The observations of an MSF worker during his fourth assignment in Iraq, in April 2004.

"The scariest day in my life," that is how Ibrahim Younis describes the Sunday on which he assessed medical needs in the besieged city of Fallujah. The assignment in April was his fourth in Iraq. Ibrahim, member of the Medecins Sans Frontieres (MSF) emergency pool, went to Baghdad for the first time at the end of 2003 and stayed there throughout the bombardments by the US military. He spent two weeks in jails, having been arrested by the Iraqi security forces. Yet, nothing made him as scared as having to travel down the road to Fallujah with a US military escort.

"The Coalition forces are a target for the insurgents in Iraq,"  says Ibrahim after returning to Brussels. "Along this road I saw the carcasses of military vehicles that had been hit by mortars or rocket-propelled grenades. The Americans told us they needed to escort us, as there were many fighters in that particular area. But I would have felt much safer without them."

While the work in the three MSF clinics in Sadr City, on the outskirts of Baghdad, continues with an average of 3,000 consultations per week and active support to the reference hospital, the international staff have temporarily withdrawn to Amman. One of Ibrahim's tasks during his latest trip was to reassess the security risks. In a period during which dozens of foreigners got kidnapped and with less and less distinction between those who are aligned to the military coalition and those who are truly civilian, the risks connected with staying in the country were simply unacceptably high. Around one hundred Iraqi MSF staff continue the work, with active support from Amman and Brussels.

The most urgent job for Ibrahim was to get new supplies to Baghdad. "We were running low on stock. Since the fighting rapidly intensified in March - particularly in parts of Baghdad and Fallujah - we had been donating emergency supplies to hospitals and to the Ministry of Health. Our cargo with medical materials and high-protein biscuits arrived on Baghdad airport, but nobody was keen to transport it any further as convoys were almost routinely attacked on the road to the city. In the end we did manage to get the materials to our warehouse. But the difficulty of arranging such a humanitarian transport already indicates how complex it has become to do anything significant in Iraq today."

When Ibrahim arrived in Baghdad, only weeks after his previous stay, he immediately noticed how much things had changed. The absence of US troops in the streets was very noticeable during the first days; they stayed in their own quarters leaving general security up to the poorly prepared Iraqi police. The city had become much more tense and more violent. The manager of one of the graveyards told Ibrahim he was hosting an average of 16 funerals per day now; many if not most of the dead were casualties of the warfare.

Through local contacts, Ibrahim got his first information about the situation inside Fallujah. The large public hospital was not functioning as the compound had been taken over by the Coalition forces. Local medical staff had set up a field hospital, which reportedly was poorly equipped. When the Iraqi Red Crescent successfully negotiated a humanitarian convoy to supply Fallujah, MSF contributed 1.5 tons of emergency medical and surgical materials. But it was urgent that MSF would have a look around in the city, assess the needs and judge whether it would be possible to provide more active assistance.

Ibrahim joined a convoy of the Iraqi Red Crescent, the only organisation that is respected by all parties in the conflict. Dressed in an MSF-shirt, to make sure there could be no misunderstanding about who he represented, he got in one of their cars. They found their way through checkpoints until they came to the stretch where they were forced to accept the US escort. For Ibrahim who over the past year has invested so much in trying to explain MSF's independence to Iraqi leaders, in the hope that recognition of such independence would limit the risks for our staff, Iraqi or international, this escort was the ultimate nightmare. His first action after arriving in Fallujah was to explain what happened and avoid misunderstanding.

Once inside the city, Ibrahim felt a lot safer. Though there was a tense atmosphere, the respect for the Red Crescent meant that he was welcomed with open arms in the field hospital and got solid advice on how to stay safe. In Fallujah, this meant not travelling around at all, as there were snipers aiming at the main streets who would consider anything that moved a target. As a result, Ibrahim was not able to see the public hospital first-hand.

"I consider it absolutely unacceptable that hospitals are militarised," says Ibrahim about the presence of troops in medical facilities. "Hospitals have to be respected, by all parties in a conflict, as neutral territory. Otherwise you end up in a situation where sick or injured civilians don't seek treatment as they fear being in a hospital compound to begin with. We have heard stories from various sources about soldiers entering hospitals and taking suspected opponents from their beds. We did not see this with our own eyes, but if these stories are true then this is a very serious breach of the neutrality of medical structures."

While the public hospital in Fallujah was off-limits, the medical staff in the improvised field hospital were doing an impressive job under difficult conditions. With hardly any working equipment and in two small rooms transformed into impromptu operating theatres, they were caring for the injured. Ibrahim saw about ten wounded in the small facility when he was there. MSF now hopes to bring in materials for an extra operating theatre, to increase the capacity for dealing with the wounded. Sadly, Ibrahim had to conclude that working with international staff in Fallujah would have been absolutely irresponsible at that point in time.

A couple of kilometres outside the city, the Red Crescent planned to set up a camp for displaced families who had fled the Fallujah siege. Though many are taken in by host families - a year ago Fallujah hosted many people who had fled the bombing of Baghdad - there are others who have to camp in the rough or are staying in public buildings in the capital. The camp, situated on a river so that the water supply was guaranteed, was to have enough capacity for 200 to 300 families. But on the second day, the US troops moved to within one kilometre from this place, making it too insecure a location for displaced civilians. The same happened to a second location, further down the river; after the Red Crescent had already begun erecting the tents the site came under fire.

Nobody can claim to have a good overview of the plight of Iraq's civilian population. The security risks are too great for aid workers, human rights researchers and journalists to do independent and comprehensive assessments. Ibrahim stresses the role of the Coalition forces in this climate of insecurity. "There is a whole string of actions that make it virtually impossible to work independently in Iraq. Soldiers driving around in cars that look exactly like cars of aid agencies, thus making every aid agency suspect. Forced military escorts like the one I was confronted with on the road to Fallujah. Embedded non-governmental organisations that choose to always be accompanied by soldiers. No matter how hard we try, we are hardly able any more to show our independence from the warring parties. Every Westerner is automatically seen as affiliated with the Coalition." This confusion is a major reason why Iraq has become too insecure for aid workers. At the end of the day, it is the civilian population of Iraq who bears the consequences of the continued warfare, and particularly the absence of assistance in times of urgent need.



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