Doctors Without Borders

1. “History & Principles—Doctors Without Borders,” www.doctorswithoutborders.org/aboutus/2012 (accessed 12/21/2012). Doctors Without Borders / Médecins Sans Frontières is usually referred to throughout this book by its acronym MSF or, where appropriate, by the abbreviated name of a section—e.g., MSF France; MSF USA, etc.

2. Over the course of the many years during which my study of MSF took place, the research was funded by relatively small grants from the Acadia Institute, the Social Sciences Research Fund associated with the Honorable Walter H. Annenberg Chair in the Social Sciences at the University of Pennsylvania, the Andrew W. Mellon Foundation, and the Nuffield Foundation (in the United Kingdom).

3. For a detailed narrative account of some of my research in Belgium, the Congo, and France, and what it involved ethnographically, see Renée C. Fox, In the Belgian Château: The Spirit and Culture of a European Society in an Age of Change (Chicago: Ivan R. Dee, 1994). See also Fox, In the Field: A Sociologist’s Journey (New Brunswick, NJ: Transaction Publishers, 2011), 135–200.

5. See Renée C. Fox, “Exploring the Moral and Spiritual Dimensions of Society and Medicine,” in Carla M. Messikomer, Judith P. Swazey, and Allen Glicksman, eds., Society and Medicine: Essays in Honor of Renée C. Fox (New Brunswick, NJ: Transaction Books, 2003), 257–271, at 268; Fox, In the Field, 367.

6. Jonathan Sacks, The Great Partnership: God, Science and the Search for Meaning (London: Hodder & Stoughton, 2011), 237, 248. Chapter 12 of Rabbi Sacks’s book reflects on “the problem of evil” and the questions of meaning it poses; the quoted words were not intended by Sacks to refer to MSF, but they nevertheless aptly and eloquently articulate key characteristics of its worldview.

8. The anthropologist Clifford Geertz first applied the philosopher Gilbert Ryle’s concept of “thick description” to what Geertz regarded as the defining characteristics of “doing ethnography”—to the kinds of cultural data that are gathered, and how they are inscribed, analyzed, and interpreted by social scientists conducting ethnographic research. See Clifford Geertz, “Thick Description: Toward an Interpretive Theory of Culture,” in The Interpretation of Cultures: Selected Essays by Clifford Geertz (New York: Basic Books, 1973), 3–30.

9. See chaps. 4, 5, 10, and 11. In Greece, I was assisted in this field research by Nicholas Christakis, and in Russia, by Olga Shevchenko, both of whom are U.S.-based sociologists. Christakis (who is also a physician) has Greek origins, and Shevchenko, Russian ones. I had the privilege of teaching each of them when they were studying for their PhDs in sociology at the University of Pennsylvania.

10. This was the case, for example, with regard to my efforts to obtain charts or diagrams of MSF’s evolving organizational structure and to identify and enter into communication with the webmaster for the “blogs from the field” that I analyze in chap. 1, and with the member of MSF who drew the cartoons at its “La Mancha” meeting that I describe in chap. 6. I finally did succeed in obtaining this information and making these contacts thanks to the help of Unni Karunakara, the international president of MSF, Hélène Ponpon, Karunakara’s assistant in MSF’s International Office in Geneva, the offices of MSF Holland in Amsterdam and MSF UK in London, and Kenneth M. Tong, manager of Online/International Media in MSF Canada’s Toronto office.

11. “A Vision for MSF: Statement of Ambitions for 2012–2021” (MSF internal document, April 2012), 1, 3.

12. Within the theoretical framework of the eminent sociologist Max Weber, such organizational developments would be seen as concomitants of the process whereby “charisma” is stabilized and institutionalized into ongoing authority structures. According to Weber, if a social organization is to survive and continue to function, some form of “routinization” of its original charismatic authority must take place. In the case of MSF, this appears to have entailed some movement in the direction of the development of what Weber would have termed a more “rational-legal authority” structure. See Weber, “The Types of Authority and Imperative Coordination,” pt. 3 of Max Weber: The Theory of Social and Economic Organization, trans. A. M. Henderson and Talcott Parsons (New York: Oxford University Press, 1947), 324–407.

14. Craig Calhoun, “The Idea of Emergency: Humanitarianism and Global (Dis) Order,” in Didier Fassin and Mariella Pandolfi, eds., Contemporary States of Emergency: The Politics of Military and Humanitarian Intervention (New York: Zone Books, 2010), 29–58, at 54–55.

16. Antonio Donini, “Humanitarianism, Perceptions, Power,” in Caroline Abu-Sada, ed., In the Eyes of Others: How People in Crises Perceive Humanitarian Aid (New York: MSF, Humanitarian Outcomes, and the NYU Center on International Cooperation, 2012), 183–192, at 191, www.doctorswithoutborders.org/publications/book/perceptions/?id=5945&cat=perceptions.

17. “Every night when I go to bed, I worry about how I’ll fulfill all the promises I’ve made. And every morning when I wake up, I think I haven’t made enough promises,” the physician and anthropologist Paul Farmer says of the medical humanitarian work in which he is engaged in association with Partners in Health, an organization he cofounded (https://donate.pih.org/page/contribute/donate).

18. For very thoughtful and richly documented analyses of these dilemmas of humanitarian action, see, e.g., Fiona Terry, Condemned to Repeat? The Paradox of Humanitarian Action (Ithaca, NY: Cornell University Press, 2002), and David Kennedy, The Dark Sides of Virtue: Reassessing International Humanitarianism (Princeton, NJ: Princeton University Press, 2004).

19. James Orbinski, An Imperfect Offering: Humanitarian Action in the Twenty-First Century (Toronto: Doubleday Canada, 2008).

20. “MSF’s primary mandate is to bring emergency medical assistance to populations in need. To reach those who need our help the most, we often work in conflict and postconflict regions. Each region involves different risks according to the context in which our humanitarian intervention takes place.… Field workers must abide by security rules and procedures throughout their mission. There is a clear chain of responsibility regarding security management” (www.msf.org.uk/working-overseas-safety-and-security).

21. Kenny Gluck, “Of Measles, Stalin and Other Risks—Reflections on Our Principles, Témoignage, and Security,” in My Sweet La Mancha: Invited and Voluntary Contributions (internal MSF document, published in 2005, “within the framework of the La Mancha process launched in 2005,” which was “not meant for diffusion or use outside of MSF”).

22. In MSF parlance, “national” staff members are indigenous to the countries where MSF projects are located and “expatriate” staff are involved in projects located outside their countries of residence.

23. Samuel Hanryon, a member of the Communications Department of MSF France, drew this cartoon, using the nom de plume Brax.

24. The lyrics of the song “The Impossible Dream” were written by Joe Darion. The composer of the music for it was Mitch Leigh.

CHAPTER ONE: Voices from the Field

1. Prinitha Pillay, “A South African Doctor in Darfur,” May 5, 2008, MSF field blog entry “I’m struggling to close the chapter,” http://blogs.msf.org/Prinitha.

3. Ibid. The primary language in which these blogs are written and recorded is English, but translations of them into other languages, including French, Dutch, German, Russian, Spanish, and Swedish, are also available online. I am indebted to Kenneth Tong, with whom I conducted telephone interviews on June 15 and on September 7, 2012, for providing me with the information about the history of the development of the MSF field blogs in this chapter, and for printed spreadsheet data that he sent me on the bloggers’ countries of origin, the “mission countries” from which they wrote their blogs, and the status roles they occupied in the field.

6. Trish Newport, “Brown bread revolutionary: Community outreach and nutrition,” January 16, 2011, MSF field blog entry “Right to be here,” http://blogs.msf.org/trishn/2011/01/16. Bashir and Zara were children suffering from severe malnutrition in the midst of a widespread malnutrition crisis that was occurring in Niger at the time that this blog was written. Trish Newport, who wrote this blog, was a community outreach nurse who was supervising the nutritional survey of the region that MSF was making.

7. Nazanin Meshkat, “Off the beaten path … PNG (Papua New Guinea),” October 1, 2007, MSF field blog entry “Writer’s Fork,” http://blogs.msf.org/NazaninM/2007/10/01.

8. Lauralee Morris, “Lauralee in Lankien,” May 25, 2008, MSF field blog entry “Blogging as Insurance Against ‘New Fridge Syndrome,’” http://blogs.msf.org/LauraleeM/2008/05/25.

13. Edith Fortier, “Vakaga Sky,” July 20 and November 14, 2008, MSF field blog entries “Adrenaline” and “Why do I do this work?” http://blogs.msf.org/EdithF.

15. This testimony by Zakariah Mwatia, a Kenyan community health nurse who served as the project coordinator of MSF’s mission in Epworth, Zimbabwe, was elicited in an interview conducted by Paul Foreman, a long-time member of MSF, who has filled many roles in the organization, and who worked with Mwatia in Zambia. “So what is it that makes you spend so much time away from home—what is it about MSF that you like so much?” Foreman asked Mwatia. Paul Foreman, “Positive Thinking: Blogging from Zimbabwe,” December 12, 2011, MSF field blog entry “Zak,” http://blogs.msf.org/paulf/2011/12/12.

16. Joe Starke, “Medicine at the frontier,” September 8, 2009, MSF field blog entry “The grinding burden of chronic disease,” http://blogs.msf.org/jstarke/page/2.

23. Edith Fortier, “Vakaga Sky,” September 23, 2008, MSF field blog entry subtitled “This little girl,” http://blogs.msf.org/2008/09/23.

28. Elisabeth Canisius, “Smiles after starvation: Critical care malnutrition in Zinder, Niger,” November 14, 2011, MSF field blog entry “Gradual recovery and slow change in season,” http://blogs.msf.org/elisabethc/2011/11/14.

29. Emmett Kearney, “My New Friend ROSS,” November 22, 2011, MSF field blog entry “Friendliness, smiling faces and fist-bumps in Raja,” http://blogs.msf.org/emmettk/2011/11/14.

31. Kartik Chandaria, “TB doc in Tajikistan,” December 22, 2011, MSF field blog entry “Mystical men and Christmas in Dushanbe,” http://blogs.msf.org/kartikc/2011/12/22.

