This introduction, and the book to which it is a prelude, encompass two interrelated quests. One is the continuous quest of Doctors Without Borders to provide international medical humanitarian assistance in ways that perpetuate and constantly revitalize its founding principles and ethos. The other is my own quest, through prolonged sociological research, to understand, chronicle, and reflectively analyze its mission, work, and distinctive culture.
Doctors Without Borders / Médecins Sans Frontières (MSF) is an international medical humanitarian organization created by a small group of French doctors and journalists in 1971. Its mission is worldwide. As many as 27,000 MSF personnel, representing dozens of nationalities, provide medical assistance to people in more than sixty countries faced with “violence, neglect, or catastrophe, primarily due to armed conflict, epidemics, malnutrition, exclusion from health care, or natural disaster.” The vast majority of these doctors, nurses, logistics experts, laboratory technicians, epidemiologists, mental health professionals, and administrators are members of the communities in crisis; only ten percent of them are drawn from the international staff. In addition to delivering medical care, MSF “reserves the right to speak out to bring attention to neglected crises, challenge inadequacies and abuses of the aid system, and to advocate for improved medical treatments and protocols.” Because ninety percent of its funding comes from private, nongovernmental sources, MSF considers itself free to “act independently,” without regard to “political, military, or religious agendas.”1
MSF views itself not just as an international organization but as an “international movement.” It is made up of several regional associations and of nineteen “associative” sections—in Australia, Austria, Belgium, Canada, Denmark, France, Germany, Greece, Holland, Hong Kong, Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, the United Kingdom, and the United States.
In this book, I present a sociological portrait of MSF—of its principles, value commitments, culture, and field missions, and of the medical and moral challenges constantly raised by its humanitarian action. The inquiry from which the book incrementally developed began in 1993.2 It grew out of my many years of immersion in Belgium, in the Democratic Republic of Congo (Zaïre; the former Belgian Congo), and in France, conducting sociological research centered on phenomena and questions associated with medicine.3 I first became aware of the existence of MSF during the time that I spent in France and in Belgium, where it established its second section in 1980. There were a number of physicians in the offices of MSF Belgium and MSF France who knew me, or knew of me, chiefly from my extensive research in Belgium. The first MSF headquarters I visited was in Brussels in 1994, where I met with one such physician, Eric Goemaere, then executive director of MSF’s Belgian section, who helped to launch me on my research inside MSF. Eight years later, in 2002, we met again, in Cape Town, South Africa. Goemaere had become the director of MSF’s mission in South Africa, where he had created its program to provide antiretroviral therapy for persons with HIV/AIDS, which I had traveled to Cape Town to observe.4
My experience in the Democratic Republic of Congo played a significant role in my decision to undertake a sociological study of MSF. Africa, and the Congo in particular, which were professionally and personally important to me, were major loci of MSF’s work. For a while I entertained the idea of returning to the Congo to conduct firsthand research where MSF had been present since 1981—a quixotic notion in light of the strife and terror, political instability, and social and medical “plagues” wracking that country.
The values that MSF espoused, and that its members pursued and concretized through their medical humanitarian action, drew me to them, and significantly influenced my decision to embark on a long-term study centered on field research. MSF’s principles in action coincided with some of my own most basic and strongly felt values. As I have written elsewhere, I hoped that my research would bring me closer to some of “the most crucial social and moral issues associated with health, illness, and medicine: the relationship of disease and sickness to poverty, inequality, … and social injustice,” and to the human suffering associated with them. “More than occasionally in the past, I had found myself questioning whether the topics to which I had devoted so much of my research and writing [had been] too remotely connected with these issues,” and too detached from action to ameliorate them.5
I was strongly drawn to MSF as well by the simultaneously realistic and idealistic way in which its members saw “the world as it is”—a world in which there are “suffering and injustice, … sickness and premature death” and “natural disasters”—while energetically “refusing to let go of its vision of the world as it ought to be.”6
The meaning that MSF had for me as a teacher also enhanced my motivation for undertaking research on it. For many of the young nurses and doctors and premedical students I was teaching, MSF exemplified global humanitarian medicine, in which they had a keen interest, and in the case of some, a desire to participate, at least for a while, in the course of their unfolding professional careers.
