Silence Heals…from the Cold War to the War on Terror, MSF Speaks Out: a Brief History

Fabrice Weissman

In a growing number of countries such as Ethiopia, Russia, Zimbabwe and Sri Lanka, national laws and government framework agreements oblige MSF to strict confidentiality. These restrictions are causing some discomfort within the organisation, which claims the right to “speak out and bear witness”, and its leaders are being forced to take a new look at an issue that has been under debate since its inception: why get involved in the public debate? Shaped by experiences in the field and the dominant ideological currents, MSF’s responses have evolved over the past forty years. Here we’d like to give a brief history of the major positions taken by the organisation during conflicts, within a context marked successively by the Cold War, the collapse of the bipolar world order, and the increase in armed international intervention in the name of human rights.

1970 to 1980: Choosing Neo-conservatism

The Good Samaritans of Disaster

Contrary to the image popularised by the media and MSF itself, the idea that silence was necessary to action was held by a majority of its founding members. The original charter of 1971 stipulated that its members would refrain from “any interference in States’ internal affairs” and abstain from “passing judgment or publicly expressing an opinion—either positive or negative—regarding events, forces or leaders who accepted their assistance”. When asked during an interview by French newspaper l’Est Républicain on 26 December 1971, “Should a doctor who witnesses atrocities remain silent?”, MSF co-founder and fire brigade colonel Dr Gérard Pigeon replied in the affirmative: “We have to be perfectly clear: doctors don’t go to be witnesses. They don’t go to write a novel or a newspaper article; they go to treat. Doctor-patient privilege exists, and should be respected. If doctors keep quiet, they’ll be allowed in; otherwise they’ll be kept out like everyone else”.

From 1971 to 1976, the fledgling organisation promoted a depoliticised image showcasing the courage of its members and the technical efficacy of its medical care. It wasn’t until 1977 that an MSF representative first violated the statutory confidentiality commitment. On returning from the Cambodian refugee camps along the Thai border, Claude Malhuret condemned, on France’s leading television station,Anne Vallaeys, Médecins Sans Frontières: La biographie, Paris: Fayard, 2004, p. 236. the “revolutionary crimes” of the Khmer Rouge who, he said, were “exterminating entire segments of the population in the name of some revamped communist ideology”. The MSF archives reveal nothing of the discussions that were prompted by this speaking out, which sparked controversy and led to the organisation receiving several letters accusing its leaders of being propagandists on the payroll of the CIA. In any event, in 1977–78, the commitment to confidentiality was officially challenged by MSF directors. In 1978, the president announced in his annual report that staff would be “reporting human rights violations and unacceptable events they witnessed to the bureau. (…) The bureau will then make an executive decision on whether to inform the public, in cases where MSF was the sole witness”.

While the majority at MSF were in favour of “the right to speak out”, the leadership team was torn about the place it should have. Bernard Kouchner and some of the other founders viewed it as the primary function of Médecins Sans Frontières, which needed to guard against becoming “bureaucrats of misery and technocrats of charity”.Vallaeys, Médecins sans frontières: La biographie, p. 248. Action was the responsibility of the (democratic) governments, and all MSF could do was to galvanise them by creating a stir in the media. Malhuret, on the other hand, wanted to anchor speaking out in the independent and effective practice of humanitarian medicine, which meant professionalising the organisation. Finding himself in the minority, Bernard Kouchner left MSF in 1979.

The Cambodian March for Survival

The new leadership team immediately put the “right to speak out” into action in Cambodia in 1979 to 1980. Convinced that the country was in the grip of a famine and that the pro-Vietnamese regime was diverting humanitarian aid, MSF demanded an internationally-monitored, large-scale distribution of aid based on cross-border access from Thailand. To that end, on 20 December 1979 MSF leaders called for a “March for Survival” for Cambodia. On 6 February 1980, about a hundred demonstrators—including Rony Brauman and Claude Malhuret for MSF, Bernard-Henry Lévy for Action Internationale Contre la Faim (AICF), and Joan Baez for the International Rescue Committee (IRC)—showed up at the Cambodian/Thai border at the head of a food convoy. Not surprisingly, they were turned away. More numerous than the demonstrators, journalists gave plenty of coverage to the event, which was criticised by the pro-Vietnamese government and its allies as an imperialist, reactionary demonstration. Dissent also grew within MSF, where some accused the leadership of being manipulated by the United States for propaganda purposes—in particular, by associating with the IRC, which many saw as a front for the CIA. To those who maintained that MSF should “do humanitarianism, not politics”, Malhuret replied, “This is politics in the true sense of the word. People are dying of hunger in Cambodia, and we can’t intervene. If you had known about Auschwitz, would you have buried your head in the sand?”Vallaeys, Médecins sans frontières: La biographie, p. 321.

 This reference to the ICRC’s controversial role during World War II was, at the time, a standard feature in the arguments put forward by Malhuret and Brauman, who saw communist totalitarianism as the source of contemporary genocidal processes. In their view, détente was just a smokescreen for a vast Soviet offensive in the third world. By the late-1970s, former Indochina was entirely in the hands of Soviet and Chinese allies, Soviet influence extended into Africa (Angola, Ethiopia, Mozambique, etc.), there were several revolutionary movements in Latin America (Nicaragua, El Salvador and Guatemala), and the Red Army had invaded Afghanistan. In its work with refugee camp populations—which grew from three million to eleven million between the late-1970s and early-1980s—MSF found that 90% of them were fleeing from communist regimes.

In terms of its stated operational objectives—ensuring independent distribution of relief—the Cambodian March for Survival was a failure. However, as the organisation would learn several years later, there wasn’t actually a famine—not because the government distributed the aid that reached them, but because there was no widespread food shortage. Contrary to popular opinion, the malnourished state of the refugees arriving in Thailand which triggered the alert was not representative of the situation inside Cambodia.Rony Brauman, “Les liaisons dangereuses du témoignage humanitaire et des propagandes politiques”, in Marc Le Pape, Johanna Siméant, and Claudine Vidal (eds), Crises extrêmes. Face aux massacres, aux guerres civiles et aux génocides, Paris: La Découverte, 2006, pp. 188–204.

 The march did, however, put the organisation back in the headlines through a political action with at least three messages: by demanding independent distribution of relief supplies, MSF was asserting that, without a minimum amount of autonomy, aid is condemned to serve the interests of political power at the population’s expense. By addressing itself to public opinion, and through it to the States themselves, it underscored the fact that such autonomy can only be won after a power struggle in which the authorities’ international image is at stake. By publicising the pro-Vietnamese government’s refusal of independent aid, it showed that autonomy was non-existent in countries with totalitarian regimes, where aid was destined to be turned into an instrument of oppression. Nine years after MSF’s creation on a foundation of silence and neutrality, its leaders made speaking out an important part of humanitarian action, supporting and extending aid policies.

The 1980s: The War Against Communism

The condemnation of Red Army crimes in Afghanistan was emblematic of how speaking out can be an extension of medical action. Working with the Afghan resistance since 1981, MSF had to cope with logistical and security constraints due not only to the clandestine nature of its mission, but also to the tribal, political and military strategies of the Afghan faction heads. “Relations with the Mujahedin gave us infinitely more trouble than the Red Army”,Anne Vallaeys, Médecins sans frontières: La biographie, p. 417. commented Juliette Fournot, the mission’s main organiser. Yet MSF did not openly criticise the obstacles imposed by the Afghan resistance; it condemned the Soviet occupation forces for massive bombing, dropping antipersonnel mines, and setting fire to villages and crops. “We were helping more people by denouncing what was happening over there than by offering assistance to the few Afghans we were able to get to. By alerting the public, we were making politicians face up to their responsibility, and forcing them to intervene to stop the massacre”,Ibid., 441. explained Malhuret, years later.

To the MSF leadership, in the context of the Cold War, “making politicians face up to their responsibility” meant calling upon the liberal democracies to redouble their efforts in the fight against communism.Cf., for example, Claude Malhuret, “Report from Afghanistan”, Foreign Affairs, Winter 1983/84 (1983), pp. 426–435.

 To this end, Malhuret made several trips to the United States between 1983 and 1985, at the invitation of neo-conservative intellectuals and Republican Senator Gordon J. Humphrey. Humphrey was one of the promoters of Operation Cyclone, the CIA programme that equipped and funded the Afghan resistance from 1979 to 1989. Media coverage of MSF’s Afghanistan activities and accounts of its experiences then became part of the moral rearmament effort launched in the mid1970s by neo-conservative intellectuals and the US administration. Taking advantage of the new political infatuation with human rights in an America seeking moral purification (the religious revival, the public’s discomfort with the atrocities committed in Vietnam, and the Watergate scandal), they used the human rights movement in the ideological war against communism, supporting Soviet dissidents, Polish trade union Solidarity, the signatories of the Charter 77 in Czechoslovakia, etc. Cf. Justin Vaïsse, Histoire du néoconservatisme aux États-Unis: Le triomphe de l’idéologie, Paris: Odile Jacob, 2008, pp. 155–58.

 MSF received several rounds of funding from the National Endowment for Democracy (NED), a foundation designed to export American “soft power” through civil society organisations.

The NED got what they paid for. In 1984, MSF created the Liberté Sans Frontières (LSF) Foundation, a think-tank on development and human rights issues. The LSF scientific committee was made up of liberal-right Atlanticist thinkers, most of them from the editorial board of Raymond Aron’s journal, Commentaire. In 1985, LSF held a symposium entitled “Third Worldism in Question”, during which it lambasted what it considered the ready-made ideology of the aid world: Third Worldism that sought to justify the NGOs’ blindly lining up behind the China- or Soviet-allied governments of newly independent states in the name of anti-imperialism. “LSF discourse is deeply imbued with the ideologies it claims to be emancipated from; it is not located
outside [any framework] but anchored in a Reaganist, pro-American thinking”, commented Alain Gresh in May 1985, in a special issue of Le Monde Diplomatique.

“Aid is Used to Oppress, Not to Save”

At the same time as it was condemning the crimes of totalitarianism, during the 1980s MSF spoke out in an attempt to extract itself from situations where it believed humanitarian aid was “having a perverse effect” to the point of becoming “complicit in criminal policies”.Rony Brauman, cited in Laurence Binet, Famine and forced relocations in Ethiopia—1984–1986, Paris: MSF International Council—CRASH/MSF Foundation, Jan. 2005, p. 64.

 In 1984–85, there was a famine followed by a large relief operation in Ethiopia financed by the western nations and private donors, mobilised by an unprecedented media campaign which culminated in the Live Aid concert, organised by Bob Geldof. In the first half of 1985, MSF— which was running nutrition and hospital programmes in several camps sheltering tens of thousands of people fleeing the famine—came to realise that the food distribution centres were traps. The government was using the food aid as blackmail, giving it only to families that agreed to participate in a relocation programme aimed mainly at depopulating rebel areas by moving people from the north to the south. Those who refused to go were taken at gunpoint.

According to MSF estimates, at least 100,000 people died while being transferred or during the first three months of resettlement. It launched a public opinion campaign in September 1985, calling upon donors and humanitarian organisations—unsuccessfully—to form a united front in demanding a moratorium on the deportations, which would kill more people than the famine itself. A month later, MSF was expelled from Ethiopia.

While this denunciation ultimately merged with MSF’s condemnation of totalitarianism’s disasters, it came out of a very different process than the public stands on Afghanistan. The intent was not to prolong emergency relief, but to challenge its use in the service of murderous policies. MSF used public opinion to pressure the UN, NGOs, and western nations; the aim was to transform their aid practices, to prevent them from stepping over “that blurry, but very real, line beyond which assistance for victims imperceptibly turns into support for their tormenters”.

In the end, by condemning communist totalitarianism as the root of the greatest human disasters and for using humanitarian action against its beneficiaries, MSF made common cause with the west during the Cold War. It saw its action as a part of the fight for human rights and democracy: “Though imperfect, the [liberal political systems] are the only ones in history that have allowed significant advances in freedoms and social justice”. Rony Brauman, Le tiers-mondisme en question, Paris: Olivier Orban, 1986.

 In the same vein, the association applied for the Council of Europe Human Rights Prize in 1988. Believing that the award would constitute “a moral recognition giving more weight to [its] interventions in the Third World”, Médecins Sans Frontières, “Candidature au prix des Droits de l’homme du Conseil de l’Europe”, 20 Dec. 1988. it pointed out that, “since its beginnings, MSF has acted to promote and defend human rights”: by its action, it responds to the “right of populations to have access to medical care”, and by its presence, it acts as “a decisive deterrent in preventing human rights abuses”. Lastly, it reserved the “right to speak out publicly on atrocities about which its teams have knowledge, when they are alone in a place where outside observers cannot investigate”.Médecins Sans Frontières, “Candidature au prix des Droits...”, 1988.

 Presented every three years, the prize was awarded to Lech Walesa in 1989; MSF won it in 1992.

The 1990s: The Gamble of Liberal Internationalism

The Hope for a “New World Order Based on Human Rights”

With the end of the Cold War, speaking out publicly and defending human rights began to gain some legitimacy within the other four sections of MSF. Created during the 1980s in Belgium, Holland, Spain and Switzerland, they had until then resolutely opposed the French practice of bearing witness, which they accused of politicising MSF in violation of its statutes. After bitter debate, in 1992 all of the sections decided to remove the provisions in the charter committing MSF to confidentiality and prohibiting it from any involvement in a country’s internal affairs. Because of the complexity in retracing how speaking out evolved from the 1990s on—characterised by evolving, contradictory messages, heavily influenced by experiences in the field and fiercely debated within the movement—we will give a selective reading, taken primarily from French section experiences.

During the 1990s, there were fewer and fewer refugee camps, and humanitarian aid began to be deployed inside conflict zones. Clandestine missions conducted under guerrilla protection gave way to larger-scale projects requiring agreement from several belligerents. The latter were especially numerous in countries like Somalia and Liberia or, like the governments of Iraq, Myanmar and Sudan, were fundamentally opposed to intervention by western NGOs. Though it had never before been so present in the midst of war, in 1992 MSF considered that, “the main problem today is that of access to victims; the authorities or factions oppose humanitarian action, an inconvenient witness to their atrocities, and insecurity makes intervention increasingly dangerous”.François Jean, “Populations en danger: les propositions de MSF”, Messages, no. 5, Dec. 1992.

Faced with these difficulties, MSF had to reckon with the resources and constraints inherent to a new type of internationalisation of conflicts. In the five years following the 1991 Gulf War—pitched by the US administration as the first act of a “new world order”—the UN Security Council launched twenty-four peacekeeping missions, as many as there had been in the whole of its first forty-five years of existence. Establishing a link between threats to peace and violations of international humanitarian law, the UN authorised the use of force to safeguard aid operations, particularly in Iraqi Kurdistan, Somalia, and Bosnia. While humanitarian doctors had traditionally followed armies onto the battlefield, “now it is the armies themselves that escort humanitarian organisations to the frontline”,Jacques de Milliano, “Foreword”, in François Jean (ed.), Life, Death and Aid. The Médecins Sans Frontières Report on World Crisis Intervention, London: Routledge, 1993, p. viii. observed a perplexed MSF in 1993.

Yet, its directors welcomed the growing involvement of the UN and western nations in the conflicts. With Soviet totalitarianism defeated, the democratic states and the UN would, more than ever, have, “an essential role to play […] in guaranteeing genuine access to victims and an end to human rights violations”. François Jean, “Introduction”, in François Jean (ed.), Life, Death and Aid…, pp. 7–8. Therefore, MSF increasingly challenged western governments and the UN, criticising in particular military interventions that claimed the protection of humanitarian actors as their mandate. Such interventions did not always improve access to victims. But more than that, they served the western powers as an alibi for avoiding what was, according to MSF, their primary responsibility—combating massive human rights violations, including by military means.

Denunciation of the Humanitarian Alibi

MSF’s first critique of the “humanitarian alibi” was in response to the international intervention in Iraq. Taking advantage of the weakened Iraqi regime in the wake of the first Gulf War, Kurds and Shiites rose up in March 1991, only to be crushed by the Republican Guard, which pushed more than a million Kurds into exodus. The displaced piled up at the Iranian and Turkish borders, causing concern in Ankara, which feared a massive influx of Kurds in the provinces where its army was already fighting an insurrection. On 5 April 1991, the Security Council condemned the repression of the Iraqi civilian population as a threat to international peace and security, and demanded that Iraq allow immediate access by international humanitarian organisations to all those in need of assistance. France and the US used their armed forces in a massive, technically successful relief and repatriation operation (Operation Provide Comfort); some sixty NGOs participated, one of them MSF. Nevertheless, the organisation criticised the cynicism with which the western nations—after having encouraged them to rebel— left the Kurds and the Shiites to be massacred. In MSF’s view, Operation Provide Comfort served to “disguise the partial failure of a Gulf War unable to put an end to Saddam Hussein’s rule”.Guy Hermet, “Les États souverains au défi des droits de l’Homme”, in François Jean (ed.), Face aux crises…, p. 191.

Implicit in the case of Kurdistan, condemnation of state humanitarianism as an alternative to war against criminal regimes was at the heart of MSF’s public opinion campaign during the Bosnian War (1992 to 1995). In addition to killing between 20,000 and 60,000 people,Cf. Xavier Bougarel, Bosnie, anatomie d’un conflit, Paris: La Découverte, 1996, pp. 11–12. that conflict displaced about two million, roughly half of the population. Prompted by terrorist tactics such as mass killing, torching of villages, executions, rape, and internment, forced displacement was not an indirect consequence of the war, but one of its main objectives. Croatian, Muslim and Serbian nationalists (the last enjoying military superiority, thanks to Yugoslav army support) all nursed more or less radical ambitions for ethnic homogeneity in the territories they claimed.

