2 July 2006
Doctors without Borders
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They operate in 70 countries, and give medical aid to those who need it most. The Médecins Sans Frontières international president is Australian Dr Rowan Gillies. This week on Background Briefing, he explains why it is important, but difficult, to stay clear of politics, cultural judgements, and too much co-ordination. And why they must sometimes just walk away.
Transcript
Transcript
This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.
THEME
Kirsten Garrett: This is Background Briefing on ABC Radio National. I'm Kirsten Garrett.
The International President of the medical aid organisations, Doctors Without Borders, is Australian doctor Rowan Gillies. In May, he spoke at the Seymour Centre, as part of the Sydney Ideas series. He took the audience through some of the realities of working on the ground in areas of catastrophe and conflict.
Dr Gillies says that Médecins sans Frontières, or MSF, must stay independent of politics and government, and the military, even sometimes other aid agencies. That independence isn't always as easy as it might seem. Rowan Gillies.
APPLAUSE
Rowan Gillies: The point of view that I speak from is a very kind of simple medical point of view. I call it the medical-humanitarian approach I suppose. And it's pretty much you've got someone who's sick and suffering, and you go and assist them based on their needs. And that's about it. Everything you do is based on need. The reason why you go to a specific patient is because they're sicker than another patient and for no other reason.
And the way I like to think of that is it's pretty much like what you expect from your doctor. You go to a doctor at the emergency department up at Prince Alfred, and they come in and you're sick, do you expect them to say 'Well look, what's going to be your benefit from me assisting you? Which political party do you belong to? Which electorate are you part of? Are you part of - should I be sending a message to that politician that he should or shouldn't do this and that over the assistance I give, or will they just say, Well you're the sickest, and you're the second sickest, so I'm going to go to you first and assist you based on that need. It's a very actual simple concept and based on very much a medical-ethical approach.
In the countries where we work and especially the countries of war, it's an impartial assistance, giving assistance based again purely on need. To do that, you need an independence of decision-making. The way we manage to have some independence of decision-making is independence of funding, but in the end you have to have independence from so many different pressures, whether it's political pressure, whether it's violent pressure or any other.
In the discussion this evening I'm not going to put any judgment on peace creation attempts, on development and on co-ordination. It's not saying that peace, conflict resolution, and development are bad things, it's just saying they're different things. If you get stuck in the George Bush approach of there's good and there's evil, then you have a problem, because one of the ideas around is that Well if we're all trying to do a good thing, therefore it's the same thing. And that's just not the case.
Kirsten Garrett: Speaking is Dr Rowan Gillies, International Head of Doctors Without Borders. His organisation operates in more than 70 countries to provide essential medical aid to those who need it most. Sometimes it is difficult to make sensitive decisions while there is chaos or conflict all around.
Rowan Gillies: I find the easiest way to discuss certain issues is talk about just field examples that we've had recently, or in the past few years, where these things are more obvious. We've just had Greg Elder, a New Zealand doctor who was our Head of Mission in Darfur during the very difficult years of 2004 and 2005. He has just been talking to people coming back just recently from Darfur, and there's a group of refugees that have come from Chad, which is unusual. Believe me, I've been Darfur, and if you're running away towards Darfur, you're having a real problem. And these people have left Chad to go to Darfur, and they're placed about 34 kilometres north in West Darfur. And we've been to assess them and there's a significant nutrition issue, and these people need food. The team there went to the World Food Program which have been doing an amazing job during 2005 to give assistance, and said Well these people need food. And they said, No, we can't do that. And naturally we asked why. And they said, Well, there's two reasons: 1) that group of people, that ethnic group, are aligned to a certain commander in Chad who is not agreeing with the peace process, therefore we can't assist his people, that's No.1. And No.2, although it's safe to go there, we might give the impression that it's safe all over Darfur, and we don't want to give that impression because we want everyone to understand how bad the security is and therefore to have a political response or military response.
So this is a situation where the humanitarian actor has made a decision based on political reasons not to assist. And that is very, very dangerous when you start along that line.
In Angola in 2002, there was a sort of a peace accord being drawn up, and then a few months later there was an agreement on the peace from the capital from Rwanda, the government forces. And one of the problems with the peace is that there were a lot of people in the so-called Grey Zone, they were people who'd been living under Unita control for many, many years, and had been actually at the point of starvation at this stage. There was a decision made by a number of humanitarian actors, and UN and various other actors, not to assist these people because they wanted to get a good peace deal from the government. The government said if you assist them, we will have a problem with the peace we're trying to create.
