Historicising Humanitarian Action. Synchronicity in Historical Research and Archiving Humanitarian Missions
Bertrand Taithe, Fabrice Weissman & Mickaël Le Paih
Born in France, Professor Bertrand Taithe studied at the Sorbonne with Professor François Crouzet and began his career as a historian of urban sociology. He later moved into the history of medicine and sexuality and is particularly interested in the history of humanitarian aid.Professor Taithe is a prolific author, Editor of the European Review of History, and Executive Director of HCRI. His publications are available here.
Graduated from the Institut d'Etudes Politiques de Paris, Fabrice Weissman joined MSF in 1995. He spent several years as logistician and head of mission in Sub-Saharian Africa (Sudan, Eritrea, Ethiopia, Liberia, Sierra Leone, Guinea, etc.), Kosovo, Sri Lanka and more recently Syria. He has published several articles and books on humanitarian action, including "In the Shadow of Just Wars. Violence, Politics and Humanitarian Action" (ed., London, Hurst & Co., 2004), "Humanitarian Negotiations Revealed. The MSF Experience" (ed., Oxford University Press, 2011) and "Saving Lives and Staying Alive. Humanitarian Security in the Age of Risk Management" (ed., London, Hurst & Co, 2016).
Head of Mission for MSF in Cambodia.
This article was published on December 1st, 2022 in Volume 4: Issue 2 of the Journal of Humanitarian Affairs.
This roundtable was convened on 5 July 2022 and built on five years of collaborative work in Cambodia and ongoing collaborations within the Centre de Réflexion sur l’Action et les Savoirs Humanitaires (CRASH) at Médecins Sans Frontières (MSF) between Bertrand Taithe, Mickaël Le Paih and Fabrice Weissman.
The central question raised in this discussion relates to two profoundly interlinked issues for humanitarian practitioners and organisations: the use of history for humanitarian organisations, and the need for them to preserve and maintain archives. Over the past twenty years many historians and humanitarian practitioners have rung alarm bells as to the state of humanitarian archives and their availability for research.Borton, J. (2016), ‘Improving the Use of History by the International Humanitarian Sector’, European Review of History / Revue européenne d’histoire, 23:1–2, 193–209. In the UK, the Charity Commission provides basic data on all regulated non-governmental organisations (NGOs)www.gov.uk/find-charity-information (accessed 13 October 2022).while the Campaign for Voluntary Sector Archiveswww.voluntarysectorarchives.org.uk/ (accessed 13 October 2022).attempts to raise awareness. In 2007, historians set up a research resource, in Birmingham, in NGO history;The ‘NGOs in Britain 1945–1997’ project ran from 2008 to 2011 (https://www.birmingham.ac.uk/research/moderncontemporary/research/ngo.aspx) and continued the work of the DANGO project (www.birmingham.ac.uk/research/moderncontemporary/research/dango.aspx) (accessed 13 October 2022).this has since ceased to be available online – reflecting acutely the fleeting nature of digital records.Hilton, M., McKay, J., Mouhot, J-F. and Crowson, N. (2013), The Politics of Expertise: How NGOs Shaped Modern Britain (Oxford: Oxford University Press). More recently, the University of Manchester has opened the Humanitarian Archivewww.library.manchester.ac.uk/rylands/special-collections/exploring/guide-to-special-collections/humanitarian-archive/ (accessed 13 October 2022).which collects the private papers and archives of individual humanitarians and smaller humanitarian organisations. Humanitarian archives have always been key to the sustainability of any claims of accountability and transparency,Roddy, S., Strange, J. M. and Taithe, B. (2015), ‘Humanitarian Accountability, Bureaucracy, and Self-Regulation: The View from the Archive’, Disasters, 39:S2, S188–S203.yet they have often disappeared as a result of neglect and lack of resources.
A recent example is how the archive of MERLIN, once a leading British medical NGO, has been flooded and damaged irretrievably. Many short-lived organisations have left limited records, which are in danger of disappearing altogether. More recent spontaneous ‘citizen aid’Fechter, A-M. and Schwittay, A. (2019), ‘Citizen Aid: Grassroots Interventions in Development and Humanitarianism’, Third World Quarterly, 40:10, 1769–80
Jumbert, M. G. and Pascucci, E. (eds), (2021), Citizen Humanitarianism at European Borders (London and New York: Routledge).and micro-NGOs have been engaging with the documenting and recording of their work for political and ethical reasons.Vandevoordt, R. (2019), ‘Subversive Humanitarianism: Rethinking Refugee Solidarity through Grass-roots Initiatives’, Refugee Survey Quarterly, 38:3, 245–65.
