Stretched out in the TV room of the Médecins Sans Frontières house in Kandahar, Hernan del Valle reflects on the reasons he joined MSF. An Argentine human-rights lawyer with a wicked sense of humor, del Valle has worked with several other aid organizations, including Save the Children and Oxfam, but he says only MSF has the cojones “to tell everyone else to fuck off.”
That glibness has prompted other aid organizations to label MSF as arrogant, self-righteous troublemakers. Nonetheless, it’s part of del Valle’s job as humanitarian affairs officer for Afghanistan and Pakistan to try to ensure that other organizations — the UN High Commissioner for Refugees, the two countries’ governments, foreign-aid donors — are doing what MSF believes is best for the population, and he speaks out publicly when they’re not. It’s part of what MSF calls témoignage.
The literal meaning of témoignage is “witnessing,” though it is more often translated as “advocacy.” Even that doesn’t capture the nuance of the term, so MSFers invariably uses the French word regardless of their native tongue. The organization’s main role has always been delivering medical aid, but even if advocacy makes up a small fraction of its activities — less than four percent of its operating costs in 2008 — it’s an important part of its identity. One MSFer puts it this way: “Chimpanzees share ninety-eight percent of our DNA. Témoignage is like our two percent — it’s what distinguishes us from other NGOs.” The idea goes all the way back to Bernard Kouchner and Biafra, though it’s not easy to pin down, and MSF admits that it’s a source of continuous debate. The criteria for speaking out are fluid; individuals have their own interpretations of when it is appropriate, and prevailing views are different among the sections. Jean-Hervé Bradol, a past president of MSF-France — where the concept perhaps has the most resonance — says it’s misleading to think about delivering medical aid and témoignage as two entirely separate actions. “From my point of view, there isn’t such a distinction between speaking and acting. I think we permanently speak out, in a way.” He’s referring to the idea that the mere presence of an international NGO offers some deterrent to injustice.
Speaking out has its price, however, and not only in other organizations’ ill will. It also goes against the principle of neutrality, a pillar of humanitarianism, and it puts teams in the field at risk of retaliation. After treating hundreds of brutally raped women and children in Sudan’s Darfur region, for example, the Dutch section published a report on the abuse in March 2005. The eight-page document stopped short of blaming Khartoum explicitly, but it described how most of the attackers wore military uniforms and stated that local authorities were tolerating the crimes. The Sudanese government demanded that the organization produce evidence for the claims, and when it wasn’t satisfied, it arrested two MSF staffers, Paul Foreman and Vincent Hoedt, and charged them with crimes against the state. The charges were later dropped, but human-rights groups report that aid workers in the country have been routinely threatened by Sudanese troops. A lingering resentment against MSF may even have played a role in the abduction of Laura Archer and her colleagues in Darfur in 2009.
Brian Phillip Möller says MSF’s commitment to humanitarian ideals was the reason he signed on. “Once I read the charter, the decision was made for me. There are other NGOs that I might like to work for in the future, but until they remove me forcibly, or I have to crawl away on my hands and knees, I will stay with MSF.” Yet he admits he struggled to uphold those ideals during his two missions in Gaza in 2008, the year the Israel Defense Forces launched Operation Warm Winter on what they said were military targets. “When you see that sixty percent of the victims are women and children, you are going to make your conclusions,” Möller says. “I found it very difficult to maintain impartiality and neutrality. I would love to go back to Gaza, but realistically it is going to take me two or three years before I can re-establish my neutrality. I think it’s natural: if you are on one side of the fence, you’re going to see that perspective.”
Dealing with your own emotions is hard enough, but during his time in Gaza, Möller remembers that the organization itself almost stepped over the line. The Paris office was approached by someone representing the family of Gilad Shalit, the Israeli soldier who was abducted by Palestinian militants in June 2006 and has been held captive ever since. Shalit has French citizenship, and diplomats in France have been involved in negotiating his release. Now MSF was being asked to step in and deliver a letter to the young soldier and get information about his status. “That could have been very dangerous for the field team,” Möller says, “and could potentially have compromised our neutrality. The issue for us in the field was that you had one Israeli soldier held captive somewhere in the Gaza Strip, while on the Israeli side of the fence you have twelve thousand Palestinian prisoners. We are going to be concerned about the welfare and health of one Israeli soldier, but not the health of the twelve thousand Palestinian prisoners?” Möller wondered how that would look to the Palestinian patients in MSF’s clinics. “It took a lot to form relationships with the various political groups in Gaza and to get their consent for us to be there. All that could have been destroyed in one weekend. In the end, they listened to the field team and we did not go down that road. And in all honesty, in my seven missions that is the only time we have even come close to compromising neutrality.”
