Informed and active associations and their representatives are crucial to assuring the relevance of our actions and the maintenance of a strong MSF international movement. Invigorating participation … at all levels of MSF is essential to building and maintaining credible, competent and relevant international governance.
DOCTORS WITHOUT BORDERS / MÉDECINS SANS FRONTIÈRES, “LA MANCHA AGREEMENT” (2006)
MSF South Africa officially became a new MSF “association” on December 16, 2011, the first day of MSF’s first International General Assembly in Paris, France, and of the simultaneous fortieth anniversary celebration of the movement’s foundation.1
Discussions at MSF’s international “La Mancha” conference in 2004 had catalyzed the recognition of MSF South Africa, bringing home to members that as many as ninety percent of the field positions in the countries where MSF had missions were filled by indigenous “national” personnel, and that over seventy percent of its projects were situated in Africa. Notwithstanding its “without borders” vision and commitment, MSF was still mainly run by western Europeans, however, and in many contexts where it worked, it was perceived as a predominantly foreign and white, if “international,” organization.2
Within the post–La Mancha framework, questions arose about how to deal with MSF’s extraordinary growth. The challenge was to fuse furthering MSF’s internationalization and its social mission with the “desire for a compact and dynamic movement, cautious of being headquarters-heavy and eager to engage the great growth that MSF had undergone over time.”3 New “entities” were developing around MSF in countries where it was in the field—including Argentina, Brazil, the Czech Republic, India, Ireland, Kenya, Mexico, Portugal, South Africa, Turkey, and the United Arab Emirates—and a number of these had asked for formal status in MSF. They wanted to be recognized at least as something akin to a branch office, but perhaps hoped, as was true of the group that had coalesced in South Africa, to be eventually recognized as a “real MSF section.”
As the vagueness and generality of the term “entities” suggests, it was not at all clear what such units ought to be—or what they should be called, or how to go about creating them, or what criteria they would have to meet to be approved, presumably by MSF’s International Council. This uncertainty is apparent in a 2007 memorandum concerning “new entities in Brazil and South Africa” that Gorik Ooms, then the director-general of the Brussels Operational Center (OCB), sent to the OCB board and the International Office’s committee of direction. In this memo, Ooms spoke of his perplexity about what to advise the groups in Brazil and South Africa about the necessary next steps toward becoming MSF affiliates:
I personally informed the MSF International Office about the intention to create MSF entities in Brazil and South Africa, and asked which procedure I needed to follow to obtain permission. I was told that there is no procedure for new entities as long as they don’t become independent sections (as long as they are controlled by one of the 19 sections). … We can only guess which criteria the International Council will use to accept or reject the demand coming from the new MSF entities to become a real MSF section.4
The two most important of these criteria would probably be “the existence of a solid associative basis,”5 he conjectured, consisting of “a majority of field staff or former field staff members … to make sure that [these entities] can develop an independent position on all [the] dilemmas MSF is confronted with” and “financial independence.” The latter seemed “almost impossible” for South Africa, he stated. “This is a bit of a headache,” he pointed out, “because as long as MSF South Africa is not accepted as a real MSF section, it must be under the control of an existing MSF section or operational center. It is a ‘catch 22’ situation”:
• As long as MSF South Africa cannot achieve financial independence, it will not be accepted as an MSF section;
• As long as MSF South Africa is not accepted as an MSF section, it cannot have a formal associative structure.
