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H&HN Daily, April 1, 2014
Doctors Without Borders calls the world's attention to human calamity, both natural and man-made. Forty-two years after its founding, this group, once described as "medical commandos," has matured and changed — and has much to teach anyone seeking to heal others.
In 1968, Biafra, a southern province of Nigeria, tried to secede from that nation. The Nigerian government reacted with force, launching attacks and pursuing a strangling siege that soon led to massive suffering among Biafrans. The International Committee of the Red Cross issued a call for volunteers, and several young French physicians — some of them veterans of other humanitarian crises, and many of them activist children of the 1960s — heeded the call. They witnessed what they perceived as intentional starvation, attacks on hospitals, and other inhumane acts; and they criticized the Red Cross and other aid groups and governments for not speaking out about these atrocities.
Soon, other physicians were speaking out about the situation in Biafra, and eventually some of them came together with a few French health care journalists to form an organization that would, in the words of its official history, practice "a new and questioning form of humanitarianism that would … prioritize the welfare of those suffering." The 13 physician and journalist founders were joined by nearly 300 others, and Médecins Sans Frontières (MSF; Doctors Without Borders in English) was born in December 1971.
The official history goes on to state that "MSF was created on the belief that all people have the right to medical care regardless of gender, race, religion, creed or political affiliation, and that the needs of these people outweigh respect for national boundaries." In its charter, the infant organization (which preferred, and still prefers, to be described as a "movement") required that all of its members agree to honor these principles:
Twenty-two years after MSF was founded, Renée C. Fox, a pioneering medical sociologist who had made major contributions to the understanding of everything from ethics dilemmas in medicine to the challenges of organ transplantation, decided to study MSF and determine, if she could, how they operated and what made them tick. The results of her odyssey with MSF, which stretched from Paris and Brussels to the poorest neighborhoods in Cape Town, South Africa, and the desperate prisons of Siberia in Russia, became a book, Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières. It is a remarkable story of healing, conflict and the journey of an organization once dismissed as a bunch of "medical commandos," which has gone from being perceived as just another product of the turbulent 1960s to winning the 1999 Nobel Peace Prize to becoming one of the most important health care humanitarian organizations in the world.
The book will be published by Johns Hopkins University Press next month. Here is the book's web page.
It will also be available through Amazon.
Having long ago been inspired by both MSF and Fox, I thought the twin stories of MSF's development and her involvement with them were worth telling.
At the time of MSF's founding, the world was not short of medical humanitarian organizations, many of which did — and still do — outstanding work. But the quid pro quo to which many of these organizations agreed in disaster situations — especially those where the disaster was the product of politics, war, genocide or other human actions — was to keep quiet about the sources of the calamity, and sometimes even about the atrocities that field workers on the ground witnessed. In some cases, these agreements were literally in writing and had to be signed by caregivers.
The founders of MSF were having none of that; the silence they had encountered in Biafra had convinced them that to say nothing was, to put it simply, wrong. And so they committed themselves and the organization to the concept of témoignage, which in French means (depending on which dictionary you consult) "telling a story," "giving testimony" or "bearing witness." Whichever definition appeals to you, the point is that MSF leaders and field staff feel obligated to report on what they encounter so the world cannot pretend it did not know.
Given that most of the international community managed to look the other way while genocide occurred in Cambodia from 1975 to 1979 and Rwanda in 1994 (to name only two unfortunate recent examples), such a commitment is both admirable and badly needed.
Maurits van Pelt, an attorney from the Netherlands who served as MSF mission chief in Phnom Penh, Cambodia, for 11 years, says, "Témoignage, as a core belief of MSF, has always been there. It has been there from the beginning. Témoignage is the whole thing. And it makes MSF very different."
Over the years, this obligation to bear witness has not been free of problems. It involves at least three risks: the danger that MSF members who speak out will be silenced, perhaps violently; the danger that MSF field workers (90 percent of whom are indigenous to the country in which they are working) can suffer harm because nonindigenous MSF representatives speak out; and the fact that MSF could be thrown out of the country where its members are serving because they have caused an offense through bearing witness — and then they can't help anyone in the place where they had been working.
