Quelles que soient les rai-. Mais c'est bien de cela qu'il s'agit! Pour nous, il y a toujours eu une place pour les Juifs dans le monde arabe [on sait laquelle]. Il faut bien croire que si le souverain jordanien choisit cette voie suicidaire, c'est qu'il ne peut faire autrement. Et les chefs suivent. C'est ce.
Tel-Aviv Information Office octobre Cependant, Conflits internationaux gardons-nous de trop d'illusions. Mai Notes 1. Bravo for the courageous journalism of the liberal Zionist paper. The Zionist will hinder that Corbyn could become prime minister in the future. In fact, Corbyn is neither a Zionist nor an ati-semitic..
General, principle of analysis:. Abu Dhabi is the cuckoo nest of Zionist penetration into the Muslim civilizational sphere. UAE also participate in the torturing of Yemen's people. The pope also is a head of state, as well as a chief of the Catholic church. Today, an attack either from Russia, China or Iran is a pure speculation instigating tension. February 10, The Mail on Sunday tries to disqualify him by lack of acceptable character. The West can hinder massive Muslim immigration while preserving correct relations with Muslim countries on equal terms.
Program for However, orthodox and reformist Zionists — Netanyahu and Soros - together serve - perhaps by different tactic — Israel:. NYT Dec. It also tries to assimilate the geopolitical anti-Zionism to anti-Semitism. Goldberg —Israelism became the key of shared Jewish identity. Jet according to Israeli basic law of Return all Jews — diaspora included — are potential Israeli citizens.
Nobody is elected, if less than fifty percent goes to the urns. This would oblige the representatives to listen more to the general population. In reality, these organizations have not a representative public mandate, - often are financed in large part by Zionist or other politically interested oligarchies, therefore they are biased. November In the American politics the united bipartisan Zionist front is reestablished: Cain died and Senator Lindsey Graham is now well associated with Trump.
Ivanka Kushner will travel with Graham to Africa. Macron and Merkel also in name of the European Union and its values while they have not more institutional standing in the Union than the chiefs of any other EU country. Times of Israel. What can do the arabo-Muslim civilizational sphere against the subordination of Islamic Golf- monarchies to Zionism?
Netanyahu in Oman, Oct. Midterm election in US. Democrate or Republican?
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Anyway, the foreign policy is bipartisan , follows Zionist narrative. In November 4. The killing of Khasoggi is also an Salafist action against the Muslim Brotherhood. Indeed, polarization in the public opinion is not new. What is new that the liberal force is now in minority. This is the case with Christianity, Islam and Buddhism. Now Netanyahu and Lieberman prepare to bombard the Hezbollah in Lebanon. Indo-Pacific military exercise on one side, - and Russian-Chinese on the other side:. August Common military exercise of China and Russia. This Eurasian continental cooperation is the principal geopolitical guarantee to maintain a global civilizational pluralism in face of the universal ambition of the West directed more and more by the Zionists.
Jeremy Corbyn has reason. The NYT also publish often articles about reconstruction of peripheral old abandoned disaffected synagogues which have been reconstructed partly by public fund. This is the complete sufficient explanation. David D. Kirkpatrick has fully reason NYT July 28,, He shows also Charles Hagel was reticent.
Hagel will not be sufficiently in lock step! Anyway in the description of the killing of democratic movement within the political Islamism David D. For the Contemporary Sociology May , , , it is "clear" what is same-sex marriage in the "post"-marriage era. This campaign against Corbyn goes on for months, - now harder since Israel declared itself an Jewish national state. In order to have a just and lasting peace with the arabo-Muslim geopolitical sphere the West should recognize that - in general - in the countries with Muslim majority the Islamist parties win the democratic election, - like in Israel the Zionist parties.
The American Zionist establishment is irritated, frustrated if president Trump had face-to-face contact with president Putin, when they are assisted only! Indeed, in this case the Zionist lobby can't immediately interfere in the US state affaires. It is deplorable that the dependance of the US adminstration from the Zionist lobby became so totalitarian.
Trump handle very roughly all his weaker allies Merkel etc. Without this evidence, you can't understand present international relations. Indeed, since they count statistically "whites who are not Hispanic origin"! The nonwhite is namly only an excluding category and not a group in sociological sense. For this purpose, Halvey contacted representatives of countries - with UK's and Netherlands' help -, but without result. In fact, John R.
He has certainly in Israel. June 14, And in this case the totalitarian regime will be called simply authoritarian like Saud Arabian. Coherence of the US foreign policy For the US foreign policy - as well as the mass media - it would be a sacrilege to distinguish! NYT June 9,, p. Finally Friedman accepts in a tweet that in fact "American support of Israel needs to be bipartisan". Indeed, US Congress is not the Knesset but still - today - without being Zionist, politicians have no access the the American Congress.
I n reality Israel First;. By chance all are Muslim countries. NYT April 26,,9. June 9, Since, the Korean issue is not a Zionist priority, it is also possible that the extreme emphasis on this issue is a diversionary manoeuver to hidden the preparation of actions against Iran and its force in Syria. The G7 by raising the possiblity for Russia to reintegrate perhaps? The "world" and its representatives, the UNSC is not "divided" about this issue, - the US was obliged to use its veto right against all!