So this is a new situation where people were sacrificed for the purpose of creating a peace. We disagreed with that at that stage, and we went ahead and assisted those people, and there's thousands of people requiring assistance from malnutrition. Three years later we've discussed it with various actors, and they agree that it was a mistake at that stage, but at the time it's all very well to look at a mistake backwards, but for the people who died on the way, it's not that good for them.
There's many, many examples, unfortunately like this. Sierra Leone. I was there in 1999; I wanted to do an exploratory mission in the area of RUF. They're very nasty guys, this rebel group, they cut off hands and all this kind of stuff. But there's about seven nasty groups in Sierra Leone at this stage. The decision was made again, not to assist the people under their control because of the political ramifications it might have on the peace process, and we got a lot of flak for doing an exploratory program in that area. We did the program, it was successful to some degree, it was very unsuccessful in other ways, but the point was that your responsibility as a medical actor, a humanitarian actor is to assist not based on a political act.
When we talk about peacekeeping, look at the Democratic Republic of Congo. I worked there a couple of times last year, and there's a peacekeeping force, the Moluk, and they're getting more robust, they've got a quite robust mandate, a Chapter 7 mandate from the UN, which means that they can go out and be quite proactive in their actions, which means they end up killing people, and that's their job. Their job at times is to haul in militias and have battles with militias if required. They're one of the warring parties of this stage. The difficulty is though, that you have many humanitarian actors driving the same cars as the Moluk troops, just white Land Cruisers, and you have not just the UN, but other humanitarian actors going along with these convoys. And we're concerned about this, and when the militias came to us and said, Look, UN guys are killing us, we want to kill them. But we understand that you're humanitarian; how are we going to tell the difference, because a lot of humanitarian actors are driving around in these white cars. So we painted our cars pink, and I went to see the Director of Peacekeeping in New York, but he had a Russian aide with him, and I just told him we'd painted our cars pink, and the Russian guy said, We will never, ever paint our cars pink. So there was a small success there.
OK, I think one of the challenges we are having in the Democratic Republic of Congo is an incredible number of people who have been raped. The level of rape is incredibly high in that country and we're seeing more and more women and children and some men who've been raped. Now we've been asked by the International Criminal Court to hand over the medical certificates that we write for these people. When these people come in, we give them post-exposure prophylaxis for HIV-AIDS, treatment for sexually transmitted diseases, surgery if required, and so on. But we also give them a medical certificate. And the International Criminal Court has said, Well, we want that evidence because we want to go and look for the bad guys. This might seem a nice approach from the point of view of justice and personally I'm not against justice, however we've got a medical responsibility to look after that patient and the confidentiality for that patient. Secondly, we have a responsibility to try and stay in the country, and if we get involved as a humanitarian organisation, in the essentially political act of justice, there again we have a big problem. And to the point where the militias again are coming to us and saying, Do you give information to the International Criminal Court? Our answer is No, we don't, we don't collect information for that purpose, we collect it for medical purposes. So again, it's very important for us to separate ourselves from these attempts to create peace and justice. And the fact is, the more robust and the better they get at bringing in this justice even if it is generally symbolic, and one or two people get arrested, the more useful they are, the more we have to separate ourselves from these approaches. And in many ways that's what I would say about the human rights approach as well.
The human rights approach tries to give a framework of what is acceptable and what is not, and the better it gets at that, the more necessary it is to have someone acting outside that framework.
The other problem of course for justice is political. It's very hard to get very just justice in many ways, and I think the example in northern Uganda is a pertinent one. There's no doubt that there's been indictment of the Leaders of the Lords Resistance Army. But there's indictment of only one side of the conflict. That gives you an example of where justice is not perceived to be particularly just, and actually the LRA have said they will attack humanitarian actors and so on because they've been indicted by the Criminal Court.
So pretty much there's a humanitarian symbol and then there's the development approach and peace and justice approach. What I'm asking for is that these humanitarian symbol and approach is not co-opted by political desires, whether they are what you might consider appropriate ones, such as peacekeeping, or whether we act as a kind of after sales service for the military interventions, for example the one in Afghanistan.
As Colin Powell said, he said to NGOs, I think it was 2003? He described international NGOs as "an important part of our combat team." There is nothing worse for your security to have Colin Power saying that about your organisation, believe me. And we've actually had five people executed in Afghanistan in 2004, and it was claimed by the Taliban, (whether they did it or not is another question, it was claimed by them), and they said, Well, they're implementing American foreign policy, therefore they are a target.
What we basically need is separation of responsibilities based on the goals. On the goals of people.
