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Judith Soussan

Graduated in International relations (Institut d'Etudes Politiques de Paris), Logistics in humanitarian settings (Bioforce-Développement) and Anthropology (University Paris I), Judith Soussan joined MSF in 1999. After missions in Sri Lanka, Ethiopia, Sudan and the Palestinian territories, she worked in Paris, in particular on protection of civilians. Following a few years break from MSF working as a radio reporter, she has come back to Crash in 2015. She contributed to the book "Saving lives and staying alive. Humanitarian Security in the Age of Risk Management" (chapter "Security Issues and Practices in an MSF Mission in the Land of Jihad" - London: Hurst and Co, 2016).


The wording of the objectives, 2003-2007    

The emergence of violence at the centre of the MSF project in North Kivu    

Inside the conflict, at the heart of violence     


The concern for safety in the sphere of medical care   

Beyond care when faced with violence: shifting boundaries and the expansion of the ‘care sphere’  


Artemis 2003: the arguments over a public stance     

Violence, operationality and positionings    


This case study focuses on current MSF action in North Kivu (Democratic Republic of Congo), while taking into consideration its activities in the region between 2003 and 2007.

The choice of this case study was motivated by the extent to which MSF’s work in North Kivu is affected by the problem of violence, and in particular sexual violence, which has a bearing on our subject in several respects. In the first instance, it sets violence as a central feature of the operational project. Second, it appears to raise the issue of a more personalized relationship to the victim. Finally, MSF’s assumption of responsibility for such cases has given rise to a practice – certification – which (to our knowledge) is the only undisputed ‘legitimate’ use of the word ‘protection’ at MSF today. These respective motivations are addressed to varying degrees in the document.

Unlike the other two studies, the present paper is not organized chronologically. As it is impossible to pinpoint specific problems to specific time frames, and given the chronic nature of the issues described, a thematic presentation seemed the best way to proceed. We shall of course attempt to highlight, within each theme, the developments that emerged as time went on.

In keeping with the other studies the working definition is deliberately left open, but it is centred on the practices (activities other than care in the strictest sense, the adoption of public positions) that have evolved in relation to the violence. When MSF is confronted with violence, with the forms of violence inflicted on civilians, with “victims of sexual violence” and “direct” or “indirect” victims of violence, what does it do, what does it say, what degree of responsibility is assumed by staff at headquarters and those in the field, how does MSF position itself in relation to international initiatives designed to “protect civilians”, etc?Note: Quotations are enclosed in double quotation marks; single quotation marks represent author’s emphasis. Abbreviations of humanitarian/MSF terms - Sitrep: situation report (weekly or monthly report) – Board: Board of directors – AR: President’s annual report – FC or Field co: Field coordinator – HoM: head of mission (or coordinator) –  PM: programmes manager (desk) – DPM: deputy programmes manager – VSV: victims of sexual violence – STI: sexually transmitted infections – TFC: therapeutic feeding centre – SFC: supplementary feeding centre – PHC: primary health care – HRW: Human Rights Watch – DPKO: UN Department of Peacekeeping Operations. DRC abbreviations - NK: North Kivu – KY: Kayna – RU: Rutshuru – KB: Kanyabayonga – FARDC: Forces Armées de RDC (DRC national army) – MONUC: United Nations Mission in DR Congo – MM: Mai-Mai – FDLR: Front Démocratique de libération du Rwanda (Democratic Front of Liberation of Rwanda) – RCD: Rassemblement Congolais pour la Démocratie (Congolese Gathering for Democracy) – UPDF: Ugandan Peoples’ Defence Force – MLC: Mouvement pour la Libération du Congo (Movement for the Liberation of Congo) – ADF: Allied Democratic Forces (Uganda) – NALU: National Army of Liberation of Uganda – IB: integrated Brigades.




War returned to the Democratic Republic of Congo (DRC) in 1998, following Laurent-Désiré Kabila’s split with Rwanda and Uganda, both of which had helped him to seize power in late 1996. These two states backed a UPDF-led rebellion, which gained ground in the eastern part of the country. Other rebel groups (MLC, RCD and RCD-G) appeared shortly after. Following clashes in 1999, the United Nations authorised the deployment of a force to monitor respect for the Lusaka accords. MONUC, the UN Mission in DR Congo, was created in late 1999. Under Chapter 7 of the UN Charter, it was tasked with monitoring the implementation of the cease-fire agreement, disarming the militias and facilitating humanitarian assistance and respect for human rights. MONUC was authorised to “take the necessary action, in the areas of deployment of its infantry battalions and as it deems within its capabilities, to protect United Nations and co- located JMC [joint military commission] personnel, facilities, installations and equipment, ensure the security and freedom of movement of its personnel, and protect civilians under imminent threat of physical violence.”

In 2000, MSF reported that the conflict had displaced 200,000 people, while civilians were being subjected to multiple acts of violence by the various rebel groups. In January 2001, six members of the ICRC were killed and all agencies withdrew from the area. Despite an extremely tense and volatile situation characterized by repeated attacks on civilian populations, a peace agreement with Rwanda was signed in July 2002, followed by an agreement with Uganda in September of that year. In December 2002, a “comprehensive peace deal” launched a transition process which would eventually lead to elections. The deal also provided for the brassage (integration into the national army) of the various rebel groups, conducted within the framework of a MONUC- supported programme known as DDRRR (demobilisation, disarmament, repatriation, reintegration and resettlement).

MSF-France, already working in Katanga, sent two exploratory missions to the area but took no further action for reasons of security. The French section finally arrived in North Kivu in December 2002, opening a mission at Beni following another wave of violence and its consequent population displacements.

In early 2003, the Bunia (Ituri) area, not far from Beni, became the scene of mounting tensions as competing rebel groups kindled tribal animosity, particularly between the Hema and the Lendu. In April, MSF, increasingly concerned, began discussing the possibility of releasing a report on the plight of civilians.

Intense fighting occurred in the Bunia area between 9 and 12 May. Several NGOs (Oxfam, Merlin, Human Rights Watch) called for the rapid deployment of troops to protect civilians. MSF ‘briefed’ officials from the UN Department of Peacekeeping Operations (DPKO) and members of the Security Council, making it clear that “if they don’t act now, they will be left to count the bodies”. On 30 May, the Security Council authorized the deployment of an Interim Emergency Multinational Force with the aim of “stabilizing security conditions” in the town of Bunia. Known as Operation Artemis, the first troops began arriving in June. On 25 July, MSF issued a report entitled Unkept Promises? A Pretence of Protection and Inadequate Assistance. The document highlighted “the inability of the armed international presence to fully assure the safety of civilian populations”.

In late 2003, MSF, besides running the Beni mission (which gave priority to displaced populations), opened a programme to combat malnutrition at Kayna.

Over the course of 2004, the continuing turmoil created by the power struggles between various groups provoked a large number of population movements. In February, thousands fled Kayna for Kaynabayonga; in June, RCD-G rebels attacked and seized the town of Bukavu; in July, thousands fled Rutshuru; in October, the entire population of Kaynabayonga fled the town; in December, tension between the regular army, the FARDC and the Rwandan-backed RDC-G reached new levels. Besides these peaks in the conflict, the level of violence remained very high; MSF was increasingly concentrating its efforts on the direct consequences, including – and especially sexual violence, the treatment of which became routine at Beni in June 2004.

At the beginning of 2005, the instability in the Kayna area provoked a unique situation: the population, infuriated by the lack of security and the presence of NGOs – which seemed to be doing nothing to improve matters – decided to “reject aid”, refusing to accept aid distributions and obstructing humanitarian activities. Although MSF was relatively unaffected, it sought to understand the reasons for such a reaction. In mid-2005, it began contemplating a third programme in the Rutshuru area, the scene of rampant and permanent violence. This opened in August 2005. The violence reached new heights in late 2005, with the launching of a joint operation between MONUC and the FARDC to drive the rebel ADF out of the Beni area. This operation had long been envisaged, and humanitarian organizations had been asked to prepare for its consequences. It continued until February 2006, triggering significant population displacements.

At the beginning of 2006, MSF conducted an emergency intervention in order to help the newly displaced persons (Linzo). Other emergencies arose in the  Rutshuru  area  during  this  period: there were battles between the FARDC and insurgents in January, and battles and population displacements in the Kayna-Kaynabayonga area in February. But the factor with  the  greatest impact on the area’s civilian population seems to have been the constant insecurity.

In July 2006, the long-awaited elections finally took place in relatively peaceful conditions. In September 2006, MSF began discussing the possibility of a project in Nyanzale, a highly unstable and once virtually inaccessible area from which many of the victims of sexual violence treated in Rutshuru had fled. The project opened in October. In November, fighting broke out in the Rutshuru-Nyanzale area. As this had no major consequences on which MSF could have an effect, it conducted an emergency intervention to combat the high incidence of malaria that had coincided with the clashes.

