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Chapter I In the beginning

Rony Brauman
Rony
Brauman

Medical doctor, specialized in tropical medicine and epidemiology. Involved in humanitarian action since 1977, he has been on numerous missions, mainly in contexts of armed conflicts and IDP situations. President of Médecins sans Frontières from 1982 to1994, he also teaches at the Humanitarian and Conflict Response Institute (HCRI) and is a regular contributor to Alternatives Economiques. He has published several books and articles, including "Guerre humanitaires ? Mensonges et Intox" (Textuel, 2018), "La Médecine Humanitaire" (PUF, 2010), "Penser dans l'urgence" (Editions du Seuil, 2006) and "Utopies Sanitaires" (Editions Le Pommier, 2000).

1. THE SOURCES OF MODERN HUMANITARIANISM

The first international humanitarian organisation that specialised professionally in medicine was created in France. The project was conceived during the Biafran secession war (1967-1970). The French Red Cross had joined the relief effort set up by the International Committee of the Red Cross (ICRC), which from early 1968 had involved several national Red Cross societies, primarily from Scandinavia, and Catholic and Protestant religious organisations. This operation was the first to combine a major deployment of NGOs and the Red Cross in a conflict situation in a third-world country, and is seen by key figures in the humanitarian sector as a major turning point in emergency aid.

From a purely factual point of view, the origins of this new wave of humanitarian aid in the form of a large-scale intervention in a distant location can be found in Congo-Kinshasa during the war of Katanga (1962-65). Shortly after the former Belgian colony achieved independence, the Congolese government found itself facing secession by the provinces of Katanga and South Kasaï and requested UN intervention. The fighting continued to spread, however, causing tens of thousands of deaths and significant movements of population. A large number of Red Cross organisations were sent to the Congo by their respective countries at the time, alongside the UN peacekeepers. Medical care, vaccinations and food supplies were dispensed on a scale not seen since the Second World War. The manipulation of UN forces by the West, however, their inability to stem the rising tide of violence and their support for the military coup by Mobutu (1965) quickly erased the memory of the relief operation.

The event seen as the trigger for the development of contemporary humanitarian aid, like the Battle of Solferino for the creation of the Red Cross and humanitarian law, was the Biafran War. This was due less to the intensity of the violence or the scale of international aid, which were comparable to those in the Congo referred to above, than the link that was established between emergency aid and public denunciation. For the first time, those directly involved in the emergency, or at least some of them, decided to appeal to public opinion to try to put an end to what they believed was genocide. Such an interpretation, which, it should be noted, should be complemented by the new role played by televised reporting, is well founded in historical terms.For a detailed analysis of this position, see Rony Brauman, “Les Laisons dangereuses du témoignage humanitaire et de la propagande politique”, in Marc Le Pape, Johanna Siméant, Claudine Vidal (dir.), Crises extrêmes, Face aux massacres, aux guerres civiles et aux génocides, La Découverte, 2006.Nonetheless, it conceals the principal innovation that occurred at the time in the area of international assistance, namely the idea of creating a medical organisation specialising in emergency aid and particularly in wars and natural disasters, in line with the experience of the medical teams of the French Red Cross in the Biafran enclave.

The general relief apparatus into which they were incorporated had nothing specific, insofar as medicine was just one element amongst others. The doctors’ particular needs – technical and logistical support – and the more “political” decisions concerning positioning and medical priorities were diluted into the emergency assistance provided by the International Red Cross. The sense of a lack of responsiveness felt by doctors with the French Red Cross lay behind a first organisation whose name – Groupe d’intervention médico-chirurgical d’urgence (Emergency medical and surgical intervention group) – clearly stated its intention: to create an emergency services-type organisation operating in accordance with humanitarian principles on an international scale. This group, known as Gimcu, was to become MSF (Médecins Sans Frontières) in December 1971. What was innovative about MSF and then Aide Médicale Internationale and Médecins du Monde in the late 1970s, was that they introduced medical care practised on the battlefield and in catastrophes by civilians health workers outside the institutions with legitimate authority to do so at the time. This initiative did not come out of the blue, as bringing care to the wounded on the battlefield is an old practice, as old as war. They were, in fact, following in the footsteps of the Red Cross over a century after its creation in 1863.

