Dr. Muhamed brought the baby girl into the world in the midst of a war zone in southern Syria. A few hours later, his hospital lay in ruins.
The baby's tiny head shimmered, she blinked her eyes and her first cry sounded light but strong. It was a difficult birth and the mother needed blood from the rare O-negative group. Dr. Muhamed issued a call for blood donors at his city's mosque -- and that was when the catastrophe began.
Their rotors pounding loudly, helicopters approached the hospital that evening and the first barrel bombs struck the operating room, injuring dozens of patients. The call for blood donations had led the Syrian regime to believe that a large number of enemy rebels was being treated in Muhamed's hospital.
After the attack, Dr. Muhamed had two hours to evacuate the hospital. Then the helicopters returned. The next barrel bombs destroyed the gynecology department, the laboratories and the dialysis ward. This was the account Dr. Muhamed gave in a conversation via Skype with members of the organization Doctors Without Borders in Jordan, who provide him with support from afar.
For decades, hospitals had been treated as the last havens of humanity in times of war. In keeping with the Hippocratic oath, doctors treated the wounded without regard for their political views, race or religion. Whether farmer, scholar, Assad supporter, Taliban member, Huthi rebel or Islamic State (IS) fanatic, every human being must receive medical care, even in a war, if he or she is stricken and no longer fighting. Under the Geneva Conventions, ratified by 196 countries, human beings have a right to medical treatment. Doctors and hospitals are also protected under the Geneva Conventions.
The conventions are a sliver of civilization in the midst of the barbarity of war. But with a number of countries no longer abiding by international law in armed conflicts, this achievement is now under threat. In fact, four of the five permanent members of the United Nations Security Council are currently participating in coalitions that have bombed hospitals in Syria, Yemen and Afghanistan.
In the era of the War on Terror, governments are increasingly ignoring the rights of their wounded enemies, who they characterize as terrorists or criminals. In contrast to the combatants in earlier wars, they seek to refuse treatment to their enemies.
This development is extremely dangerous for humanitarian aid workers. Many warring parties see them as supporters of terrorists and are disregarding the neutrality of medical professionals in war zones. As a result, hospitals have gone from being protected zones to death traps.
One organization affected especially dramatically by this development is Doctors Without Borders, known as Médecins Sans Frontières, or MSF in French, the language of its founders. It is the world's largest, best-organized medical aid organization, with 37,000 volunteers working in 69 countries, funded almost entirely by private donations.
They are experts in coping with natural disasters and civil wars. They are viewed as activists, as courageous members of a flexible organization prepared to take risks, with little conceit and hardly any bureaucracy. Since its founding almost 45 years ago, MSF has become an enormous aid organization and received the Nobel Peace Prize in 1999. It is confident and convinced that it is among the best of aid organizations. Still, in 2016 its self-assurance has been shaken to the core, with volunteers now wondering: "How can I save lives without losing my own?"
They refer to the unsettling trend that has made their work extremely dangerous, leaving thousands upon thousands without medical treatment, as "medical care under fire." Hardly a week goes by without horrific reports of hospitals being destroyed and attacks on aid workers.
On Oct. 3, 2015, the US Air Force fired on an MSF hospital in Kunduz, Afghanistan. Forty-two people died, including 14 members of the organization.
On Jan. 20, 2015, a jet operated by the Sudanese regime dropped bombs on an MSF hospital in the town of Farandalla. There were 150 patients and staff inside.
On May 18, 2016, unknown assailants attacked an MSF off-road vehicle in the Central African Republic and shot the driver.
In late July 2016, the Syrian regime attacked four hospitals supported by MSF in Aleppo. Two hospitals came under fire as patients were being transferred between their facilities.
In Yemen, both the Saudi-led coalition and Huthi rebels have repeatedly launched air strikes on MSF hospitals. On Aug. 15, 2016, 19 people died and more than 20 were injured in one such attack. Four days later, MSF announced that it was withdrawing its staff from six hospitals in northern Yemen.
What does it mean for the world's most important medical aid organization when its employees are being threatened and shot at, and its hospitals bombed? Doctors Without Borders provided SPIEGEL with an in-depth look at its work over a period of several months in the bush of the Central African Republic; at its Geneva headquarters; and in Jordan, along the Syrian border. A reporter hoping to describe the world of Doctors Without Borders in armed conflicts can only do so by becoming embedded, which means living in compounds with MSF staff and following their rules.