Today, Israel kills more than fifteen unarmed Palestinians. New York Times , may 23, , Indeed, the Zionist lobby exercises its unbridled influence:. Trump denounces the Iranian nuclear agreement. Israel as well as the Western powers bombarded one-sidedly Syria without any counter-measure. The Chinese-Russian cooperation remains the only counterweight against the Zionist world-coalitions. Indeed, the Zionist influence is so strong in the West that in order to preserve its independence and economic viability Iran can count only on Russia and China.
Afghanistan, etc. In the spirit of the old Oded Yinon plan of all Israel's regional rivals should be eliminated or dismembered , - however Syria and Iran remains. Trump and Macron in April The West's battle to assuring Israel's - at least regional! According to the old plan of Oded Yinon Israel's rivals Iraq, Libya lost power and Syria is now under breaking up.
It remains Iran as independent state.
The subject of discussion is only: which is the cheapest way to reach this goal. April 7, , The Zionist censorship tactic is to systematically qualify anti-Zionist as anti-Semite. He also is affiliated with the Anti-Defamation League. Zionist Purification in the U. Trump is already encircled by the Orthodox Zionists like. Jason Greenblatt, and David M. Friedman ambassador and "West Bank Settler". New York Times febr. Its desirability depends from the number and speed of the arrivals as well as the cultural difference between the persons arriving and the autochthon population. Ankerl: Migration overspead in tropical Africa.
In the new so-called global world order only one country can make the immigration dependent from religion, Israel. The Global Empire plays the Holy See:. The plot against Hariri has not worked. NYT February 6,18,10? Because Trump follows the policy: Israel first, US second. Many men fought in the Zionist underground later became establishment figures in Israel. In reality, it is not a large group in the population itself and is subservient to Zionism.
Shared ethical and moral foundations; the feeling of kinship between two settler democracies with a sense of their own exceptionalism; the impulse to partner against enemies of the democratic West The major reason for Trump pro-israeli policy is the predominant Zioniat pressure group around the American political establishment. As well-know Trump is submerged by an Orthodox Zionist circle which exercise a quasi unlimited influence. Jared Kushner, Jaron Greenblatt etc. All Netanyahu's men.
Bush was. Kurds as Israel's proxies. To follow the old Yinon plan of Israel will continue to diminish the influence of its regional rivals by American assistance. Now remain Iran and Syria. One of the main instruments, proxies are the Kurds in Iraq as well in Syria. December 18, The destruction of all Muslim countries , independent from Zionism is the goal.
It is not a simple reproduction of the traditional Shiite-Sunnit opposition. October 13, In normal turn the next director should be an Arab, - e. It is again the putchist Sisi's Egypt, - the Zionists' Trojan horse. The end result was Israel and USA have the voting right until the end of the year Ebessi will grant amnesty for Ben Ali.
The submission of arabo-Muslim world is re-established. And of course the new Islamic revolts in January are not without ground. From unicentric world order to polycentric one. The Western hegemony goes to end. Apparently China tries to replace by a bipolar world order. Ankerl Bharat should have a place in this pluralistic world order. Mattis visite India Sept. Cf, Indo-Pacific project. The West will encircle Eurasia, - and in addition reign over the Arabo-Muslim civilizational sphere.
It would be interesting to know what he means when he reads in all Zionist publications the expression: Jewish People. Should also be replaced by Jewish population? Or exceptionalism? If Kurdistan comes, it will be first recognized by Israel; namely it will be its Trojan horse in the Muslim world. See the declaration of Ajelet Saked, Israeli minister of justice. At beginning, Israel is provided with arms mainly by help from the Zionist oligarchy in the Diaspora. This investment in the Israeli cause has a multiplied effect.
The war against Iraq exemplifies this tendency. The present situation:. President Trump is encircled by the Zionists. Both serve primarily Israel's interest defined by Netanyahu. The consequences are: systematic anti-Iran policy, military penetration into Syria, as well as weakening Putin's "post-Khodorkovsky" Russia. Iran is U. S's rival? No, it is too small to be. China is U. Iran is Israel's rival which has hegemony in the Near East. In this case the America First will be replaced by the Israel first and America second. The Zionist inspired U. And they try to reverse the governments which resist.
This generates Islamist resistance and emigration. The Western aggressive penetration and occupation in Muslim lands;. Under the previous US Administrations the West eliminated already Israel's Arabo-Muslim rivals like Iraq, Libya, and it "works" now on Syria sending there first time even American military units ["stabilization team"] and bombarding Syria too. Saudi Arabia has been already used to demolish the Democratic Egypt in directed by the movment of the Muslim Brotherhood, - the most important Arabo-Muslim independent Muslimist N.
Cevik political world-organization. Qatar is an important middleman between the yet indepedent Arabo-Muslim states Iran and formations Muslim Brotherhood, Taliban, Hamas etc. Mehran Kamrava: Qatar. Small State, Big Politics. Tillerson ties to maintaining good relation with Qatar. He prefers to clean his department. How long time can he resist the Zionist pressure exercised by Kushner and the whole Israeli lobby?
