When we look back on 1999, we shall inevitably think about how, even at the end of the 20th century, global society has failed to secure basic respect for human beings and human dignity on any continent of the world. While we have continued to see injustices and suffering imposed on the people of Africa, we have also seen crises of oppression in Kosovo, East Timor and Chechnya. All of these crises represent major threats to independent humanitarian action.

Threat to impartiality

At the heart of humanitarian action we face a disturbing problem. Humanitarian action is supposed to be out of the power play between states and armies - it is neutral, impartial and independent assistance to civilians in crisis. This basic task is supposed to be an act of humanity during inhumane times. But for humanitarian actors to go in to crisis situations they have to have the acceptance of those groups in war.

Therefore, humanitarian action can be denied (even when it is allowed by international law); it can be manipulated to support political agendas; it may also be diverted to help powerful elites increase their wealth, power or forward their military strategies; or it can be used to hide a lack of political action. In Kosovo and East Timor the international community intervened to stop the violence and oppression of civilians in Kosovo.

Military operations were launched through consensus in the West - but not through the Security Council. The military interventions were opposed by many states and leaders and were seen very much as the actions of the US and other Western countries. The military was also used to provide humanitarian assistance; the same governments that were dropping bombs on Kosovo, funded NGOs to bring relief.

Victims and aggressors alike began to see Western politicians, their militaries and humanitarian aid as parts of a single effort. Milosovic did not allow us in as neutral and independent humanitarians, but denied us access as instruments of the West. Humanitarian action is not designed to take sides, but to ensure that a minimum of critical assistance is offered to all those caught up in crisis.

The actions in Kosovo and East Timor have undermined this necessary perception of impartiality, neutrality and independence. The new moral brand of intervention on grounds of humanitarian concerns did not stretch to Chechnya. And in Chechnya, the humanitarian agencies have also been denied access. We have managed to serve the refugees in Ingushetia and Georgia but in the first phases of the crisis, we were unable to access the people caught up in Chechnya.

We were not allowed or given the security reassurances to enter Chechnya and work alongside those shattered people. If humanitarian action in war represents a minimum standard for civilisation (to care about the fate of ordinary civilians), then Chechnya, Kosovo, East Timor, Angola and the Sudan are bad signs for the health and vigour of global human civilisation in the new century.

Limits to our work

In 1999, MSF committed to investigate strategies to improve on the understanding, meaning and use of humanitarian aid. We held a series of workshops in the field, gathering senior programme members, to talk about the barriers to their action and the manipulation of their help. These regional meetings served to highlight the emerging problems we are all facing in simply trying to offer the weakest some assistance, and to identify strategies to improve our work. The most critical factor is being clear about our limits - what we can and cannot do and what we are there for.

Understanding the limits to our work is important. MSF cannot act to enforce and guarantee all human rights - and we must realise that some violations are worse than others. Many critics see human rights activism as an act of Western cultural dominance. In June of 1999, we gathered five philosophers and practitioners from different fields for a meeting in Holland.

The panel members spent two days interacting with MSF field co-ordinators from all over the world. We discussed the morality and ethics of a western agency going in to other people's societies in support of their right to assistance.

We concluded that while culture and diversity are extremely important, it is essential and valid to try and help others in dire need of basic assistance. Essentially, culture and diversity add richness to humanity but do not divorce us from the basic fact we are all human.

We do have the responsibility to act, but we must invest more time and effort understanding the views of those we work with and explaining and expanding our actions.

The Silent Crisis of Displacement

There are estimated to be between 25 and 40 million displaced people in the world, forced from their homes through oppression and violence - the highest number ever. Humanitarian aid for them has become a palliative - containing crisis and excusing the absence of political action to find lasting solutions. The UN has a special High Commission for Refugees that tries to guarantee refugees assistance and protection.

There is no such international mechanism to protect internally displaced persons. 1999 was the first year (since World War II) that the number of internally displaced persons exceeded the number of refugees that crossed borders. This huge number represents a global crisis of desperate homelessness, dependence on the help of others, catastrophic health conditions and the complete loss of control over their own lives.

The instrumental use of humanitarian aid to contain people within their own countries in crisis and the abandonment of the norms for offering refugee asylum represents a decline in official state and public willingness to care and is another black comment on humanity's march to create a compassionate global civilisation.

