by Rony Brauman and Joelle Tanguy (1998)

The 1971 creation of Médecins Sans Frontières brought about a small revolution in the world of humanitarianism. The purpose of this text is to record how that revolution came about, and how it continues today, more than a quarter-century later.

How MSF Began

It was the commiseration of two groups of frustrated international relief doctors that sparked the genesis of Doctors Without Borders/Médecins Sans Frontières (MSF). Independently, both groups had reached the same conclusion: that deference to the will of individual nations obstructed efforts to provide medical relief quickly and effectively.

The first group of doctors had become recognized for its work in Biafra, a region of Nigeria torn apart by a brutal civil war, where it operated from 1968 to 1970 on behalf of the French Red Cross. The second group had become known for having volunteered in 1970 to treat the victims of a tidal wave in eastern Pakistan (now Bangladesh). Independently, these groups discovered -- the first during a war, the second during the aftermath of a natural disaster -- the short-comings of international aid as it was then configured. This configuration provided too little medical assistance and was too deferential to international law to be effective in crisis situations. MSF was founded on December 20, 1971, when these two groups joined forces. By forming MSF, this core group of doctors intended to change the way humanitarian aid was delivered by providing more medical assistance more rapidly and by being less deterred by national borders at times of crisis.

Red Cross Roots

MSF's creation was actually the culmination of a trend initiated ten years earlier by the International Committee of the Red Cross (ICRC), a trend that was in itself a response to the work of Red Cross societies. During the early part of the twentieth century, humanitarian emergency aid was provided primarily by the Red Cross movement. But the effectiveness of its actions has been compromised by slow transport facilities and cumbersome administrative and diplomatic formalities.

In times of war, the ICRC intervened. Its main role was to make sure that the belligerent nations complied with the Geneva Conventions providing for the protection of and assistance to prisoners and civilians in time of war. Until the beginning of the 1960s, the Geneva-based ICRC carried out its duties without sending medical units to battle sites.

The ICRC was not encouraged to send out medical units because most conflicts in the past century involved either industrialized nations opposing each other or industrialized nations opposing their colonies. In both types of conflict medical care was provided by the military of the countries involved. In the first type of conflict most victims were soldiers. The armies facing each other were medically well equipped: each had its own medical unit to treat its own wounded. Military doctors were assisted by nurses and stretcher bearers from the Red Cross sections of only their own countries. In the second type of conflict, the colonial powers used the principle of noninterference to outlaw any foreign medical assistance to nationalist guerrillas. Here, too, war medicine was limited to military medicine.

It took the multiplication of civil wars in the developing world after the decolonization era (Katanga in 1960, Yemen in 1962, Biafra in 1967) to prompt the ICRC to add medical assistance to its roster of help. These new conflicts were much harder on the civilian population than earlier wars because, for example, of food blockades, and because guerrilla and counter-guerrilla strategies caused massive flows of refugees and internally displaced persons under very precarious circumstances. Most of these conflicts tore apart countries already lacking doctors and therefore limited in their capability to deal with the public health problems with which they were abruptly confronted through the confluence of underdevelopment and war.

The Consequences of Biafra

The ICRC began its emergency medical efforts by sending out a few doctors, whom it hired temporarily for renewable three-month terms. These doctors were recruited by the national Red Cross societies. During the summer of 1968, the ICRC offered the French Red Cross (FRC) the opportunity to run its own independent medical mission in Biafra. The FRC accepted readily, particularly since its acceptance enabled the French government to support the Biafra secession without too much compromise.

From September 1968 until January 1970, under extremely dangerous circumstances, the FRC managed to send some 50 doctors to Biafra. These doctors were driven by a mixture of compassion, religious conviction, and a desire to use their professional skills to save as many lives as possible. Among them were the future founders of MSF, including Bernard Kouchner, who later became France's first Minister of Humanitarian Affairs.