Clearly, it was impossible for a solo researcher to conduct a firsthand study of all of MSF’s sections—its hundreds of projects, located at any one time in as many as seventy countries, and the thousands of people who worked with and for it in numerous different capacities. The decisions that I had to make about crafting and focusing the research so that it would be both feasible and sociologically meaningful were based on pragmatic, opportunistic, empirical, and analytical grounds.7 In the end, I spent the most concentrated periods with MSF France and MSF Belgium, two of the most important operational sections of the organization. They formed the primary launching pads for the trips that I made to observe MSF in action in the field. During the years of my research I also spent time in the national offices of MSF Australia, Canada, Greece, Holland, Sweden, South Africa, the United Kingdom, and the United States. In addition, the international meetings of MSF that I was invited to attend allowed me to observe the interactions between its multiple sections as they grappled with a range of common questions and problems in a characteristically MSF way.
The three major contexts in which I did intensive field research were in Athens, Greece, Cape Town, South Africa, and Moscow, Russia. These journeys into the field enabled me to make “thickly descriptive”8 studies of an array of MSF projects in different societal and cultural settings, showing the kinds of issues with which MSF has been confronted in the course of carrying out its humanitarian work. In MSF Greece, I saw firsthand an especially dramatic and crisis-ridden instance of the struggles inside of MSF that striving to live up to the “without borders,” and the “independence from all political … powers” principles of its Charter have involved.9
My research benefited greatly from content analyses of the primary and secondary documents to which I was freely given access. These included communications between MSF staff members within the offices of its various headquarters, from headquarters to the field and from the field to headquarters, and transcripts of internal group discussions and meetings. This messaging was often accompanied by explanatory comments and expressions of opinion from the members of MSF who provided me with the documents. In addition, MSF’s many websites were of inestimable value to my research, as chapter 1 demonstrates.
That virtually no restrictions were placed on my participant observation and interviewing or on the documentary material I was permitted to use was testimony to MSF’s principles of “transparency” and “accountability.” Another MSF principle, “proximity” (its commitment to members “being in the field,” physically present with the people whom they assist), was manifest in the receptivity and responsiveness given to my field research. My research was also seen as consistent with MSF’s view of itself as “a place of ideas,” and with its conviction that “ideas matter for action.” In the eyes of the MSFers I met, I was a “semi-outside person.” I occupied an “insider-outsider” status, whose observations and interview conversations “fit” their organization’s ethos. Some said their oral and written exchanges helped them understand what one long-standing member wittily referred to as “that mystery of nature called MSF,” and their “adventures” and experiences within it. Others said my inquiry strengthened their relationship to “the challenges of the world.”
However, my research was not free of difficulties. There were many times when it took me a long while to locate the MSF people I was looking for, or to obtain relevant data (which in some instances did not exist in any of MSF’s offices).10 MSF members were invariably willing to assist me. But some of the characteristics of MSF’s social organization impeded my task. These included:
• The size to which it has grown over the course of its history
• The global scope of its action
• The complexity of its operations
• The geographical dispersion of its staff, their mobility, and their turnover
• The relative independence of each of its multiple sections
• Its decentralized overall structure and diffuse processes of governance and decision-making
• What some refer to as the latent “informal hierarchy” that exists within MSF, which helps to make it more functionally viable—but whose members and their influence are not always easy to identify
• The hiatuses and lapses in MSF’s “institutional memory” that result from these organizational characteristics
Underlying MSF’s structural features is its characteristic culture. I had to learn to navigate in it, and it became an important focus of my research. MSF is determined to live up to its collective self-definition as a movement. It seeks to fulfill its commitment to its basic principles and their implementation in action, in ways that replenish the charismatic spirit and the effervescence of its founding days. Yet it is equally determined not to succumb to romantically heroic, evangelical, or ideologically partisan notions of humanitarianism. Integral to MSF’s resolute conception of itself is what it calls with some pride, its “culture of debate”: the vigorous and often combative self-reflection and self-criticism in which it continually engages as part of its “constant quest to translate [its] principles into [more] effective assistance to people in need,” and to “learn from [its] failures as well as successes.”11
MSF members are mindful that over time, their organization has not only proliferated, but tended to become more formally structured, hierarchically ordered, and bureaucratic. These developments, which have accompanied its growth in personnel, finances, and matériel, as well as the expansion of its activities in range and complexity, are sociologically predictable. To some extent, they contribute to MSF’s operational capacity to function efficiently, and are necessary for an organization of this magnitude to do so.12 However, MSF is inclined to view these trends as problematic: one of the sets of “internal challenges” that it faces at this historical juncture, and as it “looks forward to [its] next decade.”13 Within MSF, such institutional thickening is regarded as antithetic to the value that it places on egalitarianism, participatory democracy, consensual decision-making, the spontaneous exchange of ideas, and effervescence—qualities that MSF associates with its conception of itself as a movement, rather than a formal institution that is “just an organization.” Paradoxically, as various case studies in this book demonstrate, some of the steps that MSF has taken over the years to reform its structure have inadvertently added to the elaborateness and complexity of its organization. This has made it less comprehensible to many of its members—and to me as well.