There are two developments in particular that endanger MSF staff during their work. The first is the disintegration of states. In failed states like the Central African Republic, aid workers who provide services that would normally be administered by the government are at risk, because there is no authority to protect them. The second development is the growing incidence of targeted attacks by warring parties on aid workers, in violation of the provisions of humanitarian international law.
This journey begins in the Central African Republic, one of the world's poorest countries, a place where Doctors Without Borders must pay close attention to security. The curfew for staff members in the nation's capital begins at 6 p.m. After that, they are permitted to frequent six selected restaurants, provided a vehicle waits for them outside. They are instructed to walk no more than 300 meters (984 feet) on the street and otherwise travel in motor vehicles. When they begin their deployment, they leave behind passwords for Facebook and Twitter in a safe so that their accounts can be deleted if they are killed. They think up questions to which only they know the answers, so that coworkers can identify them if they are abducted. Those who end up here know that they can die at any time.
Central African Republic -- Negotiating with Rebel Chiefs
On a balmy June evening in the bush, French nurse Miriam Peters, 27, was confronted with the extreme danger involved in her work. Her team was having a beer at the MSF compound in the town of Bambari when two masked men wielding machetes stepped onto the veranda.
They said nothing as they looked at the foreigners: a male nurse, a logistics expert, a financial expert from Canada, the drivers and Miriam Peters, who was in charge of local security at the time. "What do you want?" Peters asked the masked men.
The robbers seized money, radios and computers, and then they ordered the aid workers to lie on the ground. For 10 minutes, the assailants beat the aid workers with the butts of their machetes to humiliate them. Peters ended up with a scrape on her cheek, another woman had bruises on her shoulder and a man was hardly able to sit down the next day.
It was only one of many incidents that make it so difficult for MSF staff to work in this country. There was an attack on an MSF meeting, in which militants shot and killed 16 people. There have also been attacks on MSF vehicles, and in one incident, villagers used iron bars to force their way into a hospital, where they attacked patients.
A few weeks later, Miriam Peters is sitting on the veranda where the attack occurred. She is wearing faded jeans and Creole earrings as she reviews a list of medications prior to leaving for the hospital to check on a girl with burn wounds. "We need a roof next to the latrines," she calls out to a coworker. These are the small things for which she gave up the big things in Europe, like her job in an intensive care unit in London and her boyfriend, who is forced to wait for her when she is abroad with MSF.
Next to the Democratic Republic of Congo and South Sudan, the Central African Republic is one of the countries where MSF staff are most heavily engaged. The country is like a boiler, ready to explode at any time. Following a coup in 2013 and massacres between Muslim Seleka and Christian anti-Balaka militias, the Central African Republic has an elected president again, but state structures are essentially non-existent.
Insignificant by Comparison
Bambari, where Peters is stationed, resembles a giant refugee camp. Thousands who have fled there from the bush now live in huts or the ruins of buildings. The rebels have divided up the city among themselves, and gunfire can be heard at all times of the day.
Peters doesn't like to talk about the attack that night. She views the violence she suffered as being insignificant compared to what the local population experiences. "I feel a little fragile, but this sort of thing can always happen here," she says.
The volunteers took a few days off after the attack, with some flying to the capital to eat pizza. They also set up a new volleyball net, but no one left the project because of the attack. "It was not a targeted attack on MSF," says Peters. Afterwards, she went to the rebels and told them that violence would not be tolerated. "Otherwise we will shut down the project," she warned.
Before MSF launches a "mission," investigative teams study the situation in the region. If there is more than one death per 10,000 people a day, MSF considers it an emergency and springs into action.
As a first step, Doctors Without Borders explains to all parties to a conflict that they are neutral volunteers who have no interest in politics. Before they treat patients, they meet every rebel chief and every imam, to explain who they are and what they plan to do. They say to the warring parties: "If you want us to care for your people, you must allow us to have access to your enemies."
In the jargon of aid workers, this is called "negotiating access." It is essential for survival that everyone understands that MSF is independent and requires a reasonable level of security in return for the aid it provides. "To be protected by an armed group would violate our principle of independence," says Peters.
