Humanitarianism and Constant Conflict: Dr. Leslie Shanks’ HHR Keynote Address

UTIHP’s Health and Human Rights Conference took place over two days, providing attendees with an enriching experience on medical humanitarian interventions in conflict zones. The first day of the conference welcomed Dr. Leslie Shanks as the keynote speaker.

Dr. Shanks began her work with Médecins Sans Frontières (MSF) in 1994 in the former Yugoslavia. MSF worked closely with the UN Peacekeeping forces, who supplied them with bulletproof vests and armored cars. The Serbian forces did not feel the UN (and by extension, MSF) maintained neutrality in the region, and began targeting MSF aid workers. Dr. Shanks herself narrowly avoided a shell aimed at their vehicle as her team was targeted at the Serbian-Bosnian frontlines. She highlighted the importance of MSF needing to separate their work from militaristic/interventionist liaisons.

Soon after she began her work in the former Yugoslavia, Dr. Shanks flew from Bosnia to Goma, Zaire, to aid in the aftermath of the 1994 Rwandan Genocide. Upon her arrival, a local told her it was a good time to come because they were finally able to use the roads again. Prior to her arrival the roads had been so clogged with bodies of the deceased that it was impossible to drive anywhere. The French military had just cleared the bodies into mass graves.

In the aftermath of the tragic genocide, a refugee crisis of unseen proportions emerged. Approximately two million refugees were migrating from Rwanda to Zaire and Tanzania. MSF had operated small local health setups in Zaire but were nowhere near equipped enough to deal with the massive influx of refugees in need of urgent care. Cholera soon broke out and was not met with the proper medical-humanitarian response. Cholera is easily treatable, but without facilities for rehydration, even twenty-four hours without treatment can result in death. As a result, the mortality rate surpassed what was predicted: in a normal outbreak, typical mortality is 2% - here it was over 50%.

The refugee camp conditions were horrific. About a million people slept without tarps directly on hard volcanic rock, while a nearby volcano spewed angrily, threatening to erupt. Dysentery, meningitis, and cholera ravaged the camps.

To make matters worse, the military leaders who had planned and executed the genocide against the Tutsis were living among civilians in the camps. They quickly gained control of the aid effort and the international community became concerned that MSF was indirectly supporting the perpetrators of the genocide. The aid workers stationed in Zaire were faced with a difficult moral dilemma – was their presence doing more harm than good? Dr. Shanks highlighted this question as a necessary reflection in all humanitarian work - the ability to be critical about the context of your impact as an aid worker. Their signal to leave came when they achieved significant reduction in mortality rates, although civil unrest was on the rise.

Dr. Shanks went on to discuss her work in Zaire during the First Congo War. The region had poor healthcare infrastructure to begin with but the excessive mortality observed was entirely due to the conditions of conflict. She and her team later started an HIV treatment program in the Democratic Republic of the Congo, despite huge pushback from the international medical community, who questioned their ability to consistently administer HIV treatments in a conflict setting. Despite these criticisms they were able to show the world that HIV treatment in a conflict zone was indeed feasible and effective with prudent contingency planning.

They began to implement multi-drug-resistant tuberculosis (MDR-TB) treatments in the refugee camps as well. TB and MDR-TB had never been treated in refugee camps, but the situation was relatively stable at the time so the medical aid workers decided they could not longer let people die when they had the treatment readily available. Twenty-four months of injections and blood testing later (using planes to transport samples to remote MSF labs), the group of MDR-TB patients had been successfully treated. Dr. Shanks explained the monumental significance of this feat – that it is possible, even in a remote jungle in the Congo with no labs or medical facilities, to effectively treat those in need.

Dr. Shanks concluded her talk by discussing an issue that has garnered a lot of attention in recent times: the deliberate targeting of hospitals and aid centres in conflict zones. MSF maintains a strict no gun policy to enforce the humanitarian values of the organization, to remind external parties that MSF is separate from military forces. This all changed when an MSF hospital was bombed in Afghanistan by American forces who were aware it was operated by MSF. They targeted the surgical ward and intensive care unit, knowing they held the sickest patients, and gunned down individuals in the courtyard. This unfathomable act of American exceptionalism was branded as “collateral damage” in an attempt to neutralize a reported Taliban threat. Forty-two people were killed and the hospital was destroyed. The airstrike constituted a clear breach of international humanitarian law; Dr. Shanks suggested the message it sent to rest of the world was perhaps the most damaging of all.

Earlier this year, a Saudi-led coalition bombed an MSF-operated hospital in northern Yemen, followed by Russian-led hospital airstrikes in Syria. These were very targeted, calculated bombing campaigns driven by major global powers – not small rebel armies. Their strategy, striking once and waiting for first responders to appear on scene, then attacking a second time, was devised to kill and injure as many civilians and aid workers as possible. MSF’s #NotATarget social media campaign was launched in response to these attacks in an act of solidarity with civilians, medical staff, and hospitals in conflict zones. Dr. Shanks emphasized that the right to health care must be recognized by all countries involved in conflict. Adherence to international humanitarian law is often sidelined in war zones, but allowing for hospitals to be used as tokens for militaristic gain is an egregious instance of global immorality as well as a war crime.

Dr. Shanks has led a distinguished career as former Medical Director of MSF Amsterdam and the Sherbourne Health Center. Currently, she leads at Inner City Health Associates (ICHA) as a Medical Director. Her clinical work in Canada focuses primarily on marginalized and underrepresented communities, and her extensive and selfless work in international conflict zones served as an inspiration to all those in attendance at HHR.

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