Life in crisis: The ethical journey of doctors without borders
University of California Press, 2013. 338 pages.
“Should we only get involved in beautiful, sexy emergencies or also in hopeless places? Our work is to keep trying amid pessimism” (p. 241). These are the words of a Médecins Sans Frontières (MSF) doctor alluding to what Peter Redfield terms “residual hope” that drives and prevails among MSF workers providing aid in settings of crisis. Redfield’s ethnography about “the ethical journey of doctors without borders” is a rare opportunity to gain in-depth insight into the evolving history and current practices, beliefs and values of the humanitarian organization MSF. His work is based on many years of multi-sited ethnographic fieldwork on three continents and the “floating space of electronic exchange” (p. 3). Engaging in different versions of the expat life, he conducted participant observation and interviews with over a hundred individuals in MSF field offices in New York, Paris, Amsterdam, Brussels, and Geneva and immersed himself in field projects in different parts of Uganda. He further enriched his empirical data through the collection of material culture that is MSF’s self-representation in form of brochures, electronic postings, studies, essays, conferences, and other exchanges. Bringing this rich material together, Redfield has created a remarkable and very accessible ethnography in three parts in which he presents MSF’s (non-linear) evolution and the emergence of new practices and tools, the interplay of human and financial resources across borders, and the limits and uncertainties of the organization’s actions.
Part One: Terms of Engagement. MSF is one of the best-known medical humanitarian non-governmental organizations (NGOs) worldwide. Since its foundation in 1971 in Paris, it has provided medical aid in contexts of armed conflict, epidemics, famines, and natural disasters; runs longer-term initiatives to combat HIV/AIDS, sleeping sickness, and neglected diseases; and campaigns for greater access to essential medicines. Simply put, MSF’s main mission is to help “people in situations of crisis” (p. 13) that is, in critical conditions that require professional response. To determine who is in crisis seems, at first, straightforward, especially if suffering is obvious and basic needs are clearly unmet. Treatments also appear to be fairly simple in such contexts, including the provision of basic needs like shelter, food, or water, and, most importantly, medical interventions such as nutrition, basic treatment, and life-saving health advice. Such “moral clarity” and “pure medicine” appeals to doctors trained in contexts of excess.
But, of course, nothing is as simple as it first seems. Redfield conceives of “crisis” as an elastic concept and argues that as crises protract, as they so often do, lives continue and needs become more complex. An ethnographic account of the many activities involved in the provision of medical aid in a camp in northern Uganda provides a glimpse into the practical quandaries involved in proving aid on a daily basis. It becomes apparent that people in need, health problems, diagnostic tools, aid supplies, and infrastructure cannot be easily separated from conflicts between different aid organizations, vested interests of camp leaders, entrepreneurs and traders, and distrust directed against aid workers and dispensed products. The concepts of crisis and humanitarian aid become even more intricate when they move farther away from “emergency” and become attached to “chronic” or even “structural” issues. For instance, the provision of life-prolonging treatments for AIDS or the advocacy for greater access to medicine does not respond to emergencies in the classical sense. Unlike emergency aid, such interventions are longer-term missions, which are carried out despite the knowledge and worry that sustainability cannot be guaranteed. The provision of humanitarian aid is, thus, not at all a straightforward or morally clear process.
What then are the moral values and intellectual traditions that undergird MSF’s approach to humanitarianism? While the organization helps people first and foremost in their struggle for survival through the management of birth and death rates, infant mortality, life expectancy, and health expenditure, it is also concerned with creating safe spaces in which people can regain their rights and dignity as human beings. Redfield abstains from glossing these complex undertakings over with overstressed concepts like ‘biopolitics’ or ‘bare life’. He toys briefly with the idea of “minimal biopolitics”, but admits on the same page that the label doesn’t actually capture the ethical vision of MSF. Instead, he turns to the past to excavate and reassemble the building blocks that attach MSF to life itself.
