May 24, 2011
Democratic Republic of Congo 1994 © Roger Job
Editor’s Note: This is an expanded version of a recent “Insider’s Letter” that drew a great deal of feedback, convincing us it was worthwhile to delve further into the issues discussed.
In 2010, the international aid system came under scrutiny in the media, sparked in great part by its responses to the crises in Haiti and other parts of the world. “Where is the money going?” became a common question from donors, reporters, politicians, and beneficiaries alike. The charge that humanitarian agencies are accountable to nobody, that they can support local war economies, and that, in the worst case, they do more harm than good was leveled in several forums—most pointedly in “The Crisis Caravan” by Dutch journalist Linda Polman, in reviews of her book, and in articles by journalists such as The New Yorker’s Philip Gourevitch, who used Polman’s book as an entry point for a broader critique of the delivery of humanitarian assistance.
I’d like to share with you our thoughts on these issues— the nature, value, and accountability of the international aid system—and take the opportunity to reflect on Doctors Without Borders/Médecins Sans Frontières (MSF)’s role and responsibilities when it comes to humanitarian action today.
North Korea 1997 © Peter Van Quaille
MSF puts a high value on critiquing the quality of our programs. From our earliest days, we have been examining the ways our decisions impact the communities in which we work and seeking to identify strategies to achieve the best outcomes for patients. Given the nature of our work, we confront these dilemmas as a matter of course, and while we disagree with much of the commentary that has been put forth, important questions have been raised—for individual organizations, for the broader international humanitarian effort, and, most importantly, for the people aid workers are ostensibly trying to serve.
Can a humanitarian agency do more harm than good? Yes, if that organization takes action without paying sufficient attention to the potential impact of its work on the socio-political environment. MSF understands this only too well. In 1994, for example, hundreds of thousands of refugees fleeing the genocide in Rwanda gathered in camps in Goma, on the eastern edge of the Democratic Republic of Congo. MSF immediately mounted an enormous emergency response—only to realize, as the months went on, that much of the international aid pouring into the area was being diverted to support the Interhamwe, the militias that had perpetrated the genocide and were, at that moment, taking control over the camps.
Our teams were faced with an agonizing decision, one that almost led to a split within the organization. Should our teams stay, knowing that by doing so, they are strengthening the Interhamwe—providing them shelter, food, water, and medical care—as they re-grouped and re-armed, using the camps as cover for military activities? Or do we withdraw, knowing that many civilians in the camps, including women and children, would then stop receiving our medical and humanitarian assistance?
In the end, MSF decided to withdraw. We did this due to our publicly-stated belief that if we remained, we risked strengthening groups that had perpetrated a horrific genocide and intended to continue the fight. We risked violating one of the primary tenets of both medicine and humanitarianism: do no harm.
In 1998, we faced a similar situation in North Korea. MSF had been providing massive nutritional and medical support to the national health system for three years. But we had been unable to secure the government’s approval for direct access to health centers and to the most impoverished regions of the country, which we knew had been ravaged by years of starvation and natural disasters. Despite facing one of the worst famines in the nation’s history, the North Korean government insisted that aid be channeled only through the Public Distribution System and that aid organizations be restricted from independently assessing the needs and providing direct assistance.
We had thoroughly studied the structure of this system and were fully aware that it classified aid recipients according to loyalty to the regime. If we could not independently access the population and make choices based solely on medical and nutritional needs, any assistance we gave would be funneled through this same discriminatory system. It would be given first to Party members, to the elite, and to loyalists, rather than the most vulnerable members of the population—the priority for anyone providing humanitarian assistance.
As it happens, I was working with MSF in Rwanda in the immediate aftermath of the genocide there and was later responsible for developing direct operational strategies to reach the North Korean beneficiaries. It was excruciating to pull out of these places. But we believed it was the right decision for MSF given our principles and given the conditions with which we were confronted.
