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Themes From the Project Part 1Caroline Abu-Sada An initial set of working hypotheses was formulated at the start of the project. Some of them were confirmed by the study, others disproved. First of all, it should be noted that the following observations are the result of discussions with different people; they are perceptions, not facts. (For instance, just because some people think that MSF performs clinical experiments on prisoners in Bishkek, Kyrgyzstan, does not mean it is true.) Perception is a reality in itself, the validity and basis of which is debatable. We will divide our analysis into three sections: MSF as an institution (including the question of definitions concerning humanitarian action); factors influencing perception; and the perceptions of certain groups of people interviewed. MSF as an InstitutionOn several occasions, MSF was nicknamed Médecins AVEC Frontières—Doctors WITH Borders. A number of explanations were given for this. To begin with, MSF’s interventions are organized by country and not by region. The nutrition program in Magaria, southern Niger, is an example: 70 percent of children enrolled come from northern Nigeria and many of the people questioned did not understand the logic of having a nutrition program in Niger alone. This perception was also strengthened by the issues raised by MSF’s vertical projects. Indeed, in Cameroon, the Buruli[1] program did not treat other diseases even though, for example, child mortality due to malaria was high. Many people questioned this lack of treatment and asked for a broadening of MSF’s medical activities. The name of the organization is often misleading for groups such as refugees and internally displaced persons faced with problems of mobility. “Without borders” is interpreted as expressing an ability to cross borders, giving the impression that the organization’s employees do not need visas and have unlimited access to all countries. This presumed mobility prompts insistent requests by local populations to publicly denounce human rights violations in the country concerned. Additionally, the organization’s offices, medical facilities, and compounds create both a physical and symbolic distance between teams and local people, which can be detrimental to the acceptance of projects and teams. The way some missions are organized, with international staff isolated and having only limited interaction with locals, further widens that gap. Most of the time, this isolation is due to security arrangements designed to reduce the risk of kidnapping. This nevertheless hinders the organization’s attempts to establish relations with the population. This aspect was particularly salient in Cameroon, where inhabitants praised the “Chinese approach” (Chinese workers were living in camps near the stadium they were building and were, therefore, close to the people, while the NGO workers were living in highly protected districts). Similarly, the vocabulary used by the organization can be perceived as military and sometimes casts doubt over its very nature. For instance, the organization talks about bases, compounds, missions, sections, action plans, etc., without even realizing the impression such terminology may give. Most of the people consulted still do not make the connection between the acronym MSF, the various translations of the organization’s name, and the name in French. In Iraqi Kurdistan, for example, some people had not realized that MSF, Médecins Sans Frontières, Doctors Without Borders, and Attûba Bala Huddud (Arabic translation) were one and the same organization. Confusion is also possible between the acronyms of different organizations, for example MSF and MNF-I (Multi-National Force—Iraq, i.e., the coalition led by the United States, from which MSF is keen to distinguish itself at all costs). This confusion can give rise to security problems for the teams. Moreover, the MSF logo and visual communication are not always known or understood. In Kenya, people tend to associate the logo with a man holding a spear (to destroy kala azar)[2] rather than with MSF. Even more crucially, a large number of those interviewed remember the “no guns” sticker more clearly than the logo. The red lines through the gun are neither noticed nor understood, and the gun is therefore interpreted as a threat.[3] Some come to the conclusion that the facilities are managed by the Kenyan government, others that it is necessary to carry a weapon in order to enter MSF’s medical facilities.
Various respondents noted that the foreigners working for MSF come from far away, and therefore have different habits and cultures, which are not always appropriate. They all said Challenges of DefinitionThe study showed that, in different contexts, the participants defined the notions of “humanitarian action” (an action intended to alleviate human suffering and provide goods and services free of charge) and “humanitarian personnel” (philanthropists and benefactors) identically.[5] In general, humanitarian aid is considered important and is favorably received in the countries. Most people associate humanitarian aid with a charitable wish to help others.[6] It is often considered useful—as all types of aid are necessary—and positive, although people do question the role of the state, particularly its management of the health system.