March 26, March 29, Nikki R. March 18, Israel is the USA's spoiled child because the overwhelming influence of the Israel lobby in the States. Moyar says: "America's enemies are right to afraid. This sound good, however follows a reversed logic. If it has enemies, it has mainly for two reasons:. Muslim counters like Egypt, Libya, Iraq etc. If these circumstances are suppressed the U'S, would be in security even without an army like Costa Rica. Truly not Israel first, - anymore? A "maximalist" Western offer to the Palestinian poeple.
Past president Carter asks that the U. For the matter. Friedman etc. Indeed, we repeat the submission to Zionism is "bipartisan". INYT Thanksgiving , 7 and July 3, the democratically elected Morsi - of the Muslim Brotherhood - as president of Egypt is reversed by a putsch orchestrated by his defense minister Sisi. US, and Israel recognize in tree days the putschist president.
Consequently the Salafists find justification for violent political actions worldwide. ISIS etc. Following Western interventions the large Arabo-Muslim states like Iraq, Libya, perhaps Syria are dislocated , dismembered. Balkanization of Near East by dismemberment of the great Muslim states into small ethno-sectarian enclaves. Mahdi Darius Nazemroaya: Yinon revanche? A panoramic of chaos in the Arab World. Arab-American University Graduates Inc. Delmont , Mass. Special Document no. Yinon idea quoted by Thomas L. Friedman in the New York Times. World power equilibrium yesterday and today.
Yesterday: Soviet Union was much stronger than Russia is today, but at this time Soviet Union and China were in conflict not like today. China and Russia are more or less united. Who does serve better Zionist interest? In: Orientations Kivnim no 14,. A panoramique of chaos in the Arab World. Friedman Our American friends offer us money, arms and advice.
We take the money, we take the arms and we decline the advice. Yet it's uncertain? Roger Cohen knows why: because the ironclad blackmail of the Zionist oligarchy. Curious Zionist control within! Assad's plans Nuclear vulnerability of both! No Muslim is born as "terrorist". The situation creates terrorism, people are radicalized.
Therefore the solution of terrorism problem in the West is not an issue of police but a policy, namely the liberation of the Western policy from one-sided Zionist influence. Indeed, Islamism is the political Islam, while Zionism the political Judaism, Both concepts include more then one strategical tendencies, namely democratic as well violent one. See also Muslamism in Turkey and Beyond. Religion in Modern World. INYT June 3,, p. We can foresee! Indeed, in Jun Brazil's, Argentina's image became better because the regime change. Turkey's, Venezuela's, Equator's, Bolivia's, Iran's.
Russia's are the worst. The Zionists don't accept an independent Muslim state in Israel's neighborhood. And Netanyahu's Zionists didn't arrive to prevent the Iran- West agreement, now they try to make its realization impossible by maintaining U. Cohen, E. Edelman and R. Trakeyh: Time to get tough on Iran. In: Foreign Affairs, Febr. Roger Cohen: U. INYT May 7,16, 9. Why did it change? In this year Erdogan had a conflict with Netanyahu about the Gaza help action. Ghannouchi subordinated himself and his party to Western instructions. The West doesn't accept that an Islamist movement with its majority leads even a Muslim country cf Morsi.
Defense against invasion by soft power:. Is this an expression of the dictatorship of an authoritarian non-democratic state? No, "powerful natons, including Russia and even India! There a ren't in the U. Double standard! Ambassador for Israel David M. INYT Nov.
British Zionist supervision of Labour Party:. Since Jeremy Corbyn is the leader of British Labour Party the party is no more unanimously subordinated to the Zionist cause. Khan former transport minister is an observant Muslim, however the other candidate, Mr. Goldsmith's religious belonging is not indicated in the article. Indeed, Syria has now a chance to win the internationalized civil war with Russian assistance. By this American involvement the number of victims in Syria will increase.
Apropos: Impeachment in Brasilia INYT, April 21, However, it is self-inflicted anti-Semitism. Meanwhile U. Israeli settlements operation in the West Bank. It finances the main think tanks in order to substitute Israeli interest for Western one e. The only question remain open in And in , of course, all the US presidential candidates are Zionist. Basic dilemma of Europe:.
The Western civilization. See the global Zionist front:. INYT April 16,16, p. New York Times' Zionist prpaganda. Title of an article:. The democratically elected Islamist president of Egypt had been overthrow by a military putsch accepted — and even assisted — by the Zionist USA. Now the Salafists find justification for their violent policy. INYT Apr. INYT April 5,,p In the campaign against Erdogan the apostat clerk, Fethullah Gulen living in the U.
INYT March 30, Meanwhile, as we said already, the campaign against Erdogan goes on since , when Israel attaqued the Turkish Ship sent to Gaza. In the US the Zionist control is stronger in the Treasury and Defense Departments than in the State departement, - because the financial and military blackmails are more effective means than the rhetorical and diplomatico-legal. The West, and the confrontation between Islamism, the political Islam and the Zionism, the political Judaism.
Indeed, there are Zionist control of the US foreign policy on 3 levels:. The same plutocracy controll the media and therefore all the communication between the poltical decisionmakers and the people. He criticizes their financing which according to him comes from the Right and brings biased views. Largely the bipartisan Zionist — or called also neoconservative - lobby supports them Cf. Mearsheimer-Walt However, in the current literature about think tanks the Zionist connection is rarely identified.
This statement is valid roughly for the whole special literature because the most authors themselves are engaged Zionists.