“The efforts of humanitarian … workers are remarkable and noble,” Craig Calhoun writes. “It takes nothing away from the significance of their labors to say, however, that they are fraught with tensions. Indeed, humanitarian workers are a highly self-critical group, constantly struggling with the contradictions of their work.”14
As my research progressed, I became increasingly aware that what a member of MSF once called “the numerous dilemmas … of the humanitarian act” and “the permanent questioning [that they] engender” permeated the data I was gathering. I saw it in MSF’s organization and personnel, its value commitments and culture, its modes of decision-making and operation, its forms of action and field experiences, and the critical events in its history. MSFers were highly aware of these dilemmas, and of the challenges associated with their practical difficulties and ethical complexities. In their office headquarters, in the field, and in most of their prolific meetings, MSF members struggled constantly with these issues—sometimes with angst, sometimes with self-deriding humor, and often with a mixture of both:
• How to be “global” and at the same time “multicultural.”15 This dilemma emanates from MSF’s “without borders” vision and founding commitments. It calls for balancing and blending universalism with respect for particularistic differences within and between the many societies and cultures in which MSF works, and also between MSF’s national sections and its multinational personnel. It throws into relief the essentially moral question of “whether or not it is feasible, intellectually and practically, to devise a more culturally grounded approach to providing assistance and protection to people in extremis … that is based on truly universal values—a sort of ‘universal universalism’—rather than on the currently dominant Western universalism.”16
• How to allocate MSF’s commitments, personnel, and material resources in relationship to the world’s natural and human-made disasters in a way that is faithful to MSF’s principles of globally and impartially responding to “populations in danger.” Intricate questions of priorities are involved, including: Where and when should MSF intervene? What actions should it undertake, and which reject? Should projects entailing long-term medical care be pursued, as well as those calling for shorter-term emergency care, and if so, to what extent? How long should MSF maintain particular projects, and when should it withdraw from them, transfer, or terminate them? Issues of triage also arise in this connection. A tension exists between the commitment to care for each patient individually, and to do what is the most beneficial for him or her, and the commitment to safeguarding and furthering the well-being of a community called for in the name of public health—sometimes in disregard of, or at the expense of categories or groups of individuals.
• How to address the sense of many MSF members that “we should, and we can do more and better,” which seems to heighten the feelings they bring to such “allocation” questions.17
• How to think about and deal with the uncertainties and the paradoxes of humanitarian action—with the unintended negative consequences, and especially the harm that can result even from virtuously motivated, competent, and well-planned interventions.18
• How to cope with the finitude of humanitarian action—with its limited ability to change the economic, political, social, and cultural conditions that surround and underlie the forms of human suffering that it addresses. In a Sisyphean way, humanitarian workers must continue to do what they can for those whom they are trying to aid, while recognizing that no matter how hard and ardently they strive, they will never succeed in pushing the huge stone they are trying to budge to the top of the hill, and that in this sense and others their action is “an imperfect offering.”19
Wrestling with the limits and limitations of humanitarian action also entails confronting its inherent risks. “As volunteers, members understand the risks and dangers of the missions they carry out,” MSF’s Charter states. While MSF is committed to assuming the risks of providing assistance to people in critical need, it attempts to curtail and manage them through the security rules and regulations that it asks its field workers to observe.20 MSF personnel have been facing increased dangers of looting, kidnapping, violence, and even death. Such situations raise deeply troubling questions about the “balance between the individual’s right to take risks in order to provide assistance” and MSF’s right “to limit this risk”—about whether it is “legitimate” for a humanitarian organization like MSF to “refuse to engage in [such] risk,” or to withdraw from the field because of it, and if so, under what circumstances with what consequences.21
This book begins on the ground—with the women and men of MSF in the field, engaged in the work that is MSF’s raison d’être: “assisting people in danger” and in “distress,” primarily by providing medical care. On MSF’s “blogs from the field” website, they chronicle in moving detail what they experience as they give this care, and also how they feel and see things when they return from the field.
