John Pringle is an epidemiologist and a member of MSF. On the same subject as a chapter he recently published in an MSF's book edited by Caroline Abu-Sada "Dilemmas, Challenges, and Ethics of Humanitarian Action: Reflections on Médecins Sans Frontières' Perception Project", he wrote the following piece. In it, he suggests that MSF, when tackling economy-generated environmental disasters, should not hesitate to question the ‘forces that deny our patients the societal determinants of health'.

The humanitarian vocation has been defined as bringing "a measure of humanity, always insufficient, into situations that should not exist" (Rieff, 2002 p. 19). This definition raises three important considerations. The first is humanity. As MSF aid workers, the measure of humanity that we provide is in the form of direct medical care and public health assistance. The second consideration is insufficiency. While our operations may always be insufficient in relation to need, we refuse to be defeatist. With each project we recommit to professionalism, innovation, and critical self-awareness.

Situations that should not exist

The third consideration, situations that should not exist, is the focus of this article. Public health emergencies are largely predictable and preventable. In fact, when entire populations are without adequate disease surveillance or public health infrastructure, a form of emergency is already underway. Those in what Collier (2007) refers to as "the bottom billion" live out their lives in states of emergency. When war, malnutrition and outbreaks inevitably occur, few ever see a humanitarian response.

As MSF, we embrace our collective humanitarian action as a movement, one that creates proximity between those in crisis and qualified aid providers. Whatever our individual motivations, we share a universalist view of distributive justice and collective responsibility, which we enact through what Calain (2011) calls our cosmopolitan outreach. Our outreach includes advocacy. For example, when we witnessed how life-saving essential medicines were not available to our patients due to cost and scarcity, we responded with the Access Campaign. We refused to take a hyper-individualistic and atomistic view of our work, and instead developed an understanding of the international pharmaceutical market and Trade-Related Intellectual Property Rights (MSF, 2012). We did this because we considered it our social mission to speak out against a system that inherently excludes not just our patients, but entire segments of the global population.
Along this line, many of us, while providing care for our patients and their families, are witnessing economy-generated disasters. We are seeing first-hand the suffering caused by the global financial crisis and subsequent austerity measures. We want to speak out against the suffering that is seen as a ‘natural' correction to the global financial market.
The global financial crisis was not a natural occurrence. It was triggered by international efforts to free markets internationally by privatizing public goods, stripping environment and labour protections, and removing tariffs and financial regulations. Political scholars refer to this as neoliberal capitalism (Harvey, 2007). Vulnerable populations are seeing ever reduced public expenditure on social services such as health and education. Public health surveillance and security is increasingly privatized and militarized. Those on the fringes are experiencing forced migration, food insecurity, energy scarcity, and ecological collapse.

The economy of crises

Our global health is up for sale. Where we see instability, corporations and financial speculators see opportunity for profit. A political economy creates, perpetuates and exploits the state of emergency, while concentrating wealth and widening inequity (Klein, 2007). These factors create situations that should not exist. I have written about the protracted lead poisoning disaster in Nigeria, where high gold prices drove subsistence farmers into artisanal mining in a context of poverty and inadequate public health security, resulting in the deaths of hundreds of children and the poisoning of thousands of others (Pringle & Cole, 2012).
Humanitarianism is incorporated in the political economy of crises. As global financial institutions abandon the needs of the poor, the international humanitarian sector is called upon for damage control. For humanitarian and health-related NGOs, there is a growth in funding for emergency response, driving expansion in both the number of organizations and the scope and depth of operations (Garrett, 2007). While we may congratulate ourselves for MSF's large operating budget, the surge in humanitarian funding may well reflect divestment in global health development, where anti-poverty and environment-protection projects are abandoned in favour of reactionary emergency responses. It requires relatively little expense to turn a humanitarian emergency back into a baseline of low-level suffering.

The humanitarian sector

More funding for humanitarians may be a political solution, but it is not an ethical one. As Bradol (2011) points out, since the 1970s, not a single transnational public health effort has been able to thrive under initial market conditions, whether it is immunization, contraception, the use of national essential drugs lists or drugs for AIDS. Without differential pricing for infant feeding, countless children will continue to succumb to the deadly combination of under-nutrition and infection. The crisis in malnutrition is climate- and economy-related (Bradol, 2011). No amount of humanitarian funding can heal the problem. And meanwhile, more money is siphoned from poor countries to rich countries than is donated by rich countries to poor countries.
To promote global health is to fight inequality. As Brauman (2010) points out:
"The dizzying increase in the gap between the world's rich and poor over the past thirty years calls for other responses than those offered by the compassionate conservatism underpinning the millennium goals. Improving the lot of humanity is less about reducing poverty than about fighting inequality. For the poor to be less poor, the rich have to be less rich."
This is not an ideological argument. This is a substantive argument about the current state of global health. MSF responds to inequity by redistributing wealth in the form of medical and public health services. As a principled humanitarian organization, we maintain independence from political structures such as the UN Development Millennium Goals (Brauman, 2010).