37. Starke, “Medicine at the frontier,” December 22, 2009, MSF field blog entry “Closing snapshots of life and work in NWFP,” http://blogs.msf.org/jstarke/2009/12/22.

38. Pillay, “South African Doctor in Darfur,” “I’m struggling to close this chapter”; Fortier, “Vakaga Sky,” “Falling in Love.”

41. This passage was extracted from a blog entry reproduced in James Maskalyk, Six Months in Sudan: A Young Doctor in a War-Torn Village (New York: Spiegel & Grau, 2009), 300.

42. These are packets of “Plumpy Nut,” a ready-to-eat nutrition supplement for children suffering from severe malnutrition.

43. Abeyei is a north-south border town in the south of Northern Sudan, where this blogger spent a six-month-long MSF mission.

45. Grant Assenheimer, “Pré Avis in the Congo,” June 2, 2010, and June 21, 2010, MSF field blog entries “Thanks for the chickens” and “Pré Avis,” http://blogs.msf.org/ drcdubie.

48. Joe Starke, “Medicine at the frontier,” December 22, 2009, MSF blog entry “Closing snapshots of life and work in NWFP,” http://blogs.msf.org/2009/12/22.

49. Elina Pelekanou, “Thoughts from the Palestinian Territories,” September 5 and September 15, 2008, MSF field blog entries “Days go by …” and “Belongings,” http//blogs.msf.org/ElinaP.

57. Ed Rackley, “MSF Changed My Life,” in Un regard dans le rétroviseur de l’année 2000 (MSF internal publication, September 2000), 57.

CHAPTER TWO: Origins, Schisms, Crises

1. Tony Judt, Past Imperfect: French Intellectuals, 1944–1956 (New York: New York University Press, 2011), 1.

3. Between 1956 and 1962, eighteen French colonies in Africa gained independence: Tunisia (1956), Morocco (1956), Guinea (1958), Cameroon (1960), Senegal (1960), Togo (1960), Mali (1960), Madagascar (1960), Benin (1960), Niger (1960), Burkina Faso (1960), Ivory Coast (1960), Chad (1960), Central African Republic (1960), (French) Congo (1960), Gabon (1960), Mauritania (1960), and Algeria (1962). Most traumatic of all for France was the Algerian War that took place between France and Algerian independence movements from 1954 to 1962, which resulted in Algeria’s independence.

5. Xavier Emmanuelli, Les Prédateurs de l’Action Humanitaire (Paris: Flammarion, 1990), 16.

7. In a challenging paper, Rony Brauman has questioned whether what was deemed “genocide in Biafra” actually took place, or was intended. See “Dangerous Liaisons: Bearing Witness and Political Propaganda. Biafra and Cambodia—the Founding Myths of Médecins Sans Frontières” (CRASH [Centre de Réflexion sur l’Action et les Savoirs Humanitaires], 2006), www.msf-crash.org/drive/877a-rb-2006dangerous-liaisons-%28fr-p.14%29.pdf.

8. “Why Doesn’t the ICRC Denounce Unacceptable Behavior More Often?” Question 15 in Bernard Obserson, Nathalie Floras, et al., ICRC: Answers to Your Questions (Geneva: ICRC, Public Information Division, 1995), 34.

The text states that the ICRC “does not remain silent about violations of humanitarian law,” but uses “confidential approaches, oral and written, to those responsible, and sends reports and recommendations to the parties in the conflict.” If these confidential approaches “prove ineffective, the ICRC may break its self-imposed rule of discretion, but only if certain criteria—which are in the public domain—are met” (34).

10. These Paris-based intellectuals included Raymond Aron, André Glucksman, Bernard-Henri Lévy, Claude Mauriac, Edgar Morin, Jean-François Revel, and Jean-Paul Sartre.

11. In connection with their sense of mission to rescue the Vietnamese refugees, it should be noted that France had been involved, religiously, politically, and economically, with Vietnam since the seventeenth century. Vietnam was a part of French Indochina, France’s colony, from 1885 to 1954, when at the end of the First Indochina War, it won its independence.

13. In addition, in a more diffuse way, Brauman’s influence within MSF France had become considerable. It is not surprising that he succeeded Malhuret as president in 1982, or that he held this office for twelve years (until 1994).

14. This article was published in the December 4, 1978, issue of Le Quotidien du médecin. Emmanuelli titled it “Un bateau pour Saint-Germain des-Prés,” making sarcastic reference to the association of the “Boat-for-Vietnam” project with the Paris arrondisement of Saint-German-des-Prés (the 16th) on the Left Bank of the Seine, a haunt of post–World War II existentialists—notably of Jean-Paul Sartre, Simone de Beauvoir, and their entourage.

15. Rony Brauman, Penser dans l’urgence: Parcours critique d’un humanitaire. Entretiens avec Catherine Portevin (Paris: Seuil, 2006), 79. Xavier Emmanuelli and Raymond Borel were the only ones of the founding group who stayed with MSF.

16. Since 1988, Bernard Kouchner has been secretary of state in the [French] Cabinet for Humanitarian Action (1988); French minister of health (1992–1993); a member of the European Parliament (1993–1997); minister of health again (1997); UN special representative in Kosovo (1999–2001); and French minister of foreign and European affairs (2007–2010).

18. Tribunal de Première Instance de Bruxelles, Audience publique des référés du 15 juillet 1985, 5.

20. Tribunal de Première Instance de Bruxelles, Audience publique, 5. See Rony Brauman, ed., Le Tiers-mondisme en question: Actes du colloque de Liberté sans frontières en juillet 1985 (Paris: Olivier Orban, 1986).

23. Ibid., 7–8. At the end of the official document containing her decision and the legal grounds for it, the vice president of the Tribunal signed herself simply as “Halsberghe.”

24. P. H., “Guerre franco-belge chez Médecins Sans Frontières,” Libération, July 10, 1985.

25. Max Weber, “The Sociology of Charismatic Authority,” chap. 9 in From Max Weber: Essays in Sociology, trans. from Weber’s Wirtschaft und Gesellschaft, pt. 3, chap. 9, by H. H. Gerth and C. Wright Mills (New York: Oxford University Press, 1946), 245–252; Talcott Parsons, Max Weber: The Theory of Social and Economic Organization, trans. A. M. Henderson and Talcott Parsons, ed. Parsons (New York: Oxford University Press, 1947), 64–77, and chap. 3, “The Types of Authority and Imperative Coordination,” esp. 358–373.

26. The document in my files that contains this provisional statute is not headed by a title, dated, or signed. However, it is attached to a communication and an editorial dated January 20, 1985, which were sent together to the members of MSF Belgium by its director, Philippe Laurent, and that contain the section’s strong objections to Liberté Sans Frontières. It is notable that notwithstanding its “sans frontières”/“without borders” appellation, at this stage in its history and development, MSF’s conception of “internationalizing” was confined strictly to becoming more European.

29. See Stany Grelet and Mathieu Potte-Bonneville, “qu’est-ce-qu’on fait là?” (interview with Rony Brauman), Vacarme 04/05 (1997) 1–7, at 1–2, www.vacarme.org/article1174.html. Like Brauman, Claude Malhuret, the co-organizer of the colloquium, had also made a transition from the political Left to the political Right. In 1986, he had been a militant member of the Parti Socialiste Unifié (PSU), a small radical party that dissolved itself a few years later, and the founder and director of one of the Sorbonne University sections of the student syndicate, Union nationale des Étudiants en France. Brauman referred to Malhuret as his “accomplice” in this era.

32. Grelet and Potte-Bonneville, “qu’est-ce-qu’on fait là?” 2; Brauman, Penser dans l’urgence, 108.

36. These ideas are expressed in an anonymous, undated, seven-page photocopied typescript in my files, on whose first page the letterhead and the icon of the “Fondation Liberté Sans Frontières Pour l’Information sur les Droits de l’Homme et le Développement” are printed.

38. Fiona Terry, Condemned to Repeat? The Paradox of Humanitarian Action (Ithaca, NY: Cornell University Press, 2002), 48–49. Terry has spent more than twenty years involved in humanitarian relief operations in different parts of the world. From 2000 to 2003, she worked as a research director in MSF France’s Paris office. She holds a PhD in international relations and political science from the Australian National University.

41. MSF Belgium, which was present in a different area of Ethiopia in 1994 than MSF France, disagreed publicly with the stance that the latter had taken, because of the role it played in MSF France’s enforced withdrawal from Ethiopia, and its consequent inability to render further assistance to the Ethiopian population. MSF Holland also took exception to MSF France’s decision.

42. Grelet and Potte-Bonneville, “qu’est-ce-qu’on fait là?” “Rony Brauman s’est trompé sur la vraie nature du communisme,” 3.

44. Rony Brauman, personal communication to the author, August 21, 2011. Two members of MSF Belgium told me that after Liberté Sans Frontières expired, Brauman quietly expressed some after-the-fact regrets about having created it and deemed this to have been a “mistake.” However, this is not a sentiment to which he gave voice in the several conversations that I had with him. The closest that he came to saying this was in the form of a passing remark that he made to the effect that he should have realized how “political” Liberté Sans Frontières was.

46. Mitterand’s first term as president of France was during the years 1981 to 1988, and his second term ran from 1988 to 1995.

48. Personal communication to the author from a long-standing member of MSF, May 24, 2006.

CHAPTER THREE: “Nobel or Rebel?”

1. James Orbinski, An Imperfect Offering: Humanitarian Action in the Twenty-First Century (Toronto: Doubleday Canada, 2008), 334.

3. “MSF Japan Members Celebrate Nobel Prize,” Daily Yomiuri, October 17, 1999, 2.

4. Patrick Wieland, “Don’t Give Up the Fight,” MSF Nobel Peace Prize Journal (produced on the occasion of receiving the Nobel Peace Prize in 1999), 15.

7. Albert Camus, L’Homme Révolté, trans. Anthony Bower as The Rebel: An Essay on Man in Revolt (New York: Vintage Books, 1991), 13, 16, 22, 302–303, 305.