Lerner, G. F. (2021), ‘Migrant Stories between the Archive and the Garbage Dump in the Mediterranean’, in Skalle, C. E. and Gjesdal, A. M. (eds), Transnational Narratives of Migration and Exile. Perspectives from the Humanities (Oslo: Scandinavian University Press), pp.166–88.
Markodimitrakis, M. C. (2021), ‘Living in the European Borderlands: Representation, Humanitarian Work, and Integration in Times of “Crises” in Greece’ (PhD dissertation, Bowling Green State University). Tentative archivingAn example of this can be found in relation to recent rescue operations in Greece: https://medium.com/tag/refugees-in-greece/archive (accessed 13 October 2022).always stands for the realisation of what power the archives embody on who tells the story ultimatelySteedman, C. (1998), ‘The Space of Memory: In an Archive’, History of the Human Sciences, 11:4, 65–83.or whether a story ever gets told at all.Graham, L., (2021), ‘Recovery Projects: Haitian Memory, Humanitarian Response and the Affordances of the Digital Disaster Archive’, in Punzi, E., Singer, C. and Wächter, C. (eds), Negotiating Institutional Heritage and Wellbeing (Leiden: Brill), pp. 90–114.As Osborne put it, the archive is a means through which one can establish ethical and epistemological credibility.Osborne, T. (1999), ‘The Ordinariness of the Archive’, History of the Human Sciences, 12:2, p. 51.According to Osborne, the archive, as a deposit, gains this legitimacy by recording both details and mundane information, often pertaining to governanceIbid., p. 58, which remain open to interpretation. Of course, any archive is made of absences and silences: repressed voices which are only perceptible through the repressive apparatus – subaltern lives which never get fully recorded.Thomas, D., Fowler, S. and Johnson, V. (2017), The Silence of the Archive (London: Facet Publishing). But, in everything there is a crack, and information enters the archive accidentally; even systematic silencing leaves an imprint.Carter, R. G. S. (2006), ‘Of Things Said and Unsaid: Power, Archival Silences, and Power in Silence’, Archivaria, 61 (September), 215–33.Archival power is never complete.Mbembe, A. (2002), ‘The Power of the Archive and its Limits’, in Hamilton, C. et al. (eds), Refiguring the Archive (Dordrecht: Springer), pp.19–27.
Archives exist because of institutional desires to retain records that ensure continuity of governance or even historicity, but also because accidental circumstances force together organisations and people whose records can become an archive, such as a war, a legal process or a United Nations (UN) mission.Whiting, R. A. (2021), ‘The Archive as an Artefact of Conflict: The North Iraq Dataset’, Critical Military Studies, 7:4, 435–49.
Riaño-Alcalá, P. and Baines, E. (2011), ‘The Archive in the Witness: Documentation in Settings of Chronic Insecurity’, International Journal of Transitional Justice, 5:3, 412–33.
Ketelaar, E. (2009), ‘A Living Archive, Shared by Communities of Records’, in Bastian, J. and Alexander, B.(eds), Community Archives: The Shaping of Memory (London: Facet Publishing), pp.109–32.These tend to be more unstable and often more revelatory than perfectly curated records, but they are also more fragile, often un-resourced and sometimes subject to wilful acts of destruction.
The humanitarian archives (that is the archive of humanitarians and organisations purporting to act for humanitarian aims), when they exist, are no more virtuous than any other record depository of any organisation. They contain the same accounts, plans, personal papers and mundane material as that of any other institutional archives. They are prone to accidental deposits and deletions. They register power plays, conceptual variations and inconsistencies, debates and prejudices like any other organisational record. When they exist, more often than not, historians have had to complete them with oral history.Golding, B. and Hargreaves, J. (2018), ‘Humanitarian Nursing with Médecins Sans Frontières: Foregrounding the Listening Guide as a Method for Analysing Oral History Data’, Journal of Advanced Nursing, 74:8, 1984–92.Laurence Binet, who has compiled and edited from humanitarian archives a series of volumes on controversies that entailed public ‘speaking out’ by MSF, always had to go beyond the mere documents available to reconstitute chronologies or context.Binet, L. (2016), ‘Lessons from Speaking Out’, Human Rights Defender, 25:1, 32–3.The representativity of sources is variable over time and space as is their intentionality: some archives are curated for the purpose of reputation building,Baughan, E. (2021), Saving the Children: Humanitarianism, Internationalism, and Empire (Vol. 19) (Berkeley: University of California Press).many are fragmentary and accidental. Until the 1990s many humanitarian archives were intentionally closed and the late John Hutchinson mocked the similarity between Soviet and Red Cross archival practices at the time.Hutchinson, J. F. (2019), ‘Introduction: The Sacred Cow and the Skeptical Historian’, in Hutchinson, J. F., Champions of Charity: War and the Rise of the Red Cross (New York and London: Routledge), p. 2.Over the last thirty odd years, however, as they opened their archives for a wide range of research projects, humanitarian organisations such as MSF have faced new issues associated with the deployment of new technologies. Ironically as paper archives became more available, the new records became more fragmentary and archives became more fragile – digital records became more haphazard and ‘natural electronic archives’, to use Esteva’s definition,Esteva, M. (2008), ‘Formation Process and Preservation of a Natural Electronic Archive’, Proceedings of the American Society for Information Science and Technology, 45:1, 1–9.took time to emerge. More fundamentally, the use of records and the use of history has become more salient, not only in broad terms on what humanitarianism might be, for instance, or what the history of an organisation was,Davey, E. (2015), Idealism beyond Borders: The French Revolutionary Left and the Rise of Humanitarianism, 1954–1988 (Cambridge: Cambridge University Press).but also in developing operational thinking.
