Marie-Pierre Allié 
President of the French section of Médecins Sans Frontières

Between 2004 and 2008, nine members of Médecins Sans Frontières were killed in the course of their missions in Afghanistan, Central African Republic and Somalia. In 2008 and 2009, several MSF sectionsMSF is an international movement with nineteen sections, overseen by boards of directors, and grouped into five operational platforms in France, Belgium, Holland, Switzerland and Spain. had to leave Niger and the north of Sudan because the authorities had either suspended their activities or issued them with a deportation order. In 2009, under threat of expulsion from Sri Lanka, MSF signed a Memorandum of Understanding obliging it to remain silent—but still did not gain access to the combat zones. In Yemen, in January 2010, the organisation was forced to withdraw public statements deemed inaccurate and insulting by the government in order to keep its activities running.
Should we conclude from these events that the “humanitarian space” is shrinking, as many observers of the humanitarian scene have been claiming in recent years? NGOs, United Nations agencies and donors are unanimous in deploring a “growing tendency to close the door to humanitarians, preventing them from helping victims”.Echo, “The humanitarian space under pressure”, http://ec.europa.eu.

 This would be in stark contrast with a so-called “golden age” when humanitarian actors supposedly occupied “a special position on the international political chessboard, within a privileged space, untroubled by the geostrategic and political considerations of governments”.“L’espace humanitaire en danger”, Université d’automne de l’humanitaire, 4th édition. 28–30 Sept. 2006: proceedings.

 Since then, according to United Nations (UN) agencies, their space has been eroded by the “blurred distinctions between the roles of military and humanitarian organisations; political manipulation of humanitarian assistance [and the] perceived lack of independence of humanitarian actors from donors or from host governments”.Quoted in “Humanitarian action under siege”, OCHA, 18 Aug. 2009.

Since the end of the 1990s, MSF has also been vehemently denouncing the harm caused by the “blurring of lines”, heightened with the revival of western military interventionism in the wake of 9/11, the development of international criminal justice and the integration of the aid system in the United Nations’ political strategies. With their actions now equated with military, judicial and political forms of interventionism, NGOs such as MSF would be encountering increasing hostility in developing countries. They would be seemingly faced with a reaffirmation of sovereignty on the part of post-colonial states benefiting from the diplomatic and economic support of emerging powers.
This book does not set out to deny the consequences of belligerents using humanitarian rhetoric, or the fact that western aid organisations come up against specific difficulties in countries where international forces are deployed. But it does argue the impact of this environment on aid operations, if only on the grounds that the global volume of humanitarian assistance continues to grow. Between 1988 and 2008, the humanitarian aid budget increased ten-fold to reach 11.2 billion US dollars.Don Hubert, Cynthia Brassard Boudreau, “Shrinking humanitarian space? Trends and prospects on security and access”, The Journal of Humanitarian Assistance, 24 Nov. 2010.