8. The debate took place in a mixture of French and English. The excerpts from it here were all taken from a transcript entitled “Nobel ou rebelle, a Nobel without a cause?”

10. Philippe Biberson and Rony Brauman, “‘The Right of Intervention’—A Deceptive Catch-Phrase,” Nobel Peace Prize Journal, 7.

12. The nineteen MSF sections were created in the following order: France (1971), Belgium and Switzerland (1980), Holland (1984), Luxembourg and Spain (1986), the United States and Greece, (1990), Canada and Italy (1991), Japan (1992), Sweden, Denmark, Germany, and the United Kingdom (1993), Australia, Austria, and Hong Kong (1994), Norway (1995).

13. James Orbinski, “Where to From Here?” (internal MSF document, November 24, 2000).

15. It was not until January 1997 that MSF established an international council. Before that no entity existed within it that facilitated communication and coordination among its sections.

16. James Orbinski served as president of the International Council from 1998 to 2001. He had worked with MSF since 1992—including in the setting of Baidoa, Somalia, in 1992–1993, during a time of civil war and famine; in Kigali, Rwanda, in the midst of the 1994 genocide there; and in Goma, Zaïre (now the Democratic Republic of Congo), while it was undergoing a Rwandan refugee crisis.

17. The International Office of MSF was located in Brussels at this time. It is currently in Geneva.

19. For an extensive, firsthand account of MSF’s TB project in Russia, see chap. 11 of this book.

22. The five operational sections of MSF at this time were MSF Belgium, MSF France, MSF Holland, MSF Spain, and MSF Switzerland.

23. The partner sections (known as “delegate offices” until 1997) were Australia, Austria, Canada, Denmark, Germany, Greece, Hong Kong, Italy, Japan, Luxembourg, Norway, Sweden, the United Kingdom, and the United States.

25. I believe I first heard the term “informal hierarchy” from Jean-Marie Kindermans in the course of a personal conversation about my continuing perplexity regarding how decisions are made in the “everyone is equal,” “anti-institutionalization” context of MSF. Kindermans (born in France), a physician, whose special fields are public health and tropical medicine, is also a qualified engineer. He first became associated with MSF in 1982 and has worked in Thailand, Chad, Afghanistan, Lebanon, Vietnam, and Central America. Among the positions that he has held in MSF are those of director of MSF Belgium, member of MSF Belgium’s board of directors, member of MSF’s International Council, and secretary-general of MSF.

26. December 10, the anniversary of Albert Nobel’s death, is the day that the Nobel Peace Prize is traditionally awarded.

27. This so-called Second Chechen Campaign was initiated in 1999. The First Chechen Campaign launched by Russian troops in an attempt to stop Chechnya from seceding from the Russian Federation had taken place in 1994 to 1996. Officially, the conflict between Chechnya and Russia ended in 2000, but insurgent activity continued.

28. The murals on the walls of the Central Hall were painted by Henrik Sørensen between 1938 and 1950.

30. The acceptance speech was thirty-five minutes long. The passages that I have excerpted from it and quoted above are not presented in the order in which they appear in the speech. For a complete, verbatim transcript, see “The Nobel Prize Acceptance Speech,” December 10, 1999, www.doctorswithoutborders.org/publications/article.cfm?id=708.

CHAPTER FOUR: MSF Greece Ostracized

1. Minutes of the meeting of the International Council of MSF, Brussels, September 9, 1994.

3. The letter, originally written in French, is reproduced in L’Odyssée de Médecins Sans Frontières–Grèce (The Odyssey of MSF–Greece), a 1997 MSF “memorandum” printed in both French and English versions, Annex 7, 43.

8. “Movement” is written with a capital “M” in Orbinski’s communication.

9. “Memorandum présenté par Médecins Sans Frontières–Grèce: MSF victime du conflit du Kosovo” (memorandum presented by Médecins Sans Frontiers–Greece: MSF Victim of the Kosovo Conflict), Brussels, January 26, 2000, 4.

12. Nicholas Christakis subsequently became professor of medicine and of sociology at Harvard. On July 1, 2013, he moved to Yale to become the Sol Goldman Family Professor of Social and Natural Science.

13. Our relationship began when Christakis was studying for his PhD in sociology at the University of Pennsylvania, where I was his one of his teachers, his faculty advisor, and the director of his dissertation.

CHAPTER FIVE: The Return of MSF Greece

1. The two persons who had carried out the fact-finding mission to MSF Greece were Laure Delcros and Kostas Moschochoritis. They made an oral presentation to the International Council meeting based on their written report about the mission. My account of the report and the presentation, and of what transpired at the International Council meeting, is based on “IC [International Council] Meeting Minutes, Barcelona, November 22–24, 2002.”

2. Among the sections of MSF that the “invited guests” at this meeting represented were MSF France, MSF Holland, MSF Switzerland, MSF Germany, MSF UK, and MSF Sweden.

3. The quoted words and the account of what transpired at this Extraordinary General Assembly centered on the “Kosovo debate” that follows are taken from “Report on Kosovo Debate—XGA MSF GR, 13th January 2007,” which, in effect, constitutes detailed minutes of the meeting.

5. By late 2010, the unemployment rate in Greece had reached eighteen percent, rising to thirty-five percent for young persons between the ages of fifteen and twenty-nine. Rachel Donadio, “With Work Scarce in Athens, Greeks Go Back to the Land,” New York Times, December 9, 2012, A1 and A7.

6. This paragraph is based on three documents, from which the quoted passages were drawn: “MSF–GR Annual Plan 2011: Executive Summary”; “MSF–GR Annual Plan 2012: Executive Summary”; and “MSF Greece: Medical-Operational Support Unit (SOMA).”

7. “MSF Malaria Intervention in Greece: Executive Summary,” Athens, December 1, 2011.

9. Reveka Papadopoulou, personal communication to the author, February 14, 2012.

10. Reveka Papadopoulou, personal communication to the author, September 19, 2011, from which all the quotations in this paragraph are drawn.

11. Michaël Neuman, interview with Reveka Papdopoulou, “En Grèce, des bidonvilles sont dans une situation comparable à celle de terrains plus traditionnels de MSF,” Libération, March 12, 2012, http://humanitaire.blogs.liberation.fr/msf/page/3.

12. Reveka Papadopoulou, personal communication to the author, February 14, 2012.

CHAPTER SIX: La Mancha

Epigraph. “The Impossible Dream (The Quest)” is sung by Don Quixote all the way through the musical Man of La Mancha. Copyright 1965. Words by Joe Darion. Music by Mitch Leigh. Andrew Scott Music, Helena Music Company, ASCAP. Permission for use of lyrics from “The Impossible Dream” has been granted by Alan S. Honig.

1. Rowan Gillies, “Why La Mancha?” in My Sweet La Mancha (internal MSF publication, December 2005), 10–15, at 10.

2. Rowan Gillies, “From Here to the La Mancha Agreement,” La Mancha Gazette (internal MSF newsletter), May 2006, 1–2, at 1.

4. “Brax” is Samuel Hanryon, a member of the Communications Department of MSF France.

5. I was present as an observer at the La Mancha meeting, by permission of the president of the International Council, Rowan Gillies, and with the assent of MSF members who knew me. In an e-mail sent after the meeting, Gillies wrote me: “Thank you very much for coming to the La Mancha conference. I think it was ideal for us to have a semi-outside person there, but one who understands the peculiarities and particularities of MSF.”

6. This is a consequence of two developments: as a result of MSF’s expansion and greater internationalization, most of its sections are no longer headquartered in French-speaking countries; and at this historical juncture, English has succeeded French as the global language.

7. There were only a few incidental exceptions to this pattern that I observed, when several French and Belgian attendees who had been members of MSF for many years referred jokingly to their affiliation with Marxism or Maoism in their youth.

10. The tale, which originated in India, has been widely diffused, and exists in many different versions.

11. Marie Buissonière, “La Mancha, here we come!” La Mancha Gazette (internal MSF newsletter), May 2006, 2–3.

12. At this time, seventy-eight percent of MSF’s financial resources came from more than three million private donors.

15. Ulrike von Pilar, “Sharing Knowledge! The La Mancha Training Centre,” La Mancha Gazette (internal MSF newsletter), May 2006, 12. The self-accusations of being “colonialist” that were voiced at the conference probably had some connection with MSF’s complex institutional and personal relationships with the history of colonialism in Africa. Belgian, French, and British members of MSF, for example, are members of societies that were once colonial powers in Africa, and some of them have relatives who went to Africa as missionaries, physicians, government administrators, or commercial agents during the colonial era. For these reasons, they may be especially inclined to feel strongly identified with Africa and Africans, on the one hand, and highly condemnatory of colonial ways of thinking, feeling, and behaving, on the other.

16. Vincent Janssens, “If the Glove Doesn’t Fit, Shrink the Hand?” in My Sweet La Mancha, 181–182, at 181. I have retained the author’s unconventional style.

18. James Orbinski, “MSF: Where to From Here?” (internal MSF document), November 24, 2000, 1–6, at 1 and 3.

20. Erwin van’t Land, “At Our Core, a Resounding Non!” in My Sweet La Mancha, 186–187, at 186.

23. Report from the June 1989 MSF France board of directors meeting, cited in Jean-Hervé Bradol and Elizabeth Szumlin, “AIDS: A New Pandemic Leading to New Medical and Political Practices,” in Jean-Hervé Bradol and Claudine Vidal, eds., Medical Innovations in Humanitarian Situations (New York: MSF USA, 2011), 178–199, at 181. For more details of these earlier MSF debates about the pros and cons of MSF becoming involved with HIV/AIDS, see chap. 7.

24. MSF inaugurated the International Campaign for Access to Essential Medicines in 1999, with its Nobel Peace Prize money. See chap. 3.

25. Quoted in Eric Goemaere, “HIV/AIDS Programs’ Impact on Our Operational Principles—A Subtle Balance Between Political Involvement and Medical Responsibility,” in My Sweet La Mancha, 214–219, at 214.