The utility of MSF medical intervention in the central European country—with its modern healthcare system and qualified medical personnel—was marginal. The organisation focused primarily on helping the displaced and providing medical supplies to Muslim enclaves surrounded by Bosnian Serb forces. “Aside from material assistance, we saw our presence in those besieged towns as a symbolic act: the need to be witnesses”, reflected Pierre Salignon, a member of MSF-France’s mission in Bosnia. Anne Vallaeys, Médecins sans frontières: La biographie, p. 686.

Witness to the blockade of enclaves packed with thousands of displaced persons and exposed to sniper fire and Serb artillery, and aware of the civilian internment camps and the terrorist methods being used by militias to drive out populations, MSF had no intention of remaining neutral between the besiegers and the besieged, the deported and those organising the deportations. Beginning in April 1992, and then during the June visit to Sarajevo by French president François Mitterrand—who explained that French and UN involvement would be limited to protecting humanitarian aid—MSF heads stepped up their statements to the press. They criticised the “passivity of the international community” and, more particularly, of European countries, in the face of the “ethnic cleansing” in Bosnia. For MSF, ethnic homogenisation of certain areas by Serb militias signalled the resurgence of genocidal totalitarianism in the heart of Europe. This is why MSF considered humanitarian action by NGOs to be derisory, if not complicit, given its role of accompanying—even helping—a criminal policy.Cf. for instance, Rony Brauman, “Introduction”, in François Jean (ed.), Populations in Danger, London: John Libbey, 1992, p. 5.

 In 1992, the French section suggested that the entire movement halt all its operations in Bosnia. As Rony Brauman declared on French radio station RTL in April 1992, “It’s the hills of Sarajevo that should be bombed. We should declare war on the Serb nationalists”.Anne Vallaeys, Médecins sans frontières: La biographie, p. 666.

In addition to the spectre of genocide, MSF’s call to arms was anchored in international humanitarian law. In November 1992, the teams conducted a survey—the first of its kind—among sixty or so Bosnian refugees in France. Seeking to retrace the history of their flight and give a legal definition to the violence they survived, the report on the “process of ethnic cleansing in the Kazarac region” concluded that “the atrocities committed by the Serbs of Bosnia-Herzegovina were not just human rights violations or war crimes, but a crime against humanity, according to the definition of the Nuremberg Tribunal”. The report was distributed to the press and to numerous institutions, such as the US Congress and the United Nations Special Rapporteur for Yugoslavia. The call to arms took the form of an appeal for an “international policing operation (…); governments have the duty to use all necessary means to halt serious violations of humanitarian law”.Françoise Bouchet-Saulnier, “Peacekeeping Operations Above Humanitarian Law”, in François Jean (ed.), Life, Death and Aid…, pp. 128, 130. NOTES pp [187–193]

By demanding that western governments make war against oppressive regimes, rather than protect relief operations, MSF entered the public debate alongside neo-conservatives and liberal internationalists. Since the fall of the Berlin Wall, the latter insisted that liberal democracies had a responsibility, and an interest, in using their military power to defend human rights beyond their borders. Surprisingly, MSF’s pro-Bosnian involvement did not seem to provoke direct reprisals by the Serb militias, with whom it had to negotiate its presence in the former Yugoslavia. The neo-conservative rhetoric it helped amplify, however, was sharply criticised by Bosnia-Herzegovina specialists as a factor in the radicalisation of the conflict. This call to arms, which painted Serb nationalism as a contemporary form of Nazism, encouraged the military escalation and use of the victim strategy by Croatian nationalists and Muslims suspected of deliberately exposing their civilian populations in order to get armed support from the west.See, for example, Bougarel, Bosnie, anatomie d’un conflict, p. 17.

Somalia, Rwanda: “People were Killed Under the Banner of Humanitarianism”

MSF interventionism was, however, shaken in Somalia, where the association realised that the international military remedy could turn out to be worse than the disease. The primary mandate of the American and UN troops landing in Mogadishu in 1992–93 was to safeguard humanitarian relief operations in a context of famine and widespread insecurity. The arrival of foreign forces was met with ambivalence by MSF. The Belgian section was officially in favour, seeing it as a way “to gain access to rural areas, to guarantee [humanitarian organisations] more effective protection” as well as “an end to the vicious cycle of paying militias”. With the collapse of the Somali government and the privatisation of violence, MSF was, in effect, forced to hire the services of armed guards made available by warlords, whom it was thus directly funding, prompting criticism from journalists and staff. The French and Dutch sections, on the other hand, were more sceptical of the international troops’ highly publicised arrival, believing that the strategy of dialogue and negotiation hitherto used by the United Nations Special Representative was more likely to create conditions conducive to expanding relief activities.

In the early months of 1993, the international deployment allowed more food aid distributions in the interior of the country, which helped to contain the already-declining famine. But the international forces quickly became party to the conflict, committing countless atrocities, including the bombing of hospitals and local relief organisations, the torture and killing of non-combatants, and civilian massacres. Associated in people’s minds with the international forces, humanitarian organisations were being targeted by the factions against whom the UN and US had declared war. The French section withdrew from the country in 1993, condemning the “military-humanitarian confusion” that had put them in danger and the perversion of humanitarian logic. “In Somalia, people were killed for the first time under the banner of humanitarianism”. Rony Brauman, Le crime humanitaire. Somalie, Paris: Arléa, 1993, p. 31.

 The experience convinced MSF that international armed protection was a trap, and that once a government has collapsed, the only political objective of military intervention is an international protectorate—with its colonialist overtones and impossible political and financial costs.Cf. for instance, Guy Hermet, “Rwanda: l’outrage humanitaire”, in François Jean (ed.), Populations en danger 1995. Rapport annuel sur les crises majeures, Paris: La Découverte, 1995, pp. 94–95.

After the experience in Somalia, MSF sketched out its first public critique of international military interventionism. It underscored its limits, its potential for degenerating into brutal war, and the perverse effects on relief workers, who were seen as no different than the soldiers charged with protecting them. These reservations would be swept aside, however, by the extraordinarily grave crisis that devastated central Africa’s Great Lakes region from 1994 to 1997.

Calls to Arms

Between April and July 1994, Rwanda’s Tutsi population was systematically hunted down and exterminated. Working in several Rwandan towns, MSF gradually became aware of the genocidal nature of the massacres. Though genocide was expressly denied by United Nations Security Council members—who had, for various reasons, decided not to intervene—MSF, for the first time in its history, launched an explicit appeal for international armed intervention against a regime conducting “the planned, methodical extermination of a community”.Appeal by MSF-France published in Le Monde, 18 June 1994.

 In the latter half of 1994, MSF protested the reconstitution of the genocidal administration in Rwandan refugee camps with close to two million people in Zaire and Tanzania. While the UN secretary general was not able to assemble the forces needed to neutralise the genocidal network, MSF called upon the UN and western powers to demilitarise the camps, provide policing, and arrest the organisers behind the genocide. The failure of these efforts convinced the organisation to leave the camps between 1994 and 1995, in order not to be “accomplices of the genocide’s perpetrators”,Libération, 15 Nov. 1994. against whom it had called for war.

A year later, the camps in Zaire were attacked one after the other by the new Rwandan regime’s army and its Congolese allies. After returning to the region in November 1996, MSF once again called for armed international intervention, “to protect the refugees and guarantee access to aid”. But, arguing that large numbers of refugees had returned to Rwanda, the western nations declared the crisis over and the intervention never happened. Several hundred thousand Rwandans refused to return to their country, however. They were hunted down mercilessly by the Rwandan army and its Congolese allies, who used humanitarian organisations as bait to attract those who fled—not to deport them, as in Ethiopia, but to physically eradicate them. Throughout 1997, MSF publicly condemned the massacres and human rights violations that its teams had knowledge of, without any real success in prompting efforts to stop the killers.

In 1997, recalling that MSF had done everything it could to try to “humanise the inhuman”, the president of MSF-France acknowledged the limits of the organisation’s actions and public statements in the face of extreme violence: “We tried to do the least possible harm”.Philippe Biberson, rapport moral 1996/1997, MSF, Paris.

 From the mid-1990s, the post-Cold War euphoria fuelling hope for a “new world order based on human rights” François Jean, “Introduction”, in François Jean (ed.), Life, Death and Aid…, p. 7. gave way to somewhat bitter caution. As Philippe Biberson declared at the 1996 General Assembly, “One must beware of the megalomaniacal vision which aims to wage a universal struggle for justice and democracy and of the UN’s vision of well-being shared by all”. MSF began to refocus its public stance on assistance policies and distance itself from liberal interventionism, entrusting the UN—backed by the western democracies—with the responsibility for ensuring respect for human rights on a global scale.

1999 and Beyond: Navigating Between Imperialism and Despotism

“Blurring of Lines”

As MSF was questioning the significance of its appeals to the UN and western nations, the number of international military interventions was growing. In March 1999, NATO launched a campaign of air strikes against the Federal Republic of Yugoslavia, forcing the Serb army terrorising the Albanian-speaking population of Kosovo to withdraw. Five months later, Australian troops landed in East Timor under the UN flag, putting an end to atrocities by pro-Indonesian militias opposed to independence for the former Portuguese colony. In May 2000, a contingent of British paratroopers joined UN troops deployed in Sierra Leone, helping to bring a fragile calm to the country devas-tated by ten years of civil war. A year later, the September 11 2001 attacks against the United States were followed by the invasions of Afghanistan in 2001, and Iraq in 2003. At the same time, UN peacekeeping operations were stepped up, as their mandate now included protecting civilian populations inter alia and not just humanitarian relief operations.These UN operations took place, in particular, in the Democratic Republic of Congo (1999), Liberia (2003), Haiti (2004), Côte d’Ivoire (2004), Burundi (2004), and Sudan (2005).

With 140,000 soldiers and police deployed in sixteen countries, by 2006, UN forces became the second largest army operating on foreign soil, after that of the United States.

This resurgence in interventionism was rationalised by security concerns (protecting democracy from global threats such as pandemics, migration, organised crime, terrorism, etc.) and humanitarian considerations (combating mass human rights violations and freeing populations from want and oppression). As British Prime Minister Tony Blair declared in April 1999, “we [Europe and the US] cannot turn our backs on conflicts and the violation of human rights within other countries if we want still to be secure”. The new secretary general of the UN, Kofi Annan, justified sending Australian troops to East Timor in terms of the member States’ responsibility to collectively assert the primacy of human rights over national sovereignty. Urging the Security Council to adopt a doctrine of intervention—“the responsibility to protect”—that would authorise the use of force in response “to a Rwanda, to a Srebrenica—to gross and systematic violations of human rights”,“We the Peoples: the Role of the United Nations in the 21st Century”, Millennium Report of the Secretary-General of the United Nations, 2000. http://www.un.org/millennium/sg/report/. he characterised as “historic” the 1 July 2002 creation of the International Criminal Court, the first permanent court charged with trying the perpetrators of war crimes against humanity and genocide.United Nations, press release, New York, 1 July 2002.

Asserting that the UN and western powers shared the same aims as the humanitarian organisations, institutional donors suggested that the latter abandon their neutrality and join the political and military coalitions being steered from New York and Washington. With the exception of Iraq, where European and American NGOs disagreed on the appropriateness of using force, many allied themselves with the international troops and participated in stabilisation policies (in Kosovo, Sierra Leone, Afghanistan, the DRC, etc.). Many felt that in this way they were contributing to “the only truly humanitarian goal: hastening the end of a war” and “replacing a murderous regime by a civilized government as quickly as possible” (in the words of former humanitarian volunteer and academic Michael Barry, on Afghanistan).Michael Barry, “L’humanitaire n’est jamais neutre”, Libération, 6 Nov. 2001.

Beginning with the NATO intervention in Kosovo, MSF declared itself neutral in all conflicts where international forces were involved. It vigorously criticised the notion of “humanitarian war” evoked by Tony Blair and NATO, seeing it as a formula that “makes it easier to forget the human cost arising from the use of force and the political repercussions of violating state sovereignty”.Jean-Hervé Bradol, “Introduction”, in Fabrice Weissman (ed.), In the Shadow of ‘Just Wars’: Violence, Politics, and Humanitarian Action, London: Hurst & Company, 2004, p. 12.

 Using humanitarianism to justify war weakens democratic debate and exposes aid organisations to the risks of military-humanitarian confusion. In the organisation’s view, that confusion was being exacerbated by the involvement of foreign armies in civilian relief efforts, and the fact that those armies presented psychological warfare operations as humanitarian assistance. Such practices cast doubt on the independence and impartiality of humanitarian NGOs, no longer seen as outsiders to the conflict by either the population or the belligerents opposed to the presence of international troops. The criticism became even more extreme after the June 2004 murder of five MSF members in Afghanistan.

Wherever international forces were involved, MSF would judge what it considered correct or incorrect uses of humanitarian semantics, condemning the “blurring of lines” at every level—such-and-such a war was not “humanitarian”, certain aid was not “humanitarian”, certain NGOs were not “humanitarian”—without, however, demonstrating by its operations or public positions the independence it was proclaiming. In Afghanistan and Iraq, for example, it lost interest in the victims of the war on terror. Aside from some isolated statements by the president of MSF-France, it remained silent in the face of the November 2001 massacres of thousands of prisoners of war by Coalition forces and their Afghan allies—massacres that prompted no demand for an international investigation. It said nothing about the US administration’s legalisation of torture, nor did it try to provide care for the victims released from Abu-Ghraib prison. It did not protest when allied forces rejected the distinction between combatants and non-combatants, considering it obsolete in the “war on terror”—an argument taken up in particular by the governments of Russia, Colombia, Algeria, Pakistan and Sri Lanka, which accused NGOs that criticised them of having a double standard.

From 1998 to 2003, however, MSF was extremely critical of the lack of interest shown by the UN and its member states in the violence in Chechnya, Liberia, Algeria, and Colombia, where warring factions enjoyed a “license to kill”,Fabrice Weissman (ed.), In the Shadow of ‘Just Wars’, p. 18. thus reducing the population’s chances of survival and humanitarian organisations’ ability to help them. It also denounced the inability of relief operations to save the victims of war and famine in North Korea (1996–98) and in Sudan (1998), due to their subjugation to crisis management strategies dictated by the foreign policies of the biggest institutional donors (United States, European Union and Japan).

“MSF and Protection—Pending or Closed?”Judith Soussan, MSF and Protection: Pending or Closed? Discourses and practice surrounding the ‘protection of civilians’, Paris: CRASH/Foundation MSF, July 2008.

Yet, by publicly exposing war crimes and the misappropriation or obstruction of humanitarian assistance, MSF may in fact have been encouraging the use of international military or legal measures against the perpetrators. This new dimension of speaking out prompted quite different reactions within each section.
Some were pleased; in the view of one MSF lawyer, the threat of legal (and military) action was “sharper teeth than we are used to having at our disposal”, and “could give us leverage in negotiating with those in control—either for better treatment of the civilians in their power (…) or for permission to provide humanitarian assistance to those populations”.Kate Mackintosh, “The development of the International Criminal Court: some implications for humanitarian action”, Humanitarian Exchange Magazine, Issue 32, Dec. 2005.

 Supporters of this view believed, however, that military operations to protect civilians were not sufficiently systematic, and overly guided by ulterior political agendas, which substantially reduced their impact.

This is why, from 1998 to 2005, MSF campaigned to get the UN and the nations participating in military operations in Bosnia and Rwanda to appoint Commissions of Inquiry, so that they could “learn lessons from these bloody failures, in order to prevent future deceptive deployments of soldiers to stand by—tied and bound—and do nothing in the face of criminal policies”.Jean-Hervé Bradol, “Une commission d’enquête sur Srebrenica!”, Le Monde, 13 July 2000.

 MSF urged the UN and Security Council members to adopt a “military doctrine on the protection of populations”, making it possible to “translate it into [detailed, concrete] military actions and objectives”.Françoise Bouchet-Saulnier, “Les actions militaro-humanitaires: vrais problèmes et faux débats”, Coëtquidan colloquium on international humanitarian law, organised by the French Ministry of Defence, May 2001.

Another line of thought at MSF was more sceptical about criminalising and militarising the fight against mass human rights violations. As one MSF representative commented, “a Russian soldier in Chechnya, a faction head in Congo, or an American officer in Afghanistan, indeed all those who might have a concern, founded or not, that they may one day have to account for their actions in front of a court, will see in the provision of the ICC a powerful incentive to remove any humanitarian presence”.Eric Dachy, “Justice and Humanitarian action: A Conflict of Interest”, in Fabrice Weissman (ed.), In the Shadow of ‘Just Wars’…, p. 318.

 Especially since the prosecutor and the NGOs supporting his action called explicitly for humanitarian organisations to provide information to help him determine the appropriateness of launching an investigation and prepare the cases.International Coalition for the ICC, “The role of NGOs”, http://www.iccnow.org, consulted on 2 Apr. 2009.

 And coupled with this controversy was a fierce debate on the political virtues of the international criminal justice system.See, for example, Fabrice Weissman, “Humanitarian aid and the International Criminal Court: Grounds for divorce”, Making Sense of Sudan, http://africanarguments.org/category/sudan/humanitarian/, July 2009.