MSF has two clinics in Bambari -- one on the Christian and one on the Muslim side, partly to preserve neutrality. They treat the injured, people suffering from malaria and starving children. They also distribute bags of "Plumpy'nut" peanut-based paste to families.
The principle of emergency aid is to alleviate the worst problems and then to move on. But in the Central African Republic, MSF has now permanently taken over what would normally be the government's task of caring for the population. Its volunteers will probably be there for decades. Never would they exert pressure on those in power by threatening to pull out, of threatening to allow a child to suffer now so that another child may have a better life 10 years from now. But is it possible that this makes aid workers complicit in an injustice?
It is a question that drove the founders of Doctors Without Borders 45 years ago when they separated from the International Red Cross. To understand what motivated them, it is worth looking back at the year 1859, to Italy, where Swiss businessman Henry Dunant was witness to an abomination during a carriage journey. His experience would become the big bang of humanitarian aid. It was during the Sardinian War, between the Kingdom of Austria and the Kingdom of Sardinia, when Dunant passed a battlefield near the Italian town of Solferino. He looked on with horror as thousands of Frenchmen and Austrians died in agony. Dunant organized help for the soldiers, but he would never forget the images he saw.
In 1864, he convinced European nations to sign an agreement at the First Geneva Convention for the Amelioration of the Condition of the Wounded in Armies in the Field. It declared that the wounded of all parties in a war have the same right to assistance. It placed volunteers and medical staff under the protection of neutrality. The convention marked the beginning of a Holy Scripture of sorts, which MSF still strives to uphold today.
Dunant founded the mother of all humanitarian organizations, the International Committee of the Red Cross (ICRC), which cared for the wounded on battlefields. The ICRC received a mandate, under international law, to serve as the advocate of the Geneva Conventions in war. The aim of its volunteers was to civilize war.
Tantamount to Betrayal
To achieve this goal, the Red Cross is dependent on the good will of the powerful. It takes no public positions, nor does it charge anyone with war crimes. Its critics feel that the Red Cross all too often enters into a pact with the devil.
This was also the opinion of a group of young French Red Cross doctors when the Biafra region in southeastern Nigeria declared its independence in 1967. Nigerian government forces surrounded the rebels and starved them to death. For the doctors, including the later French foreign minister, Bernard Kouchner, the silence of the Red Cross was intolerable and tantamount to betrayal.
In a media campaign, Kouchner accused the Nigerian government of genocide and in 1971, a group of doctors headed by Kouchner founded Médecins Sans Frontières. A new idea had been born, the notion that doctors could continue to treat patients while also testifying to injustice. It was the birth of MSF, a child of activism.
Today the Red Cross and MSF are fundamentally different organizations. Through its mandate under international law, the ICRC has different objectives and is subject to different constraints than privately funded aid workers. Nevertheless, the two groups complement each other or coordinate their activities. The ICRC has become somewhat louder over the years, while MSF has become less vociferous. "The Red Cross is slow and bureaucratic," says a woman who has worked in famine relief for 25 years. "MSF are activists, but their emergency aid is of little use outside wars. It's too transient for that."
It is a day in July of this year and fighting has once again erupted in the Central African Republic. Hundreds of people have fled from the bush to a sugarcane field south of Bambari and Doctors Without Borders wants to help them, which is why Miriam Peters pays a visit to Ali Darassa, the warlord in charge of the Muslim Ex-Seleka. His militia controls the road to the south.
Darassa takes his time, but after half an hour, he finally steps out of a clearing, escorted by armed men. A giant of a man dressed in camouflage and combat boots, he has an inscrutable expression on his face.
Peters asks a polite question: "Can we go to the civilians in the sugarcane field?" -- "Of course!" the self-proclaimed general bellows with a smile. "There are no problems whatsoever in our zone." -- "Okay," says Peter, "because we would like to begin our medical activities there. It would be important to know whether to expect incidents on the way."
The general gazes into the distance. He doesn't find the question amusing. Darassa knows that the new president is having all rebels disarmed, and he doesn't want this to happen to his men. It could also be that he doesn't have a complete picture of what is happening in the bush. He refuses to provide any guarantees.
"The man who is responsible for disarming my soldiers has disappeared and gone to Europe," says Darassa. "But of course you can go." Peters smiles and shakes his hand.