These are just two examples. If we looked at MSF’s outspokenness against the Thai government’s plans to forcibly repatriate Hmong refugees to Laos in 2005, our work in rebel-held areas during the Angolan Civil War, our decision to pull out of Afghanistan after five staff members were killed there in 2004, or our work in Sierra Leone when British-sponsored forces were being employed to fight militias in that country—to name just a few—we could find more instances when the organization’s medical work took place in contexts that were far from black-and-white. Trying to aid communities in need is not a zero sum game, after all. There are almost always shades of gray, shifting parameters, and innumerable cultural, political, and historical factors at play. The task in every situation is to understand the environment and the ways in which MSF can, or cannot, assist.
THE MEANING OF HUMANITARIAN ACTION
Humanitarian aid should not be complicit with the perpetuation of suffering. That much is clear—at least in theory. In practice, it can prove to be more complex. There are times when it is very possible, perhaps even inevitable, that an organization trying to achieve humanitarian ends will in some roundabout way provide support to a warring faction or oppressive regime. Its work can be co-opted. Its presence can confer a sense of legitimacy on certain groups or be seen as absolving them of responsibilities to the population—an outsourcing of functions they’re unwilling to perform. Movements and assessments can be confined to certain areas.
Angola 1999 © Robert Knoth
This is why aid groups need to take responsibility for ensuring that their socio-political impact remains as minimal and impartial as it can be, and that the populations most in need gain the most benefit from humanitarian efforts. Speaking about conflict situations, Fabrice Weissman, the director of MSF’s Center for Reflection on Humanitarian Action (CRASH) writes, “humanitarian organizations firstly need to recognize that the risk of humanitarian aid being co-opted materially or symbolically in the war effort is real and that it should be taken into consideration when setting up operations.” The organizations them selves are responsible for making sure that their work is not proscribed, exploited, or misused to the extent that they are, in fact, doing more harm than good.
We have a duty to question our actions whenever we see this balance tipped. That is why independence matters so much to us at MSF. By remaining independent, by staying out of agreements that would leave us beholden to the agenda of any interested government, party, or faction, we can make choices based first and foremost on the reality of a given situation.
Questions should be asked about the quality and accountability of humanitarian action. It can be done badly. Both Polman and Gourevitch criticize the humanitarian community for relying too much on self criticism as an accountability tool. That is a valid point, and we welcome thorough examinations of our work. But I would also submit that in the 40 years of its existence, MSF has been one of the toughest critics of our own operations, and that our own examinations are often far more stringent and, yes, critical, than those from the outside. We have a host of accountability measures in place and some highly empowered mechanisms that review operations, push for improvements in our field work, and advocate for the best possible outcomes for patients. These include not only our regular program evaluations but also our research and investigation centers: Epicentre (www.epicentre.msf.org/), which focuses on epidemiological dynamics, and CRASH (www.msf-crash.org/en), which performs critical reviews of our interventions, taking into account the political context in which they occur, in order to find lessons that can be used in the future. MSF’s best critical mechanism, however, is its associative structure, which means that the organization is governed by a board elected by people who have worked or are working in the field and can challenge executive decisions and operational priorities at any time, forcing changes if need be.
Sri Lanka 2009 © Anne Yzebe/MSF
In this discussion, it is important to clarify what actually constitutes humanitarian action. Humanitarian action, by definition, must be provided by independent actors who have no stake in the crisis, who seek no profit from their work, and who provide assistance based on need and need alone. Yet what is commonly labeled humanitarian action often has little to do with this definition. The word “humanitarian” is often used interchangeably when describing experienced aid agencies such as MSF, whose work is based on medical ethics, independence, impartiality, and neutrality; aid agencies contracted by warring parties in an effort to win the hearts and minds of the local population or to further long-term agendas (thus forcing people to “choose sides” if they accept assistance); or individuals who turn up in a crisis with good intentions but no real way of responding to people’s needs. Polman and Gourevitch, among others, fail to make these distinctions, which is unfortunate. A vigorous and transparent debate about the international aid system is absolutely necessary, but the debate often ranges far off target, with something as basic as the meaning of the term humanitarian—which is clearly defined under international law—misinterpreted again and again.