26. This program was established in the township of Khayelitsha, Cape Town, South Africa where, in greatly expanded form, it still exists. For a detailed account of its history, development, and operation, based in part on my firsthand field observations, see chaps. 7 and 8.

29. Kenny Gluck, “Measles, Stalin, and Other Risks—Reflections on Our Principles, Témoignage, and Security,” in My Sweet La Mancha, 150–155, at 150.

31. Pierre Salignon, “From Taking Risks to Putting Lives in Danger?” in My Sweet La Mancha, 285–287, at 285.

33. Colin L. Powell, “Remarks to the National Foreign Policy Conference for Leaders of Non-Governmental Organizations, State Department, Washington DC, October 26, 2001,” cited and quoted in Rony Brauman and Pierre Salignon, “ideas & opinions from MSF: Iraq: in Search of a ‘Humanitarian Crisis,’” April 16, 2004 (e-mail to the author).

35. It is possible that what influenced Brax to use French rather than English for these cartoons is that a number of French humanitarian organizations figured prominently in a consortium of NGOS that were particularly outspoken in questioning the necessity of going to war in Iraq. They included La Croix-Rouge Française, Action Contre la Faim, Médecins du Monde, Première Urgence, and Solidarité et Enfants du Monde. Cited in Brauman and Salignon, “ideas & opinions.”

CHAPTER SEVEN: Struggling with HIV/AIDS

Epigraphs. Treating 1 Million by 2005: Making It Happen. The WHO Strategy, the WHO and UNAIDS Global Initiative to Provide Anti-Retroviral Therapy to 3 Million People in Developing Countries by the End of 2005 (Geneva: World Health Organization, 2003), 3–4; Peter Piot, No Time to Lose: A Life in Pursuit of Deadly Viruses (New York: Norton, 2012), x; Albert Camus, The Plague, trans. Stuart Gilbert (New York: Knopf, 1950), 35, 278.

1. As many as twenty-five new infectious diseases had emerged since the founding of MSF in 1971; and among the old infectious diseases that had reemerged, multi-drug-resistant forms of tuberculosis, malaria, and measles were some of the most serious.

2. Helen Epstein and Lincoln Chen, “Can AIDS Be Stopped?” New York Review of Books 49, no. 4 (March 14, 2002): 29–31. See Helen Epstein, The Invisible Cure: Africa, the West, and the Fight Against AIDS (New York: Farrar, Straus & Giroux, 2007).

4. The HIV retrovirus was identified as the biological cause of AIDS in 1983–1984; anti-retroviral drugs to treat AIDS were introduced in 1987.

5. In 2001, MSF Belgium’s board held a debate on “MSF and AIDS.” Prior to, and in preparation for this, they sought the “opinions, attitudes and wishes” of its members on a number of AIDS-relevant questions. Among the documents circulated to members in this connection was one on “AIDS treatment for MSF employees. A kick-off for discussion.” The text quoted above was written in response to this document by the head of the MSF Belgium mission in Rwanda, who sent it to the Brussels office by e-mail on May 14, 2001. In order to maintain confidentiality, he changed the names of the persons who he cited in it.

6. Gorick Ooms, “AIDS: Mega-Atomic Time Bomb” (MSF Belgium document, September 2000, 19–21, circulated internally as part of a collection of articles and reports issued in connection with the section’s stocktaking at the end of the year 2000).

7. Eric Goemaere is a physician trained in economics, tropical medicine, public health, and epidemiology. He was the executive director of MSF Belgium from 1994 to 1999. Alex Parisel has an undergraduate university degree in business and management, and a graduate degree in the management of health institutions. He succeeded Goemaere as executive director of the section. Gorik Ooms is a human rights lawyer, with a PhD in medical sciences. He served as executive director of MSF Belgium from 2004 to 2008.

8. For a brief account of the nature of MSF’s Campaign for Access to Essential Medicines, see chap. 3. Eric Goemaere was in charge of the portfolio for access to second-line drugs for multi-drug-resistant forms of tuberculosis.

Bernard Pécoul, a French physician, joined MSF France in 1983. He spent five years working on field projects in Latin America, Asia, and Africa. After his return to France in the late 1990s, he co-founded Epicentre, MSF’s center for epidemiological research, in Paris and led its research and training until he was named executive director of MSF France, in which position he served for seven years. At the end of that term, in 1998, he assumed the role of executive director of MSF’s Campaign for Access to Essential Medicines. Subsequently, in 2003, he became a founder and the executive director of the Drugs for Neglected Diseases Initiatives (DNDi), located in Geneva—a position that he still holds.

9. In calling Goemaere a member of the “1968 generation,” Parisel was alluding to the student uprisings that took place on European university campuses during that period, and to the fact that when he was a student at the Université Catholique de Louvain in Belgium, Goemaere had seriously studied Marx’s Das Kapital and considered himself to be a Trotskyite in his political outlook. He was also impressed and influenced by radically oriented students from Latin America who were enrolled at Louvain at the time—including disciples of Ernesto “Che” Guevara who were enrolled with him in a macro-economics course.

10. MSF was active in South Africa throughout the 1980s, until 1993, in assisting refugees from Mozambique.

11. At the time, the prevention-of-mother-to-child transmission (PMTCT) regimen consisted of giving AZT to pregnant women in the thirty-sixth week of their pregnancy, and during labor, following a pilot protocol (ACTG 076), which had been tested in Thailand. The results of this trial, published in 1998, had shown that administering AZT in this way reduced vertical transmission from mother to child by fifty percent.

12. “Coloured” in South Africa refers to persons of “mixed” ancestry, including black-white, black-Asian, white-Asian, and black-Coloured descendants.

13. The quotations in this paragraph come from an interview that I conducted with Eric Goemaere in Cape Town on September 25, 2002.

14. When Hermann Reuter began his medical education, Namibia (then South West Africa) was a South African mandated territory. He completed his medical studies in 1991, one year after Namibia gained its independence.

16. Eric Goemaere, interview, September 25, 2002. Goemaere attributed the nurses’ failure to recognize how many of the patients they were seeing were infected with HIV partly to the fact that at this time, “hardly anyone was tested for HIV.” “I recorded that only 450 HIV tests had been done in 1998 for the whole township,” he told me.

18. Toby Kasper, David Coetzee, Françoise Louise, Andrew Boulle, and Katherine Hilderbrand, “Demystifying Antiretroviral Therapy in Resource Poor Settings,” Essential Drugs Monitor 32 (2003): 20–21; Quarraisha Abdool Karim, “HIV Treatment in South Africa: Overcoming Impediments to Getting Started,” Lancet 363, no. 9418 (April 24, 2004), www.thelancet.com/journals/lancet/article/PIIS0140–6736%2804%2916055–8/ fulltext.

19. Marleen Boelaert, Consultancy Report: MSF Khayelitsha Project, South Africa (Antwerp: Department of Public Health, Institute of Tropical Medicine, June 2002), 1.

20. All the quotations from Eric Goemaere in this paragraph are drawn from a personal communication to the author on February 1, 2005.

21. The Khayelitsha group has conducted and published a great deal of medical, epidemiological, public health, and primary-care-relevant research on its endeavors—much of it in collaboration with members of University of Cape Town’s School of Public Health and Family Medicine. A major figure in this research is Katherine Hilderbrand, who is a research associate at HIV/TB Services of Khayelitsha and in the Centre for Infectious Disease Epidemiology and Research in the University of Cape Town’s School of Public Health. She is also Eric Goemaere’s wife.

22. These patients included 159 adults and 18 children under fourteen years of age. The mean age of the adults on HAART was thirty-two (ranging from fourteen to fifty-four), and sixty-nine percent of them were women. According to a joint “preliminary report” issued by MSF and the School of Public Health and Family Medicine of the University of Cape Town, there were more women on HAART than men “because more women [made] use of public facilities.” Médecins Sans Frontières (MSF), and School of Public Health and Family Medicine, University of Cape Town, “Providing Antiretroviral Therapy at Primary Health Care Clinics in Resource Poor Settings: Preliminary Report, May 2001–May 2002,” 5.

23. In 2002, Zackie Achmat, along with two other members of TAC (Matthew Damane and Nomandla Yako), and Joyce Phekane of the Congress of South African Trade Unions (COSATU) made a trip to Brazil to observe the Brazilian government’s AIDS program, and to see how it had been able to circumvent the international drug companies’ protection of the patents on anti-retroviral drugs in order to make affordable generic versions of them. They brought back to South Africa generic antiretrovirals from the Brazilian pharmaceutical laboratory Farmanguinhos for use in the MSF Khayelitsha project. All three of the TAC members were living openly with HIV, and two of them (Damane and Yako) were receiving treatment in Khayelitsha. The main witnessing and advocacy goal of their trip was to show that if the South African government took the necessary action, anti-retroviral drugs could be provided at half the price that was being charged by the multinational drug companies in South Africa.

24. For an ethnographic account of this research, see Renée C. Fox, In the Field: A Sociologist’s Journey (New Brunswick, NJ: Transaction Publishers, 2010), 123–300.

CHAPTER EIGHT: In Khayelitsha

2. Although this story is not factually true, there is a real sense in which it was true “in spirit.” Because of the efforts of the Danish government and thousands of Danes from wide-ranging backgrounds, when the Nazis ordered the arrest and deportation of Danish Jews in October 1943, many of them had been hidden and sheltered by Danish citizens, and some 7,000 had been helped to escape in boats to Sweden, with which the Danish government had secretly negotiated an agreement to receive them. In the end, about 475 Danish Jews were deported to the Theresienstadt concentration camp (now in the Czech Republic), of whom twenty died en route, and fifty in the camp. See, e.g., “The Fate of the Jews of Denmark,” www.holocaustresearchproject.org/nazioccupation/danishjews.html, and “The History of Jews in Denmark,” www.jewishgen.org/scandinavia/history.htm.

3. The nurses’ epaulettes, which differed in color, indicated the various branches of nursing in which they were trained and registered.