Sophie Delaunay, executive director of Doctors Without Borders–USA, which is based in New York City, says of the latter risk, "The tension between speaking out and continuing operations remains; it will never be resolved. But that is helpful for us. As long as we remain ready to express outrage, the rest will sort itself out."
She adds, "I don't think we have ever been kicked out of a country because of communicating [a word that MSF members often use to describe speaking out], but it is a fear that we have internalized. There is always a pendulum swinging, and we went too far in recent years in trying to preserve operations and not to speak out, and now the needle is moving the other way — you can see that in our public positions on the situations in Syria, the Central African Republic and South Sudan. We are achieving more of a balance; we are moving more toward taking strong public positions and are less governed by fear."
But, as Fox warned me in an interview, "It's not just getting kicked out of the country; the indigenous people working with … [nonindigenous MSF staff] could come to harm. They could be endangering their colleagues. The expats [slang for expatriates, who constitute 10 percent of the MSF field work force] can get out of the country; the indigenous workers cannot. That's one reason for the balancing act."
MSF also has wrestled from the beginning with a challenge shared by other activist organizations: How structured should this movement be? Should it continue as a loose amalgam of strike forces of young physicians who show up with emergency supplies and services, or should it have more of an infrastructure?
At the annual MSF general assembly in 1979, after much debate, a vote was taken on making the organization more structured. That proposal won overwhelmingly. Later on, some of its founders left the organization and went on to form Doctors of the World (Médecins du Monde).
As the movement grew, the questions of how much infrastructure it should have, and how it should be organized, did not disappear. In 1995 and again in 2006 and 2011, MSF membership gatherings considered and revised, to some extent, the movement's basic underpinnings.
These discussions were necessary. From its early, barely organized, medical commando days, MSF has grown into a $1 billion multinational entity, with between 25,000 and 27,000 staff members (again, 90 percent of whom live in the countries where they serve with MSF), 19 sections (sort of like chapters), and various associated groups and mission offices all over the world. At any one time, it is working on 450 projects in at least 70 countries.
Of that $1 billion, $850 million goes to operations. MSF spends 12.3 percent of its money on fundraising, which is not an insignificant figure, but it is largely due to the fact that MSF will not accept money from most governments, will never accept money from a government that is even tangentially involved in the crisis at hand (including, as near as I can tell, a government that might have some historic responsibility for the situation) and would prefer not to accept government money at all. As it stands, 85 percent of all MSF funding comes from nongovernment sources.
How well MSF has arranged itself is best left to organizational theorists. But, in trying to understand this outfit, I must admit that I was amused by an observation in Fox's book: "Some of the steps that MSF has taken over the years to reform its structure have inadvertently added to the elaborateness and complexity of its organization. This has made it less comprehensible to many of its members — and to me as well." I second that.
But internal organizational scrutiny is part and parcel of MSF. In health care in the United States, we speak of "learning organizations" and "healing organizations." Well, MSF is a thinking organization (or, as they prefer to see themselves, movement). "It's a flat organization," says van Pelt, the former Phnom Penh MSF chief of mission. "Anyone can say or write what he or she wants and express himself or herself. There are no barriers to that from the organization; you can say what you think."
Fox added in our interview, "Theirs is a very special culture — a culture of debate, of self-mocking, of a belief that they can always do better. MSF is also transparent — to a high degree; they welcome anyone who wants to look into what they are doing." In an increasingly dictatorial and oligarchic world, this movement has — for better or worse — managed to hang onto its almost quixotic 1960s-ish version of democracy. They are not only self-mocking (at one crucial conference, one of their members produced a string of critical cartoons that were projected onto a screen for all to see); they are seriously self-critical. Mistakes (and MSF does make them, as all organizations do) are analyzed and used for self-improvement; any major issue is debated; decisions are judged thoroughly and sternly.
