Too much Never Enough : Social Support at MSF

Looking at MSF programming today we see a variety of social support initiatives, as well as projects aimed at treating people in situations of socio-economic difficulty: programs for drug users in Iran, cash distributions for HIV and cancer patients in Malawi, protection and social support for migrants and refugees in Libya. However, the provision of social support is often seen as a marginal activity and there is debate about the appropriateness or relevance, or even the effectiveness, of such activities.
 
This paper by Jacob Burns on social support is divided in two parts. In the introduction “Practices and Motivations”, he suggests a rough outline of different ‘social’ problems that MSF has turned to and the moments at which it has done so, between the 1980s and the 2010s: street children and people living in slums ; Mission France ; Projects addressing human immunodeficiency virus, tuberculosis, and sexual and gender-based violence ; the responses to the Ebola epidemic in West Africa (2013-2015) and the Democratic Republic of Congo (2018-2019). The author argues that it is possible to break down the motivations for providing social support into three broad categories: to help achieve therapeutic success, to aid the effectiveness of our operations, to enhance the ‘well-being’ of the person.
 
The second part of the paper is a report of a field visit conducted in October – November 2023 to Goma, DRC. The visit was undertaken with an ethnographic approach: completing observations of the teams’ work with conversations with team members during which Jacob Burns tried to understand as much as possible their reasoning and motivations for the decisions they took. As the author himself says, this paper poses more questions than it provides answers: how do we judge what the ‘real’ needs of people are? What role giving money should have in the provision of humanitarian aid? What agency a person should have when receiving aid? To what extent MSF should work on the sources of the problems it is trying to address, rather than just their symptoms or consequences?

The introduction of this research work is available online below, you can download the full PDF-version of this paper here.

Contents

---  Preface
---  Introduction – Practices and Motivation
---  Case Study: Goma, Democratic Republic of Congo
---  ‘Be curious’ – An epilogue
---  Appendix: List of interviewees

Introduction - Practices and Motivations

This project started with 33 interviews with MSF practitioners, chosen purposively because of their implication in certain projects or periods associated with the provision of social support, or because they hold a leadership position within the organisation (see Appendix). They were asked to recount their experiences with MSF where social support had been a component of our response, or where MSF had responded to ‘social’ problems.  The intention here is not to precisely reconstruct the history of social support, or social interventions, at MSF, but the interviews undertaken allow me to suggest a rough outline of different ‘social’ problems that MSF has turned itself to and the moments at which it has done so:  

•    A series of ‘social projects’, often concerned with street children and people living in slums, beginning in the 1980s and continuing until the early 2000s;
•    Mission France, beginning in the late 1980s, which has connections to those other social projects and yet has a different history and operational logic;
•    Projects addressing human immunodeficiency virus (HIV), tuberculosis (TB), and sexual and gender-based violence (SGBV), which came to form an important part of MSF’s portfolio in the late 1990s and early 2000s;
•    The responses to Ebola in West Africa and the Democratic Republic of Congo after 2014.

In the 1980s the desire to take on social problems amongst a section of MSF volunteers expressed itself in a series of projects aimed at people living in slums in the so-called third world, such as one in GuatemalaAuthor interview with Rony Brauman, Director of Studies at CRASH and President 1982-1994, 3 May 2022, in French.. There, MSF supported the slum’s governing committee with money and technical expertise to install a water and sanitation system in the slum and lent political credit to the slum’s struggle for legitimacy, thus finding concrete and achievable objectives even in the absence of acute medical needs:

There were no medical activities… It was that which bothered me at the beginning… [but] finally we were useful. That’s always my argument: if we’re not doing medicine, but we’re useful for something, really useful, and we are filling a role that no one else can fill, then that’s good for meAuthor interview with Brauman..

While the complete absence of medical activities was unusual, projects that targeted specific groups in society rather than pathologies or emergency situations were a common feature of MSF programming in the 80s and 90s.

A report was commissioned to Marie-Helène Jouve in 2007 to “provide food for thought for a collective debate on these “exclusion and social violence” projects”, against a backdrop of profound questioning of these interventions. The author called on MSF to move away from “the universally accepted definition of humanitarian action” designed to “alleviate vital risk”: in a context of great social insecurity, she concluded, “it is a question of providing aid that goes beyond care, so that this medical aid has meaning”, and of also focusing the intervention on “the general well-being of the patients”Marie-Hélène Jouve, Eléments pour une analyse des projets « Exclusion, Violences sociales », MSF-France, 2007..