I mentioned development before. I just want to give you a little example from Niger, which is last year. Niger's a very poor African country, reasonably peaceful. And there was a huge nutrition crisis there last year, to the point that we were getting thousands and thousands of malnourished children in various areas. The problem was that when you have malnourished children they usually need food, and we were giving them acute assistance, but they needed a general food distribution and basic injection of food into the system. Unfortunately from May, June and July last year, the Niger government, supported by the French government, as a donor, and also the WFP, the World Food Program, refused to give food for free, because they were concerned about damaging the market. So it's a clear balance of a future nebulous goal of having a good market and a good economy, versus people actually dying of starvation today. And there was a decision made at that stage not to give people food.
Since July, August, they started to give food out, and then the - actually the food didn't go to the right place when it was given, but after a few more months, the situation started to improve. But again, it's a clear example where there's a development policy and there's humanitarian requirements. You have the same people doing the same thing. These will always clash and often the political goals will supersede the humanitarian goals. That's just the nature of the way things work.
I mentioned co-ordination. I don't want to attack the UN too much because I'm being a bit negative about some of the things, and I think that many, many people in the UN system are trying their very best to make a difficult situation better. And there's a lot of positive work done. But there's an approach from the UN about co-ordination these days. There's a general belief that if everyone just co-ordinated, and things went in the right place, everything would be fine, the responses would work better. The problem I have with that, and I'll give you an example of the tsunami on Aceh, there were about 120 co-ordination meetings a week. Believe me, there's plenty of co-ordination, and maybe not particularly good co-ordination but it did exist. So this desire, Well there's not enough co-ordination, and it's one of the greatest excuses when there's a political decision not to do something, which may be for a good reason or for a bad reason, it's often passed off in the future as a technical problem. 'We just need to fix up the technical problems and then those things won't happen'.
Angola. the problem in Angola was said, 'Oh, it's more of a technical issue'. In Niger last year, we spoke out, and after speaking to everyone privately, then we spoke publicly saying 'This is unacceptable'. And it's been described by the UN Humanitarian Co-ordinator, 'The only problem there was a problem of co-ordination; MSF didn't co-ordinate their speaking in public with the UN'. We never had a desire to co-ordinate our speaking in public with them, the whole point was to try to get them to act. And there was a very well-co-ordinated holding back of assistance from a large group of people. So I think it's often one of the best excuses used, but not a particularly honest one.
But the desire at the moment is to have a system where basically the UN Humanitarian Co-ordinator, Jan Eckerlans his name is, he can basically press a button when there's a crisis, and MSF does the medical stuff; Oxfam does the water; Save the Children does mosquito net distribution, or whatever. And it's all going to happen, everything is going to work fine, that's the answer to the world's problems.
The danger is, I think you have to think about who is the UN? The UN is a group of governments with foreign policy. That's what it is. And more importantly, they actually have a lot of constraints put on them by this government. Everyone has different goals, some of them are good, some of them bad, but they are different. I think even dangerously it suggested there is a way to solve all the world's problems if we just integrate and co-ordinate together.
This is not only delusional, but incredibly dangerous, it's a utopian view of the fact that if we just get our act together, the world will get better, and unfortunately, from my point of view, it doesn't seem to work like that.
Finally, something much more dangerous than peace action alone or development action alone, is humanitarian action alone. There is a huge danger of thinking that humanitarian assistance is the answer. It's not the answer, it's a stopgap and that's all it is, that's all we're doing. We're putting a band aid on the problem, keeping people alive while the political actions can try and solve the problem.
An example where humanitarian action is used as a kind of alibi for not doing action is in Darfur, 2004. I was watching the BBC, and there's a British Member of Parliament, people are saying to him, 'What are you doing at Darfur, what's happening?' He said, 'It's OK, we're funding humanitarian organisations to respond to Darfur, we're doing our bit.' I think it's good that they are funding humanitarian organisations to respond. In fact at that stage we were one of them. The fact is though, governments have responsibilities. They've got responsibilities under international law, they've got responsibilities as members of the UN and so on, to try and get a political response to these problems. So they cannot hide behind purely humanitarian, purely responsive actions to essentially political problems. In the end, what I think is essential is that there is ability for different actors to act in conflict, and in many of these crises. The idea of trying to co-ordinate everything together and put everything in the one box that are clearly, clearly different goals and different responses, is a mistake and it's incredibly dangerous, mainly for the people we're trying to assist. Thanks.
APPLAUSE
Rowan Gillies: What I'd like to do now is really get things started with some questions, because I think it's a lot easier for me to - I'd rather not tell you what I would like to tell you, but ...