Abelson, D. Do think tanks matter? Montreal Ithaca, N. The business of Ideas: the think tank industry in the USA. In Think Tank Traditions, Policy research. Manchester: Manchester University Press. A capitol idea: think tanks and US foreign policy. Adler, E. Haas Conclusion: epistemic communities, world order, and the creation of a.
International Organisation, 46 , Bentham, J. The Political Quarterly, 77 , European think tanks and the EU. In Berlaymont Papers, eds. Bertelli, A. British Journal of Political Science, 39 , Braml, J. German Policy Studies, 3 , Dickson, P. Think tanks. New York: Ballatine. Fischer, F. Technology and the Politics of Expertise.
Homepage of the Interuniversity Institute (INU), Geneve. Ver.
United States: Sage. Reframing Public Policy. Discursive Politics and Deliberative Practices. Oxford: Oxford University Press. Gaffney, J. West European Politics, 1 , Haas, P. International Organization, 46 , Hajer, M. Discourse Coalitions. In The Argumentative Turn in. Policy and Planning, eds. Forester, London: University College Press. Jochem, S. Recalibration of Corporatist Policy Making?
Doctioral thesis. McGann et al. McGann, J. Georgetown Journal of International Affairs, 11 , Mcgann, J. Global think tanks: policy networks and governance. New York:. Think tanks and civil societies: catalysts for ideas and action. Think tanks and civil societies. Medvetz, T. Think Tanks as an Emergent Field. The Social Science Research Council. Qual Sociol. Osborne, T. Economy and Society , Pautz, H. British Journal of Politics and International Relations, 12 , Public Policy and Administration, 26 , Palgrave Macmillan.
With the exception of Iraq, where European and American NGOs disagreed on the appropriateness of using force, many allied themselves with the international troops and participated in stabilisation policies in Kosovo, Sierra Leone, Afghanistan, the DRC, etc. Using humanitarianism to justify war weakens democratic debate and exposes aid organisations to the risks of military-humanitarian confusion.
Such practices cast doubt on the independence and impartiality of humanitarian NGOs, no longer seen as outsiders to the conflict by either the population or the belligerents opposed to the presence of international troops. The criticism became even more extreme after the June murder of five MSF members in Afghanistan.
In Afghanistan and Iraq, for example, it lost interest in the victims of the war on terror. Aside from some isolated statements by the president of MSF-France, it remained silent in the face of the November massacres of thousands of prisoners of war by Coalition forces and their Afghan allies—massacres that prompted no demand for an international investigation.
It also denounced the inability of relief operations to save the victims of war and famine in North Korea —98 and in Sudan , due to their subjugation to crisis management strategies dictated by the foreign policies of the biggest institutional donors United States, European Union and Japan. Yet, by publicly exposing war crimes and the misappropriation or obstruction of humanitarian assistance, MSF may in fact have been encouraging the use of international military or legal measures against the perpetrators.
This new dimension of speaking out prompted quite different reactions within each section. Supporters of this view believed, however, that military operations to protect civilians were not sufficiently systematic, and overly guided by ulterior political agendas, which substantially reduced their impact. Another line of thought at MSF was more sceptical about criminalising and militarising the fight against mass human rights violations.
Especially since the prosecutor and the NGOs supporting his action called explicitly for humanitarian organisations to provide information to help him determine the appropriateness of launching an investigation and prepare the cases. And coupled with this controversy was a fierce debate on the political virtues of the international criminal justice system. In the same vein, those who held this view tended to think that armed protection of civilians in conflicts was just as deadly a trap as the armed protection of aid workers.
This involved a war operation in itself, with the attendant risk of failure, escalation, and casualties. Moreover, they maintained that MSF could not be seen as favouring armed action without endangering its access to crisis zones. So, for some at MSF, the military and punitive overtone adopted by liberal interventionism oriented it toward a repressive moralism unlikely to promote humanitarian action and human rights.
The Darfur crisis proved that liberal interventionism could be both a resource and a liability. Present since in the Sudanese conflict between the central government and the rebels struggling against the political and economic marginalisation of their region, MSF was able to deploy only a dozen people in Darfur in early In February , MSF managed to provide very basic assistance to nearly 65, people, at a time when the UN placed the number of people driven from their villages by the gov-ernment sponsored massacres and scorched earth policy at more than a million.
In early March , MSF teams came to believe that speaking out publicly was the only way to trigger a relief operation sufficient to the needs of Darfur, and push the Sudanese government to end the most deadly and brutal aspects of its counterinsurgency strategy. But it wasthe UN humanitarian coordinator for Sudan who broke the silence; on 19 March , he alerted the press to the severity of the violence and hardship, comparing the catastrophe in Darfur to that of Rwanda in On 7 April , while the 10th anniversary of the start of the Rwandan genocide was being commemorated in Kigali, Kofi Annan urged the international community not to repeat the mistakes of Rwanda.
He called upon member states to use military means if the Sudanese government continued to restrict access by humanitarian organisations and human rights investigators to Darfur. UN press release, 7 Apr. In July , Britain, Australia and Norway offered to commit troops to the UN, and in September , US secretary of state Colin Powell declared that genocide had indeed been committed in Darfur, and that it might continue. This international pressure did, however, contribute to a significant reduction in violence and an unprecedented opening of northern Sudan to aid organisations. Beginning in the winter of , more than 13, humanitarian workers— of them international—were deployed by international NGOs and UN agencies.
