Médecins Sans Frontières / MSF - Addresses - People's Health Assembly - December 2000
Médecins Sans Frontières / MSF
December 4, 2000
Verbal Text of Dr. James Orbinski,
Opening Session
Email: James_Orbinski@bi.msf.org
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Thank you for asking me to speak today. It is a true pleasure to be here, at what we as MSF hope will be an historic beginning to a genuine people’s health movement. Since our beginning thirty years ago, MSF has typically struggled to demand respect for peoples’ right to humanitarian assistance and protection in war, chronic crisis and natural disaster. More recently – in the last year- we have been active with other NGOs in the struggle to ensure people’s access to essential medicines. I have been asked this morning to talk about MSF’s experience as a movement committed to medical humanitarian action – and particularly our vision, our action, and our voice. As many of you know, MSF is not perfect, and nor do we pretend to be. If we entertained such pretensions, it would be the end of what has been and is today a genuine movement of people committed to humanitarian principles and most importantly, to practical medical humanitarian action. This is an action that is by definition fraught with paradox, dilemmas and uncertainties. Indeed, we know only too well that there are often no right answers, but only what are so obviously wrong answers, actions, and postures that acquiesce to the apparent futility of reality - or to “the way the world is”. I will try to put our experience into a context that is relevant for this People’s Health Assembly. This is difficult, as today’s international context is by no means clear. MSF has no prescriptions in how to make a people’s health movement a reality, but we are very glad to be asked to share our own experiences with you. These three ideas - “vision, action, and voice” - are an oversimplified way of talking about the MSF movement, but perhaps they may be helpful to this assembly.
So what is the medical humanitarian “action” of MSF today? Concretely, it is in our therapeutic feeding centers in Ethiopia. It is in the Congo with women and girls who are victims of rape as a weapon of war. It is in Sierra Leone with unaccompanied children and in our surgical units for people who have had their hands and feet cut off in order to force their political submission. It is in Angola with people who starve and suffer in war while the government tries to create the illusion that “ all is normal”. It is in Cambodia and Guatemala with sex workers and street children pulverized by poverty. It is in the Sudan and Chechnya where people have suffered indiscriminate bombing by government forces. It is in Kosovo where the limits of our humanitarian action are increasingly apparent. It is in Timor, Belgium and Italy, and in 80 countries around the world. And it is in our newly launched Access to Essential Medicines Campaign, where along with many other NGOs, we are fighting to overcome access barriers to essential life saving medicines. The Access Campaign means tackling the TRIPS agreement and exposing the limits of patent protection and intellectual property rights laws; it means insisting on production of what we call orphaned medicines - those that exist, but that are not commercially viable; and as well, it means insisting on research and development for neglected diseases.
These are our actions today. And what is our vision? For MSF, humanitarian action seeks to relieve suffering, to restore peoples’ autonomy so that they can make their own decisions, to reveal injustice, to provoke change, and to locate and insist on political responsibility. In principle humanitarian action is very simple to describe, but in practice it is very difficult to achieve. It is a daily and imperfect struggle to create humanitarian space for our actions, and we are necessarily limited in our means.
And what is our voice? The best way to tell you about this is to tell you about our beginning. We were founded in 1971 by a group of French journalists and doctors. The doctors had worked for the Red Cross during the Biafra war, and were outraged at the fact that international humanitarian law (IHL) prevented the Red Cross from speaking out against what was effectively a state policy of forced starvation and migration. The original MSF doctors refused to remain silent, even in the face of restrictive IHL. This ethic of refusal was the genesis of our movement, and remains today at the heart of who we are. One of the first names of MSF was the “Committee against Genocide in Biafra”. For many, silence has long been confused with neutrality, and has been presented as a necessary condition for humanitarian action. From our beginning, MSF was created in opposition to this assumption. In the last 30 years MSF has been, and is irrevocably committed to this ethic of refusal. This ethic affirms MSF’s commitment to universal medical ethics; to our understanding that all people - regardless of state borders or existing interpretations of international law - be it humanitarian law, or law governing trade in intellectual property rights, or any law or border or barrier- that all people have a right to exist as human beings. More than anything, bringing direct medical action to bear, and doing so without regard for borders or other artificial barriers, this is the essence of MSF’s work. Our work sees human beings not as a means to any end, but as an end in themselves possessing an inherent dignity. It affirms that how human beings are treated anywhere, concerns everyone everywhere. And it demands that this irreducible human dignity must be at the center of any political project.