The premise of this roundtable was to take stock of recent works in historical writing and to explore archiving developments within an operational setting in MSF. We aimed to draw from this experience some preliminary issues and reflections which might help us engage with the manner in which history can help humanitarians think about their practices. A first pilot was the ambitious project led by Fabrice Weissman and Judith Soussan to write a ‘total history’ (histoire totale) of an MSF operation in Borno,The Borno historical study can be found on the website of CRASH: https://msf-crash.org/fr/publications/acteurs-et-pratiques-humanitaires/msf-france-dans-la-guerre-du-nord-est-du-nigeria (accessed 13 October 2022).northern Nigeria.Foucher, V. and Weissman, F. (2019), ‘La fabrique d’une “crise humanitaire”. Le cas du conflit entre Boko Haram et le gouvernement nigérian (2010–2018)’, Politique africaine, 156 :4, 143–70. The second focuses on the manner in which Mickaël Le Paih developed operational digital archiving practices that exceeded what MSF had previously encouraged its staff to maintain. Fabrice Weissman engages with this experience from the perspective of his own project to document a significant new oncology programme in Malawi in which MSF plays a central part. Bertrand Taithe has been engaged with both for the past five years in discussing how synchronous historical writingTaithe, B. and Le Paih, M. (forthcoming), Making Hepatitis C History.within missions and humanitarian operations can contribute to institutional stock taking (or capitalisation to use the MSF terminology) and to strategic awareness of the historical significance of recent developments in humanitarian medicine. Mickaël Le Paih and Fabrice Weissman, who now work on hepatitis C and cancer programmes respectively, are thus well placed to reflect on the use of history in contemporary humanitarian work.
Arguably some lessons arising from our experiences are specific to a medical NGO which has the peculiarity of having no institutional donors requiring reporting and documenting and which, nevertheless, has had a tradition of record keeping from its origins. The projects we are discussing and the specific work they are documenting are also unrepresentative of what many think humanitarian medical work might be: the archiving was not taking place in a war or sudden disaster setting; the projects have developmental features rather than urgent response aspects. Yet, because the development of operational archives is set against broad strategic aims, we believe that these case studies enlighten the issues faced by humanitarians who consider a historical perspective grounded in archival work useful for humanitarian practice. The power plays and negotiations these large missions entail, the diversity of social and economic partners, the complexity of engaging with ministries of health (MOH), universities and research institutes, pharmaceutical industries and international networks all add to the complexity of establishing archives which might enable historical thinking in the present and future of these missions.
Bertrand: Fabrice, a rapid introduction of your humanitarian history?
Fabrice: Very briefly. I have been working with MSF for over 30 years. I began as an intern in 1992 working on Populations in Danger.Jean, F. (1992), Populations en Danger (Paris: Hachette).I have worked for CRASH and in the field as logistician, project coordinator – which is my favourite role – and head of mission. I have been based in Malawi for the last two years, alternating between the coordination of MSF emergency responses (COVID-19, floods, cholera outbreaks) and CRASH work.
Mickaël: I began in the voluntary sector when I was a teenager. I studied with Bioforcewww.bioforce.org/en/ (accessed 13 October 2022).in 1993 and worked on a humanitarian project abroad for the first time with Pharmaciens Sans Frontières in 1994 as logistician.Pharmaciens Sans Frontières France was taken over by ACTED in 2009 following the end of its activities, other national branches still exist in Switzerland (https://psf.ch/), for instance.I joined MSF in 1999 and I have been working mostly in head of mission roles. Between 2012 and 2016 I worked with ECHOhttps://reliefweb.int/organization/echo (accessed 13 October 2022).and was simultaneously elected to the board (Conseil d’administration) of MSF France before going to Cambodia for four and a half years as head of mission. Since my return in 2021, I have continued to work on hepatitis C with a partnership including the Drugs for Neglected Diseases Initiativehttps://dndi.org/about/ (accessed 13 October 2022).(DNDI),Chatelain, E. and Ioset, J-R. (2011), ‘Drug Discovery and Development for Neglected Diseases: The DNDi Model’, Drug Design, Development and Therapy, 5, 175–181. doi:10.2147/DDDT.S16381.
