February 2007

Urban violence and health care, a new challenge for MSF?

Haiti, the poorest country of the Americas with eight million inhabitants has been plagued by political violence for most of its history. A rebellion forced President Aristide out of the country in 2004. The UN Security Council, by its resolution 1542 of 30 April 2004, decided to establish the United Nations Stabilization Mission in Haiti (MINUSTAH) composed by more than 8,000 troops, led by Brazil.

René Preval won presidential elections in February 2006 with 51% of the vote.

Port-au-Prince, Haiti’s capital city is regularly hit by waves of violence. Large part of the city are controlled by armed groups, specially deprived neighbourhoods such as Martissant and Cité Soleil.

Since December 2006 Medecins Sans Frontieres (MSF) has opened a new project in Martissant, a deprived slum of Port-au-Prince where armed groups are fighting among themselves to control the zone. MSF decided to open the project because there were no other health facilities in the whole neighbourhood.

The MSF emergency room aims to respond to the local population need in terms of emergency care. Patients wounded by gunshots, by machete, victims of car accidents and general casualties are seen every day by MSF doctors and nurses. Since the beginning of the project MSF has visited more than 1,000 patients.

Patients in need of a second level of care are transferred to other MSF facilities of the city: the trauma centre of La Trinité and the Obstetric Care Hospital of Jude Anne.

In the meantime MSF keeps working in the slum of Cité Soleil where the population live trapped in violence and insecurity. Fighting between UN troops and local armed groups erupt regularly. In Cité Soleil, MSF supports the Hospital of St. Catherine and the primary health centre of Chapi.

Interview with Loris De Filippi, ex-MSF Head of Mission in Haiti

You have just returned from Port-au-Prince (Haiti), where you opened two projects in frameworks of urban violence, in Cité Soleil and Martissant.  How would you define a framework of urban violence?

Many shantytowns in the world live in situations of undeclared war; there is an extremely high number of people wounded by firearms; a substantial amount of murders; people do not leave their homes out of fear and, when forced to do so, are often victims of cross-fire. These frameworks are often considered as B-series conflicts; not even local newspapers keep the sad accounting of the number of victims.  Few organisations have the courage and opportunity to enter into frameworks such as these. At times, the police or international peace forces respond in an exaggerated manner to attacks by armed groups, but no-one is there to give credible witness to it.

What does it mean for a humanitarian organisation like MSF to work in a framework of urban violence and what are its peculiarities?
First of all, it means responding to the organisation’s mandate and principles, placing oneself at the service of people who are victims of violence and deprived of medical assistance, particularly in very unstable contexts.  It implies having to deal with the local authorities or with the leaders of armed groups, without suffering blackmail, extortion or pressure of other kinds.  It means being well aware of the evolution of a framework which undergoes constant change, hour after hour.  It compels us to place the safety of our operators and of the people who we treat at the centre of our activities and to keep the constant stress to which they are subjected well in mind.

How are the principles of impartiality, independence and neutrality applied in Cité Soleil or in Martissant, where different armed groups fight against each other and against a United Nations peacekeeping force?
It is very difficult in both cases, although the two frameworks are completely different from each other.  The principles of MSF activities must often be repeated, by meeting with the leaders of the armed groups and personally negotiating the methods by which our activities are performed and our daily entrance into these real urban enclaves.

Doubtlessly, it is less complicated to manage projects in a zone of urban conflict such as Cité Soleil, where international forces for the re-establishment of peace and organised armed groups contend for the territory.  The actors can easily be identified and the dynamics of the clashes are more predictable.  We regularly meet the United Nations soldiers and the leaders of the armed groups to illustrate our projects and our methods of action; we do not leave anything to chance.  Both the belligerents know the routes we take each day with our convoys, in order to reach the medical structures in which we work.  We are also in constant contact with the belligerents during the clashes, in order to understand the dynamics and decide on our movements. 