What Ooms proposed was “creating a formal associative structure, with a board of which at least 50% of the members are appointed by the OCB board. It fits with the rules of MSF (controlled by an existing MSF operational center) and it fits with South African law.”6
In the concluding section of his memorandum, Ooms gave vent to the frustration he was experiencing in dealing with his own and other MSF operational centers and their boards about matters that were not confined to new MSF entities issues:
The whole idea of creating an OCB Board was to simplify and improve the governance of the OCB. I cannot do the job you want me to do, if for every decision I need to discuss with ten directors in Brussels, six general directors outside of Brussels, and seven national boards (in total: about 100 people to be convinced.) And that does not even include the international MSF platforms, which increasingly decide what MSF operational centers are allowed to do, and what they’re not allowed to do.7
Notwithstanding MSF’s commitment to defining itself as a movement rather than an organization, and its wariness about becoming overly institutionalized, dealing with questions about new entities entangled it in what critical members called “structural navel-gazing,” and the assumption that “designing [and redesigning] structures” would resolve issues and “fix problems.” In November 2006, MSF South Africa was officially recognized by the International Council as a “branch office” that would function under the Brussels Operational Center. This was partly a consequence of a three-month-long “feasibility study,” involving interviewing a wide variety of “stakeholders” in South Africa, mandated by the International Council.
The study concluded that creating an MSF entity in South Africa would be a win-win situation, good for both MSF and South Africa:
There is clearly willingness and a momentum to start an entity of MSF in South Africa. … a momentum to grasp. This willingness is not only manifested among members of the MSF team in South Africa, but also among … South African partners … (many triggered by the HIV/AIDS fight) … [who have been] discussing the idea of MSF [for] some time.… A strong network exists made up of individuals and organizations that favor and support the initiative. They represent a source of legitimacy to start.… The capacity and the environment to open an MSF entity are present and look inviting.8
MSF veterans like Ooms and Goemaere regarded designating MSF South Africa a branch office under the control of the Brussels Operational Center, rather than making it an independent new section, as a “half-baked solution” at best.9
MSF South Africa’s office is located in Johannesburg, where, at its inception, it was run by its founding director-general, Sharon Ekambaram, a dynamic, astutely intelligent woman.10 Ekambaram’s family came to South Africa from a Tamil-speaking area of India. She was raised in South Africa by her parents in what she describes as “a very British manner”; but her involvement in “the struggle against apartheid,” she says, “gave me a black identity.” She defines herself as “a Marxist” and a “committed activist,” dedicated to socioeconomic equality, “passionate in [her] outrage against any form of injustice,” and “an organizer in building movements.”11
Ekambaram was propelled toward involvement with MSF by her “burnout” from dealing with all the people dying from HIV/AIDS whom she had come to know through her work for the AIDS Consortium (“a network organisation primarily concerned with servicing people infected and affected by HIV and AIDS”),12 at a time when few South Africans had access to antiretroviral drugs. Eric Goemaere, with whom she had had some contact since the early 2000s, was her chief link with MSF. She admired his firsthand knowledge of the HIV/AIDS situation in South Africa gained through field experience, the cogency of the data he had gathered based on that experience, and above all, the role that the presentation of these data to South African officials had played in the passage of legislation supporting universal access to antiretroviral therapy. Goemaere is one of the persons inside of MSF to whom she feels the most indebted for the international organization’s recognition of MSF South Africa.
Because she was “intrigued by, and in awe of an organization [like MSF] that … delivers and does not [just] churn out rhetoric” like other NGOs, she felt that it was “worth being part of a battle to change it.”13 A crucial change, in her view, was to avoid duplicating how MSF’s five operational centers in Europe were “entrenched,” in a way conducive to “empire building.” She was convinced that MSF South Africa should neither be nationally “Afrocentric” nor “based on narrow geographic reasoning.” Thus, from the beginning, she, as director, along with its board, had “conceptualized” the branch office as regional, rather than national in scope—as MSF Southern Africa, not just MSF South Africa—“with members from across the Southern Africa region, encompassing Malawi, Mozambique, Lesotho, Swaziland, Zambia, and Zimbabwe,” as well as South Africa. “MSF SA did not want to give the impression that it represents the entire continent, or that it would be defined by national boundaries,” Ekambaram explained.14
Given the current role of the South African state in the rest of Africa … [with] its potential … of being the richest country … or one of the richest in Africa … it is often described as having imperialist intentions. Many surrounding countries are nervous [about this].… So the structure that is developing is based on working in the region on issues relevant to the operations that are within the proximity of the office.… [It has a] cross-operational center character.