The Israel-Palestine conflict has raised some controversies within the organization. If MSF is neutral and impartial, some ask, why do they work only in the Palestinian Territories and not with Israeli civilians? Möller says it has been considered — two towns near the Gaza border, Sderot and Ashkelon, are often hit with rockets fired by Palestinian militants — but the idea was abandoned when it became clear that civilians in those towns were adequately cared for. “Realistically, there are no needs in Israel. Whereas in Gaza, there are needs, and those needs exist because international law has been broken. MSF chooses to assist Palestinians not because they are Palestinians, but because there is a medical need.”
Möller was routinely frustrated by the hoops he and his team had to jump through to get access to their patients in Gaza. “Anybody coming in or out of the Strip had to have permission, and the Israelis are able to delay that permission. They say who goes in and who doesn’t: you can spend three months trying to get permission for one person to enter, and someone else can get it after four days. It’s not an international border, but when you pass through Erez, which is the only passage point that is allowed to humanitarian aid workers, they control every single thing that goes in and out of the Strip. I’ve done a lot of traveling in my life, but by far that is the most difficult crossing I’ve ever done. It’s really tough. Many strip searches. Three times going through Erez we came under rocket attack, mortar fire. We got held up in Erez sometimes for six or seven hours being searched and questioned.”
The consequences of straying from neutrality are serious enough for expat teams; for the populations they serve, however, they can be far more dire. While an international team can pull out of a project that becomes dangerous, their local staff has no such luxury. One MSFer remembers an overzealous head of mission he worked with in Colombia, a “stupid cowboy” who talked about going to the media with a list of human-rights violations he witnessed. “The local staff turned white and said, ‘If you do that they’re going to kill my family tomorrow.’”
In extreme cases, where MSF publicly denounces a regime, it must withdraw from the country — as it did in Ethiopia in 1985, and in North Korea in 1998. The population it had been serving, however imperfectly, may then be left with no health care, which is why denunciation is a last resort, an exasperated admission that all other avenues have failed. Drawing the world’s attention to human-rights violations is not the core business of MSF, as it is for groups like Amnesty International or Human Rights Watch. But when a suffering population needs more than health care and no one else is around to say that, or when medical aid is being abused, MSF will stretch its mandate. “During the famine in North Korea,” says Rony Brauman, “we realized that everything we were bringing — whether medical services or high-protein food — was being used by the North Korean regime to strengthen itself. It was a resource for the perpetrators, and not a resource for the victims.” Rather than be manipulated, MSF chose to withdraw its teams from the country and publicly expose the situation. “The idea is that it’s a cost in terms of public image to endure documented criticism by an NGO. So we can establish a kind of balance of power — we don’t have weapons, we don’t have anything we can threaten the country with. But we can blur its image; we can weaken it.”
Brauman also feels that MSF is justified in speaking out when it is the only witness to massive crimes against civilians. That happened in Angola in 2002, when the organization was the first NGO to enter some areas after the war ended. “We came across vast groups of the population in an appalling state: starvation, extreme weakness due to forced labor, slavery, rapes, terrible things. Those people had been used as slaves by both the government forces and the guerrilla forces. We were the only witnesses of this, and we decided we had to report on it, because if we didn’t say anything nobody would, and we couldn’t keep this to ourselves.”
Then there is the pragmatic element of MSF’s advocacy work, the one that Hernan del Valle put into practice when he went to bat for displaced Afghans. Here, again, MSF is criticized for appointing itself the guardian of the population’s interest and assuming it always knows what’s best. And here, too, del Valle plays MSF’s trump card: the independence that comes from raising most of its own funds. “In this job you have the luxury of saying, ‘I am advocating for the people.’ And who can go against that? You can actually go to a meeting and say, ‘We’re not asking for more water for this camp because we want more money from UNHCR. It’s because people need to drink.’” He says other NGOs will grudgingly admit they wished they had the same freedom to speak up, but they worry about losing contracts from the UN or government agencies. “They will tell you off the record, ‘We agree with what you’re saying, we think that’s the right principle, but our salaries come from there.’” That’s why journalist David Rieff, who has written critically about how aid agencies can be co-opted by donor interests, has said that MSF “is both envied and resented by other groups. It is, in an important sense, the conscience of the humanitarian world.”
In March 2002, UNHCR and the Afghan and Pakistani governments began the enormous effort of helping hundreds of thousands of Afghan refugees go home. By August 2003, some 2.3 million had returned from Pakistan and Iran, with another 10,000 or so following every week. On the surface, it sounded like a good-news story. But, according to MSF, not all of them were moving willingly. “MSF has been against the repatriation in Afghanistan, and very vocal, because we think it is premature,” says del Valle. UNHCR has a formal mandate to uphold international refugee law — which includes a refugee’s right not to be repatriated against his will — and if MSF believes it is failing in that responsibility, it will scream and shout.