MSF, so the (hi)story goes, is firmly rooted in the Enlightenment tradition and the intellectual debates triggered by the 1755 earthquake that destroyed the city of Lisbon. A paradigmatic event, the disaster shifted intellectual discourses from fatalism and theological justifications to a secular perspective appealing to public action to relieve suffering. The realization that people did not bring such disaster upon themselves, made it possible to think of them as ‘victims’ who deserved others’ empathy and aid. This change in thinking, in turn, gave birth to the first “humanitarians” who paved the way for the establishment of a “humanitarian arena”. Prominent among them were Henry Dunant, the founder of the International Committee of the Red Cross (ICRC), who was shocked into action after seeing the many wounded soldiers on the battlefield of Solverino in 1859 or missionaries like David Livingstone who set out to “alleviate the pain of others” in African colonies through medical care. Following in their footsteps, Albert Schweizer built for instance the famous hospital “Lambarene” in French West Africa and received the Nobel Peace Prize for his dedication and, what he himself called, “reverence for life”. Reverence for life, although conceived in the religious sense, was a moral sentiment about humanity that was positioned beyond religion or politics and thus one with which faith-based as well as secular organizations could identify. Caring for “all members of the human family” and conceptions of the “universal human” were now upheld and demanded by the 1948 Universal Declaration of Human Rights, international aid organizations like the World Health Organization, as well as powerful philanthropies.
Another watershed moment in this rapid humanitarian development was “Biafra”, the brutal conflict in Nigeria that attracted, for the first time, a great number of aid organizations trying to provide relief against all odds. According to Redfield, the Biafra conflict was a decisive moment, particularly for the Red Cross. The Red Cross physician and later co-founder of MSF, Bernard Kouchner along with his followers openly condemned the silence of the Red Cross in the face of the atrocities and formed an expeditionary brigade for the organization. After several missions and increasing alienation from the main body of the Red Cross, the activists founded a volunteer group called Secours Medical Francais (French Medical Aid) that was later to be renamed Médecins Sans Frontières. While following the Red Cross principle of “neutrality” and “medical confidentiality”, the new organization included a journalistic element allowing its members to speak out against human rights abuses. Speaking out was driven by the “secular faith of medical care” and not so much by political advocacy and, thus, allowed leading figures to encourage their followers to be restless, mobile and combative in their approach to saving lives.
About ten years following the separation from the Red Cross, another turning point occurred when Kouchner lost power due to his tendency to turn interventions into media spectacles and his defamation of MSF staff as “bureaucrats of misery and (…) technocrats of charity” (p. 60). He left the organization and successfully founded the rival Médecins du Monde (MdM). Rony Brauman took over the presidency at MSF and, under his leadership, the budget, volunteers and missions increased exponentially. Through growing professionalization, the organization was able to found and manage new branches first in Switzerland and Belgium and then in Holland, Luxemburg, and Spain; develop an intricate logistic system; and establish the Epicentre, an epidemiological wing in Paris.
Despite these managerial successes, humanitarian aid remained an experimental field with setbacks, frustrations and horrors. Particularly the conflicts in the Balkans and Rwanda showed quite plainly the limits of humanitarianism in the face of excessive violence and lack of international political commitment to resolve a crisis.
Part Two: Global Ambitions. Urgency, speed, strategy, control, efficiency, and quality are keywords with which MSF characterizes its missions. While taking the humanitarian lingo seriously, it does not drive Redfield’s analysis of the organization’s ambitions. Instead, he provides a careful analysis of mobility beginning with the story of how a flat tire of a Land Cruiser carrying patients, staff, and equipment can stall a routine operation. “Where before the engine had roared and wind whipped through the open windows, now all was quiet” (p. 70), Redfield writes while contemplating how “punches and punctures” have the power to reveal, for a brief moment, MSF’s fabric of infrastructure.
Mobility, particularly visible when abruptly halted, is one of the underlying forces that links patients with experts and life saving treatment and, thereby, achieves what Redfield calls “globalization on the ground”. To move staff and tools across borders to respond to sometimes rapidly unfolding crises situations depends on a sophisticated infrastructure labeled as the “kit”. Kits, as Redfield shows, have a military as well as medical lineage beginning as wooden vessels and developing into soldiers’ bags, chests of ship surgeons and other mobile healers, and comprehensive assemblages of medications, supplies, checklists, and manuals that can be variously put together to fit the respective crisis. As a result of the kit-evolution into a flexible matrix, something like a materialized memory was created whereby “previous experience extended directly into every new setting without having to be actively recalled” and achieved that “essential materials no longer had to be hastily assembled anew in response to every crisis or uncertainly negotiated on the ground amid fluctuating availability, quality or price” (p. 78). The drive for innovation continues, although not necessarily always with the same speed and success. AIDS programs have particularly shown the limits of emergency kits, as people in need require therapies for a lifetime and cures remain, until now, out of reach.