For many, the conflict over Biafra meant the discovery of the "Third World," of a little-known conflict, and of the inability of humanitarian action to solve crises of enormous proportions. The Biafran war, which ended in 1970 with the Nigerian government's victory and the death of one million people, clearly revealed the shortcomings of the Red Cross in responding to emergencies. Some of the future founders of MSF opposed ICRC regulations that forbade the Red Cross staff from making public statements about human rights violations and genocide. Furthermore, ICRC was not entitled to intervene in a country without the approval of the country's authorities. It had to accept the sovereignty of any state that accepted its assistance; thus, ICRC personnel had to take a reserved attitude toward the events they witnessed during a mission.

Several FRC doctors defied this prohibition by organizing a "committee against the Biafran genocide" as soon as they were back in France -- less to make the public aware of the plight of the Biafran population than to denounce the political sources of this conflict, which were too often hidden by the papers covering the war. The committee argued that medical action should not be turned into a blind and dumb instrument. These French doctors also criticized the Red Cross intervention techniques as being obsolete.

This activity attracted a group of approximately fifty people who were persuaded that conflicts such as Biafra would happen again and needed to be anticipated. Thus, the Biafra veterans began meeting once a month to share and refresh their memories. In 1970 they organized the Groupe d'Intervention Medical et Chirurgical d'Urgence (Emergency Medical and Surgical Intervention Group, or GIMCU), in the hope of setting up an independent association specializing in providing medical emergency assistance free from the administrative and legal constraints facing the ICRC.

At the same time, another group of doctors was associated in France at the initiative of the medical journal Tonus. In 1970 Tonus's editor, Raymond Borel, spoke on television about the distress of the Bangladesh tidal wave victims and the lack of French doctors at the site of the disaster. On November 23, 1970, he published an appeal in the columns of his journal to establish an association: Secours Medical Francais (French Medical Relief, or SMF).

Doctors responded to Borel's call to action for many reasons: a bad conscience in the wake of the disturbing television images; the feeling that France, because of its history, had a duty to cooperate with decolonized countries; or simply the desire to get away from routine medicine and benign pathologies in order to practice presumably more useful medicine under more stimulating conditions. On December 20, 1971, MSF was born from the merger of GIMCU and SMF.

The "French Doctors" Movement

It is no accident that MSF was set up at this time and in France, a country preoccupied with its colonial past. MSF's creation further coincided with the democratization of air transport and information, with the era of electronics and satellites, and with the increasing perception of the world as a global village. These factors, in combination, made it possible to intervene increasingly rapidly at disaster sites. The instantaneous visibility of disasters and conflicts on television made it less and less acceptable either to do nothing or to offer only a confused effort at emergency assistance.

From its inception MSF hoped to benefit from the experience of its "Biafran" firebrands and the infrastructures (offices and secretariat) of its Tonus group. But the first steps were difficult. From 1971 to 1976 MSF was more like a pool of doctors at the disposal of large development aid organizations than a truly independent medical emergency organization. Its budget was limited to a few hundred thousand francs, and its missions, with a few exceptions -- such as in Nicaragua after the 1972 earthquake and Honduras after the 1974 hurricane -- were not independent. For lack of resources and experience, these early and limited interventions were highly ineffective. In Nicaragua, for example, American assistance arrived well ahead of MSF.

MSF: The First Decade

MSF remained a very small organization in the 1970s for several reasons. First, it consisted exclusively of volunteers, each of whom was employed outside MSF. In the circles of established international organizations, the MSF volunteers were considered amateurs, tourists, or "medical hippies." Second, MSF's members refused to ask for charity from the public or to "sell" humanitarian services like a commercial product, a policy that was not conducive to growth.

MSF flourished for the first time from 1976 to 1979. A 1976 war mission in Lebanon in a Shiite neighborhood encircled by Christian militia, and a free advertising campaign offered in 1977 by an advertising agency, gave MSF an identity (an organization that dealt with dangerous emergencies) and its first public recognition. MSF was of interest not only in France but also in the United States, because the American press reported on the courage of the French doctors in Lebanon.