By late , MSF had more than expatriate volunteers working in twenty-five projects serving some , people. In most of the camps, the mortality and malnutrition rates declined steadily, falling below the emergency threshold in early This was unprecedented in the history of the Sudanese civil war, where massacres had hitherto been followed by widespread famine. None of the sections believed they were seeing an extermination policy comparable to that observed in Rwanda. Nevertheless, only the French section felt it necessary to distance itself from the dominant discourse then subscribed to by most NGOs.
In June , the French section published the results of retrospective mortality surveys conducted in IDP camps. But the section refuted the characterisation of genocide, questioning the existence of racial extermination doctrines and programmes in Sudan. It underscored the urgent need to expand humanitarian relief operations, now that the government had halted the most brutal aspects of its campaign, and diarrhoea and malnutrition had become the most common causes of death. In so doing, the propagandists of the genocidal view were misleading the public and the political powers about which actions were most necessary to save lives.
What was needed was a massive influx of aid—not troops. Heads of the French section believed that international military intervention aimed at occupying part of Sudan or overthrowing the regime would be a disaster, like in Iraq and Somalia, just when the level of violence had dropped sharply.
Using the rhetoric developed by MSF in Bosnia, he declared that the international community would not be satisfied with an aid-only policy in Darfur. A few weeks later, the Security Council took the decision to refer the Darfur crisis to the International Criminal Court. The expulsion of the two MSF sections accused of collaborating with the ICC, and the rejection of the ICC by many countries where the organisation works, cast a chill over the whole movement.
Since , MSF has been more hesitant than ever to speak out on the crises in which it intervenes, out of fear that its words will be used to justify war or international criminal prosecutions, thus jeopardising its presence. The scepticism evidenced by some toward the international criminal justice system and armed protection for civilian populations helped to justify a policy Dr Pigeon would have agreed with—silence heals. Some MSF members see this return to the charter as a major political step backward.
They point out that without international mobilisation on Darfur, MSF would never have been able to extend its operations, and that tens of thousands of Sudanese would probably have perished from hunger and continued violence. At a time when countries are more concerned than ever about their international image—to the point of codifying their intolerance of criticism in a contractual or legislative framework—MSF is reluctant to make use of its capacity to speak out.
Afraid to be seen as a stakeholder in legal or military processes, and thus compromise its access to conflict zones, it tends to let other international actors speak for it, hoping to distinguish itself as the language police by tracking down misuses of humanitarian semantics.
In so doing, it struggles to show its uniqueness, and to demonstrate by example the autonomy it demands. With the liberal democracies and the UN—upon whom it relied during its first thirty years—going to war, MSF is now being forced to diversify its diplomatic and political support without neglecting on principle its former comrades e. If it wants to offer impartial, effective aid, MSF must distance itself equally from the liberal imperialism of the societies of its origins and the des-potism of many of the countries where it intervenes.
Experience has shown that it can only succeed with the support of political and diplomatic coalitions of convenience, rallied through an engagement in the public space, without which humanitarianism is only a passive instrument in the service of power. These principles of impartiality, neutrality and independence were inspired by those of the Red Cross, and later included a reference to medical ethics.
At the beginning of the s, the prevailing trend among non-governmental organisations was to extend their action beyond patient medical care to health promotion. Presenting itself as an institution focusing on crisis situations and patient care therefore set MSF apart from other international aid organisations. However, its aim of providing care on the scale of a whole population was early evidence of a public health ambition.
They imply that MSF can single-handedly decide on its objectives and the activities to be implemented to achieve them. However unstable a situation, any humanitarian presence, especially foreign, necessarily involves negotiations with local political and health authorities, be it the governor of a region, a health official, the officer in charge of a militia, the head of a village or a slum gang-leader. So how did MSF manage to negotiate the inclusion of a new organisation of practitioners in the public health field? Dating back to the beginning of the twentieth century, this conception of public health continues to inspire health policies today.
As a result of these developments, public health has gradually taken on a dimension that extends beyond national frameworks, as well as those of colonial health, cooperation between two governments or regional cooperation between several states. Public health, tropical medicine, human and political sciences have all converged to create global health. Transnational health, a more measured expression for describing this evolution, has become a field in which institutions, public or private, local, national, regional, international or transnational, have entered into discussions, often tense, on the state of knowledge, the choice of norms, order of priorities, assessment of results and distribution of available resources.
For those operating in the field, this progression in transnational health meant determining where they stood on a series of initiatives decided within institutions such as the WHA The World Health Organization is governed by State parties, which meet once a year at the World Health Assembly WHA. World Health Assembly operating on a global level. Non-governmental organisations were being asked to help governments make the major campaigns of the United Nations a reality: the Expanded Programme on Immunization WHA, , the essential medicines list WHA, , universal access to primary healthcare in international conference on primary healthcare in Alma-Ata, , the Bamako Initiative for accelerating access to primary healthcare for African populations commitment made by African health ministers at the 37th regional meeting of the WHO, , the Global Polio Eradication Initiative AMS, and the Millennium Development Goals on health Millennium summit, United Nations headquarters in New York, What role should MSF play in the implementation of major public health policies?
