MSF and the aid system: choosing not to choose

We often hear it said within MSF that the aid system – that is to say all the institutional actors involved in international humanitarian aid – is unable to provide effective relief, or that the aid system’s ability to provide aid is in decline. These statements, which suggest that MSF is itself outside the "system", are based on the very real number of people in relief operations who need help but do not receive it, or do not receive enough of it. But such a negative assessment could equally be applied to some of the operations of which MSF staff are most proud, and it ignores the transformations – both qualitative and quantitative –in aid techniques and policies. To have a practical application, any critique of the aid system needs to be located not in the ideal world, where disasters incur no victims, but in a historical and concrete reality. Our aim is to explore MSF’s relationship with the aid system, while showing how the ambitions of the aid system itself have evolved.

I. MSF: outside the system?

It is worth noting that, far from being outside the system, MSF is one of the five largest aid organisations in the world which together account for 38% of spending by international NGOs.The State of the humanitarian system - 2012” , ALNAP Within this group, MSF is the only organisation focused specifically on health

MSF’s history is marked, from its earliest days, by its sometimes conflicted relationships with other aid actors (UN agencies, the military, the Red Cross, NGOs) and its desire not to be confused with them. MSF’s attitude has varied over time and according to context and national section. This is why it is important to understand MSF’s past ambivalent relationship with the aid system, being careful not to confuse it with the organisation’s institutional narrative. Our aim here is not to revisit MSF’s internal controversies, some of which have been the subject of detailed reviews,See MSF Speaking out case studies (www.speakingout.msf.org) but to explore how MSF’s relationship with the aid system has changed over time.

MSF’s views of its relationship with other aid actors is coloured by the myth of the organisation’s origins, specifically the breach between MSF’s founders and the Red Cross during the Biafran war (1967-1970) over MSF’s denunciation of the "genocide" perpetrated by the Nigerian army. Although this corresponds only distantly to the historical reality,Rony Brauman, « Les liaisons dangereuses du témoignage humanitaire et des propagandes politiques. Biafra, Cambodge, les mythes fondateurs de Médecins Sans Frontières », in M. Le Pape, C. Vidal, J. Siméant (dir.) Crises extrêmes, Face aux massacres, aux guerres civiles et aux génocides, Ed. La Découverte, 2006 this version of events has remained dominant, providing MSF the backdrop to its first public pronouncements and outlining it specific profile amongst other aid actors. In actual fact, the first divisions between MSF and other aid actors occurred in 1979- 1980, with the controversy over the diversion of assistance to Cambodia after the Khmer Rouge was ousted and the government of Vietnam established itself in Phnom Penh. MSF, which had close relations with the emergency aid fund of the European Commission (that resulted in the creation of ECHO)Emergency aid funded a large part of MSF’s operations on the Khmer-Thai border and at the Somali-Ethiopian border, both MSF’s major refugee camp operations at the time, believed that foreign assistance was falling into the hands of the Vietnamese army of occupation. Other NGOs challenged this, calling instead for assistance to Cambodia to be dramatically increased in the context of a presumed famine. The ‘March for Survival’, a symbolic protest at the Cambodian-Thai border in February 1980 that was organised jointly by MSF and the International Rescue Committee (IRC), provoked intense controversy within the aid community and in the press. Rony Brauman op.cit.
However, these political and ethical conflicts, reflecting Cold War dividing lines, did not affect MSF’s relations with aid actors in other areas, notably with the United Nations High Commissioner for Refugees (UNHCR).At the time, UNHCR provided funding for specialised NGOs (of which MSF was one) working in the refugee camps. As well as a donor, UNHCR was also an operational partner. MSF received funds from this UN agency, and worked alongside it in refugee camps, and continued to work with the European emergency assistance funds, participating in coordination meetings. MSF participated in the coordination mechanisms of the sectors in which it was working under the aegis of local authorities or the UN, believing these interactions to be action oriented. MSF did

not deem it necessary, however, to join the platforms of NGOs in Europe, such as the Steering Committee for Humanitarian Response (established in 1972) or Voice (1982)

The 1980s saw the creation of four new MSF sections (MSF Belgium, Switzerland, Holland and Spain), strengthening the newly formed movement’s position with regard to the aid system. It was a relationship that involved both cooperation and criticism, reflecting the political divisions of the time. Divisions also multiplied within MSF while in its period of rapid expansion: the French section and later the Dutch section worked primarily, but not exclusively, in situations involving armed conflict, the displacement of populations and natural disasters, while the Belgian, Swiss and Spanish sections were oriented more towards medical cooperation to develop and strengthen local public health structures. There were frequent disagreements between the five sections, which were evidenced both in the use of its public voice as well as with operational decisions, each desiring to present itself as the "true" MSF.