But despite its interventions during a widely reported war and the fruits of an advertising campaign, in 1978 there remained a large gap between the association's reputation in France and its actual impact. And despite its strong showing in the media, the organization's existence was more symbolic than operational. It sent out only a few dozen doctors per year.

The Refugee Camp Factor

The formidable growth of MSF after 1978 was fueled by one factor: the multiplication of refugee camps at the end of the 1970s. This single phenomenon defined for MSF its main fields of intervention. While the global refugee population remained stable between 1970 and 1976, it doubled between 1976 and 1979, from 2.7 million to 5.7 million. It doubled once again between 1979 and 1982, settling at 11 million persons until 1985.

This increase was due to the sharp growth in the number of conflicts in the Southern Hemisphere after 1975. These conflicts were caused largely by the reemergence, after the decolonization era, of old national antagonisms and ethnic rivalries, as well as the fact that the East-West confrontation had moved out of Europe.

At the same time, the Soviet Union began to increase its influence in several developing countries, profiting from 1975 onward from the U.S. withdrawal after the Vietnam defeat and the instability brought about in southern and eastern Africa because of the Portuguese decolonization and the fall of the Ethiopian Negus. The Soviet expansion fueled a number of conflicts in Angola and Mozambique between pro-Soviet regimes and counterrevolutionary guerrillas, as well as in the African Horn. There, Somalia and Ethiopia began to fight in 1977 over the control of the Ogaden region, an Ethiopian territory inhabited mostly by Somalis. In addition, the 1975 communist takeover of Indochina led to the exodus of hundreds of thousands of boat people and other refugees to Thailand, Malaysia, and Indonesia. Meanwhile, ethnic and religious minorities in Eritrea and Lebanon began or continued civil wars to obtain their independence or more power. Millions of people were packed in camps along the borders of these warring countries, often under very poor sanitary conditions. Although the United Nations High Commissioner for Refugees (UNHCR) assumed responsibility for the refugees, and built and supplied camps, it had tremendous difficulty finding medical personnel willing to work in these areas.

MSF saw the increasing number of refugee settlements in the world as a fertile field of action. In contrast to the UNHCR, MSF did not lack doctors. In the second half of the 1960s the French job market was flooded by doctors from the baby-boom generation who did not have to repay their student loans (as they did in the United States) and who often had had their first taste of the "Third World" during their military service. Many general practitioners of this generation were experiencing an identity crisis. Faced in their daily practice with benign pathologies that did not interest them and unsolvable problems that they could only refer to specialists, many of them were tempted to practice what they saw as a "more authentic" form of medicine in the developing world.

From 1976 to 1979, MSF sprang to the aid of Angolan refugees in the former Zaire; Somali refugees in Djibouti; Saharan refugees in Algeria and Eritrea; and, above all, Vietnamese, Cambodian, and Laotian refugees in Thailand. Initially MSF offered modest help to the American humanitarian organizations that had already been on the scene for over a year (particularly the International Rescue Committee and World Vision). Yet the French doctors sometimes questioned the motivations of the organizations for which they were working, suspecting them of acting as much for political objectives (anticommunism) and religious reasons (proselytizing) as for humanitarian goals.

During this period, MSF gradually expanded its operations in Thailand, slowly replacing the American organizations, which began to withdraw from the refugee camps as the memory of the Vietnam War began to fade. In December 1979 MSF also sent 100 doctors and nurses to the Cambodian border.

The Tension of Growth

The multiplication of its missions in refugee camps at the end of the 1970s forced MSF to adopt a more professional approach, which meant, for example, paying a coordinator in Bangkok and providing small stipends for doctors sent out for six-month periods. This trend, far from being welcomed by every MSF member, began to divide those who longed for the days of purely voluntary emergency medicine (including the veterans of Biafra) from the new generation of doctors wanting to serve for longer terms in refugee camps and to provide more demanding medical services. In 1979 these long-submerged tensions led to a split within MSF.

