Like all great cultures, Médecins Sans Frontières has its own creation myth. The story is based in historical fact, but it’s related and remembered differently by the people who were there. In the standard version, a group of young French doctors goes to work in a Red Cross hospital in the breakaway Nigerian state of Biafra in 1968. They are appalled by what they see — hundreds of thousands of children dying from malnutrition — and believe they are witnessing a genocide. Although the Red Cross demands the utmost discretion from its volunteers, the French doctors, led by the charismatic Bernard Kouchner, cannot remain silent. They angrily tear the Red Cross armbands from their sleeves and denounce the Nigerian government. On returning to France, they organize a committee to raise awareness of the genocide and, later, a group of doctors devoted to emergency medical aid. Around the same time, a Paris medical journal publishes a call for volunteer doctors to help the victims of earthquakes and floods. The two groups eventually come together in 1971 to form Médecins Sans Frontières. Twenty-nine years later, the organization accepts the Nobel Peace Prize for being “emergency aid rebels” who “blazed new trails in international humanitarian work.” In his 2002 book, A Bed for the Night, journalist David Rieff, who has covered wars and emergencies around the globe, calls this group “the most important humanitarian NGO in the world.”

Médecins Sans Frontières — also known in North America as Doctors Without Borders, and universally as MSF — is the world’s largest independent medical humanitarian organization. In 2008, it ran projects in 65 countries, requiring more than 26,000 staff in the field. While it is best known for its high-profile projects in conflict zones, refugee camps, and countries hit by famine, MSF also runs smaller programs outside the media spotlight: supporting rural health clinics, providing antiretroviral treatment for people with AIDS, and bringing fresh water and sanitation to remote villages.

To understand the work of MSF, it’s important to clarify some of the terminology used in the aid community. To begin with, aid groups make a distinction between development and relief. There’s an old adage that says, “Give a man a fish and you feed him for a day; teach a man to fish and he can feed himself for life.” Development agencies concentrate on the latter goal: their projects are usually long-term, focusing on building local capacity, always with a view to sustainability. Many development programs are foreign aid projects funded by Western governments. Non-governmental organizations (NGOs) that do development work may have a religious bent (World Vision and Tearfund, for example) though many others (Oxfam, Save the Children) do not.

Relief organizations, by contrast, are primarily concerned with aiding populations in acute crises, such as war or famine, epidemics or natural disasters. MSF has always been in this category, with a focus on the medical needs of the people it serves. Members may work in an area for several years, but addressing the underlying causes of the emergencies is not part of their mandate. MSF operates feeding centers for starving people, but does not supply shovels and seeds to grow crops; it brings health care to poor areas, but does not try to eradicate poverty.

There is also a fundamental difference between humanitarian and human-rights organizations, and it’s a distinction that is often missed. Both types of groups uphold international law (as set out in the Geneva Conventions, the Universal Declaration of Human Rights and other codes), but human-rights organizations tend to be more activist, with lobbying at the heart of their work (Amnesty International is the most familiar example). Humanitarian agencies, on the other hand, must remain neutral in order to get access to victims on all sides. MSF is foremost a humanitarian organization — neutrality is enshrined in its charter — but from its earliest days it has wrestled with the knowledge that, in cases of extreme brutality and oppression, neutrality may be tantamount to complicity. While not a human-rights group per se, MSF often has a toe in the same waters.

When MSF emerged in France in 1971, nothing like it had existed before. There were other aid agencies, of course — Save the Children was already more than 50 years old, Oxfam almost 30 — but the International Committee of the Red Cross (ICRC) was the only group bringing significant medical relief to the victims of war and natural disaster around the world. But as conflicts in the late 1970s displaced millions of people, the new private organization soon found a niche in the refugee camps of Southeast Asia, Africa, and Central and South America.

From the beginning, MSF’s reputation exceeded its actual impact in the countries where it worked. Its early emergency projects were small, often poorly coordinated, and modest in their success. Yet with the flamboyant and media-savvy Kouchner at the helm, MSF gained a reputation for going into the most dangerous areas just as other aid agencies were fleeing. Newspapers carried pictures of the fearless and heroic doctors riding on donkeys into Soviet-occupied Afghanistan, trekking the jungles of a newly independent Angola, and tending to Cambodians in the shadow of the Khmer Rouge. Among the French press and the public, Médecins Sans Frontières became known as medical mavericks, the cowboys of emergency aid, a reputation that clings to them — for better or worse — to the present day.

Inside the organization, however, tensions were simmering between the founders and a younger generation of doctors that was growing weary of Kouchner’s media stunts. In late 1978, as thousands of boat people fled Vietnam, Kouchner announced a plan to send a rescue ship (and television crews) to the China Sea, an operation most of the younger MSFers felt was naive and futile. Bitter arguments ensued, and within a few months Kouchner and his allies were gone, forced out of the organization they had created.

During the 1980s, MSF added offices in Belgium, Switzerland, Holland, Spain and Luxembourg, each with considerable autonomy. Its reputation continued to grow, and so did its outspokenness: MSF criticized Pol Pot’s regime in Cambodia in 1980, then was expelled from Ethiopia after it took Colonel Mengistu to task in 1985. Now well funded by UN agencies, European governments and private donors, MSF became admired for its logistics and its frugal use of resources. As its teams moved quickly and efficiently by plane, Land Cruiser, canoe and on foot to deliver medical aid to the most perilous and remote places on earth, MSF acquired a paradoxical image. On one hand, it was an informal movement with a culture of debate that prevented it from knee-jerk actions, while on the other it was hailed for its decisiveness. It was an organization of swashbucklers with technical expertise who spoke with equal parts brazenness and sophistication.

The 1980s has been called the golden age of humanitarianism. Western governments had not yet co-opted humanitarian aid as a tool to “win the hearts and minds” of people in occupied countries. The Ethiopian famine that began in 1983 sparked Live Aid and countless other fundraisers, and money poured into the coffers of aid agencies. Being an aid worker now carried cachet, and by the end of the decade, when French citizens were surveyed about their ideal job, a third of them said they wanted to be a médecin sans frontières. “Without Borders” suggested a gatecrashing fearlessness that appealed to those who were tired of the timidity of the United Nations, and perhaps even the neutrality of the Red Cross.

During the 1990s, MSF became a global organization, adding sections in the United States, Canada, Japan, Hong Kong and Australia. But as it did so, the golden age of humanitarianism gave way to an unprecedented period of soul-searching in the aid community. People shed their innocence about the impact of aid, realizing that it can create a culture of dependency and even exacerbate conflicts. The crises of those years dramatically revealed the moral ambiguity of relief and intervention: in Bosnia, where UN peacekeepers failed to stop the massacre of 7,000 people in Srebrenica; in Rwanda, where aid poured in to help Hutus who had just perpetrated the worst genocide since the Second World War; and in Kosovo, where the perverse term “humanitarian bombing” was born in 1999. That same year, Médecins Sans Frontières received the Nobel Peace Prize, largely for its leadership during this difficult period in the aid community.

The first decade of the new millennium brought new challenges, from the post–September 11 “war on terror,” to the horrors of Darfur and neighboring Chad, to the famine in Niger. MSF has continued to evolve as an organization: adding new partner sections in predominantly Muslim countries; expanding its offices in South America, Africa and Asia; and giving more and more responsibility to its local staff.

Through it all, MSF’s doctors, nurses and other workers continue to grip the imagination of the public. People are captivated by the drama of surgery in war zones, the idea of prosperous professionals who leave behind comfortable lives for deprivation in the field. That’s part of the MSF story, but the big picture is far more complex — and thankfully so. A nuanced portrait is far more compelling than a caricature.