[7] In some countries, the people interviewed compared foreign humanitarian assistance with local charitable practices such as taimako in Niger[8] and apuyu, gbawuaka, or gbomon in Liberia.[9] In the Middle East, these practices have been likened to the Islamic practice of Zakat.[10] Local circumstances alter the way humanitarian action is perceived, filtering it through a cultural, religious, or political lens. Humanitarian PrinciplesWe sought to collect information on how the core principles of MSF’s work (neutrality, impartiality, independence),[11] as well as the notions of transparency and credibility, were understood and perceived by the different stakeholders. It seems important to link the way people interpreted these principles to the way this interpretation has influenced MSF’s activities and the security of its staff. The applicability of the principles was challenged in some countries, however. Respondents gave various definitions of humanitarian principles to the researchers. It is interesting to note that volunteers, employees, and members within the same organization do not always agree on a single definition of these principles. Therefore, responses were unsurprisingly varied. Moreover, it is sometimes very difficult for the teams in the field to put these principles into practice in the daily life of a project. Practical application of the principles of neutrality and impartiality was called into question in Cameroon, either because “neutrality” was not seen as compatible with human subjectivity,[12] or because MSF’s involvement with the national authorities forced it to take sides. Many respondents in Cameroon also doubted MSF’s neutrality as it only treats one disease, even though the medical needs in the areas where MSF is present are huge. Similarly, in Kenya, although most community representatives believed that projects honored the organization’s principles and that the quality of the free care was good, national staff members felt that the organization’s actions were overly limited given the needs of the region and said that the project was no longer faithful to either the principles or the charter, as it only treated a single disease.[13] This type of situation suggests the problem is that the organization sometimes places greater focus on the disease than on the patient. It was pointed out that, by implementing projects that address neglected diseases—interventions that are possible thanks to its financial independence—MSF sometimes risks concentrating solely on the disease (diagnosis and treatment) to the detriment of a holistic treatment of the patient’s medical needs. This demonstrates the difficulty of clearly explaining intervention criteria to the people concerned. Meanwhile, in Kyrgyzstan, members of human rights organizations and medical personnel who were questioned said that MSF is sometimes “too” independent and should collaborate more with other social and medical actors. Some informants questioned MSF’s neutrality, believing that the organization sided with the government by not diffusing information about the situation in the country’s prisons. Doubts were also expressed about the principle of neutrality in the Middle East, where the difference between humanitarian organizations and human rights organizations is not very clear to the general public. The interviews revealed a widely held belief that an organization working in emergency situations has an obligation to publicly denounce any violation of human rights. In Kenya, a neutral organization was described as “one in the middle,” “that is central, neither cold nor hot,” and one that “stands without following others.”[14] Neutrality was also directly linked to the presence of foreigners in the field: “a neutral organization is one that has no brokers. MSF has no middlemen, the whites bring the services to us.”[15] An impartial organization was described as one that “helps people that are most in need, without favoritism, like MSF does as [they] help those who are very sick, without discrimination” and one that “does not lie on one side.”[16] For MSF, the need for independence includes both financial independence and independence in assessing the needs of a given population[17] and the need for action. Consequently, MSF endeavors to obtain as much of its funding as possible from private sources and to diversify its institutional donors, refusing any financing that could compromise its freedom of action. Unfortunately, the majority of the people interviewed within the framework of this study were not aware of the private origin of the organization’s funding. Several participants were surprised to learn that no government funding was used in contexts such as Iraq, the Occupied Palestinian Territories, Somalia, etc. In Guatemala, it was essential to stress the organization’s independence from the political agendas of financial institutions and donors, which are often European governments. In discussions with Kurds in Iraq, a clear link was established between transparency and credibility. They believed that some international organizations were spying for intelligence agencies, although MSF seemed more credible in their eyes: “We don’t think that they [MSF] have a political agenda because they work throughout the world and come from a lot of different countries. We know they are volunteers. It’s important to know that MSF got the Nobel Peace Prize, because it means that it’s done something very big for humanity.”