At times the MSF movement came close to breaking point, as evidenced by the exclusion of the Greek section in 2000 following the war in Kosovo. The leaders of the MSF movement felt that MSF-Greece was too closely aligned to the Serb nationalists during the war. This instance aside, the desire to maintain the relationship between MSF sections has always prevailed in the end. Nonetheless, tensions between them have complicated MSF’s ability to make shared appeals to bodies for help. On the ground, it is still the case that each MSF section has its own seat and its own representation in local coordination meetings, although there is strong internal pressure for sections to pool representatives.

However, common positions between MSF and its colleagues within the international aid community were taken up. For instance, MSF adopted and promoted the essential drugs list of the World Health Organization (WHO); it helped to develop, whilst at the same time arguing against the role entrusted by the WHO to “Community Health Workers” in the strategy of primary healthcare. Similarly MSF actively supported the Expanded Programme on Immunization (EPI) promoted by the WHO and UNICEF, while criticising the vaccination campaigns supported by UNICEFSee Jean-Hervé Bradol, Caring for Health, in « Humanitarian negotiations revealed : the MSF experience »,

The famine in Ethiopia in 1984 – and the international relief operation that followed – marked the first time in MSF’s history that it had broken ranks with the entire aid system, including both the UN and NGOs (the only one other time was in the aftermath of the Indian Ocean tsunami of 2004). The French section of MSF accused the Ethiopian government of using aid to implement its strategy of forced population transfer and confronted all the aid actors working on the ground in Ethiopia, with this issue, starting with the United Nations Development Programme (UNDP).

Three criticisms were levelled at MSF by the aid community, and these are still used to this day: that speaking out is a breach of the principle of humanitarian neutrality, that emergency actors do not understand the challenges of development, and lastly that speaking out sabotages fundraising efforts. To varying degrees and applied to a widerange of circumstances, these same arguments would later be at the heart of other public controversies (especially following the 2004 tsunami).

MSF’s breaking ranks in Ethiopia did not permanently damage cooperation with its usual partners, but it did illustrate the uniqueness of some of MSF’s positions within the NGO community. Humanitarian principles can lend themselves to very different interpretations, making disagreements perhaps inevitable.

It was in order to regulate these disagreements that, in the late 1980s, MSF committed to establishing an international structure. The objective was threefold: to manage MSF’s brand and logo; to set up a platform to help resolve quarrels between sections – with the fresh memory of MSF-France suing MSF-Belgium in court in 1985; and to ensure unified representation to international organisations. In 1990, MSF’s International Council was created, composed of two leaders of each section. Additionally, an International Secretariat was set up in Brussels (moving to Geneva in 2004). This was confirmation of the desire for MSF’s national sections to be reconciled, and of the need for MSF to maintain relationships with the major players by demonstrating a shared commitment to its mission and by speaking with one voice.

MSF’s reforms subsequently facilitated the work of the organisations with others. During the 1990s, MSF supported the International Campaign to Ban Landmines (as a member of the coalition) and actively participated in the NGO coalition campaigning for the International Criminal Court and also to the initial phases of the Sphere Project.See below

II. Aid as a tool for crisis management

With the end of the Cold War, deploying aid in areas affected by conflict assumed an increasingly important place on the UN’s agenda. Large scale militarized emergency relief became a tool for crisis management, leading in the 1990s to a series of institutional decisions.