In the same vein, those who held this view tended to think that armed protection of civilians in conflicts was just as deadly a trap as the armed protection of aid workers. In practice, protecting populations meant occupying some or all of a country and/or toppling an oppressive regime. This involved a war operation in itself, with the attendant risk of failure, escalation, and casualties. For example, the NATO intervention in Kosovo precipitated the exodus of hundreds of thousands of Kosovars in March and April of 1999. The 40,000 soldiers deployed after the withdrawal of Serb troops over an area twice the size of a French département failed to prevent the backlash of oppression that led to the expulsion of large portions of the Serb, Bosnian and Romani minorities from the province. To those people at MSF, “calling for the military protection of a population signals the desire for a ‘just war’ and for the advent through violence of a new political order—and this is an undertaking that always has uncertain outcomes and which inevitably creates victims among the people it is trying to save”.Fabrice Weissman, “Not In Our Name: Why Médecins Sans Frontières Does Not Support the ‘Responsibility to Protect’”, 2010, Criminal Justice Ethics, 29: 2, pp. 194–207. pp [194–204] NOTES

 Moreover, they maintained that MSF could not be seen as favouring armed action without endangering its access to crisis zones.

Darfur: a Return to the 1971 Charter?

So, for some at MSF, the military and punitive overtone adopted by liberal interventionism oriented it toward a repressive moralism unlikely to promote humanitarian action and human rights. Others, in contrast, saw it as a promising resource giving MSF’s public statements more bite. The Darfur crisis proved that liberal interventionism could be both a resource and a liability.

Present since 2003 in the Sudanese conflict between the central government and the rebels struggling against the political and economic marginalisation of their region, MSF was able to deploy only a dozen people in Darfur in early 2004. The government, conducting an extremely murderous campaign against the insurrection’s social base, was drastically limiting aid. In February 2004, MSF managed to provide very basic assistance to nearly 65,000 people, at a time when the UN placed the number of people driven from their villages by the gov-ernment sponsored massacres and scorched earth policy at more than a million.

In early March 2004, MSF teams came to believe that speaking out publicly was the only way to trigger a relief operation sufficient to the needs of Darfur, and push the Sudanese government to end the most deadly and brutal aspects of its counterinsurgency strategy. But it wasthe UN humanitarian coordinator for Sudan who broke the silence; on 19 March 2004, he alerted the press to the severity of the violence and hardship, comparing the catastrophe in Darfur to that of Rwanda in 1994. On 7 April 2004, while the 10th anniversary of the start of the Rwandan genocide was being commemorated in Kigali, Kofi Annan urged the international community not to repeat the mistakes of Rwanda. He called upon member states to use military means if the Sudanese government continued to restrict access by humanitarian organisations and human rights investigators to Darfur.Cf. UN press release, 7 Apr. 2004.

Statements by UN representatives were accompanied by a powerful public opinion campaign in the United States (just as the Abu-Ghraib prison torture scandal was erupting) demanding military intervention to put a stop to a “genocide” or a campaign of “ethnic cleansing”.Cf. Fabrice Weissman, “‘Urgence Darfour’. Les artifices d’une rhétorique néoconservatrice”, in Olfa Lamloun (ed.), Médias et islamisme, Beirut: Presses de l’IFPO, 2010, pp. 113–132.

 In July 2004, Britain, Australia and Norway offered to commit troops to the UN, and in September 2004, US secretary of state Colin Powell declared that genocide had indeed been committed in Darfur, and that it might continue. At the same time, the spokesman for the Sudanese National Assembly, invoking Iraq, threatened to “open the doors of Hell”AFP, 19 Sept. 2004. should there be a foreign invasion of his country. Sudanese president Omar al-Bashir maintained that “humanitarian organisations are the real enemy” AFP, 29 Oct. 2004. of Sudan.

This international pressure did, however, contribute to a significant reduction in violence and an unprecedented opening of northern Sudan to aid organisations. Beginning in the winter of 2004, more than 13,000 humanitarian workers—900 of them international—were deployed by international NGOs and UN agencies. By late 2004, MSF had more than 200 expatriate volunteers working in twenty-five projects serving some 600,000 people. In most of the camps, the mortality and malnutrition rates declined steadily, falling below the emergency threshold in early 2005. This was unprecedented in the history of the Sudanese civil war, where massacres had hitherto been followed by widespread famine.

While exposure of the crisis—and the ensuing media and diplomatic mobilisation—made such an opening possible, MSF was divided about what attitude it should take regarding the public opinion campaign for an international military intervention to “stop a genocide” in Darfur. None of the sections believed they were seeing an extermination policy comparable to that observed in Rwanda. Nevertheless, only the French section felt it necessary to distance itself from the dominant discourse then subscribed to by most NGOs.

In June 2004, the French section published the results of retrospective mortality surveys conducted in IDP camps. These were the first epidemiological field data to contradict the government’s claim that there were no massacres, and showed that pro-government militias had killed several thousand people (4% to 5% of the original population of attacked villages) during the counter-insurgency campaign. But the section refuted the characterisation of genocide, questioning the existence of racial extermination doctrines and programmes in Sudan. It underscored the urgent need to expand humanitarian relief operations, now that the government had halted the most brutal aspects of its campaign, and diarrhoea and malnutrition had become the most common causes of death. The genocidal view is the result of “propagandistic distortions” wrote the president of MSF-France, condemning “certain human rights organisations” for trying to impose “a new international political order where serious human rights violations would be subject to systematic—and, if necessary, armed—international intervention”.Jean-Hervé Bradol, Le Quotidien du Médecin, 19 July 2004.

 In so doing, the propagandists of the genocidal view were misleading the public and the political powers about which actions were most necessary to save lives. What was needed was a massive influx of aid—not troops.

Heads of the French section believed that international military intervention aimed at occupying part of Sudan or overthrowing the regime would be a disaster, like in Iraq and Somalia, just when the level of violence had dropped sharply. MSF Holland’s operations director was of the opposite opinion. Using the rhetoric developed by MSF in Bosnia, he declared that the international community would not be satisfied with an aid-only policy in Darfur. His remarks were then used by supporters of intervention, like New York Times columnist Nicholas Kristof, who maintained “the aid effort is sustaining victims so they can be killed with full stomachs”. While the public opinion campaign condemned the rapes committed by pro-government militias as part of an “ethnic cleansing” strategy, the Dutch section published a report in March 2005 documenting over 500 cases of sexual violence and demanding that the impunity enjoyed by the perpetrators be brought to an end. A few weeks later, the Security Council took the decision to refer the Darfur crisis to the International Criminal Court. In March 2009, the ICC decided to charge Sudanese president Omar al-Bashir with war crimes and crimes against humanity. The French and Dutch sections were then expelled from Sudan, along with nine other international NGOs, accused by the government of having “violated [their] mission as humanitarian organisations” by cooperating with the “socalled International Criminal Court”.“Sudan expels 10 aid NGOs and dissolves 2 local groups”, Sudan Tribune, 5 Mar. 2009.

The expulsion of the two MSF sections accused of collaborating with the ICC, and the rejection of the ICC by many countries where the organisation works, cast a chill over the whole movement. Since 2009, MSF has been more hesitant than ever to speak out on the crises in which it intervenes, out of fear that its words will be used to justify war or international criminal prosecutions, thus jeopardising its presence. The scepticism evidenced by some toward the international criminal justice system and armed protection for civilian populations helped to justify a policy Dr Pigeon would have agreed with—silence heals.

Some MSF members see this return to the 1971 charter as a major political step backward. They point out that without international mobilisation on Darfur, MSF would never have been able to extend its operations, and that tens of thousands of Sudanese would probably have perished from hunger and continued violence. In other words, if the United Nations hadn’t broken the silence in March 2004, MSF would have had to speak out, even if that meant fuelling a political dynamic leading to the possibility of criminal or military sanctions against the Sudanese leadership. What’s more, they point out, by not making a concerted effort to condemn both the regime’s crimes and the propagandist lies of the neo-conservative lobbies, the entire MSF movement lost the opportunity to build political alliances beyond the western powers and the UN.

At a time when countries are more concerned than ever about their international image—to the point of codifying their intolerance of criticism in a contractual or legislative framework—MSF is reluctant to make use of its capacity to speak out. Afraid to be seen as a stakeholder in legal or military processes, and thus compromise its access to conflict zones, it tends to let other international actors speak for it, hoping to distinguish itself as the language police by tracking down misuses of humanitarian semantics. In so doing, it struggles to show its uniqueness, and to demonstrate by example the autonomy it demands.

MSF’s public positions have been built on its experiences in the field, using the ideological frameworks of the moment, in the hope of strengthening and prolonging its policies for assisting populations. Influenced by neo-conservatism in the 1970s and 1980s, and then tilting toward liberal internationalism in the 1990s, MSF must now pursue its own policy based on the rejection of sacrificeJean-Hervé Bradol, “The Sacrificial International Order and Humanitarian Action”, in Fabrice Weissman (ed.), In the Shadow of ‘Just Wars’…, pp. 1–22. and ad hoc choice of its alliances. With the liberal democracies and the UN—upon whom it relied during its first thirty years—going to war, MSF is now being forced to diversify its diplomatic and political support without neglecting on principle its former comrades (e.g., UN agencies, human rights groups, western diplomacy and other humanitarian NGOs). If it wants to offer impartial, effective aid, MSF must distance itself equally from the liberal imperialism of the societies of its origins and the des-potism of many of the countries where it intervenes. Experience has shown that it can only succeed with the support of political and diplomatic coalitions of convenience, rallied through an engagement in the public space, without which humanitarianism is only a passive instrument in the service of power.

Translated from French by Nina Friedman

***

 

Caring for Health

Jean-Hervé Bradol

The first step taken by the founders of MSF was to create an organisation made up “exclusively of doctors and members of the health sector” to assist “victims of natural disasters, collective accidents and situations of belligerence”. MSF’s first charter, drafted in 1971, MSF Board of Directors archives, Paris.

 At its first general assembly, they drew up a charterMSF charter, amended in 1992, http://www.msf.fr. setting forth the principles that would guide the action of the organisation. These principles of impartiality, neutrality and independence were inspired by those of the Red Cross, and later included a reference to medical ethics.

At the beginning of the 1970s, the prevailing trend among non-governmental organisations was to extend their action beyond patient medical care to health promotion. Presenting itself as an institution focusing on crisis situations and patient care therefore set MSF apart from other international aid organisations. However, its aim of providing care on the scale of a whole population was early evidence of a public health ambition. This ambition, implicit in the first version of MSF’s charter (1971), was no longer so in the second version (1992), with its explicit reference to “populations in distress”.

The terms “non-governmental organisation”, “without borders” [sans frontières] and the “independence” of humanitarian aid workers are misleading. They imply that MSF can single-handedly decide on its objectives and the activities to be implemented to achieve them. In reality, there is no such thing as a “no man’s land”. However unstable a situation, any humanitarian presence, especially foreign, necessarily involves negotiations with local political and health authorities, be it the governor of a region, a health official, the officer in charge of a militia, the head of a village or a slum gang-leader. So how did MSF manage to negotiate the inclusion of a new organisation of practitioners in the public health field? This chapter does not tell the story; it is more a journey through forty years of history seen from three different angles: the discourse, the field missions and the management of the organisation’s institutional development.

Contemporary public health was born in Europe and the United States in the nineteenth century during a period of social reformism and advances in knowledge on the transmission and control of infectious diseases: “Public HealthCharles-Edward Amory Winslow, The untilled fields of public health”, Science, 1920, 51: 23–33. is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, control of community infections, educating people in personal hygiene, organisation of healthcare services for the early diagnosis and preventive treatment of disease and the development of social measures to ensure to every member of the community an adequate standard of living for the maintenance of health”.

Charles-Edward Amory Winslow, “The untilled fields of public health”, Science, 1920, 51: 23–33, quoted in Karen Buhler-Wilkerson, “Public health nursing: in sickness or in health?”, American Journal of Public Health, 1985, 75: 1155–1161.

 Dating back to the beginning of the twentieth century, this conception of public health continues to inspire health policies today.

The period we look at in this chapter (1971 to 2011) has seen major geopolitical upheavals, including decolonisation, the Cold War, the collapse of the Soviet Union, India and China’s membership of the World Trade Organisation, Brazil’s emergence as a global player and the extension of the European Union. As a result of these developments, public health has gradually taken on a dimension that extends beyond national frameworks, as well as those of colonial health, cooperation between two governments or regional cooperation between several states. Public health, tropical medicine, human and political sciences have all converged to create global health. Transnational health, a more measured expression for describing this evolution, has become a field in which institutions, public or private, local, national, regional, international or transnational, have entered into discussions, often tense, on the state of knowledge, the choice of norms, order of priorities, assessment of results and distribution of available resources.

For those operating in the field, this progression in transnational health meant determining where they stood on a series of initiatives decided within institutions such as the WHAThe World Health Organization is governed by 193 State parties, which meet once a year at the World Health Assembly (WHA). (World Health Assembly) operating on a global level. Non-governmental organisations were being asked to help governments make the major campaigns of the United Nations a reality: the Expanded Programme on Immunization (WHA, 1974), the essential medicines list (WHA, 1977), universal access to primary healthcare in 2000 (international conference on primary healthcare in Alma-Ata, 1978), the Bamako Initiative for accelerating access to primary healthcare for African populations (commitment made by African health ministers at the 37th regional meeting of the WHO, 1987), the Global Polio Eradication Initiative (AMS, 1988) and the Millennium Development Goals on health (Millennium summit, United Nations headquarters in New York, 2000).

What role should MSF play in the implementation of major public health policies? This has been the subject of debate since the organisation’s first general assembly in 1972: “There are two opposing positions: the first argues for medical care to be delivered by volunteers who can be rapidly mobilised for short missions. […] The second, supported by volunteers returning from Bangladesh and Upper Volta [now Burkina Faso], defends the principle of intervening in that other emergency: the chronic lack of medical care in the third world”.Anne Vallaeys, Médecins Sans Frontières. La biographie, Paris: Fayard, 2004.

At the beginning of the 1970s, this divergence was handled with pragmatism. In order to exist, and also to gain recognition, MSF’s priority was to send an increasing number of doctors and nurses out to the field. This was the rationale behind its offer to second personnel to other organisations (Red Cross, UNICEF, UNHCR, Frères des Hommes, etc.), as well as to health ministries and even to the French Ministry of Cooperation, as in this project discussed in 1973: “In Yemen, the hospital would be built by the government and MSF would be responsible for running it. […]. This type of mission could make MSF an international player. […]. And what’s more, it could be developed by young doctors on compulsory civilian service”.Minutes from the peer group management meeting on 31 Jan. 1973, MSF, Paris.

Resisting Totalitarianism and Supporting the United Nations’ Major Campaigns

During the 1980s, MSF field missions increased. Concerns about the organisation’s survival continued in an increasingly competitive environment which saw the founding of medical NGOs, such as Médecins du Monde (1980), and other bodies working in related fields, such as Action Internationale Contre la Faim (1979). MSF needed to affirm its existence, but also to distinguish itself through its presence in the field, the nature of its activities and its arguments voiced in the public arena. Meanwhile, ideological debates were gaining ground in NGOs, fuelled by political clashes in the international arena.

In the Cold War climate, the so-called under-developed countries, mainly former colonies which had recently gained independence, found themselves at the centre of a struggle for influence between the two blocs. In 1949, combating under-development was already one of the four key messages in US President Harry S. Truman’s inaugural address:

 http://www.trumanlibrary.org/calendar/viewpapers.php?pid=1030.

“We must embark on a bold new programme to make the benefits of our scientific advances and industrial progress available for the improvement and growth of under-developed regions. More than half the people in the world are living in conditions approaching misery. Their food is inadequate. They are victims of disease. Their economic life is primitive and stagnant. Their poverty is a handicap and a threat both to them and to more prosperous areas”. This ambition for development was shared and, to a large extent, it transcended political divisions, as had the civilising mission of colonialism in other times. But although there was consensus on the objective of development, there was also fundamental disagreement on how to achieve it: Public or private services? Economies administered by state agents or “market” agents? Capitalism or socialism?

Third-worldism, development, poor countries’ debt, famine and international health issues were at the heart of the debate led by Liberté Sans Frontières (LSF), a foundation created in France by MSF (1984 to 1989). In the proceedings from the 1985 conference “Le Tiers-mondisme en question”, LSF made its criticisms clear: “Basically, the tenets of the ‘new order’,In 1974, the United Nations General Assembly adopted a declaration concerning the establishment of a New International Economic Order (NIEO), one of whose objectives was to address development issues related to the cost of raw materials. supported by the whole third world movement, have the singular characteristic of pursuing perfectly admirable objectives through means that can only lead to their failure”.Rony Brauman (ed.), Le Tiers-Mondisme en question, Paris: Olivier Orban, 1986.

 LSF described third-worldism as the love child of “Leninism and Social Christianity”, “a sort of extension of traditional social morality on a worldwide scale”. These public stances were the reflection of the organisation’s commitment, alongside the neo-liberals, to the various struggles underway at the end of the Cold War. So it is hardly surprising that the humanitarian doctors came out of the war in Afghanistan (1979 to 1989) saddled with the affectionate nickname of “French doctors”.

The financial issues relating to health did not escape this trend towards neo-liberal theses: “Research is a long and costly process that only pharmaceutical companies can afford, and the pharmaceutical industrialisation of the third world is no panacea”.Alain Destexhe (ed.), Santé, médicaments et développement. Les soins primaires à l’épreuve des faits, Paris: Fondation Liberté Sans Frontières publications, 1987, p. 12.

 These opinions were adopted at the instigation of some of MSF’s management in Paris, but this marked political stance against third-worldism met with fierce and broad-based opposition among the members of the organisation in France, as well as in Belgium, where a section had been created in 1980.