2. THE RED CROSS. MAKING WAR MORE CIVILISED?

What was new about the creation of the Red Cross was not the provision of care to the wounded but the plan to provide it systematically and independently of any preference or affiliation of any kind whatsoever. Its founder, Henry Dunant, a philanthropic Genevan banker whose investment projects had by chance taken him to a battlefield in Lombardy, in Solferino, had witnessed the agony of thousands of wounded men left abandoned following the only “battle in the 19th century that could be placed on a par with the battles of Borodino, Leipzig or Waterloo in terms of the number of losses it caused.”Henry Dunant, Mémoires, L’Age d’homme, 1970.Revolted by the spectacle of suffering, Dunant took the initiative and came to their aid, making no distinction between French and Austrians. What mattered to Dunant and the impromptu relief workers who volunteered was that everyone was suffering in the same way. Similar spontaneous movements to help the wounded, based purely on humanitarian concerns, took place in other areas where there were confrontations between the French/Sardinian and Austrian armies in 1859. Henry Dunant described these in his book A Memory of Solferino, published in 1862, in which he also detailed the atrocities that took place during the war. His account was more than just a simple description, however. Dunant’s book was designed to serve a purpose: to put forward the idea of creating permanent organisations to provide relief to the wounded and the adoption of an agreement that would regulate how they operated: “If war is a duel between two nations,” he wrote, “as a duel is a war between two individuals, is it not right and proper to try to mitigate its horrors and ward off its consequences by measures similar, for example, to those used every day to deal with the bloody consequences of the duel?”Henry Dunant, L’Avenir sanglant, Zoé, 1994.

Both the outstanding success of A Memory of Solferino in several European countries and the speed with which its first objectives were achieved, show the shift in sensitivities. The Red Cross was created a year after the book’s publication and the first Geneva Convention concerning the war wounded was adopted the following year. From then on, medical staff operating under a white flag with a red Maltese Cross, their patients, the places where they were treated and ambulances, were to be considered neutral, and thus outside the combat zone. The red cross emblem adopted by those who negotiated the Convention in tribute to their Swiss host (it is an inverted version of the Swiss flag) identified these areas to remove them from the hostilities. It has become the humanitarian symbol par excellence.

The word “humanitarian”, which was first used by Lamartine in 1835, had until then been used to describe a philanthropic cast of mind and an attitude of trust in humanity as a whole. Anything that was “intended to benefit humanity”Dictionnaire historique de la langue française, Alain Rey (dir.), Robert, 2000.was classified as humanitarian. With the adoption of the Geneva Convention and the creation of the Red Cross, the term ‘humanitarian’ no longer referred solely to an optimistic anthropology but to a dispositive and a set of norms. Its meaning therefore narrowed to a form of action and a set of obligations, implemented in the name of the spirit of Christian charity, which was supposed to be a requirement for the leaders of this world, as much as the value assigned to every human being. For Dunant and those who supported his undertaking, the glory achieved on the battlefield and the bravery of the combatants could only be enhanced by consenting to limit the use of violence and showing concern for the victims. Under the French Ancien Régime, he recalls in his book, there were protected areas reserved for providing relief to the wounded, underlining the fact that the rules of war and offering help to the injured were a long-established practice. This rule no longer applied, however, after the French Revolution. Restrictions were therefore to be imposed on the conduct of war and help organised to rescue bodies from where the violence was taking place.