Until 1977 Bernard Kouchner had been the organization's undisputed leader. But his power was challenged in 1978 by the new generation of refugee camp doctors and by his most brilliant disciple, Claude Malhuret. The baby-boomers, Malhuret's generation, were more numerous than Kouchner's followers, and they were also more pragmatic. Malhuret and his generation were concerned about the technical insufficiency of MSF interventions in refugee camps. Foremost among technical problems were logistical difficulties, including communications between Paris and the field and delivery of medical supplies. Advocates of short, independent, voluntary missions, the older generation were afraid that MSF would be turned into a bureaucracy if it addressed these problems.

The second disagreement between the two groups focused on MSF's media posture. Despite some of its founders' opposition to the Red Cross's policy of silence, until 1977 the MSF charter forbade its members to talk about what they had witnessed during their missions. The policy of silence was intended as a strong symbol of political neutrality as well as a strategic posture to ensure its ability to perform "border-free" operations, since it was thought that no state would accept the presence of overly garrulous doctors on its territory.

Many factors combined to create widespread agreement in French society in the late 1970s on the primacy of human rights. Some examples include the revelations of abuses and oppression in the Soviet Union by Russian dissident author Alexander Solzhenitsyn; growing awareness of severe oppression by dictatorships in Latin America, such as Chile and Uruguay; and the 1977 award of the Nobel Peace Prize to Amnesty International. After 1978 some members of MSF spoke to the press, in the belief that testimony in MSF's name would shake the public from indifference.

When Bernard Kouchner chartered a ship to rescue Vietnamese refugees in the Chinese Sea, he triggered the crisis that led to the 1979 split. Two hundred thousand boat people had fled communist Vietnam since 1975. Those who survived assaults by pirates and storms (only half) went to Thailand, Indonesia, or Malaysia. In 1978 the capacity of these three countries became saturated by the sudden arrival of massive numbers of refugees. To put a spectacular end to international indifference to its problem, Malaysia decided on November 15 to close its Hai Kong coast to a drifting coaster carrying 2,564 Vietnamese refugees. The maneuver succeeded, and along with reports of the intolerable sanitary and hygienic conditions on the vessel, it aroused the indignation of the world press and international public opinion. On November 22, a group of French intellectuals, moved by the Hai Kong tragedy, founded the Ship for Vietnam committee, whose purpose was to charter a vessel to receive refugees off the Vietnamese coast and to transport them to a host country.

The committee soon asked MSF to take medical responsibility for the refugees received on the ship, which MSF agreed to do. But several MSF members accused Bernard Kouchner of playing too active a role in the operation without consulting others. Although they did not underestimate the media and symbolic interest of this initiative, both for the refugees and MSF, Claude Malhuret and MSF cofounder Xavier Emmanuelli nevertheless disputed its technical legitimacy: they considered a single ship insufficient to receive the host of refugees whom its presence encouraged to flee.

The correctness of this criticism prompted MSF to withdraw from the operation and was confirmed by the new objective the committee assigned the ship, L'Ile de Lumiere (Island of Light), in April 1979. The vessel was no longer destined to receive boat people in the Chinese Sea, but was to become a hospital ship designed to treat the forty thousand Vietnamese refugees on Poulo Boudong island. This controversy led to the final split between the majority of MSF founders (except Xavier Emmanuelli and Raymond Borel) and the new generation in power. In 1979 Bernard Kouchner left MSF to found Médecins du Monde, or Doctors of the World.

Survival and Growth

From 1979 to 1986 the scope of MSF's activities grew at a galloping pace. This growth also led to its internationalization in the early 1980s. The MSF movement, while born in France, was enriched by the organization of Belgian and Swiss sections in 1981, a Dutch section in 1983, and Spanish and Luxembourgian sections in 1985. Between 1986 and 1995, this expansion continued with the creation of supporting sections in Australia, Austria, Canada, Denmark, Germany, Greece, Hong Kong, Italy, Japan, Norway, Sweden, the United States, and United Kingdom.

After serious competitive tensions arose among the various national sections during the 1980s, the increasing globalization of the world in which the organization works during the 1990s brought about the recognition of the need for greater cooperation and cohesiveness. Today many emergency missions are undertaken by international teams drawn from the various sections. Directors of the sections meet regularly to decide on main lines and strategy. In 1990 both an international council and international secretariat were created to facilitate coordination among all MSF sections.