Pakistan had already accepted more refugees than it felt it could handle, and it closed its border at Chaman in February 2002. Some 25,000 Afghans were trapped in a no-man’s-land that came to be called the Waiting Area. “A big and somewhat ridiculous debate about their status began,” del Valle says. “The discussion revolved around a patch of desert, a total space less than three hundred meters south or north of the line dividing the two countries.” Put simply, the people in the Waiting Area needed food, water and medical care, and MSF says no one wanted to provide it — not Afghanistan, not Pakistan and not UNHCR. “All the actors interpreted the situation in a way in which they could get away without providing assistance.”
For their part, UNHCR and both governments argued — fairly, even MSF would concede — that the improvised Waiting Area had none of the services of an official refugee camp. Water had to be brought in by truck, sanitation was inadequate and the whole area was dangerous, as coalition forces clashed with the resurgent Taliban in nearby towns. In May 2003, the refugees in the Waiting Area were given a choice: return to their homes; move to Mohammed Kheil (a camp deeper inside Pakistan); or relocate to the newly erected Zhare Dasht camp on the Afghan side of the border, where they would no longer be classed as refugees but as internally displaced people. After a mass exodus in July, almost 11,000 ended up in Zhare Dasht, while some 7,800 agreed to move to Mohammed Kheil. There they received the food and other aid that comes with official refugee status.
The relocation addressed one of MSF’s concerns, but by this time the Waiting Area had been occupied for 15 months and people were just beginning to adapt to life there. Because the settlement was so close to the towns of Chaman and Spin Boldak, del Valle says, some of the inhabitants had even found work. “Ironically, when people finally had developed survival strategies, adapted to the place, built their mud houses, and got some daily labor in the bazaar, they were informed that they had to leave the area without delay and move again into other temporary settlements — not a durable solution, but just another relocation.” The population, MSF argued, was manipulated. “There were push factors that undermined their ability to choose freely: to get food you had to register to move. Having said that, when we saw the decision to move them was irreversible, MSF decided to concentrate on damage control. We concentrated our advocacy on how the relocation was going to be carried out and tried to get the best deal for the refugees, since we could not do anything else at that point. Staying behind — as most of them wanted to do — was no longer an option.”
“It was on 8 December 2000, at 8:30 in the evening, that we were attacked by government soldiers who took us for rebels, but they were mainly interested in stealing.” The words are read in musical tones by a young Congolese man in front of a small audience in a downtown Toronto auditorium. He’s narrating a passage from a book of testimonies collected by MSF teams in the Democratic Republic of the Congo (DRC). This is the story of André, a father of three in Katanga. “They grabbed my bicycle, extorted medicines from my nephew, a member of the Red Cross, and took the belt from my little brother’s trousers. The soldiers hit me. It is painful to admit that our own soldiers beat us, but it’s true. That’s what happens.”
Even if the people in the audience that evening were acquainted with the ongoing war in DRC, chances are most had never heard the first-hand stories of individuals living through it. Congo is home to some of the organization’s biggest medical projects, and, according to one MSFer in the region, it is “among the greatest humanitarian disasters of our time.” Yet every year, the country shows up on MSF’s list of the world’s most underreported humanitarian stories. Even when African conflicts make the news in the West, the numbers are simply too large to register — millions displaced, hundreds of thousands killed. Sometimes témoignage is less about changing policies than about simply giving voice to suffering individuals like André, to dispel the idea that people in DRC and other war-torn countries have become inured to violence and don’t suffer as acutely as people in the West. “That’s complete and utter bullshit,” says an MSF doctor who has done three missions in the country. “The difference is that they don’t give up.”
MSF’s advocacy is based on first-hand observation, not reports from other groups, and is backed up by solid evidence. The organization, in fact, has developed expertise at tracking disease outbreaks, doing nutritional surveys and collecting epidemiological data in emergencies. In 1987, MSF created Epicentre, a Paris-based consulting organization that offers these services to other NGOs. No one questions the value of this information, but within MSF there are those who feel this type of témoignage is overly technical and gets away from a fundamental principle of humanitarianism: that it is a compassionate response to suffering and doesn’t need to be justified by science. “In modern life, and this goes way beyond MSF, there’s a tendency to overvalue things that can be quantified,” says Richard Bedell, who has been an adviser on medical ethics for MSF-Holland. “There’s an idea in the modern rational mind that if you can put a number to it, it’s somehow harder and more reproducible, and more real than anything that you can’t put a number to. It’s an unexamined assumption that what’s quantifiable and calculable is probably superior.”