6. Women were given several options about how to feed their babies. At first the policy was to recommend formula feeding exclusively, in order to prevent the transmission of HIV to the baby through the mother’s milk. Later, a “mixed feeding” option of breast and formula feeding was added, but as a less desirable alternative.

8. She mentioned in passing that this desire on her part was partly connected with her membership in an Adventist Christian faith community.

9. Vuyiseka Dubula’s account of how she became involved in HIV/AIDS issues, and a leading figure in the development of Ulwazi, was shared with me via a Skype-conducted personal interview with her on May 3, 2012.

10. Vuyiseka Dubula is now (in 2012) the secretary-general of TAC. Her work is still focused on HIV/AIDS, tuberculosis, and their interconnection, but her role has become more political, she said, more bureaucratic, and in certain ways “not as interesting” as her earlier activities in the context of Ulwazi.

11. This is taken from my field notes, and was published in Fox, “Khayelitsha Journal,” 73–74, along with my overview account of the meeting.

12. In the afternoon, the group reconvened for a meeting that concentrated on instructing them how to teach others about HIV/AIDS—its symptoms, modes of transmission (especially through sexual relations), its prevention, and its treatment.

13. In 2011, Poole graduated as a medical doctor, and began specialty training in intensive care.

15. A male TAC volunteer who sat next to me in the classroom kindly translated the Afrikaans for me, although I understood some of what was being said on my own, because Afrikaans is a Low Franconian, West Germanic language, derived from seventeenth-century Dutch, and from my years of research in Belgium, I am acquainted with West Flanders / Flemish Dutch.

17. “Give Government Credit for Great Strides in Health Care,” Sunday Independent, October 12, 2003, 8. This article contained an edited version of Graça Machel’s speech.

19. “Open Letter to the South African Government From Médecins Sans Frontières,” February 12, 2003, signed by Dr. Morten Rostrop, president, MSF International Council, and Dr. Eric Goemaere, head of mission, MSF South Africa.

20. At this time, the cost of treating a patient with antiretroviral drugs was approximately $8,000 a year. Given the magnitude of the epidemic of HIV/AIDS in South Africa, what it would have meant economically for the government to try to make this therapy available to all who needed it would have been economically staggering.

21. Katherine Hilderbrand, a research associate on the MSF Khayelitsha staff (for more on her, see chap. 7, n. 21), was the chief designer of the questionnaire, and it was she who invited me to meet with the group. My account of this meeting here coincides with the description of it in Fox, “Khayelitsha Journal,” 72–73.

22. Ibid., 72. I identified these components of witchcraft from anthropological works about Central African societies and culture, and from my own firsthand knowledge of witchcraft in the Democratic Republic of Congo.

23. Willy De Craemer, Jan Vansina, and Renée C. Fox, “Religious Movements in Central Africa: A Theoretical Study,” Comparative Studies in Society and History 18, no. 4 (October 1976): 458–475, at 461.

24. Contributing to the ability of the Khayelitsha program to increase its patient intake was the initiation of the national government plan for treatment and care of HIV/AIDS, which unlocked international funding, with the result that, beginning in July 2004, as much as eighty percent of Khayelitsha’s antiretroviral drug supply was supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. MSF also augmented its funding of the program. In addition, the majority of the staff began to be paid by the Western Cape Provincial Department of Health; and the sources of the high-quality, relatively low-cost generic forms of antiretroviral drug that it prescribed for patients had expanded from the Brazilian company from which they had originally been purchased to several Indian companies, along with Aspen Pharmacare of South Africa.

25. For a somewhat more detailed account of Khayelitsha’s “patient selection” processes, and the ethical questions that they posed for the clinics’ staff, see Renée C. Fox and Eric Goemaere, “They Call It ‘Patient Selection’ in Khayelitsha: The Experience of Médecins Sans Frontières–South Africa in Enrolling Patients to Receive Antiretroviral Treatment for HIV/AIDS,” Cambridge Quarterly of Healthcare Ethics 16, no. 1 (Winter 2006): 302–312.

26. Although this is written in the first person, I was accompanied by my colleague Judith Swazey, and by a young woman physician, a Coloured South African general practitioner, who made regular visits to the hospice.

27. This constituted a major alteration in the “Directly Observed Therapy for the Treatment of Tuberculosis” regimen that the World Health Organization (WHO) had instituted and was recommending during the period in 1985 when I made my first field trip to Khayelitsha. At that time, the procedure for DOTS treatment that WHO advised involved having a trained health worker not only provide the prescribed TB drugs but also watch each patient swallow every dose.

28. South Africa has the highest incidence of rape in the world, only a fraction of which are reported. Studies conducted by the South Africa Medical Research Council, the World Health Organization, and the Community of Information, Empowerment and Transparency all confirm this extraordinarily high incidence.

30. The volume of clients seen by the rape clinic has continued to increase since my last field trip to Khayelitsha in 1995, and the clinic is now under the auspices of a local NGO.

33. “Saying Goodbye to Lesotho’s Highlands, Khayelitsha Heartland: Rachel Cohen, MSF Head of Mission, looks back at three years of making a difference,” MAMELA! May 2009, 1–3, at 1. http://msf.org.za/Newsletter/MAMELA!/MAMELA_May09.html.

35. Peter Piot, No Time To Lose: A Life in Pursuit of Deadly Viruses (New York: Norton, 2012), 367.

36. According to an article in the Lancet, in 2007, SANAC endorsed a National Strategic Plan for HIV and AIDS and Sexually Transmitted Infections (2007–2011). “But a midterm review of implementation of the plan identified serious problems with SANAC. The review found that the high number and lack of definition of targets, weak coordination between different implementers, and between implementers and SANAC had seriously hampered reporting on national progress in the strategic plan.” However, the article went on to say that with the very recent appointment of “widely respected” Dr. Fareed Abdullah as SANAC’s new chief executive, who would lead the restructuring of the organization, there was now real promise that its Monitoring and Evaluation Unit would be “crucially strengthen[ed]” (“South Africa’s AIDS Response: The Next 5 Years,” Lancet 379, no. 9824 [April 14, 2012]: 1365). As recounted earlier in this chapter, in 1999, Abdullah had initiated the program to prevent mother-to-child transmission of HIV/AIDS in the Western Cape—long before it became legally obligatory for such treatment to be provided nationally. It was in this connection that he was one of the first persons to welcome Eric Goemaere to Khayelitsha.

37. Jon Cohen, “Reversal of Misfortunes,” Science 339, no. 6122 (February 22, 2013): 898–903. The “alarming rise in coinfection with HIV and TB has been dubbed the HIV/TB syndemic [the author of this article comments] because, for both biological and social reasons such as poverty, the two diseases have synergistic effects, with each making the other worse.”

38. “Disappointment: The Ruling Party’s 100th Anniversary Failed to Mask a Host of Worries,” Economist 42, no. 8767 (January 14–20, 2012): 45.

39. “Breaking the Grip of Poverty and Inequality in South Africa, 2004–2014: Current Trends, Issues and Future Policy Options” (executive summary coordinated by J. P. Landman, with the assistance of Haroon Bhorat, Servaas van de Berg, and Carl van Aardt, December 2003), www.sarpn.org/documents/d0000649/P661-Povertyreport3b.pdf), 3, 5, and 7.

40. Lydia Polgreen, “Fatal Stampede in South Africa Points Up University Crisis,” New York Times, January 11, 2012, A1 and A9, at A1).

42. Sophie Delaunay, “External Challenges: Working Group on Governance” (internal MSF document, May 2009), 2.

43. www.msf.org.za/download/file/fid/3706. This statement was issued by the Budget Expenditure Monitoring Forum (BEMF), a group of organizations concerned with HIV/AIDS funding in South Africa and the Southern African region. BEMF includes Section 27, the Treatment Action Campaign, Médecins Sans Frontières South Africa, the Centre for Economic Governance and AIDS in Africa, and the Free State Aids Coalition and World Vision. See www.tac.org.za/community/BEMF.

44. Eric Goemaere, personal communications to the author, November 30, 2011 and December 2, 2011. With regard to invoking the media, see, e.g., Alex Duval Smith, “World Aids Day: South Africa Pioneer Decries Cut in Global Funding: Eric Goemaere, a Médecins Sans Frontières Doctor Who Led Early Battle Against Aids in South Africa, Says Cut in Grants From Global Fund Threatens a Decade of Progress Against HIV in Africa,” Guardian, December 1, 2011, www.theguardian.com/pioneer-eric-goemaer. In the e-mail that he sent to me on December 2, 2011, Goemaere (who by this time had become MSF South Africa’s senior regional HIV/TB advisor) commented that, “unfortunately,” in his view, this article (which was based on an extensive interview with him) was “too personal.” Nevertheless, he added, “it says clearly what I believe might happen here.”

Optimism and momentum [have] been building around the real possibility that an AIDS-free generation is imminent. Public enthusiasm is fuelled by news about the rapid scale-up of antiretroviral therapy evidence that HIV treatment can prevent new infections, and expanded coverage of programmes to prevent mother-to-child transmission of HIV. Yet the most recent estimates of HIV prevalence and incidence of AIDS-related mortality released by UNAIDS, together with data from the Global Burden of Diseases Study 2010 in The Lancet, make it clear that AIDS is not over.…

Looking at the most common causes of death globally, HIV/AIDS ranked sixth in 2004, and held the same position in 2010. The Global Burden of Disease study 2010 estimates 1.5 million AIDS-related deaths in 2010, whereas UNAIDS data show 1.8 … million AIDS-related deaths. Both estimates highlight a persistent, significant, and egregious burden of avoidable death.…

[D]espite substantial reductions in AIDS mortality rates in many countries, AIDS remains the leading cause of death in southern and eastern Africa.…

Thus, while much progress has been made in treatment and prevention, the persistent and substantial global burden associated with HIV and AIDS compels us to do more—and do better—to achieve the AIDS-free generation the world is waiting for.

1. For a detailed account and analysis of this meeting, see chap. 12 of this book.

3. ICB/ExDir Working Group New Entries, “Plan for MSF ‘New Entities’ and Related Considerations” (internal MSF document, June 2008, final version), 6.