[18] Some representatives of civil society considered that humanitarian assistance must be transparent to local people in order to be better accepted. Almost all the informants from local organizations said that they expected greater transparency from international NGOs and hoped for improved coordination between them. In Guatemala, the surveys revealed that MSF’s credibility is an important factor. Indeed, the organization has a reputation for being independent (in relation to authorities and having no political agenda) and neutral (unlike American NGOs, which are financed by USAID[19] and/or are faith-based). This opinion is largely based on specific actions rather than on a clear understanding of the organization and its structure. Generally speaking, neutrality is the principle that was most questioned, since the establishment of a project in a given context is already the result of a political choice. Many noted that it is necessary to be more transparent about the difficulty of certain operational choices and stressed the need to take the time to explain these dilemmas. By contrast, the principle of impartiality was more widely recognized and appreciated by people, as it is easily understandable and visible in MSF’s medical facilities. Independence is perceived positively as it allows the organization to make its own choices. However, this independence can give rise to isolation. Finally, the transparency and credibility of international organizations were generally identified as criteria for assessing humanitarian work. For many, these notions are linked to MSF because it is a medical organization believed to deliver quality treatment. The varied scope of the work done by other NGOs (sanitation, shelters, nutrition, etc.) makes it harder for people to understand their activities clearly. Consequently, they are perceived as less transparent and less credible. Factors Influencing PerceptionSeveral factors emerged during the study that influence the perception of humanitarian action in general, and the work of MSF in particular. Some were identified at the start of the project, but subsequently did not seem important, such as the duration of its presence in a country. Even MSF’s very structure as a “movement”[20] was questioned. The importance of the political and social environment of the projects, and particularly the framework of analysis used by the local populations, proved to be crucial. Moreover, one aspect emerged, the importance of which had not been recognized at the start of the project: the religious context. Finally, the structure of the aid system and the power relationships that run through it are essential for an in-depth understanding of perception. Duration of MSF Operations in a CountryWe tried to ascertain whether the duration of MSF’s presence in a country had an effect on its acceptance by local people. The killing of five MSF members in Afghanistan in 2004 called into question the causal link between duration of presence in a country and knowledge and acceptance of the organization by the population. In fact, all the research carried out in the field showed that acceptance is much more closely linked to the quality of the treatment provided, the appropriateness of the response proposed by MSF to meet the needs of the population, and the quality of the networks established by the organization with local stakeholders. In addition, many respondents referred to the need to adapt to the increasing complexity of certain contexts: “You can no longer work in these types of contexts like before; you have to go out and build networks.”[21] Although MSF had been perceived well in Iraqi Kurdistan thanks to the medical activities set up in 1991, its departure from Iraq in April 2004 was taken badly by many Iraqis, who felt that MSF had left them at the time when they most needed emergency medical aid. That departure resulted in a loss of networks from 2004 to 2006 (when MSF returned to Iraq), making it difficult to start new projects in the country. Moreover, the very notion of longevity is questionable given that MSF’s institutional memory is rather poor, giving rise to a loss of history and knowledge about certain contexts. Effect of the Presence of Five MSF Operational Sections in the FieldAt the majority of the field sites visited, we noted that, apart from those in direct contact with section administrations, most people interviewed do not distinguish between the different MSF sections. In general, we observed that having several sections can be a double-edged sword. For example, in Darfur, only two of the five sections[22] were expelled, which enabled the others to continue to provide medical care. On the other hand, the problems encountered by one section can affect other sections present in the same region or country. An example is the Spanish section’s difficulty registering in Syria in 2008, where the poor relationship established with the Syrian authorities had a negative effect on the other sections present in Jordan. It should also be noted that, in some contexts, especially in dealings with state authorities, the five MSF sections are known and the differences between them are sometimes exploited for national political ends. Importance of the Local, National, and International ContextsIn the words of Rony Brauman: If we are to be the least bit realistic, we must acknowledge that, in reality, humanitarian action exists alongside politics, even if it is intrinsically driven to try to separate itself from political forces. Humanitarian organizations certainly operate in a highly charged political environment, but must constantly strive to steer their actions to ensure that the results of their work are not political and they do not favor a particular group or clan. Humanitarian organizations must be able to play the social game with politicians to avoid becoming a passive instrument of politics. They must adopt an active stanceand not allow themselves to be treated like objects, dragged around the political spectrum.