If the French have historically been the passionate voice of le mouvement, Holland has been the section most likely to lean in the overly pragmatic direction Bedell warns about. “I feel nowadays that the Dutch section is closer to the core ideas of MSF than it was back when I started to work at headquarters in 1996,” he says, “when I felt that they were drifting perilously away from some core issues in the charter. I felt they were heading toward a certain kind of public-health approach. There are some really good ideas in public health and a lot of good methods, but it missed a lot of what’s ethically important at MSF, such as the regard for the specific individual. That kind of thing, which is preserved within the classic MSF view, can get lost if you overemphasize the public-health perspective.”
Being on the ground, interacting directly with patients and their families, is part of that classic MSF view, and it challenges medical team members to put their own value judgments on hold. Bedell recalls running a project in Taliban-controlled Afghanistan and meeting a man who refused to let male caregivers treat his wife. “It’s important to remind yourself that, except in the most bizarre, extreme situation, a man does not want to harm his wife. A man does not want to see his wife die, even in Afghanistan. He simply doesn’t see the choice. That’s what we can’t forget. We can’t forget to respect people, even if we don’t understand. Because trying to change people from a stance other than respect is hopeless. To coerce, to ridicule, will never work. I don’t think we do this very well. There is some general exposure to the phenomenon of cultural difference during the preparatory course that most people do before their first field mission, but even with our best efforts, one would find situations that one didn’t expect. So what you need to do is equip people with a certain attitude for learning, a certain readiness to observe, listen and learn.”
Whether expat humanitarian workers can ever show true solidarity with the people to whom they deliver aid is questionable. “I’m less convinced than many people in MSF,” says Fiona Terry, research director at Fondation Médecins Sans Frontières, the organization’s think tank in Paris. “I don’t know if the presence of someone with an MSF T-shirt is going to make me feel any better. I’m rather uncomfortable with this notion of solidarity. I think in some respects in MSF it’s become too much of a slogan. I mean, what do we really mean by it? We don’t live by their side, we go back to our comfortable houses at night, we drive in our nice four-wheel drives, we have all the modern conveniences of email, we can talk with our friends and family. Can we really say we’re in solidarity with them? It sounds nice, it makes us feel better, but it might be naive to think that victims in the field feel this.”
Some relief NGOs employ local staff almost exclusively in the field, with expats acting only as managers working in the capitals. MSF has made a conscious decision not to follow that model. “From the very beginning we wanted to promote the relationship between societies,” says Jean-Marie Kindermans of MSF-Belgium. “MSF is to help people, but it’s also to have people meeting each other from different societies, to increase tolerance, to increase understanding. It’s a richness to put together people from different cultures, and it’s a richness that the people coming from Europe, meeting volunteers in other countries, come back and speak to their own society.” As the organization has grown, it has struggled to hold on to this ideal of proximity. In 2002, for example, MSF reported that its operational costs rose 19 percent over the previous three years, while its number of field positions increased only five percent. “We are getting more and more office-heavy,” wrote Morten Rostrup, international president at the time. In an internal paper, Rostrup related how he had recently made a visit to the field, where he was picked up by a black BMW and driven to the gated MSF compound, complete with satellite TV, two refrigerators and laptops with satellite modems. None of the expats on the team did any direct consultations with patients.
When I asked if this really was necessary, I got the answer that this was the least MSF could do when they “sacrificed” themselves to the benefit of the locals … I wondered whether some of the volunteers, despite being there physically, were really mentally in the field … What kind of relationship did we actually have to the people that were living there, the people we assisted with health care? What kind of relationship do we expect if we fence ourselves away from the local population, if we drive in our big white Land Cruisers, if we only have social contact with other expats, if we never treat the patients ourselves? What does the MSF slogan “proximity” really mean?
Martin Girard sums it up this way: “We’ve got more people behind computers and fewer people sitting around the fire with the poor bastard in South Sudan, trying to understand the guy.” For Girard, humanitarian action is intensely personal, and even if he and the South Sudanese never fully understand one another, there’s value in just being there around that fire. “You get involved in this kind of organization because of your feeling of human solidarity, that’s the bottom line. Do you feel any solidarity with an African who is in shit up to his eyeballs, or not? It’s a very simple question, and I answer yes, one hundred percent. I’m motivated to stand side by side with these guys and say, ‘Some of the people where I come from benefit from your situation, but I don’t agree with that, and I’m here to show you that we’re not all the same.’ The locals witness your efforts, and they respect that. But when you get to a village they’re not on their knees going, ‘Thank you, thank you, white man from MSF, we’re so happy to see you.’ MSF vehicles have gotten rocks thrown at them, spears and arrows, because they didn’t handle the situation well, or they fucked up in the field.
“We’re not anthropologists, but when you’re in the bush in South Sudan and you’re dealing with the Dinka and the Nuer, you’re on Mars. There’s absolutely nothing that links these people to your way of life. These are hunters and cattle herders and nomads, and they have a thousand-year history. But you strive to understand their suffering — what they have been through. Your understanding of it will always be imperfect. You think you, with your white ass, are going to understand after three months in the field? But they say, ‘Wow, you didn’t forget about us.’ This is where the solidarity comes in, because you leave a rich country, or a nice livelihood, and you jump in the shit up to your shoulders with them for nine hundred bucks a month.”