Kirsten Garrett: This is Background Briefing on ABC Radio National. The first question to Dr Rowan Gillies asked for further explanation of what he had meant about not mixing up humanitarian work with a tightly co-ordinated approach.
Rowan Gillies: The point is, there's a desire to say Well this is the answer to a problem. This is the humanitarian peace and conflict answer to all these issues. If we do this, we do this, we do this, we assist people here, we do a political action here, a political action there, this is the way we're going to fix the problems in a country. And whether it's co-ordinated by the UN or NATO or a government. We found that just doesn't work, because people have different goals, and it suggests that one response is the answer, and there's one idea as the answer. There is no problem at all with the military going to Afghanistan and assisting the population there. But don't pretend you're there purely for the benefit and the needs of the population. Governments do actions because they governments, they've got political responsibilities, either for their relationships with other governments, or to their own populace. It's a political decision to intervene in a country, and hopefully the political decision can often mean that they must help the population, but you get very confused and this is the problem we have in Afghanistan. A large number of people in Afghanistan feel that the people from the West, coming in at the moment, including the humanitarian actors, including all the different militaries, are an occupation force. And they feel that it's just like the old day with the Russians, and it's very difficult once you've confused the military objective and the democracy peacekeeping objective, with the humanitarian objective. Once you've confused that, it's very difficult just to go and say 'I'm here just to help, not to impose my system upon you.'
An example is the American army dropped leaflets in Afghanistan saying that 'If you want to get your aid, you have to give us information on al-Qa'eda, the Taliban, who are the other people? There's a couple of commanders and so on, that you've got to give us information on if you want to get your aid.' That is incredibly dangerous for us as actors, when our people died there were 50-something humanitarian workers killed, and even more dangerous for the population who are not going to get the assistance because of that.
Man: I was just wondering what do you think MSF's long-term goals are? And whether you see it changing in the future?
Rowan Gillies: The nature of our work is very short-term. I'm not convinced MSF should exist for a long time, I think if we keep doing what we say we're doing which is assisting people based on need, then we should keep existing. By the time you get institutionally protective, you start to protect your institution, and you do things for the reasons of protecting your institution and longevity, instead of the reasons that you say you're there for, then you're in a huge crisis. It's a bit like in Hitchiker's Guide to the Galaxy where they say you need faith to believe in God. And this guy proved that God exists, therefore God disappeared because proof denies faith, and God disappeared in a puff of logic. And for me, that's the same. If as MSF we start doing things to protect the institution instead of based on principles, we'll find that we will lose what makes us exist. So long-term goals, we need to improve what we do. That's the first thing. We provide medical assistance in 76 countries or something, 77 now if we get to Timor, we provide a reasonable standard of care. But that's not good enough I don't think. I think if you take the time to get someone into the field, if you take the time and money to get someone on site, I think the best thing is to buy as high quality assistance as you can, and at the moment we've improved dramatically on our treatment of malaria. Tuberculosis, we really haven't managed to deal with that issue, and with AIDS we were not treating with anti-retrovirals until 2001 and that was a disgrace. Now we're starting to treat and we're finding we don't actually have the tools to treat a large number of people in these countries. At the moment there's I think 5-million people who need anti-retrovirals today and about 1-million are getting them. So in the end, I think it's improvement in quality of what we do, but also the things we've been talking about this afternoon make it clear that it's possible for us to do our work based on need and not have political influence on the work we do.
Man: I've got a couple of questions if you don't mind, they're both quick. The first one is, I've got a bit of personal exposure to conflict between the political pressures playing out behind the scenes and the pure desire to help people. Personally, how do you go about dealing with that because I found personally myself there was a real tug-o'-war going on inside me, I just didn't know how to handle it, and I think I handled it very badly. And the second one is, I don't think we hear anything about the actual realities of how you deal with all the warring factions and all that, and I'm just quite interested in how that all sort of comes together and how you negotiate truces with these people and how they don't target you and how you sort of broker everything with all of them.
Rowan Gillies: On the first one, yes, dealing with the sort of political shenanigans and so on. It's about getting facts and exposing them in many cases. The first thing we do is we find out what's going on and is there pressure. Then we go to the people who are being pressured, or doing the pressure. We go and speak with them quietly, and say 'What's going on? This is unacceptable'. And how do we deal with warring commanders? I was putting to Francoise this afternoon about what do we do about late data from various warring factions, how do we get things to move along? And the first thing you do is you go to the guy who's the boss, and you go and say, 'Look, this is happening, this is unacceptable, you know what we're like, we might talk about it, so what are you going to do?' So that's one approach. If you want them to actually change some of the way they're acting.