4. Gorik Ooms, “Re: New MSF Entities in Brazil and South Africa” (internal MSF document, January 16, 2007), 1.

5. This refers to the fact that each MSF section has an association, which is composed mainly of persons working in the field, and persons who have returned from the field, and additionally, some persons working in MSF offices. Among these, one-third of the members are expected to be medical professionals. Each MSF section subscribes to the MSF Charter and its Chantilly text on MSF’s identity and guiding principles. A general assembly is held annually by each section at which members of its board and the president of its board are elected. The board is not permitted to be “homogeneously national.” The board presidents sit on the International Council (which, at the end of 2011, became the International General Assembly).

8. Eric Stobbaerts, with Erwin Van’t Land, Sebastian Roy, and James Kliffen, “Feasibility Study: MSF Africa” (draft internal MSF document, March 2006), 7 and 105.

9. Gorick Ooms, e-mail to the OCB Board concerning “Creation of an MSF South Africa board (and perhaps an MSF Brazil advisory board”), January 27, 2007.

10. Subsequently, in 2007, after she felt that the new South African office had been successfully launched, and was “promoted” by MSF International to the status of a “delegate office,” Ekambaram made a transition from general director to head of the Programs Unit—a post for which, in her opinion, she was suited by her attributes as an activist and organizer. She was succeeded as general director by Liz Thomson.

11. Sharon Ekambaram, personal communications to the author, January 28 and February 3, 2011.

15. Sharon Ekambaram, “MSF SA—Looking at Africa from an African Angle” (internal MSF SA document).

18. These countries included the Central African Republic, the Democratic Republic of Congo, the Republic of Congo (Brazzaville), Somalia, and Zimbabwe.

19. “Xenophobic Violence: One Year on the Specter Still Lurks,” MAMELA! May 2009, 1–2. http://msf.org.za/Newsletter/MAMELA!/MAMELA_May09.html. MSF Belgium also responded to these xenophobic attacks by sending a team of logisticians and medical personnel to assist with providing medical care and counseling for the foreign nationals living in makeshift shelters.

20. The name of the village in southern Sudan is Pagil. The town in the Democratic Republic of Congo—Masisi—is located in the country’s North Kivu Province.

24. This paper, dated January–February 2010, was written for the MSF international conference on governance reform held in Barcelona on March 11–13, 2010, which was attended by Eric Goemaere and Hermann Reuter as delegates from MSF South Africa. The paper was endorsed by five MSF South Africa board members: Goemaere, an exofficio member of the board; Reuter, then president of the board, and the focal point for drug-resistant TB management in a decentralized HIV/TB program in Swaziland, who was formerly the first South African staff member of the Khayelitsha program and subsequently the program coordinator who established the HIV/ARV program in rural clinics in the Eastern Cape; Elma de Vries, a member of the Family Medicine Department at the University of Cape Town and of the Rural Doctors Association of Southern Africa, and a former president of the MSF South Africa board; Prinitha Pillay, who received her medical education and training in Johannesburg at the University of the Witwatersrand, had worked with MSF since 2006, participating in medical missions in Lesotho, India, South Sudan, and Sierra Leone, and became president of MSF SA’s Board following Hermann Reuter; and Haroon Salooje, a co-opted member of the board, who was head of community pediatrics at Witwatersrand University. For more details about Goemaere and Reuters, see chaps. 7 and 8 in this book.

25. The words “Migrant,” “Black,” “Muslim,” “Civilian,” “Armed Opposition,” “Male,” and “Citizen” were printed in boldface.

26. Foreigners arriving in South Africa from other African countries to the north usually did not speak any of the local African languages, and their “babble” sounded like kwirikwirikwiri to the local township inhabitants, who applied the onomatopoeic term kwerikwere (plural amakwerekwere) to them.

27. The data in this paragraph come from a “short profile” that MSF South Africa prepared as a candidate to become a new association, which it presented to MSF’s International General Assembly in Paris on December 16, 2011. See chap. 12 in this book for a detailed account of this meeting.

28. Sharon Ekambaram, personal communication to the author, February 21, 2012. and April 14, 2012.

CHAPTER TEN: Reaching Out to the Homeless and Street Children of Moscow

1. The course was based on Inkeles’s scholarly work. See Alex Inkeles, Public Opinion in Soviet Russia: A Study in Mass Persuasion (Cambridge, MA: Harvard University Press, 1950); Inkeles and Raymond A. Bauer, The Soviet Citizen: Daily Life in a Totalitarian Society (Cambridge, MA: Harvard University Press, 195l); Alex Inkeles, Social Change in Soviet Russia (New York: Simon & Schuster, 1968).

3. Olga Shevchenko’s dissertation “Living on a Volcano: The Lived Experience of Social Change in Russia” was presented to the faculties of the University of Pennsylvania in partial fulfillment of the requirements for the degree of doctor of philosophy in 2002.

4. Olga Shevchenko, Crisis and the Everyday in Postsocialist Moscow (Indianapolis: University of Indiana Press, 2009), 8.

5. In June 2001, we also made a short trip to Saint Petersburg, where we met with several persons whom MSF staff members had recommended we see because of the significant roles they had played in MSF’s homeless programs. We also spent some time there with personnel associated with the Paris and New York offices of Médecins du Monde / Doctors of the World, the organization that arose from the split in Médecins Sans Frontières in 1979–1980 between members of its founding generation. Between 1997 and 1999, MSF had run a medical and social assistance center for the homeless in Saint Petersburg, which closed after the city adopted an “Aid to Homeless Persons and Ex-Prisoners” program and opened a free medical center for them in the Botkin Hospital.

6. The First Chechen Campaign took place from 1994 to 1996, when Russian troops attempted to stop Chechnya from seceding from the Russian Federation. The Second Chechen Campaign was initiated in 1999 by an incursion of Russian troops into the area. In addition to continuing the fight to bring the breakaway Chechen Republic back under Russian rule, its stated objectives were to quell what were alleged to be bandits, criminals, separatist rebels, and terrorists in the region.

7. According to “The Trauma of Ongoing War in Chechnya,” a report issued by MSF Holland in August 2004, more than fifty international humanitarian workers had been abducted in that region since 1995, and some of them [had] been murdered, including six members of the International Red Cross. During the period of our research in Russia, the two most publicized kidnappings of MSF personnel were those of Kenneth Gluck and Arjan Erkel. Gluck, a U.S. citizen associated with MSF Holland, was working as head of mission for the North Caucasus Project. He was abducted on January 9, 2001, while traveling in a humanitarian convoy near the village of Starye Atagi in Chechnya, and released on February 3, 2001. Erkel, a citizen of the Netherlands, was head of mission for MSF Switzerland’s program in Dagestan when he was abducted in Makhachkala on August 12, 2002, by gunmen, who kept him in captivity until April 11, 2004.

10. Throughout the eighteenth and nineteenth centuries, and during the first years of the twentieth, an extensive network of charitable establishments and institutions existed in Russia, including places to live for the needy and hospitals for people without means. One of the most important of these was the Empress Maria Fyodorovna Department of Institutions, founded by and named for the wife of Emperor Paul I. In May 2000, a collection campaign was initiated in Saint Petersburg to erect a monument to the empress as part of what was called a “Russian charitable revival.” The brochure issued in this connection mentions that plans to erect such a monument had already existed in 1911, but had been subverted by “historical events,” and by the fact that “the word ‘charity’ was no longer in use.”

11. Alexei Nikiforov, “Homelessness—Yesterday, Today and Tomorrow?” (unpublished MSF document).

13. Hedwige told us that throughout the stressful time that she and her colleagues had undergone, their solidarity remained strong. They talked to each other every day about what they were experiencing and feeling, and gave each other support. Upon their arrival in Moscow, MSF Belgium sent two persons from its Human Relations Department in Brussels to debrief them and provide them with psychological counseling. When they recounted what they had experienced in the field, Hedwige said, laughing, the human relations personnel were so stricken that “we had to console them,” rather than the reverse.

14. Although we did not learn this from Alexei, Dr. Chazov was also celebrated because of the number of Russian and world leaders whose personal physician he had been, and because, in collaboration with the American cardiologist Dr. Bernard Lown, he cofounded International Physicians for the Prevention of Nuclear War. In 1985, IPPNW was awarded the Nobel Peace Prize, which Chazov and Lown received on behalf of the movement. Chazov “holds a Guinness Book world record for treating 19 leaders from 16 different countries,” according to http://russiapedia.rt.com/prominent-russians/science-and-technology/evgeny-chazov.

16. The Center for Epidemiology and Sanitation was the first service in Moscow to recognize the needs of the homeless and to respond to them. In 1984, it gave homeless persons free access to three disinfection and sanitary stations, where those suffering from lice or scabies could receive treatment for these conditions and shower while their clothes were disinfected.

19. MSF received help from the Catholic relief agency Caritas, from religious Sisters belonging to Mother Teresa’s Missionaries of Charity, from the Salvation Army, and from a few of the more progressive local Russian Orthodox churches in providing clothing and food for its homeless clients.

20. Jeanmart estimated that over the years, MSF sent more than one thousand letters to Moscow officials proposing that they open a municipal center for medical and social assistance to the homeless (“Special Report: Ten Years of Work with Moscow’s Homeless”).

21. Jeanmart had left MSF Belgium’s Moscow office soon after this project was approved, primarily because she was expecting to give birth imminently to a second child; so at the time that Olga interviewed Alexei, he was working on it with another member of the MSF staff, project coordinator Gabriella Muretto, who had recently arrived in Moscow.

22. Interview with Jeanmart in “Special Report: Ten Years of Work With Moscow’s Homeless.”

24. Samusocial Moscow, which has French origins, is a “Russian non-commercial organization,” associated with Samusocial International. Its Governing Board and Board of Trustees are “made up of both Russians and long-term expatriates, who are familiar both with the French approach and the local situation,” and its members are “experts on issues concerning children, notably in the medical, psychological, legal, and financial sectors” (www.samu.ru/en/aboutus).