And what is political reality today? It is in too many cases a neo-liberal social order that excludes, that marginalizes, and that literally leaves open to sacrifice the lives and dignity of billions of people in the name of some future economic benefit that will “trickle down” to the poor, given enough time. Today the state is reducing in its capacity, while private enterprise- and particularly MNCs – are growing in their unrestrained and unlocalised power. The commodification of nearly all forms of human interaction is increasingly taking precedence over the rights and dignity of people. And many NGOs – the so-called “third voluntary sector”- are replacing the role and responsibility of the state as providers or guarantors of public goods – like the right to access to health care.
Today’s new political buzzword is poverty - either its’ alleviation or eradication. But let us be clear. Ours is a time of unprecedented wealth. And yet politicians and their patrons tell us ceaselessly that we live in an era of limited resources, and this “truth” has been taken up by those responsible for formulating social policy. But there is more money - more wealth today that at anytime in human history. On average, everyone is apparently “doing better”, but scratch the surface of “averages” and it is clear that the rich are richer, the poor are poorer, the rich are fewer and fewer, and the poor are many, many more. 800 million people have no access to any form of basic health care. 1.3 billion people live on less than 1 USD per day, and 2.6 billion do not have access to safe and effective water and sanitation – the most elemental indicator of access to health care. The “market mantra” rules, and yet, the world’s poor are not a market. They are people who have need, but not enough money. A rising tide of wealth does not lift all boats. It lifts some but capsizes many many more. A commitment to the right of all people to access health care must be a fundamental political imperative, and the results today are simply “not good enough”.
Lets' also be clear about what some of the problems are. Treatable infectious diseases are the leading cause of death worldwide. More than 90% of all death and suffering from infectious diseases like malaria, TB, sleeping sickness and HIV/AIDS, occurs in the developing world. One of the reasons that people die from diseases like AIDS is that life saving essential medicines are too expensive because of patent protection. Since the beginning of the AIDS epidemic, 16 million are dead, now 34 million people live with HIV world wide, 90% of these are in the South, and 83% of all AIDS deaths are in the South. The vast majority of the people living with HIV/AIDS do not have viable access to patented essential life saving medicines - medicines for the treatment of HIV itself. This is not because the drugs do not exist, but because in part, the majority of people with disease do not exist on the balance sheets and profit calculations of the major pharmaceutical producers. And where have our governments been on these issues? Who have they represented? Certainly not the majority of people with HIV/AIDS. The AIDS epidemic is out of control, and its reality today is nothing short of a profound political failure – a failure that is obscene. There is no other way to describe it.
The so-called solutions proposed by many UN Agencies, governments and MNCs has been donations or price reductions of patented drugs, public-private partnerships to support these initiatives, and corporate “community programs” to support highly specific public infrastructure and training programs. Are such programs the responsibility of corporations, or of governments? Are donations or price reductions of patented drugs a sustainable solution for access for all? Are public private partnerships viable solutions to the long-term responsibility of states to protect, promote and ensure the right to access health care? Is it acceptable that some foundations should set and drive the international health agenda by virtue of the sheer size and power of their financial resources? Where is the state in meeting these responsibilities? In the case of the HIV/AIDS epidemic, these kinds of initiatives allow the pharmaceutical industry to sidestep the threat that compulsory licensing and generic drug competition represents to their profits. More importantly, they perpetuate the notion that private charity – an act of privilege- is a viable alternative to a public or state duty to promote, protect and ensure the right to access health care. It allows politicians to respond with political platitudes, and with what amounts to effectively piecemeal private actions that create a humanitarian alibi for the failure to achieve real access to health care for all.
And NGOs – ourselves included- have been complicit in this humanitarian alibi. In many ways, NGOs have become co-managers of misery with the state, providing a salve instead of a cure, allowing charity to mask duty, and failing to demand real political change over political platitudes, or statements of “concern”. We have failed to insist on political responsibility not just for the rich or the included, but for everyone - the rich, the poor, the dispossessed, the excluded. Now that the sufferings and diseases of the poor are a “threat” to national security and to expanding global markets, there is political interest. We must take this new found political interest, and not allow an economic and state security agenda to drive our agenda, which is one that must be committed to real justice for all – the included and the excluded. The economist Anartus Sen has argued that poverty is not just about economics, but also about a fundamental lack of freedoms. For we here in this assembly, how we choose to use our liberty – what we see as our vision, what we do in our actions, and how we use our voice – matters. We must choose to demand more. We have been too passive, too polite, and too deferential to political platitudes and to partial and imperfect private initiatives.
There are many who claim to speak for the poor. We see the World Bank, the IMF, and many UN agencies claiming and in effect, co-opting this voice. As I said earlier, “poverty” and “poverty alleviation” have become buzzwords, devoid of genuine meaning for the people who are actually poor. For MSF, our voice is our own. We do not pretend to speak “for” anyone - for victims of war, for the marginalized, the excluded, the poor, or anyone else. We speak as ourselves, with our own voice, of our own direct experience of solidarity in our projects, of our own outrage, and of our own demands. We act and speak not to participate in a “mediatized” and oversimplified pornography of poverty or suffering, but to witness our own direct experience and reflections, to restore autonomy, to reveal injustice, to provoke change, and to locate and insist on political responsibility. And we are able to do this because we are operationally, politically and financially independent. Independence is central to the MSF movement.