In December 1991, in the aftermath of 'Operation Provide Comfort' (referring to the repatriation under Allied protection of the Kurdish population in northern Iraq, following the first Iraq War), General Assembly Resolution 46/182 reaffirmed the UN's role in the leadership and coordination of the humanitarian response. A Department of Humanitarian Affairs was established to replace the UN’s Disaster Relief Organization, a body that struggled to assert its utility. The Inter-Agency Standing Committee (IASC) was set up under the chairmanship of the UN’s Emergency Relief Coordinator. The European Union established ECHO, a branch of humanitarian aid from the European Commission, intended to oversee and fund relief operations. The ‘Agenda for Peace’ of UN Secretary-General Boutros Boutros-Ghali, developed in July 1992, advocated an integrated approach, bringing together various UN bodies in the service of its primary mission and declaring: “maintaining international peace and security could not be dissociated from its task of solving international problems of an economic, social, cultural or humanitarian character.” Jeff Crisp, “ Humanitarian action and coordination” , in The Oxford Handbook on the United Nations, 2008.

Somalia in 1992, without a government and plagued by war and famine, provided the UN Secretary-General with a testing ground for this new form of intervention, including emergency assistance, law enforcement and state building. A year later, protesting that,for the first time in its history, people were being killed in the name of humanitarianism, MSF France withdrew from Somalia, declaring with insistence that it dissociated itself from this policyVoir Rony Brauman, Le crime humanitaire - Somalie, 1993, Arléa. Available on line: http:/ / www.msfcrash.org/ drive/ 95d4-rb-1993-somalia-a-humanitarian-crime-_uk-p.10_.pdf) yet all the while remaining part of the system and strengthening its links with other agencies.

During the 1990s, MSF actually sought to generate debate within the humanitarian arena on the protection of populations in need and the quality of the assistance provided. An observer to International Council of Voluntary Agencies (ICVA) since 1991, MSF joined the Steering Committee for Humanitarian Response (SCHR) in July 1997 at the request of the ICRC who was a member and felt isolated. It therefore became a signatory to the Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations in Disaster Relief, which had been established in 1994.

MSF – along with many other aid agencies too – viewed the sharing of information and the creation of a common language within the aid system as a necessity in the context of the major relief operations of the 1990s, whose scope and ambitions (in term of protecting civilians, accountability, and the speed and extent of coverage) were completely different from those of the 1980s.

Concerns that humanitarian aid was being reduced to a technical performance came to the fore in June 1994 as international aid efforts focused on the camps for Rwandan refugees around Goma. After the initial emergency phase responding to outbreaks of cholera and shigellosis, which killed more than 50,000 people in the space of a few weeks“Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994?” , Goma Epidemiology Group. Lancet. 1995 Feb 11;345(8946):339-44.;, the aid effort became more organised. Technically correct, but blind to the political realities of the region, the resources provided for this effort became an instrument that could be used by the military and administrative leaders of the genocide that had taken control of the camps. For most in the aid community, the failure was in qualitative deficiencies, which were clearly evident in aid operations in this region. MSF stated, however, that, while the response to the cholera epidemic in its early stages had been very weak, the most important thing was to recognise the limits of humanitarian action and to reflect critically on the diversion of aid – of NGOs and International bodies – with criminal intent.Rony Brauman, La responsabilité humanitaire, article from the “ dossier des Etats généraux de l’action et de droit humanitaire” , Colloquium organised by the ICRC, Paris, 27 et 28 novembre 2001

MSF saw its participation in the Sphere project set up in 1997 at the initiative of the SCHR to define "a set of minimum standards in the core areas of humanitarian assistance" and establish a “Humanitarian charter” as a mean to agree with other participants on basic principles of Humanitarian action and to share and disseminate techniques. It took part in the initiative while recognising that the standards established by Sphere were below those MSF had already defined as part of its policy. Eventually, MSF withdrew from the Sphere Project in 2003. The decision was in part justified by the argument that "humanitarian action [was] too complex to be reduced to technical performance" alone, and in part by the argument that Sphere’s norms had become too rigid. Letter sent to the missions by Rafa Villa Sanjuan, International Secretary of MSF, 25 March 2003.

III. The illusion of crisis without victims

The crises of the early and mid-1990s accelerated the race to define norms and standards, a step considered essential to improve the overall quality of assistance. Flaws had become apparent after the “Joint Evaluation of Emergency Assistance to Rwanda” was conducted under the auspices of the OECD

http:/ / www.oecd.org/ derec/ 50189439.pdf. Although it could be argued that Goma, because of the particular magnitude of the crisis and the difficulties of the terrain, was not the most appropriate location to conduct an evaluation, the evaluation exercise eventually led to a number of improvements in the aid response.