The change introduced by the Geneva Convention of 1864 was to transform benevolent attitudes, which until then had been left to the discretion of military leaders, into a diplomatic treaty that had to be applied at all times and in all places. The Convention, signed by 12 StatesThe 12 States were: the Grand Duchy of Baden, Belgium, Denmark, France, the Grand Duchy of Hesse, Italy, the Netherlands, Portugal, Prussia, Spain, Switzerland and Wurtemberg.on 22 August 1864, is considered the founding act of contemporary international humanitarian law and more particularly, the “law of Geneva”, which focuses on the treatment of the victims of war, whilst the “law of The Hague”, introduced by the 1907 Convention, governs the conduct of hostilities.

The unity of the human species and its rights was the basis of the humanitarian approach and prevailed over any division into nations, ethnic groups or religions, combining the spirit of the Enlightenment and Christian philanthropy. The provision humanitarian aid in situations of armed conflict was to be secured by the signatory states in the form of national relief organisations recognised by all countries – the national Red Cross associations – and treaties intended to control and regulate the conduct of war, with the defence and promotion of these falling to the ICRC.

There was immediate opposition and criticism, some of which persists today. For some in philanthropic circles, humanising armed conflict meant making it more acceptable and therefore more likely; in their view, it was war itself that needed to be stopped; to do anything else was to be complicit in it. For others, in particular military strategists, imposing limitations on war would only make it longer and suffering would increase as a result; according to the generals, only a lightning victory, won on the basis of an intense use of violence, would in the end spare more human lives. Both these objections, apparently polar opposites of each other, share some degree of similarity insofar as they are both based on an abstract conception of the world: one side imagines human and social relationships without violence, whilst the other sees war as a relationship based purely on military strength. The founders of the Red Cross, including General Dufour, Commander-in-Chief of the Swiss army, brought a measure of realism to the debate by accepting the existence of war as a fact in order to mitigate its consequences more effectively. For all that, precisely because it was supported by national governments, without which it would never have got off the ground, the project to “civilise war” in the name of humanity also became an instrument of power.

Red Cross organisations were mobilised for the exclusive benefit of their respective countries’ own soldiers and propaganda during later European conflicts, in particular during the Great War, a phenomenon that was far from the original philanthropic project of caring for friendly and enemy soldiers indiscriminately. Only the ICRC managed to maintain a position of neutrality, escaping from “Red Cross patriotism”,John Hutchinson, Champions of Charity, War and the Rise of the Red Cross, Westview Press, Oxford, 1996 and Annette Becker, Oubliés de la grande guerre, Humanitaire et culture de guerre, Noêsis, 1998. but was heavily criticised by the warring parties as a result.

Furthermore, the institution of humanitarian assistance organisation was taking shape in a conquering Europe at a time when the continent was convinced of the superiority of its civilisation. The humanitarian conventions applied only to armed conflicts between nation states, or in other words recognised powers, primarily European ones. They paid no attention to colonial wars and undertakings, which were not constrained by any kind of codified international obligation. Humanity was undoubtedly one, but this form of unity remained a distant prospect for “backwarded peoples” who were still far from “civilised”. Humanitarian law and principles did not seem to apply until the task of humanising the “savage tribes” by civilising them was complete.

3. CARING TO COLONISE

Medicine played a major role in colonial expansion. Illnesses and epidemics decimated Europeans in coastal settlements even more than the Africans, long prohibiting further exploration of the continent, which became known as the “white man’s tomb”. The use of quinine to combat malaria, which began in Algeria during the 1830s, marked a turning point. As an instrument of conquest, colonial medicine was an extension of military medicine, and reproduced some of its coercive methods. It was also used as an aid to development. On the French side, an administrative apparatus was set up in the second half of the 19th century, forming the outlines of a health monitoring network that would continue to be developed as time went on. With the creation of the Corps de santé des colonies (Colonial Health Corps) (1890) and the Assistance médicale indigene (Indigenous Medical Assistance) (1905), health problems came to be thought of collectively in terms of public hygiene and prophylaxis. “Outside the home country, any military campaign must be first and foremost a health campaign,” wrote one General, commenting on the success of an antimalaria campaign in 1916.Cited by Jean-François Saluzzo, Des Hommes et des germes, PUF, 2004.Indigenous medical auxiliaries, assistant doctors, midwives and vaccination nurses were trained and put at work.