Coriat, B., Abecassis, P., Alessandrini, J-F., Coutinet, N. and Leyronas, S. (2019), ‘Developing Innovative Drugs through the Commons Lessons from the DNDi Experience’, https://hal.archives-ouvertes.fr/hal-03408089/.and the Hepatitis C PACT.https://dndi.org/publications/2021/hepatitis-c-pact/ (accessed 13 October 2022).
Bertrand: As for myself I am a historian of humanitarian aid. I have been working with CRASH for a while and with MSF for about 22 years, I co-founded the Humanitarian and Conflict Response Institute (HCRI) in 2008 with colleagues at the University of Manchester.HCRI was founded by Peter Gatrell, Tim Jacoby, Tanja Müller, Tony Redmond, Bertrand Taithe and James Thompson. Bertrand Taithe directed it between 2008 and 2021 (www.hcri.manchester.ac.uk, accessed 13 October 2022).What interests me in both your careers is the fact that you have a background in humanitarian logistics. Could we expand on this a little?
Mickaël: These non-medical roles have a privileged position in the field: they contribute to building up projects alongside medical staff. The responsibilities in logistics or administration lead you to grasp the humanitarian context and understand the scope of what is necessary to deliver humanitarian assistance.
Bertrand: From the historiographical perspective, logistics tends to be under-studiedDaud, M. S. M., Hussein, M. Z. S. M., Nasir, M. E., Abdullah, R., Kassim, R., Suliman, M. S. and Salu-Din, M. R. (2016), ‘Humanitarian Logistics and its Challenges: The Literature Review’, International Journal of Supply Chain Management, 5:3, 107–10.and there is little written on or by logisticians. Historians have paid less attention as to what was delivered on the ground with only few recent exceptions.Rodogno, D. (2022), Night on Earth: A History of International Humanitarianism in the Near East, 1918–1930 (Cambridge: Cambridge University Press).Yet when one looks at one of the first attempts to compile a historical and archival manual to humanitarian work – the one edited by a German social worker, Quaker convert, Hertha KrausBussiek, B. (2003), ‘Hertha Kraus: Quaker Spirit and Competence. Impulses for Professional Social Work in Germany and the United States (Deutschland)’, Hering, S. and B. Waaldijk, B. (eds), History of Social Work in Europe (1900–1960): Female Pioneers and Their Influence on the Development of International Social Organizations (Wiesbaden: VS Verlag für Sozialwissenschaften), pp. 53–64.for Quaker and Mennonite volunteers who were about to be deployed in WWII EuropeKraus, H. (1944), International Relief in Action, 1914–1943 (Scottdale, PA: The Herald Press).– one finds that much of the book is a history of humanitarian logistics in the previous forty years in humanitarian aid. She attempted to transfer knowledge across crises using archives produced by humanitarian initiatives then. It may be a lesson to us all. You mentioned the role of logisticians in knowledge transmission Mickaël, could you expand on this?
Mickaël: I linked it to logistics but of course every post has a responsibility in transmitting knowledge across professions. In MSF it is part of the DNA. If we go back into the history of MSF, in the 1980s, you see that Jacques Pinel, a pharmacist, is the first who set up medical kits and structured logistics for MSF in the Thai border campsVidal, C. and Pinel, J., (2011), ‘MSF “Satellites”: A Strategy Underlying Different Medical Practices’, in Vidal, C. and Bradol, J.-H. (eds), Medical Innovations in Humanitarian Situations (Paris: MSF), pp. 22–38.
Taithe, B. (2016), ‘The Cradle of the New Humanitarian System? International Work and European Volunteers at the Cambodian Border Camps, 1979–1993’, Contemporary European History, 25:2, 335–58.which was at the heart of the organisation’s expansion and increasing ambitions. In this context, logistic ambition played a central role in the practice and history of MSF.
Bertrand: Fabrice, you have mentioned that when you first arrived in Malawi, the well-established mission you joined had little in terms of official records or archives locally. So, I guess, one of the key questions is: how did this transmission of knowledge take place? Was it informal or accidental and what part did staff play?