In one situation (about which I will not provide details, as I learned of it during a private conversation), MSF negotiated a cease-fire in order to evacuate innocent civilians from a situation of severe danger; one combatant side took advantage of the cease-fire to violate it and improve its position on the field, and a great many people were killed.
I was told that MSF representatives held agonizing, self-critical discussions all night and for days thereafter, wondering if the outcome would have been different had they not negotiated the cease-fire. (As it happens, I am familiar with this situation, and I think the result would have been the same — but then, I wasn't there, and hindsight is always both acute and useless.)
Perhaps the best example of MSF's being true to its code of questioning is that, when it won the 1999 Nobel Peace Prize — an award for which most organizations would be on their knees with thanks — Fox writes in her book that there was a lively internal debate as to whether the prize would "legitimate" the movement too much; the phrase that emerged was "Nobel or rebel?" They accepted it, then engaged in another lively debate over who should physically receive the prize and who should give the acceptance speech, which then took three months to write while everyone contributed.
I state this with great respect and understanding — I'm a child of the '60s myself — but you gotta love these guys. Anyone else on the planet would be all agog at having won what many consider to be the highest award for service that humanity can bestow on itself. But the people of MSF had to discuss it first.
And yet, somehow, amidst self-criticism and organizational growing pains, philosophical tensions and increasing danger on the ground, MSF continues to go, as its founders envisioned, "where the patients are."
I asked Delaunay about what I considered to be the near-miraculous accomplishment of MSF, after the horrible earthquake in Haiti in 2010, of being in Port-au-Prince with a fully staffed inflatable hospital (yes, there is such a thing) within hours of news of the quake. In the matter-of-fact manner that many MSF staff members have when describing heroic actions, she replied, "The level of devastation was the worst we had ever encountered. But we already had 800 staff members on the ground. And wherever we are working, we always have three months of stock with us, such as medicines. Our stock was exhausted in five days, but that was sufficient to buy us time and allow us to bring in new supplies and fresh staff."
In our interview, I asked van Pelt the same question: How can this large, almost mysteriously complex movement respond to crisis in the blink of an eye? He said, "That's because it's all ready. That's not a problem, not a big thing. It's fast because it needs to be. But the ICRC [International Committee of the Red Cross] can do the same thing; I've seen them do it. That's not what makes MSF different."
Apparently not, but they sure are good at it.
There is a certain glamour in emergency response — the news media love to film the white-clad doctors and nurses trying to save photogenic little children.
But this tends to be more true of natural disasters — the Haitian earthquake, the Indonesian tsunami and many others — where there is not a political overlay (although I have heard — not from anyone at MSF — that the government of Indonesia dragged its feet in getting aid to certain areas hit by the 2004 tsunami because many of the residents might have been supporters of rebel forces).
Crises created, exacerbated or prolonged by man are a different matter. Two of the areas where Fox did extensive field observation of MSF projects were Khayelitsha, a low-income shantytown in the Cape Town metropolitan area, where HIV and AIDS had reached severe epidemic levels, and Colony 33, a men's prison in Siberia, where multiple drug-resistant tuberculosis was at similarly epidemic levels. In each case, external forces made MSF's work exceedingly difficult.
In South Africa, which at the time had one of the highest HIV infection rates in the world, the then-president of the country consistently professed disbelief that rates were that high, that traditional treatments did not work as well as Western medicine, or that the AIDS virus even existed. This "denialist" attitude was shared by many other officials and ordinary South Africans, and, given what many black South Africans had experienced at the hands of whites, paranoia was an easy sell. Although MSF eventually did achieve a great deal, it was accomplished despite the denialism, the very common problem of tuberculosis and HIV/AIDS being present in the same patients, and the widespread occurrence of rape that infected many women.
The situation in Siberia was equally grim. The prisons were dreadfully overcrowded, and because of an insufficient supply of tuberculosis drugs, lax enforcement of treatment regimens and, sometimes, just plain lousy medical practice, strains of TB had developed that were resistant to first-line drugs. Stringent poly-drug regimens were required to stop the spread of the disease.