 MSF’s own operational spending rose from 260 million euros in 2001 to 634 million in 2010, most notably in Niger and Darfur (Sudan) where the organisation carried out two of the largest missions in its history. Furthermore, evoking a “golden age” in which aid actors were able to realise their ambitions unfettered is to underplay the very real difficulties encountered during the forced displacements in Ethiopia in the 1980s, for example, or, in the 1990s, the massacres in ex-Yugoslavia and the genocide in Rwanda.
Contrary to the “shrinking space” theory—which frees aid actors from any responsibility for conquering and defending their own sphere of activity—there are no legitimate perimeters to humanitarian action, valid at all times and in all situations, which become clearly visible once the mists of “military-humanitarian confusion” have lifted and humanitarians are protected from any political fallout. There is, however, a space for negotiation, power games and interest-seeking between aid actors and authorities. MSF’s freedom of action is not rooted in a legal and moral “space of sovereignty” that simply needs to be proclaimed in order to be automatically acknowledged and respected. It is the product of repeated transactions with local and international political and military forces. Its scope depends largely on the organisation’s ambitions, the diplomatic and political support it can rely on and the interest taken in its action by those in power.
This book follows on from the Populations in Danger series initiated by MSF under the direction of François Jean in 1992, and has been inspired by MSF’s in-house debates on the evolution of its freedom of action. Eight years after the publication of In the Shadow of Just Wars,Fabrice Weissman (ed.), In the Shadow of Just Wars: Violence, Politics and Humanitarian Action, London: Hurst & Co. Publishers Ltd, 2004. it examines the precept that the political exploitation of aid is not a misuse of its vocation, but its principal condition of existence. If this is the case, how can MSF ensure that the negotiations it undertakes will result in an agreement it can live with? Because acknowledging that humanitarian aid is only possible when it coincides with the interests of the “powers that be” does not have to mean giving way to political forces. We are not looking to replace a school of thought that sees the humanitarian principles—independence, neutrality and impartiality—as a magic key to the humanitarian space with an attitude of ultra-pragmatism. Nor are we looking to transform adaptation to circumstance into an operational policy mantra.
But how can we judge whether a compromise is acceptable? We felt that this question should be examined in the light of MSF’s concrete experience of negotiations by analysing the choices made by the organisation in specific situations of confrontation and collaboration. In doing so, the authors of this book have drawn on the association’s archives, interviews with key protagonists and on their own experience, since most of them have worked with MSF in the field.
The chapters in the first part of the book describe specific negotiation situations. They contain a main case study and, in some cases, shorter pieces which help shed more light on the issue in question.

In each of these narratives, the authors highlight the shared and diverging interests of MSF, as a humanitarian medical organisation, and the political actors with whom it has to deal. What are these interests and what are the different motivations behind each party’s action? For the organisation, they may involve providing impartial assistance to the direct victims of a conflict (Pakistan, Afghanistan, Palestinian Territories, Somalia, Sri Lanka, Ethiopia) and raising awareness of the violence of war in the hope of helping to attenuate it (Yemen, Ethiopia, Sri Lanka, Somalia, Palestinian Territories). They may also involve responding to the consequences of neglected public health problems (recurrent epidemics in Nigeria, malnutrition in India or AIDS in South Africa) or caring for populations who have been deliberately excluded from social and healthcare systems (migrants in France and ethnic minorities in Myanmar).
These ambitions may then come up against those of an army or a rebel movement using humanitarian aid as a means of gaining local or international legitimacy (Afghanistan, Pakistan, Palestinian Territories); those of foreign governments or international organisations seeking to isolate or strengthen a regime (Afghanistan, Somalia, Pakistan, Palestinian Territories) or those of armies or insurgents who make no distinction between combatants and non-combatants (Sri Lanka, Ethiopia, Yemen, Pakistan). MSF’s objectives may also come up against those of authorities who are more concerned by the political consequences of an epidemic than by its consequences on health (Nigeria, South Africa); those of a government seeking the services of health workers to help it manage a system that excludes “undesirables” (Myanmar, France and Sri Lanka) or the ambitions of activist movements defending their vision of society (South Africa, India).

It is from such encounters of interests, sometimes opposing, sometimes convergent, that compromises are born. The justifications for these compromises need to be examined in context, but also within their broader environment. This is determined by the organisation’s ambitions, the lessons it draws from its experiences in similar settings, and how it interacts with the other actors involved in managing armed conflict situations or health crises.
The chapters in the second part of the book describe the way MSF’s choices have evolved in those categories of intervention that first led to the creation, in 1971, of an organisation made up “exclusively of doctors and members of the health sector” whose activity consists in assisting “victims of natural disasters, collective accidents and situations of belligerence”.MSF’s first charter, 1971. MSF’s objectives and practices in these contexts have been altered by the ideological confrontations it has taken part in during its existence, and by the way it sees its role within the organised international community—governments, interstate organisations and transnational NGOs. In their respective chapters, Fabrice Weissman, Jean-Hervé Bradol and Rony Brauman explain the way MSF has evolved over forty years of wars, public health policies and natural disasters.
What does this journey through the contemporary narratives and long history of MSF tell us?