Fabrice: When I arrived in Malawi in 2020, I found empty shelves and new computers with poorly organised hard drives and nothing dating from two or three years beforehand. Yet MSF has been present in Malawi for more than thirty years, assisting Mozambican refugees up to the mid-1990s, responding to the disastrous HIV epidemic as well as to recurrent emergencies (cholera outbreaks, earthquakes, floods, etc.). Yet when I looked for archives on previous MSF interventions during the floods and cholera outbreaks of the previous ten years, I found nothing. As coordinator of the emergency response for the 2022 floods, I wanted to know what MSF had done previously in the area I was intervening, to compare the scale of the disasters, etc. I managed to retrieve few documents from previous expatriates, whom I contacted by mail through my personal network. But it is primarily thanks to key Malawian staff, who had kept operational documents on their personal hard drives and who remembered the mission, that I managed to reconstitute a little of the history of previous interventions. Institutional memory is fleeting in MSF. There was no policy on archiving operational documentation. Some coordinators or heads of mission who are very organised might leave very comprehensive and structured archives (including some end of mission reports, situation reports, assessment reports, visit reports) summarising in analytical and accessible way the history and challenges of the mission. But it is haphazard. When Laurence Binet worked on controversies, she interviewed people, she extracted documents and synthesised records to create an archive,www.msf.org/speakingout (accessed 13 October 2022).or when the CRASH produced a dossier on HIV,https://msf-crash.org/en/publications/medicine-and-public-health/aids-new-pandemic-leading-new-medical-and-political (accessed 13 October 2022).they produced a kind of historical perspective that is very useful.
Bertrand: There is more talk now of how the historical records of past missions may be used to help thinking through future ones at MSF, or even how they can affect wider policies in the organisation. You were yourself involved in an internal evaluation scheme, an interdisciplinary network dedicated to evaluation and feedback (RIDER)Réseau Interdisciplinaire Dédié à l’Evaluation et au Retour d’expérience / Interdisciplinary Network for Evaluation and Lessons-Learned Exercises, https://evaluation.msf.org/rider-about-us (accessed 13 October 2022).and you presented it as a project of ‘capitalisation’, a stocktaking of historical precedents. Could you define what capitalisation means precisely in the MSF context?
Fabrice: François Enten, an anthropologist who worked for MSF, distinguishes capitalisation from other forms of institutional memory, such as guidelines, which summarise know-how (how to deal with a cholera outbreak, how to react to a massive displacement of populations, how to set up a nutritional centre, etc.). Capitalisation is the history of the different moments of trial and error that eventually contributed to produce the knowledge compiled in guidelines.
Bertrand: Could you say something about writing what could be learnt from the Borno experience in historical terms?
Fabrice: We had in mind to write a total history of the Borno mission in Northern Nigeria. We wanted to understand why it had failed in 2016 to detect the famine which unfolded in the displaced camps where the Nigerian army had forcibly regrouped rural population during its counter-insurgency campaign against Boko Haram and its offshoots.Loewenberg, S. (2017), ‘Famine Fears in Northeast Nigeria as Boko Haram Fight Rages’, The Lancet, 389:10067, 352.But we wanted to avoid being teleological about it by beginning with the end. We hoped to reconstitute all the parameters of the operation. Our inspiration was a little to emulate a flight simulator with all the parameters of a flight, including weather conditions and the peculiarities of a particular plane. We wanted the reader to have the same information as the persons who were in charge at the time so as to assess their decision from their perspective. But, of course, flight parameters are limited and mostly quantifiable, while a humanitarian mission has an infinite number of parameters and is far more complex than a Boeing 737. We got lost in the layers of this story because everything presented a problem: human resources, finance and fraud, government-imposed constraints, security, etc. To tell this story became incredibly complex and the narrative went in every direction. It is not easy to read and, in the end, it comes across more as a primary source that needs to be interpreted, rather than a narrative history. So, when one attempts to write the history of a project one should take a particular perspective on it. Whether one writes a medical history, a financial and logistical history, a human resources history, a political history, a bureaucratic history or whatever, one has to choose which story to tell.
Bertrand: What I drew from reading this case study was a cultural history. What your account really cast a light on, for me, was how a chasm appeared between the field and HQ, that the field staff could not translate what they were seeing in terms that would be plausible and intelligible for the headquarters. I thought that was very interesting on different levels, but also something an NGO could seek to address.
Fabrice: Yes, you can definitely read it that way.
Bertrand: Mickaël, five years ago we began a dialogue on archiving a mission as it developed, and we took a broad approach. The hepatitis C project seemed particularly interesting in the sense that it presented, it seems to me, a fairly existential question for a medical humanitarian organisation like MSF. So, archiving a complex mission like this one was a major undertaking. Of course, this archive is not complete, we do not have documents or archives from the Cambodian MOH, but it represents a new initiative in archiving terms for MSF.
