MSF's principles and identity - The challenges ahead
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"Our isolation must not lead to confinement; on the contrary, it must push us to open up toward other actors in order to better understand them, so that we can cooperate more easily where possible or confront them when necessary."
MSF has another unique quality that separates it from many other "humanitarian" groups. It is best described by the French word témoignage, meaning to speak out and bear witness to the suffering one sees. MSF seeks to bear witness to the fate of populations as precisely as possible, not as defenders of human rights, but simply as direct witnesses to the suffering of the sick and injured and to the stolen dignity of so many men, women and children all over the world.
We bear witness because it is part of our understanding of humanitarian responsibility and our desire not to reduce our acts to the merely charitable or logistical. We bear witness because, for many victims, from Chechnya to Somalia to North Korea, there is nothing worse than neglect or indifference.
This interplay between medical ethics (beneficence, doing no harm, autonomy and justice) and humanitarian principles is the trademark of and the driving force behind MSF's dual identity. And today, both of these forces are being severely challenged because of changes in our environment and MSF's own development.
The ethical foundation on which MSF operates dates back more than a decade, to when the movement's leaders created a document to guide MSF's governance. Its key principles were and remain at the heart of a broad international and associative process of reflection and renewal within MSF. There is no doubt that this process will serve to reaffirm the ethical dimension of our work in this changing environment.
The corruption of humanitarian action
Faced with the almost complete failure of the development-aid system; the transformation of nation states; and the emergence of new international actors of all kinds (NGOs, multinational corporations and private security companies, etc.); and faced with the shocks brought about by globalization and the growing "marketization" of the world, "humanitarian" issues find themselves pushed more and more to the foreground.
A victim of its own success, humanitarian action has become a political, economic and social stake in countries in crisis as well as in our own "developed" societies. From its role as a smokescreen to hide political inaction (as in Bosnia-Herzegovina) to its role as a pseudo-catalyst for military intervention (as in Kosovo), the current thinking among many nations, the UN and many nongovernmental organizations is that humanitarian action should form an integral part of a "coherent system" - an integrated humanitarian system.
But integrated into what? Integrated into policy in the same way as are the use of force, economic development or even justice in a global quest for consistency and effectiveness?
"Impartiality is vital to continue providing medical assistance to vulnerable populations in need."
Although this vision has seduced more than one person in humanitarian circles, whether because of conviction, lack of financial or political independence or simple pragmatism, we should be clear that the integration of humanitarian action into a system is tantamount to the disintegration of its very humanitarian values.
The trap is set: By integrating humanitarian action, we transform it to the point of removing its substance, even to the point of destroying it. And that would not for one minute trouble those who want to make humanitarian action into a simple tool at the disposal of politics or of military objectives in the war against terrorism or those who see humanitarian action only through the prism of technical standards and cost-benefit ratios.
Isolation as the price of rejection
Faced with this dynamic, MSF's rejection of this type of cooperation has left it increasingly isolated, both in the plush meeting rooms of the humanitarian jet set - even to the extent that we have been called "humanitarian extremists" at some recent meetings.
More tragically, MSF has been isolated in the field, first in Angola, then in Darfur, Sudan, and now dramatically in Niger, where MSF teams have for far too long found themselves alone and largely powerless in the face of a population's suffering.
Somehow, unlike the International Committee of the Red Cross, whose isolation is largely accepted and recognized because of its mandate and its function in the international system, MSF is required to explain its position. To some extent, MSF has probably contributed to its own isolation through its own attitude, which has too often been inward-looking.
But let us make no mistake: the fundamental cause of this isolation can be found above all in the fact that the humanitarian values of independence and impartiality that we defend are themselves isolated or even undermined.
This is done not only by politics, but also by a section of the "humanitarian community."
It is part of everyone's responsibility to combat this erosion of respect for human dignity, starting at national level, where there is, at least, a legal commitment to respect and ensure respect for international humanitarian law.
On that count, the fact that the government of The Netherlands continues to sue MSF for the repayment of the ransom which the Dutch government negotiated and paid for the liberation of one of our volunteers who was detained for 20 months in the North Caucasus, is more evidence that states, including Western states, prefer to continue to deceive their constituents rather than shoulder their own responsibilities.
"The integration of humanitarian action into a system is tantamount to the disintegration of its very humanitarian values."
Nations' refusal to act can also be seen in the many months of effort and pressure it took to get the Afghan government to start taking action to find and prosecute the criminals who murdered five of our colleagues on a deserted road in Afghanistan in June 2004. In many countries, at many times, populations have been little more than consumables, to be disposed of at the whim of political and economic interests. Humanitarian action that tries to be close to such populations is not immune to this same risk.
The question of how to deal with such violent actors has become a matter of life or death. How can we talk to and convince people who take their own populations hostage that MSF is not just another puppet controlled by the military-humanitarian actions deployed by certain states? How can we be convincing enough to be accepted by all actors?
In any given situation, how far should we go in this approach, and up to what point should we take the risks inherent in working independently, in physical proximity to the victims of conflicts? Sometimes we cannot.