When it comes to negotiating access, in the end there is a benefit from having us. There's no doubt there's a benefit from having us in their territory, because people, and I think Liberia's the place I've done probably the most discussions with warlords and so on. They've got to rely on a certain civilian population, whether it's through fear or anything else, they do need to rely on a certain civilian population. And if we can say Look, we're going to come and assist your civilian population, we're not going to help you in any way, we're not going to help you militarily, but we're going to assist that, and you can explain to them that maybe their mother might go to the clinic, or their family, or whatever, it is possible to negotiate this. In addition, you can speak to their much higher commander and you say How are we going to do this? If you want to be a respectable part of this war you're going to have to agree with the rules of war, and we speak to the ICR, International Committee of the Red Cross, who take control of the Geneva Conventions. We use any argument we can to try and get access, and try and allow them to help. And surprisingly, it's not so hard to convince people, especially warlords, that we can get access, as long as they understand we're separate from the democratised process that's going on, or the political process that's going on.
It's more difficult with extra territorial groups, and this is the problem we had in Iraq, because there's so many groups involved. We left Iraq in when was it? the end of 2004? I used to wake up every morning being really scared that we'd have someone kidnapped and on the television and so on. And we ended up leaving - the problem was some of the groups that have no other desire except to attack anyone that's Western, or perceived as Western or perceived as not the right kind of Muslim and so on, then you have a problem. The other people that it's very difficult to negotiate with are the Western actors. And I have this problem speaking to the people at the Pentagon and so on, they can't get over the idea that we're both good, and we're all doing good together, why can't we just get along? And this concept takes a bit of time and I find it easier to negotiate with a Liberian warlord, than with the Pentagon. And that's just the way it is. So yes, use whatever tool you can you can be honest, straightforward, and you do a good program. If you do a very good program you're churning out patients that are better, you're doing surgery, you're doing whatever, you're doing a proper program, then people see the benefit and they don't think you're there to spy, and you're not there to destroy their future.
Kirsten Garrett: The next person asked whether the organisation has considered Natural Hygiene, that is, using simpler, more natural ways of healing that might cause less harm than the drugs sold by the big pharmaceutical companies.
Rowan Gillies: Yes, certainly the research is run by industry, that's the way it is, although to be honest, a lot of the big research developments have been actually made by universities, I mean the HIV-AIDS advances were made by American universities, funded by public money and then sold back to industry and then developed. I find I like to use two things on evidence. We're medical doctors, and we do things on evidence-based. If a treatment works for malaria, I'm going to use it, I'm not going to use a natural product that is not proven. But the treatment we use for malaria are based on a Chinese herb that's been around for 3,000 years, and it's been purified and used in medication. The new medication where you get less chance of resistance and you get a better effect, and more chance of a cure.
We've got a natural substance group as well, looking at the different natural substances and testing them against disease. But we won't do anything unless it's scientifically proven, and that's our approach at this stage. Our minds are open but I think we're going to stick with the scientific paradigm for the moment.
Man: I totally agree with the philosophy; I think it's wonderful the way you put it. Let's say for instance there's an uprising in Togo. How does it get to your attention? How do you do the scoping? How do you work out how to respond? Who makes the decisions, because you do act very quickly?
Rowan Gillies: Usually we keep an eye on what's going on in different parts of the world especially places where we might have left recently. I'll give Sri Lanka as a good example. There's been recent increase in fighting; we left Sri Lanka about a year ago. And we may get requests from local people, from local doctors or local politicians or whatever, saying 'There is a problem, can you think about intervening. Or the UN might give us a call saying This is not our thing, but you might be able to intervene. And it depends which city you call. You call Paris, you get the Parisians, and if you call Amsterdam you get the Dutch, and if you call Sydney you get the Sydney-Parisian kind of approach. So it varies. We have five operational centres, and they all do emergency operations out of that area. So the first step is to get a little bit of evidence, find if we can land in that place and get some security on landing and then have a look. If it's something like the earthquake in Indonesia, and we already had teams there, we know pretty much a big earthquake like this, you need a nephrologist because of the crush syndrome, you need a surgical team. If you can do it in the first week. After the first week it's not that exciting, but if it's a displacement of people, things happen actually more slowly than you'd think. If there's fighting and so on, people get displaced, they finally congregate somewhere maybe three or four days later, and then you can go and do an assessment.