Both the growth of the original section in France and the creation of new sections was partly due to a favorable international context in the beginning of the 1980s and to successful technical and strategic choices made by the organization. For the three leaders of the French section following Bernard Kouchner's departure, Claude Malhuret, Francis Charhon, and Rony Brauman, the challenge was to convince their more skeptical colleagues of the need for structural change. Those changes included adoption of logistics and medical departments, a salaried administrative system, and the organization of marketing activities.

In particular, they reasoned, the association needed substantial and dependable financial resources to guarantee its independence. Although the French section of MSF roughly tripled its income between 1979 and 1980 (from $1.5 to $4.3 million), its financial structure remained extremely fragile, depending mainly on the international economic situation-that is, they relied on isolated and spontaneous donations from institutions or private individuals who were prompted to donate by media representations of various disasters (for example the influx of refugees in Thailand, the Soviet invasion of Afghanistan, the famine in Uganda, the Polish siege, and the Lebanese war). This financing method clearly had its limits, and in 1982, MSF began to introduce direct-mail fund-raising techniques based on the success of these methods in American presidential elections. These techniques, at the time unknown in France, for the first time gave MSF regular income, making it less dependent on political changes and institutional donors.

The growth of private fundraising has ensured MSF's independence from any single donor or government, and the organization has set clear policy that at least half of all funds raised the must come from private sources. Despite its French origins, the organization has shied away from French government funding, which today represents less than one percent of the total budget. Some of the key institutional and government funders are the European Community Humanitarian Office (ECHO), United Nations High Commissioner for Refugees, the United States Office of Foreign Disaster Assistance, and Belgian, Dutch, Norwegian, and other governments.

Growing Professionalism

Buffeted by growing financial resources, MSF's interventions improved in effectiveness by an in-depth overhaul of its technical structures. First, to encourage participation and the stability of its pool of trained volunteers and staff, MSF began to pay a salary to the staff doctors working in the headquarters and a travel allowance and a stipend of about $700 per month to the doctors working in the field for longer term missions. Second, the staff at the headquarters was expanded as technical units grew. Third, recruitment efforts were better organized to include more screening and better orientation training; in the early 1980s the number of doctors and nurses sent out increased considerably, to up to 600 departures per year. Today the organization dispatches approximately 2,500 volunteers to medical projects each year.

MSF has developed a standardized recruitment process designed to match qualified health care professionals with appropriate projects and to train them to undertake their medical missions under conditions that might be unfamiliar to them. The organization seeks general practitioners; specialists such as surgeons, anesthesiologists, obstetrician-gynecologists, and ophthalmologists; registered nurses; midwives; and public health and nutrition experts. Candidates submit a written application detailing medical training, professional experience (especially expertise with tropical medicine), foreign language ability, and availability and flexibility. Applicants are then interviewed by MSF recruiters, who evaluate the candidate's motivation and ability to function and live with an MSF team. Once selected, candidates are placed on a recruitment reserve list.

The process of training volunteers is an essential component of MSF's commitment to the quality of its missions. MSF runs 52 weeks of courses per year, targeted to volunteers at various levels of experience and expertise. Many volunteers take a preparatory course before their first mission, which addresses specific health care issues as well as the contexts in which missions are conducted. Advanced courses in epidemiology, nutrition, immunization, and water and sanitation management are also available, as are courses in logistics coordination and management of missions.

The Logistics Revolution

The expansion of MSF's logistical capacity marked an important step forward. By 1981 logistical problems had grown to the point of paralyzing medical activity in the field. From the refugee camps in Thailand and Somalia, where supplies had to be provided for volunteer units of up to forty persons, came the awareness that non-medical activities were needed to ensure the effective provision of medical services. The first full-time logistics manager, Jacques Pinel, was appointed in Paris and was assisted by several experts in the field. Over time, he and his colleagues created the system of rapid response and support for which MSF has gained much recognition.