26. For example, MSF has been working in Sudan since 1979, in the Democratic Republic of Congo since 1981, in Russia since 1988, in Somalia since 1991, and in South Africa since 1999.

CHAPTER ELEVEN: Confronting TB in Siberian Prisons

2. Nicolas Cantau, “Aide Humanitaire en Russie: Médecins Sans Frontières Belgique” (internal MSF report), 35. Cantau headed the MSF Belgium mission in Russia from November 15, 1995, to January 8, 1998. He is now the Global Fund to Fight AIDS, Tuberculosis and Malaria’s regional portfolio manager for Eastern Europe and Central Asia.

3. Margarita V. Shilova and Christopher Dye, “The Resurgence of Tuberculosis in Russia,” Philosophical Transactions of the Royal Society of London, ser. B, 356 (2001): 1069–1075, at 1069 and 1074.

4. M. E. Kimerling, “The Russian Equation: An Evolving Paradigm in Tuberculosis Control,” International Journal of Tuberculosis and Lung Disease 4, no. 12 (2000): S160–S167, at S160.

5. Paul Farmer, “Managerial Successes, Clinical Failures” (editorial), International Journal of Tuberculosis and Lung Disease 3, no. 5 (1999): 365–367, at 365.

7. Olga Shevchenko and Renée C. Fox, “‘Nationals’ and ‘Expatriates’: Challenges of Fulfilling ‘Sans Frontières’ (‘Without Borders’) Ideals in International Humanitarian Action,” Health and Human Rights 10, no. 1 (2008): 109–122, at 118. “A TB patient cries twice—once when he is diagnosed, and once when he is cured,” it was said of these patient entitlements in the Soviet era.

9. Deputy Justice Minister Yuri Ivanovich Kalinin, 1998 interview, shortened version (© Moscow Center for Prison Reform), www.prison.org/english/expkalin.htm.

10. Three of these institutions were pre-detention centers where persons were incarcerated while awaiting a trial and sentencing. The other twenty-three were so-called “general colonies.”

12. In Russian medicine and medical schools, phthisiatry refers solely to tuberculosis and its concomitants. It is a specialty by itself, rather than being regarded as a branch of pulmonology.

13. Olga Shevchenko, interview with Dr. Natalia Nikolayevna Vezhnina, Moscow, June 7–8, 2003.

14. Dominique Lafontaine and Andrei Slavuckij, “MSF–Belgium TB Project in Siberian Region of Kemerovo, Russian Federation, 1996–2003: Conclusive Operational Report” (MSF internal report, May 2004), 5. Dr. Dominique Lafontaine served as the field coordinator of the MSF TB project in Siberia, and Dr. Andrei Slavuckij was its chief medical coordinator, beginning in 2000.

15. “Thieves in law” were the elite of the criminal world in Soviet times and were seen as the only legitimate enforcers of Russian criminals’ code of honor both within and outside of prisons. See Federico Varese, The Russian Mafia: Private Protection in a New Market Economy (New York: Oxford University Press, 2001).

16. Olga Shevchenko, interview with Dr. Natalia Nikolayevna Vezhnina, Moscow, June 7–8, 2003.

19. This was facilitated by the fact that the majority of the detainees came from the Kemerovo region of Siberia, where these pre-detention centers were located.

20. For a more detailed account of these attributes of the Russian penal system, and their implications for the incidence, treatment and spread of TB among its inmates, see Andrei Slavuckij, Vinciane Sizaire, Laura Lobera, Francine Matthys, and Michael E. Kimerling, “Decentralization of the DOTS Programme Within a Russian Penitentiary System: How to Ensure the Continuity of Tuberculosis Treatment in Pre-Trial Detention Centers,” European Journal of Public Health 12, no. 2 (2002): 94–98.

21. These first-line anti-tuberculosis drugs were ethambutol, isoniazid, pyrazinamide, rifampicin, and streptomycin. In the standard short course, the drugs are given in a certain order of introduction, sequence of phases (a high-intensity phase followed by a continuation phase), for a differing number of months and of intermittent dosing. For example, isoniazid, rifampicin, ethambutol, and pyrazinamide are given daily for two months, followed by four months of isoniazid and rifampicin given three times a week.

23. Professor Mikhail Perelman, Chief Phthisiatrist of Russia and Academician of the Russian Academy of Medical Science, was one of the strongest, most prestigious, and influential proponents of the utilization of fluoroscopy for these purposes and for mass tuberculosis screening.

26. Although the “thief in law,” also a TB patient, allowed his fellow inmates to take the DOTS drugs, he never agreed to do so himself. He died a few years later.

27. Lafontaine and Slavuckij, “MSF–Belgium TB Project,” 12n16: “Protein biscuits were abandoned later due to logistical problems and difficulties [in assessing] the real intake.” However, “nutritional input was made to the end of the program with regular survey of the nutritional status of the patients.”

28. Kimerling, “Russian Equation,” S613. Kimerling acknowledges that he received these data from the Colony 33 Statistics Unit via a personal communication from Slavuckij.

29. Shevchenko, interview with Vezhnina, July 7–8, 2003. The MSF physician who married the daughter of the Russian colony physician was Hans Kluge.

31. In July 2008, the name of the department was changed to the Department of Global Health and Social Medicine.

32. Paul Farmer, “Cruel and Unusual: Drug Resistant Tuberculosis as Punishment,” in Haun Saussy, ed., Partner to the Poor: A Paul Farmer Reader (Berkeley: University of California Press, 2010), 206–219, at 218. This article was originally published in Vivien Stern, ed., Sentenced to Die: The Problem of TB in Prisons in Eastern Europe and Central Asia (London: International Centre for Prison Studies, King’s College, 1999), 70–66.

34. The quoted passages about this meeting were all excerpted from Paul Farmer and Jim Yong Kim, “Community Based Approaches to the Control of Multidrug Resistant Tuberculosis: Introducing “Dots-Plus,” British Medical Journal 317, no. 7159 (September 5, 1998): 671–674.

35. Scientific Panel of the Working Group on DOTS-Plus for MDR-TB, “Guidelines for Establishing DOTS-Plus Pilot Projects for the Management of Multidrug-Resistant Tuberculosis [MDR-TB],” ed. Rajesh Gupta and Thuridur Arnadottir (Geneva: World Health Organization, 2000).

36. The Global Impact of Drug-Resistant Tuberculosis (Boston: Program in Infectious Disease and Social Change, Dept. of Social Medicine, Harvard Medical School, 1999). The Stop TB Partnership Task Force on TB was established in 2010. The involvement of UNAIDS in this task force emanated from the relationship between HIV/AIDS and tuberculosis, and the mounting rate of HIV/TB co-infection that exists. TB is the commonest opportunistic infection and the primary cause of death among people with HIV/AIDS. In addition, people with latent TB are increasingly becoming infected with HIV, and many develop active TB because of the weakening of their immune systems by HIV.

37. PHRI, an independent, not-for-profit research organization, originally located in New York City, was founded in 1941 by Mayor Fiorello LaGuardia, primarily to study infectious diseases, and also applied immunology, nutrition, and physiology.

38. Kimerling had previously worked as a volunteer in several MSF field programs. He had been a member of MSF Holland and MSF Belgium missions in Cambodia in 1991–1993, and from June to December 1995, he had served as medical consultant for their malaria and tuberculosis control activities there.

43. Michael Kimerling, Hans Kluge, Natalia Vezhnina, et al., “Inadequacy of the Current WHO Re-Treatment Regimen in a Central Siberian Prison: Treatment Failure and MDR-TB,” International Journal of Tuberculosis and Lung Disease 3, no. 5 (May 1999): 451–453.

45. These quotations are excerpted from a series of e-mails between Olga Shevchenko, Renée Fox, and Paul Farmer on June 6, 2008.

46. Paul E. Farmer, “Rethinking Health and Human Rights: Time for a Paradigm Shift,” in Saussy, ed., Partner to the Poor, 435–470, at 455.

47. Haun Saussy, “Introduction: The Right to Claim Rights,” in Saussy, ed., Partner to the Poor, 1–24, at 15.

52. Nagorno-Karabakh, a republic in the South Caucasus, borders Armenia to its west and Iran to its south. It is closely tied to the Republic of Armenia, uses the same currency, and has a predominantly Armenian Christian population. See www.nkrusa.org/country_profile/overview.shtml.

53. Renée Fox, telephone interview with Michael Kimerling, October 30, 2012. Kimerling’s assessment of the causes underlying MSF France’s objections to his involvement was not shared by Francis Varain, who was present at this meeting. “Working with Michael Kimerling was never seen as equivalent to accepting money from Gorgas or USAID,” Varain claims. “Other priorities of MSF France at this time, in terms of TB, were involved” (personal communication to Fox, March 24, 2013).

54. At present (October 2012), Michael Kimerling is senior program officer in the Tuberculosis Program of the Bill and Melinda Gates Foundation in Seattle, Washington, and affiliate professor in the Department of Global Health in the Division of Infectious Diseases of the Department of Medicine in the School of Medicine of the University of Washington.

55. However, MSF continued to supply drugs and other necessary materials in order to avoid doing harm to the patients.

56. From an interview with Andrei Slavuckij, conducted by Renée Fox and Olga Shevchenko, June 19, 2001. The cry “Go to the Square” alluded to the Decembrist uprising in Imperial Russia on December 26, 1825, when Russian army officers led thousands of soldiers in a protest against Nicholas I’s assumption of the throne.

57. Andrei Slavuckij first made contact with MSF in 1991 when he was working as an anesthesiologist with a Soviet organization that was rendering medical assistance in the interior of Angola where members of MSF were also present. Impressed by MSF’s action and their “strong image,” he joined their ranks as a member of MSF Belgium. During 1991–1994, he participated in a number of MSF missions in Bosnia, Rwanda, and Chechnya.

59. The second-line anti-TB drugs in question included olflaxacin, cycloserina, and capreomycin, which were available for Green Light Committee–approved programs at negotiated prices, as well as unregistered drugs such as amikacin and clofazimine.