[23] To avoid becoming a passive instrument of politics, we must become aware of national and international contexts. Humanitarian action did not evolve in the same way during the Cold War as during the war on terror. Political contexts at the national and international levels inevitably influence the image of humanitarian action and, therefore, that of MSF. The study shows that in the Middle East, as in all other contexts, as a result of historic, political, and social differences and the behavior of humanitarian actors, NGOs working in the field are suspected of having a hidden agenda.[24] In a way, they are associated with the Global War on Terror[25] (GWOT)[26] and the links between certain humanitarian organizations and political and military operations. According to Greg Hansen,[27] practically all humanitarian agencies kept a low profile in Iraq; this resulted in a tarnishing of their image, because nobody saw what they were doing. That, in turn, led to a great deal of misperception, mainly because the difference between NGOs and the UN and United States is not at all clear. We will discuss this confusion in more detail later on. Another consideration is the fact that the globalization of communication and information has important consequences for an organization such as MSF. For example, what the organization is doing in Haiti has repercussions on its activities in Pakistan via all-news channels and social networks. Similarly, information about scandals surrounding humanitarian action, such as those concerning Zoe’s Ark in Chad,[28] circulates very quickly and has a very negative effect on other organizations. This globalization increases the need for teams to explain more clearly the operational choices made by the organization. The difficult economic situation in some countries has contributed to NGOs being perceived as rich organizations. Their important role in the local economy was acknowledged, but in some cases, the security of humanitarian personnel was compromised as a result (risk of theft, kidnappings, etc.). Sometimes MSF finds itself in a situation where it is the main employer of a section of the population (Kacheliba in Kenya, Magaria in Niger, Léogâne in Haiti, for example), and that creates considerable dependence. This is a critical factor for the perception of MSF that the teams must take into account, especially when it comes to closing a project. In Iraqi Kurdistan, people consider humanitarian action as mainly needed in poor countries: “Humanitarian relief can be described as aid that poor people receive from various institutions, organizations, or even government associations, to improve their daily lives a little and rescue them from the danger of death, especially in the medical field. Because, as we know, the majority of people who receive humanitarian aid are in the third world. Countries in that part of the world lack appropriate medical care, especially from their own governments. So, medical humanitarian action is needed in that part of the world.”[29] Sometimes, it is even a question of honor: “I don’t know exactly what you mean by humanitarian action. We Kurds are not in need of humanitarian aid; what we really need is someone to help us rebuild our infrastructure to enable us to become self-sufficient again and reach the level of developed countries. We don’t need your charity because we’re not a poor country, but one of the richest countries in the world. So, please don’t talk to us about so-called ‘humanitarian action.’”[30] Some local stakeholders object to MSF’s presence because “it’s not Africa here.”[31] In Jordan, on the other hand, local stakeholders did not make any such criticisms. The Zakat committees, for example, are much more open to humanitarian NGOs: “The problem in Jordan is that aid at the different levels isn’t coordinated and there’s no discussion between NGOs, local associations, and Zakat committees.”[32] This discourse also stems from a wish to be integrated into an aid system and to be recognized as one of the main participants in social redistribution in the Arab world. People in the Middle East have difficulty understanding the motivation of secular organizations, and would feel much more comfortable dealing with organizations that assume a religious identity. Importance of the Local Population’s Analytical FrameworkThe association between MSF and religion would mainly seem to result from the organization’s involvement with local communities, which would explain why it is not considered a secular or religious organization per se, but may be perceived as such in some very specific contexts. This explanation of proximity enables us to distinguish three scenarios: political proximity (e.g., the Occupied Palestinian Territories), religious proximity (e.g. Niger), and secular proximity (e.g., Kyrgyzstan). The question is whether this proximity is perceived positively or negatively. The societies in which MSF