The team subsequently drives to the sugarcane field. But when the volunteers arrive, more people are killed in the villages and they cancel the mission.
Switzerland -- From the War on Terror
The political battle is fought 5,000 kilometers (3,100 miles) to the north. It is here, in an inconspicuous building a short walk from the lake in Geneva, Switzerland, where Doctors Without Borders lobbies to ensure its future. Marine Buissonnière, a key advisor, meets with us in the library on the ground floor.
Born in 1973, Buissonnière spent many years working abroad and also served for four years as the secretary-general of MSF. "I am a humanitarian out of conviction," she says with a laugh. Today she documents what happens in and to hospitals on the front. And she fights for the Geneva Conventions -- for the enforcement of rules aimed at making warfare a bit more humane.
"For about a year, I have noticed how warring parties try to eliminate their enemies, attacking hospitals and doctors in the process," says Buissonnière. "Some people claim that if you go into a war, you can expect to be bombed. But that's not true at all! There is something completely revolutionary about the Geneva Conventions. We cannot allow this idea to die."
Buissonnière uses the term "alarming" when she talks about the number of attacks. "It all started with Kunduz," she says. Doctors Without Borders had never before lost as many of its staff members in an airstrike as it did in Kunduz.
At 2:08 a.m. on Oct. 3, 2015, US forces fired on a trauma center in Afghanistan. MSF had opened the facility four years earlier, and its GPS coordinates were known to the Afghan government, the Taliban and NATO forces. "We had made an agreement," says Buissonnière. "The wounded were to be treated with no political discrimination, and that included Taliban fighters -- as long as they entered the hospital without weapons."
When the Taliban captured Kunduz in September 2015, the Afghan government's willingness to accept a hospital where its enemies were being treated dwindled. It is still, however, not entirely clear how it came to the attack. Photos taken after the airstrike show people dying in a place where they had hoped their lives would be saved, in beds and on operating tables.
"Kunduz was an assault on the Geneva Conventions," says Buissonnière. "If you are a civilian or an injured soldier and are no longer fighting, you always have the right to medical treatment. It sounds like a very simple idea, and yet it is now being questioned more than ever before." The manner in which warring parties think about their enemy has changed completely, she says. As a result, so has MSF's work.
From today's perspective, there was a certain wild and romantic aura to the early years of Doctors Without Borders during the Cold War. Many volunteers were attracted to the dangers involved and they felt it was natural to openly take political positions. When the Soviets bombed hospitals in Afghanistan, MSF called upon journalists to go to the country and report on the atrocities. When the Khmer Rouge committed genocide against their own people in Cambodia, MSF volunteers organized a "March for the Survival of Cambodia." Humanitarian aid was considered an enforceable right.
After the Cold War ended, governments also waged war in the name of human rights, using humanitarian aid to achieve political and military goals. Non-governmental organizations like MSF found it difficult to distance themselves from these goals. Who could distinguish between soldiers digging wells in Afghanistan and the doctors working nearby? Perceptions of soldiers and aid workers began to blur.
"Since 9/11, military theory has shifted, and so has the manner in which the enemy is viewed," says Buissonnière. "There were standards before that. A country at war ensured that its soldiers abided by certain rules. The enemy was considered equal, which meant it had the same right to medical care. The reasons why it was waging war were not considered."
With the "War on Terror" came the idea that there are "just reasons" to wage war. "This places the enemy on a lower moral plane," says Buissonnière. By this logic, she explains, it becomes "just" to kill the wounded from the "unjust side" -- even doctors, in extreme cases.
Another reason that hospitals became targets has to do with modern warfare, says Buissonnière. "When you wage war from the air and deploy special forces instead of an ordinary army, you are no longer dependent on equal treatment in the field, because your troops are never caught in a real emergency situation."
Buissonnière also believes that terrorism in Europe is contributing to the death of Dunant's legacy. "After the attacks in Paris, Brussels and Munich, many anxious people are adopting a dangerous attitude," she says. "Could there be a category of human being who doesn't deserve the same treatment?"