We responded to such a situation in Afghanistan by stopping our activities and withdrawing our teams in July 2004 and again by leaving Iraq in November 2004. Faced with this polarization of extremes, which leaves no room for humanity, we can only respond with increased engagement, tempered with caution, to reaffirm our principles of intervention.
Let us not deny this isolation. On the contrary, let us accept it as part of our right to be different, while providing further explanation to those who support us, including our private donors, or with whom we have contact in the field. With no concessions. Peace, democracy, economic development and justice are the underlying issues in, or the backdrop to, many dramas with humanitarian consequences. But they are not our fights. We must keep our action independent of these processes while still maintaining an awareness of the many interdependencies and frictions that stem from them.
This is why we refuse to be involved in the integrated system. We reject the reduction of humanitarian assistance to a role of army after-sales service, whether for the United States government in Iraq or the Russians in the North Caucasus. This is why we are against the UN's concept of integration, which may ultimately sacrifice part of the population, as happened in Sierra Leone when the choice was made not to intervene in rebel-held areas controlled by the RUF, and in Afghanistan under the Taliban's rule.
Sadly, even the UN's impartiality is of variable geometry depending on the political interests of the members of the Security Council and cannot be confused with the humanitarian impartiality demanded by MSF.
This impartiality is vital to continue providing medical assistance to vulnerable populations in need. So, if we are forced to choose between operating in an integrated system, choosing who shall be saved as a product of the political importance of the population and of working amid "organized chaos," our choice is clear.
And the choice is not made to dogmatically defend our independence, but because we are convinced that the co-existence of independent actors is the best option for populations in danger to have a chance to obtain needed care and assistance. Did this famous integrated system respond in Darfur? No. Did it work in a peaceful country like Niger that was edging toward high levels of starvation? Again, no.
By contrast, this famous system worked perfectly, even to the point of getting carried away, after the tsunami hit South Asia in December 2004, thanks to the complicity of the media, which converted the disaster into emotional entertainment.
If humanitarian action continues to be transformed into a system in which government and humanitarian action is intermingled, MSF will probably have no choice other than to accept even further isolation to maintain a certain tension, at the risk of becoming a kind of stowaway in a system going increasingly around and around in circles.
"The humanitarian values of independence and impartiality that we defend are themselves isolated or even undermined."
Using our isolation
In that light, the main issue to be examined by MSF is our capacity to emerge from our humanitarian microcosm in order for populations to better accept our actions. Indeed, above and beyond our certitude in our principles, we must make the effort to understand how we are perceived in the field on account of our attitudes, actions, views and effectiveness. We must make the effort to change the way we work and think, to adapt to that environment.
Our isolation must not lead to confinement; on the contrary, it must push us to open up toward other actors in order to better understand them, so that we can cooperate more easily where possible or confront them when necessary. Accepting this difference implies an ever-growing degree of transparency on the part of MSF and increasingly substantial accountability mechanisms.
This notion of accountability also includes transcending another paradox related to MSF's identity: the fact that, although we are perceived as a global actor, we, in fact, remain a movement comprised of national associations composed of members. It is essential that we succeed in preserving the associative aspect of the movement, which is a genuine anchor in our respective societies and which serves as a real safeguard against the technocratic and bureaucratic shifts facing so many organizations of MSF's size.
A catalyst for progress
Our identity is also linked to the way we seek creative solutions to the medical challenges facing us. I will finish with just one of these, the fight to ensure access to care for those living with HIV/AIDS, because it leads to another situation that is also about to confront MSF. In this area, MSF, in its role of pioneer and thorn-in-the-side of public institutions and private actors, cannot work alone to achieve its objectives.
Our role as a catalyst for change forces us to engage with others, whether in a cooperative way - through partnerships - or in a confrontational way that forces those in power to accept their responsibilities to help millions of people deprived of treatment.
To promote access, a few years ago, MSF created its international Campaign for Access to Essential Medicines, which has contributed to a drastic fall in the price of life-extending antiretroviral medicines. Drug prices have plummeted from about US$ 10,000 per patient per year in 2000 to less than US$ 300 per patient per year in 2003.
Faced with needs beyond its own scope of work and wanting to safeguard its foundation in the field, MSF later supported the creation of a separate organization, the Drugs for Neglected Diseases initiative (DNDi). DNDi is a logical next step that aims to stimulate the barren field of fundamental medical research for neglected diseases including sleeping sickness, kala azar and Chagas disease.
For every step forward, however, new dilemmas arise for us and for our teams in the field, such as financial constraints and the crisis in available human resources that represent the new barriers to access to care in many sub-Saharan countries.
These problems go far beyond the "traditional" responsibilities of MSF, and the situation creates another form of pressure on our identity and our principles of action. We continue to ask: How far should we go in our cooperation with others, or with confrontation? How can we set limits for ourselves as a catalyst when there is so much still to be done?
Between the temptation of the alter-globalist illusion and the trap of becoming nothing more than an aspirin to prevent headaches in our own societies, MSF must reaffirm its own medical and humanitarian identity. The current debates within MSF are signs of these tensions and of our will to take on these situations as a movement, in order to preserve the real meaning of our name.