On 1 November 2012, in the aftermath of New York City’s devastation following Hurricane Sandy, Staten Island Borough president James Molinaro shocked New Yorkers by denouncing the Red Cross and asking donors not to give to the organization. The relative rarity of criticism for the Red Cross and its ubiquitous presence made his statement quite the shocker. However, the issues that undergird his complaint - the geopolitics of relief priorities, uneven access to resources and the hegemony of powerful relief agencies are ones that are ongoing conflicts in the administration of humanitarian relief across the globe. These tensions have fueled a similar antipathy - if not outright hostility - toward humanitarians.
In this collection of case histories and personal accounts, Medecins Sans Frontières (MSF) attempts to theorize the role of humanitarian actors and to account for its own politics and practices over the last fifty years. Central to this task is the admittedly humble exercise of evaluating the controversial practices of the NGO, which have been the subject of much discussion and have led to many failures, compromises and indeed expulsions from the field of action.
MSF, along with CARE, Oxfam, and a handful of other humanitarian agencies, have been at the helm of much of the disaster and conflict relief that has become de riguer since the late twentieth century. Given the centrality of its role in ameliorating immediate human suffering, MSF has been at the frontlines of civil conflict, development and environmental debates as well as security and war policy choices. The result has been a cobbled together set of strategies led in part by moral visions and in part by necessary practical strategies.
The book is a publication of the Centre de réflexion sur l’action et les saviors humanitaires (CRASH), a unit of MSF whose stated purpose is “to encourage debate and critical reflection on the humanitarian practices of the association, in order to improve its actions.” It is a testament to MSF’s commitment to cutting-edge, progressive international political work as well its vast resources that it would develop an organization solely for self-criticism.
MSF is a collection of national organs under the broad administration of the central, French-originated NGO. As such, approaches to practice differ and relate to each sub-group’s local context. Nonetheless, all are part of an organization whose mandate is to ease suffering by providing non-state derived relief primarily in the field of medical care. Thus MSF’s work confronts head-on the questions of who to aid and how. If aid is political - and it undoubtedly is, as the book attests - then central to its effectiveness is the control of and access to resources. These queries beget the issue of distribution and effectiveness - who to aid, when, and how? Answering these questions requires humanitarian organizations to have an ethical framework, argue the authors, that is both morally sound and strategically effective.
MSF’s famous refusal to continue to deliver aid to refugees from the Rwandan genocide residing in the DRC on the basis that humanitarian aid was being used by Rwandan genocidaires to continue violence against minority populations inside and outside of Rwanda was a decisive and much challenged break from the norm of neutrality that governed the model of morality dominant in the field at the time. Since that time, MSF has been known for taking a strong stance on the politics of humanitarianism, intervention and state action and inaction. Though criticized for its politicization, such actions made MSF unique and shaped its direction. However, as the volume makes clear, it did so at a human cost.
In essence, the book suggests - with some hope - that the crux of the problem is in crafting humanitarian projects in areas where local authorities - legitimate or otherwise - are suspicious. These must be crafted with attention to both the limits imposed by area leaders and the moral requirements of humanitarian actors. The failure of negotiating this space for action is expulsion, inadequate care and assisting in prolonging conflict and oppression.
On the ground: spoiling for a fight
Perhaps the most ethically complex issues that emerge in the book are those related to humanitarian endeavors during ongoing civil conflict. The necessity of protection and of remaining in good favor is strikingly obvious when it concerns where the bombs might be dropped and the physical safety of MSF’s staff. Yet the nature of civil conflict makes for countless injured, food scarcity and difficulty in accessing medical resources, and can create situations of extreme need similar to natural disasters and epidemics. However, the context of conflict means dealing directly with combatants and states, many who commit acts of violence against the same civilian populations humanitarians target for relief. At what point (to evoke Romeo Dallaire) is it necessary to shake hands with the devil?
Part of the problem, as the book clarifies, is that humanitarian work is dependent on the invitation, or at least assent, of a sovereign government. Second, as mentioned above, it is dependent on the de facto assent of regional or local authorities that effectively grant access to populations and transit routes for staff and supplies. As MSF's experience in Yemen, for example, illustrates well, the necessary source of such assent can shift mid-conflict, making MSF’s perceived political leanings in the conflict a hotbed of controversy and forcing re-engagement in negotiations by MSF for access and protection. Even when MSF has used local physical protection - in the case of Somalia - their protectors have behaved in ways that are unsettling to humanitarian agencies, causing another ethical dilemma.
On clear option is withdrawal. MSF has indeed withdrawn, or been kicked out of, certain scenes of conflict relief. Yet withdrawal is bittersweet, and too many withdrawals will knock the NGO out of contention for dominance and donor support in the field of humanitarian medical aid. MSF has, in this book, made the case for greater negotiation, greater focus on medical aid and neutrality and, perhaps more interestingly, on the manipulation of its power - media, global reach, specific technologies, expertise in medical needs - as a means of controlling state and combat forces. In the end, though the authors drop in the need to respond to humanitarian philosophies, the book suggests that multiple political actors and complex dynamics require multiple politically grounded and malleable strategies. Though this is a realistic approach, one wonders whether the NGO has flipped from its human rights pose to a realpolitik in which consequences will eventually prove as unsavory as those of its previous high-minded idealism.