By 2007, the problematics of North Kivu had not altered for MSF. Admittedly, the MONUC’s involvement was stronger; many rebel soldiers had refused to participate in the “brassage” process, to the extent that the “brassage” was replaced by “mixage” [intermingling]. This initiative, however, also failed mid 2007 and the clashes between rebel groups continued, and local populations were still subjected to violence. MSF continued to treat the direct consequences of this violence against civilians.




Before going on to discuss protection in terms of a concrete body of actions, practices and public declarations, it is important to look at the general framework surrounding MSF activities in North Kivu. In effect, while protection has never featured among the objectives when contemplating interventions in this region, the fact remains that violence has, over the years, played an increasingly significant role and has become the cornerstone of our action’s relevance. Thus before we envisage ‘doing something’ about the violence we observe, we must be in a position to record its consequences and gain access to its most immediate victims. In other words we must harbour the explicit will to get closer to the violence, and this is precisely what is at work in the case of North Kivu.




Is violence for MSF a legitimate context for action? Should it be approached head-on, or prevented? Or should we focus on attenuating its consequences? These are the questions we shall attempt to clarify. As we proceed, we shall draw heavily on the descriptive terms found in the “annual delivery plans”, the documents drawn up at the end of each year to set out the objectives, activities and budgets for the forthcoming year. While such documents may reflect the influence of external factors (the need to standardize terminology with typologies in mind, for example), they are useful references, as annual reviews and general frameworks for action.

The 2003 annual delivery plan for Ituri/North Kivu, drawn up at the end of 2002, described the context as one of “civil war/international conflict” and noted that the conflict was “the deadliest the region has seen”. The use of the term “war” could be justified readily given the setting – battles, unbridled violence and the presence of foreign occupation troops. MSF’s intervention in Beni was described as “emergency assistance to displaced persons”; the priority was to provide access to care (with an emphasis on measles, nutrition and malaria).

A year later, at the end of 2003, the intervention context read “displaced by war, epidemics” (2004 annual delivery plan). The objective of the Beni mission was “the  continuation  of medical care for populations and vulnerable people in the Beni region” (primary health care, epidemiological surveillance, access to water, mobile clinics for the return  of  displaced  persons, etc). There were plans for a project in Kayna – the establishment of a TFC (backed      up by SFCs) to “reduce malnutrition rates in Kayna’s population”.

By the end of 2004, the context description became “armed conflict” marked by “numerous instances of violence despite the transition” (2005 annual delivery plan). At Beni, the main objective was the “provision of medical care for part of the population displaced from the Ituri region”. At Kayna, activities were directed towards “providing medical and nutritional care for part of the population which has suffered from the violence in North Kivu” (VSV, i.e. victims of sexual violence, and STI; preparation for treating the wounded; assessing the need for handling other emergencies; severe malnutrition; an advanced strategy for monitoring malnutrition in unstable areas). We note in the 2005 plan the presence of a “communications” section in which “violence” is one of the two topics on which “we might consider adopting a public position”.

At the end of 2005, the context of intervention was described as “war and violence inflicted on populations, epidemics, displaced persons” (2006 annual delivery plan). Beni was in the process of closure and was to be used as a logistical rear base. The 2006 objective for the Kayna project (focusing at the time on “secondary medical and surgical activity in Kayna  hospital”)  was  foreseen as “the handling of emergency medical  and surgical  cases  among  populations  affected by the violence” (sick and wounded in the hospital itself; care  of  malnourished  children;  treatment of victims of sexual violence and STI at Kayna and Kaynabayonga; epidemiological monitoring, etc). The new projec  at Rutshuru  (opened  2005),  had the same  general  objective  for 2006 as Kayna; its specific aims were very similar (treating the sick and wounded in Rutshuru hospital; transfers; PHC at a small clinic near Rutshuru; VSV; responding to emergencies).

Finally, the 2007 annual delivery plan described the context/country as being one of “internal instability”. The Beni project (“reason for intervention: direct/indirect victims of conflict”), had closed in 2006. The Kayna project (identical reasons for intervention), would be discussed mid-year with a view to closure. Rutshuru (identical “reasons for intervention”) would maintain the general aim of the previous year: “to  ensure the provision of emergency medical and surgical care to populations affected by violence”. Nyanzale, a new project, had been set up at the end of 2006: “reason for intervention: direct victims of conflict (sexual violence in Nyanzale and the Bwito region)”. Its aim was to “to enable efficient and high-quality handling of medical emergencies among populations affected by the violence” (VSV, malnutrition, malaria peaks/outbreaks, response to emergencies).




Despite its tedium and unavoidable scope for distortion, a review of the objectives is nonetheless useful, for it illuminates the stages of a gradual shift in the way MSF’s intervention in North Kivu has been formulated.

Until the end of 2003 therefore, the general context was one of conflict. Within that context, MSF’s activities were rather ‘conventional’ in the sense that they were aimed at displaced persons and refugees, the traditional targets of humanitarian assistance. It was a matter of addressing the consequences of the conflict – its disastrous effect on human health – by providing assistance to those who were suffering the most. Medical activity therefore focused on primary health care, vaccination, nutrition and emergency interventions. However, the desire to enhance operational efficiency by gaining access to particularly violent areas was already present: “After years of real difficulties and failures, the opening and stabilisation of missions in violent areas became a reality. Over the last two years, from Katanga to eastern DRC, the work has improved considerably” (DRC summary, Board meeting, 26 September 2003).

At the end of 2004, the word “violence” appeared in the context description and in the wording of the Kayna objectives (VSV and wounded took precedence over malnutrition as specific objectives). Its usage became established in the end-of-year documents produced in 2005 and 2006, which resonated with references to the violence “inflicted on populations”, to the people it “affect[ed]” and to the “direct/indirect victims” it produced. By the end of 2006, “war” had been replaced by “internal instability” as a “context of intervention”.In short, there appeared a kind of shift of the centre of gravity, from conflict (as a context), to violence (as a general context and as a specific phenomenon – a physical assault on an individual). However, the terms are somewhat elastic: “direct victim of conflict” and “direct victim of violence” often appear to be interchangeable. Thus direct victim of the conflict could also refer to a “displaced person” (i.e. directly affected by the consequences of the fighting) or to someone who has been wounded (i.e. direct victim of violence). For the purposes of this study, a direct victim (of conflict, violence) means anyone who has suffered a physical assault; indirect refers to displaced persons, the malnourished, etc.


MSF’s attention was particularly focused on “direct victims”; in operational terms, considerable efforts were devoted to this aspect. To talk of violence or acts of violence is therefore, beyond the overall context of conflict, to point to an actual attack on the physical integrity of a specific individual – who has been injured or victim of sexual violence. The development of surgery and the increasing concentration on the treatment of victims of sexual violence, and their prioritization over previously dominant activities such as nutrition, water and primary health care, clearly demonstrate the shift in emphasis victims such as these, who had long been out of reach, could no longer be ignored. In the case of victims of sexual violence, the most appropriate strategy was thought to be proactive: victims should be helped to come forward despite obstacles of danger, lack of money or stigmatization. To this end, a wide range of conditions, subject to constant discussion and improvement, were created, including numerous awareness campaigns, confidentiality, improvement of the protocol concerning prophylactic and medical treatment and payment of transport costs. As for the wounded, the ‘correct’ position was to ensure that we “missed” no one, particularly civilian casualties. Some examples from various sitreps show this : “Possible clash to the south of KB. In principle, we will be well positioned if there are any wounded” (sitrep, August 2005). During the events of November 2006, “the Kayna team managed to reach Nyanzale, but missed one casualty in Kabati on the way back. They’ll have to go back tomorrow.” MSF insisted on taking responsibility for the several wounded civilians in the military hospital at Rutshuru, and also contemplated “a surgical intervention on the Kitchenga site, where there are 66 war- wounded (but only one civilian)”, before noting the risk of “undertaking an intervention that would ultimately benefit only the parties to the conflict (at present, the only casualties are fighters, but that doesn’t mean there won’t be any civilians if the conflict resumes)”. The “quotes of the month” for November 2006 include the following comment: “We were hoping for wounded, but sadly all we got were nine wounded soldiers” (sitrep, events at NY, November 2006).

It should be noted that this shift was in line with the more general operational developments desired by MSF’s leaders. The 2003-2004 President’s annual report (May 2004) thus introduced a new heading, “Medical care of victims of violence”, with the following clarification: “The wording is a bit clumsy. What I mean by that is the war-wounded, people suffering severe psychological trauma, women who have been raped during military campaigns” (J-H Bradol, May 2004).

The movement towards treating “direct victims of violence” has not necessarily entailed the sidelining of ‘traditional victims’. Displaced persons, the sick and victims of epidemics all remain within the scope of MSF’s activities – with, it is true, a greater concentration on reducing mortality rates: an emphasis on emergencies and lethal epidemics, a commitment to secondary care and a relative withdrawal from primary health care. In fact, “we wanted to refocus MSF’s activity on the provision of aid in crisis situations” (interview with J-H Bradol, July 2006).