Often the target of these programs were street children, who were vulnerable to abuse and ill-health:

At the end of 1996 I was sent to Cairo. There were lots of children, and as soon as there were VIPs arriving the government rounded up all the children in the street to put them in prison. We wanted to see what was happening with these beggars, who were sometimes three years old. We worked with a local organisation, we set up a little centre where street children could wash, eat, and we treated them. And when they were in prison, we asked that we had the right to visit to at least treat them for scabies, because if one person has it then everyone gets itAuthor interview with Marie-Hélène Jouve, Head of Mission and author of a 2007 report on MSF’s social exclusion / social violence interventions, 10 June 2022, in French..

The beginning of Mission France in 1987 was also often cited in interviews as a moment in which MSF opened itself to actions of a more social type, where links with social services were part of the operational approach. The origins of the mission were very healthcare focused, however. The intention was not to address directly the precarity or poverty of the neglected groups who were having trouble accessing healthcare. It was to provide healthcare to them, refer them to social services, and use the medical activities as a base of legitimacy for advocacy efforts to establish truly universal healthcare in FranceAuthor interview with Brauman.. Later developments in the mission, however, meant that its programming responded to social exclusion first and medical issues second, particularly as the mission came to focus on protection and shelter activities for migrants.

These projects shared a desire to target a specific population who were perceived to be at a disadvantage socially. This changed with the numerous projects started in the 1990s and 2000s that targeted people living with HIV, TB sufferers, and survivors of sexual violence. Social support here was about the support of a medical objective. The activities might not have been those traditionally associated with medical action, but the logic of their deployment was to increase the chances of success of treatment. For example, it was common practice to give TB patients two months of accommodation and food, with the aim of promoting adherence to treatmentAuthor interview with Jean-Hervé Bradol, Director of Studies at CRASH and President 2000-20007, 19 April 2022, in French.. Social work was also part of the toolkit that MSF deployed when treating TB:

Honestly social support is not new. I have a lot of experience since I was national staff in the 90s, in Armenia, Nagorno Karabakh. In a project for TB we recruited a social worker, to study case by case, not with a policy, to say, “ok that’s our law”, but case by case. She did home visits to try to organise help. If the person needed money to buy food we gave cash so that the patient could decide themselves to buy foodAuthor interview with Mego Terzian, President 2013-2022, 5 May 2022, in French..

The toxicity of early antiretroviral drugs (ARVs), the necessity of close adherence to treatment for TB, and the extreme socioeconomic precarity of the people we were treating were all identified as drivers for the inclusion of more social support in MSF’s toolbox:

We realised that for the adherence, you needed psychological support, education, but also sometimes, notably for kids who lived in very difficult economic conditions, that it’s difficult to tell them, ‘take your meds every day’, when they didn’t have anything to eat that morningAuthor interview with Philippe Blasco, Patient Education & Counselling Advisor, 18 May 2022, in French..

The HIV projects, they revealed the fact that we had vulnerable people, ill people who could not work, who had to take a medication that was toxic, and they were often marginalised people, or orphans. Everything that we did around that was what I call social supportAuthor interview with Léon Salumu, Manager of Cell 5, 23 May 2022, in French..

These programs caused us to expand our understanding of patient behaviour. People did not neglect to take the drugs that they were prescribed or miss appointments just because they lacked the knowledge or the will to do so: they had material concerns that blocked them from maintaining or completing treatment. The conclusion, as a result, was that MSF had to start trying to design programs that responded to those material barriers.

The development of mental health activities and of projects aimed at survivors of sexual violence saw the creation of activities that aimed not only to address material obstacles to accessing care or continuing treatment but expanded the idea of care itself to cover the socio-economic costs incurred by a person being injured or ill:

[In Congo-Brazaville in 2000] I was involved in one of the first transversal projects that was supposed to treat women who were victims of sexual violence in a holistic manner. There was all the legal side, but also a socio-economic aspect, to help the people to reintegrate into a society from which they had been excluded. There were women that became tailors, that we helped to do so, there were women who had been excluded, who had lost their husband, their children. We’re coming back to patient- or person-centred. It was aid that was more personalised, following the violence to which they had been subjected, and how the society in which they lived had responded to itAuthor interview with Thierry Allafort, General Director, 9 May 2022, in French.. 