This logistics revolution had three central components: communications, transportation, and the preparation of emergency kits for immediate response. Communications advances gave rise to the establishment of radio links between headquarters and the field. Now satellite transmission dishes arrive in the field with staff so that they will not be without access to their home section and to the outside world. Transportation logistics were developed in collaboration with the organization Aviation Sans Frontières, or Aviation Without Borders, creating priority transport capability. For the ground, MSF bought cars and began to coordinate more efficiently its staff travel arrangements.

Finally, the logistics experts worked with medical experts to develop a sophisticated inventory of medical and field supplies. Because MSF faces the challenge of responding quickly to emergencies while adapting each response to specific and dramatically different situations (often unknown before an exploratory team is dispatched), there was a need to develop a series of medical and logistical kits that could be combined to meet any crisis.

As a result, MSF has developed ready-to-be-dispatched kits containing the hundreds of medical and non-medical supplies that are necessary to accomplish specific tasks but are so time-consuming to gather from scratch. Upon evaluating conditions and needs in the face of an emergency, MSF personnel determine the types and quantity of kits to be deployed from a ready selection of some fifty kits that includes a basic medical kit, an emergency health kit, a vaccination kit, and a surgical kit. Kits are composed of modules, or groups of basic supplies, such as bandages, that can be restocked as needed during operation at a field location. Since the kits are stocked in advance, all materials in them have been selected and tested, and are ready for use; and the cost, weight, and size of specific kits are known. By using standard kits in combination, supplemented as needed by additional modules, MSF is able to adapt quickly to serve new or changing situations.

The size and completeness of the kits sometimes surprise observers who are unfamiliar with MSF. For example, to furnish medical assistance to a displaced population of thirty thousand persons in an isolated area, MSF might elect to deploy three emergency health kits capable of serving ten thousand persons each for a period of three months, as well as various kits providing energy sources, all-terrain vehicles, office supplies, satellite communications equipment, and other equipment and tools. Each emergency health kit would include modules of medicines, selected in accordance with MSF's medical protocols, and other basic medical supplies, such as bandages, rubber gloves, thermometers, and syringes. Then, if an MSF exploratory team were to identify the risk of say, a cholera epidemic in the population, MSF would be prepared to deploy immediately an additional kit containing the medicines and supplies necessary to combat cholera. During the cholera epidemic that swept seven countries of eastern and central Africa during the winter 1997-98, teams were able to set up cholera treatment centers to treat hundreds of patients within 48 hours of the first signs of the epidemic.

The progress made by MSF with the development of kits enabled it in the spring of 1991, within the space of ten days, to send seventy-five airplanes loaded with some 2,500 tons of equipment to help the hundreds of thousands of Kurdish refugees who had fled Iraq. This progress also increased the effectiveness of MSF's interventions after certain natural disasters. After the earthquakes in Nicaragua, Algeria, and Mexico, MSF's emergency units had arrived too late at the disaster sites. Therefore, after the 1986 earthquake in El Salvador and the 1988 earthquake in Armenia, MSF elected not to provide direct medical care to victims but rather to operate in the background by treating non-urgent conditions to allow local hospitals the space for truly serious cases, and by building shelters, drinking-water reservoirs, and sanitary facilities to replace those destroyed by the disaster. The development of emergency kits has enabled MSF more often to provide life-saving aid at the scene of a disaster before it is too late. Following the 1998 earthquake in northeastern Afghanistan, which reportedly killed 5,000 people, MSF was the first organization on the scene, arriving in the hardest hit city of Rostaq within two days of the disaster to provide critical care and to evacuate the most serious cases to the MSF-run hospital in nearby Taloquan.

The Move Toward Efficiency

If the period from 1979 until 1986 was for MSF marked by growing visibility without a similar increase in efficiency, the reverse occurred from 1986 to 1992, when the organization dramatically increased its capacity to intervene in emergencies, yet experienced a drop-off in media attention. The Ethiopian mission during the famine of 1984 was a turning point in the growing awareness of the organization's technical weaknesses. Concern about this situation coincided with the arrival of a generation of doctors who were less politically oriented and more technologically minded than the previous generation. These doctors expected to have more technical resources at their disposal.

