Abstract
For over 150 years since the founding of the Red Cross, international humanitarian organizations have provided medical and material relief to citizens affected by war, famine, natural disasters, and extreme poverty. Since 1971, Médicins Sans Frontières/Doctors Without Borders (MSF) has engaged in medical humanitarian action. Beginning as a small charismatic social movement organization founded by idealistic young physicians in France, MSF received the 1999 Nobel Peace Prize and now circles the globe. In 2011, it had 27,000 staff members in more than 60 countries. Most of the field staff are natives of the countries they serve. As of June 2014, they carry out 8.4 million medical consultations each year, perform 78,000 surgical procedures, assist in 185,000 births, treat 1.6 million patients for malaria, and 284,000 HIV patients with anti-retroviral (ARV) treatment.
Sociologist Renée C. Fox has written an eloquent, sensitive, and complex ethnographic profile based on extensive fieldwork. Fox conducted numerous interviews and site visits, and attended a number of major meetings and conferences; she ended her fieldwork at a landmark event, the first meeting of a newly created International General Assembly which also marked MSF’s 40th anniversary. She describes her role as an “insider-outsider” combining access to internal information, public documents, and a staff blog. These multiple methods allowed her to become a sensitive yet detached and objective observer of the social relationships and culture of MSF. She traveled widely and her detailed discussions of challenges and controversies in a select number of sites—Greece, Moscow, Siberia, and South Africa—suggest to this reader that the book only reports a portion of the rich data she collected.
Fox has spent six decades of her professional career studying the culture and structure of medicine in the United States and in other societies. Her publications describe the experiences of patients whose illnesses and conditions are at the boundaries of mainstream medicine and the challenges of health care delivery in post-Colonial societies. Her work on MSF draws on her earlier ethnographic research in Belgium and in the Republic of the Congo. But the issues raised in this book depart significantly from her previous work. The size and complexity of the overall enterprise of MSF defies detailed description by one researcher. Fox selected a series of meaningful and instructive case studies to illuminate broader issues: the temporary expulsion of MSF Greece for its unapproved project in neighboring Bosnia; the work of MSF Belgium in South Africa providing ARVs at a time when the country’s President did not believe that HIV was the cause of AIDS; and projects dealing with TB and other health conditions among the homeless in Moscow—where homelessness does not “officially exist”—and in Siberian prison camps.
MSF faces a number of challenges that are common to local, national, and transnational non-profit organizations. MSF refers to itself as a “movement,” not an organization. This is intentional as it strives to maintain its vitality, passion, and values while responding to significant internal and external challenges. MSF has grown rapidly from one section in 1971 to 23 “associations” at the present time. This growth has meant modifications in its structure and governance procedures. Most of the new MSF sections are based in first-world countries. The scope and the responsibility for MSF’s humanitarian actions are becoming more global since new MSF units have been established in developing nations, including Brazil and South Africa. Most of the recently formed MSF groups, which operate as affiliates of existing sections, are located in the global south. Governing this complex network of organizations poses important challenges given the organization’s commitment to a contradictory set of values: creating a cohesive and unified organization while stressing the importance of self-reflection, a “culture of debate,” and a commitment to being non-hierarchical, egalitarian, and highly participatory.
Three central ideas serve as important unifying principles: accountability, transparency, and witnessing (temoignage in French). The commitment to bear witness led former French and International Red Cross (IRC) volunteers to form MSF because they objected to the IRC’s total impartiality. Two other important values, independence and neutrality, are in many ways very difficult to achieve given the willingness to bear witness when members observe violations of humanitarian principles. MSF views itself as non-political yet it was willing to spearhead access to ARVs in South Africa—challenging the South African government, international patent regulations, and drug companies. It also serves Palestinians, but not Israeli terror victims, in the Middle East (an issue that is not covered in this book), a commitment that has placed the organization in a position of taking sides in a protracted conflict.
The commitment to operate “without borders” creates another important set of challenges. Global inequality is especially apparent in health disparities and despite its huge scale, MSF cannot respond to all crises or to the fact that many of the societies where they operate lack the resources to sustain its work because MSF’s engagement is intended to be short term. Thus, MSF continually falls short of its potential mission, and its members recognize the impossibility of ever achieving its “without borders” quality, often wondering if their work can ever truly solve the social issues they confront. MSF’s members identify with Don Quixote who shares a commitment to a “glorious quest“ and an “impossible dream,” in the words of a song in the musical, Man of La Mancha (Wasserman, Darion, & Leigh, 1965). This imagery and the lyrics to the song appeared on t-shirts distributed at an International Council meeting in 2004, an important milestone in a multi-year process of self-reflection which was in fact called “La Mancha,” another reference to Don Quixote.
But the contradictory nature of its commitment to impartial humanitarian action, to neutrality and to bearing witness, the obligation to call attention to injustices when they are encountered, are, as Fox describes them, an impossible dream. The book’s subtitle captures an important conundrum and a critical moral issue: MSF may try to be neutral but, by its very commitment to serving some citizens and not others, inevitably takes sides in global conflicts. Unlike the Red Cross, whose lack of temoignage motivated the desire to create MSF, its workers are either not seen as neutral parties or are caught in the cross fire in the conflict areas where they operate. This has led to a sobering reality: the kidnapping and deaths of MSF workers whose motives may be purely humanitarian but for whom neutrality in conflict areas is, as Fox points out in her subtitle, both a “humanitarian quest” and an “impossible dream.” With the recent ascendance of the Islamic State in Iraq and Syria (ISIS), the dangers of humanitarian work have become even more palpable.