Moving tools and personnel comes with a price tag and depends on funding, accounting, and business plans. MSF receives most of its funding through personal donations, trying to stay clear of government funding to remain “independent of powerful interests” (p. 91). Yet private donations also come with strings attached, as they call for “contractual returns” through transparency and accountability. Redfield writes pointedly: “MSF must guard its public profile, attending to the sensibilities and expectations of those who contribute to its cause. In this sense money constitutes an intensely moral matter, not simply a profane necessity” (p.91).
The moral maze that MSF navigates extends far beyond bureaucratic and financial management. In addition to money and medical expertise, human solidarity and passionate appeals for justice require the willingness to witness and re-testify. Temoignage, the duty to witness and to speak out, is connected to notions of decency and humility. However, witnessing, speaking out, decency, and humility are in no way straightforward concepts but rather issues open to debate and interpretation. Are they a matter of individual conscience or collective policy? Is their purpose to identify human rights abuses or to agitate for particular state action? Should they take the form of narrative testimony or medical data? Should medical neutrality be abandoned? Obviously, there is not one of way of being a witness or advocate for human rights and, consequently, plural practices emerged between and within MSF country teams. Redfield provides a detailed account of different forms of expressions of bearing witness including the Belgium reference tool handbook “MSF and Temoignage” that lists strategic options; the Dutch “Advocacy Information Kit” that trains volunteers in appropriate witnessing through “witness statement forms”; and the French series of case studies “MSF Speaking Out”, which contains primary documents and fragmentary oral histories related to the event in question.
In an attempt to distinguish itself from human rights organizations like Amnesty International or Human Rights Watch, MSF largely attempts to establish the reality of suffering through scientific “facts” ranging from accounts by victims and their family members, photography and statistical studies. The combination of words, images and numbers produce particular truth claims, or what Redfield calls “motivated facts”.
In such morally-laden contexts, what happens to neutrality? On its website, MSF states clearly: “Our actions are guided by medical ethics and the principles of neutrality and impartiality”. While neutrality and temoignage seem to be mutually exclusive at first sight, Redfield cautions his readers to view neutrality not simply as a abstract principle, but rather as “situated action” and “political strategy” that change depending on the respective historical context in which they are enacted.
Another issue in need of complication is the image of MSF’s mobility: the notion of “without borders”. To assume that mobility, whether material or ideological, is unrestricted would paint a wrong picture as organizations like MSF face, in fact, myriad borders and constraints. Heightened security controlling the import and export of people and goods, political authorities making demands, and access to jobs, transportation, and visas all relativize what it means to be mobile. Mobility is experienced differently depending on who or what is on the move. At the inception of the organization, the stereotypical MSF worker was a cowboy-like figure tirelessly on the go. These white men of action often portrayed themselves as independent, living lightly, and bound to the organization rather than to social obligations at home. This prototype does not hold anymore as MSF hires local staff for whom working with the organization is a career option rather than a lifestyle, retired doctors wanting to contribute to humanitarian missions, and women and men with caring responsibilities. Unequal power dynamics become especially visible between “nationals” and “expats”. Local staffs predominantly work in support roles and are considered employees rather than volunteers. Also, they might not have crossed a border to get to their job, rendering them bounded and rooted rather than jetsetters without borders. The latter status is reserved for the “expat” who navigates local contexts lightly by shielding herself from the historical, political and cultural knowledge that is not absolutely essential to provide medical aid.
Part Three: Testing Limits. How far do local and international aid providers dare to venture out to aid those in need? In contexts of crisis, death is not simply a passage putting someone out of her misery. It often signifies failure resulting in self-doubt, especially when a curable disease or violence could not be stopped in its tracks. In other situations, however, death seems unpreventable as science has no solution to offer and infection rates are high. Redfield refers to the 2001 outbreak of the Ebola virus in Uganda as a case in which MSF workers appeared relatively helpless. A health worker reflected, “The public health response was probably being dealt with in the traditional (local) way by shutting people away in the barn and not feeding them or looking after them. Such a response traditionally would probably have broken the epidemic as quickly as anything we did, but the motivation for MSF was the alleviation of individual suffering. Alleviation of suffering and dying with dignity was enormously important” (p. 157). Thus, palliative care and relieving pain was all that could be offered, leaving some of the aid workers questioning what the purpose and mode of intervention of an organization like MSF should be in such a situation.