Mickaël: To start with, I want to return to what Fabrice said about how we write history. I believe that for the Cambodian hepatitis C project we have managed to document/archive coherently the project because of the nature of the existing diagnostic and treatment tools. The strategies of decentralisation and simplification of the care model enabled us in return to simplify the way we could archive and build a narrative of the mission as well. The investment on scientific-based knowledge generation through data management and epidemiology led the project to go beyond archiving it for MSF, we published about nine papers.For instance: Lynch, E., Falq, G., Sun, C., Bunchhoeung, P. D. T., Huerga, H., Loarec, A., Dousset, J-P., Marquardt, T., Le Paih, M. and Maman, D. (2021), ‘Hepatitis C Viraemic and Seroprevalence and Risk Factors for Positivity in Northwest Cambodia: A Household Cross-sectional Serosurvey’, BMC Infectious Diseases, 21:1, 1–9.
Walker, J. G., Mafirakureva, N., Iwamoto, M., Campbell, L., Kim, C. S., Hastings, R. A., Doussett, J-P., Le Paih, M., Balkan, S., Marquardt, T., Maman, D., Loarec, A., Coast, J. and Vickerman, P. (2020), ‘Cost and Cost-Effectiveness of a Simplified Treatment Model with Direct-Acting Antivirals for Chronic Hepatitis C in Cambodia’, Liver International, 40:10, 2356–66.
Zhang, M., O’Keefe, D., Craig, J., Samley, K., Bunreth, V., Jolivet, P., Balkan, S., Marquardt, T., Dousset, J-P. and Le Paih, M. (2021), ‘Decentralised Hepatitis C Testing and Treatment in Rural Cambodia: Evaluation of a Simplified Service Model Integrated in an Existing Public Health System’, The Lancet Gastroenterology & Hepatology, 6:5, 371–80.
Bertrand: It seems to me that this simplification narrative is the endpoint and not where you started. There were some hypotheses that happened to be verified and converging circumstances, but an equally ambitious mission might have failed. In Malawi, Fabrice, there is a campaign against cervical cancer and you are perceiving this ongoing project as quite challenging to account for.
Fabrice: The cervical cancer project in Malawi was launched in 2018 with the ambition to reduce the gap with rich countries. In Western countries, cervical cancer has become a rare disease with a reasonably good prognostic. It is not the case in Malawi, where incidence rates of cervical cancers are among the highest in the world and where cervical cancer is synonymous with a long, painful and lonely death. Oncology is a field in which MSF has little experience and which is globally neglected by national and global health policies in Africa, which are primarily geared towards infectious disease and malnutrition. To a large extent, the Malawi cervical cancer project is an innovation for MSF, for Malawi and for the Global Health landscape. We would like to keep a record of this experience to be able to share it, to change our practices and perhaps to feed into policy changes in countries in which we work. So, we needed a description of our project which would map the transformation of our practices and of our partner health providers locally and internationally. When you start thinking about it, it is a very ambitious and complex project. Malawi is one of the least medicalised countries in Africa: it has less than 4 physicians per 100,000 inhabitants, compared to 23 per 100,000 for sub-Saharan Africa globally and close to 400 per 100,000 in Europe. There is only one medical school (opened 30 years ago), with no curriculum for oncology or histopathology. No radiotherapy, only one public laboratory for histopathology and only two places for chemotherapy. Screening activities were introduced in 2005, but coverage rates are ridiculously low, as is the coverage of the vaccination against HPV (a virus associated with a very high-risk of cervical cancer). Up to 50 per cent of patients diagnosed are at an incurable stage of the disease and in need of palliative care, which is grossly under-resourced.
So, the project involves adapting complex biomedical technologies to a resource-poor environment. It also involves behaviour changes among the wider population in relation to screening and among medical staff in relation to patient-centred care. It also involves negotiating with a multitude of partners and with many levels of the MOH, patients’ associations, which may or may not exist and which would need to help families socially, etc. It also involves the university hospital of Blantyre, NGOs working in palliative care, private for-profit partners who offer access to radiotherapy, cash transfer with an NGO specialist, etc. So, to go back to Mickaël’s phrase, it is multi-layered. Yet, I think that one of the historical perspectives one might follow, beyond the clinical care dimension, is one that is patient-centred. Patient-centred care is a kind of mantra, but here it is the object of myriad initiatives which are worth documenting. Another history could concern decision makers. How was the project piloted through so many uncertainties? Documenting this history would be from the coordination point of view and from the perspective of partners, which would include patients, because they are partners when undergoing such heavy treatments.