Initiatives succeeded each other in rapid succession: People in Aid was set up in 1995 to “promote better management and support of staff and volunteers”; it was followed by the Active Learning Network for Accountability and Performance (ALNAP) in 1997, dedicated to “improving the quality and accountability of humanitarian action”. The

Humanitarian Ombudsman Project was set up in 1999, to be replaced in 2003 by the Humanitarian Accountability Partnership (HAP); the Good Humanitarian Donorship was established in 2003, “an attempt”, no less, ”to fix one share of the humanitarian system”. The Humanitarian Accountability and Quality Management Standard was established in 2007, followed in 2009 by Enhancing Learning and Research for Humanitarian Assistance (ELRHA), which is currently considering ways of certifying and accrediting humanitarian staff, and by the Inter-Agency Standing Committee’s Needs Assessment Task Force. The list continues.

The State of the Humanitarian System ReportThe State of the humanitarian system - 2012” , ALNAP estimated in 2012 that there were 4,400 NGOs "undertaking humanitarian action on an on-going basis", there were 274,000 aid workers, and that "between 1988 and 2008, the humanitarian aid budget increased tenfold to reach US$11.2 billion"Don Hubert, Cynthia Brassard Boudreau, “Shrinking humanitarian space? Trends and prospects on security and access” , the Journal of Humanitarian assistance, 24 Nov. 2010. At the same time, the ambitions of the aid system are continuing to grow. ALNAP suggests that "another part of defining the ’humanitarian system' involves not what the system is, but what it is expected to do. The range of action considered 'humanitarian' varies and seems expanding".

The State of the humanitarian system - 2012” , op.cit.

To determine the direct impact of the initiatives above on the practice of humanitarian actors would require a detailed investigation. But even without this, it is clear that, in many recent crises – such as Darfur/Chad in 2003 and post-earthquake Haiti in January 2010 – professional help and concern for quality have produced results, some of which are measurable.

Take Darfur, for example. Food security and nutrition assessment of the conflict-affected population in Darfur (2007) reported a significant decrease in mortality amongst displaced people and residents in areas affected by the conflict, falling from 0.72 in 2004 to 0.46 in 2005, 0.35 in 2006 and 0.29 in 2007 – well below the emergency threshold of one death per 10,000 people per day. Malnutrition also declined, albeit by smaller proportions, falling from 21.8% in 2004 to 16.1% in 2007. Despite persistent problems reported by MSF in the camps, particularly amongst younger children, we have seen improvements in the overall health status of a population who has been affected by violent conflict and mass displacement and whose health status appears to be largely dependent on international humanitarian aid.

Judging by the dominant discourse within the aid system, including within MSF, these positive aspects are rarely noted – and even fewer successes are mentioned in the field of natural disasters. The response to the 2010 earthquake in Haiti conjures up the images of chaos, a failure of coordination on the part of the government and the UN, as well as the "international well-documented failings of the aid community".See the IASC Transformative Agenda Information note for NGOs April 2012 from SCHR, InterAction and ICVA However, this chaos did not prevent the start of the relief effort, especially emergency medical care, in the early hours of the disaster, and over the next 15 days an increase in relief to unprecedented levels, despite extremely difficult access (a destroyed airport, congested access roads and a government left in tatters).Rony Brauman et Fabrice Weissman, Aide internationale : ce qui se passe en Haïti, 12 janvier 2011. http:/ / www.msf-crash.org/ sur-le-vif/ 2011/ 01/ 14/ 409/ aide-internationale-ce-qui-se-passe-en-haiti/Drinking water was provided and food supplies were brought in and distributed, and all of this was conducted in an acceptable manner, given the magnitude and suddenness of the disaster.

Note that the Haiti earthquake has few parallels in history: what other peacetime disaster has caused tens of thousands of deaths and huge numbers of injuries in the space of just a few minutes? A couple of recent and comparable natural disasters come to mind – the 2005 Kashmir earthquake and the 2004 Indian Ocean tsunami – but a quick look at the response to these events shows major differences.

In Kashmir, the Pakistani army provided effective management of the aid effort, assisted by powerful local NGOs, including activists.Marion Pechayre, Humanitarian action in Pakistan 2005 – 2010, Feinstein International Centers, Tufts University, 2011. International aid efforts by the Red Cross and MSF, amongst others, supplemented what was already being done on the ground. This is the opposite of what happened in Haiti, where some 15,000 wounded were cared for under the auspices of international aid, despite the shortcomings in coordination.