As far as MSF’s management team was concerned, this rejection of third-worldism was not simply ideological opposition to attempts at social and health engineering, which it perceived as being tinged with totalitarianism. The organisation’s experience with assistance to refugees and its management’s anti-communism fed off each other. According to the UNHCR, between 1976 and 1982, the number of refugees worldwide rose from three million to eleven million, and continued to increase until the 1990s. These refugees were Vietnamese, Cambodian, Laotian, Afghan, Ethiopian… and were proof “by their very existence of the failure of communism, as the ‘people’s republics’ of the third world ‘produced’ nearly 90 per cent of the total number of the world’s refugees”.“Introduction”, in François Jean (ed.), Populations in Danger, London: John Libbey, 1992.

Missions to assist refugees were a political choice, but the camps, delimited and relatively stable, were also the perfect place for learning medical and health practices. In these camps, as a result of successive delegations (from the Ministry of Health to the UNHCR and from the UNHCR to MSF), humanitarian doctors found themselves in charge of public health. It was therefore crucial for them to shake off their image as well-intentioned, medical adventure-seekers, but ineffectual in public health terms. An image taken to heart by many humanitarian doctors, they developed an inferiority complex vis-à-vis their peers. The refugee camps in Thailand, Pakistan, Sudan, Somalia, Malawi, Rwanda, Zambia, South Africa and Honduras provided an ideal introduction to public health practices for MSF teams.

The acquisition of new expertise soon led to the compiling of clinical and therapeutic handbooks and essential medicines guidelines adapted to the specific circumstances of humanitarian medical practice. On the basis of these guidelines, medicine and medical equipment kits were put together to facilitate the launch of emergency operations and, in 1986, a logistics procurement centre was set up in France to supply the different programmes.Claudine Vidal, Jacques Pinel, “‘Satellites’: A Strategy Underlying Different Medical Practices”, Jean-Hervé Bradol & Claudine Vidal (eds), Medical innovations in humanitarian situations, The work of Médecins Sans Frontières, Médecins Sans Frontières, 2011, pp. 22–39.

 Internal training courses were organised and health managers were sent to public health schools in the United States. The intervention epidemiology developed by the CDC (Centers for Disease Control and Prevention) thus became a model for Epicentre, created in 1987, whose objective was to carry out epidemiological studies to improve the assessment of programmes and measure the results obtained in terms of public health.

The work carried out by Epicentre resulted in the drawing up of a series of priorities to be taken into account when opening a camp in an emergency situation: needs assessment, measles immunisation, water and sanitation, food, shelter, site planning and organisation, health-care, control of communicable diseases, epidemiological surveillance, staff recruitment and training, and the coordination of operators. In this respect, the intervention in Malawi in the 1980s was viewed as the most successful refugee assistance operation: “In managing the health of almost half of the refugee population, Approximately 200,000 people. from site planning, nutrition, hygiene and public health, through to on-going epidemiological surveillance, we had to develop expertise that for the most part we only used intermittently”. But there was another side to the coin. MSF personnel were busy with tasks increasingly removed from patient care. Doctors sent out to the field encountered public health for the first time and threw themselves with all the enthusiasm of novices into sanitarian campaigns with illusory outcomes, made up of authoritarian injunctions aimed at the people living in the camps.

From the early years, MSF’s medical assistance to people affected by armed conflict coexisted with interventions of medical technical assistance, the aim of which was to “transfer knowledge” and help “governments set up and manage their country’s health programme at national or regional level”. Vincent Brown, “Impact des grands slogans des Nations unies sur les programmes d’assistance technique de Médecins Sans Frontières”, MSF internal report, Paris, 1991, p. 17.

 For MSF’s French section, of the forty or so missions underway at the end of the 1980s, eight fell into the technical assistance category (Yemen, Madagascar, Guinea, Niger, Guatemala, Romania, Vietnam and Laos). These projects consisted of setting up immunisation programmes and primary or community healthcare programmes (water, hygiene and sanitation in the Mezquital slum in Ciudad de Guatemala). However, during the 1980s, the organisation’s growing international dimension shifted the balance between missions responding to conflict situations and technical assistance.

Most of the activity (and sometimes all) of the Belgian, Swiss, Dutch and Spanish sections was, until the beginning of the 1990s, medical technical assistance.

Begun in 1981 when expatriate doctors were sent out to make up for the absence of qualified national staff in two prefectures in the north of the country, MSF-Belgium’s work in Chad was a perfect example of how to support the administration of a health district, i.e. a referral hospital with a network of dispensaries. In 1983, MSF opened a pharmaceutical store to supply the hospitals and dispensaries and, by 1985, in nine prefectures of the country which had no medical school to train its own doctors, all the “préfets sanitaires”, to use the country’s terminology, with only one exception, were doctors sent by MSF: “De facto, Chad sub-contracted its health strategy to an NGO. From 1983, MSF had in N’Djamena an effective radio communications network, collected data, drew up epidemiological curves and planned programmes. MSF’s offices were adjacent to the Ministry of Health”. Eric Goemaere, “Une ONG au ministère”, in Rony Brauman (ed.), Utopies sanitaires, Paris: Le Pommier, 2000.

All these technical assistance missions followed in the wake of the major public health drives coordinated by the United Nations, in spite of Liberté Sans Frontières’ reservations regarding the final declaration of the 1978 Alma-Ata conference: “Some saw it as a revolutionary text urging a radical change to society. Village health workers were presented as ‘liberators’ who would free their people”. Destexhe (ed.), Santé, médicaments et développement, p. 10.

 The first criticism concerned the goal of “health for all the people of the world by 2000”, which seemed to promise a totalitarian utopia: “The Conference strongly reaffirms that health […] is a state of full physical, mental and social wellbeing, and not merely the absence of disease or infirmity”. The second criticism was of the means for achieving this goal, and especially the role accorded to village health workers, modelled on the “bare-foot doctors” of Maoist China. The level of responsibility entrusted to a category of personnel with no medical or paramedical skills did not bode well for their chances of success, especially given the lack of training, supervision and material resources available to them.

In spite of these criticisms, the will to disseminate biomedical practices in countries said to be under-developed, combined with the principle of equity at the core of the primary healthcare strategy, had a unifying effect. Vaccinating children, targeting priority diseases according to their impact on mortality and the chances of treating them successfully, standardising protocols for the treatment of diseases, establishing a list of essential medicines to be supplied as generics, improving the organisation and management of healthcare facilities, all these goals seemed to be an enormous improvement on the way third world hospitals and dispensaries were usually run. The 1987 Bamako Conference had also eased some of the concerns raised by the Alma-Ata Declaration. It proposed decentralising management to health centres where care would be delivered under the supervision of qualified healthcare professionals, and suggested a means of addressing the issue of funding: users contributing towards the cost of health services. This measure was in phase with the Structural Adjustments policies of the World Bank and the International Monetary Fund that sounded the death knell of the welfare state.

MSF’s overall assessment of its technical assistance activities was summed up in the report made by MSF France’s president at its general assembly in 1988, a year that had been marked by financial difficulties for the organisation: “The usefulness of these missions is beyond doubt and it is very likely that in the years to come there will be extensive opportunities for funding them”. XVIIth general assembly of Médecins Sans Frontières, president’s report by Dr Rony Brauman, op. cit, p. 5.

The Missed Opportunities of Development and the Victory of Neo-liberalism

The growing influence of neo-liberalism at the beginning of the 1980s and its effects on health systems were not called into question by MSF at the time. Yet those of the organisation’s doctors who had assumed responsibilities in public health administrations found themselves in the frontline when it came to dealing with the obstacles in implementing primary healthcare. In the wake of the Bamako Conference, these doctors had become the administrators of user contributions to the cost of health services in the hope that the revenues raised would allow access to quality care for all. But the reality was quite different: the contributions made by families could not offset the financial disengagement of the states. Anyone with insufficient means was excluded.

These budgetary tensions impacted negatively on the running of health structures and the quality of care. There was a lack of motivation amongst health staff, particularly those on the lowest salaries, sometimes resulting in high levels of absenteeism, protests, and even strikes. The adoption of new therapeutic protocols, sorely needed because bacteria and parasites were becoming increasingly resistant to usual treatments, was being hindered by budget restrictions imposed on governments.

The diversity of the health techniques required for the successful completion of these missions weighed heavily on MSF’s technical support departments and the other medical, epidemiological and logistical structures established to support its operations. The recruitment department rarely found staff with the qualifications necessary to handle all the tasks at hand. In Europe, head office managers were finding it increasingly difficult to answer the questions from the field, as their own knowledge of health policies was limited. They had little contact with the two United Nations agencies, UNICEF and the World Health Organization (WHO), which were trying to coordinate the implementation of the policies.

The absence or inadequacy of biomedical practices observed over vast geographical areas, a phenomenon portrayed as the “healthcare desert”, was at the origin of technical assistance missions. It pleaded in favour of a “knowledge transfer” to countries described as under-developed. However, the users showed little interest in a healthcare offer that required them to contribute in the name of “community” participation, when there had been no definition of the “community” concerned or of the healthcare expectations of the members of this so-called “community”. At the end of the 1990s, an analysis of MSF activities in Guinea’s Kankan prefecture clearly illustrated the limits of these types of missions: “Rapidly, the biggest problem identified by all the partners was ‘low attendance rates in the dispensaries. […] There had never been any measurement of the population’s satisfaction nor of the objective parameters of morbidity or mortality. […] Because of the cost recovery system, the sale price of drugs was partly calculated on the basis of amounts sold, and so low attendance posed a problem of financial survival for the programme”.Philippe Biberson (president of MSF-France from 1994 to 2000), “Le désert sanitaire”, in Rony Brauman (ed.), Utopies sanitaires, op. cit., pp. 93, 95, 96.

 For all that, did this mean giving up on technical assistance and the idea of third world development?

In 1992 criticism within MSF was no longer limited to third-worldism: the very idea that humanitarian aid should aim to contribute to development was being contested. A new definition of humanitarian action was put forward in the introduction to the first collective book to be published since Liberté Sans Frontières was made dormant in 1989: “First, let us hazard a minimum definition. Humanitarian action aims to preserve life and human dignity and to restore people’s ability to choose. To accept such a definition is to say that in contrast to other areas of international solidarity, humanitarian aid does not aim to transform society but to help its members get through a crisis period, in other words when there has been a break with a previous balance”.“Introduction”, in François Jean (ed.), Populations in Danger, 1992, op. cit., pp. 3–9.

This appeal to end attempts at social and health engineering also pleaded in favour of greater autonomy for MSF vis-à-vis public health policies decided by governments and the United Nations. One of the consequences of this change in position was that the organisation refocused its operations on situations of conflict and the response to epidemics and natural disasters, in tune with a new conception of humanitarian action’s specific scope: emergencies. However, such interventions were too unpredictable and often too short-lived to be the only action on which to base the organisation’s development. Providing assistance to refugees appeared to offer a more secure working framework, while staying within the limits set by the definition of 1992. However, this new strategy coincided with the breakup of the communist bloc, and the victory of neo-liberalism transformed perceptions of the refugee issue.

“The [Vietnamese] boat people have lost their political heft, their symbolic status and their media visibility. They are now treated on the same footing as the Albanian boat people, who were sent back to poverty by the Italian authorities, or the Haitians returned to dictatorship by the American Coast Guard in total disregard of the principles set out in the 1951 Convention on refugees. […] The time is past when refugees testified to the superiority of democratic systems and the ‘great misery’ of communism”. Jeanm “Refugees and displaced persons...”, pp. 121–6.

 The image of the dissident seeking escape, once seen as “a hymn to freedom”, was replaced by that of the undesirable economic immigrant. This mutation in perception was partly due to the reticence of funding agencies, accentuated by the UNHCR’s poor resource management. Host countries and funding agencies alike exerted constant pressure to ensure ever-greater reductions in aid. Any assistance to refugees was suspected of inciting economic migration.

Yet as the Cold War came to an end, civil wars in Afghanistan, Myanmar, Liberia, Somalia, Bosnia, Georgia, Sierra Leone, Burundi, Rwanda, Chechnya, etc., triggered massive exoduses, which the major powers and the United Nations attempted to contain by injecting aid into conflict zones. Internally displaced persons camps and “safe humanitarian zones” served through “humanitarian corridors” rapidly replaced camps set up beyond national borders. Yet the protection and the standard of aid received in these new camps were far inferior to that provided to refugees living in countries at peace.

Repatriation, not always safe or voluntary, replaced asylum as the key word in refugee management policies.

MSF’s reaction to the tensions caused by this new policy towards peoples fleeing conflict was to call for respect for their rights and compliance with health standards adopted in a geopolitical context that, since the fall of the Berlin Wall, belonged to the past. In 1989 and 1990, this shift in position led to an epidemic of pellagra among the 400,000 or so Mozambicans living in camps in Malawi.Pellagra is a disease caused by malnutrition (vitamin PP or trytophane deficiency), which in the most serious cases can lead to dementia and death.

 Forty thousand cases of the disease were recorded, caused by dietary deficiencies, but MSF had the utmost difficulty obtaining recognition Alain Moren, Dominique Lemoult, “Pellagra cases in Mozambican refugees”, The Lancet, 1990; 335, pp. 1403–4. of the fact that the epidemic originated from shortfalls in an aid system that didn’t meet its own nutritional standards.

Learning Political Autonomy

In the middle of the 1990s, MSF’s experience with technical assistance missions enabled it to recognise the need to focus attention on those excluded from primary healthcare: economic migrants, inhabitants of third world slums, unemployed people living on the streets in rich countries, low-income workers and peasants, sex workers, drug-users, under-privileged children (in orphanages and detention centres for minors or the homeless), common-law prisoners, the destitute elderly, semi-nomadic peoples, and so on. Some MSF employees on their way to work found themselves regularly stepping over people whose living conditions were so atrocious it was hard to tell whether they were still alive. Others, out for a meal in the evening, would hand a few coins to children in rags and in obviously deplorable health to keep an eye on their cars. For those who witnessed, either professionally or personally, the health of people housed in secure institutions (orphanages, prisons, detention centres for minors, hospices, asylums, etc.), the shock was even greater. Confronted with situations of distress that their actions were not addressing, getting involved in these new fields of intervention was a means of responding to the moral and political quandary in which MSF’s teams found themselves. This new focus also increased the number of programmes institutional funding bodies were willing to support and contributed towards MSF’s rapid growth.

The expression “new fields of intervention” implicitly referred to those programmes that did not fit into the category of aid to disaster-stricken populations (war, epidemics, natural disasters and famine) or that of technical assistance, although some of them had already been running for several years. The Mezquital slum mission in Ciudad de Guatemala and the Mission France, both opened in 1987, were prime examples.

By gradually abandoning technical assistance projects to concentrate on situations being presented as “new”, MSF did not completely forsake the major United Nations campaigns, which in the meantime had evolved. In fact, the image of development had blurred to the extent that it was now suspected of exhausting the world’s natural resources. As for economic growth, it had been accompanied by such an increase in social inequality that it had become difficult to believe that one day it could actually benefit the most vulnerable populations. Consequently, the United Nation’s lexicon of economic and social action was updated, development policy became linked to poverty reduction, and 1996 was proclaimed international year for the eradication of poverty. In this new context, the goal was no longer “health for all the people of the world by 2000”, but the partial reduction of some of the main health scourges by 2015: malnutrition, maternal, infant and child mortality, AIDS, malaria and tuberculosis. The method put forward to reach this goal relied on the combined effects of economic growth and specialised assistance programmes for the excluded, and was made up of health activities selected on the basis of a good cost-effectiveness ratio. The public health programmes promoted by the United Nations and WHO abandoned their generalist vocation to become almost exclusively specialised. Specialisation—so-called vertical programmes focusing on a delimited category of care, such as the malaria eradication programme—had existed since the beginning of the 1950s, but became systematic by the end of the 1990s.

This new policy adopted by governments and the United Nations did not garner as much support as the arguments put forward in favour of development in the 1970s. The failure of the “cost recovery” system in health centres had left its mark, especially as it was still in use. MSF’s fear was of once again being associated with a policy that might backfire on its supposed beneficiaries. Rather than gamble on the hypothetical combined benefits of economic growth and assistance programmes specialised in caring for those overlooked by development, the organisation advocated for the re-inclusion of excluded populations in common-law health systems. For MSF, this didn’t mean simply demanding the enforcement of existing rights, but formulating new ones and promoting their incorporation in national and international legislation. Thus, in France the organisation was not only active in drafting the law on universal health coverage but battled over each and every point of the decree.

In the case of MSF’s programme in Madagascar, which provided medical treatment to “street children”, aspirations for the government to assume its role became so intense that it led to its closure in 2005, despite the ever-increasing number of people excluded from healthcare with no public services lined up to replace it: “Today, 70% of the capital’s inhabitants live below the poverty line. There is less and less difference between homeless families living in the street and everybody else. […] Yet the issue of medical treatment and healthcare for the poor is a political, economic and social one, and should be addressed by the public authorities. Poverty reduction is today’s goal. […] A humanitarian organisation such as MSF has neither the mandate nor the ability to replace the authorities and provide access to healthcare for all of a town’s impoverished population”.“12 ans auprès des enfants en situation difficile à Tananarive. Les raisons de la fermeture et le bilan du programme”, MSF, Paris, 2005, www.msf.fr.

 But the fact remains that even if the cooperation with the health ministries had not always helped improve access to healthcare for the least well-off, breaking it off completely was going to cause further hardship.