Medical sovereignty: the politics of global-local health aid
Several chapters capture the knotty politics of aid in situations of multiple political actors. Complex authority structures are a fundamental and inescapable political dimension of aid delivery and create legitimacy crises for both domestic actors and MSF units. The most complex situations occur when assistance is related to ongoing state health issues that necessarily bring up internal politics, especially those related to inequality, ideology, and electoral politics. MSF has used direct activism — as in France in the early 1990s, as noted by Michael Neuman in his chapter “France Managing the “Undesirables” - and appeasement - as Neuman explains was the case in millennial debates over medical insurance rights for migrants in France - as strategies for engaging domestic health policy and action to varying success.
Similar to the organization's fraught choices between silence and obeisance or public pressure and international rights advocacy in conflict relief, the activism/appeasement strategies are marked by both attention to MSF’s objectives as a powerful global NGO that must maintain its survival in competition with other actors in the field and its care delivery and ethical mandates to deliver meaningful aid. Furthermore, while in the French case the structures for democratic political process were relatively easy to access, and MSF has its most permanent roots in the state, in other cases MSF’s relative unfamiliarity and the political instability of some states hindered the organizations abilities to adequately strategize its efforts.
In the French examples above, both strategies were successful and both show the sub-strategy of positioning MSF as a key policy engineer. The latest efforts saw MSF-France positioning itself as the “good” NGO and as the site of expertise on migrant health in a way that allowed the government to appear both benevolent and au courant, while maintaining a strong and legitimate place for MSF-France to exercise authority as the health expert in the area of migrant health.
In India and Nigeria, however, the presence of existing competitors for that role (in India, the Right to Food movement) and multiple layers of political authorities - from state to community religious leaders — complicated the process of using either of these strategies. Regardless of the locale, political leaders are motivated to a great extent by remaining in control, an in control of access to resources. Popular disapproval, as in the case of Indian authorities in Madhya Pradesh, can turn the tide in MSF’s favor. On the other hand, without engaging local and elite political dynamics, the organization can find itself hamstrung regardless of the health crises occurring locally.
In a chapter entitled “The Expert and the Militant,” in which the title hints at the book's sometimes disturbing assessments of south state politics, the controversy over the use of a nutritional supplement produced in the North - Plumpy Nut - sheds light on the specific political perspectives of both Indian civil society and electoral politics. Rather than a technologically driven short term approach to malnutrition, the Indian model favored by the hunger advocacy movement Right to Food surveys global and structural relationships to ongoing malnutrition in India. This ideological and practical difference is one that author Stephanie Doyon fleshes out well in her description of the routes to aid delivery but is dismissed as intransigence at the peril of aid agencies. The article examines the mixture of alliances, silences and action used by MSF-Spain, UNICEF, and Access Campaign to deliver nutritional aid. In the end, it was discretion that won the day after a series of negotiations, illegal imports, tense confrontations and a variety of nutritional crises. Yet the issues of Indianization, philosophy of care and the specifics of national political and social needs remain.
In Nigeria, MSF-France’s attempts to alternately act upon meningitis, yellow fever, polio, cholera and measles were challenged by similar differences in authority, particularly as a result the decentralization of healthcare that occurred in Nigeria in the late 1980’s. As author Claire Mangone explains, this led to local authorities managing the funds for healthcare as part of larger managing of local area funds. Lack of resources and increasing corruption were a recipe for problems that reached an apex in the replacement of vaccines with water injections and the use of health centers in Kano as testing grounds for the drug company Pfizer - with the widely suspected authority of the Kano government. In 1999, politicians openly requested that MSF not publicize increasing cholera epidemics prior to the FIFA under-20’S football competition, followed by refusals to allow treatment of measles epidemics and finally the withdrawal of MSF from Kano after five mostly fruitless years in Nigeria. Successive attempts by MSF at shaming the Nigerian government in the press did little to change the situation.
The tide turned upon MSF’s return to Nigeria in 2005, revealing the importance of timing to the application of aid delivery strategies. An upcoming election, a visual campaign of starvation pictures displayed across the global media and Nigeria’s own attempt to seem a resourced and giving neighbor within its region combined to make Nigeria vulnerable to MSF threats of exposure and withdrawal. Nonetheless, it was the largely blameless nature of the epidemic - meningitis is not caused by the failures of the state or local leaders to deliver resources - and the need for MSF to open up relations somewhere in Nigeria that drove this strategy. The results were disappointing, and arguably, set into motion by MSF’s earlier confrontations in Kano.
Realistic idealism and the future of MSF — and humanitarianism
Given the mixed success of MSF’s strategies, and the variety of cases in which they provide aid, what future might be envisioned for MSF? All of the authors agree that single strategy is a mistake. Furthermore, most encourage caution - if tempered with ethics. All are certain that political abstention is a fantasy, but that engagement must be tempered by long-ranging strategy. One major need will be to see more South states engaged in the humanitarian game, especially in regions of high need. Another will be efforts to improve data gathering especially for epidemiological purposes.
Beyond these paths, MSF has to carve a place for itself that is more than technical, less than political, linked to rights claims, but free of burdensome constraints. This place likely cannot exist. MSF’s objections to the responsibility to protect, its fear of over-emphasis on human rights, and its determination to negotiation will never change its fundamentally justice-based place in the international system. The frustrations of the borough president above and the Right to Food critics also mentioned will remain as long as MSF is a powerful North NGO.
The author’s concern that MSF move from its mid-90s idealism is convincing, but more convincing is the need of the organization and its peers to do more research and analysis of the type this book exemplifies.