Chris Day says that when MSF rolls into town, the receptiveness of the population varies widely. “In Kashmir, we were the only NGO there, and people don’t have a wide range of experience with expatriates coming into their villages. It was mixed: Kashmir has a highly educated population, and you have quite a few people who will say, ‘Go home to your country and tell them what’s going on here,’ and others will come flat out and say, ‘You’re just an instrument of the American government. Go away with your cultural imperialism.’ In African countries like Liberia and Sierra Leone, where NGOs have been coming and going for over a decade, humanitarian aid, NGOs, and expatriates just become part of how society functions, because we’re providing substitutes for a lot of services that don’t exist. They become part of how people survive.
“I can totally understand why some people think it’s self-indulgent to talk about solidarity. It is self-indulgent. MSF was founded very much to give white doctors from Europe an opportunity to experience a Third World country — very French. And that loosely translates into solidarity now.”
People in crisis, however, are often buoyed by knowing the world hasn’t forgotten about them. “I am absolutely convinced that it matters to people,” says Richard Bedell. “Sometimes they even realize that it matters more than the technical assistance.” He knows MSFers in Kosovo and Chechnya who were told as much by the population. “That sense that the world knows they’re there, and that they’re suffering, is tremendously important. We don’t want to just make symbolic acts, but we shouldn’t underestimate the importance of them either, in terms of motivating people to help themselves. We’re not giving assistance to a bunch of people sitting around passively with their hands open. It’s an interactive thing, and if we can give them some hope, they’re able to interact with us much more successfully. That’s part of what we’re giving.”
“I’m not trying to suggest that the solidarity that MSF shows is somehow better than what another organization would show,” says physician Michael Schull. “But it is true that some organizations don’t utilize expatriates as much. Refugees may be poor and powerless, but they’re rarely stupid. They recognize how the world works, and the fact that many of our expatriates come from countries that are relatively powerful politically.”
Schull saw this when he worked among Burmese refugees in Bangladesh. The Bangladeshi government was bent on sending the refugees back against their will, even though that violated international law. Many UNHCR officials in the camp were Bangladeshis who did not speak the refugees’ language, and people questioned the validity of their interviews. “There was concern that the translations were not being done accurately, that the refugees were being made to appear that they wanted to go home when they didn’t. And we used to get notes thrown to us by refugees as our cars were coming in or leaving the camp. They didn’t want to be seen passing us information, but they were saying, ‘We’re being sent home against our will; please get this message out to the world.’”
If humanitarian agencies ever felt that their presence among people in crisis was an uncomplicated act of goodness, that notion died in Rwanda.
On April 6, 1994, extremist Hutus, Rwanda’s ethnic majority, began their meticulous slaughter of some 800,000 Tutsis and moderate Hutus. Urged on by propaganda that spilled from radios, the killers began house-by-house searches for Tutsi “cockroaches” and systematically cut them down with machetes. That spring, the three largest MSF sections — France, Belgium and Holland — all had teams on the ground, mostly working with people displaced by the ongoing conflict in Rwanda and neighboring countries. But while some of these teams had been in the region for several years and had seen countless atrocities, nothing would prepare them for what they were about to witness.
Just two days after the massacres began, MSF-France decided to evacuate its team from a camp in southeastern Rwanda. Thirty expats and about fifty locals, mostly Tutsis, climbed into a dozen vehicles and headed for the Burundi border, where they had arranged to meet with MSFers based on the other side. When they arrived at customs, however, they were told the Rwandans would not be allowed to leave the country. After hours of negotiation, darkness began to fall and the officials announced that the border would close at 6 p.m. The expats were forced to make the decision to leave their staff behind as they crossed into Burundi. In his end-of-mission report, a French logistician described the chilling scene:
At 5:15 p.m., “A” [an MSF expat] was still negotiating, but only for four Tutsi women who were certain to be killed. The customs officers still refused point blank. “A” started to shout out loud, which created considerable tension and led to a temporary break in the negotiations. Then the coordinators of each camp made their decision … Emotional scenes followed. I said good-bye to my driver, who had been with me for several months, and to others who I liked a lot, but I felt I had done all I could to try and get them to come with us. Other expats burst into tears at the sight of them leaving. “A,” depressed by his failure, went to find the [expat] coordinators and informed them bluntly that they would have the death of thirty Rwandans on their conscience. He was still convinced we could have got them through, that nothing could happen to a group of thirty expats overnight at the border …
There was a rift in the group between the majority, who had wanted to go through without the staff, and the others who thought that we should have continued to negotiate, that we had let forty people go to their deaths. In Bujumbura, during sessions organised by two headquarters staff who had come to help us “air our dirty laundry,” all the animosity came out.
