Sans Frontieres

[Gauthier Zitnik]

Feworganizations in the humanitarian field elicit such strong reactions as Mdecins Sans Frontires (MSF), also known as Doctors without Borders. MSF was started by a handful of doctors and journalists in the early 1970s. Almost 50 years later, it has become the second biggest non-governmental organization in the world with 21 national and 17 branch offices, an annual budget of 1536 million euros, and 47,318 staff (MSF 2019b).1

The organization consists of 21 sections plus 17 so-called branch offices (MSF 2019a, see also Table 9).2 Five operational centres manage operations and have decision-making authority over which projects to initiate. Sixteen partner sections contribute to operations via arranging staff and funds, and raising awareness. Some sections have opened branch offices to facilitate their work more regionally.

The fundamental purpose of all humanitarian activity is the global prevention and alleviation of human suffering (Calhoun 2008; Barnett 2011). This duty is referred to as the humanitarian imperative. Whereas such purpose suggests that humanitarian aid is void of power or politics, historical accounts of the sector show that the various interpretations of humanitarianism are closely related to historical, economic and political developments (Barnett 2011).

All humanitarian organizations claim to adhere to a set of humanitarian principles that guide their actions. The most basic ones are outlined in the International Committee of the Red Cross Code of Conduct and thus originate from the era of imperial humanitarianism (ICRC 1994):

How impartiality, neutrality and independence relate to one another and how these principles are best achieved in operational practice has been a recurring topic of debate (Kanter and Summers 1987; Slim 1997). While providing a common frame of reference for legitimation, the principles leave room for re-interpretation and experimentation (Schneiberg and Lounsbury 2008; Zietsma and McBright 2009).

Neutrality is not synonymous with silence. Our proximity to people in distress implies a duty to raise awareness on their plight to ultimately help improve their situation. We may seek to bring attention to extreme need and suffering, when access to lifesaving medical care is hindered, when our teams witness extreme acts of violence, when crises are neglected, or when the provision of aid is abused. (MSF, n.d.c)

Mdecins Sans Frontires provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions.

Mdecins Sans Frontires observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.

As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.

We began formally in 1971 as a group of French doctors and journalists who decided to make themselves available to assist. This meant sometimes a rejection of the practices of states that directly assault the dignity of people. Silence has long been confused with neutrality, and has been presented as a necessary condition for humanitarian action. From its beginning, MSF was created in opposition to this assumption. We are not sure that words can always save lives, but we know that silence can certainly kill. (MSF 1999)

Since its foundation MSF presents an alternative means to achieve the humanitarian imperative that they argue to be more effective. Although not widely shared among humanitarian organizations, it has come to be accepted as one interpretation of humanitarianism, and as a prominent and distinguishing feature of MSF (Hilhorst and Schmiemann 2002).

The witnessing principle was an important topic of debate when the two groups merged. Kouchner and his colleagues argued that this principle had to be upheld under all circumstances, whereas the Tontus colleagues pleaded for a more controlled use of the principle. In the end, it was agreed that the witnessing principle could only be exercised if explicitly approved by higher management (Barnett 2011: 144).

In 1974, Kouchner challenged this agreement and sent out a team to help Kurdish fighters in Iraq, against the wish of the Tontus colleagues (Barnett 2011: 146). In 1975, during the Cambodia and Vietnam conflicts, internal tensions further increased, especially about the question whether MSF should also provide longer term aid and whether the organization should professionalize. Kouchner argued for a continued focus on short-term medical relief, whereas others argued that the work in the refugee camps in the region required a longer term approach. Kouchner won this battle.

As the Nobel Prize illustrated, MSF had become an established actor in the humanitarian sector. In the 30 years of its existence it had expanded from one French section to 19 sections spread all over the world. It was developing into a full-fledged multi-national professional organization, meeting the objectives expressed by the MSF Assembly by the end of the 1970s.

However, from 2001 on, the production of HRM documents steeply increased: whereas in 1992 only a few HRM formal documents could be counted, in 2008 there were about 425 (see Fig. 11.2), focusing predominantly on outlining rules and procedures regarding rewards for services, but also on topics such as employee well-being, and leave and absence (Korff 2012: 53). In addition, the organization developed a full-fledged training program for its staff, ranging from an introduction and socialization training for new staff (Korff 2012) to management trainings, and specialist trainings in medicine and logistics (Visser 2015).

Not long after the start of the La Mancha process, a tsunami hit South-East Asia, after which MSF exhibited a particularly fierce interpretation of the independence principle. Within days, millions of Euros in funds were raised to support the emergency response in the affected areas. Numerous humanitarian organizations encouraged and accepted the contributions (Telford and Cosgrave 2007). MSF, in contrast, took a perplexing step: after receiving sufficient funds for the foreseen emergency response within days, a statement was issued on the international MSF homepage discouraging further donations earmarked for the tsunami affected regions. The humanitarian community and the media accused MSF of undercutting the flow of donations by giving the impression that further funds were superfluous (Bennhold 2005). Instead of conceding to such criticism, MSF contacted private donors to request their approval for making the allocated funds available for less prominent and underfunded crises, such as Darfur.

In March 2006, the anticipated General Assembly started in which more than 200 MSF representatives participated to decide on the outcomes of the La Mancha process. One important realization was how much MSF had changed from a predominantly Western expatriate organization to being dependent on national staff who had unequal employment and salary conditions compared to expats. All sections vowed to work towards a more associative international form of governance, acknowledging the need for decentralization, increased quality of interventions, equal employment conditions for all staff, and being transparent and accountable (Fox 2014).

Mdecins sans Frontires (MSF) created some welcome upheaval in the international humanitarian discourse recently, with their compelling Where is Everyone? report, lamenting the scarcity of humanitarian agencies operating in difficult environments. As an organization forged from righteous anger, MSF has never reserved criticism for governments and warring parties alone. Often its barbs are directed horizontally at humanitarian counterparts, and this one clearly stung. (Stoddard 2014)

Meanwhile, Europe was confronted with an increased refugee influx. Especially Syrians were finding their way to EU countries, via Turkey and the Greek isles, but also the number of migrants who crossed the Mediterranean Sea from North Africa increased. MSF was already providing aid to the latter group on the island of Lampedusa since 2002. In 2015, MSF decided to launch a search and rescue operation in the Mediterranean Sea, after the Italian government decided to terminate Operation Mare Nostrum, which aimed at rescuing boat refugees from Northern Africa. Although MSF had never engaged in such activities before, they chose to do so on the basis of the humanitarian imperative and the witnessing principle:

As a humanitarian organization, we believe our presence is needed to save lives, as well as to witness and speak out about the human costs of the policies and politics at play in the Mediterranean Sea. (MSF, n.d.g)

In this decade, MSF seems to add a dimension to its role as critic of the humanitarian sector. In the report for the Humanitarian Summit, MSF did not spare itself and also discussed its own actions critically (MSF 2014: 20). Later, in 2015, MSF admitted to having made mistakes in the Ebola response, which was painful since it had first criticized other international agencies for their failed response (Hussain 2015).

This chapter has tried to answer the question how MSF could evolve into a public guardian of humanitarian values and thrive as an organization, while at the same time acting as a provocateur. We explored how the organization was successful in maintaining its reputation, capitalizing on a nonconformist attitude, while internally navigating through growing pains and conflicts.

Our roots are in radicalism. Our founders were activists who wanted to shake up the humanitarian aid system. They wanted a form of action that was more challenging to governments. It is still very much part of our ethos.

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