La biographie, Paris: Fayard, At the beginning of the s, this divergence was handled with pragmatism. This type of mission could make MSF an international player. Minutes from the peer group management meeting on 31 Jan. During the s, MSF field missions increased. MSF needed to affirm its existence, but also to distinguish itself through its presence in the field, the nature of its activities and its arguments voiced in the public arena.
Meanwhile, ideological debates were gaining ground in NGOs, fuelled by political clashes in the international arena. In the Cold War climate, the so-called under-developed countries, mainly former colonies which had recently gained independence, found themselves at the centre of a struggle for influence between the two blocs. In , combating under-development was already one of the four key messages in US President Harry S. More than half the people in the world are living in conditions approaching misery. Their food is inadequate. They are victims of disease. Their economic life is primitive and stagnant.
This ambition for development was shared and, to a large extent, it transcended political divisions, as had the civilising mission of colonialism in other times. But although there was consensus on the objective of development, there was also fundamental disagreement on how to achieve it: Public or private services? Capitalism or socialism? Rony Brauman ed. Alain Destexhe ed. According to the UNHCR, between and , the number of refugees worldwide rose from three million to eleven million, and continued to increase until the s. Missions to assist refugees were a political choice, but the camps, delimited and relatively stable, were also the perfect place for learning medical and health practices.
It was therefore crucial for them to shake off their image as well-intentioned, medical adventure-seekers, but ineffectual in public health terms. The acquisition of new expertise soon led to the compiling of clinical and therapeutic handbooks and essential medicines guidelines adapted to the specific circumstances of humanitarian medical practice. On the basis of these guidelines, medicine and medical equipment kits were put together to facilitate the launch of emergency operations and, in , a logistics procurement centre was set up in France to supply the different programmes.
Internal training courses were organised and health managers were sent to public health schools in the United States. The intervention epidemiology developed by the CDC Centers for Disease Control and Prevention thus became a model for Epicentre, created in , whose objective was to carry out epidemiological studies to improve the assessment of programmes and measure the results obtained in terms of public health.
The work carried out by Epicentre resulted in the drawing up of a series of priorities to be taken into account when opening a camp in an emergency situation: needs assessment, measles immunisation, water and sanitation, food, shelter, site planning and organisation, health-care, control of communicable diseases, epidemiological surveillance, staff recruitment and training, and the coordination of operators. But there was another side to the coin. MSF personnel were busy with tasks increasingly removed from patient care. Doctors sent out to the field encountered public health for the first time and threw themselves with all the enthusiasm of novices into sanitarian campaigns with illusory outcomes, made up of authoritarian injunctions aimed at the people living in the camps.
These projects consisted of setting up immunisation programmes and primary or community healthcare programmes water, hygiene and sanitation in the Mezquital slum in Ciudad de Guatemala. Most of the activity and sometimes all of the Belgian, Swiss, Dutch and Spanish sections was, until the beginning of the s, medical technical assistance. Destexhe ed. The level of responsibility entrusted to a category of personnel with no medical or paramedical skills did not bode well for their chances of success, especially given the lack of training, supervision and material resources available to them.
In spite of these criticisms, the will to disseminate biomedical practices in countries said to be under-developed, combined with the principle of equity at the core of the primary healthcare strategy, had a unifying effect. Vaccinating children, targeting priority diseases according to their impact on mortality and the chances of treating them successfully, standardising protocols for the treatment of diseases, establishing a list of essential medicines to be supplied as generics, improving the organisation and management of healthcare facilities, all these goals seemed to be an enormous improvement on the way third world hospitals and dispensaries were usually run.
It proposed decentralising management to health centres where care would be delivered under the supervision of qualified healthcare professionals, and suggested a means of addressing the issue of funding: users contributing towards the cost of health services. This measure was in phase with the Structural Adjustments policies of the World Bank and the International Monetary Fund that sounded the death knell of the welfare state.
The growing influence of neo-liberalism at the beginning of the s and its effects on health systems were not called into question by MSF at the time.
In the wake of the Bamako Conference, these doctors had become the administrators of user contributions to the cost of health services in the hope that the revenues raised would allow access to quality care for all. But the reality was quite different: the contributions made by families could not offset the financial disengagement of the states.
Anyone with insufficient means was excluded. These budgetary tensions impacted negatively on the running of health structures and the quality of care. There was a lack of motivation amongst health staff, particularly those on the lowest salaries, sometimes resulting in high levels of absenteeism, protests, and even strikes. The adoption of new therapeutic protocols, sorely needed because bacteria and parasites were becoming increasingly resistant to usual treatments, was being hindered by budget restrictions imposed on governments.
The recruitment department rarely found staff with the qualifications necessary to handle all the tasks at hand. In Europe, head office managers were finding it increasingly difficult to answer the questions from the field, as their own knowledge of health policies was limited. For all that, did this mean giving up on technical assistance and the idea of third world development? In criticism within MSF was no longer limited to third-worldism: the very idea that humanitarian aid should aim to contribute to development was being contested.