In another example, in Haiti in the late 2000s, MSF stood as the guarantor for loans made to women survivors of sexual violence that they could use to start businesses with:

The social workers made an assessment based on their previous experience, where they lived, what opportunities existed, if there were government institutions that could help them. We helped maybe around ten, in partnership with a microcredit initiative who gave them a small amount of money to help them set up their business, which was a small thing, like selling food in the road… it was around 500 USD. Not a huge amount. The loans were at zero percent. All ten reimbursed their loans and were completely independentAuthor interview with Isabelle Mouniaman-Nara, Deputy Director of Operations, 4 May 2022, in French..

The logic of these interventions is based on a radically expanded conception of the pathway of care. Not only does it consider what the patients will be interested by in the provision of healthcare and how they can be helped to access that care, but also what follows their discharge. It takes into account the actions necessary to ensure that the benefit of the provision of care does not become cancelled out by the social or economic detriment incurred by the injury or illness itself. 

Sometimes these efforts to understand the environments in which our patients were living and the problems they had led to programming that prioritised non-medical aid, as was the case in the emergency response to the 2005 Pakistan earthquake:

One day we said that it was cold, so we are going to buy these Iranian heaters, not even 10 dollars each, and kerosene, and instead of doing water trucking we did kerosene trucking. And voilà, the people heated their tents and they stopped coming to the clinic. 17,000 families, everyone criticised me, everyone was saying that it was not MSF. In what way is that not MSFAuthor interview with Mego Terzian.?

In reading these examples we begin to see how large the perimeter is for social support at MSF. There is an idea in there somewhere of the kinds of activities that MSF means when it says it is doing social support, a centre of gravity around which diverse experiences orbit. But how do we make sense of these activities? What links heating oil for earthquake victims with tailoring for survivors of sexual violence?

One obstacle to analysing the field of social support becomes clear when people who are all agreed on its necessity in a particular context discuss their ideas for how it should be implemented. It is there that we see that there are different ideas at work, different conceptions of what ‘social support’ means, and that the different ideas lead to quite different programming.

This is the case with Ebola, where numerous people identified social support as an important element to develop in the context of our responses. However, their explanations of the reasons for providing social support and the way it would be implemented showed quite different intentions at work:

I also bet that in the social [support] was all the relationships that you would create, someone that you really helped, perhaps he would be more inclined to come to the hospital when he was really ill… if you had created a relation with them, you would help them cover their needs, better follow the confinement – because they wouldn’t have been able to if you didn’t help them – and so there was surely a public health effect… When we were struggling with the second vaccine in the epidemic in Congo, I said that ok we need a second vaccine… but I thought that it was better to work on the social aspect, because you could – in part – help to control the epidemic through those actionsAuthor interview with Thierry Allafort..

Here the operative logic is to use an individual action in the hope that – once reproduced at scale – it would contribute to the reduction of the transmission of the virus, because in effect we would be providing material motivations for the person to comply with public health recommendations. It is social support aimed at increasing the effectiveness of our operations.

Other rationales were more concerned with using social support to compensate for the devastating economic impacts of Ebola and to use the social support to facilitate the use of new treatments, in a way targeted using positive results:

People are scared of being diagnosed with Ebola, OK, but you have to tell them that the sooner they come the more chance they have to survive… [Ebola] means a huge loss of money for the family, the house is burnt, the beds are burnt, you lose your job, you are isolated, so as well as the fear of death I thought that there was a big economic part to the fear of being diagnosed with Ebola… I thought that we should use money to encourage people to get tested, but not to pay everyone, not to compensate all of the negatives, only the positives. I start from the principle that the people who really have Ebola, they know they have Ebola, because they hide… [The money] might have encouraged them to come [to the treatment centre]Author interview with Isabelle Defourny, President 2022- , 19 May 2022, via Teams, in French..

So here again, part of the reason for the provision is about increasing operational efficiency, though this time more about getting people into treatment than preventing the spread of the disease. Another part of it is about compensating the socio-economic costs incurred by the person and their family when a person becomes unwell. It resembles the idea from sexual violence projects where the treatment pathway was being extended beyond the treatment of the physical injury to attempt to compensate the costs incurred by it.

