The project raises the issues of extreme operational environments and new and innovative approaches when standard operational strategies are inadequate. It is crucial to differentiate between operations that are able to accept the status quo and those that are driven towards unacceptable compromises.

In an effort to answer the humanitarian needs in Iraq, MSF has started a remote operations project, providing essential supplies to five medical facilities. It is one of the first attempts at restarting operations in the country since the movement left in October 2004 because of insecurity and the direct targeting of aid workers. Reports from Iraq indicate the needs in the country are severe.

From August 2006 to January 2007, more than 100 people were killed each and every day on average in Iraq and many more were severely wounded. At the same time, an estimated 1.7 million people had been driven out of the country with another 500,000 displaced within Iraq. It presents a situation of violence, neglect and deliberate abuse.

A new kind of aid

Today MSF has a programme for Iraq, that is based in Amman, Jordan, a neighbouring country to the west. It is responding to the extreme insecurity inside Iraq using non-traditional, intervention strategies and innovative approaches. This programme challenges preconceived ideas of how MSF provides medical aid. The organisation relaunched the Iraq programme after speaking to doctors who had worked with MSF prior to the 2004 closure, Meeting with these doctors in Amman in 2006, MSF staff heard that the situation had become far worse.

A lack of basic materials

The Iraqi Ministry of Health was managing to provide meagre salaries to medical staff, but almost nothing else. Hospitals in areas suffering the worst of the violence were left without needed supplies to treat the flow of war casualties. When MSF staff asked the doctors how the organisation could best help, they were told that it would be suicidal for them to invite MSF into their hospitals. MSF's traditional proximity, one of its firm principles, could lead to the murder of the very doctors the organisation wanted to help. Instead, they asked for surgical materials, equipment and supplies.

Former general hospitals, previously used to referring all but basic emergency cases, were now performing complex emergency surgery with only the most basic equipment and drugs. Doctors had to ask the relatives of injured patients to search local pharmacies for blood bags, sutures and infusions before they could start emergency surgery. Doctors, frequently faced with life or death situations, told MSF staff of their frustration about the choices they were forced to make due to a lack of the most basic materials.

Supporting emergency care

Early results from the first hospital, where MSF started assistance in October 2006, included in this remote support programme show that since its inclusion, doctors have carried out 2,882 surgical interventions in the first three months (Oct -Dec '06), of which, 1,871 were emergencies (64.9%) and 1,482 were violence-related (51.4%). The volunteer doctors involved in this programme travel to Amman every two months to give MSF their orders for supplies, share their data and participate in meetings.

A strategic direction

The MSF management team has outlined a strategic direction for this project and others like it in the coming years. The project raises the issues of extreme operational environments and new and innovative approaches when standard operational strategies are inadequate. In the Middle East, politics, religion and society are all inescapably linked. In order to function in this environment, MSF needs a growing understanding of how its view of humanitarianism can sit within this mix.

It is crucial to differentiate between operations that are able to accept the status quo and those that are driven towards unacceptable compromises. The decisions being made in this programme confront some of the realities that must be faced by humanitarian organisations searching for ways to remain relevant worldwide in its operations.