Mr de Maio started by calling on the international community, the Afghan and Pakistani governments and armed opposition groups to take into account the humanitarian situation when devising and implementing their political and military agendas.

The conflict is having a dramatic effect on a huge population that is inaccessible to humanitarian workers and journalists. All parties involved in the violence have a duty to conduct their operations in a manner that respects civilians, prisoners, the sick and the wounded.

“There’s no such thing as a clean war,” he conceded, before going on to emphasize that “international humanitarian law does apply in Afghanistan and Pakistan and there is room for improvement in compliance with its requirements of protection, distinction, proportionality and precaution. Better respect for the law of war will minimize casualties among civilians and other non-combatants.”

Mr de Maio pointed out that now, more than ever, civilians are bearing the consequences of the armed conflict in Afghanistan and Pakistan. “Too many are being killed, maimed, humiliated and deprived of medical treatment because of the fighting and insecurity.”

More fighting, more victims

Mr de Maio has no illusions about the immediate future: ”The armed conflict in Afghanistan is increasing in intensity and expanding in scope,” he said. “The increased contact surface between opposing sides will inevitably increase suffering and the potential for violations of IHL. In Pakistan, conflict and armed insecurity are likely to continue, and so is their impact on civilians.”

The widening gap between needs and response

At the same time as humanitarian needs are set to increase in Afghanistan and Pakistan, the gap between those needs and the response to them is widening. It is impossible for humanitarian agencies to operate in many areas of Pakistan and Afghanistan. That includes the ICRC, even though the organization still has a unique degree of access. People in the inaccessible areas are not receiving the help they need. But as needs increase, so do the ICRC’s efforts. Mr de Maio reported that “The ICRC has already stepped up its operations in the fields of protection, assistance and health, and we will continue to expand our work significantly during 2009.”

Internally displaced persons

Accurate figures are impossible to come by, but the ICRC does know that 200,000 to 350,000 people have been displaced inside Pakistan since August 2008. “The difficulty in obtaining accurate statistics lies in the fact that the displaced population is constantly changing and is constantly on the move,” explained Mr de Maio. “People in the region have good coping mechanisms, they’re mobile, and they can often call on the help of relatives or members of their clans. As a result, many are living outside organized camps.”

Similarly, the ICRC has no exact IDP figures for Afghanistan. Here, access is extremely difficult, and all but impossible in many areas. Nonetheless, one can safely say that there are several tens of thousands of relatively new IDPs in Afghanistan.

The ICRC’s role in assisting IDPs has expanded dramatically in just two years. From zero in 2007, the number of IDPs assisted by the organization rose to 40,000 in 2008 and in 2009 that figure is likely to rise to over 140,000. Most of the hostility/security-related IDPs in Pakistan are in Swat district, other parts of North West Frontier Province and in Baluchistan, and in the tribal areas, especially Mohmand and Bajaur.

As Mr de Maio pointed out, how the ICRC assists these IDPs depends on their needs. “We distribute food in some areas, to the most vulnerable families and communities. We’re not talking about feeding whole camps of people.” In other cases the organization is providing essential household items. Activities involve water and sanitation in certain areas and health care is a major element, with the ICRC providing services either directly or through other bodies, particularly the Pakistan Red Crescent Society. "The ICRC works independently and without armed escorts. This is partly to ensure that aid is both relevant and accountable, but it is also to make our strictly neutral stance clear to everybody," he added.

Casualties of the fighting

No-one can give accurate figures regarding the number of people injured in the fighting. However, the number of war-wounded civilians and combatants arriving at ICRC-supported medical facilities has increased by 50% over the past year. “And this is just the tip of the iceberg,” warned de Maio, “the people who survive until they reach ICRC facilities. Many others are dying because they don’t get treatment in time.”

Health care in Pakistan

Working with the Finnish Red Cross, the ICRC has opened a field hospital pending completion of renovation work on Peshawar Surgical Hospital. The tented facility is handling a major influx of patients from both Pakistan and Afghanistan. “Peshawar is the flagship of ICRC health care in Pakistan, but it’s only part of an overall strategy that includes supporting medical facilities, Pakistan Red Crescent Society first-aid posts and primary care units,” explained Mr de Maio. The ICRC operates 10 medical facilities in Pakistan.

Health care in Afghanistan

Mr de Maio emphasized that the ICRC’s health operations are quite different in Afghanistan. “We’re operating or supporting dozens of health facilities in Afghanistan. We’re supporting Government-run hospitals, such as Mirwais hospital in Kandahar, we’re supporting local medical and health programmes, and we’re running programmes jointly with the Afghan Red Crescent Society and the Afghan ministry of health.” The ICRC also operates first-aid posts and primary health-care centres jointly with the Afghan Red Crescent Society.

Safety of humanitarian personnel

While the ICRC is operating in many areas of Afghanistan and of north-west Pakistan, “large segments of the Pakistan border area and of Afghanistan are inaccessible even to the ICRC, at least at certain times,” explained Mr de Maio, “because we can’t get the security guarantees we need.”

Mr de Maio pointed out that the security situation is highly complex: “It’s important to understand that in addition to the conflicts as such, the region is subject to complex patterns of local armed violence and insecurity, including kidnappings, hostage-taking and crime on a large scale. This pervasive insecurity affects the work of the ICRC.”

However, the ICRC’s network, its work with the Afghan and Pakistan Red Crescent Societies and with local authorities and communities, plus its contacts with the armed opposition, all ensure access to many of the places where its help is needed. That access enables the organization to help IDPs, resident civilians, the sick, the wounded and detainees. As Mr de Maio points out: “Even those opposed to the presence of outside agencies recognize the ICRC’s neutrality, independence and modus operandi. As a result, the ICRC is operating in areas where other agencies cannot.”