Death snatches not only the needy, it increasingly waylays aid workers who are engaged in high risk environments. Over the past years, aid workers were victims of targeted kidnapping and killings, which makes apparent that the “humanitarian space” is not a sanctuary providing immunity but rather a fragile space that needs to be reinforced and defended. The maintenance of such a space automatically creates boundaries and raises questions about access, salvation, and sacrifice. According to Redfield, “actual interventions undertaken in the name of humanitarianism face an inherent problem of selection” (p. 167). This leads him to ask uneasy questions about triage: “Amid a landscape of disaster, where should aid be provided, and to whom? Who stands first in line and who must wait?” In situations of severe lack, triage prioritizes those who can live over those whose lives are impossible to save. A color-coded system indicates the hierarchy of care, with black labels representing the status of imminent death.
Triage is not just related to the medical gaze and facts of suffering. It also occurs when MSF decides in which countries to work, which crises situations are prioritized over others, which diseases are foregrounded while others are deemed as marginal, or when a project has to come to an end. Such decisions are never easy and become particularly pronounced when crisis moves beyond emergency. While it might be appropriate to state “we don’t believe much in sustainability” (p. 177) when providing aid in exceptional emergency situations, this attitude requires rethinking when dealing with long-term crisis situations such as mental health prevention, sleeping-sickness projects, or HIV/AIDS.
Redfield highlights a noticeable paradigm shift when MSF moved from being a bystander to becoming actively engaged in HIV/AIDS work. Between 2002 and 2004, patient numbers increased drastically from only 1,500 in ten countries to 13,000 in 25 countries. By the end of the decade, over 160,000 HIV/AIDs patients were under MSF’s care worldwide. Providing long-term monitoring and care for such a large number of individuals while being dependent on monetary and in-kind donations poses a huge challenge and raises worries related to all kinds of ‘what ifs’: ‘What if… funding is cut… medications run out… access to countries is not granted…?’ At the same time, ethical questions emerge concerning ‘why HIV/AIDS and not TB, malaria or mental health?’ or ‘what about other neglected diseases? Does the focus on HIV/AIDS push them even further to the margins?’ Neither the ‘what ifs’ nor the ethical questions allow for easy answers, but both force humanitarian aid workers to keep on their toes and reflect on their involvement in the humanitarian field.
However, the question remains: how is it possible to work day in day out, as if caught in a treadmill, always intervening but never really solving any problem? How is it possible to remain optimistic and keep trying despite all odds? As Redfield points out, MSF can’t boast many stories with “happy endings” and yet, it clearly saves lives, or in the words of a coordinator, “we have to accept that we’re not fixing anything, just working on something and moving all the time”.
Redfield’s ethnography of MSF gripped me for several reasons. He compellingly discusses the grey areas and often incommensurable-seeming realities that shape the humanitarian space without dissolving them into a neatly-fitting overarching explanatory model. Instead, by treating the in-between domains of not-success/not-failure with great care and respect Redfield opens up a space for more than intellectual meanderings, but for actual learning. He offers an exciting and educational journey through the beliefs and practices of the humanitarian organization, the strategies and spontaneous gut reactions through which its members shape and reshape it at different times and places, and its situatedness in and influence on very particular locales as well as the more elusive global arena. The book is an immense achievement. I would recommend it to academics and students as well as those working in the humanitarian arena who grapple with the complex linkages between crises, human suffering, and medical aid and broader questions related to ethics, morality, and doubtful hope.
Hanna Kienzler is a Lecturer in the Department of Social Science, Health & Medicine (SSHM) at King’s College London and has a long-standing academic interest in the field of global health, in connection with organised violence, ethnic conflict, and complex emergencies, and their mental health outcomes. Within this broad field of inquiry, she is particularly interested in the social determinants of health and illness, gender based violence, trauma, PTSD, local idioms of distress, resilience, and local forms of healing as well as in the growing field of human rights and humanitarian and clinical interventions. She conducts research in Kosovo, Palestine, and Nepal.
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