It should be noted, however, that whilst these measures did mitigate the shock of conquest, the first phase, until immediately before the First World War, was marked by a net demographic decline in the African population. The development of communications routes, “portage”, the expansion of cultivated land and internal migration were just some of the factors that prompted the development of fatal epidemics on a scale previously unknown on the continent. Exploitation of the conquered lands required a significant labour force and men who were in robust health and it was the doctors’ task to ensure the workforce could be replenished; this was made possible by medical progress and at the same time earned French domination some degree of humanitarian support. This comes across clearly in a speech made by the founder of the Algiers School of Medicine: “If, as it has been christianly thought and magnificently expressed, we have taken charge of people’s souls in taking possession of a faithful and barbaric land, medicine has its part to play in rebuilding a degraded population…”Jacques Léonard, “Médecine et colonisation en Algérie”, in Médecins, malades et société dans la France du XIXème siècle, Ed. Sciences en situation, p.140, Paris, 1992.

The medical corps, however, did not behave unanimously as a docile instrument of colonial power. Tensions between some doctors and administrators were not infrequent, with the former making clear to the latter their indignation over the poor treatment reserved for their “indigenous” patients or insisting on the pathogenic consequences of colonial intrusion for both Europeans and local populations: “[the army] suffers annual mortality of seven thousand combatants simply as a result of the climate. It asks for a son from over twenty thousand families every year. […] To date, the Arab race has proven resistant to religious conversion, resistant to European civilisation and resistant to integration everywhere. In brief, the immense sacrifices we have made in terms of blood and wealth have to date produced negative colonisation in Africa and a glaring decrease in the strength of our country on the continent.”Ibid.

Efforts to combat sleeping sickness, led by Eugène Jamot, provided the model for mass medicine with both a preventive and a curative role. As a doctor with the Colonial Health Corps, he came up with the idea of mobile screening and treatment teams to tackle an epidemic that had become a scourge as a result of the ecological upheavals caused by colonisation, and led the programme between 1916 and 1931. It quickly became clear that his method was effective. He refined it further and later extended it to combating other major tropical endemics with excellent results. It survived for some time after decolonisation and inspired the work of the World Health Organization (WHO) and other government and community healthcare organisations, in terms of the development of monitoring systems for major endemics and vaccination campaigns.

Military doctors operating on European battlefields and in colonial territories invented the particular form of medicine that gave rise to the practices now used by humanitarian organisations in situations of armed conflict and modern-day epidemics: war medicine and surgery, and the prevention and management of transmissible diseases. It is important to be clear at this stage, however, that not all medical assistance operations in these contexts equate to humanitarian aid. Political, religious or community solidarity may be expressed in the same way. The four hundred or so doctors who joined the International Brigades during the Spanish Civil War between 1936 and 1938 set up hospitals on the front and evacuated and operated on the wounded.Gabriel Ersler, “L’engagement des médecins pendant la guerre d’Espagne”, La Revue Agora no. 36, autumn 1995.Some of them, such as Norman Béthune, had already worked in the same way in China, in the regions controlled by the Communist Party during the Long March (1934-1935). In our own times, in Iraq and Afghanistan, support for the armed groups fighting the government in both countries is given – amongst other ways – through medical assistance (through clandestine shipments of drugs and equipment as well as operational teams). Although, on the face of it, these are similar to the operations carried out by humanitarian organisations, medical assistance missions of this kind cannot be placed in the same category, because their intention is different. They are intended to serve only one of the warring factions, rather than all victims. They are not geared to meet the needs of a population affected by war but a segment of the population determined on the basis of political or religious conviction. Similarly, doctors in the Soviet army during the war in Afghanistan in the 1980s and in the US Army in Vietnam ten years previously, who provided health care to Afghan and Vietnamese civilians, did so to serve a political cause. Their missions were categorised as “psychological operations” to use military terminology, or in other words, war propaganda.