Bertrand: I would like to come back to a few things. The first one is the metaphor of flight simulator, which seems to me to be a recurrent image in management discourses. Peter Walker and others who discuss professionalisation in humanitarian work often make reference to the transformation of the air industry, from accident prone to accident averse, through the systematic and open analysis of errors and near misses.Cranmer, H., Chan, J. L., Kayden, S., Musani, A., Gasquet, P. E., Walker, P. Burkle, E. M. and Johnson, K. (2014), ‘Development of an Evaluation Framework Suitable for Assessing Humanitarian Workforce Competencies during Crisis Simulation Exercises’, Prehospital and Disaster Medicine, 29:1, 69–74.I wonder how useful it is to think about handling complexity? Mickaël, from your ‘simple’ hepatitis C diagnostic and treatment mission you have moved on to another level of complexity in your work which we would also like to document.
Mickaël: Indeed, our tendency at MSF is to try to achieve a greater global ambition once we have learnt from the proof of concept of a project, for example how to screen a given target population, how to make a treatment accessible, and replicate where relevant. Nowadays we are seeking sustainable solutions in the context of donor funding-fatigue – the most strategic work within the Hepatitis C PACT initiative is to address sustainable health financing for countries with a high burden of HCV disease. We would like to deliver real changes and practical solutions for ministries of health which have not yet delivered treatment of hepatitis C. We have chosen to articulate this ambition by partnering with organisations with similar roles. But are such ‘global health’ ambitions delivering tangible results by associating with similar organisations? Is disembodied advocacy the solution to access to care problems we see? How could we go beyond our usual circle of influence? From archive-building perspectives, yes, we indeed need to document this rare experience to make informed choices in the future, for example on the content of partnerships and with which partners we can have the most concrete impact. These are histories we need to learn from.
Bertrand: To return to the Cambodian project, the mission was to develop screening, to identify treatments and to deliver curative solutions thanks to an unusually effective ‘magic bullet’ – of a kind one does not encounter much in the history of medicine [sofosbuvir, a drug developed by Gilead] – at a price that campaigners, including from MSF, managed to bring down to a fraction of its initial costing. At the end of the MSF mission, there was the announcement of an MOH national plan for hepatitis C. MSF then withdrew from Cambodia for the first time in nearly fifty years. Then what happened?
Mickaël: Well, perhaps one of the few good things the current partnerships enabled is that after the mission closed, MSF kept in contact with MOH colleagues in Cambodia and, more widely, the government. They are aligned with the Hep C PACT initiative that is seeking financing for sustainable solutions. As a result of our continuous discussions with the top levels of the ministry, they may release domestic funds. For 2023, we are talking about a million dollars, which is a lot, and yet not nearly enough. It would be significant, though, because it would be a rare occurrence of the Cambodian government investing in a national programme campaign without financial support from international donors.
Bertrand: For MSF and humanitarian medicine, a project on oncology or the elimination of hepatitis C in countries where it is rife but under-diagnosed, seems to me to be, if not an entirely new departure, as tuberculosis and chronic treatments of HIV were already challenging notions of humanitarian medicine as being only for short-term emergencies, at least something of historical significance. Do you agree?
Mickaël: Indeed, we are currently working on how to finance a health programme (in this case a hepatitis C elimination programme) in lower income countries that do not receive international donor support. We may be revisiting old ground, though, like in Guinea at the end of the 1990s when we implemented long-debated cost-recovery projects.Van Damme, W. (1998), Medical Assistance to Self-settled Refugees; Guinea, 1990–96 (Antwerp: ITG Press).So, I do not know if this is a new cycle in humanitarianism, but the fundamental point of your question Bertrand is to determine for MSF: to what extent do we want to engage routinely in such a space, and should health financing be part of our project objectives? How to use history to help the organisation to judge better its role? These are major questions we need to think through. We need to access archives of past arguments and to keep archiving on-going actions as well.
Bertrand: In terms of archiving practices, what does this documenting represent? In the past, MSF generated good paper records, often well-preserved, from missions and, in particular, at the end of each mission,Balabeau, A. (2002), ‘Gestion des archives chez Médecins Sans Frontières: une approche records management’ (diplome, Haute école de gestion de Genève).when the mission lead would write a report which usually explained how he or she had salvaged the mission – MSF managed its self-critique even in the archives.Rambaud, E. (2015), Médecins Sans Frontières : Sociologie d’une institution critique (Paris: Dalloz).Prior to mobile phones or the internet of course, as Mark Duffield pointed out,Duffield, M. (2018), Post-Humanitarianism: Governing Precarity in the Digital World (Cambridge: Polity).humanitarian practices were very differently wired and correspondence played a major role and left traces of exchanges which are now often untraceable. There were then some gaps in terms of who had a voice in the archive; national staff and logistical support often featured very little. In Cambodia we recorded a few of these voices insofar as possible and asked them to give an open account of their time in the mission if they wished to. How are we to deal with archives in the digital era?