The coordinators’ difficult decision to go ahead without the Rwandan staff had been the right one. It was out of the question that we should spend the night with those soldiers who had no commanding officer and were drunk as well. Moreover, MSF cannot infringe the laws of the host country. The Rwandan staff continued to work in the camps, but we heard that seventeen of them were killed, and, no doubt, the rest met with the same fate.
Then on April 22 and 23, in the southern city of Butare, 150 Tutsi patients in the hospital were hacked to death in front of the MSF medical staff. When the Hutu soldiers grabbed a Rwandan nurse — seven months pregnant and a close friend of the expat team — one of the Belgian doctors stepped in: “They came to take Sabine and I intervened physically and said, ‘Leave Sabine alone. Sabine has nothing to do with this … and besides, she is a Hutu.’ The captain who was responsible for the different teams looked at me very carefully, and then he opened his pocket and took out a piece of paper, and on this piece of paper there was a list of names, typed. And Sabine’s name was on it. He looked at the paper and he looked at me and said, ‘Yes, you are right. Sabine is a Hutu. But her husband is a Tutsi. And his baby is going to be a Tutsi.’ I suddenly realized the cruel reality that in Rwanda the baby follows the paternal line. So Sabine was killed and so was the baby.”
By the middle of April, MSF began to discuss whether it should make an official public declaration about what was happening in Rwanda, despite the attendant problems of singling out the Hutus. For aid workers on the ground, being perceived as anything other than neutral could be a death sentence. As it was, some MSF doctors in Rwanda defected to the International Committee of the Red Cross, feeling that the Red Cross’s discretion would offer them more safety. MSF, for its part, decided that discretion was no longer an option and, on May 13, the Paris office went public with the news that almost a hundred of their Rwandan staff had been murdered. The desire to speak out, while not unanimous, was particularly fervent in France, because the government of François Mitterrand was an ally of the Hutu regime. On May 18, MSF-France spent 70,000 francs to publish an open letter to Mitterrand in Le Monde: “Mr. President, the international community, and France in particular, must accept its political responsibilities and put a stop to the massacres.” After the letter appeared, Jean-Hervé Bradol said in a television interview that “the French state knows these people [the Hutu regime] only too well, since it has provided them with equipment.” Mitterrand’s advisers later requested a meeting with MSF, where Bradol was told, “You must know that the president took your TV interview rather badly. That wasn’t very bright of you.”
As the weeks progressed and the UN continued to dither, MSF-France made an unprecedented decision. On June 7, the board agreed to call for an armed intervention to stop the genocide. In its 23-year history of working in the most brutal wars, MSF had never before taken this step, nor has it done so since. Some argued that it was inappropriate for a humanitarian organization to call for a military offensive under any circumstances. They wondered, too, whether the French government, already considering an intervention, would exploit MSF’s position for its own political gain. The majority, however, believed that using force to stop the killings was the only ethical response, and one entirely sanctioned by international law. (The 1948 Convention on the Prevention and Punishment of the Crime of Genocide, to which Rwanda is a signatory, not only permits but requires other states to intervene to halt a genocide.) On June 17, when MSF-France held a press conference to present its case, it used the unforgettable slogan On n’arrete pas un génocide avec des médecins: “You can’t stop a genocide with doctors.”
Between July and September, the French army carried out Operation Turquoise to establish safe havens in Rwanda. Although the intervention and its motives were highly controversial, it slowed the exodus of refugees and probably saved thousands of Tutsi lives. But the problems were far from over for Rwanda and for MSF. In Tanzania, Zaire (as the Democratic Republic of the Congo was then called) and Burundi,
huge numbers of Rwandan refugees had already gathered. Immediately after the killing began in April, the Tutsi-dominated Rwandan Patriotic Front (RPF) launched a counterattack, and by the end of the month a quarter of a million Hutus had fled across the Tanzanian border. In those early days of the refugee crisis, aid workers could honestly claim they believed that the Hutus were simply fleeing the advance of the RPF. By early June, though, they could see that Hutu military leaders were orchestrating the exodus from Rwanda, dragging civilians along with them. Their plan was carefully laid out in documents later uncovered in the camps: once they crossed the borders into the waiting arms of aid agencies, these mass murderers would extort international relief and use it to finance their regime. They would use the protection of the camps to rest, regroup and plot their return to Rwanda to finish the genocide they had started. The aid groups, unwittingly, played right into their hands.