4. SOCIAL MEDICINE

It was important to locate care for those wounded in the field in its historical perspective to gain a better insight, at a distance, of the complex relationship between humanitarianism and political power. Taking a step back in this way helps us to grasp the broad outlines of the process through which, in the 19th century, medicine and humanitarian relief entered the political arena and in turn played a part in reshaping it. We will find, with some similarities and some differences, this same ambivalent relationship in describing the practices used and messages conveyed by contemporary humanitarian medicine. Battlefield medicine and colonial medicine are certainly the principal ancestors of contemporary humanitarian medicine, but its antecedents are not limited to the practice of military medicine.

Assistance for the poor, long provided by the Church and later, from the 16th century onwards, by the State as well and to a marginal extent by philanthropists, is another source and one that it is important to consider, for the same reasons. Hospitals at the time were places to which people were relegated as much as they were places where they could seek assistance. The creation of the general hospital in the 17th century was part of a process of locking up poor people, vagabonds and the “dissolute”. During the 19th century, hospitals became places where medicine was practised and were thus dissociated from prisons and asylums as part of an evolution in which the authority of doctors expanded at a much faster pace than their actual effectiveness.Jacques Léonard, L’Historien et le philosophe, in Médecins, malades et société dans la France du XIXème siècle, op. cit.It was primarily the public authorities that responded to the demand for health in a process that extended the use of medical treatment, even though a few affluent individuals did create small hospitals with very limited medical facilities in the countryside, intended for the “deserving poor.”Olivier Faure, “La Médicalisation vue par les historiens”, in Pierre Aïach and Pierre Delanoë (dir.) L’Ere de la médicalisation, Ecce homo sanitas, Ed. Anthropos, Paris, 1998.

From the middle of the 18th century, doctors moved away from previous practices and started to make observations about sick bodies and link them to their environment. Since this period, they “have presented themselves as advisers to those in power and social mentors, guiding mores and behaviours.”Ibid.The cholera epidemic that broke out in 1832, killing 15,000 people in Paris within a few days, accentuated the tendancy. Whilst it was evident to the authorities at the time that illness affected the poor much more than the rich, it also became apparent that the progress of the epidemic was linked to housing density, which led doctors and social researchers to look at the conditions in which people were living.François Delaporte, Le savoir sur la maladie, PUF, Paris, 1991.The promiscuity that characterised the lifestyle of the poor became a medical theme in a context of social transformation and crisis linked to industrialisation and urbanisation, marked by the first workers’ revolts and the fear that the “dangerous classes”, these “domestic barbarians”, inspired in the elite. The names of Louis-René Villermé (1782-1863) and Rudolf Virchow (1821-1902), a surgeon and doctor/pathologist respectively, are still associated with the concept of medicine as a social science. The former devoted his career to the question of social inequalities and occupational health; the latter, writing that “politics is nothing more than medicine practised on a grand scale”, created the first municipal hospitals in Germany but also promoted urban development projects (parks and waste water drainage).