Fabrice: We are of course all acutely aware of the disappearance of electronic/digital records, but to talk of disappearing archives is to presume that they existed in the first place and were then lost. Operational documents often do not exist at all. MSF is independent from institutional donors and not having to produce proposals and reports means that many documents are not now produced. We end up with limited sources and many regular reports do not mention problems: they list activities and intentions but not problems. This obviously points to the need to use oral history, which is a richer source and gives a sense of the reality. As to the issue of voices, with time, the difference between national and international staff is becoming blurred. At managerial level one finds national staff in project leadership roles. What kind of questions did you ask ancillary staff?
Bertrand: We asked simple questions as to what people were doing and why. These questions elicited open responses and some stories which were interesting. Some showed for instance that they were uncomfortable, or even afraid, doing fly-in screening in isolated rural areas. They told how they had been threatened by an alcoholic armed with a long machete. More widely, some had a history with MSF which predated the mission and gave them comparative perspectives. Mickaël organised an itinerant exhibition on the history of MSF work in Cambodia which in turn elicited many witnesses to recall how this humanitarian history was really theirs. It is not always easy to replicate, and it remains impressionistic. But for many long-standing humanitarian missions, recording these voices is a necessity, it seems to me. But to go back to the practical issues of archiving, Mickaël could you explain what you did?
Mickaël: What I realised very early on is that if we wished to document either the project as a whole or layers of it, we had to develop a common method. From when? Which email or which report should be archived? Which layer of management should be involved? Who? Why? When? and How? were the essential questions we had to answer early on. This is something to which we had to return a number of times over the duration of the project. The archives we now have reflect somewhat the narrative we have built over time, but, of course, there are gaps: some colleagues did not contribute and documents that mattered may not have made it to the drives. The fact that we now use WhatsApp, Teams, Messenger, Facebook, etc. in our everyday work made some digital records difficult to capture. Agreeing on what we wanted to archive is a central point in establishing the historicity of missions. We agreed on a filing system which was open to all level-9 staff and above – a drive which was open to them (with the exception of HR, obviously). Starting in 2016, I only realised two years later that MOH staff used Telegram for most of their communications. Archiving methods could not prevent loss of documentation coming from them and therefore we started to archive documents from the Telegram application as well.
Bertrand: Of course, archives are by nature incomplete and archiving will always be a choice – so making a choice and being consistent is a political decision about what you want to recall.
Fabrice: And what discipline it requires!
Mickaël: We need indeed to develop this archiving culture. We were lucky in Cambodia, we had little staff turnover, but we had losses due to carelessness. We kept notes of meetings and minutes and perhaps because we did so much that was electronic-based it ended up being somewhat easier.
Bertrand: These losses will always be there. The archives created in Cambodia were still primarily decisional, but they cover many of the gaps you identified, Fabrice, and certainly compensated for institutional amnesia.
Fabrice: But one needs some authority to get this done.
Mickaël: Well, the mechanics of archive building are structuring people’s responsibilities and ownership of the project. We can joke and have fun in our everyday emails and meetings – we should always remember the famous phrase of François Jean ‘these are serious and responsible people who have fun working’ – but we are also indeed accountable. Documenting missions has also been used to feed accountability narratives for ever-expanding structures – but we can change the narrative and archive for historicity alone, for historical authenticity, not to justify the growth of the organisation.
Bertrand: The archive you constituted is exceptional because it is rich while still being operational and commonplace.
Fabrice: Is it normal, in fact? But what about the ethics of making people contribute to the archives?
Bertrand: The archive as a common good is something that people understand, but issues of data confidentiality exist also in the archive and consenting to becoming part of an archive is something we asked about before recording oral history. Beyond this, for me, the wider question is why others are not archiving at that level? From an ethical perspective one should certainly ask the question too.
Fabrice: On ethical grounds, since aid is not subject to political accountability, such as elections – though local authorities are clearly stricter – this makes us more accountable and makes it our duty to be reflexive. It is undoubtedly an ethical responsibility.
To cite this content :
Bertrand Taithe, Fabrice Weissman, Mickaël Le Paih, “Historicising Humanitarian Action. Synchronicity in Historical Research and Archiving Humanitarian Missions ”, 30 juin 2023, URL : https://msf-crash.org/en/humanitarian-actors-and-practices/historicising-humanitarian-action-synchronicity-historical
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