We've got this thing called a Rapid Health Assessment, and basically it's about betting information on demography, the people, the type of diseases they're having, the type of disease they might have potentially. Watch their water situation and so on. So you send a team in, the decision's made by one of the five operational centres whichever - they ring the other ones up and say Are you going? I'm going to go, and they make a decision between them. So that's on the phone, that usually takes about half an hour, or longer if they're fighting. About an hour. And then they send a team in the next day or two and they respond. Pakistan, we sent an Australian guy, Nick Lawson who's Head of Mission. I went to an art exhibition with him on the Sunday morning in Paris, and he left on the Sunday afternoon to go and he just got the call and went off, got on the ground, and then you make your assessment. Because there's a big danger - this is what happened a little bit in the tsunami and other things. You start making decisions without knowing what's going on and the reports you get are often wrong and often very confusing, and you find the focus of your program is - it might be what you want to do, but it may not be what people need. So we do take a bit of time to assess. But some things like measles or meningitis outbreaks, once you've got the figures, then we have a very fast rollout. If you've got a meningitis problem (I think it was Chad, we had one), then you can send a team quite quickly within a few days, get the vaccines and logistically we're reasonably good but we're actually trying to improve.
Woman: Hi Dr Gillies, just a question it's probably in the vein of how do you cope with the politics and things. How do you cope when you're in a lot of African countries? I've been reading a fair bit about cultural issues that people have problems with like the female genital mutilation? How do you deal with something like that, even just as a doctor or as a sort of person without getting too involved? Do you actually take a stand and say that you think something is right or wrong?
Rowan Gillies: I think on a medical bases we can take a stand but not on cultural bases. So for example, we won't do female genital mutilation. But then again these women keep coming in with sepsis from their genital mutilation and people come and ask for a cleaner razor; do you give them that? We don't do that, but it's an ethical question which doesn't have a particularly straightforward answer. And to be honest, things like abortion, but we don't take a public position on specific abortion in the country where it's illegal, for example, because our ability to assist women in a certain context may be limited by that. So it really depends on the context, on the issue. But you also have to be careful that you're looking after the patient you've got instead of necessarily the cultural mores. Having said that, there's usually a good way to work through the culture. The culture's been dealing with these issues for a long time. Female genital mutilation is a very, very difficult one, but issues such as rape, for example, and the talking about rape. And this is what we found in Congo, Brazzaville and places like that, and in Darfur as well, that you can actually get people to discuss rape and you can get them to come forward for assistance. If they know you can give them something. There's no point, from our point of view, going and asking a woman 'Have you been raped? That's good for my statistics thanks very much'. From a medical point of view if we someone who's been raped then we need to give them whatever assistance we can, whatever follow-up assistance and so on. So we do take positions that have political implications but based on the medical needs we see in our desire to assist that patient, and that is as freedom to take positions that are perceived as political. We've said some strong things about what's happening in Darfur. The Sudanese government understands also that if we see something else happening somewhere else, we're being kind of fair if we base on our medical actions. So it's tricky and it's very much case-by-case, and we argue about it all the time. We argue a lot. I don't know if you know, but within a very small area there are a number of countries in Europe, and they all think a little bit differently and speak very differently and I've come to learn this. I really wasn't aware about the very different cultural differences between different European countries but it makes it difficult to debate. Luckily everyone's final goal is similar in the end, but how to get there? We have a lot of debates about these things, and that's what makes it interesting really, working out these difficult problems.
Woman: What sort of role does MSF play in terms of education in the countries? Do you take a role in that in terms of health?
Rowan Gillies: The problem with health education is you have to do it very well. If you have a camp, basically one of the things you do is have community health workers distribution soap, telling people to go and use latrines and all this kind of stuff, and they're usually people from the community. They're in charge of a certain area of the camp and they go through health education and they give talks and they speak to mothers about their babies that they must come in to us when you're contracting and so on. The broader prospect of improving the health of a country, I think that's beyond our abilities and probably better done by people who are experts at it. I think it's very important to try and do what you can, but also to try and limit things to what you're good at.
Man: You mentioned MSF receives independent funding. I was just wondering many humanitarian organisations have problems with the characteristics of funding, that they're often crisis driven and many donors prefer short term investments, short term help. How does MSF deal with that, and how do you think it impacts on preparedness for emergencies and development?
Rowan Gillies: I think you describe a situation very well there. There is a difficulty with not just the political influence on the funding, I mean US-AID, the US government funding says, they're very honest, they say clearly, Our funding is to promote US foreign policy, whatever that happens to be. And that's clear. They're bit more honest for me than DIFID which is the British government. They say, No, no, we're doing humanitarian action, so there's one issue, the political issue but also what's in, what's out at the time and so on is a very difficult thing to do, because we've invested significantly in getting private funding. Now 80% of our funds are from individuals who agree to assist MSF based on us doing what we say we do, and the approach in some ways, as opposed to a specific context. We do get ear-marked funds at different times for different emergencies, but generally we have that capacity due to the funding from individuals. So that's the way we manage to deal with it.