By 2007, therefore, MSF’s project in North Kivu was one of medical assistance taking into account the co-existence of various types of violence. On the one hand, clashes between rebel groups and MONUC or the FARDC, or between the rebels themselves, would produce new peaks of violence. This in turn exposed the populations of disputed areas to yet more looting, rape and assaults although it did not generally result in large numbers of wounded civilians. On the other, “violence against populations” was also a fact of everyday life; it was ‘chronic’ and its level remained remarkably high. It is this second phenomenon which was predominant in the sitreps; these documents recorded a catalogue of violence which had little to do with ‘politics’ but throve on a range of elements the proliferation of weapons, survival strategies, theft and pillage, soldiers who had not been paid, the very fact that the violence had become a feature of everyday life, etc. Civilian populations were being robbed of the little they possessed, but above all, they were forced to endure rampant, repetitive, widespread violence on a daily basis.The following list provides a more detailed view of the chronic violence (emphasis added): “Increasing frequency of looting” (general sitrep, September 2004). “Systematic looting of every dwelling” (Kayna, January 2005). “While people are in the fields, the ANC takes the opportunity to rob the empty houses. At night [they] pillage the fields and steal cattle, or those animals that remain. And still the rapes continue” (general sitrep, March 2005). “Constant pillaging of fields at Miriki despite the presence of the FARDC, who let them do it and advise the population not to interfere” (general sitrep, April 2005). “Rape and serious attacks on civilians continue all the time (AR 2004-2005). “The same old story: soldiers extort money and possessions from the population after dark” (sitrep KY, June 2005). “Soldiers commandeer the animals and the civilian populations continue to pay the price through displacements, rapes, looting and murder” (general sitrep, July 2005). “Just as much banditry around Lubero” (sitrep, September 2005). “Looting in KB every day, sometimes accompanied by kidnapping, murder and rape” (NK summary, week 36, September 2006). “Continuing violence against the civilian pop in the Bwisha area” (general sitrep, September 2006). On the extent of the violence: “Attacks occur everywhere (field, house, on the roads, in the bush)” (NK summary, week 37, September 2006), and are committed by all participants: “Everybody knows and says that soldiers are responsible for these abuses … Since the MM arrived, the population has been complaining about looting and rape” (sitrep, September 2004). When visiting a clinic, a minister “confirms that almost all of our women and girls have at some point been used by NALU soldiers“ (sitrep, Beni, week 17, April 2006).

The North Kivu programmes gained their legitimacy precisely from their proximity to areas that were both unstable (where confrontations were likely to occur) and noted for a chronically high level of violence (sexual violence, theft and pillage). Given the constant and widespread violence (and the absence of camps which could have provided relatively safe havens), being “at its heart” or “as close to it as possible” had become a central issue: “To be in KY/KB means being as close as possible to the violence … It was a considered decision, taken because we want to respond to the humanitarian issue generated by these attacks on civilians” (PM, DRC Desk, “environment week”, June 2006). North Kivu required “a reactive approach, constant repositioning in areas of violence” (PM, Desk, presentation to the Board, 30 March 2007). “In North Kivu, we succeeded in placing ourselves at the centre of the conflict …” “We are at the heart of the violence in the Rutshuru area and Kayna.” A request for clarification drew the following response: “Perhaps ‘being at the heart of the conflict’ is not the best way to put it. Being at the heart of the violence – that’s clear enough” (interview with the North Kivu Coordinator). “Our activity is all about being in the right place, the place where the peaks occur” (interview with the DPM, DRC Desk).

The desire to be as close as possible to the violence, and therefore to its victims, is evident in the way operations are implemented and managed. It was already apparent in 2003, when it was couched in terms of being as close as possible to people’s needs: “The strategy adopted at the programme’s outset was to follow population displacements and ensure that we could provide emergency medical aid to those fleeing the fighting and the violence. This is why various clinics in the Beni-Mambasa area were opened and closed between December and March 2003” (2004 annual strategic plan, December 2003). To be “as close as possible” therefore required a permanent state of readiness. This obligation was constantly stressed and was the basis for reactive operations, which included a series of short emergency interventions launched in response to the changing situation on the ground.

The decisions to close the Beni programme and open another in Nyanzale in 2006 were taken for the same reasons. Beni had not suddenly become a peaceful area – far from it – but the gradual return of displaced persons and the development of the profile of victims of sexual violence (now mostly women attacked several months beforehand, rather than recent cases), together with the willingness of the authorities to take at least partial responsibility for them, indicated that Beni was no longer at the “centre” of the troubles, the place to be: “Beni was no longer afflicted by the type of violence that prevailed in the Rutshuru area … In Beni, there was a shift to domestic violence, the proportions were reversed” (interview with the North Kivu Coordinator). Furthermore, in 2006, MSF found that it was treating an increasing number of women in Rutshuru who came from Nyanzale, a previously almost inaccessible area with a reputation for extreme volatility. Their attackers were usually armed men. The number of victims, combined with the profile of the attackers and the volatility of the area, convinced MSF that it should attempt to position itself there rather than receive patients every week at the hospital in Rutshuru.


By definition, the reactive approach MSF maintains in North Kivu is designed to react to events. It attempts to follow the movements of populations as they flee en masse from their villages, and to treat the consequences of the violence inflicted upon them: as we have already seen, what is at stake here is medical operational response – at no time does the question of MSF adopting a protective role arise. The local populations make no mistake: they do not wait for MSF before taking their own decisions. As all the reports make clear, they regard flight as the dominant option and will resort to it as a preventive measure or whenever the danger is immediate (according to the FC Rusthuru, people at the roadside will disappear into the forest at the mere sight of an MSF vehicle, and will emerge only when they recognize the logo). Nor is it a question of acting as a human rights watchdog in North Kivu.

Yet there seems to be a solid ‘core’ to the will to be where the violence is most intense, where populations are suffering the most, although it defies easy description. The sitreps do not refer to it – probably because it is so difficult to express – but the concern to reach ‘beyond the medical’, what it means to be ‘by the victim’s side’, can nevertheless be detected in all the interviews we conducted for this study. “Beyond the medical care, the issue, and therefore the relevance, is to reveal this violence” (PM Desk, environment week, June 2006). There is a need to “do more with regard to the violence”, to do more than provide medical care (discussion, May 2007). While people may not think that MSF’s task is to protect them, “the idea is still there, though it’s not easy to approach or describe … a confidence, a kind of reassurance … people will say, ‘Because MSF is here, we can get the authorities to listen to us a bit more’. They demand security from the MONUC, the authorities and the IB [integrated brigades]. I get the impression that they feel more confident due to the presence of MSF it’s like an unconscious support there is a genuine bond of trust developing between MSF and civilian populations” (interview with the Coordinator, North Kivu).

In this sense, while the MSF project never refers to the idea of protection as an objective, de facto MSF finds itself faced with issues of protection of civilians as defined by international humanitarian law, through direct contact with the “protected”, i.e. the wounded and direct victims of physical violence.




Having examined the general framework of the MSF project in North Kivu the attempts to get as close as possible to the violence and the primacy of operational and medical activities – we now turn to what actually occurs within this context. What practices do the field teams employ, what action is taken in the light of the violence and dangers noted above? Is there a place for practices other than those specifically related to health care, and which are motivated by the desire to attenuate, avoid or prevent acts of violence? If indeed there is, are they simply tolerated, contained or encouraged? Where do their boundaries lie, and who defines those boundaries? Such questions enable us to distinguish between activities that are an extension of care provision, practices adopted to deal with situations outside the sphere of medical care, and, finally, the various approaches to a public position, which will be discussed in section three. 




Given the context of widespread violence in North Kivu and the MSF framework of medical care for its victims, the teams are often directly confronted with the issue of dangers hanging over local populations. It appears that MSF started considering periods prior to and following the actual provision of care as entering its sphere of responsibility. The desire to ensure safety in care and to avoid exposure to danger in the periods surrounding it led to a series of measures which became systematized into procedures as the project advanced. Most of the examples below involve victims of sexual violence.

Safety in the actual provision of care was the first area of reflection and systematisation. In the case of “VSV”, these mainly focused on two specific issues: confidentiality and certification.

