A few days after the start of the operation 'Protective edge', Jonathan Whittall, Head of Humanitarian Analysis at Médecins Sans Frontières/Doctors Without Borders (MSF) posted an opinion on the 'Opinion and Debate' page of MSF - UK in which he questions MSF's role in Gaza. Michaël Neuman, Director of research at MSF - Crash responds.

The limits of humanitarianism in Gaza
By Jonathan Whittall

An entire population is trapped in what is essentially an open-air prison. They can't leave and only the most limited supplies - essential for basic survival - are allowed to enter. The population of the prison have elected representatives and organised social services. Some of the prisoners have organised into armed groups and resist their indefinite detention by firing rockets over the prison wall. However, the prison guards are the ones who have the capacity to launch large scale and highly destructive attacks on the open-air prison.
Gaza is one of the most densely populated parts of the world, with 1.8 million people living under siege in the strip.

Locked doors

Humanitarian assistance is still allowed to enter Gaza and there is the possibility for an independent organisation like MSF to provide emergency care to the population. But the doors to the prison remain firmly locked. People are not able to flee, to seek safety away from the immediate danger of a large scale offensive.

Everyone pays the price for living under siege and for their acts of resistance. Medical workers have been killed and health structures damaged. In such a densely populated environment - the claims of not targeting civilians in air raids is of little comfort.

There are always limits to humanitarian action. Humanitarian organisations like MSF can treat the wounded, but we can't open borders or end violence.

These limits are not unique to Gaza. In 2012, MSF closed its projects in the prisons of Misrata, Libya. Our doctors were outraged to be in a position where we were providing treatment to patients that were being tortured by state authorities.

At the time, MSF spoke out strongly: "Our role is to provide medical care to war casualties and sick detainees, not to repeatedly treat the same patients between torture sessions."

Limited impact

As the violence once again erupts in Gaza, with Israel pounding the strip from the air - and Hamas fires rockets into Israel - MSF is mobilising to again respond to the medical needs that are caused by air strikes on a trapped population. MSF has a surgical team on standby if the capacity of the Gaza health facilities is overwhelmed.

This is not the first time that MSF has scaled up its response to an escalation in violence. Since 2010, MSF has run a post-operation clinic in Gaza city where 80 percent of the patients suffer from severe burns, does specialised hand-surgery in Nasser hospital, Khan Younis, and provides intensive care training to medical and paramedical personnel of Nasser and Ah-Shifa hospitals.

MSF provided emergency care to the people of Gaza during the ‘Cast Lead' military operation in 2009 and ‘Pillar of Defense' in 2012.

However, in previous operations, and at the time of writing, the impact that MSF was able to have has been limited. Part of the reason for this is that Gaza has a well functioning medical system, even though it is under strain from the siege and could be quickly overwhelmed.

In addition to the limited impact, the voice of outrage of MSF medical teams is drowned out by the propaganda war that erupts each time an operation such as this takes place and by the concerns that too loud a voice of criticism could cut off the organisations surgical teams from being able to reach the Gaza strip.

Complicit?

Once the bombs fall silent and the people of Gaza pick up the pieces after this assault on their life and dignity, MSF should ask itself whether it can keep working in such an environment. At what point does MSF's repeated medical action in an unacceptable situation become complicity to aggression and oppression?

Would MSF accept to work in a prison where the guards had thrown away the key and threw explosive devises over the wall into the overcrowded den of human suffering? Should MSF stay and deliver care, while bearing witness - or walk away in outrage, refusing to be complicit?

Confronting the limits of humanitarianism is a daily reality for MSF field workers. In Gaza, it is made only more apparent by the duration of the suffering and the international political configuration that allows for the sick political stalemates and endless violence to continue.

In the midst of this latest emergency, MSF's decision is to provide treatment and to try to save lives. During this offensive, Gaza faces a unique set of circumstances, which makes the uncomfortable reality of yet again responding to the needs caused by an Israeli military operation an essential task: the offensive might last longer, with a real possibility of a ground operation, and the Rafah border crossing remains largely closed. These factors will certainly exacerbate the chronic problems facing the Gaza strip in terms of shortages of drugs and fuel.Lift the blockade

As the open-air prison of Gaza braces for more airstrikes and a possible ground operation, the limits of humanitarianism will remain all too obvious. People should be allowed to move freely and to seek safety in times of violence, including into Egypt - and the wounded who require more specialised care should be allowed to be referred to the nearest hospitals outside of the Gaza strip when necessary.