“The spirit with which MSF SA is being built is strongly influenced by the spirit of ‘struggle’ from which South Africa is emerging,” Ekambaram asserts. “The central logic behind the MSF South Africa office” is, however, to “enable MSF to look at Africa—where two-thirds of MSF’s work is done—from an African perspective.”15
What Ekambaram refers to as MSF South Africa’s spirit of “struggle” and “activism,” with its passionate indignation about social injustice and social suffering, and its “vibrant, … almost celebrat[ory]” ambiance,16 pervades the e-newsletter that MSF SA inaugurated in August 2008, MAMELA!17 Mamela, a Sesotho word, means “listen.” Ekambaram chose it as the title of the editorial that she wrote for the first issue, which began by asking: “What does South Africa have to offer the MSF international movement?” It answered the question thus:
As a movement, MSF has a rich history of using the oral concept of témoignage or witnessing, which has strong resonance in South Africa. South Africans spoke out and resisted apartheid. This rich tradition is still very much in the fabric of our society. We experienced this again with the struggle for access to treatment for people living with HIV and more recently the rallying of forces to support refugees violently kicked out of their makeshift shelters in various communities. This spirit of collaboration and solidarity is what MSF SA wants to bring to the MSF international movement.
“To mark this first edition of MAMELA!” the editorial continued, “I want to inform you of the work done by MSF as part of its medical humanitarian support: Addressing the plight of vulnerable women. This, as we celebrate this month, on August 9, the role played by brave women in the struggle against apartheid, and to inspire you as we feel anger thinking about the way many, many poor oppressed women are treated all over the world”:
In December 2006 MSF related the stories of 10 Congolese women who were brave enough to tell their stories. These testimonies were used [by MSF] as a tool to try and end the sexual violence against women who cross the border from the Democratic Republic of Congo into Angola, then only to be expelled by the perpetrators … of this sexual abuse … many of whom [are] soldiers in the Angolan army. By MSF medical staff working in the field, speaking out and confirming the stories of otherwise voiceless women, MSF legitimized their experience and brought the attention of the world to witness this crime, forcing a reaction from the authorities concerned.
In its conclusion, the editorial dedicated the first edition of MAMELA! to “the memory of Promise Sanelisiwe Tshiloane, who worked as a supply assistant in the co-ordination office in the MSF project in Khayelitsha”:
On Friday, 4 July, around 15:00, Promise’s body was discovered by the police in her flat in Parklands, Cape Town. She was killed by her husband who afterwards committed suicide.… Promise was a young and beautiful woman, struggling to deal with everyday challenges that women are faced with. Hate crimes of this nature are witnessed on a daily basis, often adversely affecting those most vulnerable. Speaking out about this restores dignity to women facing violent crimes and hopefully will force more people to commit to addressing this horrible blight on the human race.
Subsequent issues inveighed against the “xenophobic violence” unleashed on “foreign nationals” from neighboring African countries seeking refuge and asylum in South Africa.18 A fervent article commemorated the attacks by “marauding mobs” in the Alexandra township of Johannesburg in May 2008, when 62 foreigners had been killed and 100,000 displaced. MAMELA! described how MSF SA responded. In the immediate wake of the attacks, it treated “nearly 4,000 people for gunshot and stab wounds, diarrhea, respiratory infections, and trauma related illnesses”; it distribute[d] “thousands of blankets, hygiene kits, and other goods, while conducting approximately 11,000 medical consultations among traumatized foreigners in numerous makeshift camps” in the South African province of Gauteng; it spoke out in protest, and along with others, through court action, prevented Gauteng authorities from “moving approximately 1700 displaced foreigners from a makeshift camp to a formalized camp which was set in a veritable lion’s den—between aggressive hostel dwellers and a dusty mine dump”; and it worked in the camps housing foreign nationals “left helpless and homeless,” who were now “living in conditions that resembled incarceration.”19
A number of newsletter articles recounted some of the humanitarian crises “across borders” to which MSF was responding. These included the devastating earthquake that struck Haiti; catastrophic floods that occurred in Pakistan; the “alarmingly high” incidence of leishmaniasis, a life-threatening protozoan disease, in a village in southern Sudan; and caring for the sick and the wounded in a region of the Democratic Republic of Congo that was ravaged by terrorist conflict and the raping of women.20
MSF workers’ outrage at the poverty, hunger, disease, and violence they saw in such field situations also came through in MAMELA!