Confidentiality, a central element in any discussion concerning victims of sexual violence, is closely linked to the issue of ensuring that the patient is not exposed to danger. When a patient has suffered this particular form of violence, it is crucial to avoid divulging any information which might expose her to the risk of stigmatisation or of rejection by the husband, and especially to reprisals by her assailant For this reason, confidentiality is almost always – and quite rightly – stressed when encouraging victims to come forward: the perception of danger would immediately deter the patient from seeking a consultation.. Following the project’s expansion in 2005, the reports clearly indicate a determination to preserve confidentiality: “MONUC’s protection section has asked us for the names of VSV in order to create a database … we will provide no data with names. Respect for confidentiality, which is vital in this type of activity … all documents should be handed to the patient if that is what she wants …” (general sitrep, April 2005). Note the paradox here: MONUC requested such data for the specific purpose of “protection”, whereas MSF saw it as having the opposite effect, as jeopardizing the patient’s safety. We can also observe the emergence in this context of a more individualised relationship to the patient: the victim will make the decisions; her personal safety comes before the compilation of data to support the denunciation of the overall situation. As MSF was setting up consultations at the hospital in Rutshuru hospital in 2006, discussions centred on the crucial issue of a secure location for the treatment of VSV, a site which would not “harm the victims”. “It seems that the best way to conduct this activity for the benefit of the patients at Rutshuru remains the association with STI cases in a clinic” (sitrep Rutshuru, week 6, February 2006). Slides from a “VSV” presentation at an operations meeting (20 June 2006) bore titles such as “Setting up the provision of care (2): safety of victims: confidentiality …” Confidentiality was not factored into the various programmes before they were launched, but constitutes a recent and ongoing battle. Before the concern for confidentiality and the organizational structures to ensure its effectiveness were translated into a systematic approach, innumerable instances of non-respect for confidentiality had most certainly occurred. It is probable that teams’ efforts to gain access (encouraged by the injunction from headquarters to deal with VSV, a long-neglected category) did in certain cases much to jeopardize confidentiality (asking traditional chiefs to count the number of rape victims is just one example of this type of indiscretion). Sensitivity to the issue, encouraged in a proactive fashion, is now increasing. This only highlights however the irreducible tension between the demands of access and those of confidentiality.

Two similar problems arise from the certificate offered to a victim of sexual violence following a consultation. Today, certificates are put forward as an integral part of medical responsibility, yet they only appeared very recently in the care package offered to victims of violence. The practice was adopted systematically only after several individuals had made repeated efforts to introduce itEspecially MSF Legal director, who strove to ensure that the document was suitably adapted to the situation in the field. The difficulties involved in the systematic provision of certificates can be traced through the discussions at meetings and courses on “Violence”, where the issue is always explored in depth and there is an obvious need for input from field workers.It has now become established, and the document is offered to the victim as a matter of course. As mentioned in the introduction, certification is currently regarded as a form of “protection”, and indeed represents one of, if not the only, legitimate uses of the word at MSF today for example in the “protection” section during a presentation of the North Kivu project (Board meeting, 30 March 2007). At that meeting, the programme manager, when asked what MSF was doing in terms of lobbying, referred to the distribution of reports (see below) and added: “Protection goes as far as issuing the medical certificate to anyone who asks for it that’s more or less our limit in terms of protection”. Similarly, several individuals, when informed of the present study, claimed that we “don’t do protection”, before remarking that we did in fact “do certificates”. The term’s legal connotation tends to generate endless confusion between protection as defined in law and protection in the sense of practices designed to reduce or prevent violence. The paradox of comparing the certificate to a “protection practice” (which is the paradox of any practice defined in advance as protective) is that the document contains extremely sensitive information, and may thus actually endanger the person to whom it is issued. This is precisely the risk that teams and desk constantly warn against. Field workers, when asked if the certificate is offered systematically, will say “yes, it is offered systematically, but the women don’t want it and we can’t force them to accept it” (email, Desk- Coordination, January 2006). In effect, “once she is in possession of this document, the woman is in an unsafe position: ‘It’s dangerous for me/I’ll be raped again/my husband will throw me out.’”. This may explain why the document is accepted in only 17% of cases (PM, DRC Desk, “VSV appraisal”, operations meeting, 20 June 2006). The teams are therefore given detailed instructions on how to handle such sensitive material: “MSF will not pass the certificate [to the legal authorities or the police] unless the victim requests it MSF will not pass certificates or names of victims to representatives of national or international human rights organizations” but can direct victims to these organizations (DRC visit report, Legal director, August 2006).

Safety in the sphere of medical care also encompasses protection of the hospital space. This is usually the first point to arise whenever protection is discussed. Teams are fully aware of the need to prevent attempts to manipulate, exploit or intrude upon this space. On one occasion, soldiers from the FARDC entered a clinic and demanded medicines: “It’s the principle rather than the quantity that bothers me, so I’ll have to have a word with the commander of the 5th [integrated brigade]” (sitrep, Rutshuru, week 4, October 2005). On another, troops from MONUC entered a clinic to remove a wounded patient belonging to the FDLR: “Our immediate reaction vis-à-vis the hospital authorities and DDRRR representative was to indicate our total disagreement”. At a meeting, MONUC’s commander “understood MSF’s position perfectly – that in terms of protecting our work space, we considered it unacceptable” (situation update, 30 August 2006). “We fought to stop guys from the 9th and MONUC entering the hospital in order to interrogate [wounded] FDLR. We forced the guys from the 9th to leave the hospital. They were [hanging around] there, terrorizing people” (interview with the Field coordinator, Rutshuru). At one point, rebels infiltrated Rutshuru hospital in an attempt to discover whether people were hiding there: “I have to talk about all this in detail with Vincker [the hospital’s director] [we must] preserve the neutrality of this work space!” This is an interesting example, for the incident occurred when the expatriate team had been evacuated and the hospital was full of people seeking refuge from the confrontations: “Rutshuru is completely empty, and there are about 1,000 people taking refuge in the hospital” (NK/RU update, 22 January 2006). These people were not patients, but when the team returned to Rutshuru and discovered them in the hospital, there was no question of moving them on. While somehow passive, this shielding was vividly defended by the team, in the name of the immunity of the medical space, when rebels tried to intrude in the hospital.

Similarly, we note the concern to ensure the safety of health centres supported by MSF, given the prevalence of looting, including of buildings associated with medical care. The reports express fears that distributions might encourage pillage: “Looting at Kihito as a result, we didn’t go to the health centre at Niakahanga (on the edge of Kihito) as we didn’t want to cause any more problems in that area. If bandits knew the MSF vehicle had come through, there would have been a risk of looting a few hours later” (sitrep, Rutshuru, week 8, 2006). The same sitrep also refers to the provisioning of another health centre, which has attracted a marginal note from the Desk: “OK watch out for looting”. However, most of the information regarding looting is recorded bluntly, without commentary, as one more element in the catalogue of abuse and violence that forms the ‘setting’ for the action but has little bearing on the way it is managed.

Finally, the safety of MSF staff is perceived as an integral part of our responsibilities with regard to the violence. This responsibility was translated into practical measures according to the risks assessed, especially the risks faced by Congolese staff. In the case of targeted pillage: “We are speeding up the current process of payment by bank draft” following systematic “visits” to the homes of MSF staff the day after they were paid (sitrep, October 2006). With regard to danger on the roads: “As we collected statements from our patients, we became aware that when looting occurred, those who had nothing were almost systematically injured or killed”, a situation that led to the establishment of “envelopes” for drivers (sitrep, September 2006). But there were also dangers linked to certification and legal action. These were discussed extensively; some thought that the risks taken by staff asked to write certificates was very high, while others argued that stressing these risks was a symptom of the reluctance to get to grips with the issue of violence (discussion following the “North Kivu VSV assessment”, operations meeting, 20 June 2006). The risk-reduction policy grew out of these contradictory positions. Detailed recommendations were drafted, making it clear that doctors would not appear in court and that MSF’s role would be restricted to the authentication of certificates: “MSF seeks to restrict the obligations on MSF doctors in the matter of medico-legal certification. The aim is to avoid exposing doctors to contact with aggressors, the police and legal authorities; it is prompted by a concern for safety and the will to preserve MSF’s independence vis-à-vis these power structures” (visit report, Legal director, August 2006). 

In short, the fine-tuning of medical case management was accompanied by a series of practices designed to reduce the exposure of patients and staff during the provision of care and in the care space. What emerges here is a form of responsibility that is primarily concerned with our own action – and above all else, the requirement of providing “quality” care – before we proceed to look elsewhere. Is there then a place for a form of responsibility which projects beyond the internal realm? Can this internal responsibility be extended, and to what point? How does MSF go about managing the situations of violence it is aware of, but which do not impinge upon its medical activities? 




Questions such as these raise the question of boundaries. In an environment such as North Kivu where, in addition to the conflict, the population is subjected to various forms of abuse on a daily basis, is violence more than simply a context of action? We may ask ourselves under what circumstances, in what situations beyond the ‘care sphere’ (the contours of which could form the basis of another discussion) does MSF’s responsibility come into play? And if this responsibility does indeed exist, is it clearly defined and in what way?

When considering the boundaries of action, we are forced to examine our practices from different perspectives. There is an internal boundary, the basic level of responsibility which we are obliged to accept if we are to retain our humanitarian principles and ensure that our action has a meaning. This may be described as a ‘moral’ boundary, and is connected to a certain perception of what cannot be tolerated. There is also an external boundary; to step beyond it is to emerge from our role and yield to what some call the “human-rightist temptation” or a “protectionist drift”. This boundary is institutional in the sense that it reflects the desire to maintain the coherence of our “social mission”. Both boundaries are subject to constantevision and displacement whenever concrete action is debated. Somewhere between them, in the space which separates them, lies ‘our’ field, the site of standard, legitimate, systematic practices (which we cannot relinquish) and of many others which have no proper status. Some of these practices are encouraged and some are simply tolerated, while others are in the process of being systematized or abandoned on the grounds that they exceed MSF’s external boundary.