The role of social medicine advocated by doctors working in the field of public hygiene remains in many respects more rhetorical than practical, but medicine plays an important role in determining what is socially acceptable or intolerable. During the same period, the 1830s, a movement formed in France and Great Britain that questioned the working conditions of children recruited to work in factories from the age of four or five, even before literature, from David Copperfield to Les Misérables, tackled the subject of the violence inflicted on poor children.Patrice Bourdelais, “L’Intolérable du travail des enfants”, in Didier Fassin and Patrice Bourdelais (dir.), Les Constructions de l’intolérable, Etudes d’anthropologie et d’histoire sur les frontières de l’espace moral, La Découverte, Paris, 2005.More generally, the role of the State regarding public health and well-being was expressed as a duty by these reforming doctors, who quantified particular phenomena on the basis of statistical analysis and proposed practical measures to the legislature. In his Tableau de l’état physique et moral des ouvriers [Review of the physical and moral condition of workers], Villermé demonstrated that the high mortality rate amongst workers could not be explained by specific illnesses or accidents, but that “the principal explanation is to be found in their living conditions, in particular poverty […] and overcrowding in housing […]. Increasing their wages is therefore the most urgent measure to be taken.”Didier Fassin, L’espace politique de la santé, PUF, 1996, p. 251.

If the public authorities are to have the necessary information for taking action on health, there need to be surveys on the state of the population, with rankings drawn up and mortality tables produced. Education, sanitation and assistance programmes and preventive measures all depend on this. In the minds of these socially-oriented doctors, scientific description and political reformism went hand-in-hand; as a result, the process gradually established public health as a branch of scientific understanding and a moral and political imperative. In this respect, contemporary advocates of humanitarian medicine, public health and human rights are the heirs to this reforming trend.

Most care for the sick in the 19th century, however, was provided by healers, religious groups and health officers, who were accessible to the poor in financial terms. Independent doctors, meanwhile, subsidised the care they provided to the poor from the fees paid by their more affluent patients. “The doctor offers a reduction in his fees and the lord of the manor pays for the tenant farmer and the head of the household for the servant. This paternalistic concept results in dispensing charity and free rural medical services, and is a joint effort by municipalities, free subscribers, nuns tasked with caring for the sick, pharmacists and doctors,” wrote Jacques Léonard. As their name indicates, in the eyes of the population healers were more effective than doctors. The relationships between them were often conflictual, based on denouncing superstition and obscurantism on the one hand, and powerlessness to heal and cupidity on the other, although an examination of their practices shows that in fact, each side drew heavily on the other.

Faced with their illegal competitors, in the middle of the century doctors decided to organise medical care for the poor in order to remove the charitable pretexts under which the healers claimed to work. In fact, the subsequent development of mutual assistance societies for workers, the provision of free care services to the rural poor and the creation of Assistance Médicale Gratuite [Free Medical Assistance] (AMG) in 1893 resulted in a significant increase in the use of official medicine by the underprivileged and a concomitant decrease in the frequency with which healers were consulted.Jacques Léonard, “Les Guérisseurs”, in Médecins, malades et société dans la France du XIXème siècle, Ed. Sciences en situation, Paris, 1992.During this period, private charitable organisations were incorporated into the public health care system. In 1904, notes Jacques Léonard, 900,000 people were cared for free of charge in public institutions of this kind, compared with 225,000 forty years earlier, a sign of the success of the policy.

In the 20th century, health care in France largely falls within the remit of the public authorities rather than private charitable initiatives. The trend towards greater equality in access to health care is being seen throughout Europe, in different ways depending on the country, supported by the privately funded public health associations that increased in number from the end of the 19th century onwards. These differ from charitable works insofar as their approach is based on their scientific knowledge: often led by doctors, they too are intended to relieve and prevent illnesses associated with poverty, such as tuberculosis, infant mortality and venereal diseases, through public education, disseminating preventive practices, visiting the sick and providing treatment. Public health is indissociable from the trend towards strengthening centralised state institutions and in our day has become a responsibility of the State, or what Didier Fassion calls “the government of life”.Didier Fassin, Op. cit.When they become elements in public policy, health-related initiatives taken by private organisations move out of the charitable or humanitarian sphere and into the political arena. Emphasising this change of category is not simply about classification but about pointing to a fundamental shift in the system. Private initiatives are by their very nature incomplete. Only decisions made by the State can have effect in law and thus, at least in principle, be of benefit to all. Institutions to protect babies and young children, and by extension their mothers as well, provide a particularly clear illustration. The high mortality rates amongst newborn babies and very young children in poor families had long been recognised, before they became a subject of general concern, in Great Britain, the United States and France in particular, at the end of the 19th century. Until then, apart from criticisms by a small number of philanthropists, these societies had seen death on this scale as a question of fate. Why the change? It stemmed from concerns amongst the authorities about demographic and therefore military and economic decline, which was seen as a consequence of poor health amongst children. It was also brought about by the activism of charitable associations combined with the commitment of doctors at the Institut Pasteur, who were determined to make the distribution of sterilised milk to newborn babies more widespread.Ibid., p. 258.Issues of public safety, humanitarian concern and, in some cases, scientific progress then came together in a joint dynamic.