Civilians and civilian infrastructure - including medical workers, health centres and ambulances - should never be targeted. Humanitarian aid and its workers should be given unhindered access at all times - not as a favour but as a legal responsibility. The blockade must be lifted.

Yet these most basic provisions continue to go unmet. While the blockade on Gaza remains firmly in place, MSF is continuing to work in an open-air prison to patch up prisoners in between their torture sessions.

Michaël Neuman's response

In the above post, Jonathan Whittall argues that, in Gaza, MSF works "in an open-air prison to patch up prisoners in between their torture sessions." In this analogy the author refers to a recent situation encountered by MSF in Libya, where the organisation decided in January 2012 to suspend its operations in detention centres in Misrata concerned that it might have indeed crossed "the blurry, but very real, line beyond which assistance for victims imperceptibly turns into support for their tormentors"Rony Brauman, President's report, 1987, MSF-France. Whether humanitarians are doing more harm than good by working in Gaza in the current conditions is a question worth asking and the author builds a convincing case.

While not holding a very strong view as to whether MSF should indeed suspend its operations in Gaza until the blockade is lifted, I would like to introduce a number of arguments that should also be considered in the debate.

Our organisation, as well as other observers of the Israel-Palestine conflict, have been debating the role of humanitarian action in Gaza for a long time. In her chapter, Gaza Strip, a Perilous Transition, in the book "Humanitarian Negotiations Revealed", Caroline Abu-Sada summarised the context in which such positions had been taken in the past Caroline Abu-Sada, ‘Gaza. Strip a Perilous Transition', in C. Magone et al. "Humanitarian negotiations revealed", Hurst and Co, London : 2011.:

'In such conditions, is it possible for medical aid organisations such as MSF to avoid becoming the healthcare assistants of the occupying power? The issue of NGOs assisting the occupation was explicitly raised by the president of MSF in 2002: "Until now, international humanitarian aid has only played a peripheral role in this conflict, but there is a danger of it being expected to assume that of assistant prison guard at the centre of a pitiless system of domination and segregation. After the capacity for resistance of the Palestinian population, it is now the independence of foreign relief workers that is being put to the test".

Left-wing Israeli intellectuals also questioned the role of humanitarian aid at a time when four-fifths of Gaza's population were reliant upon it. In their opinion, it was serving to "suspend the catastrophe" and freed Israel from the obligation of finding a way out of the conflict. For Adi Ophir and Arielle Azoulay, "the normal operation [of humanitarian and human rights organisations] is an extension of the ruling apparatus, one of its branches, the one responsible for the suspension of the catastrophe and the creation of chronic disaster".

Dov Weissglas, adviser to Prime Minister Ehud Olmert, in an attempt in early 2006 to justify the blockade after Hamas' victory in the legislative elections, commented: "It's like an appointment with the dietician. The Palestinians will get a lot thinner, but they won't die". Some Palestinians also criticised the presence of NGOs in the occupied territories, believing that assistance programmes helped "normalise" the situation and relieved Israel of its responsibilities as the occupying power.'

Is the situation in Gaza as exceptional as it seems, compared to all the situations in which MSF, and humanitarians, have been accused of sustaining, or prolonging war? The argument is as old as modern humanitarianism, being one of the first used by the opponents to the ambitions of ‘civilizing war' contained in the Geneva Conventions.

However, the fact that this is not a new argument should indeed not distract the organisation from asking the question again. In doing so, one should examine the importance of MSF operations - or humanitarian apparatus as a whole - and its actual role in prolonging the occupation.

The second question is related to consent. Before pulling out, should not we ask the population of Gaza what they think of the assistance provided by MSF? At a time when the ‘aid system' is all about strengthening its relationship with the ‘beneficiaries', would it not seem odd to pull out without considering the opinion of the parties primarily concerned?

As of now, it seems that there has not been much of a public support by the population of Gaza for a withdrawal of MSF, or for that matter, of a much larger actor, UNRWA, even if as mentioned earlier there have been anecdotal discussions of that nature.

A last argument in favour of maintaining operations - and highly related to the second - is that the inhabitants of Gaza themselves are getting organised to treat the wounded. In that regard, MSF is only intervening in support of Palestinian efforts.

We saw no such parallels in the Libyan prisons where I don't recall fellow prisoners patching up their friends before bringing them back into the torture chamber... As valid as Jonathan Whittall's case may be, I'm not sure the comparison with Misrata is the most accurate.

In any event, when considering the question of its work in the Gaza strip, or in the Occupied Territories in general, it might be useful for MSF to see how to use its voice in the public space, if only to testify about the indiscriminate and massive killings of civilians and the responsibilities of the warring parties in the conduct of hostilities.