Having said that there are ways. The European Union eco-funding that they have, they do give tranches of money for emergency preparedness that can be available quite quickly to some organisations. But it's been a challenge for some NGOs, there are some very good NGOs, who really are stymied by the need to get donor agreement to go ahead and respond to an emergency. We find our ability to respond is pretty good because of this borrowed funding.
Man: Sorry to be the undergrad Devil's Advocate, but one school of thought on humanitarian aid posits that humanitarian aid can in fact prolong a conflict, and I'd like your comments on that. And secondly, in that way, doesn't humanitarian aid become inherently political?
Rowan Gillies: I'll answer the second question first. Yes, the results of humanitarian assistance are political, the fact of being there you're showing a political failure. It's usually political complete neglect as opposed to a political decision, but you're showing a political failure of some sort by being there, so yes, the results are political. My argument is that the desire to be there and the intent is humanitarian as opposed to political. So that's where that balance is. Do humanitarian actors prolong conflict? Sometimes yes, for sure. I think that's a fair thing to say. The question is, do you know which ones are and which ones are not? It's very difficult to know and are you prepared to let a number of individuals die, thousands and hundreds of thousands die for the benefit of a future gain that may come from a ceasefire? I still cannot predict these things. I see all these pieces being written, I still cannot predict what will work, what won't. And I think it's a dangerous thing when you know that are you going to do surgery on someone who's had a war trauma? Are you going to give them a malaria tablet, they'll be better in five days, you know that's going to work. Your prediction in the future about whether letting this person die is actually for a good thing is a much more difficult decision to make and from the medical point of view, I can't make that decision. That would be the approach to that, but yes, it's true there's no doubt that conflicts happen because of aid sometimes. And sometimes we've left as well. We left in the camps in Banako camp in December '94, we left Banako camp which was full of the genocidees in post-Rwanda. It was a refugee camp of 250,000 people and it was basically being run by the Hutu extremists who'd committed the genocide. And they were diverting their assistance and they were getting ready to go back. And we actually left the camp because we felt that humanitarian assistance was actually being diverted for genocidal purposes in many ways. And we ended up leaving, which is a very difficult decision to leave your patients. It's difficult to know whether it was the right one, but in hindsight it seemed like the appropriate thing to do.
Man: Yes, Dr Gillies, this non-political sort of idea, I just want you to paint a picture of what it's like getting your stuff on the ground, maybe in a remote area. Do you lease planes. The image I have with the UN is a big Hercules or whatever plane, the four-wheel-drives roll out. How is it for Médecins sans Frontières ?
Rowan Gillies: I only saw that - what's that film with Ralph Fiennes, The Constant Gardener, because they gave the impression that they were landing a C130, and it's very difficult to land a Hercules in these places, so normally it's a smaller plane and they do all these drops from those. We do use planes, and sometimes we have cars in planes. We'll get in any way we can. Usually fly into the country and when we first start you might hire some four-wheel-drives. We've got our own land cruiser type specification thing, just because we want nice safe cars so we can run away if we need to, and with radios and all that kind of stuff. So we do have the big white car approach, white guys in white cars approach, although to be honest people working in MSF are 90% local staff, and more and more the expatriate staff are actually from other countries in Africa. So that image is going a little bit, but we do do that especially in war countries where you've got the humanitarian symbol of the white car despite it being - or the pink car as things go. And it's a reasonably high logistic approach because it's actually very difficult specifically on security circumstances, to go in a very low key approach. Having said that, I think they're doing a donkey program in Darfur at the moment, we're going up into hard terrain with donkeys. So it's horses for courses, or donkeys for courses.
Woman: Hi, I'm just wondering a little bit about sort of the internal organisation of MSF and your sort of long term planning. Specifically about that, how you keep yourselves real in terms of what your own political views are, coming into it, and then also how you deal with having representation from lower income countries or countries that you're assisting in your long-term planning and where you're going as an organisation?
Rowan Gillies: It's what you describe as a robust debating culture. We've actually had a big gathering which is to try to sort out the internal organisation MSF in March in Luxembourg, and we had a lot of national staff working with us, but getting more input into our management and our direction from the staff of the countries in which we work. What we don't plan to do is get government people in those countries because we want people who are civil society people in those countries to assist us in making good decisions. So yes, that's the plan in the future. First it was Francocentric, then it was Eurocentric, now it's Westerncentric, and after that it's going to be just centric. I think. I don't know how it works.