In High Demand
This is why Buissonnière and her colleagues are engaging in lobbying efforts to save Dunant's legacy. They include steps like testifying before the British parliament and training military doctors. Attacks are "described as mistakes, denied or simply covered up," MSF President Joanne Liu said in a furious speech given before the United Nations Security Council. Hospitals and patients, she said, are being "dragged onto the battlefield." In May, the Security Council issued a statement condemning attacks on hospitals, but failed to enact consequences.
Despite the danger, jobs at MSF are in high demand, with about 15,000 people applying to go abroad each year. The organization seeks flexible team players who are analytical, willing to take risks and have strong social skills. In addition to doctors, MSF needs, for examples, political scientists, mechanical engineers and people with business backgrounds.
Many who work at MSF admit that they like the adrenalin rush that comes with the work, even though this is officially frowned upon. And their personal lives? They shouldn't be that important, because positions for families are rare. A so-called mission usually lasts a year. In high-risk areas, teams are replaced every month and volunteers are required to take a vacation every three months.
Many who volunteer at MSF secretly see themselves as a better version of the United Nations and a more courageous ICRC -- and as being in touch with the times. But the one thing they have experienced above all else in the war in Syria, the biggest human disaster of our time, is helplessness.
Jordan -- Smuggling Routes and Talks with Islamic State
Dr. Muhamed, the doctor from southern Syria whose destroyed hospital was mentioned at the beginning of this story, speaks with a hoarse voice. His face appears on a screen in the MSF office in Amman, Jordan as he talks to the team that supports him from the Jordanian capital, the same team that helped him build a new hospital. "Our city was bombed four times this week," he says wearily. He's a graying man in his early 50s.
The regime often stages "double-tap attacks," in which the first rocket is followed by a second one 20 to 60 minutes later. "The second one is intended to kill the helpers who come to recover the injured."
"They don't just target hospitals, but also market squares, schools and playgrounds -- all the places where normal civilians congregate," says Dr. Muhamed. This is the regime's way of punishing people for living in rebel-held territory, he explains. "I pray that we will not have large numbers of casualties again today," he says. "When we admit patients, we only have a few minutes to make life-and-death decisions." When 20, 30 or 40 casualties arrive at the same time, the doctors sort them using a traffic signal system.
"Green are the ones who can still walk. Yellow means critical but stable. Red means that the injured patient needs surgery immediately. Black means it's too late -- or that the injury is so complicated that three reds would die if you operated on someone in the black category."
"That's the reality," Dr. Muhamed says via Skype. "Thank you, doctor," says Bettina Weitz, country director for Syria, "is there anything else you need?"
"No," he replies.
Weitz says goodbye and looks into the tense faces of her team members. The office of the Spanish section of MSF is in an inconspicuous office district of Amman, its walls are covered with maps of Syria. MSF supports 17 facilities in southern Syria from this office, and there are 150 facilities throughout the country.
Weitz has never met Dr. Muhamed in person. But, she says, "we talk to each other so often that it feels like family." MSF has only a few local staff members in Syria, and it is close to impossible for them to verify the information they receive from inside the country.
Ever since Islamic State (IS) kidnapped five of its international staff, MSF has only provided assistance in the form of what it calls "remote management," from the neighboring countries of Turkey, Lebanon, Iraq and Jordan. Weitz calls the system "the most frustrating experience of our time."
Weitz, a 45-year-old Berlin native, has just returned from a mission in Sudan with her young child. MSF offered her the new position because it is one that allows staff to bring along family members.
One of the skills she has had to learn in Jordan is how to smuggle. Every month, Weitz and her team load a truck with medications, water, oxygen bottles and gasoline for generators. The truck is driven to Ramtha, where the Jordanian authorities allow a Syrian NGO to take over. "Everyone knows that we use an unofficial border crossing," says Weitz. "But they all look the other way."
Since the war in Syria began five years ago, the regime and its allies have murdered 698 Syrian doctors and nurses, according to the organization Physicians for Human Rights, which documents attacks on healthcare facilities. Some 63 hospitals supported by Doctors Without Borders were bombed in 2015 and a further 16 have been attacked by August of this year. When officials planned to rebuild a hospital in southern Syria, the local residents protested -- out of fear. The attacks have not just singled out organizations like MSF, but also local clinics and hospitals.