works are often very religious, and that has an effect on the way people perceive the organization and its activities. Communities may give a religious connotation to organizations working in their country because that is the “analytical framework” they use. MSF has always positioned itself outside the secular/faith-based dichotomy, considering the debate irrelevant for the implementation of its medical activities in the field. Surveys have revealed, however, that religion influences the way its operations are perceived. This is partly due to the origin of its managerial staff and international volunteers,[33] the way the “missions” are set up, and the vocabulary used,[34] particularly in internal documents, which can have religious or military connotations (mission,field workers,[35] sections, and so on), or the religiousness of the societies in which MSF works. Pascal Dauvin and Johanna Siméant have shown that humanitarian workers in French organizations are usually involved with religious institutions, or that their religious education influenced their decision to work in the humanitarian sector. However, it would seem that the main motivation of international personnel choosing humanitarian work is its “social utility.”[36] It would nonetheless be very difficult to try to pinpoint the motivations of people working within MSF, as they largely depend on personal paths rather than general trends. That said, while individuals have their own motivations, the organization as an institution must assert its own motivations, which its members are expected to adopt. A few years ago, in a contribution to MSF’s strategic review process,[37] Jonathan Benthall raised the question of whether MSF could legitimately be regarded as a faith-based organization. His point was that, although no religious connection is visible at first sight “because, historically, the creation of MSF resulted mainly from an alliance of medicine, journalism and the political left—all entirely secular institutions,”[38] three essential components of MSF’s identity could give that impression. Firstly, its name and inspiration derive from medicine. Consequently, MSF could benefit from a sort of “secular sanctity.” Its association with emergency medical care only accentuates the connotation of religious sensibility, which consists of making sense of death. Secondly, due to its transnational nature, it represents all the religions of the world. Third, it shares with religious organizations a tradition of effective mass communication. According to J. Benthall, the history of the schism (first from the ICRC, then from Médecins du Monde [MdM]), and MSF’s “martyrs” (people who have died during missions) are two other elements that support this theory. Consequently, MSF could be referred to as a “secular faith-based organization.” This categorization would hardly surprise those in the West who are familiar with MSF, its history, origins, and cultural framework. It would be less evident to the populations in direct contact with the organization in the field, including national staff, who do not necessarily have all the information required to place MSF in the context of its creation and evolution. Organizational identity depends not only on the image that MSF wants to convey, but also on what the organization means to people. It is also important to note that, when the perception project questionnaire was designed, religion had not yet been identified as a fundamental consideration. This factor will certainly have skewed the results, but the research team had assumed that religion would not be part of MSF’s constructed identity. The religious dimension was not, therefore, taken into account at the beginning of the project since MSF is relatively rooted in French secularism, or, at least, in the belief that it is essential to distinguish between the public and private spheres, religion being viewed as belonging to the private sphere. Other aspects were given priority, such as the assumption that MSF’s financial independence would be recognized by most of the people interacting with the organization. The process of defining the terms of the project itself therefore clearly took place within a European cultural frame of reference. If that frame of reference is not explained by the teams in the field, it cannot be understood in certain contexts by groups of people for whom religion is a reference system. The principle of humanitarian action outside of any religious framework can be difficult to explain, although MSF never uses it as a cultural reference or as a way to identify itself. Consequently, religion is never part of the message that it sends out to the societies in which it works; nor does MSF define itself as secular in its public messages. If it had to, it would describe itself as nondenominational. The question of religion is only addressed when it affects impartiality and access to patients or vulnerable populations. The issue is not really whether MSF’s discourse has religious overtones, however, but rather how that discourse is perceived, because that perception will influence its ability to carry out its operations. Indeed, perceptions can turn into political facts. In Kenya and Uganda,[39] for example, nearly all the people questioned associated humanitarian aid with charity and, consequently, a sort of divine intervention. MSF, like other humanitarian actors, is often described as an example of “goodness” and is therefore associated with God. In particular, it is compared with “God who created Earth” (torotot), “Gods who prolong life and give life to the disabled,” or even “someone who helps like God” (kingoro kut).