In July, as many as 800,000 more Rwandan refugees — again, mostly Hutus coerced by their leaders — crossed into Goma, Zaire, in just four days. Almost immediately, there were massive cholera and dysentery outbreaks. By July 28, MSF reported 14,000 deaths in Goma, and the ultimate toll may have been 50,000. The Belgian and Dutch sections moved to intervene, and Leslie Shanks was among the doctors who flew to Zaire that summer with MSF-Holland. “I remember very clearly thinking on the plane that this would really be a test of my humanitarian principles. In June and July we still didn’t have a very good picture of what had happened during the genocide, but I knew that génocidaires were in the camp where I was going — people who had perpetrated an incredible massacre — and I was going to save them. But when it comes right down to it, I’m a medical person, and if someone’s sick it doesn’t matter what they’ve done before or what they’re going to do. If they’re sick, my job is to treat them, not to make judgments about them. Nobody deserves to die from a simple thing like cholera, which is so easy to treat.”
Once the cholera was under control, however, some people in MSF began to question whether they could still justify that logic. In late August, a third wave of refugees — up to 400,000 — settled in Bukavu, Zaire. Now some two million Hutus were stationed just outside their home country. “As for us,” said a senior MSFer, “we’re just running along behind.” Fiona Terry, then MSF-France’s head of mission in Tanzania, would later write: “It is not unusual for aid to have unavoidable side effects. But in the case of the Rwandan camps, it was nothing but the aid which was sustaining the viability of the old regime.” On top of all this, aid workers were receiving death threats if they acted against the wishes of the Hutu leaders. MSF began to mutter about pulling out and publicly denouncing the situation. An agency with limited funds can’t help every suffering population, but can it refuse to give aid on moral grounds? What about the Hutu civilians in the camp who were not killers? Would MSF abandon the women and children in its programs to die while it took a principled stand? If MSF was aware that its aid was being manipulated, did that make it an accomplice? These were just a few of the questions the teams hotly debated on October 14, when they met in the Rwandan capital of Kigali to discuss what to do next.
During the Kigali meeting, representatives from France, Holland and Belgium tried to arrive at a consensus, but it proved impossible. To varying degrees, the Dutch and the Belgians argued that it would be better to stay in the camps in the short term and deliver health care, while at the same time documenting the abuse and lobbying governments for improvements. (When these improvements never happened, the Belgian and Dutch sections decided in 1995 to withdraw as well.) MSF-France, in contrast, unilaterally announced on October 28 that it was withdrawing from Tanzania and Zaire within a month. This decision upset many people in the other sections and even some within MSF-France, as they felt the office had ignored the teams in the field. Any time headquarters proposes evacuating a team, emotions run high in the field, where expats have developed a bond with their local staff and their patients. In Rwanda, these emotions had been magnified tenfold. “I remember being proudly told in my initial briefings that MSF is an association where everyone has an equal voice,” an angry Fiona Terry wrote in a fax to Paris after learning that her team would have to leave Tanzania. “At the time I realized that was an exaggeration but I never realized the extent of this farce until today.”
Many other relief organizations debated the situation in the Rwandan refugee camps, but in the end the US-based International Rescue Committee was the only other major group to pull out, citing reasons similar to those of MSF-France. As David Rieff points out, their position was like that of a conscientious objector:
It was a complicated gesture, at once principled and hollow. For while it was important that NGOs take such a stand … there were other relief groups already poised to take the place of those who withdrew … The real question, and it was one that, fortunately for them, neither IRC nor MSF had to face, was whether they would have withdrawn in a situation that was analogous politically, but in which they were the only aid groups on the scene.
Rwanda was a watershed for Médecins Sans Frontières and the entire humanitarian community. Aid had been abused before, agencies manipulated and refugee camps used as sanctuaries by exiled military regimes. But never before had the stakes been so high and the role of aid agencies so integral to the strategy of the perpetrators. “It pushed all of us in MSF to reflect deeply on what humanitarian action represents,” Fiona Terry writes, “and at what point it loses its sense and becomes a technical function in the service of evil.”
More than a decade later, that reflection continued. As the 10th anniversary of the genocide approached in the spring of 2004, MSF’s international office decided there would be no témoignage campaign to commemorate the event. For the doctors who could not stop a genocide, the wounds opened in Rwanda still have not healed.
The horror of Rwanda, and the impossible situation it created for Médecins Sans Frontières and other agencies, was the most dramatic example of the limits of humanitarian action. But it was not the first one, nor the last. From Biafra to the ongoing conflicts in Sudan, four decades of intervention have muddied whatever moral clarity may have once existed in MSF and the aid community. Only the hopelessly naive are blind to the dilemmas of providing assistance — and yet, at the same time, only the hopelessly cynical have given up on the idea. As James Orbinski explained in his Nobel lecture, “Today we struggle as an imperfect movement, but strong in thousands of volunteers and national staff, and with millions of donors who support, both financially and morally, the project that is MSF.”