In concrete terms, we are referring here to practices which may be introduced in response to the violence MSF has experienced or witnessed, or which it anticipates or fears; any practices, in fact, which extend beyond what MSF considers to be its fundamental field of responsibility – the provision of care.


We shall first examine the way MSF deals with the risks victims face as they travel the roads  after the actual provision of care. The initial offer of care for victims of sexual violence encompassed free transport (paid for by MSF); encouraging patients to come forward  and making it easier for them to do so were regarded as priorities. The danger represented by the presence of armed men on the roads, was part of the setting and beyond MSF’s power to control. Therefore, these risks, particularly acute during the hours of darkness, were not among MSF’s concerns. However, once the gravity of the situation had become apparent, decisions were taken and acted upon systematically: a new practice entered the field of our activity.

“It struck us that MSF had made mistakes by putting people on the roads at night. Afterwards, we acknowledged that we’d really blown it. It happened, and then the FC inquired as to the whereabouts of a patient. We said, ‘we sent her back last night,’ and he reacted and then we realised… – ‘Shit…’ we thought”.

This new awareness led to practical decisions which in turn were made systematic through a risk-reduction strategy. While it could not aspire to total security, it did at least pinpoint particularly dangerous areas which could then be avoided. Standard procedures seem to have been established in 2005:

“At Beni, for example, we were receiving lots of women that NGOs had sent from the Ruwenzori area; we often received 4-5, 10 women in one day. We paid for their transport and the hotel. Once they’d been treated, we paid for the hotel again, and on the following day made sure they returned in relatively safe transport. It was planned, part of the operation, budgeted for. These cases always come up, you think about it as you go along, then you try to organize things a bit more systematically … – But we thought about this issue, whereas we hadn’t done so before? Yes.” (interview with the North Kivu coordinator concerning activities between early 2005 and early 2006).


By 2006, the Rutshuru project had benefited from the lessons afforded by other missions, and it seems to have become accepted that the dangers on the roads could no longer be ignored. “We never let anyone leave after nightfall Everything that happens before and after the hospital also exposes people to danger, physical danger, since the violence around Rutshuru took place on the roads” (interview with the Field co, Rutshuru, regarding the summer of 2006). Thus the concern for safety in care eventually extended to the patient’s movements prior to and following its provision – an expansion of the sphere of care as an MSF sphere of responsibility.

A further insight into the way in which a set of problems ‘entered the field’ may be gained from the issue of recidivism in the case of rape and the risk of recidivism. This phenomenon does not feature in the sitreps, either as a problem or as information, until 2006. In the field reports up to the beginning of 2006, the information recorded in the “VSV” section is in most instances extremely succinct, taking the form of figures for “new cases” (anyone presenting for rape was a new case), their provenance, and the figures for the patients returning for a follow- up.115 An increase in the number of cases from a particular area was underlined mostly as a “barometer which indicates trouble spots” (general sitrep, February 2006). But neither the profile of the victim nor that of the attacker was targeted for specific attention. There are several references to recidivism or rape by a known person, but the field teams refrain from comment. For example, the “VSV” section of a report dated June 2006 contains the following observation: “To note, one case of a fourth occurrence and another of a second occurrence”, without further comment. The Desk has added a note in the margin: “Recidivism? Protection?” (sitrep, Kayna week 21, June 2006). Another report states: “3 cases of attackers known to the victim this month, one case where it’s the victim’s brother-in-law and another where it’s a neighbour” (sitrep, July 2006). Comment is confined to the action taken by the victims: “no complaint was filed”. In all probability, particularly acute situations sometimes came to MSF’s attention and were treated on a case by case basis but were not mentioned in the paperwork, as the North Kivu coordinator has indicated:

“– Did we ask ourselves whether, with regard to rape by a known individual for example, a woman would be able to go back to her home, etc? Yes, the question has arisen. It’s really case by case. [We asked the question] because there have been times when, for example, parents or relatives have said ‘We know it’s the uncle; it will happen again.’ We either offered to settle people in Goma or pay the cost of transport if they had family elsewhere. We tell them they’ve got a medical certificate if they want to file a complaint it doesn’t go much further than that” (interview with the North Kivu coordinator, 2005-2006).

The problem became increasingly acute over the course of 2006. In the summer of that year, the new FC felt it was an issue:

“We wanted to establish a follow-up who was leaving, who was returning and we realized that some women were returning for ‘second rapes’. Then we thought ‘Woah’. I think that was the first time it came up, given the fact that the FC position had been filled up by the capital a lot: you keep things going, there are gaps in the follow-up. I thought ‘well’… you think about Brauman’s text on ‘torturer doctors’ you ask yourself ‘What exactly am I doing?’” (interview).

Shortly afterwards, MSF’s Legal director arrived in North Kivu. Her visit seems to have marked a turning point in the way the issue was approached. In her report, she affirms that the threat of recidivism is a legitimate MSF concern:

“In the case of an attack, we can hope that the victim will face no further personal danger. On the other hand, there are situations where the victim has been identified as an isolated and vulnerable individual and may therefore face the permanent threat of further attacks by the rapist. It is important that we attempt to identify the structural elements of vulnerability and work with the victim and other partners in trying to find solutions to them. The risk in this instance is one of recidivism, of having to treat the same victim several times for the consequences of the same crime committed by the same attacker.” (Legal director, DRC visit report, August 2006).


Described thus as a phenomenon linked to a set of conditions (some of them structural) that foster vulnerability, the recurrence of violence could no longer be regarded as simply inevitable. Increasingly perceived as a ‘failure to protect’, the idea that we should restrict our intervention to the treatment of the consequences of recurrent violence thus became less acceptable. Therefore, the report invited us to investigate the possibilities for intervention, beginning with the collection of more detailed information.

Hence further questions were added to the questionnaire attached to the medical file : “does the victim have access to safe accommodation? Does she have anybody to help her?” “What MSF seeks to know is whether the victim is still in danger after the attack and whether there is any particular risk attached to sending her home”. The report reviewed the factors which may contribute to individual and collective vulnerability and outlined possible MSF responses: “In individual cases, MSF can keep the victim in hospital for the time it takes to comprehend the situation and find an appropriate solution (removing the victim from the area, helping with a change of residence, making contact with other members of the family, etc.)” For collective cases, it recommended that once the “schemes of collective violence” have been identified, attempts should be made to sensitise the various groups involved (victims and perpetrators). From this point, recidivism and attacks by known persons received greater attention and statistics concerning the profiles of aggressors and recidivists began to appear“Field teams have been asked to start collecting the following data immediately: incidents of recidivism concerning     VSV already treated by MSF.” (North Kivu update, week 37, September 2006). “Collection of statements regarding violence and recidivism … Meeting with Unicef, UNFPA … we raised the problem of recidivism and protection in general” (sitrep, VSV  section., September 2006). “39 cases of recidivism this month” (sitrep, October 2006). Note the  use of protection in its most concrete and personal sense – protection of specific individuals who have been identified     as being at risk. Where known offenders are concerned, information is collected but the possibility of re-offending is     not subjected to any systematic analysis (discussion with DRC desk members). . During the first months of 2007, we also note the emergence of specific references to child rape: “35% of civilians, 2 cases of recidivism, 2 cases of female children needing surgical treatment … the proportion of known or unknown civilians is still increasing, most often responsible for the rape of very young girls” (medical sitrep, March 2007). The focus on minors also increased following the Legal director’s visit which, according to the Desk, highlighted the fact that amidst the prevailing climate of violence the ‘norm’ for the teams working in the DRC there were forms of violence we should never consider ‘acceptable’. In short, the Legal director set a boundary, that of child rape, which “we cannot ignore” (discussion PM Desk).


Despite the wealth of new, more specific and detailed data, the reports contain no indication of concrete action taken by MSF teams. There was no institutionalization in the sense of procedures geared to fit various situations. However, the Desk encouraged and supported every effort to help patients who asked for shelter or expressed the fear that they were still at risk: “As long as we can do something, we’re certainly not going to stop ourselves from doing it”. Individual cases were handled on an “informal, case by case” basis. Assistance could take the form of providing financial support for the victim’s resettlement, for example, or referring him/her to another organization. As for the issue of child rape, it is currently handled primarily through highlighting its existence, creating a separate category for it in reports and calling in a doctor in the consultation as a matter of course. In cases where there is no evidence of circumstantial or structural vulnerability, teams nevertheless attempt to find out what they can: “As Rutshuru is served by four major roads, we tried to find out where the rapes occurred most frequently. I did a lot of work on that to see if there were any correlations” (interview with the FC, Rutshuru). In short, the boundaries between ‘what we do’ and what exceeds our field of legitimacy (or of action) have shifted. We have included within this field new practices linked with the recurrence of violence or the persistence of a threat on an individual, yet without making them systematic. Such practices are almost certain to undergo changes as the data collection on these new categories will affect the way we piece together an overall picture of the situation.  


