Civilians attacked, bombed, and cut off from aid in Pakistan, Somalia, Yemen, Sri Lanka, Afghanistan, and the Democratic Republic of Congo (DRC), along with stagnant funding for treating HIV/AIDS and ongoing neglect of other diseases, were among the worst emergencies in 2009, the international medical humanitarian organization Médecins Sans Frontières (MSF) reported in its annual list of the "Top Ten" humanitarian crises.

Continuing crises in north and south Sudan, along with the failure of the international community to finally combat childhood malnutrition were also included on this year's list. The list is drawn from MSF's operational activities in close to 70 countries, where the organization's medical teams witnessed some of the worst humanitarian conditions.

Three distinct patterns dominated in 2009: governments blocked lifesaving assistance to trapped populations, including in Sri Lanka, Pakistan, and Sudan, where aid groups—including some MSF teams—were expelled from Darfur; respect for civilian safety and neutral humanitarian action further eroded, such as in Yemen, Afghanistan, Pakistan, DRC, and Somalia, where people—and in some cases aid workers—were either indiscriminately or directly attacked; people suffering from a host of largely ignored diseases were again neglected by the international community, and those living with HIV/AIDS saw their chances of receiving life extending therapy further diminished.

"There is no question that civilians are increasingly victimized in conflicts and further cut off from lifesaving assistance, often deliberately," said MSF International Council President Dr. Christophe Fournier. "In places like Sri Lanka and Yemen, where armed conflicts raged in 2009, aid groups were either blocked from accessing those in need or forced out because they too came under fire. This unacceptable dynamic is becoming the norm. Our teams on the ground are witnessing the very tangible human consequences of these crises directly, either in war zones or in the AIDS and nutrition clinics in which they work," he said. We're therefore compelled and obligated to speak out."

In Sri Lanka, tens of thousands of civilians were trapped with no aid and limited medical care as government forces battled Tamil Tiger rebels in the spring. Aid groups, including MSF, were banned from entering the conflict zone. In Somalia, civilians continued to bear the brunt of a vicious civil war. More than 200,000 people fled the capital, Mogadishu, in just the first few months of 2009 and aid workers were increasingly targeted – at least 42 relief workers have been killed since 2008, including three MSF staff.

In Yemen, civilians and hospitals were heavily affected by fighting in the Saada region in the north of the country as government forces fought rebels. The fighting forced tens of thousands of people from their homes and compelled MSF to close the only hospital serving an entire district after it was shelled. And in a glaring case of abuse of humanitarian action for military gain, civilians gathered with their children at MSF vaccination sites in North Kivu, DRC in October, came under attack by government forces. The attack threatened to severely undermine the trust necessary to carry out independent medical humanitarian work in conflict settings.

In Pakistan, where tens of thousands fled fighting, hospitals were struck by mortar fire and two MSF workers were killed in Swat Valley, where the organization ultimately suspended its operations due to the violence there.