I’ve been working as a nurse for MSF in southern Sudan since the beginning of 2010. The security situation in the region remains precarious and the people suffer from malnutrition, which has grown worse due to a late harvest. Leishmaniasis … is common here.… Without treatment, the majority of patients die. Because leishmaniasis mainly occurs in poorer countries where patients can’t afford medicine, there are very few therapies available. The pharmaceutical industry doesn’t invest in treatments as there’s no profit to be had. We treat almost all our patients with a combination of drugs through intramuscular injections over 17 days, which causes them a great deal of pain.…
In mid August I left Lankien for Pagli, a small village … where leishmaniasis is a particularly serious problem. The nearest health clinics are about three days’ walk away. The rainy season has made the region inaccessible to vehicles.… [T]here are no medical personnel and we have to provide the treatment ourselves.21
I’ve been working for more than a year now in the DRC [Democratic Republic of Congo].… North Kivu is a large region, full of hills and narrow valleys, there are villages (and people) everywhere, and while doing mobile clinics or transferring patients, we inevitably meet armed groups. Most of them respect us—we also cure them when they are sick or wounded, we treat their families like anyone else’s. Although we never know when it is the case, because we never ask anything, we treat all people equally, but they let you know.… So somehow they say thanks, and they let us pass. But then one week later you hear there was some shooting in that area, and some villages in the neighborhood were ransacked and burned, people fled. That night you imagine that they were the same fighters that you met on the road.…
… warriors and terrorized population all in the same patch of territory, all of them close to each other, separated by just a few kilometers.…
But fighting can start everywhere, and violence occurs even without shooting: There’s rape and threats and looting, all the time, and we only know it when people come to seek shelter or are wounded and brought to the hospital.…
All of this [is] so sad, this has gone on for years but seems never ending. Difficult to keep the hope [sic] in these circumstances. But as they say in the Eastern Congo, every day may bring new hope, as long as we’re alive.22
With a mixture of candor and intrepidness, some of the notices in MAMELA! addressed to potential MSF recruits alluded to the hardships that they should be prepared for:
In addition to the required medical skills, MSF SA invites applications from persons who wish to work in places such as the desolated [sic] deserts of Sudan or humid Liberia; people who are able to cope with the isolation of Mali and the complexity of Chad. Above all, MSF needs applicants who are willing to work in an environment avoided by most.23
Over the course of the years 2006–2011, MSF South Africa evolved dynamically, growing in size, membership, diversity, dedication, and fund-raising capacity. At the governance level, it elected a multinational board and convened annual general assemblies, which served as forums for discussion and for its collective decision-making.
As the South Africa office became more integrated into the overarching organization of MSF, some of the South Africans became more outspokenly critical of how “Western” and “European” MSF, seen as a whole, continued to be in its outlook, “institutional architecture,” and functioning. These sentiments were vigorously presented in an internal paper by Jonathan Whittall and Ekambaram, “Genuine Reform: Adapting to a Changing Global Environment,”24 which declared:
We can acknowledge our Western roots, but it is time to internationalize and accept that Europe is no longer the center of the universe.… Being of Western origin is not the problem, but functioning in the current world as a Western organization is.…
MSF is not keeping up with a changing global environment. [T]he West’s influence is declining relative to the rising economic powers of Brazil, China, South Africa, and India. States affected by “humanitarian crises” are increasingly taking a more proactive stance in delivering services, and occupying powers—such as the US in Iraq—are offering “humanitarian assistance” to achieve the goal of stabilization and state building.… This requires MSF to navigate [the] newly emerging framework. Considering that the international humanitarian framework, traditionally the reference point for all of MSF’s work, is increasingly being co-opted by a state-led moral humanitarian imperative, where does that leave us?