Whereas yet another view sought to utilise the same tools – cash and material social support – to catch infections as quickly as possible to give the person the best chance of benefitting from treatment. Yet it did so in a manner that did not distinguish between those who tested positive and those who tested negative, and that recognised the social costs of even being suspected of having Ebola:

As soon as we knew that we had a treatment for Ebola, we also knew that if you gave it early to someone infected with Ebola then the chances of survival were very high, and if you gave that treatment too late then you’d die… [but in Kivu] the chance of them actually getting to somewhere they can get a test to prove they have Ebola and get the treatment in time for us to make a difference is limited… we know that the people who eventually develop Ebola are the people who were in contact with Ebola, and the people who are in contact with Ebola have been caring for other people with Ebola. So, we said that we know who’s going to get sick… [and you give them] a support package, and so that was basic things like some food, some hygiene supplies, some cash. We didn’t want people to disappear off the radar, we wanted people to hang around, stick close to home. The most important part of the package was a mobile phone, with some credit, and we said we’ll call you every day, but we want you to call us if there’s anything weird – even a headache, give us a call… And if you don’t get sick, you don’t get sick, it’s fineAuthor interview with Natalie Roberts, Director of Studies and Manager of the Emergency Desk 2017-2019, 10 May 2022, in English..

The three examples all address the same disease with the same will to use social support, and yet each have distinct criteria for the provision of support, distinct relations to the use of medical tools, and distinct objectives. They show that even minor differences in how we think about the use of social support can produce very different programming, which can make it difficult for the teams on the ground to interpret and implement the injunction to provide social support, or to navigate discussions about its implementation.

What I think this brief survey reveals is that social support is impossible to analyse at the level of what is done. This is because we are faced with a field that is filled both with examples that do not resemble one another at all and examples of what look at first to be the same activity but on closer inspection are actually trying to fulfil quite different objectives. If we kept our analysis purely at the level of what is done, for example by trying to group actions into categories, we would always come up against this problem: that the actions are simultaneously too similar and too diverse to enable useful categorisation.

Instead, as we see with Ebola, useful comparisons can only begin to be made when we move the conversation away from what is done and towards why we are doing it. It is, I think, only by looking at the intentions for the provision of social support that we can find a way to analyse the field, to understand what our ambitions are for social support and what discussions we need to have about it in order to implement it usefully.

 I believe that we can break down the motivations for providing social support into three broad categories:

1.    To help achieve therapeutic success

This, in its limited sense, is like when we give food to HIV patients so that they can take their medication because it is nauseating on an empty stomach. Actions that are designed to create conditions where the treatment can be followed. Or it can be actions that are part of an understanding of therapeutic success that goes beyond purely clinical indicators to include socio-economic ones, where we recognise that being ill or being hurt has a cost and that the benefit of our medical activity can be outweighed by that cost if we do not help people cover it.

2.    To aid the effectiveness of our operations

The most frequent activity of this type is the payment of transport costs for people coming to our clinic or hospital. We want to provide services to a certain type of person, we know that they cannot easily access the project, and so to promote the project’s reach we remove the economic barriers to coming to us. This can also sometimes take a logic of providing benefits to people to increase the uptake of testing or treatment. Or it can be motivated by what we see as the judicious use of resources: we provide a relatively cheap food ration to the family of a malnourished child to mitigate the risk of the relatively expensive nutritional supplement being shared with other children in the family.

3.    To enhance the ‘well-being’ of the person

This very broad category encompasses a range of objectives and scales of action. At its simplest, it is about increasing the autonomy of the person, for example by giving displaced people cash to buy the things they need instead of imposing our analysis of their needs on them by the provision of a non-food item (NFI) kit. Then there is the idea of responding to a non-medical need or relieving non-medical suffering by providing an immediate improvement of the material conditions of a person: providing food for the hungry, warmth for the cold, shelter for the homeless. Then there are the objectives that target a more fundamental or longer-term change in a person’s circumstances, for example providing legal assistance to a migrant in a situation of administrative irregularity, referring a patient to other existing social services, or providing financial assistance to someone to allow them to start a business.

These categories are inevitably personal, and the lines between them are sometimes unclear or debatable. Others may wish to break down our motivations for doing social support in other ways. That is not a problem. What is important here is not the categories themselves but the necessity to ask ourselves the question about what we are trying to do, what the problem we are trying to resolve is. It is once we have established which objective we are trying to achieve in each case that we can run through a series of questions that allow us to make critical judgements about our provision of social support. What are the limits to what we can do in trying to achieve that objective? What criteria are we basing our actions on? Which people and resources are necessary to achieve that objective? And, finally, how are we going to work with other partners and our patients to achieve that objective? These are the types of questions that I witnessed our teams try to answer in the field visit that I undertook for this project.