As the above developments will have broadly shown, information gathering is at the very root of the concern to avoid exposure and to provide shelter, and of its translation into action. Without knowledge or understanding, dangerous situations or exposure to risk cannot be prevented or managed the desire to know which is constantly reviewed and constantly opens up new areas of anxiety. 



Having examined the concrete practices designed to provide shelter and avoid exposure, we now turn to the various forms of public discourse related to the violence. Why should we adopt a public stance, and on what should we base it? It could be argued that given the widespread and chronic nature of the violence, as well as the presence of a great many factions whose political aims lack credibility, there is little point in adopting a public stance on the violence in the DRC at the present time. But this has not always been the case: we spoke out on the situation in the Ituri region in 2003. While it may have been a source of controversy from the outset, it sheds a great deal of light on the internal workings of MSF.

A change of context? A cultural shift? Such questions cannot be settled easily, but we shall attempt to illuminate the issues surrounding them by comparing the various stances adopted in relation to the violence. 


By early 2003, MSF-France, having begun work in Beni in late 2002, was confronted with a situation of extreme instability in the nearby Ituri region. Moreover, MSF-Switzerland was operating in Bunia, the capital of Ituri province.

As the Ugandan troops occupying the area prepared to withdraw on 24 April, there were increasing fears that rebels groups would begin slaughtering people on ethnic grounds. A briefing paper dated 22 April was written prior to MSF’s approaches to the UN Department of Peacekeeping Operations in order to obtain greater “protection”. Evoking an “escalation of the violence” that bordered on “genocidal logic”, MSF expressed its concern and its “worries regarding the concrete measures planned to assure the protection of civilian populations during and following the departure of Ugandan forces”. The document referred to “serious failures” of previous missions to protect populations (like during the genocide in Rwanda), and implied that the current situation, a period of peace negotiations which could degenerate into an episode of extreme violence, was little different. It concluded: “In order to avoid civilian populations paying with their lives for the lethal ambiguity of the UN mission, MSF calls on the states involved in the peace process to provide concrete guarantees with regard to the manpower and materials deployed by the UN, in order to ensure the effective protection of civilian populations …” (briefing paper, 22 April 2003). At an inter-section meeting on 23 April, the participants discussed the possibility of releasing a report on the plight of civilians in the DRC. Among the arguments advanced to justify this initiative, we read: “support a clear demand for the strengthening and clarification of MONUC’s mandate in terms of protecting civilian populations”.

At the beginning of May, intense fighting occurred in Bunia. Civilians were subjected to repeated attacks between 9 and 12 May; “hundreds” of people were killed in a context of extreme violence inflamed by the rhetoric of ethnic differences. Several NGOs took it in turn to call for “the protection of the population”. On 12 May, Oxfam urged the UN to protect the population. On 8 and 21 May, Human Rights Watch (HRW) reiterated its calls for the rapid deployment of troops in the Ituri region: “Only an emergency intervention can put a stop to these continuing massacres”. On 22 May, Merlin backed a coordinated response in Ituri. On 30 May, Oxfam called for the immediate deployment of a rapid reaction force. On 6 June, HRW sent a letter to the UN Security Council demanding a rapid intervention in order to protect civilians and end the impunity of the perpetrators; it also called for the mandate to be strengthened. Meanwhile, MSF briefed members of the State Department and Security Council, stressing the imminence of disaster and the risk of being ‘too late’: “Brief them on the situation and remind them that if they don’t act now, they will be left to count the bodies (remember Rwanda/Arusha tribunal and Srebrenica)” (Communications Officer, MSF-France, teleconference update, 15 May 2003).

The Security Council finally authorized the deployment of an EU-led interim force. Composed of French troops, the mission, known as Operation Artemis, was launched in early June, with a mandate to secure the town of Bunia until September.


This was the point at which divisions between and within sections emerged. They were based on different views regarding MSF’s public position, initially in relation to the media and later, at the beginning of July, during the drafting of a report on the plight of civilians in Ituri province.

The idea for the report originated with MSF-France which, given its presence in Beni, was taking in the people who had fled Bunia. All sections were involved, however. Accounts were collected from displaced persons as they emerged from the forest; they all described a scene of deliberate, extreme if not systematic violence, leading many to feel there was an urgency to alert the need to pass on the victims’ accounts and the desire to prevent more violence were probably intermingled.Accounts collected by the MSF-France Communications officer. Once again, we note the correlation between the desire to speak out and the distance from the ‘heart of the action’ (Bunia): MSF-France, rather than MSF-Switzerland, was the first section to take this initiative.The first draft, spurred by the sense of urgency and largely composed of descriptions of the violence inflicted on local populations, clearly conveyed the message that greater protection was needed. The means available to the international force therefore had to be increased. Attempts to resolve the conflict within the UN framework should “provide for a genuine capability to protect the populations under threat … We know from the recent fighting involving UN intervention forces that they cannot guarantee the security of populations if they are not governed by a policy concerned with security”. The international community “must, as a matter of urgency, concentrate on protecting those most at risk”. The report concluded by describing the international presence as “cosmetic”, given its inability to “prevent the massacres and atrocities”: MONUC had demonstrated “its inability to guarantee any protection whatsoever for civilians”; the mandate of the interim force was inadequate. The final part stressed that “international initiatives, whether aimed at a political resolution of the crisis or the implementation of peace agreements, must establish the protection of populations as an absolute priority” (draft report, July 2003).

The exchange of views generated by the draft report, which was re-examined by all sections, reveals a range of expectations regarding the final version. There was general agreement on the objective – the achievement of “greater protection”, but opinions diverged as to the precise content of the message. MSF-Holland believed it should focus on the strengthening of protective measures and their concrete implementation, rather than on negative observations, which might convey the impression that no form of action could succeed“The international community should do its utmost to assure protection for the civilians who are most at risk from the violence … final paragraph on page 3 might give the impression that nothing is enough not can be done (sic) while we should stress [that] something needs to be done!! … One immediate issue … is what MONUC’s new mandate will look like” (member of HAD, MSF-H, 1 July 2003).. At MSF-France, the draft’s authors pointed out that besides protection, increased assistance was also a short- term objective, and stressed that it was entirely appropriate for MSF to remind the international community of the gulf between discourse and realityThe MSF-France Desk, banking on the pressure of public opinion, argued against detailed recommendations. But “in the meantime we go straight to some implicated political bodies to remind them that we will be on their back every time they will pretend to act for the protection and assistance, and they won’t, or won’t do enough” (email, DRC Desk, 2 July). The legal department doubted the “the relevance of publishing a report on Ituri without taking a position on the protection force’s mandate” at that stage, when media interest was already considerable (email, 12 July). . Finally, others at MSF- France and elsewhere criticized the report for its “human rights” aspect, which made it indistinguishable from a “HRW report”.

 Ultimately revised to present a stronger viewpoint on international intervention, the report was animated throughout by the idea of illusion and false promises. The title of the final document, Ituri, Unkept Promises? A Pretence of Protection and Inadequate Assistance (25 July) was eloquent in this respectOther titles within the document also underwent significant changes: Part I, initially entitled “War and Terror before May”, became “A Reinforcement Interim Multinational Force: Just a Broken Promise?” Part 2, “War in Bunia: a Wave of Violence Overwhelms the Entire Population”, became “The War during MONUC’s Deployment”, etc. . The word ‘protection’ was used in a negative sense to highlight its absence or inadequacy: “MSF would like to emphasize that recent military deployments have failed to provide Ituri’s civilians with proper protection … MONUC has not been given the means to prevent the massacres”. The only ‘positive’ mention of protection was formulated in the past tense: “In April, MSF had asked the UN peacekeeping operations department to take concrete measures to guarantee the protection of civilians…” This was once again a way of highlighting the lack of political will if not the cynicism of states which were aware of the situation but had failed to take action at the appropriate time. The report therefore called not for greater protection, but for an end to the misleading of populations: “Having witnessed these painful experiences [Rwanda and Bosnia], MSF urges the international community not to give, once again, a dangerous illusion of protection to the civilian population of Ituri. Whatever the decisions regarding the mandate and means of the international presence in Ituri, MSF calls on the Security Council to keep its promise …” The accompanying press release denounced “the absence of protection” and “the international community’s lack of political will”.

The report swiftly attracted internal criticism for insisting on UN failures at the expense of a more nuanced description of the reality. At the end of August 2003, a member of the board (who had regularly been informed during the drafting process) returning from a visit to the DRC, where he had observed reactions to the report, stressed : “It should be noted very clearly (and in my view the MSF report of 25 July was not clear enough) that the presence of the interim international force actually prevented armed militias from engaging in violence and abuse during daylight hours in Bunia” (Board meeting minutes, 29 August 2003). It seems that the tensions the report generated in the field, as well as the sharp reactions it aroused from the French Ministry of Defence, contributed to its disavowal. Its impact and relevance are still disputed today, precisely because of the discord it aroused on its releaseYet, while the drafting of the report may have been a tortuous process, it was certainly no secret (the fact that the report was released in the middle of the summer holiday period has often led to such claims). It seems that the Desk was indeed left to get on with its finalization, which included modifying the overly “human rights” slant of the first draft. This does not necessarily imply, however, that the people originally involved were not consulted over the later drafts (discussions with the Communications officer). It is also possible that the report suffered from a perceived lack of legitimacy because it had not been endorsed by someone in a senior position.. Whatever the case, this episode is informative for the light it sheds on later developments. In particular, the report seems to mark the term of a shift in our approach to public positions, and could be said to constitute a pivot.

