The way humanitarian aid workers are perceived has recently attracted increased attention, mainly because of the emergence of new elements in crisis contexts that challenge the very foundations of humanitarian action, and of growing difficulties in accessing populations in conflict zones. Different studies have sought to understand the mechanisms that determine the perception of humanitarian action. The aim of this work is to develop the debate on the role of humanitarian action in crisis contexts through an evaluation of how MSF’s work is perceived in volatile environments.
Doctors Without Borders/Médecins Sans Frontières
MSF is a nonprofit, nongovernmental organization that provides medical assistance to populations caught up in crises that threaten their survival: mainly armed conflicts, but also epidemics, pandemics, natural disasters, or even exclusion from health care. Created in 1971 in France by doctors and journalists, it is now an international movement made up of 19 associations, each under the responsibility of a Board of Directors elected by its members (current and former MSF field staff) during an annual general assembly. In 1999, MSF was awarded the Nobel Peace Prize. Today, MSF provides aid in more than 60 countries and employs nearly 27,000 people. The organization considers it important, at this point in its history, to launch the Perception Project, with the goal of giving voice to the people living in the areas where MSF provides medical relief. This book presents the results and reflections resulting from the study.
MSF acts according to the humanitarian principles of independence, neutrality, and impartiality. To a degree, these principles have become MSF’s hallmark and have led it to refuse to collaborate with other actors or use the infrastructures and resources used by other humanitarian or international organizations in the field, a strategy that some consider more isolationist than independent. Unlike other humanitarian actors, however, MSF enjoys financial independence, which sets it apart and now forms part of its identity. Témoignage is another concept very specific to the organization and was one of the main reasons for its creation. Following the Biafran War, MSF’s founders wanted to create an organization that would speak out publicly about events in the field rather than remaining silent, as they believed the International Committee of the Red Cross (ICRC) had done. Forty years later, témoignage is still considered an integral part of MSF’s work, although medical action remains the priority.
Through its communications and operations, MSF aims to highlight its total independence from political and other external influence. MSF believes that its capacity for independent humanitarian action is compromised by the initiatives of certain states and international organizations to use humanitarian aid as a tool to achieve political objectives. They use humanitarian aid to further broader objectives such as establishing peace, promoting democratic reforms or stabilization, or simply imposing national political agendas. Consequently, MSF acts at two levels, in two spaces: the countries in which it operates and, more broadly, in the international arena. These two spaces influence each other; and while this influence ensures adaptability to a range of contexts, it also renders it more difficult for MSF to convey a coherent image and message (especially across 19 different associations).
This challenge of conveying a unified message also raises the issue of humanitarian space, a concept which many people associate with MSF, as it was first defined by the organization’s former president, Rony Brauman: a symbolic space in which nongovernmental organizations (NGOs) enjoy freedom to speak to and establish dialogue with the people with whom they work; freedom of movement; freedom to assess needs; and freedom to monitor the distribution of aid. The ICRC proposed that humanitarian space could be conceptualized using “Dunant’s pyramid.” In this view, it consists of a complex mixture of humanitarian principles (independence, impartiality, and neutrality), which form the sides of the pyramid; humanity, which forms the tip; and international humanitarian law, which forms the base. In the United Nations (UN) system, humanitarian space is defined as the working environment of humanitarian organizations. Therefore, the notion of perception is inseparable from the concept of humanitarian space.
Perception has a considerable impact on the quality of an organization’s operations, as well as on the safety of both national and international staff in the field, and the beneficiaries of those operations. Consequently, NGO teams must pay special attention to the notion of perception, both in the field and at their headquarters. The way a humanitarian organization like MSF is perceived depends on a range of diverse and varied factors that can be difficult to understand. Indeed, such perceptions are the result of both context-independent factors (the organization’s activities in other parts of the world, its reputation, its visibility on the international stage, the consistency of its principles and activities); context-dependent factors (the way the organization implements its operations in the country, the relevance of its activities to the needs of the local population, its communication strategy, its position in relation to national political issues, or even its management of local human resources or its integration into the pre-existing social fabric); and characteristics linked directly to the environment in which it is operating, such as political context (history of colonization, previous military or humanitarian interventions, number and types of foreign actors present, role of religious, political, economic, and military authorities).
One of MSF’s main challenges is how best to translate the central humanitarian principles of independence, neutrality, and impartiality into operational realities. The application of humanitarian principles may vary in conflict as opposed to neglected contexts. The Practical Guide to Humanitarian Law states that the interpretation of humanitarian principles must be done “in a practical manner within the context of relief operations,” as it is this adherence that protects the presence of humanitarian organizations in armed conflicts under the Geneva Conventions. While this assertion is useful during armed conflicts, it is less relevant in settings where MSF is working with neglected populations and/or neglected diseases. Only 22 percent of MSF’s interventions in 2009 were emergency/short-term interventions, which shows that MSF has also made a place for itself as a provider of longer-term medical assistance.
MSF strives for acceptance of its activities through adhering to humanitarian principles to ensure the safety of its teams in the field. This strategy only works if the populations with which MSF is working are aware of its activities and its specific approach centered on independent humanitarian action. Unlike the ICRC, MSF does not have a mandate validated by international conventions and must therefore gain its legitimacy through the relevance of its medical actions in the field. Due to changing norms and international attitudes toward humanitarian actors, including the desire by crisis-affected states to maintain greater sovereignty and control over international activities within their borders, MSF must adapt its actions in the medical, administrative, and political spheres. In the medical sphere, these changes raise questions about the choice of medical intervention (who decides?); standards and quality of care (is MSF a standard-setting institution?); impact (to what extent should MSF be accountable for its impact in a crisis situation, given other influencing variables?); existing health systems and global health actors (is it better to prioritize integration/partnerships or emphasize autonomy/independence?); as well as ethical issues (paternalism, autonomy, resource allocation, responsibility in the event of medical errors, exceptions in emergencies). Similarly, changing norms require a reinterpretation of administrative issues such as the certification of doctors’ qualifications, the management of local human resources, and so on. In the political sphere, this means that MSF must be more aware of its impact on local power structures and, therefore, more careful in its dealings with authorities.
MSF is becoming increasingly aware of its limitations as a medical humanitarian organization. It therefore decided to undertake this three-year perception study in order to gain a better understanding of the way in which it is seen in the field by a wide variety of stakeholders, with a view to optimizing the implementation of medical projects. For the Operations Department, and in the organization’s interactions with other actors, a thorough evaluation of perception is also the key to maintaining MSF’s status as an independent and impartial actor, free of any religious, economic, or political interests.
While the French and Arabic versions were published with an independent publisher, it seemed important for MSF to co-publish the English version with the Center on International Cooperation of New York University and Humanitarian Outcomes, whose staff has been involved for years in researching the humanitarian sector and humanitarian aid operations. This ability to provide a reflective and critical look at the issues addressed by the study is demonstrated most clearly in Abby Stoddard’s article.