Millions of people depend upon assistance for their very survival, but the lack of understanding about what actually constitutes humanitarian action undermines the reputation of humanitarian action itself and those who carry it out. In the worst case, people don’t get the help they need. That is why it is incumbent on both the media and aid organizations to clarify what humanitarian action is—and incumbent on NGOs to adhere to humanitarian principles, particularly independence.
Afghanistan 1994 © Didier Lefevre
At MSF, we find ourselves constantly revisiting this issue, and restating our position, in meetings with governments, militaries (particularly the American military and NATO), the European Union, indigenous factions, journalists, in public communications, and with other NGOs. We take the position that humanitarian action is more than simply providing assistance. It must be carried out based solely on need and delivered independent of political, social, or religious agendas.
THE QUESTION OF ACCOUNTABILITY
When it comes to concerns about accountability, Gourevitch and Polman are not alone. There have been a number of articles in recent months questioning the accountability of aid organizations—particularly with regard to shortcomings in the international responses in Haiti, Afghanistan, Pakistan, and elsewhere. At MSF, we welcome this debate. Ideally, of course, we should be accountable to the beneficiaries of our work, to our patients. But in reality, despite our best intentions and our best efforts on their behalf, this is something of an illusion. We must acknowledge that the victim in a crisis is seldom in a position to exercise choice or to challenge our work or presence.
We are, however, very much accountable to our donors and to the governments or authorities in the countries where we work. This accountability alone does not guarantee the quality of our interventions—just like democratically-elected governments are never a guarantee of good governance—but it does provide control through a legal and regulatory framework. In project countries, we usually sign a Memorandum of Understanding with the host government. This is not an endorsement of that government or its policies, but rather an agreement that defines the scope of our intervention and our obligations. With our donors, we have a system for reporting our activities and for maintaining transparent accounting to explain how funds are being spent—and, in some cases, such as the Indian Ocean tsunami of 2005 or, more recently, the earthquake in Japan, why there are limitations to the services we can provide (and why we are therefore not actually in a position to spend donations supporters would like to earmark for a given emergency). Should MSF not live up to the standards inherent in these systems, donors can choose to discontinue their support. And if governments excessively restrict MSF’s ability to provide care to those who need it, MSF can decide that it can no longer be party to the arrangement.
Thailand 2008 © Daniela Abadi/MSF
At the same time, it is important to remember that the role of humanitarian organizations, and MSF in particular, is very specific. It is not our job to come up with political solutions. That is the job of governments and political actors. The role of humanitarian agencies is, or should be, quite limited and decidedly pragmatic: to bring quality care to people caught in crises with a view to alleviating their suffering. As part of a broader aid community, we often find ourselves working in the same areas as other humanitarian agencies, local NGOs, government-funded NGOs, and government actors. This broader international aid community has an obligation to provide the best quality services with the resources at its disposal.
This is an ironic moment, however. Never have there been so many resources devoted to some of today’s humanitarian crises, and never has MSF felt so alone in dealing with some of these emergencies. This is particularly true in Haiti’s health sector. It is of great concern to us that cholera, an easily preventable and treatable disease, claimed the lives of more than 3,700 Haitians between October 2010 and March 2011. Despite the proliferation of aid organizations that flocked to the country following the earthquake in January 2010, our medical teams treated more than 60 percent of all cholera patients in the country. And what’s more, there has been insufficient progress made on sanitation, shelter, and other key concerns that could have prevented an outbreak of the sort that occurred.
AN ONGOING PROCESS
There are right now more than 22,000 people working with MSF in more than 60 countries around the world. They are responding to wars, political upheavals, natural disasters, neglected diseases and neglected communities, and they are doing so because they believe providing medical care to people who need it—whose lives may well depend on it—is a worthwhile undertaking.
We are also more than happy to talk about the work that these people are doing in the field, about the work that headquarters staff does to support them, and about the choices we make regarding where we work and why we work there. And we are more than happy to have open discussions about the broader aid system, such as it is, or to bring criticism to bear on our own operations. This is how we get better at getting people the assistance they need.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)