Natural disaster aid

Reacting to natural disasters may seem much less complicated than serving people in conflict areas. However, we have learned that our role under these circumstances has not always been as effective as we would hope. With the help of Wageningen University, we undertook a major review. It became clear that we may be less successful in responding to some natural disasters for varied reasons.

We are often too late, local authorities may try to do as much as they can, many different groups come to help and are badly co-ordinated, many of the health needs only last for a short period of time - after which, large scale infra-structure reconstruction is needed, and we may not know what is the most useful assistance to provide or who needs help the most.

We therefore realised we have to be much more selective in our reaction to natural disasters. We decided to focus on areas where we are already on familiar ground, because we already have a presence. Knowing the needs of the people and the potential of the authorities and civil groups enables us to target the unassisted and effectively compliment or extend local actions. This has helped target our actions in droughts, famines, floods and earthquakes as diverse as those in Turkey, Venezuela, Mexico - and in preparing for natural disaster in highly effected areas of China and Bangladesh.

Changes in our medical actions

As a medical agency, MSF aims to save life, alleviate suffering and reintroduce an element of care into societies that are suffering from brutality. Traditionally, we have tried to support local health care systems to offer medical help to all people who need such help, no matter what the disease. There has been a progressive decline in support and investment in health care systems in the developing world, because some societies have been progressively torn apart by long-running crisis and conflict (i.e. South Sudan, the Democratic Republic of Congo and Angola).

Trained health care workers have died or fled these areas, leaving no future generation of trained staff. When we enter an area there are insufficient residual health care services capable of such services for us to support.

At the same time there have been increases in deadly diseases that were more or less under control during times of peace and investment, when there was more comprehensive public health action. In addition, many of the societies we work in are being further decimated by the twin scourges of AIDS and tuberculosis. So now we are forced to increase the number of programmes focusing both on treatment of specific killer diseases.

The involvement in such programmes has left our medical staff confronting the problems of lack of availability of basic medicines to treat such diseases, either because drugs are not available, too costly or no longer effective. MSF has been forced to launch an international campaign to advocate for increased research and development into medicines to treat the diseases of the poor; and to advocate for lowering of prices for drugs. Campaigning has become another necessary tool for combating diseases that further destabilise weak and impoverished societies. In this annual report there is a special chapter on this campaign. We have also carried out pioneering research in order to simplify field treatment of our patients.

We have conducted major field trials into the use of different diagnostic tests and cheaper treatments of the killer disease kala azar. Through this research it should be cheaper, easier and more accurate to diagnose and treat kala azar for any health provider in East Africa than it was five years ago. This should greatly expand the probability that the thousands of patients in the area will receive effective and affordable treatment.

Mental health care

In addition to responding to killer diseases, we are also compelled to respond to the needs of the whole human being. At the beginning of the century, one or two out of every ten victims of war were civilians, the rest were soldiers. Now, nine out of ten victims of war are estimated to be civilians.

In many of the wars we face, for example in Sierra Leone, Lebanon, Angola or Chechnya, the degree of violence faced by ordinary people is extreme. Thousands of men, women, children and elderly people have experienced torture, executions or brutal destruction of their livehoods. Most of the people we work with have to cope with these experiences while being homeless, torn from family members and facing an uncertain future.

Since we started our first mental health programme in Gaza in 1990, we have increasingly had to recognise and respond to civil mental distress.

In most cases we do this by training local people in methods to help and support themselves to deal with the consequences of violence and crisis. Truly responding to the needs of the people we work for, in a full and humane manner, means we cannot treat their physical ailments and ignore their mental trauma.

A humanitarian coalition

25 years ago, humanitarian action was a small and little known activity. Humanitarianism has become much better known and has increasingly become part of the concerns of the general public, the media, academics and government.

The increased interest and activity has led to humanitarian action being used by some as a means to an end and the potential for the co-optation of humanitarian action for other ends. But, as a growing number of people and institutions become interested in humanitarian action, we are able to build broader coalitions through direct action, operational research, networking with experts and campaigning for action.

While it is more difficult to retain a humanitarian agenda, it may be possible to have a much wider relevance and impact. We very much hope that the awarding of the Nobel peace prize to MSF in 1999 will allow us to mobilise our volunteer force and consolidate new and more intensive alliances and networks within society.

By expanding this humanitarian coalition we must vitalise and extend the breadth, scope and impact of humanitarian action.