About separating the political from the keeping yourself appropriate, there's a cultural issue that you've got within the organisation. You have to go to the field. You have no legitimacy unless you've been in the field and working actually at the patient level, or very close to it. So that's one of the things that people at the top, all levels go to the field regularly. The worst insult about someone said behind a corridor is, 'You know, he hasn't been to the field for a year now'. That's a real insult, and that helps. But also you've got to understand, we all have political desires, we're all human beings and have political decisions, but also what's appropriate for MSF as opposed what's your political opinion. And I think we're quite clear about saying I think this, but I don't think that's appropriate for MSF. And I think it's important to clarify the difference between your personal beliefs and what we need to make this action work.
Man: You talked earlier about going in and treating some of the physical complications with rape. Along with it, there's the whole mental side and the same thing with the tsunami aspect with children losing their entire family. Is the mental health issue something that MSF looks at, or is that too far down the food chain from an immediate humanitarian need?
Rowan Gillies: We're actually doing increasingly large amounts of mental health. For example, in tsunami one of our major interventions was mental health because a lot of the other things were dealt with. Certainly the package for someone who's been raped includes psycho-social assistance, and sometimes we work with local actors, women's groups and so on, and in different ways. It's not just the psycho-social assistance at the time, but a social reintegration into their village and so on. So yes, we take that all the way, but if there's someone else that can do it better, we'll have a collaboration with them. And one interesting place is Kashmir, where you would think there's a war going on, maybe surgery's the best thing. Well actually medically Kashmir was OK. This is before the earthquake. But one of the huge issues is people living on a frontline for 20, 30 years of their life, is the psycho-social issues and psychiatric issues in fact. So yes, it's increasingly part of us. It's been very much part of our response to trauma especially in the last four or five years.
Man: Just a follow up to that then, you were talking about other people that might do it better; in your viewpoint who would that be? Other NGOs, or is it, what groups do you associate with that service?
Rowan Gillies: There're certain other NGOs that do specifically work on this. Some of them are very good, and it depends sometimes who they have in the country at the time. Local groups are very useful especially for the sensitivisation on some of these issues. It really depends, and you can't just do psychological care as you would in New York, and you don't necessarily do Dr Katz kind of stuff, you have to do what's appropriate for the context. So I won't name names because for me in my own experience was in Congo with an organisation. They seem to be doing a reasonable job, but I'm not very good at assessing that either, that's the other thing. Our team is, just not me.
Woman: My question relates also to the internal workings I suppose of MSF. You've spoken about the Congo so I'll use that as an example. In the DRC at the moment you've already talked about the violent physical crime that exists there. It's also a country that's going into its first democratic elections, it's got a huge peacekeeping force there in readiness for that, a process that may or may not go peacefully. So how do you prepare your field officers for not only the physical trauma that they'll see and experience, but also for the internal conflict or their own morale. How do you prepare them for what they're going to be suffering while they're trying to deal with the physical suffering?
Rowan Gillies: There's the ideal way we do things, then there's the mistakes we make. I think that's important to say. We do prepare people, we tell them exactly what the context is going to be like, and also it's important to say to people, Well some days you're going to think it's all rubbish, some days you're going to feel you're responsible for everything, and everything's going badly, and if you understand that, when it does happen, at least you know it's happened to someone else. So there's a discussion before people go and there's preparation on various levels. And it depends on the support of the team. If often depends a lot on the Head of Mission or their field- co-ordinator there, who's usually experienced, and been in different contexts before. And can be someone to lean on. This is all the ideal of course, doesn't always happen like this and we do make mistakes.
I think the other thing is after it there's psychological and psychiatric follow up if required. The Dutch do it slightly differently to the French and the Spanish and so on, but there's something available for people who come back. For example, you make an appointment with a psychologist or psychiatrist and say The appointment's for you, you can go or you don't have to go. And that's when they come back and are supported in that sense. So there are a number of systems around. For me I find the most useful thing is well, you say, I'm suffering and I'm upset, but compared to the people in the country with me, they're going a lot worse than I ever will, so I'm not saying you enjoy the fact that you're a superior, but you do realise that your life isn't going so badly.
APPLAUSE
Kirsten Garrett: That talk, recorded for Background Briefing, was by Dr Rowan Gillies, International President of Doctors Without Borders, at the Seymour Centre for the Sydney Ideas series, and that was at the end of May.