In Part II of the book, key events in MSF’s early history and development are recounted and examined. These include its founding by a small group of French physicians and journalists; its connection with the 1967–1970 Nigerian Civil War, and with the International Red Cross in that context; its relationship to the ideological and political climate surrounding the French intelligentsia and student youth in the wake of World War II, and during the 1960s; and, in 1999, its receipt of the Nobel Prize for Peace. One of the most notable characteristics of these first decades of MSF’s existence were the inner controversies and schisms with which it was fraught over its “without borders,” transnational vision, and its precepts of “neutrality,” “impartiality,” and “independence.” In addition, its conception of itself as a movement was challenged by its growth, its institutionalization, and its success in the world. Throughout this section of the book, MSF’s “culture of debate” is pervasive.
Part III illumines the culture of debate and the self-scrutiny integral to it, through a firsthand account and analysis of MSF’s 2005 “La Mancha” conference—a pivotal event in an organization-wide reassessment of MSF’s operating framework in light of internal and external challenges. MSF’s “permanent state of permanent questioning” and its inimitable self-mockery were on full display at this meeting.
Parts IV and V are situated in postapartheid South Africa and postsocialist Russia, two of the countries on two of the continents where MSF has been intensively involved in medical humanitarian action for prolonged periods of time. Based on my field research, we observe national and expatriate staff22 in the impoverished black township Khayelitsha, Cape Town, and in the penal colonies of Siberia, as they struggle to deal with national epidemics of the infectious diseases that are the most common causes of death globally: HIV/AIDS, tuberculosis, their synergistic coexistence, and their development into multi-drug-resistant forms. We also join MSFers in Moscow as they create means of medical and social assistance for the thousands of homeless adults and children on that city’s streets.
The kinds of witnessing and advocacy in which MSF has engaged in South Africa and Russia are described in these sections of the book. How MSF interacted and dealt with government officials in this connection vividly illustrates the sense in which (in the words of MSF’s Nobel Prize acceptance speech) “the humanitarian act is the most apolitical of all acts,” with “the most profound of political implications”—implications and consequences that can be beneficial, harmful, or both.
In addition, chapter 9 takes us inside of MSF Africa, with its deeply African spirit and its committed universalistic outlook, as it strives to be granted equal status with the still-predominant western European sections of MSF.
The distinguishing features of MSF’s culture and organization, the dilemmas intrinsic to humanitarian action with which it is recurrently and inextricably faced, and MSF’s characteristic ways of thinking about and handling them, are saliently present throughout the book. They cross-cut and link its various chapters and sections. They appear prominently again in the final chapter of the book, at the meeting in Paris in 2011 where MSF celebrated its fortieth anniversary, and launched its newly established International General Assembly. That meeting also marked the final episode in my sociological questing, as a participant observer, to understand medical humanitarianism as exemplified by MSF.
I chose the title Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières for this book because I feel that it captures the social and cultural essences of MSF, and the ambience in which it does its humanitarian work. Watching those qualities being dramaturgically played out at MSF’s “La Mancha” conference had a lasting impact on me and deeply influenced my choice of this title. At that assemblage, convoked to critically examine MSF’s principles, organization, governance, decision-making, and action, its participating members were clad in T-shirts designed to express the Don Quixote motif of the meeting. On the front of the T-shirts was a cartoon image of Don Quixote and his squire Sancho Panza, who were wearing doublets imprinted with the MSF logo. Sitting astride tiny, dilapidated versions of the Land Rover vehicles that MSF uses on its field missions, they were driving toward eccentric-looking windmills in the near distance that were silhouetted against star-studded skies.23 Printed on the back of these T-shirts was the full text of the lyrics of “The Impossible Dream,” the theme song of the Broadway musical Man of La Mancha (The Quest).24