Everything is Open to Negotiation

As the interview with Benoît Leduc on MSF’s project in Somalia demonstrates, “everything is open to negotiation”. No parameter is fixed from the outset: the safety of personnel, the presence of expatriates, MSF’s intervention priorities, the quality of the assistance provided, control over resources, etc. They are all the result of concessions, some justified by harsh realities—employing armed guards, for example— and others by their temporary nature, such as the remote management of programmes. Negotiation frameworks do not include universal markers indicating the line that must not be crossed; and MSF must therefore pay attention to the developing dynamic of each situation and to its own ability to revoke compromises that were only acceptable because they were temporary.

Judge for Ourselves

In negotiations concerning MSF’s action, the aim is to talk freely with the population, monitor the aid chain and reassess the situation as it develops. This is necessary for MSF’s teams to make independent judgements. Whatever the situation, it is essential to know which policies the organisation is supporting: thus, although France’s policies for excluding migrants have real consequences on their health, they are accompanied by a system of healthcare safety nets that the government encourages NGOs to help it manage. But by treating people without challenging the political and social origins of their exclusion, is MSF not confining itself to the role expected of it by the authorities? In other words, playing into their hands by looking after the people deliberately rejected at the margins of society? This is the question raised in the chapter “Managing the ‘Undesirables’”, which discusses the way MSF’s ambitions have changed regarding its programmes in France.
In extreme situations, MSF’s ability to judge is what enables it to keep a distance from “that blurry, but very real, line beyond which assistance for victims imperceptibly turns into support for their tormenters”.Rony Brauman, president’s report, 1987, MSF-France.

 The organisation’s experiences over the years are clear evidence of this, for example, its inability to account for the use of assistance provided to Cambodia in 1980; participation in a lethal policy of forced displacements in Ethiopia in 1985; and the horror of serving as bait and facilitating the work of the executioners in Zaire/ Democratic Republic of Congo in 1996–1997.See after, Fabrice Weissman, “Silence heals...”, pp. 177–97.

 In such circumstances, the objective for a humanitarian doctor, as Paul Ricoeur reminds us in the book Médecins tortionnaires, médecins resistants,Paul Ricœur, “Foreword”, Medical commission of Amnesty International’s French section, and Valérie Marange, Médecins tortionnaires, médecins résistants, Paris: La Découverte, 1989. is to avoid the “crude [contradiction] between treating a patient and declaring a person sentenced to death to be fit enough to die. […] It is not through his medical expertise that the doctor will find a way out, but in his moral and political judgement”.
But however painful this dilemma may be, it is never posed in such clear terms at the time. The case study on Sri Lanka, “Amid All-Out War”, shows how difficult it is for MSF to be sure of its decisions, or even of its observations: isn’t the real purpose of the internment camps of the Tamil population to slowly wipe this population out? How can we be sure that MSF’s hospital is receiving the most serious cases? Is its hospital not simply being used as a propaganda smokescreen by a government seeking to give an appearance of normality? Are the patients being selected according to their supposed political affiliation? These were the questions raised by MSF, which had become the regime’s de facto public health auxiliary.

Keep Silent?

The case studies reveal that, over the years, MSF has often opted to sacrifice its freedom of speech. The organisation decided to keep a “low profile”, for example, on the bombings it witnessed in Yemen and chose to keep quiet about the consequences of the war in Sri Lanka. In Myanmar, it also decided to say nothing about the constraints the regime was imposing on it, described in the chapter “Golfing with the Generals”.
Does refusing to speak out about violence against civilians mean MSF has lost faith in the impact of its statements? In the chapter, “Silence Heals…”, Fabrice Weissman analyses the complex relationship between MSF and its public positioning—aimed at influencing the course of a conflict or health crisis or preventing the misappropriation of aid—in an international context marked by the Cold War, the collapse of the bi-polar world order and the development of international criminal justice and so-called humanitarian wars.