The Response to Epidemics and Immersion in Global Health

Is it possible to oppose public policies that are detrimental to patient care without becoming isolated and giving up on trying to influence them? A public health action on a global scale—the relaunch of the combat against infectious diseases—gave MSF the opportunity to explore different avenues to answer this question. The renewed interest of governments and international organisations in infectious diseases was triggered by a prognosis made in 1992 by the National Academy of Science in the United States, which presented infectious diseases as a threat to health likely to “persist and even intensify in the future”.Joshua Lederberg, Robert E. Shope and Stanley C. Oaks, Jr., editors, Emerging Infections: Microbial Threats to Health in the United States, Committee on Emerging Microbial Threats to Health, Division of Health Sciences Policy, Division of International Health, Institute of Medicine, National Academy Press, Washington D.C., 1992.

 In 1995, the WHO set up a division headed by a director recruited from the CDC for the surveillance and control of emerging and communicable diseases.

MSF had been involved in responses to epidemics and major endemics, both in refugee camps and in so-called open environments, for more than fifteen years as part of its technical assistance. Programmes aimed at controlling sleeping sickness had begun in Moyo, Uganda in 1986 and since the beginning of the 1980s, interventions in the camps had brought the teams up against a wide range of epidemics: cholera, measles, meningitis, shigellosis, etc.

In 1995, MSF helped to relaunch the combat against infectious diseases, partly to address real needs on the ground and partly to offset the reduction in technical assistance projects and programmes in refugee camps. At the beginning of 1996 MSF ran a meningitis immunisation campaign in the northern states of Nigeria: almost three million people were vaccinated and thirty thousand patients were treated for the infection.

The emergence of new epidemics (Ebola and AIDS, in particular), the re-emergence of old diseases (such as tuberculosis and hemorrhagic dengue), and the fear of bioterrorism (rekindled by a handful of anthrax letter attacks in some big North American cities in 2001), prompted governments to take action. In 2000, in a report that has since become famous, “The Global Infectious Disease Threat and Its Implications for the United States”, John C. Gannon, Chairman, National Intelligence Council, CIA, NIE 99–17D, Jan. 2000. the CIA confirmed that the issue was being taken very seriously as “infectious diseases posed a threat to national security, the economy and political stability”. The concern, not necessarily justified from an epidemiological point of view, was provoked mainly by the progression of epidemics due to HIV. Resolution 1308 of the United Nations Security Council in 2000 “stress[ed] that the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security”. The World Bank described AIDS as the “crisis of development”. In September 2000, the United Nations General Assembly adopted the Millennium Declaration, with one of its goals formulated as follows: “to have […] halted, and begun to reverse, the spread of HIV/AIDS, the scourge of malaria and other major diseases that afflict humanity” by the year 2015.

For international organisations and governments providing the funding for this goal, the programme that eradicated smallpox in 1979 was an ideal model for combating infectious diseases. Based on preventing new cases by containing transmission to such an extent that the disease disappeared, it required an initial investment of several years (the immunisation campaign) and resulted in a conclusive outcome (the elimination of the disease).

Three conditions are required for implementing such a strategy: effectiveness, price and universal availability. Yet the cost of new medical products prior to large-scale use is always prohibitive for public health institutions and users. They can only be widely prescribed once
specific economic models are developed for the launch of major public health actions.

But there is a further constraint specific to drugs for treating infections. Treatments must be renewed rapidly because bacteria, parasites and viruses develop resistances at a fast rate. In infectiology, practitioners usually need recent and expensive drugs. Yet at the end of the 1990s, the situation had deteriorated to such an extent that even the old but still effective medicines were beginning to run out. At the international medical symposium on the response to epidemics organised by MSF in 1996,International medical symposium, MSF internal document, Paris, 20 Oct. 1996. participants pointed to a lack of research: among the 1,000 new molecules put on the market since 1975 only ten or so had been developed for the treatment of tropical diseases and tuberculosis. After the symposium, this issue became the subject of a publication: Dr Patrice Trouiller, Piero Olliaro, Els Torreele, James Orbinski, Richard Laing, Nathan Ford, “Drug development for neglected diseases: a deficient market and a public-health policy failure”, The Lancet, Volume 359, Issue 9324, pp. 2188–94, 22 June 2002.

 As a result, in the middle of the 1990s, medicines—whether for treating epidemics (AIDS, meningitis, etc.), major endemics (tuberculosis, sleeping sickness) or banal community infections (pneumonia, malaria, etc.)—were in increasingly short supply. The response by governments and international organisations to malaria (insecticides and mosquito nets) and AIDS (drive to change sexual behaviour and promote use of condoms) focused exclusively on preventive measures. Treatment for tuberculosis was concentrated on patients who had the bacteria in their sputum and could therefore contaminate their entourage. There was a clear gap between the offer (the medical products available) and the demand (clinical and health priorities in infectiology). Practitioners working in countries where infectious diseases were still the primary cause of mortality gradually found themselves without the means to take effective action.

At the beginning of the 2000s, a multitude of institutions (national public administrations, international organisations, pharmaceutical companies, private national and international associations, religious institutions, trade unions, political parties, etc.) endeavoured to improve this situation of penury. The internet was the preferred vector for relations that transcended borders, evolved and reached out to the most peripheral stakeholders (patients, care providers, citizens) and the summits of health institutions (WHO, UNICEF, etc.), economic institutions (World Trade Organization, WTO), and political institutions (United Nations General Assembly and Security Council, G8). Until then, questions concerning access to medicines had been discussed behind closed doors and the only participants were experts, industrialists and state representatives. Now, the debate on conditions of access to new medicines had become the object of considerable media attention and the presence of AIDS-response organisations and practitioners such as MSF at the negotiating table was deemed necessary.

Remembering the lessons learnt from its experience with medical technical assistance, MSF created the Campaign for Access to Essential Medicines, financed in part by the Nobel Peace Prize that it had been awarded in 1999. It was important to avoid finding itself once again being associated with a transnational public health campaign without having any influence over the decisions taken at the top, whether at national level in the ministries of health or within international organisations such as the WHO. MSF urged that the fight against infectious diseases should not be based exclusively on preventive measures to eradicate the pathogenic agents, but that it should also include treatment for those suffering from them. To this end, new medical products would be needed and their use incorporated into national and international strategies.

At the end of the 1990s, MSF decided that to influence public policies action was required at the very root of the problem. This meant identifying levers to secure changes in policy and establish new alliances. So MSF developed links with activist organisations such as South Africa’s Treatment Action Campaign and countries such as Brazil and Thailand, which were striving to broaden access to medicines protected by patents in middle-income countries. MSF was now represented at every link in the chain: at the patient’s bedside, at meetings in hospitals, in the office of the physician in charge of health at district or regional level, at the ministry, at the offices of international organisations, at scientific congresses, whenever and wherever international activists were organised (the G8 counter-summits, for example), but also in the offices of the heads of states’ sherpas, at the headquarters and factories of pharmaceutical companies, in the administrative departments responsible for importing medical products—and of course in the public debate.Marc Le Pape, Isabelle Defourny, “Controversy as a policy”, in Jean-Hervé Bradol and Claudine Vidal (eds), Medical innovations in Humanitarian situations, Médecins Sans Frontières, 2011.

Why was it that in the case of AIDS, for example, the national governments providing the funding agreed to derogate from the “smallpox elimination” model and undertook to spend several billion euros annually in treating millions of patients, in spite of the fact that there was little prospect of the disease being eliminated? A partial explanation for this untypical behaviour is to be found in the threat AIDS poses to public security, the exceptional level of social mobilisation, the fear of serious economic fallout and the rapid scientific advances. It was also essential to take into account the importance of public debate on the issue of intellectual property rights and the pharmaceuticals trade.

At the end of the 1990s, the WTO focused on the globalisation of the rules on intellectual property rights applicable to trade. But the commercial monopoly granted to pharmaceutical laboratories depositing a patent was largely responsible for the high price of new treatments, especially antiretrovirals. A public health disaster coupled with the prohibitive cost of medicines (several thousand dollars per year and per patient) raised the question of the compatibility of intellectual property rules with public security and, notably, health. The stakes were high: the tension between the two imperatives, respect for private property and public security, was weakening the economic system. It thus became urgent for the United States, the European Union and Japan, the main promoters of the new rules on intellectual property, to make a number of concessions on access to medicines. Their attitude of indifference, aggressiveness even, shared by the major pharmaceutical multinationals, was in danger of triggering a strong reaction against the extension of intellectual property rules to world trade as a whole. Thus, a few months before the WTO Ministerial Conference in Doha (2001), and against the backdrop of the Pretoria court case,In 1998, a coalition of forty or so pharmaceutical laboratories took the South African government to court in an attempt to prevent it from applying a law passed in 1997 in favour of the production of generic medicines. The suit was dropped in 2001 after the waging of an opinion campaign supported by MSF. United States trade representative Robert B. Zoellick appealed to the pharmaceutical companies to see reason: “If they don’t get ahead of this issue, the hostility that generates could put at risk the whole intellectual property rights system”.Paul Blustein, “Getting out in front on trade: New U.S. representative adds ‘values’ to his globalization plan”, The Washington Post, 13 Mar. 2001.

 In the wake of his appeal, the major economic powers meeting at the Doha Conference agreed to moderate their stance on the enforcement of intellectual property rights in the strict domain of the pharmaceuticals trade with public health institutions. As a result, tritherapies against HIV appeared on the market in the form of generics and in fixed-dose combinations: their price fell to below 100 dollars per year, per patient. More than five million patients in low- or middle-income countries are now receiving this treatment.

The struggle against AIDS has benefited from exceptional economic and political circumstances. Indeed, to develop the political autonomy of humanitarian medicine it is essential to recognise, and sometimes anticipate, the appearance of such 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.

In such times, a breach in the political space opens up and offers an opportunity to reshape social relations, some of which may have been frozen for years. This is then an ideal opportunity to attempt 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. In view of the huge health gaps prevailing in large communities, the impact of humanitarian medical action is not to be restricted to the specific needs of marginal groups. Take the example of AIDS: the care protocol developed by humanitarian doctors has made it possible to treat millions of infected people throughout the world. This protocol is characterised by the non-participation of patients in the cost of tritherapies, the prescription of generic antiretrovirals combined into a single tablet, as few laboratory tests as possible, the transfer of therapeutic information and responsibilities to patients and a member of their entourage, and the participation of paramedics in the prescription.

Humanitarian medicine is not a marginal practice on the fringes of biomedicine and public health; it is an attempt to respond to the expectations of those people who are deprived of access to healthcare, in spite of their sometimes considerable demographic weight. Its specific and most important contribution to public health consists in developing medical practices that are better adapted to the living conditions and priorities of patients who are generally ignored. So not only must it constantly renew its own practices, but also, in order to prove the effectiveness of these practices, publish the results and comply with the standards of biomedicine and evidence-based medicine. However, political decision and scientific certitude operate on different time-scales. Supporting or contesting a public health policy means daring to hope for a change that may not happen.

There are many examples of humanitarian medical action becoming more effective when it allows patients supported by their families more autonomy and establishes a less asymmetrical relationship with them. The implementation of HIV treatment programmes therefore provided an opportunity to change old habits with regard to the sharing of responsibilities between patients, their entourage and the medical team, and between the medics and paramedics on the care team. In another domain, the introduction of new products to treat malnutrition in young children has been extremely instructive:Cf. supra “The expert and the militant”, pp. 147–60. the success of this innovation is due in part to improvements in the composition of therapeutic foods, but ultimately to the fact that these foods respond to requests from mothers who want to be able to treat their children at home as simply as possible. This suggests that, in order to better draw up the terms of its relationship with patients and the people around them, humanitarian medicine should pay heed to social sciences, and especially to schools of thought that, like the theories of care,See, for example, Joan Tronto, Moral Boundaries: A Political Argument for an Ethic of Care, New York: Routledge, 1993. offer a new perception of the relationship between the person cared for and the care provider.
However, demonstrating the superiority of a therapeutic protocol through a few innovative programmes is not enough to ensure its integration in public health policy. The emergence of a new economic model that supports innovation is essential for it to be disseminated at public health level, and this means forming political and economic alliances. The attitude of national governments, international organisations and private companies and foundations towards finding solutions to public health crises is critical, as it can have grave consequences on the way these evolve. The political aspect of the humanitarian operator’s work therefore first consists in exposing this responsibility by offering tangible proof that it is possible to do better. But dissidence is quickly replaced by the search for consensus on the reforms of care protocols. Consequently, the humanitarian doctor is a political ally who is neither stable nor faithful: sometimes dissident, sometimes consensual. The political autonomy of humanitarian medicine is founded on the mobility of its alliances.

***

 

Natural Disasters: “Do Something!”

Rony Brauman, interviewed by Claudine Vidal

Has MSF always considered natural disasters part of its mission?

Alongside armed conflicts, natural disasters are the first category of intervention to be cited by the authors of MSF’s charter and by-laws. Moreover, among the events that led to the founding of MSF were the earthquake in Peru that killed 30,000 people in May 1970, and the Bhola cyclone that hit eastern Pakistan in November in the same year, leaving 250,000 to 500,000 people dead. Natural disasters have always taken centre stage for the organisation. If you remember, MSF was formed through the merger of two associations created in 1970: GIMCU (Groupe d’intervention médico-chirurgicale d’urgence— Group for Medical and Surgical Emergency Intervention), founded by former Red Cross volunteers in Biafra, and SMF (Secours médical français—French Medical Relief), set up by medical journal Tonus to respond to the disaster in eastern Pakistan. This was the time when emergency medicine was gaining momentum as a specific category of care and “collective accidents”, as they were curiously named in the charter, were the ideal field in which to practise it.

But GIMCU’s first experience in a disaster situation, Peru in 1970, was a failure: the French doctors arrived on the scene a week after the earthquake and, in spite of the scale of the disaster, didn’t encounter a single injured person. What they did find was that the countries in the region, including the United States, had already delivered emergency relief.

The lesson learnt from this first attempt at emergency intervention held sway for a long time and became a principle for all earthquakes: to implement a life-saving operation in such situations, medical assistance had to come on stream within the first forty-eight hours. Any later and the victims trapped under rubble, the injured suffering from multiple trauma—with or without crush syndrome—would have no chance of survival. So, MSF focused from the outset on reducing deployment time by ensuring emergency supplies (“kits”) were ready and waiting, and doing its utmost to get its teams out to the disaster area within twenty-four hours of the alert. But to no avail. It wasn’t until 2005 and the earthquake in Pakistan’s Kashmir that we actually operated on casualties for the first time—although we weren’t on site and operational immediately.

Earthquakes and other disasters have become more frequent in recent years. According to the CRED (Centre for Research on the Epidemiology of Disasters), the yearly average number of earthquakes causing more than ten fatalities increased from twenty-one between 1960 and 1990 to thirty at the beginning of the twenty-first century, with peaks recorded in 1990, 2003 and 2004. But only a few led to an international relief operation. In fact, we only respond to large earthquakes, when the initial estimate of fatalities is in the thousands and the national authorities call for international assistance. This is a useful reminder to us that, in spite of this type of disaster’s high rank in the hierarchy of emergency humanitarian assistance, MSF had had very little experience in the field until the beginning of the new millennium. Furthermore, as over 80% of earthquakes occur in the “Pacific Ring”, the distance from Europe makes the objective dictated by the precepts of emergency medical assistance of getting to the disaster site within forty-eight hours totally unrealistic. But distance and time to deploy do not explain everything, as we saw in 1990 when an earthquake leaving 37,000 dead hit Zandjan in Iran. MSF’s medico-surgical teams were on site twenty-six hours later, but as their sole medical activity was providing routine consultations and totally unrelated to the traumatology they were expecting, ten days later they packed their bags and left.

It took us some time to realise that earthquakes didn’t lead to a particularly high number of casualties, and that most of these received immediate treatment in local health facilities around the disaster area. Foreign medical teams, unless they were already on site, were in fact superfluous to requirement. Earthquakes were far from providing the situation par excellence that we had imagined for exercising emergency medicine, in spite of breathtaking figures evoking thousands, or even tens of thousands of casualties. However, given the symbolic importance of natural disasters in emergency assistance, it was almost inconceivable for an organisation claiming emergency response as its culture and expertise not to be part of the action. So, at the beginning of the 1990s, MSF changed direction and focused on its other skill, logistics, securing the supply of drinking water, for example, and when necessary setting up medical consultations in the places where the victims were assembled. The images of numerous surgical teams rushed off their feet and operating non-stop that we have witnessed since the earthquake in Port-au-Prince are so close to conventional representations of disaster medicine that we tend to forget that they are, in fact, relatively new, as they were seen for the first time in Kashmir in 2005.

What happened in Kashmir in October 2005? Did the relief operations launched in response to this disaster differ from previous experience?

When news of the earthquake reached us, MSF-France’s operations managers were initially extremely reluctant to intervene, for all the reasons I’ve just mentioned. But MSF-Belgium and MSF-Holland were in the country at the time and their teams were reporting back to us on the enormity of the disaster and particularly on the huge number of casualties. The province’s health facilities were all completely overwhelmed. According to official estimates, there were tens of thousands of critically and seriously injured people in need of orthopaedic and intensive medical care. However accurate these figures, and I’ll come back to this point later, it was clear that for the first time in an emergency situation the local facilities were submerged by the inflow of polytraumatised patients and unable to cope.