MSF had everything stacked against it. Fox writes that many Russian prison physicians — although some were welcoming and completely supportive of MSF's efforts — opposed the proposed regimens. A kingpin of prison society believed that MSF meant the prisoners harm, and it took MSF physicians a long time to convince him that they were trying to save his fellow inmates' lives. (It is interesting to me that an organization that can turn on a dime can also be so very patient.)
Some government officials took an extremely dim view of the whole thing. And if a prisoner was released, the chances of his receiving the proper drug regimen — which would have to be followed for years — were dismal.
In the end, Russian government entities refused to approve the necessary poly-drug regimens, meaning not only that prisoners would die, essentially helpless, while incarcerated, but also that those who were released would likely spread the terrifying XDR, or extensively drug-resistant, form of tuberculosis — which is resistant to all known treatments — through the civilian population.
Faced with being forced to follow a regimen that would not be effective, MSF Belgium (the lead section on this project) chose, as Fox writes, "to terminate its involvement in TB control in the Kemerovo region at the end of the year 2003." She quotes Nicolas Cantau, MSF chief of mission for the Russian Federation, whose heartbroken statement read, in part, "We are forced to quit, as the only alternative would be to provide incomplete, inadequate treatment to the patients. We have no options left, but given the scale of the problem with TB in Siberia and our investment over seven years, it feels like a very painful defeat."
This was not the only time that MSF has had to withdraw from a project site, and the decision is never taken lightly. I have concluded that there are at least four reasons MSF leaves a project, and they are all very serious indeed:
When the safety of the field staff is too much at risk. No one goes into an area like Afghanistan or the Democratic Republic of Congo as an aid volunteer and expects a walk in the park, but the situation on the ground can become too dangerous for MSF workers to be confident of surviving, let alone getting anything done. In recent years, MSF has had to withdraw from Afghanistan, Somalia and, most recently, parts of South Sudan.
These decisions are undoubtedly discussed and debated long and hard, and are probably opposed by some of those on the ground, but MSF workers do not always walk away from field situations unscathed. Some have died, although Delaunay says that most of these deaths were due to health problems, auto accidents or other situations unrelated to the immediate crisis. However, some MSF staff members have been killed in connection with their work — by gunfire, improvised explosive devices or other means. Also, at least 100 MSF workers have been kidnapped at one time or another, sometimes for only a few hours and once for 18 months, but most of them eventually were returned physically unhurt.
MSF feels an acute responsibility for those whom it sends into these threatening situations, and will pull them out when it feels it must.
When MSF field staff are prevented from doing their job. The situation in the Siberian prison system is an example.
When it is morally impossible to continue. This may be unique to MSF. Van Pelt tells of the situation when, by the time the genocidal Cambodian holocaust under the Khmer Rouge (KR) ended in 1979, hundreds of thousands of Cambodian refugees had fled to camps in Thailand.
Their experiences varied considerably, depending on the camp. In one, the United Nations high commissioner for refugees was in charge, and many of the camp residents had a chance of relocation to Western countries. In another, a particularly vicious KR commander, Ta Mok, who had fled to Thailand claiming to be a victim, took over the camp and continued the reign of terror from which the refugees had so recently escaped.
In other camps, former Cambodian government officials used the opportunity to build an army with which they sought to invade Cambodia and fight the Vietnamese, who had occupied the country after liberating it from the KR. Male refugees had little choice: Join the makeshift army, be killed or face denial of food to you and your family.
MSF workers were serving in those Thai camps, and they remembered.
In 1994, longtime ethnic tensions in Rwanda boiled over, and 1 million people, mostly ethnic Tutsis and politically moderate Hutus, were slaughtered by Hutus egged on by radical Hutu politicians, militias and thugs. An invading army of expatriate Tutsis stopped the killing and took over the country. Hutus were then at risk, and tens of thousands fled to refugee camps in neighboring Zaire (now the Democratic Republic of Congo). Although some of these Hutus had participated in the genocide, most were innocent people fleeing the violence.