Providing assistance to refugees appeared to offer a more secure working framework, while staying within the limits set by the definition of However, this new strategy coincided with the breakup of the communist bloc, and the victory of neo-liberalism transformed perceptions of the refugee issue. They are now treated on the same footing as the Albanian boat people, who were sent back to poverty by the Italian authorities, or the Haitians returned to dictatorship by the American Coast Guard in total disregard of the principles set out in the Convention on refugees.
Host countries and funding agencies alike exerted constant pressure to ensure ever-greater reductions in aid. Any assistance to refugees was suspected of inciting economic migration. Yet the protection and the standard of aid received in these new camps were far inferior to that provided to refugees living in countries at peace. Repatriation, not always safe or voluntary, replaced asylum as the key word in refugee management policies.
In and , this shift in position led to an epidemic of pellagra among the , or so Mozambicans living in camps in Malawi. Pellagra is a disease caused by malnutrition vitamin PP or trytophane deficiency , which in the most serious cases can lead to dementia and death. Some MSF employees on their way to work found themselves regularly stepping over people whose living conditions were so atrocious it was hard to tell whether they were still alive. Others, out for a meal in the evening, would hand a few coins to children in rags and in obviously deplorable health to keep an eye on their cars.
For those who witnessed, either professionally or personally, the health of people housed in secure institutions orphanages, prisons, detention centres for minors, hospices, asylums, etc.
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The Mezquital slum mission in Ciudad de Guatemala and the Mission France, both opened in , were prime examples. As for economic growth, it had been accompanied by such an increase in social inequality that it had become difficult to believe that one day it could actually benefit the most vulnerable populations. The method put forward to reach this goal relied on the combined effects of economic growth and specialised assistance programmes for the excluded, and was made up of health activities selected on the basis of a good cost-effectiveness ratio.
The public health programmes promoted by the United Nations and WHO abandoned their generalist vocation to become almost exclusively specialised. Specialisation—so-called vertical programmes focusing on a delimited category of care, such as the malaria eradication programme—had existed since the beginning of the s, but became systematic by the end of the s. This new policy adopted by governments and the United Nations did not garner as much support as the arguments put forward in favour of development in the s.
Rather than gamble on the hypothetical combined benefits of economic growth and assistance programmes specialised in caring for those overlooked by development, the organisation advocated for the re-inclusion of excluded populations in common-law health systems. Thus, in France the organisation was not only active in drafting the law on universal health coverage but battled over each and every point of the decree. There is less and less difference between homeless families living in the street and everybody else.
But the fact remains that even if the cooperation with the health ministries had not always helped improve access to healthcare for the least well-off, breaking it off completely was going to cause further hardship. Is it possible to oppose public policies that are detrimental to patient care without becoming isolated and giving up on trying to influence them? A public health action on a global scale—the relaunch of the combat against infectious diseases—gave MSF the opportunity to explore different avenues to answer this question. Joshua Lederberg, Robert E. Shope and Stanley C.
Oaks, Jr. In , the WHO set up a division headed by a director recruited from the CDC for the surveillance and control of emerging and communicable diseases. MSF had been involved in responses to epidemics and major endemics, both in refugee camps and in so-called open environments, for more than fifteen years as part of its technical assistance.
Programmes aimed at controlling sleeping sickness had begun in Moyo, Uganda in and since the beginning of the s, interventions in the camps had brought the teams up against a wide range of epidemics: cholera, measles, meningitis, shigellosis, etc. In , MSF helped to relaunch the combat against infectious diseases, partly to address real needs on the ground and partly to offset the reduction in technical assistance projects and programmes in refugee camps. At the beginning of MSF ran a meningitis immunisation campaign in the northern states of Nigeria: almost three million people were vaccinated and thirty thousand patients were treated for the infection.
The emergence of new epidemics Ebola and AIDS, in particular , the re-emergence of old diseases such as tuberculosis and hemorrhagic dengue , and the fear of bioterrorism rekindled by a handful of anthrax letter attacks in some big North American cities in , prompted governments to take action. The concern, not necessarily justified from an epidemiological point of view, was provoked mainly by the progression of epidemics due to HIV.
For international organisations and governments providing the funding for this goal, the programme that eradicated smallpox in was an ideal model for combating infectious diseases. Based on preventing new cases by containing transmission to such an extent that the disease disappeared, it required an initial investment of several years the immunisation campaign and resulted in a conclusive outcome the elimination of the disease.
Three conditions are required for implementing such a strategy: effectiveness, price and universal availability. Yet the cost of new medical products prior to large-scale use is always prohibitive for public health institutions and users. They can only be widely prescribed once specific economic models are developed for the launch of major public health actions. But there is a further constraint specific to drugs for treating infections.
Treatments must be renewed rapidly because bacteria, parasites and viruses develop resistances at a fast rate. In infectiology, practitioners usually need recent and expensive drugs. Yet at the end of the s, the situation had deteriorated to such an extent that even the old but still effective medicines were beginning to run out. As a result, in the middle of the s, medicines—whether for treating epidemics AIDS, meningitis, etc. The response by governments and international organisations to malaria insecticides and mosquito nets and AIDS drive to change sexual behaviour and promote use of condoms focused exclusively on preventive measures.
Treatment for tuberculosis was concentrated on patients who had the bacteria in their sputum and could therefore contaminate their entourage. There was a clear gap between the offer the medical products available and the demand clinical and health priorities in infectiology. Practitioners working in countries where infectious diseases were still the primary cause of mortality gradually found themselves without the means to take effective action. At the beginning of the s, a multitude of institutions national public administrations, international organisations, pharmaceutical companies, private national and international associations, religious institutions, trade unions, political parties, etc.