I think the explanation behind this sudden increase in the number of injured is the trend towards urbanisation, in other words, the densification of badly built dwellings in a high-risk seismic region. In Kashmir, people were no longer living in shantytowns, but in unsound houses made of poorly cemented breezeblocks and stones. While partial collapse of this type of construction results in crushed limbs, the victims are not buried under rubble, as they would be in buildings with several floors. But shantytowns at least have an advantage in that the wooden, plastic or sheet metal partitions used to build them cause little damage when they collapse. A reminder that all that is “natural” in a disaster is what causes it, i.e. the origin of the seismic or climatic event. Whereas the aftermath is the result of decisions made by people, such as the location or construction standards or insufficiently protected industrial installations in hazard zones. To return to the situation in Kashmir, urban densification was not simply the result of the rural exodus common to all countries, but was also part of a deliberate population distribution strategy linked to separatist intrigues and the ongoing territorial dispute with India since partition in 1947. Nonetheless, for the first time in the history of emergency responses to an earthquake, international medical and surgical teams had a real and major role.

In 2005, the press reported that access to the victims was often impossible. What practical solutions were found to overcome this?

Access to the region was indeed difficult at first because of its geography, but also because of its politics. Kashmir is a sloping plateau in the east and is easily accessible from India. But, on the Pakistani side, there is a barrier of escarpments which is difficult to cross. Landslides stopped us from using the roads and as it was early winter, poor weather conditions further complicated matters. We had to use helicopters, which are great for transporting personnel, but their low cargo capacity meant they were not suitable for a disaster of such magnitude. These practical difficulties were the main problems we encountered, if we don’t count the initial resistance of the Pakistani army, whose main concern at that point was to provide assistance to its own troops and maintain control over a province of strategic importance in its dispute with India.

The physical obstacles could have been overcome by bringing aid in via India, and the Indian government did indeed offer assistance to Pakistan. But such an offer was unacceptable to the Pakistani army, which refused it outright, although it did agree to a partial opening of the border. This doesn’t mean, however, that the army only concerned itself with its own personnel and territorial security, leaving the population without assistance. On the contrary, after a few days, it did more and more, bringing in aid supplies, treating and evacuating the injured by helicopter, and managing the coordination of the relief operations. Restrictions on movements were lifted and special permits were no longer required to travel around the tribal areas.

A multitude of local NGOs quickly got down to work, helping the victims get organised in collective centres and providing shelters. Some had highly competent personnel and were particularly well-equipped— in particular, the Al Rasheed Trust. An Islamic organisation ideologically close to the Pakistani Taliban, it set up a sixty-bed hospital for orthopaedic surgery and ran outreach and relief activities. Our collaboration with the army, the Health Ministry and Al Rasheed was excellent on the whole, much to the surprise of MSF’s management staff, who had expected things to be more complicated. The local Islamic organisations, which benefit from well-established social aid networks, took immediate action and supplied a considerable amount of aid.

Let’s not lose sight of the fact that most of the search for survivors and provision of food and shelter in the early stages of any disaster situation are always handled by local people and organisations. Contrary to conventional belief, it isn’t a state of shock that we witness but rather active solidarity, at least during the first few weeks. So, although there was nothing surprising about the extent of local mobilisation in Kashmir, it needs to be said that once they had seen that MSF wasn’t involved in any proselytising and that patients were being properly cared for, the Islamic NGOs were particularly cooperative. Islamic organisation members even praised the invaluable logistical assistance it had received from the American army.

The situation was one of close cooperation with the Ministry of Health, the army—whose helicopters we even used on occasion—and religious NGOs. Our constructive relationship with our natural partners, the health authorities and the Pakistani NGOs, raised no issues for MSF. However, despite the crucial role it played, as we have seen, the same could not be said of the army, viewed by MSF as a compromising partner. Some of the MSF operational leaders even suggested trimming down the teams in order to limit contact. This determination to reassert the distinction between military and humanitarian operators, motivated by concerns for the teams’ safety, ended up taking a back seat to imperatives for urgent action in a context marked by the ongoing emergency and the otherwise fruitful working relations with all the different actors, whatever conflicts may have opposed them in the past.

In situations of natural disaster, the national army is usually the best placed and the best equipped to respond and, apart from exceptional cases (such as in the zone controlled by the LTTE in Sri Lanka after the 2004 tsunami), is welcomed by the victims. So there is no reason to actively distance ourselves, as we rightly do in situations of conflict. This applies equally to medical relief and logistics provided by foreign armed forces.

Taking into account the material difficulties caused by the geography of the area, the deployment of the aid operation was dynamic and, within three weeks, had reached a level where the needs were being met. However, when it came to medical care MSF’s teams noted that, whereas the country’s response had been rapid and profuse, standards were not so satisfactory: amputations were numerous, probably overly so, and already conservative orthopaedic interventions—for saving injured limbs—were often below par. Let’s keep in mind that most of the surgery performed by MSF’s teams, who had not dealt with the initial influx of casualties, consisted in secondary surgery. However, I should point out that any reservations regarding the quality of the medical treatment stem from clinical impressions rather than from the findings of epidemiological studies, and that this was a context of damage-control surgery in the face of a very high number of wounded patients.

But overwhelmed medical facilities do not explain everything. In my opinion, we should also examine why war surgery techniques were used. Penetrating wounds caused by projectiles (bullets, shrapnel, etc.) can lead to complications, notably infections, which, in the uncertain environment of an armed conflict, may prompt the surgeon to perform more radical surgery. But wounds caused by crushing, the common lot of civilian surgery, permit the use of more conservative techniques. Yet, as we saw in Indonesia during the 2004 tsunami and again after the Haiti earthquake in 2010, the paradigm of war, or in this case a blitzkrieg, always seems to prevail. The medical teams are just as much influenced by this representation as the observers, as revealed by a remark made by a team of American relief workers: “Overworked surgeons […] amputated limbs and debrided infected tissue. […] For the next two days, we practiced continuous battlefield medicine”.Paul S. Auerbach et al., “Civil-military Collaboration in the Initial Medical Response to the Earthquake in Haiti”, The New England Journal of Medicine, Feb. 2010.

 We are justified in asking ourselves if this kind of representation has an impact on the techniques used, and studies are being conducted using medical data collected in Haiti, the only other natural disaster, along with the one in Kashmir, to have caused such massive numbers of casualties.Notably led by Prof Anthony Redmond and Dr Simon Mardel, HCRI, University of Manchester.

 The very recent experience of mass surgery in such circumstances explains the current lack of systematised knowledge on the subject.

We also lack reliable quantitative data to draw up a comprehensive evaluation of the relief operation in Pakistan. The figures provided the day after the disaster—54,000 dead, 77,000 injured and hundreds of thousands made homeless—give an indication of the scale of the catastrophe, but should be viewed with caution, particularly from a medical standpoint. In the light of the absence of civilian registration and demographic data, the number of fatalities can only be a rough estimate.

The civil-military cooperation—read “military leadership” of the relief operations—was hailed as a success by the United Nations and the NGOs. The dividing up into sector-based groups of responsibility or “clusters” (logistics, health, sanitation, etc.), which the army had less trouble adapting to than the humanitarian operators (as was noted with some irony by the United Nations representative),Lieutenant General Ahmed Nadeem and Andrew Mc Leod, “Non-interfering coordination: the key to Pakistan’s successful relief effort”, Liaison Online 4, no. 1 (2008) was also a success.

However, de facto truces resulting from a natural disaster do not signal an end to hostilities, and we mustn’t lose sight of the political or even counter-insurrectional dimension of aid. The extremely sensitive deployment of US and NATO forces in response to the earthquake was explicitly dictated by such considerations. It encountered no visible opposition, as all the population was concerned with what was provided and not with who was providing it. As for the Islamic groups, they mostly kept silent, although some of them did express their approval publically. A study conducted by the US Institute for Peace concludes that the objective of “winning hearts and minds” remained theoretical, for the activist groups and for the United States and NATO, as momentary gratitude does not lead to political loyalty. But as this belief tends to hold sway, it results in more latitude for action, as nobody wants to be seen as the one depriving the people of valuable aid during a period of acute crisis.

What is your definition of a natural disaster?

A disaster disrupts the ordinary course of things. From the purely practical standpoint of an emergency medical organisation, this first means earthquakes and then severe climatic events—storms, cyclones and flooding—occurring in or close to densely populated areas. Earthquakes have been our sole topic of conversation so far, as they have recently become the main cause of emergency medical operations. But looking at things from a broader angle, and to use more commonly accepted definitions, a disaster can be defined as a sudden encounter between natural forces of harm and a people in harm’s way, where demands exceed the disaster-affected community’s capacity to cope or, in other words, it is “the product of the encounter between hazards and vulnerability”.Grégory Quénet, “Catastrophe naturelle”, in Yves Dupont (ed.), Dictionnaire des risques, Paris: Armand Colin, 2007.

The problem with these definitions resides in the definition of “natural”. The causal event may be natural, but the aftermath is closely linked to the way society is organised in the places where they occur. For example, you may remember that in Ethiopia (1985) and Niger (2005), the drought and the ensuing invasion of locusts were described by the authorities as a “natural disaster”, and the primary cause of a situation of acute malnutrition or famine. The stakes were high because attributing these consequences to this cause determined the response. MSF was expelled from both countries after a political controversy on these issues.To be more precise, MSF-France’s activities were suspended in Niger in 2008 on the orders of the head of state two years after the public controversies, but directly related to them.

 Remember the ironically evocative titles of the two books published by the organisation on the subject: Ethiopie. Du bon usage de la famine [Ethiopia: How to make best use of a famine], and A Not-So Natural Disaster, Niger 2005.Respectively, François Jean, (ed.), MSF, 1986; Xavier Crombé & Jean-Hervé Jézéquel (eds), London: Hurst and Co., 2009.

The cholera outbreak in Haiti during the winter of 2010 to 2011 was the source of an intense controversy of the same nature: the advocates of a “natural” hypothesis attributed its origin to plankton and opposed all those who claimed that the infestation was of human origin (caused by the emptying of a septic tank containing cholera germs into a river). Everyone agreed that the disease had only been able to result in so many fatalities (4,800 in total) because of the country’s deplorable hygiene conditions, but the circumstances that led to the outbreak were the subject of virulent dissension, even within MSF. The fact that the human origin was blamed on a contingent of United Nations peace-keepers, themselves embroiled in political clashes as a result of the election campaign underway at the time, only served to accentuate the political dimension of the epidemic. As it happens, an enquiry conducted by the United Nations later confirmed the second hypothesis.“Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti”, May 2011.

 Once again, it was not simply a matter of determining the origin of the epidemic; understanding its cause had practical consequences on how the immediate medico-sanitary response was organised.

The controversies seem to be as much due to the definition of natural disasters as to the evaluation of their consequences?

As we have just seen, the rebranding of a situation from major crisis to natural disaster can lead to controversy because of the political responsibilities that such a categorisation engages. But independent of any disagreement on this aspect, the consequences of a disaster can also be a source of controversy, particularly (but not exclusively), with regard to the epidemics they might cause, and hence the emergency resources that should be deployed. Because of the unprecedented media attention it attracted, the 2004 tsunami saw this question propelled into the public arena.

A few days after this exceptionally large-scale disaster, the WHO’s operations director announced: “We may see as many fatalities from disease as from the actual disaster itself”.“WHO warns up to five million people without access to basic health services”, 30 Dec. 2004.

 So the subject was raised of a possible second wave of mortality due to epidemics, which threatened to double the number of victims caused by the actual tsunami. It was brought up by the WHO at subsequent press conferences and passed on enthusiastically by the media, with the result that the relief effort focused on providing emergency assistance to save some 150,000 people supposedly in danger of imminent death. The success of such announcements, without scientific or empirical basis, stems from how well they fit in with the widespread belief that decomposing bodies are a source of infectious contamination. Yet as several research studies have shown, there have been no cases of a fatal epidemic in the wake of a disaster, whatever the scale.C. de Ville de Goyet, Stop Propagating Disaster Myths, The Lancet, 2000, 356: 762–4, Nathalie Floret et al., “Negligible Risk for Epidemics after Geophysical Disasters”, Emerging Infectious Diseases, www.cdc.gov/eid, Vol. 12, 4 Apr. 2006.

 Put quite simply, epidemics cause corpses, but corpses don’t cause epidemics. Some epidemic foci of digestive and respiratory infections may occur and require preventive and curative action, but their effects are nothing like the scaremongering announcements I just mentioned.

More generally, and for reasons similar to those I talked about earlier in relation to earthquakes, there was no life-and-death emergency after the tsunami. The horrendous ordeal suffered by a large number of survivors, some of whom lost everything, justified in itself the appeal for solidarity, and I’m certainly not disputing the need to respond to it. But the model adopted of “rescuing a population in peril” was totally inappropriate. At one point, we saw up to twelve surgeons gathered around just one casualty in Indonesia, right when we were talking in terms of hundreds of thousands of casualties! In practice, to be of real help to the victims of the disaster, the need was for financial and material resources to clear up and start rebuilding—quite different from launching an emergency medical operation. However, media pressure was such that it made it difficult for MSF to stay away. The field teams lost no time in raising the issue; some of the most experienced members had grasped what was happening within a few days. But withdrawing from the country would not have been understood in a situation so emotionally-charged, and the organisation’s leadership decided to switch the focus to non-medical aid.

Can the way a disaster is presented after the event make a difference then?

As we’ve seen, the scale of mobilisation shrank all the narrations, beliefs and prevailing representations of the event. Talk was of casualties, refugees, epidemics and, when UNICEF issued a statement, orphans too. We have already discussed casualties and epidemics, but the issue of refugees and orphans was much the same. I’ll say more about this in a moment, but first I want to emphasise that these four themes, recurrent during the first few weeks, formed a narration of the consequences usually observed in armed conflicts. In other words, with the benefit of a little hindsight, it becomes clear that we were unconsciously reacting to a natural disaster as if it were a war.

There were endless pictures and non-stop television images of the after-effects of the disaster, focusing on a few hundred people assembled in makeshift shelters, “showing” the existence of refugee camps, whereas, in reality, people were not gathering, but rather dispersing. Most of them wanted to stay as close to their homes as possible and were living with neighbours or family and moving back and forth between their former homes and their temporary accommodation. The same goes for the destruction caused by the tsunami. In Sri Lanka, for example (except in the hardest hit region in the north), it was concentrated along a narrow strip of land between 50–300 metres wide, depending on the lay of the land where the wave hit. So the survivors were in fact only a few minutes’ walk at most from the unaffected parts of the country, something we couldn’t tell from the pictures we were seeing. This kind of metonymical representation, of which aid workers are as guilty as journalists, is seriously misleading. I should also add that the thousands of Sri Lankan doctors and nurses, who arrived within hours to help their colleagues and fellow citizens, were no more visible as they were indistinguishable from the disaster victims. These misinterpretations were given such credence because they fit in so well with the preconceived notion mentioned earlier of disaster victims in a state of total shock, passively waiting for help to arrive.

As for the orphans described by the director of UNICEF as wandering the streets at the mercy of child prostitution gangs, this was a rumour spread all too hastily, but rapidly dissipated by other humanitarian organisations, and by UNICEF itself. Obviously there is no question that some children had lost their parents, but what I do contest is that they had been abandoned. I should perhaps explain at this point that the post-tsunami solidarity movement, often portrayed in the North as exemplary and cited as a reference, in fact left the concerned countries with memories of an agitated, arrogant and ineffectual mob. Despite its endeavours to distance itself from the prevailing discourse, MSF did not escape from harsh collective judgement.

But let me return for a moment to the schema of war superimposed on that of natural disaster. In spite of images that make them look very similar, they are in fact diametrically opposed. Disasters are concentrated into a very limited time period and a very restricted geographical area, whereas armed conflicts are spread over an extended time period and wide geographical area. Wars are drawn out affairs, erratic in their movements, killing and injuring in their path, causing the displacement and re-assembly of populations between one region and another, creating intense and relentless pressure, rampant and massive impoverishment and wide-spread destruction, including of health facilities. These vulnerability factors, producing all these effects and creating a high potential for epidemics, cannot be caused by a one-off event. A natural disaster, however horrendous, cannot engender the same consequences as a war.

Is there a clear association between the myths surrounding events after a disaster and political situations?

International emergency aid is loaded with a specific kind of symbolism that has nothing to do with its real usefulness, as we have just seen.

It is inevitably an intrinsic part of the pre-existing dynamics of international relations—and becomes an extension of them. For example, when Iran was hit by an earthquake in June 1990, the French government offered to send in specialised teams, even though the two countries had broken off diplomatic relations: the emergency aid brought to light the fact that Paris and Teheran had secretly resumed talks. The same can be said of China sending a plane full of aid supplies to Haiti after the earthquake in January 2010, in spite of the absence of diplomatic relations between the two countries owing to Haiti’s recognition of Taiwan. This was a first. Beijing had never before contributed towards disaster relief operations outside its regional sphere of influence in Asia. However, the fact that China now wants to assert its status as a global power meant taking part in the international relief effort. Just as the earthquake in Pakistan proved the existence of a “disaster policy”, there is also “disaster diplomacy”, whereby the special circumstances created by an emergency allow governments to dem-onstrate their strategic choices at little cost.

In this respect, the case of Cyclone Nargis, which hit Myanmar in 2008, merits attention. In May 2008, the Irrawaddy delta was swept by winds reaching 240 km per hour, followed by a wave four to six metres high, which surged up the river resulting in extensive loss of life and massive destruction in this densely populated and fertile region. The Myanmar junta, faithful to its obsession with maintaining order and as ever indifferent to the fate of its people, did not react, simply appealing to the United Nations for international aid and refusing any new foreign presence on its soil. However, right from the first few days, members of MSF and other NGOs already working in the country were able to travel to the area, assess the extent of the damage and launch the relief effort with the local resources at hand. At the same time, planes from neighbouring India, Thailand, Bangladesh and Malaysia, as well as from western counties acting on behalf of UN agencies, were landing in the capital city, Yangon. In the meantime, the press and western governments, apparently unable to see beyond the junta’s sovereigntist and isolationist rhetoric, were talking about restrictions and even a total blockade of outside aid. On 11 May, the NGO Oxfam issued a communiqué and the first few lines set the tone: “International agency Oxfam said today (11 May) that in the coming weeks and months the lives of up to 1.5 million people are in danger in the Myanmar cyclone zone because of the risk of disease and a public health catastrophe if clean water and sanitation are not urgently provided”.