Know Our Place

For MSF, negotiating with actors with whom it shares interests, however temporarily, means being willing to adjust its own plans and ambitions. Unless one party’s interests are subsumed by the others, an agreement means compromise. The value of this compromise cannot be gauged from a quick glance at the nature of the allies (army, government, armed groups, “civil society” organisations, etc.); it requires a careful examination of the motivations underpinning it and of the real effects it has on relief efforts. Thus, since 2007, the Pakistani army has been a major hindrance to MSF’s attempts to provide care to the victims of the war against the armed opposition (see “The Other Side of the COIN”). However, in the response to the earthquake in Pakistani Kashmir in 2005, it was not only the main relief provider, but also a constructive partner for MSF, as Rony Brauman explains in the chapter “Do Something!”.
While in a compromise, “everyone keeps their place; no-one is stripped of their order of justification”,Paul Ricœur, “Pour une éthique du compromis”. Interviews by Jean-Marie Muller and François Vaillant, Alternatives non violentes, n° 80, Oct. 1991. a dishonest compromise is “a vicious mixture of plans and postulates”.Ricoeur, “Pour une éthique du compromis”.

 In other words, when MSF seeks the reasons for its actions in justifications (peace, stability, justice, growth, etc.), other than its own, it runs the risk of turning a fair deal into a dishonest compromise. So, as discussed in the chapter “Public (Health) Relations”, can the organisation justify organising a mass meningitis immunisation campaign with a negligible medical impact as a tactic for maintaining good relations with the north Nigerian authorities?

Justifying its Choices

How does MSF justify its choices to itself and to others? In the chapter, “In the Name of Emergency”, Marc Le Pape presents “a (partial) mapping of the range of choices and justifications actually adopted over the course of MSF’s interventions during the decade 2000 to 2010 [without suggesting] a preferred route” which illustrates how the organisation evokes, successively or simultaneously, both its role as a “specific actor” with unique experience and “reputedly universal principles” in an attempt to gain ground.
It seems to us that MSF can only justify its compromises to itself in an ethics of action founded on a principle of medical effectiveness and a refusal to be party to policies of domination.
If, by its actions in a given context, MSF cannot hope “to reduce the number of deaths, the suffering and the frequency of incapacitating handicaps within groups of people who are usually poorly served by public health systems”,See after, Jean-Hervé Bradol, “Caring for health”, p. 216. then the compromises it agrees to are neither justifiable nor acceptable. In this respect, however critical one may be of MSF’s intervention in Myanmar, we have to admit that the concessions it accepted—limited intervention zones, restrictions on international staff’s access to the population and silence about the regime’s oppressive policies—produced results. These can be seen in the number of lives saved by a programme for the large-scale treatment of patients with HIV. On the other hand, MSF interventions in natural disasters show that the “imperative for action”, whose premises are challenged by Rony Brauman, has long been at odds with the need to do something medically useful. It was only in 2005 in Pakistani Kashmir, and then in Haiti in 2010, that MSF was finally able to show its practical usefulness, and notably its surgical capacity, in the response to earthquakes affecting zones with a dense urban population and unsound housing, which generated large numbers of casualties.
Refusing to be party to policies of domination is an essential ambition for any humanitarian organisation committed to providing impartial and effective aid. All societies inevitably generate their quota of victims—their excluded populations—groups with no share in society, who are doomed to a violent death or to be deprived of things that are essential to their survival (water, food, shelter and medical care). The civilian populations massacred in Sri Lanka during an all-out war fought in the name of the emancipation of the Tamil people for some and the promise of lasting peace for others, and the populations cut off from assistance or the victims of the bombings in the “war on terror” in Afghanistan and Pakistan, are a reminder that imposing peace, democracy and development always costs lives. In conditions such as these, “humanitarian action is necessarily subversive, since partisans of the established order rarely empathise with those whose elimination they tolerate or decree. In other words, the first condition for the success of humanitarian action is refusal to collaborate in this fatal selection process”.Jean-Hervé Bradol, “Introduction”, Fabrice Weissman (ed.), In the Shadow of Just Wars…, p. 9.

