MSF’s top ten – how disconnection affects public health

It’s hard to look forward to something as difficult and sad as Medicine Sans Frontieres top ten list of global humanitarian crises. I noted last year that this appears to be the season for top ten lists, and that these lists range from the positive to the extremely disconcerting. MSF’s list is certainly discomfiting, but it’s also a very helpful reminder of what stories we should be paying attention to.

Two of MSF’s top ten focus on Somalia and the ethnically Somali portion of Ethiopia. MSF reports a massive refugee crisis in Somalia, connected to ongoing instability and violence. Unfortunately, MSF is able to provide little help within Somalia – the situation is simply too dangerous for their staff. Three staff were killed by a roadside bomb in Kisamayo, and MSF pulled its international staff out of the country in early 2008 – their local staff continues to work despite a high degree of risk.

Eastern Ethiopia, a region that’s majority Somali-speaking, is facing a severe food crisis. Many of the people who live in this region are pastoralists. An ongoing conflict between the Ethiopian government and rebels have made much of the region inaccessible, which is preventing herds from reaching water and food. Here MSF is constrained from acting not so much by violence, but by an uncooperative Ethiopian government, which has put major hurdles in front of the organization and which forced an MSF project to close in the region.

(While I’ve complained in the past about how little attention is paid to Somalia, the rising threat of piracy has helped attract some attention to that country’s problems. But news from the Somali region of Ethiopia is almost nonexistent – try a search for “Jijiga”, the regional capital, on Google News, or within the New York Times, where most results are from the second World War. A paper from Dr. Abdi Aden Mohamed – whose views are clearly anti-Ethiopian and pro-independence for the region – gives a sense for how isolated this region is: “… 3. There is no electricity any where in the region and most of the people in the region have never seen a Television or Cinemas. 4. No communications like postal services, and most of the people have not seen or used up to now telephones, faxes etc., because there aren’t any in the region. 5. There are no roads in the region except dirty dusty ones and trails created by the nomads and their herds.”

The difficulty MSF is having in reaching Somalia and the Somali region aren’t just coincidental – the disconnection of these areas helps explain why they are in such dire straits. Political and military strategist Dr. Tom Barnett offers the maxim “disconnection defines danger”. Countries that are tightly integrated into global communication, financial, trade and military systems tend not to fail catastrophically in meeting the needs of their people. The idea is not unrelated to Dr. Amartya Sen’s assertion than functioning democracies don’t experience famines – they’re able to access markets and seek help from other nations to avert this sort of catastrophe. (If you’re as disconnected as North Korea, you’ll find your neighbors using food aid as a carrot to try to coax better behavior from you.) This helps explain why Burma, still recovering from Cyclone Nargis, makes MSF’s list. It’s not a surprise that MSF hasn’t been able to send international staff into Burma – the military government has refused to issue visas, leaving the task of providing critically needed medical care to local staff.

I’d always assumed that MSF’s purpose in publishing this list was to fundraise. Oddly, there’s no link to giving information on their site – if you’re in the US and want to support their important work, you can find a link on the Doctors Without Borders site. The idea of disconnection suggests another reason – MSF can’t work in many of the places on their top ten list without better security for their doctors, or international support in obtaining visas. Without more “connectivity” – in Barnett’s sense – these are largely crises they have to watch from afar and help with only indirectly. Top ten lists, whatever else they’re good for, are a way of directing attention, and attention is a necessary precursor to connection.