Once they were in the camps, former Rwandan political leaders tried to require Hutu men to join an armed force that was being trained to take Rwanda back from the Tutsis who now controlled it. Once again, "recruitment" involved threats of death and denial of food.
MSF workers were serving in the camps in Zaire as well — and MSF has an acute organizational memory. Van Pelt recalls, "MSF said, 'We've seen this before. We don't want this again. Refugees are refugees.'" Standing up for the rights of the Hutu refugees likely constituted a difficult situation for MSF workers who were fully aware of the slaughter of the Tutsis, including women and children, who were killed in often unimaginably horrible ways.
Nonetheless, MSF representatives insisted that the United Nations, not former Rwandan political leaders, be placed in charge of food distribution, so that food would not once again be used to prolong a war, in this case by extorting refugee Hutus into joining the new armed force. Unable to achieve this, MSF terminated its work in the Zaire camps. Van Pelt adds, "Other aid groups said, 'What a strange organization.'"
MSF sometimes sacrifices a lot for its principles. But that, van Pelt says, is a consequence of what he terms MSF's "innocence." "They are very honest," he observes, and I suspect they would not have it any other way. How honest? When they believed that they had received too many donations for their work in the wake of the Indonesian tsunami, MSF leaders took the extraordinary step of not accepting any more tsunami-related earmarked donations, and offered to return those funds to donors.
When the work can be turned over to local authorities. What Fox termed in our interview "the missionary dilemma" — when the work is never done, can you ever morally leave it? — resonates with MSF. When it has been forced to leave a project behind, its workers are almost universally unhappy and frustrated. But sometimes, enough has been accomplished that indigenous staff can take over the work, which must be seen as a victory. The inheritors of the project will likely stumble and fall occasionally; but then, so does MSF. That is one of the prices of being MSF.
I should add that every MSF worker coming back from the field is debriefed and, says Delaunay, in New York City there is a psychosocial unit through which returning volunteers can meet with a psychologist. Further treatment is available for those who have suffered traumatic emotional damage, and MSF will endeavor to cover the cost of such care.
It is often needed. "In Haiti," Delaunay reports, "we sent in a team of psychologists for our staff, because they were so traumatized that this was the only way for them to keep going — to receive this type of support." This was unique for MSF — which often includes psychologists on its emergency teams — because this time they were sent primarily to care for staff. But, Delaunay says, "Every time our teams face an extreme situation, we do send some psychologists. I also remember that in Rwanda, right after the Kibeho massacre [a mass killing of Hutus in a refugee camp committed by members of the Tutsi-led Rwandan Patriotic Front], MSF France sent us a psychologist to debrief the whole team," who were then sent home.
But MSF people can be resilient as well. Fox told me, "Sometimes the counselors are so traumatized by what they hear that the MSF workers end up counseling them!"
It is not just the trauma of seeing the hideous, of humankind at its absolute worst, because there are always incidents of courage and compassion that accompany the horror. I believe that one of the worst experiences an MSF worker can have is to be confronted with a situation in which he or she can do nothing to help. The profound sadness of the MSF chief of mission in announcing the withdrawal from the Siberian project was palpable; even more so was the anguish of an MSF official who arrived at the scene of a pitiless genocide, alone and isolated, and not able to do anything. The grief in his voice when we spoke was evident years after the event.
These are people who want to act as well as to witness; resting on one's laurels is not in the lexicon. Individually and organizationally, they are highly uncomfortable with inaction, and they are repelled by the idea of being rendered helpless. As van Pelt said lightheartedly, "I want to be involved in aid, not fermentation." (Although, in the interest of fermentation, he pointed out that it produces wine, beer and cheese, as well as dysfunction in aid organizations.)