The internet was the preferred vector for relations that transcended borders, evolved and reached out to the most peripheral stakeholders patients, care providers, citizens and the summits of health institutions WHO, UNICEF, etc. Until then, questions concerning access to medicines had been discussed behind closed doors and the only participants were experts, industrialists and state representatives. Now, the debate on conditions of access to new medicines had become the object of considerable media attention and the presence of AIDS-response organisations and practitioners such as MSF at the negotiating table was deemed necessary.
Remembering the lessons learnt from its experience with medical technical assistance, MSF created the Campaign for Access to Essential Medicines, financed in part by the Nobel Peace Prize that it had been awarded in It was important to avoid finding itself once again being associated with a transnational public health campaign without having any influence over the decisions taken at the top, whether at national level in the ministries of health or within international organisations such as the WHO.
MSF urged that the fight against infectious diseases should not be based exclusively on preventive measures to eradicate the pathogenic agents, but that it should also include treatment for those suffering from them. To this end, new medical products would be needed and their use incorporated into national and international strategies. At the end of the s, MSF decided that to influence public policies action was required at the very root of the problem. This meant identifying levers to secure changes in policy and establish new alliances. A partial explanation for this untypical behaviour is to be found in the threat AIDS poses to public security, the exceptional level of social mobilisation, the fear of serious economic fallout and the rapid scientific advances.
It was also essential to take into account the importance of public debate on the issue of intellectual property rights and the pharmaceuticals trade. At the end of the s, the WTO focused on the globalisation of the rules on intellectual property rights applicable to trade. But the commercial monopoly granted to pharmaceutical laboratories depositing a patent was largely responsible for the high price of new treatments, especially antiretrovirals.
A public health disaster coupled with the prohibitive cost of medicines several thousand dollars per year and per patient raised the question of the compatibility of intellectual property rules with public security and, notably, health. The stakes were high: the tension between the two imperatives, respect for private property and public security, was weakening the economic system. It thus became urgent for the United States, the European Union and Japan, the main promoters of the new rules on intellectual property, to make a number of concessions on access to medicines.
Their attitude of indifference, aggressiveness even, shared by the major pharmaceutical multinationals, was in danger of triggering a strong reaction against the extension of intellectual property rules to world trade as a whole. Thus, a few months before the WTO Ministerial Conference in Doha , and against the backdrop of the Pretoria court case, In , a coalition of forty or so pharmaceutical laboratories took the South African government to court in an attempt to prevent it from applying a law passed in in favour of the production of generic medicines.
The suit was dropped in after the waging of an opinion campaign supported by MSF. United States trade representative Robert B. In the wake of his appeal, the major economic powers meeting at the Doha Conference agreed to moderate their stance on the enforcement of intellectual property rights in the strict domain of the pharmaceuticals trade with public health institutions. As a result, tritherapies against HIV appeared on the market in the form of generics and in fixed-dose combinations: their price fell to below dollars per year, per patient.
More than five million patients in low- or middle-income countries are now receiving this treatment. The struggle against AIDS has benefited from exceptional economic and political circumstances. Indeed, to develop the political autonomy of humanitarian medicine it is essential to recognise, and sometimes anticipate, the appearance of such favourable circumstances, as this is when the most rapid and profound changes to public health policies can be achieved.
Such circumstances can be neither permanent nor artificially induced through advocacy. In such times, a breach in the political space opens up and offers an opportunity to reshape social relations, some of which may have been frozen for years. This is then an ideal opportunity to attempt to reduce the number of deaths, the suffering and the frequency of incapacitating handicaps within groups of people who are usually poorly served by public health systems. In view of the huge health gaps prevailing in large communities, the impact of humanitarian medical action is not to be restricted to the specific needs of marginal groups.
Take the example of AIDS: the care protocol developed by humanitarian doctors has made it possible to treat millions of infected people throughout the world. This protocol is characterised by the non-participation of patients in the cost of tritherapies, the prescription of generic antiretrovirals combined into a single tablet, as few laboratory tests as possible, the transfer of therapeutic information and responsibilities to patients and a member of their entourage, and the participation of paramedics in the prescription.
Humanitarian medicine is not a marginal practice on the fringes of biomedicine and public health; it is an attempt to respond to the expectations of those people who are deprived of access to healthcare, in spite of their sometimes considerable demographic weight.
Its specific and most important contribution to public health consists in developing medical practices that are better adapted to the living conditions and priorities of patients who are generally ignored. So not only must it constantly renew its own practices, but also, in order to prove the effectiveness of these practices, publish the results and comply with the standards of biomedicine and evidence-based medicine. However, political decision and scientific certitude operate on different time-scales. Supporting or contesting a public health policy means daring to hope for a change that may not happen.
There are many examples of humanitarian medical action becoming more effective when it allows patients supported by their families more autonomy and establishes a less asymmetrical relationship with them. The implementation of HIV treatment programmes therefore provided an opportunity to change old habits with regard to the sharing of responsibilities between patients, their entourage and the medical team, and between the medics and paramedics on the care team.