The suppression of Syrian doctors began in 2011, during the first, peaceful protests against President Bashar Assad. Damascus refused to allow MSF to enter Syria, with the government accusing the organization of being a branch of al-Qaida. At the time, Assad's thugs were already persecuting anyone in Syria who treated wounded demonstrators. After a few months, MSF began helping Syrian doctors working underground from its offices in Lebanon.
The Arrival of IS
They smuggled emergency kits to treatment units in bathrooms, caves and basements, where doctors provided emergency care to wounded members of the opposition. When the demonstrations became more violent, MSF helped to build more stable field hospitals. The organization sent medications to Syria, but it is unclear whether they ever arrived.
In June 2012, MSF was able to enter rebel territory in northern Syria for the first time and set up the first field hospital in a villa near the Turkish border. A month later, in July 2012, the Syrian government enacted a new anti-terror law, which criminalized any medical aid for the opposition. From that point on, Doctors Without Borders could only operate in secret.
In the summer of 2013, Islamic State expanded its area of influence in northern Syria and its representatives demanded that the aid workers operate their hospitals in accordance with Islamic rules, as interpreted by IS. "They wanted us to separate men and women in the emergency room, even when all were brought in at the same time after a bombing attack," says the employee who negotiated with IS. "We were supposed to have male and female doctors to treat male and female patients, respectively. And they wanted the Niqab, the facial veil, to be a requirement."
Islamic State was not pleased to hear that Doctors Without Borders had a decontamination unit in which men and women were treated in the nude with water after a poison gas attack.
MSF suspended its operations in territory held by IS and withdrew all international workers after Islamic State kidnapped 13 staff members from a hospital in Latakia Province in January 2014. Eight were Syrians and were soon released. The five international staff members remained in captivity for months.
Today, the ongoing airstrikes have increased the threat to doctors and volunteers. With each new targeted attack, Doctors Without Borders must decide how to respond.
One of the main objectives of doctors is to treat every individual, which is why aid workers, even in the midst of the war on terror, will continue to insist that the powers involved observe the conventions they have signed. Doctors believe that helping and healing should not be a deadly occupation.
In the dusty Jordanian town of Ramtha on the Syrian border, 82-year-old Canadian doctor Edgar Escalante, an orthopedic surgeon, is making his final rounds through a field hospital. His mission is about to come to an end.
In his 14 months here, he has seen things he will never forget, including a Syrian who arrived with a makeshift tracheotomy consisting of a plastic bottle cut in half. He has also seen severed limbs, mothers in a panic, a patient with bullet wounds in his stomach. "There was a boy who had been ripped apart by bomb fragments and was on the verge of death. When I had given up all hope, he squeezed my hand and signaled to me not to give up."
Dr. Escalante, who has seven children of his own, once worked as a doctor in the jungles of Nicaragua. "I spent my entire life working, so that they could have a better future," he says. "When I retired, my wife said: Now it's time for you to fulfill your dream."
He began working as a surgeon for MSF in Kunduz, and he flew to Yemen three months later. It was his team that died in the American airstrike in Kunduz.
Dr. Escalante bends over a Syrian who is so thin and pale that it seems clear he is on the verge of death. "You'll make it," he whispers into his ear.
He spent 20 months working for MSF in war zones. Does he have anything to say about the bombs and the attacks on doctors? He shakes his head. "We do our work here," he says. "No one will prevent us from doing that." The wounds of his Syrian patients have been getting worse lately, he says. "The projectiles are creating bigger holes."
At the end of his rounds, shortly before Dr. Escalante is to hand in his MSF coat, he stands in the street and begins to weep. Life and death, fear and joy, all of these things have created a close bond between him and this place and his colleagues here. "Hold the fort, and keep on going," he says quietly as he says his goodbyes.
He knows how difficult it is for his fellow doctors and aid workers to listen to the bombs falling in nearby Syrian villages every night. The border has been closed since IS staged an attack on Jordanian soldiers in June. An estimated 75,000 refugees are now stuck in the desert, and no new patients are being brought to Ramtha.
"The authorities here fear that there are terrorists among the refugees," says Dr. Escalante. A few days ago, Syrians tried to get an injured girl across the border to the hospital where Escalante worked, but they were denied entry.
The girl bled to death at the border.
Translated from the German by Christopher Sultan
The article you are reading originally appeared in German in issue 37/2016 (September 10th, 2016) of DER SPIEGEL.
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