60. “MSF Ends Tuberculosis Treatment in Kemerovo Region, Russia” (MSF press release, September 9, 2003).

61. “MSF could not find common language with penitentiary system of RF,” the Russian nongovernmental REGNUM News Agency reported on October 21, 2003. MSF esteemed Kalinin and his reforms of the penal system. They interpreted his statement as a benevolent attempt to help foster a reconciliation between the hostile Ministry of Health and MSF.

62. Our account of some of the exchanges that took place at these meetings are drawn from the text of Slavuckij’s and Sheyanenko’s report.

64. According to the program, GUIN’s chief TB specialist, Dr. Svetlana Sidorova, was to have made this presentation, but Smirnov, a new member of GUIN, spoke in her stead.

65. For Slavuckij, the meaning of this metaphor was both “precise” and grave, because he interpreted the black pencil as representing XDR-TB.

66. We (Renée Fox and Olga Shevchenko) maintained contact with Dr. Vezhnina after her dismissal from her position as assistant head of the Medical Division of GUIN in the Kemerovo region. In the fall of 2003, we invited her to act as a chronicler of the events that transpired in connection with, and in the aftermath of, the termination of MSF Belgium’s TB program in Kemerovo, including follow-up news regarding the members of its staff and the Russian officials who were key figures in its history and its demise. She agreed to take on this role, principally because she thought that the story underlying what MSF Belgium had accomplished, the obstacles it had encountered, and the factors that had led to its closure ought to be documented, written up, analyzed as a case history, and eventually circulated. From mid-October 2003 through 2004, she sent us periodic communications, chiefly via e-mail, concerning what she knew about pertinent events taking place in and around Colony 33, and about the professional activities of its previous and present medical staff and relevant officials. She also provided us with a number of relevant documents.

71. Almaty, the former capital of Kazakhstan, is its largest city, and its major commercial and cultural center. Cantau and Slavuckij helped arrange for Vezhnina to be offered this position.

72. Subsequently, Dr. Vezhnina’s “dream” was partially fulfilled. She was appointed to the position of advisor on HIV/TB and Penal System Projects with AFEW. In this capacity, she conducted training sessions on the mutually compounding effects of the HIV/AIDS and TB epidemics in the penal institutions of the Central Asian Republics. She has also piloted a number of projects relevant to co-infection with HIV/AIDS and TB that have been institutionalized and replicated throughout the system.

73. The plan had been for this training program to be funded by USAID through the Gorgas TB Initiative at the University of Alabama, and for its administrative and financial management to be provided by the Kemerovo Region Committee of the Russian Red Cross Society. Gorgas TB Initative, http://138.26.145.28/gorgas/Novokuznetsk.htm.

74. This information about what Dr. Vezhnina referred to as “the order of things in Colony 33” since the “dissolution” of MSF Belgium’s TB project came to us via a long, undated communication that she sent to us in October 2004.

75. Hans Kluge, the Belgian physician who married the daughter of one of the Russian doctors in Colony 33, renewed his contract with the project three successive times.

78. Andrei Slavuckij shared these sentiments with us (Olga Shevchenko and Renée Fox) in 2013 as part of his highly detailed review of a draft of this chapter that we sent to him for his comments, criticisms, and corrections. In turn, he passed the manuscript on to three colleagues closely connected with MSF’s TB-related activities (Nicolas Cantau, Myriam Henkens, and Francis Varain), and asked for their input to it. The four of them compiled their feedback to us in the form of extensive, computerized marginal notes throughout the pages of the manuscript. Natalia Vezhnina also read this chapter in manuscript in an earlier version than the one seen by Slavuckij et al. We are grateful to all of them for their invaluable contributions.

CODA: Remembering the Past and Envisioning the Future

1. Saint-Denis was also the site of a vigorous socialist movement; and until the mid-1930s, virtually all of its mayors were members of the French Communist Party. It is still called la ville rouge (the red city) or the banlieue rouge (red suburb). It has a high crime rate. And according to the Wikipedia, in 1999, 35.6 percent of its residents were “born outside of metropolitan France.” (This is the definition of an “immigrant” in France. Persons who have become French citizens since moving to France are still defined as immigrants in French statistics.) See “Saint-Denis,” http://en.wikepedia.org/wiki/Saint-Denis.

4. In alphabetical order, these representatives were affiliated with MSF 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.

5. Unni Karunakara, personal communication to Renée Fox, June 6, 2011. I had previously made it known to Karunakara and to several other MSF members that I would welcome an opportunity to attend the meeting. In addition, by prearrangement, they cordially agreed to my request that my colleague Judith P. Swazey accompany me to the meeting. Notwithstanding Karunakara’s invitation to me to participate in the discussion that took place at the meeting, I confined my role to that of an observer and to informal interaction with many MSF members who I already knew and some who I met for the first time on this occasion. In his opening remarks on December 16, 2011, Karunakara introduced me as a professor of sociology at the University of Pennsylvania, “a longtime friend of MSF,” and “a sort of historian.”

6. Rip Hopkins, Jean Lacouture, and Rony Brauman Sept fois à terre, huit fois debout [Seven Times on the Ground, Eight Times Standing] (Paris: Chêne, 2011).

7. Ibid., “Mérite, engagement et T-shirts [Merit, Commitment and T-Shirts],” 7.

8. The last photograph in the book is of Hopkins himself in an MSF T-shirt, holding two nude, squirming, crying, auburn-haired babies in his arms, who look like twins and as if they are his children. The photo is subtitled “je le fais pour moi” (I do it for myself), “Rip Hopkins, photographe iconoclaste” (iconoclastic photographer).

11. Karunakara did not mention that rather than accepting contributions specifically earmarked for Japan, MSF drew on its unrestricted donations funds. In response to a contribution that I had sent in the aftermath of the earthquake and tsunami, I received a message thanking me, informing me of MSF’s policy of not accepting donations specifically designated for this purpose, and offering to return mine unless I earmarked it for the general fund.

12. With the adoption of the new statutes in June 2011 that reformed MSF’s international governance structure, the International Council had been replaced by the International General Assembly.

13. Marie-Pierre Allié, introduction titled “Agir à tout prix?”/“Acting at Any Price?” in Claire Magone, Michaël Neuman, and Fabrice Weissman, eds., Agir à tout prix? Négotiations humanitaires: L’expérience de Médecins Sans Frontières (Paris: La Découverte, 2011)/Humanitarian Negotiations Revealed: The MSF Experience (New York: Columbia University Press, 2011), 1. Many of the contributors to this volume are affiliated with MSF’s research center in Paris, the Centre de Réflexions sur l’Action et les Savoirs Humanitaires (CRASH). The English-language edition contains an Afterword by David Rieff that is not included in the French-language edition.

15. The presentation that preceded this long-awaited session was a keynote address—“What Access to Health Care for the 7 Billion?”—delivered by Hans Rosling, a Swedish physician, trained in public health and statistics, as well as medicine, who is a professor of international health at the Karolinska Institutet, a Stockholm medical school. He spent many years studying outbreaks of konzo, an epidemic paralytic disease, among rural populations in Africa, which opened onto his research on the relationship between economic development, agriculture, poverty, and health in Latin America and Asia, as well as in Africa. He is the developer of so-called Trendanalyzer software that converts statistical data into animated, moving graphs. He was also one of the initiators of MSF in Sweden.

Using Trendanalyzer software to visualize global demographic developments, Rosling delivered a riveting and highly entertaining lecture on the fact that the world’s population may reach more than seven billion persons by mid-century, the probable consequences for health, the provision of health care, and access to it in high-, middle-, and low-income countries, and the implications for MSF’s actions and aspirations.

16. Jean-Hervé Bradol and Marc Le Pape, “Innovation?” in Bradol and Claudine Vidal, eds., Medical Innovations in Humanitarian Situations: The Work of Médecins Sans Frontières (New York: MSF USA, 2011), 3–21, at 5.

17. For a fuller account of this episode in the founding of MSF, see Chapter 2, “Origins, Schisms, Crises.”

22. New sections of MSF were created in the United States and Greece in 1990; in Canada and Italy in 1991; in Japan in 1992; in Sweden, Denmark, Germany, and the United Kingdom in 1993; in Australia, Austria, and Hong Kong in 1994; and in Norway in 1995.

23. Out of the approximately 27,000 MSF workers in the field, some 22,000 are national staff.

24. For a more extensive discussion of “expatriates/nationals” issues, see chap. 6.

25. The already-appointed members of the International Board—the presidents of MSF’s five operational centers, its international president, and its international treasurer—included five physicians.

26. In addition to the position that Morten Rostrup had held as founding president of the MSF Norway section, Jean-Marie Kindermans had served as president of MSF Belgium (2002–2010), and Darin Portnoy as president of MSF USA (2004–2009). As indicated previously, Rostrup had also been vice president and president of the International Council. Kindermans held the post of secretary-general of the International Office from 1996 to 2001. And after serving as flying coordinator (2006–2007), Fotiadis became the International Association coordinator (2007–2011). Among the elected International Board members, Fotiadis and Rostrup had been the most actively involved in MSF’s inner reform. Fotiadis is the husband of Reveka Papadopoulou, general director of MSF Greece.

29. See Max Weber, The Theory of Social and Economic Organization, trans. A. M. Henderson and Talcott Parsons (New York: Oxford University Press, 1947), 358–373.

NOTES

THE QUESTS: An Introduction

CHAPTER ONE: Voices from the Field

CHAPTER TWO: Origins, Schisms, Crises

CHAPTER THREE: “Nobel or Rebel?”

CHAPTER FOUR: MSF Greece Ostracized

CHAPTER FIVE: The Return of MSF Greece

CHAPTER SIX: La Mancha

CHAPTER SEVEN: Struggling with HIV/AIDS

CHAPTER EIGHT: In Khayelitsha

CHAPTER NINE: A “Non-Western Entity” Is Born

CHAPTER TEN: Reaching Out to the Homeless and Street Children of Moscow

CHAPTER ELEVEN: Confronting TB in Siberian Prisons

CODA: Remembering the Past and Envisioning the Future