Seen from the field, this scaremongering was far from justified. It was true that the army had been seen diverting aid for its own purposes or to make a profit out of distributing it but, as always, the population got itself organised on different levels. Local organisations and authorities, the Red Cross, Buddhist temples and wealthy businessmen all distributed water, food and equipment, and foreign aid began arriving via the NGOs. As for the injured and the threats of epidemic, I repeat what I said earlier about the tsunami; they were non-existent.

It was striking that most of the television coverage, whether videos made by local people or official television reports, all showed scenes of aid distribution almost everywhere. We saw endless short scenes of businessmen arriving with their lorries and handing out bottles of water, sacks of rice, etc. Elsewhere, Buddhist monks were similarly shown, as was the army, an NGO or the Myanmar Red Cross. Basically, we were seeing the usual images of food distribution and, here and there, one or two bodies. Watching the media coverage attentively, I realised that the commentaries accompanying the pictures were actually contradicting everything they were showing, insisting on the total absence of aid and the numbers of decomposing bodies, which were described as bacteriological time bombs on the brink of spreading their deadly emanations. When I asked some journalists during interviews on the subject what they thought about the dissonance between the pictures and the commentary, they said they hadn’t noticed it and were obviously suspicious of any challenge to the general alarmist view.

So it was in this context that threats of military intervention to impose aid by force first began to appear in the press. Gareth Evans, one of the authors of the UN’s “Responsibility to protect” concept, started the ball rolling on 12 May,Gareth Evans, “Facing up to our responsibilities, The Guardian, 12 May 2008 followed two days later by Robert Kaplan, one of the most prominent neo-conservative strategists, who sketched the outline for armed intervention in an article entitled, “Aid at the Point of a Gun”.The New York Times, 14 May 2008.

 And on 19 May, French foreign minister Bernard Kouchner published an article reminding us that “the Secu-rity Council can at any time decide to intervene to force a passage for humanitarian aid, as has been done in the past”.Bernard Kouchner, “Birmanie: morale de l’extrême urgence”, Le Monde, 19 May 2008.

 Three military vessels, British, French and American, were thus hastened to the Myanmar coast as a sign of their governments’ determination to prevent the supposed deaths of hundreds of thousands of innocent people.

It must be said that this time, unlike after the tsunami, the WHO posted on its website that corpses posed no risk and that survivors of the cyclone were in no danger of a deadly epidemic. But this was not enough to prevent the British Foreign Office from warning of the “peril”, or to dissuade the advocates of armed interventionism, governments and associations alike, from using it to encourage the Security Council to activate the “Responsibility to protect” mechanism.John D. Kraemer, Dhrubajyoti Bhattacharya, Lawrence O. Gostin, “Blocking humanitarian assistance: a crime against humanity?”, The Lancet, Vol. 372, 4 Oct. 2008.

Until the war in Libya in March 2011, instigated by the same governments (France, UK and the US), this was the only debate in which the Security Council had actually envisaged implementing this mechanism.

Did emergency relief organisations learn any new lessons from the earthquake in Haiti?

The January 2010 earthquake in Haiti was the second mass medico-surgical emergency after the one in Pakistan in 2005. MSF had been working in Haiti for several years when the disaster struck and so was in the right place to respond rapidly. Three surgical units were set up in a container and the first major operations were performed three days after the earthquake. During the first forty-eight hours, care had been provided in the streets. The inflatable hospital used in Pakistan was sent out, so we were operating in optimum conditions from day thirteen, which is the time it took to get this really imposing piece of equipment on site and up and running. By the way, the famous fortyeight-hour window beyond which casualties cannot survive can now be filed away under “conventional wisdom”, as the Pakistan precedent had already confirmed. MSF thus took up position alongside the multitude of local and international organisations, governmental and private, which had rushed to set up operations in Port-au-Prince and the surrounding region during the two weeks following the earthquake.

There was a lot of talk at the time about the chaos in which the “humanitarian expeditionary corps” was deployed. The lack of coordination and information on needs and the running of the relief operations were severely criticised in the press, but these criticisms don’t actually hold water. Firstly, because disorder is the hallmark of a disaster, all the more so when it hits a country’s capital and therefore its seat of power. Secondly, because the shortcomings of Haiti’s public institutions were already notorious and the country was without an army, which had been dissolved under US pressure during the “Restore Democracy” operation in 1995. Lastly (and most importantly), because the response to the urgent needs was focused on a limited area, it was carried out correctly, in spite of everything, with the notable exception of the shelters, which were both unsuitable and insufficient.

There are two medically-related issues that I would like to single out: the first, quite specific, concerns the use of techniques derived from war surgery, which tend to be more radical but can be inappropriate; the high number of military surgeons in such a setting, as well as the ever-present juxtapositions with the representation of war as mentioned earlier, give pause for thought. The other issue is more general and concerns the criteria adopted explicitly or otherwise by medical teams from different professional culturesFrédérique Leichter-Flack, “Sauver ou laisser mourir”, http://www.laviedesidees.fr. for deciding which cases, medical as well as surgical, should be given priority and which should not be treated. Do the exceptionally high workload and the logic of rationing induced by a disaster, which is where triage usually comes in, lead to laxity in procedures? http://www.theworld.org/2010/02/doctors-face-ethical-decisions-in-haiti/.

 We have only fragmented and flimsy data, so I won’t attempt to answer these questions. I just want to stress the need for a methodical reflection on them.

Why is estimating the number of victims in a disaster the subject of such frequent debate?

Estimating the number of victims is another major issue as the figure is a crucial emotional marker, the trigger that “allows us to feel the disaster”Sandrine Revet, “Anthropologie d’une catastrophe, Les coulées de boue au Venezuela”, Presses Sorbonne Nouvelle, 2007, p. 267. and determine where it features on the scale of gravity. Unlike what we see in many conflict situations, the disaster toll (usually an approximation) announced by the governmental authorities and the United Nations a few days after the event is accepted by the press and aid organisations as objective, in spite of its unreliability. Three days after the Haiti earthquake, the government announced that 50,000 bodies had been recovered. This figure was to increase day after day to reach 250,000, or even 300,000 a month later, “Death toll from the earthquake could reach 300,000, according to the president of Haiti”, Le Monde, 22 Feb. 2010. making the disaster one of the most serious ever.

These evaluations were based on an estimate of population density and the number of collapsed buildings in a given district, which left considerable room for uncertainty. Respect for the victims does not proscribe challenging figures drawn up in a chaotic environment and with no credible foundation. Heads of some of the UN agencies encountered six months after the earthquake privately agreed on a death toll of somewhere between 50,000 and 70,000, based mainly on the number of mass graves dug by Minustah, the only organisation charged with the task.Encounters by the author in Port-au-Prince in June 2010.

 Similarly, after a survey of the different actors in their field, Handicap International Belgium’s head of mission estimated that the number of disabled people was closer to 1,000 than 5,000, the figure that had ended up becoming official after being bandied about in aid circles.

Reducing the estimated loss of human life is clearly a sensitive issue, as it ties into collective emotion. Bringing down the numbers exposes us to suspicions of hard-heartedness, or even hostility or shameful ulterior motives, whether in situations of natural disaster or, even more so, in other settings with a more direct political dimension, such as armed conflict, population displacement, or the quantification of atrocities.Peter Andreas, Kelly M. Green (eds), Sex, Drugs and Body Count, The Politics of Numbers in Global Crime and Conflict, New York: Cornell University Press, 2010.

 The death toll after the earthquake in Armenia in 1988, established at 100,000 deaths a few weeks after the disaster, was later reduced to 23,390 in figures published by the authorities. This reduction in the official death toll produced reactions of incomprehension, hostility even, as the original number had become a symbol of Armenian suffering and changing it was seen as a denial of this suffering. In practice, it is likely that such distortions and amplifications abound in many similar situations.

Estimating the number of victims—and the number of fatalities among them—is most definitely not a superfluous exercise, not only because this is the first question that everybody asks, but particularly because, however vague and fluctuating it may be while the aid is being set up, it allows a threshold effect to operate. It has been observed that we reason in terms of a major disaster justifying international-level deployment when the death toll reaches or exceeds ten thousand. The practical importance of such estimates from a relief agency’s point of view is, however, limited, but I raise this issue here to underline how the highly uncertain nature of the figures makes it extremely difficult to know which resources to activate, other than basing ourselves on the threshold mentioned earlier. In concrete terms, the specific information required to guide relief operations would be, on the one hand, the number and condition of the survivors in order to gauge the medical assistance requirements, as well as needs for other types of aid—shelter, food, water, telecommunications, damage clearance and transport—and on the other, information on what the other relief operators, local as well as international, are doing.

Although not victims of an executioner, disaster victims are caught up in high stakes, as the examples given above have shown. Funding, media coverage, rallying sympathy for traumatised people, all combine to produce an escalation that nobody plans, but which is fostered by the apparently indisputable nature of the cause defended—that of increasing emergency aid as high as it can go.

Translated from French by Mandy Duret

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Epilogue in the Name of Emergency

Marc Le Pape

How msf adapts and justifies its choices

Given the constraints that MSF faces when it takes on, develops and supervises interventions, what justifications does it establish and choose to ensure that its actions are acceptable within its political, cultural, military and scientific environment and to those acting in its name?

The case studies in the first section of this book all take a dynamic approach to this question. This involves understanding processes and observing how MSF participates in them, defines its reasons for taking action and succeeds (or not) in implementing them. Each case presents the justifications for choosing and implementing programmes (including control, autonomy and speaking out) and recounts the local and international background that provide the context for these choices. The accounts illustrate justifications as they are being formed and, subsequently, as they are adapted based on the events that take place in each context and on the impacts of proposed programmes, medical practices and humanitarian arguments.

When conducting a sociological analysis of modes of justification, it is useful at the outset to identify characteristic attitudes that allow us to make distinctions and identify ways of thinking. I will distinguish among realism, confrontation and abstention—three approaches and the three registers associated with them.

Realism, Confrontation and Abstention

An analysis of the cases described in this book illustrates the range of behaviours that the actors have adopted. I will initially address only those features that highlight differences and the heterogeneity of rationales for action in the face of actual or projected constraints. My approach draws on Albert Hirschman’s characterisation of the three concepts of exit, voice and loyalty. I also rely on the sociological description of the realistic attitude, as presented by Cyril Lemieux.Cyril Lemieux, Le Devoir et la Grâce, Paris: Economica, 2009, p. 85–89.

Hirschman’s analysis addresses individual and collective responses to economic and political situations. He distinguishes among exit (that is, “simply leaving”), voice (the expression of discontent) and, last, loyalty, which involves the “intimation of some influence and the expectation that, over a period of time, the right turns will more than balance the wrong ones”.Albert O. Hirschman, Exit, Voice and Loyalty, Cambridge, Mass.: Harvard University Press, 1970, p. 78.

 Hirschman seeks to identify the conditions in which these attitudes are expressed and the situations in which they contradict each other or work together.

Albert O. Hirschman, A Propensity to Self-Subversion, Cambridge, Mass.: Harvard University Press, 1995, p. 12–14.

 According to Cyril Lemieux, the realistic attitude involves, for an individual and an organisation, recognising and accepting the limits of what can be done in a particular situation and drawing the appropriate conclusions; that is, exercising self-control, while attributing positive meaning to that cautious attitude.

I have chosen a “free”—as opposed to a literal—translation of Hirschman’s three categories because this slight adaptation allows me to clarify several aspects of the choices made in MSF’s areas of intervention. Thus, for “exit”, I have chosen the term “abstention”, for “voice”, “confrontation” and, for “loyalty”, “realism”. These different terms do not mean that I have ignored Hirschman’s lesson—quite the contrary. Indeed, he stated repeatedly that these concepts could be used to analyse a wide range of social phenomena and warned against applying them mechanically.

The terms chosen by the actors and observers to designate the logic behind certain choices may vary based on whether they attribute a positive or negative value to those choices. Thus, “realism” might be referred to as “collaboration” (with its negative meaning in France following World War II and the German occupation of the country) or “diplomacy”. “Confrontation” could be seen as “irresponsibility” or “indignation”. And last, “withdrawal” could be criticised as indifference or praised as a form of courage and professional rigour and as honouring MSF’s principles. The perspective adopted is not intended to value or devalue, recommend one form of intervention over another or provide a guide to humanitarian arguments based on situations, moments in time, representatives or medical commitments. Rather, it represents 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, and does not suggest a preferred route.

There is a risk associated with this kind of description—that of creating “camps”, as if the proponents of each way of thinking form a camp, as if “caught by compelling reflexes and lumbering predictably through set motions and manoeuvres”.Albert O. Hirschman, The Rhetoric of Reaction, Cambridge, Mass., and London, England: The Belknap Press of Harvard University Press, 1991, p. 164.

 We will see that MSF is not home to camps that assert a particular way of thinking but, rather, that those who adopt the realistic position in a given situation will, at another point in the process, endorse confrontation or abstention, and vice-versa.

I will now describe how these attitudes are expressed in MSF’s projects.

Which Practices are Associated with Realism?

The general feature of the “realistic” attitude is the unchallenged acceptance of constraints imposed by national and international authorities in order to preserve opportunities for action. This involves conciliation, either in the interest of obtaining authorisation to initiate and, subsequently, develop an activity or to preserve the possibility of future action.

MSF-Holland’s intervention in Myanmar, which began in 1992, typifies this choice. To establish a presence there, the organisation initially relinquished its project to intervene in Rakhine State, where the government was brutally repressing the Rohingya minority, and accepted the site on the outskirts of Yangon that the government assigned it. The Swiss section made the same kind of concession in exchange for permission to enter the country in 1999. The second category of concessions dealt with control over the programme. Starting in late 2004, the government imposed more complicated procedures for entering the country, tightened the rules for travelling outside of Yangon, demanded that aid organisations submit lists of their employees, and required that a “liaison officer” accompany teams in their travels. In short, the government increased the restrictions limiting the autonomy of the medical teams. The third category of concessions involved the agreement made by the two MSF sections was not to publicly criticise the authorities, including criticism of the restrictions placed on their medical activities.

In order to treat malnutrition in India, MSF’s Spanish section chose to limit the visibility of its activities, restrict its work to a single district and focus on treating severe acute malnutrition. However, MSF’s nutritional programmes involve importing ready-to-use therapeutic foods (RUTF), which activists from the Right to Food campaign (with whom MSF was in discussions) criticised and the national government disapproved of. However, thanks to the limitations it had placed on its activities, MSF-Spain succeeded in signing a district-level agreement. The medical authorities then agreed to allow the organisation to use RUTF to treat severe acute malnutrition.

Facing obstacles at the local level, MSF-France chose to abandon its project and withdraw quietly. This form of withdrawal characterises both the confrontational attitude—expressed by a refusal to continue negotiating—and the realistic attitude, as demonstrated by the discretion with which it withdrew. Because the withdrawal was limited to one project, MSF was able to continue to participate in debates within India over the treatment of malnutrition.

Indeed, each case study reveals moments when the realistic attitude comes into play. Constraints exist everywhere and differ only in their intensity, reach and nature. We must learn to live with them and negotiate ways of adapting our actions to comply with them. Each situation raises the question of acceptable limits. The realistic phase of the action allows us to learn lessons from which we can assess the extent to which the humanitarian work is compatible with the constraints and, then to decide whether to continue, confront or withdraw. That is why it is useful to present situations that highlight the choice to adopt the realistic approach, as in the case studies dealing with Sri Lanka, Nigeria, the Gaza Strip, Somalia, Afghanistan and Yemen.

What Does Confrontation Mean Within MSF?

Negotiation is a form of confrontation, but it is, at first, a discreet and contained form as its goal is to reach agreements, in the spirit of realism, since MSF seeks to be able to carry out medical activities. This was the case in Afghanistan when, in 2008, MSF sought to resume the activities it had halted in 2004 after five of its members were killed. In 2008 to 2009, negotiations were undertaken on several fronts, including with US authorities. To ensure the safety of patients (whether affiliated with the opposition or not) in Lashkar Gah hospital where MSF was working, the facility had to be designated as neutral and the presence of armed men thus prohibited under the Geneva Conventions. The goal of negotiations with the armed opponents of the Karzai government was to reach an agreement allowing drugs to be transported safely on the roads. Confrontation with the US authorities was avoided when the Obama administration issued directives to the US military command that satisfied the demands MSF had made locally. However, confrontation with the armed opponents proved difficult to contain through negotiation. The representatives of the Islamic Emirate of Afghanistan (IEA) took advantage of MSF’s requests to make demands that were difficult for the latter to meet—for example, a signed commitment from the US military forces guaranteeing their compliance with the Geneva Conventions, which MSF was not in a position to obtain. Using its ability to permit or block the transport of drugs, the IEA initiated a confrontation that MSF was forced to take up and through which the government’s opponents sought political gain; that is, recognition and legitimisation of their power in the areas they controlled.