A similar pattern emerged around AIDS during the 1990s and other epidemics as well, such as malnutrition and malaria, in these cases outside of a national framework. It is important to note at this stage, however, that the social problem raised is seen under a different political light depending on whether the political and humanitarian players involved are fellow citizens of the target populations or not. In France, for example, the work of humanitarian medical NGOs with unemployed people who have reached the end of their period of entitlement to benefits was accompanied by a militant commitment to the adoption of a law to introduce so-called Universal Health Insurance (“Couverture médicale universelle” or CMU). These same medically-oriented NGOs – no doubt without borders but not without nationalities – were caught and will probably be caught again under retaliatory government measures for similar work in countries other than their own, particularly if these are former colonies. Something that is seen by a government as a legitimate issue in the first case may be seen, or exploited, as unacceptable interference in others. Bodies being places of inscription of modern political power, acting on them is never politically innocent, whatever carers motivated by ethical considerations may think.

Whether it is practised in a major crisis situation, such as armed violence or a natural catastrophe, or in a more ordinary context characterised by poverty, humanitarian medicine cannot ignore issues of sovereignty. The position of those who participate, as much as or even more than the actual substance of their actions, varies widely depending on whether they are responding to circumstantial needs, created by a critical event, or aiming to improve or modify treatment practices in more subtle ways. In some cases it is undoubtedly uncomfortable and sometimes artificial to distinguish between a state of war and a state of peace, given the increasing number of situations where the boundary between the two is blurred.Roland Marchal, “Les frontières de la paix et de la guerre”, in Politix. Revue des sciences sociales du politique, 2002, Volume 15, Number 58.Whilst they may be vague, however, these categories are still useful as a way of grasping and understanding the kinds of action that are grouped together under the heading of “humanitarian medicine”.

This cannot be reduced, far from it, to the practice of emergency medicine which, as we will see, represents only a small part of it. It often plays a part in long drawn-out crises, which appear in stages and last for a long time, which is why we have used the term “exceptional situations” to cover armed conflicts, epidemics and natural catastrophes and their medical consequences, which we will examine in detail. Although very different on the surface, these situations share the fact of being circumscribed within a limited time and space. This distinguishes them, more or less clearly depending on the case, from the “ordinary situations” in which humanitarian medical organisations also intervene but where the circumstances at the start and end of the action are more difficult to describe. The ability to perceive a turning point produced by an event after it has occurred is the differentiating factor for these different forms of intervention. It should be made clear that we will only be examining organised humanitarian practices, and not individual initiatives. We will look not only at these organisations’ actions on the ground but also their public positions. In addition to the communications imperatives designed to attract the resources needed for action, declarations and awareness-raising campaigns intended to bring certain topics to the attention of the public to get them onto the political agenda are part of the role humanitarian organisations have taken on and which society expects them to fulfil. As practitioners on the ground, experts in social issues and moral entrepreneurs, those involved in humanitarian actions take on these various roles in turn or simultaneously as sources of legitimacy with which to confront the politicians. The insight into those who practise social medicine offered in the preceding pages is intended to locate them in an already long history.