“In this context, how can we ensure continued access to vulnerable populations and independence to operate and speak out?” the paper asks. “[W]e cannot expect to fall back on the quality of our medical operations, as the only way of gaining acceptance,” it asserts:
Our ability to respond effectively to emergencies will be more based on our existing presence and our acceptance by communities rather than on our arrogance around principles which are increasingly associated with a Western industry of double standards.
We have to become more aware and distance ourselves from a number of different factors, not least of all the organic links between MSF and its European mother-ship (such as in Haiti where Al Jazeera continually referred to us as the “French NGO,” reinforcing this perception.) In addition to this, we have to distance ourselves from [the] humanitarian circus.
But, this “need for change cannot happen with multiple MSF sections working in one context,” the paper contends. “There is an inherent tendency within this environment for each section to retreat into a nationalist logic—informed by their specific (European-based) national analysis—which entrenches the very perceptions that reduce our legitimacy.”
At various points the paper refers to the colonialist and missionary-like attitudes and behavior that persist in MSF:
There needs to be a thorough understanding of the societies within which MSF international expats work. For example, many countries in Africa are regaining [their] sense of dignity and independent selfhood after decades of colonial oppression. Instead of lamenting the good old days when governments were weak and aid agencies could do whatever they wanted, MSF has to work to open itself up to establishing networks or building necessary links with progressive elements of civil society on an issue by issue basis.
… Western expats often see people in communities where we work as “beneficiaries”—passive recipients of humanitarian aid—and not as active agents capable of changing the conditions that lead to their vulnerability or at least participating in the process. At worst the role of MSF in parts of Africa cannot be distinguished from that of the missionary.
… Ask yourself how our interlocutors perceive us when another [European] “boss” arrives from headquarters. Try to explain to people outside MSF that we really are an international organization, even though all our operational centers are in Europe.
The paper ends with what it terms “the obvious conclusion” that “there is a need for an integration of the voice of the ‘non-Western’ entities within MSF.… New entities should be acknowledged as offering a solution to some of the biggest challenges facing MSF today and should be given the space and support to … address those challenges.… It is time to move beyond tokenism,” it declares. The “roadmap for change” that it proposes envisions “an equal MSF” in which a “conscious move” is made “away from the distinction and unbalanced power dynamics between ‘expat’ and ‘national’ staff, and towards valuing all staff based on their skill sets, experience, contextual understanding and analysis, and [their] … independent voice in certain contexts”; and “a more democratic process of decision making [is] established that ensures … it is not only the European sections with the most financial resources that control the decisions taken at the International Council.”
The militant ardor that surrounded MSF South Africa’s commitment to the MSF movement takes a joyous form at its yearly general assemblies. Serious business is transacted at these annual meetings in an effervescent atmosphere of camaraderie, which at times erupts into revelry.