- This report was a turning point in the assessment of armed interventions conducted in the name of protection – On the one hand, it was part of the series of public positions on “populations in danger” that MSF had adopted in the late 1990s, motivated by a sense of urgency as the likelihood of slaughter increased. But it had a different content: instead of calling for an intervention to protect populations (e.g. Zaire 1996), the report offered a critique of the spectre of the illusion of protection and, as we have seen, established a link with the broken promises of the past – through the numerous references to Bosnia and Rwanda. In substance, the denunciation of false promises constituted an appeal for promises to be honoured. On the other hand, the report signalled the end of the series: it seems that we will not be seeing any further references to protection as an objective, as a desirable idea; nor will there probably be any further ‘calls to arms’. In effect, we have moved from a critique of the illusion of protection given to populations by an international community that cannot bring itself to act, to a critique of the illusion within MSF regarding the concept of protection, an illusion that must be shedSee the 2003-2004 President’s annual report, cited in the main document (Part III, Section “MSF and the responsibility to protect”) : “We have seen the resurgence, in our discussions of conflicts, of calls for international protection which seem to me hardly realistic … We must not become the propagandists of such illusions.”.It is as if this displacement, which had started some time before, had been here permanently ratified. To put it in very simple terms, we appear to have reached the final stage of various moments of MSF distancing itself from the notion of protection. From calling into question the idea that MSF might have a role to play in protection, or the ability to provide it (Srebrenica, Kibeho), to criticizing the international community’s failure to respond to calls for effective protection (Zaire 1996), to urging the international community to keep its promises and condemning its maintenance of illusions (Ituri), we have finally arrived at a critique of the illusion within MSF that armed interventions might lead to protection (understood as a near perfect, stable, static overall state of security). After 2003, the notion of protection is tinted with doubt. The trajectory has generated the complexity we now find in internal and external positions on the subject of international interventions. For example, there may be internal acknowledgment that some interventions are capable of producing positive results, but this is accompanied by a fundamental critique of the idea that a war can be conducted in the name of protection, while the view that we cannot justify making general statements may be countered by the view that we cannot call for armed interventions but we can speak out against them.


- Concerning the justification and content of MSF’s public statements Contextually, the report was situated in the post-2001 tightening of the communications policy, a process designed to stress its “primary objective” the achievement of “more effective aid” (AR, 2001- 02). Organized around the idea of quality, the modified policy emphasized MSF’s own responsibility vis-à-vis its action, and marked the end of the tendency to highlight the shortcomings of other actors, the distribution of “good and bad points”. In this respect, the report went ‘too far’, and it is not unreasonable to suggest that its lack of nuance reinforced the idea that MSF was on shaky ground when it came to criticizing others. Moreover, the report appeared at a critical point in the debate over the content and methods of MSF communication, just as the collection of witness accounts was being called into question. In fact, the collection of victims’ accounts was at the centre of the arguments over the drafting of the reportResponding to criticism of the draft, the deputy legal advisor noted that the issue was one of knowing whether or not we wanted to publish something from the communication officer’s work on collecting victims’ accounts and use them to support the argu- ments over international intervention (e-mail deputy legal advisor, 12 July 2003). The communication officer believed that by ruling out this qualitative method of information-gathering, we not only weakened the possibility of indignation which accounts of personal experience would naturally arouse, but we also denied ourselves access to material that would enhance our understanding of the situation. (discussion with Communication officer).. Thereafter, it was in fact practically abandoned in favour of data collection and a communications policy with a greater focus on epidemiology.


Having examined the events of 2003, it is appropriate to turn our attention to the positions on violence and/or protection that MSF adopted after that period. In fact, there were far fewer of these (the Ituri report may have been an inhibiting factor, but cannot account for all the subsequent developments). Is there currently a place for the mention of violence in public position statements? If so, how is it presented?


Speaking out One observation stands out on reviewing MSF public statements since 2003: compared to the positioning on other countries, that on DRC (and on the violence occurring there) does not include marked public statements (reports, press releases). There have been no reports on the DRC since 2003The exception being a report entitled Ituri, the Violence Continues (August 2005), released by MSF-Switzerland after the cessa- tion of its activities in Bunia. The document described the “situation of populations in Ituri and the difficulties involved in providing humanitarian assistance” and contained many examples of “direct” and “indirect” violence as well as a reference to protection.. “Communications” (or témoignage or “advocacy”) does not generally feature as a concern in the sitreps or exchanges between Desk and field, and has not had its own section in the annual delivery plan since 2005 the year which saw the emergence of public communications with a different temporal focus (the production of a film and an exhibition of photographs dealing with the violence in Katanga, a forgotten zone at the centre of a forgotten conflict; the invitation to A. Vallaeys to visit a project for the book she was writing, etc). In 2006, North Kivu attracted the attention of media organisations such as CNN, the BBC and TF1, but given the interest the elections had aroused, a “message from MSF” was not considered appropriate. There were plans to prepare a detailed report based on specific, quantified and analysed data, describing MSF’s work and observations in the field. The report should have been available by late 2007 (discussion with the PM, Desk); it eventually did not happen. Similarly, between 2003 and 2007, the number of press releases fell dramatically, in accordance with the more general developments outlined above and a concern to reduce the high volume of communications.In 2003, the MSF website featured seven items, two of which were originally published by MSF-Switzerland; these were purely informative (MSF “sends a cargo” being one example). Two  items on consistent humanitarian issues (Katanga,   the displaced persons of Kanyabayonga, MSF concerns about their fate) appeared in 2004. There were four in 2005, all taken from MSF-Switzerland (on the kidnapping of two expatriates and the situation in the Ituri camps). MSF-Switzerland released two items in 2006. There were none in 2007. In short, no further press releases emanated from MSF-France   after 2005.

Generally speaking, the purpose of a more outspoken public position is not apparent: “I wonder if there is any point in producing a broader document like the MSF-Holland report on Darfur in DRC we have access to populations, we have good relations with the authorities, we have local links with the Mai-Mai and the FDLR, we haven’t had a major security incident

…” (interview with the DPM, RDC Desk). A view echoed by several headquarters staff and fieldworkersWith regard to relations with the authorities: MSF has access, at local level, to political and military leaders (which is far from being the case in many other countries), hence the different approach to external communications (discussion with the former HoM). With regard to the lack of serious issues (problems of access, security, etc.): an MSF press release, “what for”? the former programme manager asked. What added value would there be in relation to an AFP release? A “utilitarian” view of communications is implied here (discussion with former PM).. All agreed that it was hard to see the added value in a public statement, while its possible negative effects were obvious: “At the same time, when you want to send a message, it’s because you want to obtain something, more opportunities to work but in this case it won’t get you anything at all and might even achieve the opposite effect – fewer rape victims would come forward, access to certain areas could be reduced … there is no gain in operational terms, you don’t get any further in terms of relieving the suffering of populations. I don’t think we’re going to have an impact on reducing the number of abuses. I think we’d be kidding ourselves if we believed that” (interview with the coordinator, North Kivu). It was also stressed that difficulties would arise if we publicly condemned the violence committed by the very people with whom we were negotiating (in an attempt to gain access to certain areas or ensure safe passage on the roads, for example): “As medical and humanitarian actors, we distribute our reports but we are not going to target a group” (PM desk, discussion, presentation to the Board, 30 March 2007).

The pattern that emerges here appears to be one in which the recourse to speaking out is linked to the need to foreground issues that directly affect aid delivery (obstacles, lack of security). The absence of such access problems and the permanent concern of security are the reasons advanced to justify our preference for the transmission of information at field level, towards local actors (as opposed to public warnings or denunciations at an international level).


Non-public communication In this context, field discussions with the various protagonists are directed above all towards elements that will allow MSF to operate without hindrance; meetings frequently involve presentations and explanations of MSF’s work, or focus on topics such as neutrality and impartiality. However, ‘discussions’ with the authors of the violence may also provide the opportunity to question them more broadly, if only at the time of the quarterly activity report’s distribution. Indeed, MSF has been releasing information (detailed sets of facts and figures) about the outcomes of its medical activities for several years. Everyone we spoke to cited these quarterly activity reports as the principal means of highlighting the violence. They are distributed throughout the DRCForwarded to the authorities, the army, the MONUC, the various armed groups, the ICRC … according to the 2004 HoM, a total of 220 copies were printed each quarter, almost all of them for Congolese actors (discussion). and “speak for themselves”

“We already communicate implicitly by releasing all our activity reports. When you see the number of wounded and VSV, it tells you something” (interview with the DPM, DRC Desk). “MSF has shattered the taboo surrounding rape, it has revealed the vast extent of it” (Coordinator, North Kivu); “We have played our part in ensuring that rape can now be discussed” (manager of the Emergency desk, operations meeting, 20 June 2006). When the North Kivu Coordinator was asked whether there was any opportunity to ‘question’ the actions of a particular group, he replied, “Yes, when we bring up our activity reports and say ‘We’ve treated 2000 women who were raped in your area, 80% of them by armed men, you can’t say you weren’t involved.’ But it doesn’t really go much further than that.”