Economy-generated environmental disasters

The heavy metal poisoning outbreak in northern Nigeria has drawn our attention to a type of situation that should not exist: the economy-generated environmental disaster. Again we are called upon to provide a measure of humanity in the form of medical care and public health assistance. And as we respond to economy-generated environmental disasters, we navigate a myriad of challenges. We must address the recurrent and chronic nature of such emergencies. And we must interface with the corporate sector (Calain, 2012; Kramer et al., 2012). Whether it is extractive industries poisoning waterways or agribusinesses appropriating essential agricultural lands for biofuels, MSF will struggle for neutrality between the forces of economic exploitation and development.
The La Mancha Agreement reaffirms that we do not propose global or comprehensive solutions. That is neither our purpose nor our expertise. However, as with the Access Campaign, we must develop our understanding of the societal determinants of health (Birn et al, 2009). We can set our sights on international economic institutions which systematically favour the interests of capitalist endeavors over the public good (Stiglitz, 2002). Similar to how we speak out against forces that deny our patients access to essential medicines, we can speak out against forces that deny our patients the societal determinants of health.
MSF exists within a global economic system that is at the root of disaster and injustice. We cannot reconcile this contradiction. However, we can take a principled approach to economy-generated environmental disasters. We can frame the dialog as fundamentally ethical, as one about our collective global health. We can remind ourselves and others that, ultimately, such situations should not exist.

References

Birn, A-E., Pillay, Y., & Holtz, T. (2009). Societal determinants of health and social inequalities in health. Textbook of international health: Global health in a dynamic world (3rd ed.). Oxford University Press, NY: pp. 309-364.

Bradol, Jean-Hervé (22 September 2011). "If you have to starve to death, better to do it in a war-torn country." http://www.msf-crash.org/en/sur-le-vif/2011/09/22/1601/if-you-have-to-starve-to-death-better-to-do-it-in-a-war-torn-country/

Brauman, Rony (06 October 2010). "Inequality seriously damages health." http://www.msf-crash.org/en/sur-le-vif/2010/10/06/395/inequality-seriously-damages-health/

Calain, Philippe (2012). What is the relationship of medical humanitarian organisations with mining and other extractive industries? PLOS Medicine, 9(8): e1001302

Calain, Philippe (2011). In search of the ‘new informal legitimacy' of Médecins Sans Frontières. Public Health Ethics, 5(1): 56-66.

Collier, Paul (2007). The bottom billion: Why the poorest countries are failing and what can be done about it. Oxford University Press.

Garrett, Laurie (2007). The challenge of global health. Foreign Affairs, 86(1): 14-17.

Harvey, David (2007). A brief history of neoliberalism. Oxford University Press.

Klein, Naomi (2007). The Shock Doctrine: The Rise of Disaster Capitalism. Knopf Canada.

Kramer, S., Soskolne, C.L., Mustapha, B.A., & Al-Delaimy, W.K. (2012). Revised ethics guidelines for environmental epidemiologists. Environmental Health Perspectives, 120(8): a299-301.

MSF (2012). Trading away health: How the U.S.'s intellectual property demands for the Trans-Pacific Partnership Agreement threaten access to medicines. MSF Access Campaign Issue Brief, August 2012: pp. 1-22.

Pringle, John D. & Cole, Donald C. (2012). The Nigerian lead poisoning epidemic: The role of neoliberal globalization and challenges for humanitarian ethics. In: Caroline Abu-Sada (Ed.) Dilemmas, Challenges, and Ethics of Humanitarian Action: Reflections on Médecins Sans Frontières' Perception Project. Montreal: McGill-Queen's University Press. http://mqup.mcgill.ca/book.php?bookid=2920

Rieff, David. (2002). A bed for the night: Humanitarianism in crisis. Simon and Schuster: NY.

Stiglitz, Joseph (2002). Globalization and its discontents. W.W. Norton & Company: NY, London.