Both old and new tensions challenge this unique medical movement. One is that, as Delaunay concedes, the situation on the ground is ever more dangerous (at the time of this writing, a hospital in South Sudan where MSF was working had just been attacked and destroyed by forces unknown; although the patients and staff were apparently able to flee into the bush, that does not mean they are safe, and MSF has not yet accounted for all of them). Adequate security for MSF staff on the ground is a growing problem.
Another is that the clinical landscape is changing as well. In its typical self-probing way, MSF had seriously debated whether to take on HIV/AIDS, given the expense of treatment and the fact that the condition was becoming a chronic disease — a difficult leap for an organization that had been founded to provide emergency response in times of crisis. In an equally typical MSF way, its representatives managed to jawbone pharmaceutical manufacturers into providing HIV medications at a fraction of what they cost in the United States.
But with allocation of resources among 450 projects always profoundly difficult, shifting from a primary focus on acute conditions such as traumatic injury and cholera to AIDS, tuberculosis, diabetes, heart disease and other chronic conditions is proving as stressful for MSF as it is for health care systems around the world.
In addition, says Delaunay, the pattern of emergency aid is shifting as well, and many organizations once focused solely on such aid are moving to multiple missions, so that sometimes, when MSF arrives on the scene of a disaster, "We feel lonely." More important, MSF cannot shoulder the burden of enormous catastrophe on its own — "we face the challenge of dealing with the absence of organizations that used to be the backbone of emergency response." Indeed, MSF is, in fact, in danger of being harmed by its own success.
In "Something of Value," his gorgeous anthem for the future of his beloved Australia, songwriter Eric Bogle wrote of his lovely country "stumbling toward what we may yet become." MSF stumbles often enough, but its stubborn adherence to its core principles, its willingness to sacrifice for what it believes, its remarkable patience in the face of enormous obstacles, and its ability to react like lightning (even if we outsiders don't have the slightest idea of how it manages to do so) when the vulnerable are in need will see it through.
After 20 years of involvement with MSF, Fox concluded in our interview, "They will survive. They will be faced with the problems they have faced from the beginning — the intrinsic challenges of humanitarian action intervening to make the world a better place, and the challenge of not being able to say, 'OK, we've solved that problem.' I think they will never become rigid, but will retain their distinctive culture. And they will continue to face the issues that are faced by all humanitarian organizations."
She referred me to a quote in her book from Rabbi Jonathan Sacks, which was not meant to describe MSF, but does so, anyway. In Fox's telling, he speaks of people who are both realistic and idealistic, who see "the world as it is," a world in which there are "suffering and injustice … sickness and premature death" and "natural disasters," while energetically "refusing to let go of [their] vision of the world as it ought to be." I doubt that MSF will ever let go of either the reality or the ideal.
But I was most taken, in the end, with the words of an MSF official quoted in Fox's book, who had worked in one of MSF's most difficult projects — providing basic services to the homeless children and adults of Moscow, who were scorned and dismissed to a degree so extreme that it makes the United States' treatment of its homeless look downright kind. After 10 years of toiling in those unforgiving vineyards, she wrote simply of her pride in "our daily refusal of the unacceptable."
One could hardly ask more of anyone.
In the interest of total transparency, I want to state that I am a donor to MSF and have been for many years; however, my desire to write this article was sparked by my work on another project that has only coincidental ties to MSF. Frankly, after months of harrowing research, I just wanted to write about something positive in health care.
Anyone interested in learning more about MSF, including how to volunteer, should visit its U.S. website. They are in particular need of midwives, general surgeons, orthopedic surgeons, anesthesiologists, nurse anesthetists, other surgical professionals, emergency physicians, physicians with strong management experience and French speakers.
In typical MSF style, many other sections have websites as well, although most do not use English.
Correction: In my previous column ("Stopping Dr. Feelgood," Feb. 4, 2014), I misstated the name of the organization of which Sue Foster is vice president. Its name is CASAColumbia and it is "a science-based organization that conducts research and recommends best practices for prevention and treatment of the disease of addiction."
Copyright © 2014 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
First published in Hospitals & Health Networks Daily on April 1, 2014
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