE TO THOSE STILL HAUNTED BY THE TSUNAMI AND ITS TRAGICCONSEQUENCES )N *ULY   INTERNATIONAL STAFF AND MORE
THAN  NATIONAL STAFF CONTINUED TO WORK IN AFFECTED AREAS OF)NDONESIA AND )NDIA )N SOME AREAS -3& HAS BEEN ABLE TO
ORGANIZE NETWORKS OF LOCAL DOCTORS TO PROVIDE PSYCHOSOCIALSUPPORT OR HAS TRANSFERRED RESPONSIBILITY FOR MENTAL HEALTH
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THAT RECEIVE FAR LESS PUBLIC AND MEDIA ATTENTION BUT WHERE
HUMANITARIAN NEEDS ARE STAGGERING

ª'SBODFTDP;J[PMB)N AN EXTRAORDINARY SHOW OF SUPPORT THE PUBLIC CONTRIBUTED MILLION EUROS IN DONATIONS TO -3& TO PROVIDE EMERGENCYRELIEF TO PEOPLE AFFECTED BY THE TSUNAMI "Y THE END OF !UGUST -3& HAD SPENT  MILLION EUROS ON TSUNAMI RELATEDOPERATIONS 4HE ORGANIZATION EXPECTS THAT BY THE END OF IT WILL HAVE SPENT A TOTAL OF  MILLION EUROS FOR ACTIVITIES IN
THE REGION AFFECTED BY THE TSUNAMI &OR MORE FINANCIAL DETAILSSEE PAGE  

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8IBUJT$IBHBTEJTFBTF&IRST IDENTIFIED IN  #HAGAS DISEASE IS A
MOSTLY ASYMPTOMATIC PARASITIC DISEASE THATATTACKS THE HEART AND THE NERVOUS ANDDIGESTIVE SYSTEMS ! VERY SMALL PERCENTAGE
OF THOSE WHO ARE INFECTED BY THE INSECT THATCARRIES THE PARASITE DEVELOP AN IMMEDIATEAND POTENTIALLY LETHAL REACTION -OST CARRY
THE PARASITE FOR YEARS WITHOUT KNOWING IT
!PPROXIMATELY  PERCENT OF THOSE INFECTED
DEVELOP CHRONIC SYMPTOMS OVER A PERIOD OF TO  YEARS !S SYMPTOMS PROGRESS ONESQUALITY OF LIFE IS DEEPLY IMPACTED AND ULTIMATELY THOSE WITH THE DISEASE DIE PREMA
TURELY OF RELATED PROBLEMS %VEN WHEN COM
MON SYMPTOMS SUCH AS FATIGUE AND STOMACH
PAIN ARE IDENTIFIED MANY PEOPLE ARE MISDIAGNOSED BECAUSE OF IGNORANCE OF THE DIS
EASE /NLY A BLOOD TEST CAN ACCURATELY DIAGNOSE #HAGAS AND IN THE ABSENCE OF
CONCLUSIVE RESEARCH THERE IS DISAGREEMENTABOUT THE MOST APPROPRIATE TEST TO CONDUCT!PPROXIMATELY   PEOPLE DIE FROM#HAGAS DISEASE EACH YEAR IN ,ATIN !MERICA

AND  MILLION ARE AT RISK OF CONTRACTING IT
#OMBATING THE DISEASE IS NOT EASY DIAGNOSING IT IN THE ACUTE FIRST PHASE IS VERY DIF
FICULT AND TREATING IT IS EXTREMELY HARD ONCEIT HAS REACHED THE CHRONIC PHASE
4ODAY THERE ARE ONLY TWO MEDICINES AVAILABLE TO TREAT #HAGAS NIFURTIMOX AND BENZNIDAZOL WHICH ARE HIGHLY AGGRESSIVE DRUGSWITH CURE RATES OF  TO  PERCENT AT BEST&OR CHRONIC PATIENTS THOSE WHO HAVE BEEN
INFECTED MORE THAN  YEARS THE CURE RATEDROPS BELOW  PERCENT AND THE SIDE EFFECTS
ARE SO SEVERE THAT HEALTH PROFESSIONALS CONSIDER IT UNETHICAL TO TREAT THEM WITH THESE
MEDICINES
4HE SITUATION BEGS THE QUESTION 7HY WITH
SO MANY INDIVIDUALS INFECTED ARE THE DIAGNOSTIC AND TREATMENT TOOLS SO POOR 4HEANSWER IS LINKED TO THE FACT THAT THE DISEASE
MAINLY AFFECTS THE POOREST MOST MARGINALIZED PEOPLE OF ,ATIN !MERICA !LTHOUGH#HAGAS IS NOW STARTING TO AFFECT A BROAD

RANGE OF PEOPLE THROUGH UNSCREENED BLOOD
TRANSFUSIONS AND POPULATION MIGRATION IT
MOSTLY HARMS THOSE LIVING IN RURAL AREAS
WHERE THE VECTOR A COMMON BEETLE THRIVES"ECAUSE THE PHARMACEUTICAL INDUSTRY SEESLITTLE PROFIT TO BE GAINED THERE HAS BEEN NO
DEVELOPMENT OF #HAGAS MEDICINES FOR
DECADES

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THEY SHOULD HAVE BEEN A HEALTHY POPULATION  PERCENT OF THE WORKERS HAD BECOME ILLDURING THEIR FIRST SIX MONTHS IN )TALY !FTER  MONTHS IN THE COUNTRY  PERCENT OF THE
PEOPLE SURVEYED NEEDED TO SEE A DOCTOR !LMOST ALL OF THE IMMIGRANTS WHO SOUGHT A
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WHERE ) FOUND A PLACE TO SLEEP TOGETHER WITH OTHER !FRICANS 4HIS HOUSE IS NOT VERY BIG AND
THERE ARE  OF US SLEEPING HERE(ERE LIFE IS HARD ) GET UP AT  EVERY MORNING AND ) GO TO THE CROSSROADS WAITING FOR
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MENT DOES NOTHING TO HELP US ) ASKED FOR ASYLUM FROM THE )TALIAN GOVERNMENT ) HAVE A RESIDENCY PERMIT BUT ) CANT WORK ACCORDING TO THE LAW)N !FRICA PEOPLE THINK THAT IN %UROPE EVERYTHING IS EASIER 5NFORTUNATELY HERE IN )TALY )HAVENT FOUND THE PROTECTION ) WAS HOPING FOR AS A REFUGEE 4HE ONLY THING ) CAN DO TO SURVIVE IS WORK AS A FRUIT PICKER )TS HARD WORK AND BADLY PAID AND PRECARIOUS TODAY YOUWORK TOMORROW YOU DONT KNOW "ESIDES ) HAVE TO LIVE IN THAT HOUSE AND PAY RENT )N MY
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