Expecting to see another burn or trauma patient, the security guard at Médecins Sans Frontières’ (MSF) hospital in Tabarre, Port-au-Prince, peered into the window of the car at the front gate. Inside were two men, their heads covered by hoods, pointing automatic rifles at him. When he refused to let them in, one of the gunmen scaled the compound wall. “We have no idea who they were,” says Alexandre Marcou, another member of MSF’s team in Haiti’s capital, of the incident, which happened on 23 February. “It can be very shady, you don’t know who’s part of an armed group and who’s part of the police.” A day earlier, in the south of the capital at MSF’s Turgeau emergency centre, it was clearer who was threatening the health charity’s operations. Armed police officers blocked off the hospital’s entrances and exits and searched all its facilities and ambulances. It is possible the security forces were looking for four gang members rumoured to have been receiving treatment for burn wounds. MSF was able to continue its work in Turgeau but, given the growing frequency of violent incidents, it is concerned it may have to scale back operations in Haiti. “When we really can’t ensure that our team will work in a secure environment, that’s a red line,” Marcou says. The two incidents are the latest in a series of human rights violations that have left NGOs in Haiti fearing they may have to abandon the island nation and its embattled people as it sinks further into violence. Haiti has been in escalating economic, social and political chaos since its president Jovenel Moïse was assassinated in July 2021. Outgunned and unelected, the government is losing ground to gangs, who now have control of two-thirds of the capital. Human rights observers have documented a spike in the most egregious abuses, such as sexual violence, while half of the population don’t have enough food and cholera has returned, killing at least 594 people since October 2022. As the gangs grow more powerful they are terrorising humanitarian workers, who are the last line responding to the crises. On 26 January, gunmen entered an MSF-supported hospital in the capital, dragged a patient out of the emergency room and shot him in the head outside the front gates. Mahaman Bachard Iro, MSF coordinator in Haiti, says: “It is becoming increasingly difficult to work in these conditions.” The organisation has become the last treatment option for many Haitians, and is the only non-governmental group running or directly supporting hospitals in Port-au-Prince. The public health system is in almost total collapse. In the sprawling slum of Cité Soleil, home to 300,000 of the country’s most vulnerable populations – as well as its most notorious gangs – MSF runs one of only two hospitals; the other is private. Yet, they had to close the outpatient department when shootouts became so regular that stray bullets kept flying through its clinics. “The frontline of the warfare is encroaching and we don’t want the hospital to become the battleground for armed groups,” Marcou says. The violence is making operations almost impossible for civil society groups, says Fiammetta Cappellini, country representative for the Avsi Foundation, an Italian NGO. “As everything goes from bad to worse, these events are happening more often and crossing a line that for all of us humanitarians is uncrossable,” she says. MSF had to close its Martissant hospital in June 2021. “Back then, it was every few months, now it’s almost weekly that our workplace is threatened,” Marcou says. With a reputation as a frontline NGO, MSF’s decision to suspend some of its services is a portent that other groups may follow. Although it is not considering pulling out of Haiti altogether, it says, as for now it is caught in the crossfire of gang warfare and not targeted directly. Cappellini says: “We are still able to keep going with all our activities with highly restricted security protocols. If we can, we will keep going, but it is clear that if something like that happens to us we will have to take the same decision [as MSF].” Few are brave enough to predict Haiti’s future as conditions deteriorate even further. But Cappellini says the consequences of MSF continuing to limit or withdraw its services would “be a catastrophe”.