This questioning is never mentioned in the sitreps, but it does emerge during discussions with field workers. It might be a matter of pointing to trends, or quoting statistics, or sometimes stressing the contradictions between what armed groups say and the evidence of their actual behaviour; it might even involve naming dangerous areas. There are few illusions about the effectiveness of this approach; but even so, it may help to convey the message that we are not dupes, that we are present and can see what is going on.

“I went to see the Nkunda guys [supporters of Laurent Nkunda], who changed all the time, with the aim of 1) ensuring the safety of the ambulance… I said, ‘the ambulance shouldn’t be attacked, women shouldn’t be raped.’ You said things like that? Yes, I said things like that I couldn’t start moralising, and at the same time what strings was I going to pull in order to make them understand that they had no right to behave like that? So when they said, ‘No, we’re in total control, we protect the villages, we are here to provide protection …’ I came out with the figures. That was all I had, the only firm ground, though I didn’t really feel I had the upper hand, far from it that’s why I’d done so much work on the documentation …” “I often talked about the rapes with Mayanga … he didn’t give a toss but you mentioned it”. Regarding the dangers on certain roads: “I went back over the road and visited every command post [manned by the 9th IB]. It was about putting myself about, being reachable, getting it accross that it wasn’t right, them not doing their job, that we weren’t fakers stuck in our hospital” (interview with the FC, Rutshuru).

It is thus a general questioning. The teams do not denounce specific violent incidents which have no direct impact on MSF activitiesOn the one occasion that a sitrep mentions such a practice, it is considered irrelevant. Commenting in his sitrep on the “considerable looting accompanied by rape (which is becoming systematic)”, one Field co noted: “Contacts were made with various authorities in order to denounce these acts” (general sitrep, August 2006). The Desk added a note in the margin: “???? What authorities? Say what? What message?”. Overt criticism is confined to incidents intrusion, violence involving MSF property, staff or buildings. If armed men rob Congolese staff the day after they have been paid, or tamper with the MSF vehicle, or force their way into medical centres, the coordinator will complain directly to their leaders as we have seen previously.


Hence, a number of elements seem to indicate that the concern for speaking out is absent for MSF in the North Kivu context: the demanding and reactive operationality is not deliberately hindered by the local actors; the victims of violence are provided medical care; data is regularly displayed locally, in the form of activity report and statistics; not to mention the constant concern of assuring security.

Indeed, when asked whether there was a sense of frustration over the témoignage issue, one interviewee replied: “No, it’s the frustration of having to leave when we’ve got a massive job to do [a reference to the usually short evacuations prompted by the security situation] … When people go back [to France] they are thrilled, they say it’s great, that we’re at the heart of it all

there’s this satisfaction that we can do something, treat the violence, relieve this population’s suffering a little” (interview with the North Kivu coordinator). The interviews conducted for ,this study seem to indicate that operational ability overrides the desire, compulsion or need to speak out. This chimes with the hypothesis advanced in other case studies : that conversely, the feeling of operational impotence caused by barriers to access, the intolerable imbalance between the inability to prevent deaths and the ability to save lives, or between the inability to stop the violence and the ability to relieve the suffering it causes, for example – might be the wellspring of the urgent need to speak out at a given moment.


However, beyond the question of the added value of speaking out in a context where our action is not in danger, many members of MSF deplore more generally our silence on the North Kivu situation. More specifically, the very persons who said that they could not see the positive impact of communicating publicly simultaneously expressed this sort of regret. For example, just as he refuted that there would be frustration over this communication (see above), the North Kivu coordinator also said: “I think we could have done a lot more [public statements], we could have done more on VSV”. One of his sitreps contains a very rare reference to this issue: “A lot of media people have been travelling through Congo lately and that’s all to the good; we have got to keep on talking about these forgotten populations and the violence they are suffering day in, day out” (sitrep, July 2005). During 2005, the Desk also became increasingly preoccupied with the problem of communications, and was uneasy about restricting public statements to local level (discussion with the former DPM, DRC Desk). The PR released in autumn 2007 proceeded from the same uneasiness; according to the programme manager, it is the feeling of having kept silent too long which explained the need to speak out after an evacuation which was no different from the numerous others since the opening of the Nyanzale project. Those who thought it was high time we “spoke out” about the situation in the DRC were happy with this PR; others did not see the point of a PR which did not aim at any concrete improvement nor delivered a message any different from the other agencies’.

These complexities were expressed in a salient manner by a former head of mission when he questioned MSF’s attitude to MONUC’s December 2005 offensive (therefore questioning in retrospect his own decisions) In December 2005, the FARDC announced its intention to eradicate the rebel ADF in the Beni area. MONUC supported the FARDC and asked OCHA to ensure that humanitarian organizations would be ready to deal with the consequences. OCHA held meetings with NGOs in order to work out a “contingency plan” but MSF did not participate. When the displaced flooded in, MSF postponed the closure of the Beni project so it could assist 25,000 displaced persons at Linzo..At his debriefing, he lamented the fact that we “confined questions to care”: “Couldn’t we have said something, signal that it was contrary to international humanitarian law, that the consequences for the civilian population [were] extremely heavy? Even if only to complain to MONUC?”Personal notes on the debriefing, 2006.His criticism was more specific than the vague regret expressed by others; it pointed to the negative aspects of a stance centred entirely on operational concerns and suggested that the desire to react so rapidly to emergencies occluded the need for political analysis. What was acknowledged here was the existence of a routine, of an operation geared to react to the turmoil that erupted on a daily basis. “We didn’t ask ourselves what we could do about it We knew from the outset that the damage would be considerable, and we cranked up the humanitarian machine.” To be sure, the North Kivu Coordinator raised issues at local level, using “the forum with MONUC, OCHA, etc., to tell them that they were going too far displacing populations so they could stage battles, that these people had already been displaced”. But there was no discussion with Kinshasa: “there was no active communication done” either before or after the operation (interview).The repercussions of the Ituri report come to mind here.

former head of mission stressed that there was nothing unique about this 2005 episode, which was only an example. He pointed less to the absence of communication than to the lack of political analysis that fostered it. “We do not speak politically in the DRC, we have no political reflexes in the Congo … Over the duration of my mission, this kind of issue [public denunciation of a situation] did not arise … we have got to force ourselves into conducting a more intensive analysis. Then we see whether we speak out or not”.

This line of questioning is interesting because it marked a kind of break with practices that had come to be regarded as norms and were not debated. Quite similarly, some of the interviewees evoked the risk attached to certification its tendency to engender a kind of complacency and thus defuse other issues, notably speaking out. This tension between two modes of action, both of which can be called ‘protection’, (legal approach / speaking out), surfaced during discussions on the boundaries of action. When the question of “how far we should go” (given the presence of identified armed groups, on the matter of “lobbying”, in terms of protection) arose at an operations meeting, the PM replied that on a daily basis, “we confine ourselves to certification”. The Legal director, for her part, stressed that “of course going further does not mean at legal level. It would be terrible if the certificate became the cul-de-sac of MSF’s  responsibilities. If we are witnessing an epidemic of violence, I hope that we don’t tell ourselves we will help them to file a complaint, but that we have a responsibility to speak out or take some form of action! Be careful not to reduce the issue to a technicality!!”.Discussion following the DRC presentation, operations meeting, 20 June 2006 (personal notes).This review has revealed an evolution in MSF positions on the violence in North Kivu. Their scope is less public, their tonality less political, which goes along with – and is perhaps inseparable from – the strengthening of our operational ability to deal with the consequences of the violence. This evolution gives us an insight into the way MSF’s legitimate role has been defined but it also highlights the irreducible nature of the tensions that underlie the action – between individual care and collective issues, between the impulse to speak out and the reserve on the validity of such an impulse (what purpose would it serve?). Neither the efforts to frame MSF’s role, nor the unanimous agreement that our action is relevant, will exhaust these tensions, which are ground for continual reflection.


In conclusion, a certain idea of boundaries emerges from the study of MSF’s operations and positions with regard to protection in North Kivu, a project considered as one of ‘the most MSF’ of those we currently undertake. The external boundaries are clearly defined and separate an MSF field of action in which violence has become a central feature, the site of a major effort to reach and relieve the sufferings of its victims –, from anything which might exceed this field – from adopting public positions on the protection of civilians and the violence in general, to actions designed to provide protection when it is not related to care. And there is an internal threshold, MSF’s responsibilities over the aid it delivers, which entails avoiding exposure to danger. Between these two sets of responsibilities lies the space for negotiations on the meaning of words and the expansion of fields of action, the endless revisions prompted by the pressing need to invest our action with a meaning that extends “beyond care”.