Photographs of the MSF SA’s 2008 General Assembly capture this ambiance, portraying lively gatherings of black, brown, and white women and men of European and American, as well as South African and other regional African origins. Many wear T-shirts with the MSF logo or “i am positive” HIV/AIDS T-shirts. Others are clad in T-shirts with a universalistic message on the front:
REFUGEE OR MIGRANT
BLACK OR WHITE
CHRISTIAN OR MUSLIM
MILITARY OR ARMED OPPOSITION
MALE OR FEMALE
FOREIGNER OR CITIZEN25
On the backs the shirts is an affirmation taken from the MSF Charter: “MSF provides medical assistance irrespective of race, religion, creed, or political convictions.” Both statements are framed by schematic, gray, left and right footprints. Displayed in white letters on the black T-shirts of some other attendees is the word KWEREKWERE—a derogatory, xenophobic term meaning “a foreign visitor to a township”/“a foreign outsider,” which was being widely applied to immigrants and refugees in South Africa at the time.26
Included among the photos are a number of shots of different MSF members standing in the midst of the assemblage with microphones in hand, making spirited contributions to the ongoing discussion. In several instances, the enthusiastic, broadly smiling commentator, whose arms are dramatically upraised, appears to be mocking his own grandiloquence.
An especially animated group of photographs depicts the act of voting at the assemblies. The resolutions proposed were affirmed by raising yellow signs reading, “Member Voting Card.” Other photos show lines of broadly smiling people with yellow or red cards making their way toward ballot boxes.
The most celebratory of the photos are those showing General Assembly attendees beating in synchrony on traditional African drums. Each person in the room has a drum and the entire assemblage is being led in collective drum music by three professional African drummers in bright orange tops and trousers fashioned of multicolored African fabrics. The language of the drums touched everyone, deeply connecting them.
In November 2009, MSF South Africa was recognized by the International Council as a delegate office, and thereby moved one step further toward the goal of becoming a section, fully integrated into the movement, on a par with MSF’s European operational sections.
Two years later, in December 2011, when it applied to MSF’s newly formed International General Assembly to become an association, MSF South Africa had what it described as two hundred “dedicated members,” from different sections of MSF’s five Operational Centers, most of whom were “spread across the South Africa region, encompassing Malawi, Mozambique, Lesotho, South Africa, Swaziland, Zambia, and Zimbabwe.” Eighty-four percent of these members were “national staff,” sixteen percent “present and former international staff,” forty-five percent “medical and para-medical,” and fifty-five percent “non-medical.” MSF South Africa also had what it characterized as “a fully functional board,” comprised of three members delegated by the Operational Center in Brussels, five so-called “co-opted” members, and five members elected at its General Assembly. The composition of the board—four South Africans, three Belgians, two Zimbabweans, one Malawian, one Mozambican, one Zambian, and one American—was deemed “multinational.” And although MSF South Africa frankly stated that it continued to be funded by the OCB, it proudly reported that it now had a very active fund-raising unit, which had so far raised 8,989,775 rands from 2009 to 2011.27 “We hail from South Africa,” “We are Dedicated and Diverse,” We are Young and Vibrant,” MSF SA proclaimed at the December 16–18 meeting of the International General Assembly in Paris, where it was formally recognized as an accredited MSF association. It would now be a more visible presence and have a vote at the international level.
MSF South Africa still has not been accorded the status of a full-blown section, although it was considered to be closer to being granted this status. Rather anomalously, it continues to be defined as a delegate office, even though this status had supposedly been abolished by the International General Assembly and International Board. There was some concern among its members about this but, like Ekambaram, they were more focused on recent changes in MSF’s international organization. These were changes to which MSF South Africa felt it had made a significant, movement-wide contribution through its formation of “a structure that [had] direct influence over operations in the region”; its building of a regional association that was acting “like a magnet for predominantly national staff”; its “development of a different relationship with MSF other than of employee/employer”; “the [networking] relations [it had] forged across operational centers”; and its firsthand “proximity” to fields in which MSF was operating.28
MSF South Africa’s ultimate goal, Ekambaram attested, was to have a board “elected from a cadre of MSF associate members, irrespective of their ‘status’ as national or international members, but based on the quality of their input and insight into operational experience and analysis,” which would further the evolution of MSF into “a truly international movement,” with “no association to any specific geographic location.” “This is what the world needs now,” she declared—a world that is “very different from the one that MSF was born into.” In her view, MSF still had a long road to travel to realize that vision.29