However, the tensions did not confine themselves to discreet discussions with the various parties holding power and men of influence, from the local level to that of States and international institutions. The organisation’s policy in South Africa is characteristic of entering the realm of public confrontation. Allied with the Treatment Action Campaign (TAC), an activist movement that organises HIV/AIDS treatment, MSF supported TAC in its campaign against authorities whose public positions were clearly influenced by theories denying that a virus causes the illness. The campaign specifically targeted the minister of health and President Thabo Mbeki, whose position led the government to refuse to provide antiretroviral treatment to patients. Between 2008 and 2010, MSF worked with legal organisations, this time to defend the rights of Zimbabwean immigrants in South Africa to obtain medical care. In early 2008, MSF had launched medical aid programmes targeting that population along the border with Zimbabwe and in Johannesburg. It used the information gathered during medical consultations and provided its expertise to strengthen the activists’ efforts to obtain access to healthcare for immigrants.

The organisation has been involved in other forms of public critique, for example, in Ethiopia, where MSF-Switzerland closed its mission and simultaneously issued a press release denouncing the obstacles imposed by authorities on its medical activities in the Somali region. “Despite continuous attempts to improve the working relations with the authorities, our organisation can only regret the absence of any space to bring independent and impartial assistance”. MSF-Switzerland, Addis Ababa/Geneva, 10 July 2008.

 In another example, MSF-France participated in several public campaigns supporting universal healthcare coverage and, subsequently, working with other organisations, advocated for the continued right of foreigners who are ill “to remain in France legally and continue to receive medi-cal treatment”.MSF, “Commission Dasem: dernière chance pour les étrangers malades en France?” Paris, 3 May 3 2011, http://www.msf.fr/presse/communiques/commission-dasem-derniere-chance-et....

 In the former example, the organisation asked the Ethiopian government to allow it to take action and in the latter, it encouraged the French government to take action.

The strategy of roundly criticising institutions, as in the South African case and many other situations,For example, Ethiopia in 1985, Zaire in May 1997 (regarding the tracking down of Rwandan refugees), North Korea in Sept. 1998, etc. is far from the most common approach. In fact, MSF usually prefers to confine confrontation to the negotiating process. This reality contrasts with the general image of the organisation—a powerful media presence, effective in its use of public criticism and capable of harming businesses, governments and international bodies through its interventions.

Abstention

MSF adopts this behaviour regularly as establishing medical priorities means choosing certain interventions and, simultaneously, rejecting others. Marie-Pierre Allié, president of the French section, has thus stated “It is our duty to find solutions for the patients whom we have started to treat, but that does not commit us to providing care to the entire population in a given location forever”.Marie-Pierre Allié, “Après la TB, le VIH, le diabète, demain le cancer?”, Borderline, no. 1, MSF, Paris, Mar. 2011.

 However, the boundaries between intervention and abstention are becoming increasingly unclear in MSF’s work. Whereas MSF has long chosen not to address chronic infections requiring long-term treatment, the organisation currently treats patients suffering from tuberculosis and AIDS, which require treatment that may last for several months (the former) or a lifetime (the latter).

The decision to abstain or intervene provokes debates that reach beyond medical issues. Both choices have generated and regularly generate controversies, even confrontations, among MSF actors. Some support the termination of a programme on the basis that MSF is an emergency response group, shifting the discussion from the medical register to the political register, and transforming controversy into confrontation. Such an attempt to confine MSF to a narrow identity would be in mere contradiction with its actual practices, all the more observing the adaptability of the principles guiding its actions and the range of situations in which it intervenes. The identity-based argument continues to exercise a certain influence within MSF, but it is effective only if supported by those with the power to make decisions and control communications within the national sections of the organisation. This characterises the situation in which MSF-France chose to leave northern Nigeria quietly. In 2005, it opened a programme to treat severe acute malnutrition in Katsina State. When Reuters news agency reported on the nutritional crisis in the region,“Severe child malnutrition hits Nigeria’s far north”, Reuters, 26 July 2005. http://nm.onlinenigeria.com/templates/?a=3990&z=12. the minister of health, fearing the negative image conveyed by crowds of emaciated children, pushed to close the programme. MSF-France threatened to make a public statement, but when it observed the declining number of children in need of treatment, it abandoned the threat and quietly left Katsina in December 2005. During the same period, and in the years that followed, the same section adopted an entirely different approach to malnutrition in Niger, one characterised by both realism and con-frontation, “transforming limitations into challenges and challenges into choices”.Carlo Ginzburg, Rapports de force, Paris: Hautes Études, Gallimard, Seuil, 2003, p. 112. For a detailed analysis of the policy undertaken in Niger in response to the nutritional crisis, see Xavier Crombé, Jean-Hervé Jézéquel, A Not-so Natural Disaster: Niger 05, London: Hurst & Co., 2009.

The Basis of the Justifications

To characterise more accurately the arguments supporting one approach over another—specifically, realism over confrontation (or the contrary)—we must place these choices in the context of missions, as recounted by the authors of the case studies.

Realism

As we have seen, realism appears first as a necessity. Agreement must be reached with the “powers that be”. These negotiations are thus part of the typical work of MSF staff in order to open, set up, maintain and develop a mission. We are not focused here on the moment at which the realism critical to the start of a mission comes into play, but rather on how this attitude is maintained, even when the circumstances might lead to confrontation in its most diverse forms. The dominant argument asserted most regularly to justify realism is the threat of danger. It is commonly linked with the argument that criticism is pointless and “cannot make any real difference”.Hirschman, The Rhetoric of Reaction, p. 45.

Several threats are raised, often simultaneously, as in 2009, when the MSF-France head of mission in Sri Lanka made the case for cautious silence. “What should our communications strategy be when we do not have first-hand information to convey? When an organisation present in the conflict zone (i.e., the ICRC)—and thus with greater legitimacy in discussing the situation—already has an international communications structure in place? When it is fairly clear that it will have no effect on the people on whose behalf we want to intervene? When, from an operational perspective, MSF lacked the ability to respond that would have allowed us to really confront the authorities? When it has a significant risk of exposing the national staff?”MSF, internal publication, Mar.–Apr. 2009.

Realism is justified primarily by three dangers: that of abandoning patients and halting treatments; of endangering the field teams’ national staff members; The term “national staff” refers to MSF employees from the country in which the intervention takes place. and of being prohibited from expanding the area of intervention, risking expulsion and undermining future opportunities to intervene.

The Sri Lanka missions provide examples of the decision not to issue public criticism in the name of medical emergency. In 2009, the Sri Lankan army broke through the defence lines of the rebel Tamil Tigers, who controlled an increasingly limited amount of territory. Tens of thousands of civilians were evacuated from rebel zones to a transit area and then forced to gather in internment camps, referred to officially as “welfare villages”. MSF-France was initially involved near the Menik Farm camp, where it set up a surgical hospital. The programme was covered under an agreement with the Ministry of Health, but the agreement came at a price—a confidentiality clause under which MSF would refrain from any “public comment” without the approval of the Ministry of Health. This was a severe constraint for MSF, but the organisation accepted it in order to avoid expulsion, and with the goal of reducing restrictions on access to the camps so that it could provide medical assistance to internees. The restrictions remained in place. The medical work to be carried out and the proposal to expand the intervention in the camps justified that perseverance, at least in the eyes of those supporting that choice. An evaluation drafted after several MSF managers visited Sri Lanka expresses that view. “There is no shortage of work to be done on ‘the Farm’ [the Menik Farm camp]. We should become a vital cog in its operations, because that’s the only way we’ll have a chance to eliminate it (or make a stir getting out) when we think the time is right”.Fabrice Weissman, “Welcome to the Farm: MSF and the confinement of IDPs in the Vanni”, Paris, July 2009.

The desire to respond to the population’s “medical needs” and not to abandon “our patients” at any price was the overwhelming motive for staying in Myanmar. An MSF-Holland programme manager stated that clearly in 2007 on CNN. “We have a very large programme. Last year, we treated more than a million patients for malaria and AIDS. The programme activities are still going on. We are treating deadly diseases. So it is very important for us to continue the treatment of the patients”. This choice justified avoiding actions that could put the medical activities at risk, regardless of what was happening in Myanmar. The field coordinators also feared that any criticism of the regime could lead to reprisals against the organisation’s Burmese employees and endanger them. The teams working in Sri Lanka expressed the same fear. In fact, the dangers facing teams suggest that such fears are quite legitimate. In the Ogaden region of Ethiopia, national staff members were accused of spying and some were jailed. In Palestine, two Gazan employees were questioned harshly by Hamas police officers and, on 4 August 2006, seventeen employees of Action Contre la Faim were executed in Sri Lanka.

We have already noted the justification for choosing not to issue public criticism because it would make no difference—not in general, but in specific cases such as in Sri Lanka, when the MSF-France head of mission concluded that public comment “will have no effect on the people on whose behalf we want to intervene”. The futility of issuing condemnations was also put forth after the September 2009 bombing of civilians in Al Talh, Yemen. The government air force carried out the attack, which MSF-France witnessed. It was the only aid organisation present and also treated several seriously injured children at the hospital, only two of whom survived. However, the organisation chose not to condemn the bombing, concluding that such an action would not lead the belligerents to adopt less fierce methods of combat, but could threaten MSF’s medical activities and disrupt its relationship with the Yemeni government, which was critical to MSF’s ability to carry out its work. That relationship had to be preserved as humanitarian aid could not be deployed without it.

The futility argument has been asserted under other circumstances. In 2001, the MSF team in the Gaza Strip challenged the Paris operational centre, criticising it for ignoring the experience in the field and the statements the team had gathered to condemn Israel’s treatment of the Palestinian people. Several MSF-France board members responded that the Palestinian situation is one of the world’s leading news stories and that the statements gathered by MSF dealt with violence that had already received extensive coverage. The term “futile” was not used explicitly as it would have shocked its audience. However, that was the political subtext of the critique of using the statements to express an emotional and political commitment to a population subjected, here, to constant violence from operations conducted by the Israeli army.

Confrontation

The choice to confront is based on several justifications: first, “imminent danger”, according to which “it is not good enough to argue for a certain policy on the ground that it is right; one must urge that it is imperatively needed to stave off some threatening disaster”;Hirschman, The Rhetoric of Reaction, p. 244. Hirschman attributes the argument of imminent danger to the “repertoire of progressive rhetoric” that is, “[progressives] typically perceive the dangers of inaction, rather than those of action”. (p. 243). second, respect for international humanitarian law; and, third, agreement with the principles set forth in the MSF charter and several “reference documents” in which the organisation sets forth its rules for intervening and reasons for taking action.

The 2005 nutritional crisis in Niger offers a representative example of how the imminent danger argument is used. In April, MSF-France observed and publicly stated that an unusually high number of children were suffering from severe acute malnutrition and called for “general food distributions”. In early June the demand became more pressing. “Exceptional measures must be undertaken urgently so that the most vulnerable populations can gain direct, free access to food”. In late June another public statement was issued. It described the imminent danger in sharper terms than prior communications. “There will be thousands of avoidable deaths this summer”, it stated, referring to children who would die, despite the existence of nutritional products that could save them.For a description of the circumstances in which the argument of imminent danger was used in Niger, see Marc Le Pape, Isabelle Defourny, “Controversy as a Policy”, Jean-Hervé Bradol, Claudine Vidal, Medical Innovations in Humanitarian Situations: the Work of Médecins Sans Frontières, Médecins Sans Frontières, 2009.

 MSF regularly issues announcements of life-threatening risks. In general, they seek to alert national and international authorities and trigger action on their part. They correspond to a standard medical position. First, a diagnosis and a corresponding prescription exist. Second, MSF’s experts and epidemiologists have assessed the efficacy of these prescriptions in their practice and their surveys. A standard medical demand thus follows, justifying public confrontation when the organisation believes that institutions are resisting treatments with proven therapeutic affect. MSF has often undertaken this kind of confrontation to obtain acceptance of a new treatment; for example, to justify the introduction and prescription of antiretrovirals and tritherapies for HIV, and of artemesin-derived combination drug therapies in malaria epidemics when resistance to the anti-malarials previously used in Africa was recognised. Regarding confrontations related to the introduction of artemisin derivatives and antiretrovirals, see Suna Balkan, Jean-François Corty, “Malaria, Introducing ACT from Asia to Africa”, and Jean-Hervé Bradol, Elizabeth Szumilin “Aids, a New Pandemic Leading to New Medical and Political Practices”, Jean-Hervé Bradol, Claudine Vidal, ibid.

 Some link these initiatives and the political work they involve to the “universal medical ethics” referred to in the MSF charter, while others summon a professional code of ethics. Regardless, a public statement identifying a neglected danger inevitably transforms the doctor’s report into a political critique. The authorities it criticises will certainly respond— either by prohibiting certain activities, imposing additional bureaucratic obstacles, expelling the organisation or threatening to do so.

International humanitarian lawSee Françoise Bouchet-Saulnier, The Practical Guide to Humanitarian Law, Maryland: Rowan & Littlefield, 2007. is evoked regularly when the organisation’s unfettered access to populations it believes require aid is blocked. This was the case in Sri Lanka, Ogaden and Pakistan. Other references to standards are also raised, particularly those developed in the set of texts in which MSF defines the principles of medical-humanitarian action it respects; specifically, impartiality in providing care, the prohibition against weapons at sites where medical care is provided and “complete independence from all governments and political, economic and religious powers” (the MSF charter). When these principles are evoked in a public setting to support an argument, they are presented as lines that the organisation may not cross. However, even when it comes to these principles, advocates of realism can undermine advocates of confrontation. Concessions may thus be made in terms of the rules presented as essential to medical humanitarian action, such as the personal participation of MSF staff in providing medical care, the final choice of medical priorities to which MSF commits and programmes being overseen by MSF’s doctors.

Abstention

The argument regularly asserted in support of abstention can be summarised as follows: “That’s not MSF’s role”. There are several versions of that argument. One refers to MSF’s “identity” and the other relies on the language of the medical practitioner, emphasising MSF’s expertise and medical priorities to reject certain activities. In the latter case, abstention comes into play in the case of medical controversies that could become internal political confrontations when the issue of identity is advanced to impose or condemn a decision.

The case studies do not include many examples of such confrontations. Rather, the writers focus on accounts of what the MSF sections wanted to do and, subsequently, were able to do. They rarely refer to diseases that the sections chose not to treat. To understand the choice to abstain would require new investigations, specifically regarding the debates that arise when programmes are defined.

Between Realism and Confrontation: Inevitable Tensions and Interactions

Does the register of realism prevail in situations characterised by armed conflict and confrontation in peaceful ones? Indeed, in the absence of armed conflicts, there is a more systematic reliance on public criticism, confrontation and alliances with other organisations, as can be seen in the cases of South Africa and France. However, in practice, if we observe missions from start to finish, they are rarely characterised by a single style. Rather, there is almost always a shift from one kind of reasoning and register to another. This works both ways—from realism to confrontation and from confrontation to realism. These variations are related to the dynamics of each situation.

Nonetheless, the different forms of reasoning the organisation relies on may be contradictory, provoking conflicts and even crises inside the movement The choice among realism, confrontation and abstention creates tensions within the MSF movement and its sections; knowledge of/familiarity with these internal debates and conflicts would require specific investigations, which is why they are rarely referred to in this study. and its sections. Thus, those who opt for confrontation and public criticism value the approach when it produces a change that some consider progress in medical practice. However, it is questioned by others who emphasise obstacles blocking current programmes and obstructing their development. Those who advocate and practise the realistic approach in certain situations view it positively, as they believe it allows medical programmes to be implemented, even in extremely restrictive contexts. Those who take a negative viewpoint consider the concessions unacceptable in the name of the principles of humanitarian action and medical goals that they believe define MSF. Last, those who support abstention rely on the fact that certain illnesses require long-term treatment that they consider to be incompatible with MSF’s actions and responsibilities. Their critics condemn abstention and withdrawal as a form of irresponsibility toward patients—a refusal to commit on a long-term basis and a sign of the conservative nature of MSF’s medical practices.

The fact that we observe changes in the way certain approaches are valued and that the way they are described shifts from positive to negative and back again does not mean that we cannot resolve uncertainty surrounding the validity of choices. However, we must not always stand with the universal—“to claim supposedly universal principles” such as the Geneva Conventions—but must reach a compromise between the universal and the specific, invoking this particular actor’s unique medical experience to justify critiques of governmental measures or, conversely, the need to accommodate them. Indeed, “these two modes of legitimisation are not mutually exclusive. In most cases, one may even find that they are both required in order to lodge a complaint or justify an action”. Michel Feher, “Les gouvernés en politique, Vacarme, 34, winter 2006. www.vacarme.org.

In 2006, the MSF movement collectively reaffirmed several action principles. First among them, “the individual medical-humanitarian act […] is central to the work of MSF”. MSF, La Mancha agreement, 25 June 2006. This agreement is a “reference document” that describes those aspects of actions that are “both medical and humanitarian” on which all MSF sections agree. www.msf.fr.

 This principle exists in contrast with another “essential role”, that of publicly condemning “grave and ignored crimes” and “massive and neglected acts of violence against individuals and groups”MSF, La Mancha agreement, 2006. that actors in the field can witness based on medical data and their own experience.

We have seen that the tension between medical action and speaking out is, in fact, inherent to the organisation’s work and may always provoke contradictory judgments that are, to a lesser or greater degree, inflexible. This is what I sought to reconstruct by presenting the many justifications that MSF’s actors rely on to make medical programmes acceptable or, in other words, to be compatible with the many constraints facing doctors in humanitarian settings before they can take action, while medical programmes are being developed and, finally, when it is time to end those programmes. I have tried not to take sides. Some may certainly challenge that stance, particularly those who take action must make, justify and defend their choices—and accept the consequences. Nonetheless, placing myself at a distance (but not on a higher plane) is useful if it allows me to reconstruct the many ways of responding to constraints on action that MSF has adopted over the course of the 2000s.