Contrary to what is generally said, including claims by MSF, the emergency life-saving response was successful in Port-au-PrinceFabrice Weissman and Rony Brauman, ibid.

By contrast, the 2004 tsunami, which killed many more people than it wounded, should never have been described as a life-threatening emergency. Unlike Haiti, the teams sent to medical facilities in Aceh were unnecessary, and much "emergency aid" was wasted.Rony Brauman, Do Something », in « Humanitarian negotiations revealed: the MSF experience », London: Hurst & Co, 2011. (Available on line: http:/ / www.msf-crash.org/ livres/ en/ natural-disasters-do-something.) Again unlike Haiti, the reconstruction of Aceh has been a success, thanks to the policies of the Jakarta government combined with good cooperation from donors. It is striking that this rare incidence of success has gone largely ignored when it deserves to be widely studied.

In Haiti, the lack of emergency shelters and reconstruction, both in terms of quantity and quality, remains a legitimate criticism of post-earthquake assistance. The Haitian government and donors share the responsibility for this shortcoming. Did the initial announcements by the UN and NGOs claiming to tackle reconstruction ("Build Back Better") create unrealistically high expectations, relying as they did on the ability and willingness of political authorities? Some 200,000 Haitians still live in makeshift shelters three years after their homes were destroyed. How was the "aid system" to succeed, when for decades many more have lived in slums?http:/ / www.amnesty.org/ fr/ for-media/ press-releases/ haiti-three-years-earthquake-housing-situationcatastrophic-2013-01-11 It is the illusory discourse of an omnipotent aid system that should be held accountable here, and not the system’s supposed failure. False expectations that the humanitarian part of the aid system can address deep rooted political and development problems inevitably leads to the equally false conclusion that the aid system is flawed or broken.

While it is important to note the overall improvements in the performance of aid, it is no less essential to note its sectorial or geographical limitations. The issue of shelter for displaced populations is one example, as well as the longstanding weakness or nonexistence of the international response to the proliferation of health and political crises in Central Africa, a conflict that continues to carry a heavy human cost. 

We can also recall the situation in Angola in 2002, when the United Nations maid aid contingent to a political ‘resolution’ of the conflict at the cost of a blockade causing a deadly famine in areas controlled by UNITA.Christine Messiant, “ Angola : Woe to the vanquished” , in Fabrice Weissman (ed.), In the shadow of just wars. Violence, politics and humanitarian action, London: Hurst and Co, 2004.

For these reasons, MSF has remained suspicious of the attempts at coordination and standardisation that have continued to emerge in recent years from the UN and various NGOs. MSF’s suspicions were strengthened following the invasions of Afghanistan in 2001 and Iraq in 2003, especially given the tendency of most aid actors to align themselves with the political objectives of the coalitions. Between 2003 and 2007, MSF left InterAction and the SCHR and distanced itself from the cluster system established by the humanitarian reform of the UN in 2005. On these occasions, MSF time and again cited the principles of neutrality and impartiality to distinguish itself from other actors and to justify its isolationist position. MSF considered that integration within the global aid coalition geared to state-building equated to political alignment with belligerent parties.

We have emphasised the change of tenor in international aid after the end of the Cold War. By integrating humanitarian aid into the crisis management toolbox, there has been both an increase in the scale of aid operations, and its ambitions. Contented to confining assistance mainly to the peripheral areas of crises, aid alleviated some of the human consequences of crises. The new configuration of international aid aims to address problems at the root, sometimes to the extent of becoming an instrument of state-building. This ambition stems from a desire to contain conflict and displacement within national borders, and to manage international crises within the countries concerned, as in ‘Operation Restore Hope’ in Somalia.

This change of emphasis, supported by a professional workforce and increased resources, has produced relief operations on a larger scale and of a higher quality than before.

However, the aid system, of which MSF is a core component, is at risk of hubris. Analysing the genocide in Rwanda and the many victims of the Haiti earthquake as "humanitarian failures" implicitly assigns to aid a power not commensurate with its true capacity. Such unrealistic expectations threaten to condemn aid to permanent failure, and to lose sight of the fact that there are problems and deficiencies that aid can actually correct.