The subversive dimension of humanitarian action, as perceived by MSF, also includes the ability to challenge the norms, priorities and distribution of resources decided by the most influential stakeholders in global health, whose major campaigns and initiatives influence public health policies to suit whatever ideologies are in place at the time. In the chapter “Caring for Health”, Jean-Hervé Bradol looks back over forty years of tensions and relations between an organisation of doctors and transnational health policies. He recounts the times when MSF broke away from these policies because of their negative effects on the populations it was working with. It was for this reason that the organisation contested the pauperisation of healthcare for refugees in the 1980s, provided treatment to patients with infectious diseases at a time when public health priorities were focused essentially on prevention and control, and helped develop treatment protocols for people with HIV when governments and the pharmaceutical industry were still recommending leaving them to die.

Through this journey, the conditions of MSF’s political autonomy have emerged: an undertaking on the part of practitioners to provide the most effective medical assistance possible to populations who have been excluded due to raison d’Etat or market interests. It is to satisfy this undertaking that MSF must justify its alliances, question them, flush out any conflicts of interest and maintain a political watch in order to “recognise, and sometimes anticipate the appearance of […] favourable circumstances, as this is when the most rapid and profound changes to public health policies can be achieved. Such circumstances can be neither permanent nor artificially induced through advocacy”.See after, Jean-Hervé Bradol, “Caring for health”, op. cit.

Antagonisms

Attempting to bring about changes in public health policy, seeking to take charge of the management of an epidemic, formulating new rights for an excluded population, and denouncing the violence of war in the hope of influencing the way a conflict is conducted are all actions revealing an ambition to manage a population in addition, competition, or parallel with the authorities. What makes it possible to imagine an agreement between MSF and these authorities is their shared interest in the way a population is governed. Thus, “non-governmental policy [does not contest] the legitimacy claimed by those in government […], nor the interests they serve, but the modalities and effects of their management”.Michel Feher, “Les gouvernés en politique”, Vacarme, n° 34, Winter 2006.

What happens when this shared interest disappears? When the Taliban, routed by the international forces in 2001, or the Afghan warlords, marginalised in a state reconstruction process, no longer seek to govern a population or a territory, but rather to wreak terror and havoc? When, in this new strategy, are humanitarians more useful to them dead than alive? When the Ethiopian government confines MSF to the edges of a war that it is waging against the Ogaden National Liberation Front so that it can conduct its reprisals against the population behind closed doors? When the Sri Lankan government turns a deaf ear to dialogue because it has decided on a military solution for ridding itself of the Liberation Tigers of Tamil Eelam, mercilessly crushing the fighters and sacrificing the 30,000 or so people being used as human shields by the rebellion against the army’s offensive? In the kind of extreme situation seen in Sri Lanka, should we replace direct action with a “strategy of roundly criticizing institutions”See after, Marc Le Pape, “In the name of emergency”, p. 242. or abdicate and wait for the order of all-out war to be replaced by one in which humanitarian aid can play its part?
As this book goes to press, MSF is preparing to celebrate “forty years of independence”. This slogan may seem misleading as, apart from exceptional and temporary circumstances, in moments of severe disruption, MSF is never given total freedom by authorities who totally abdicate their responsibilities. In fact, not only does it need others to authorise its action, but also to take it over, amplify it, prolong it and help implement it. MSF is permeable to outside influences and ideologies.

Therefore, the issue for MSF is not so much achieving total freedom of action, but being able to choose its alliances according to its own objectives, with no allegiances and no concerns about loyalty. In this respect, it is an unreliable and unfaithful partner. It justifies this liability by the need to identify auspicious openings in the political space and seize opportunities, as is highlighted in the chapter “Afghanistan: Regaining Leverage”, which tells the tale of MSF’s return to this country in 2008. In other words, if we consider that humanitarian aid is not an exact science but an art, then the essence of this art is to create and maintain the conditions of its existence—to generate interest, make itself useful, identify conjunctures that could be propitious for change—and to be capable at all times of modifying the balance of power, creating a hiatus, permanently maintaining the right conditions for pacific conflict with forms of power that may sometimes be partners, and sometimes adversaries, to our action. At a time when humanitarian actors are questioning their ability to overcome the obstacles they are encountering, we hope that this book will help fuel the debate on their ambitions and the best ways of fulfilling them.