Indeed, even as so much has been called into question, MSF not only survives but has arguably become the most respected aid agency in the world. Its leaders have shown a remarkable ability to adapt, to stay relevant and to lead by example, and the organization’s influence goes well beyond its own health clinics and feeding centers. “While it is impossible to overstate the value of what MSF has achieved in the past,” David Rieff wrote after the Nobel Prize, “the group’s next great accomplishment may be to rescue and redefine the ideal of humanitarianism itself.”
The attacks of September 11, 2001, and the subsequent wars in Afghanistan and Iraq were opportunities to do just that, and MSF quickly learned that the task wouldn’t be easy. That October, many longtime donors in North America were outraged when MSF argued that the US military’s food drops for Afghan civilians were both cynical and dangerous. The organization knew about the risk from experience: its doctors have treated patients who were injured after mistaking cluster bombs for relief packages, or who entered mined areas to collect food. Some of the provisions may also have ended up in the hands of combatants, and in any case they were hopelessly inadequate to address the hunger. Above all, however, the military was, as an MSF press release declared, “shooting with one hand and delivering medicines with the other.”
Since that time, the co-optation of humanitarian action has become the single greatest threat to groups like MSF. Humanitarian NGOs must remain third parties in a conflict, not allies of one side or the other, and they must be perceived as neutral. But by dropping aid packages as well as bombs, the US-led coalition firmly positioned itself as part of a team that included humanitarians. “More than ever, governments and intergovernmental organizations must work in partnership with NGOs if compelling problems are to be effectively addressed,” Secretary of State Colin Powell said on October 26, 2001. “As I speak, just as surely as our diplomats and military, American NGOs are out there serving and sacrificing on the front lines of freedom.” Even the NGOs themselves, many of which are funded by the United States and other Western governments, allowed the line to be blurred.
In the circumstances, it wasn’t surprising. During those emotional weeks after September 11, when North Americans felt the world had changed overnight, people wanted something they could be sure of. They wanted to believe that humanitarian groups were the good guys, our partners in the fight against the terrorists. “The first media call I had to deal with showed how successful the propaganda of the food drops was,” says David Morley, executive director of MSF-Canada at the time. “The reporter said to me, ‘When I was having my Thanksgiving dinner, I felt so thankful that we were dropping food as well as bombs. Now, are you telling me I was wrong to feel like that?’” That’s exactly what Morley was saying: MSF had to remind the public that just because the military was delivering food, that didn’t make them humanitarians.
“We need to maintain a real distance from political and military actors, even though they may be from our society,” says Nicolas de Torrente, former executive director of MSF-USA. “Culturally, historically, politically, of course, we are closer to the US government than to the most radical Islamic groups. But we need to really believe in our principles rather than just pay lip service to them.” Impartiality during war is a fundamental tenet of humanitarianism, but it’s tough to sell that amid the rhetoric of “if you’re not with us, you’re against us.” MSF knew it was correct, however, and by the time American and British forces invaded Iraq in March 2003, even its harshest critics admitted as much. “Now, if you talk about the US using humanitarian aid to try to win over hearts and minds in a propaganda effort in Iraq, everyone says, ‘Of course,’” de Torrente said later that year. “It’s everywhere, it’s in the newspapers, it’s not a problem. But right after September 11 it was just about impossible to make that point.”
In the weeks leading up to Operation Shock and Awe in Iraq, MSF again showed its leadership. While some American NGOs refused to take funding from the US Agency for International Development because they recognized the conflict of interest, others made no such choice and became, in Rony Brauman’s words, “subcontractors to a belligerent party.” At the opposite end of the spectrum, some European aid organizations, under pressure from the general public to speak out against the impending war, actively opposed a military strike on Iraq because of the human suffering it would cause. MSF responded by asking how these NGOs knew that a US invasion would be worse than Saddam Hussein’s dictatorship. They argued — if not uniquely in the aid community, at least more forcefully than anyone else — that it is not for humanitarians to ask who is right in a war, but only who needs help. Peace is not their business, even if it is their desire. Individuals within MSF admit they sometimes find this frustrating, but they recognize it can be no other way. In the end, that is perhaps MSF’s greatest strength.
With equal parts brains, balls and heart, MSF has managed to avoid the pitfalls of humanitarian aid. Its doctors and nurses accept the limits of the aid they deliver, and they constantly question their own work. Yet they do not dither in a crisis — on the contrary, the group gets its people on the ground, delivering medical aid as quickly as any other NGO. MSF may wring its hands, but it does not bind them.
Médecins Sans Frontières cannot save the world, and it long ago stopped pretending it could. “Many of us would like to do more,” says David Morley. “We would like to see a more just world, but we have to focus on what we can do. And what we can do is something simple, small and profound.”
That’s more than a drop in the ocean; it’s a lifeboat. It may not stop the ship from going down, but it saves lives and, more important, it promises hope.