We know in looking at the history of social movements - the 300 year-long movement against slavery, the labour rights movement, the movement against child labour, the women’s suffrage movement, the civil rights movement, the human rights and the environmental movement - that each of these began in a clear articulation of principled ideas from within civil society, and then moved to a confrontation of sources of power – for example, political or economic actors that have vested interests in maintaining their power. This confrontation then moved on to include interaction with sources of power, to partnership, and then to usually legitimate and appropriate co-optation of the principles and values that gave birth to the movement in the first place. But we know that social change is rarely if ever a straight linear process, or that its process can be easily located on the overly simplistic continuum I have just painted of ‘ articulation, confrontation, interaction, partnership and co-optation’. We know too that rights achieved must be defended, and that that constant vigilance is required to maintain hard won gains. Here the status of African Americans in the United States today, and the rights of women that are not yet won the world over- are examples where gains must be constantly reasserted or demanded. The powerful have never given away anything simply because of a polite request.
A key challenge for this assembly is to organize into a global people’s movement for health. Today, when we speak of a peoples health movement, we must guard against putting the cart before the horse, we must guard against settling for premature partnerships, and guard against premature co-optation. We must be clear in our focus, clear in our purpose and clear in what we will and will not settle for. It must be a movement that recognizes the political context in which it exists, that confronts and engages sources of power, that does not simply determine a shopping or priority list, but that demands not charity, but change. It must be a movement that is able to be separate or independent from the political while engaging the political through interaction and pacific confrontation. This challenge must not be blurred by short-term gains with either the state or the private sector. The challenge is to not displace the role and responsibility of the state, or to become co-managers of misery with the state, or to allow a public-relations coup for the private sector to over-ride our long-term commitment to equity and justice. The challenge is not simply to achieve a technical standard for the few, but to demand that each human being’s dignity be at the center of any political project - a political project that is just, equitable and accountable.
The 19th Century German doctor and politician Rudolph Virchow, a father of public health, said - and I paraphrase – that “health is simply politics by other means”. We need to mobilize, and not allow our health language to homogenize, and to cleanse suffering and injustice of its real meaning. Language is determinant. How we phrase the problem defines the solutions we seek. We use phrases like “Complex humanitarian emergency”, or like “global public health crisis”. Yet, no one calls a rape a “complex gynecologic emergency”. A rape is a rape, just as a genocide is a genocide. And for example, the HIV/AIDS epidemic is not simply a global public health crisis – it is an obscenity that is a product of profound political negligence. We need to resist the sanitized language of political concern. We need to be clear in our diagnosis, to locate political responsibility, to provoke change, and to insist not on political platitudes, but on political responsibility and action.
The power of this People’s Health Assembly lies in the clarity of its purpose or its vision, in the integrity of its actions, and in the genuineness of its voice - and in its willingness to witness against the apparent futility of reality. If this People’s Health Assembly is to become a genuine global people’s health movement, it must be independent, it must have its own genuine vision, its own genuine action, and it must speak with a genuine voice. This vision, action and voice must not be co-opted, and sanitized of its intent and meaning.
As I said a moment ago, MSF started 30 years ago in a refusal to accept what were then the limits of international humanitarian law, and a refusal to remain silent. Today we work in about 400 projects in 80 different countries. We work with about 2500 expatriates and about 10,000 national staff. We are committed to deeply held principled ideas – our vision of what medical humanitarian action is. And we are committed to an ethic of refusal – an ethic that refuses to accept the apparent futility of realty, and one that refuses to silence our voice. We are faced constantly with paradox, dilemma, and uncertainty in our actions. Like any movement, we have done many things right, and we have made many mistakes. And yet, we are strong, but also fragile in our reality. We are growing in our own way, and we are organizationally imperfect. We have faced many periods of internal crisis and resolution, and we will likely face more. To be overly simplistic, MSF is committed to its vision, its action and its voice. This is the way a movement is, this is the way MSF is, and this necessarily means striving to overcome our imperfections without killing the very thing we seek to be – a movement committed to medical humanitarian action.
I hope this necessarily brief reflection will be helpful in our discussions in the coming days. We are delighted to be apart of this People’s Health Assembly, and we hope very much to be a part of a global people’s health movement that may come from it. Thank you.
Please send comments, which are very welcome, to: James_Orbinski@bi.msf.org
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