[40] Neutrality and impartiality are sometimes regarded as divine qualities: “They are neither on the side of the government nor on the side of the Church. They are people sent by God. ...They have no church, their church is the hospital” and “an impartial organization is one that works in the Spirit of God.”[41] In some regions of Kenya, the organization is thought to be linked to the Anglican missionaries, who are the only white people to have ever lived in the region. The medical activities themselves are perceived as having a divine origin: “God is no longer far away. He has come down to Earth to help us. ...The God who gives power to MSF is good and very powerful;” “their money comes to them from God, who distributes wealth;” “they [the MSF staff] are the servants of God, whom God has sent to help people, although they are not related to them.”[42] The fact that treatment is free of charge also contributes to strengthening this association with religion: “[MSF] is religious, because it is not money-orientated.” The volunteering aspect is associated with charity among both Christians and Muslims: “Al Zakat is obligatory. Not giving is a sin. But MSF is a charitable organization;”[43] “The main reason why foreigners work for humanitarian organizations is because they’ve been touched by the Spirit of God;” or “God has blessed them so that they may help others.”[44] In Zinder,[45] Niger, MSF was also regarded as a religious organization: “MSF is a religious organization because it’s pity that brings them to look after the children.” Most of the women interviewed thanked God and MSF for the free care policy and the treatment received. The majority of them made a connection between MSF’s activities, charity, the Zakat committees, and the Muslim religion. Indeed, most of them thought that MSF’s headquarters was in Saudi Arabia. It is worth noting that this presumed religious origin or the connection made between MSF and a given religion usually has a positive effect on the image of the organization and its acceptance in the social fabric. It tends to create power relationships, where international staff are seen as being “blessed” by a divine authority and, consequently, inspire more trust than local practitioners. People would therefore sometimes rather be treated by international doctors or nurses. This behavior can harm the organization’s relationships with local or traditional practitioners, and this consideration must be included in strategic planning by MSF’s field sites and headquarters. In some places, medical projects have disrupted a social organization where diseases were explained by the intervention of occult forces. In Liberia, witchcraft still has a strong presence in Nimba County.[46] It is believed that witches are able to inflict diseases on people that cannot be treated by modern medicine, which is seen to explain why some patients spend several months in the health center opened by MSF[47] without being cured. The population has integrated the presence of modern medicine into its own traditions. Expatriates are considered external to the world of magic,[48] but people interviewed stressed that MSF’s doctors should recognize their own limits in terms of their ability to treat all diseases and accept that herbalists (“traditional” doctors) can sometimes help modern medicine and should be incorporated into health care facilities. Even in Monrovia (Liberia), the hospital is viewed as the last resort (after self-medication, the local doctor, the traditional healer, the pharmacy, church, and clinic). The division between modern medicine and modern diseases, on the one hand, and traditional practitioners and diseases caused by supernatural forces, on the other, was also referred to in other projects. The way “modern” medicine explains diseases does not tally with the spiritual explanation given to certain diseases in some societies. In Cameroon, MSF carried out a vertical project designed to fight a neglected disease called Buruli ulcer. It is not yet known how this disease is transmitted. In Akonolinga,[49] patients receiving treatment for Buruli ulcer are now considered privileged. Indeed, the wing of the hospital where they are cared for has been renovated and these patients receive food rations in addition to their medicines. Previously, it was thought that patients suffering from Buruli ulcer had been punished for their sins (witchcraft, theft, rape, etc.). The disease played a social role in the community. In all discussions, even with MSF’s national staff, two types of “atom”[50] were described: the “simple” type and the “mystical” type. The simple atom can be treated in MSF’s facilities, unlike the mystical one, which, despite the willingness of the clinicians, can only be treated by the traditional healer. There were also tensions between traditional healers and MSF due to the fact that the treatment provided by MSF is free of charge, while patients must pay to be treated by traditional practitioners. The other project in Cameroon was located in Yaoundé and looked after HIV/AIDS patients. Many informants made a distinction between “biological” AIDS and a “slow poisoning” of mystical origin. Footnotes
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