The situation in Martissant, another shantytown in which approximately 300 thousand people live, is very different and more complicated.  We are not facing a declared conflict between two countries at war, the Geneva Conventions are not fully applicable and it is thus extremely difficult to convince the armed groups of the importance of respecting wounded enemies.  At least six armed groups are in conflict with each other. 

The violence and intensity of the clashes have increased exponentially since last July.  The antagonism between the groups forces us to multiply our negotiation efforts and our pleas to make them respect our space of action.  It is crucial to comprehend the dynamics of the clashes and, wherever possible, anticipate transversal vendettas and retaliations.  We are frequently in contact with the different leaders and the strong requests made for them to always respect the clinic in which we work as a neutral zone have given excellent results until now.

What made you decide to open two projects in these two shantytowns?
MSF generally opens a project when it identifies a population living in a precarious situation and which is lacking assistance.  We decided to intervene in the Haiti shantytowns as a consequence of the political crisis caused by the 2004 revolution and by the resulting flee of the ex-President Jean Bertrand Aristide.  The mortality and morbidity rates, as well as the exclusion of all forms of medical assistance, had worsened and we felt that our intervention was called for in a shantytown in which more than 250 thousand people lived and where there were no medical structures whatsoever. Martissant is the epicentre of a criminal-political conflict between armed rival groups; the presence of the international peacekeeping forces is just slightly more than symbolic; no international non-governmental organisation has tried to break the isolation and therefore at least 300 thousand people live without a single drugstore, and without any health centres or hospitals. Cité Soleil and Martissant are considered “red” zones, dangerous zones, by the United Nations.  It is absolutely forbidden for civil staff of the UN agencies to enter these areas.  This veto translates into an extremely strong recommendation to other international organisations not to intervene.  I believe that every effort should be made, with every means available, to enter the red zones and to work, naturally reducing risks to the safety of the operators to a minimum. In the hospital in Cité Soleil, 300 children a month are born and we perform 160 operations per month. 

Working in frameworks of urban violence is extremely dangerous.  Last year, the hospital in Cité Soleil was hit several times.  How are risks to staff and to beneficiaries calculated and managed?
In Cité Soleil, firearm conflicts occur daily; the management of safety is a priority for the mission leader and for the local coordinator of activities. Contacts with the belligerent forces are extremely frequent and prompt research is made to determine the reasons behind a gunshot or the dynamics of a skirmish. No movements are made in the presence of open conflict. We often concert temporary ceasefires with the two parties in order to allow the passage of our vehicles which, for more than a year and a half, enter and exit in convoy. Outside and inside our centres we have built physical protections (walls, sand bags, metal barriers) which prevent bullets from entering.

What impact has this framework had on the expatriate team and on the national staff?
Turn over is very high; the daily level of stress caused by the shooting and by the omnipresent tension often causes the expatriate staff not to remain for long, while the national staff suffer strong pressure from their families not to work in Cité Soleil and in Martissant, considered bandit domains by public opinion. The violence experienced daily in the shantytowns is often unsupportable; in the Cité Soleil hospital we get approximately 200 people wounded by non-fire weapons per month, not counting the victims of firearms and of blunt instruments.

Do you have an episode, an anecdote, which you remember more than others?
Definitely, the trickles of blood from the large number of dead people who were killed and left by the roadside or slung onto piles of trash remain the strongest memory. And also the training and professionalism of the team, especially during maxi-emergencies, particularly the one that took place on the 22nd of December 2006 in which 26 people, wounded by firearms, arrived in the Cité Soleil hospital in an extremely short period of time.  From amongst the many uncancellable emotions, I definitely recall those aroused by a boy who arrived with a cut on his face.  I asked him how it happened; he answered that he had done it himself with a kite.  Flabbergasted, I asked him to explain how this was possible and he told me that a blade was tied to the tail of the kite in order to cut the thread of the “enemy” kite.
Up until then, I had believed that more than any other game, kites represented the wish of children to soar through the air and whirl in freedom; in Cité Soleil, however, it is one of the many forms used to violently assert one’s own supremacy over another. 

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