In response to these concerns, MSF set about standardizing its procedures and protocols, beginning by drafting guidelines to be used in the most common emergency relief situations. Approximately forty books of guidelines exist, covering basic medical practice, as well as specialties such as surgery and ophthalmology. In addition, MSF has developed specialized expertise in nutrition and vaccination and has set up water and sanitation units. The latter development was important because medical teams in refugee camps must always deal with sanitary problems (well purification, construction of latrines, waste-water discharge) to prevent typhus or cholera epidemics.

Over the years MSF has helped to create several affiliated organizations that are devoted to pursuing specific areas of research in the field of emergency medicine and relief. In 1986 in Paris, MSF created Epicentre, a group of epidemiologists charged with epidemiological research and evaluation of the work of MSF and other aid organizations. In 1984 in Belgium, MSF members founded the Agence Européenne pour le Developpement et la Santé (European Agency for Health and Development, or AEDES), which consults on emergency project management, food security, and other public health matters. In 1992 in Holland, HealthNet International was founded with the support of MSF to support the redevelopment of health and social services in the aftermath of a crisis.

A Fresh Approach to Humanitarian Aid

From 1979 to 1986 wars and refugee camps became more than ever the preserve of MSF. The conflicts that started at the end of the 1970s were followed by wars in Chad and Uganda and the war between Iran and Iraq. The end of the decade was marked by the largest communist expansion in the history of the developing world-the Vietnamese invasion of Cambodia and the Soviet invasion of Afghanistan. In the early 1980s the United States decided to react to the Soviet advance. Ronald Reagan, then the U.S. president, led a crusade against communism, supporting several counterrevolutionary guerrilla movements. Regional conflicts, the center of the U.S.-Soviet struggle, continued and compounded the problem of refugees along the borders of warring nations. During this period, MSF intervened in some of the regions where the East-West antagonism was at its worst: Central America, southern Africa, the Horn of Africa, the Middle East, and Southeast Asia.

As it continued its interventions, MSF strengthened its position as an original player on the international scene, thanks to its novel concept of humanitarian action. Guiding its action were three principles: the right of access to victims, the need for monitoring of aid, and the protection of humanitarian workers. To enforce these principles, MSF was willing to violate the two intangible principles imposed on ICRC workers: respect for national borders and the duty to remain silent. MSF began to speak out against violations of these ethics (in Cambodia, Afghanistan, and Ethiopia) and to conduct clandestine missions when its presence was not officially welcomed (in Afghanistan, Kurdistan, El Salvador, and Eritrea).

In Afghanistan, where MSF intervened clandestinely just a few months after the Soviet invasion, the organization undertook one of the most dangerous assignments in its history. Here, more than in any other country or conflict, MSF made incarnate the right of all victims to be treated. MSF's stance in Afghanistan set it apart from American relief organizations and the ICRC. For ten years, together with the teams of other French organizations, the 550 MSF doctors and nurses who relayed each other on Afghan territory were the only foreign humanitarians assisting the population on the side of the Afghan resistance fighters. Because of its rarity, the medical assistance offered by MSF gave the Afghans valuable psychological and political support. The foreign doctors were their link with the West to make the international community aware of their struggle, especially from the fall of 1981 onward, when the Red Army began to bomb the hospitals in which MSF was working. At the time, MSF denounced the Soviet acts and encouraged journalists to visit Afghanistan.

The Choice to Speak Out

In Ethiopia, MSF continued its outspoken attitude, achieving a precise objective. In the spring of 1984 the organization began to send medical units to this country to help fight the famine. At the end of that year the Ethiopian government began to move the northern population victimized by the drought to fertile regions in the south. When MSF assisted with the first transfer, it saw no reason for criticism. After all, what was more logical than to move people from arid regions to fertile ones? The violence observed at times by MSF members was viewed as an isolated problem rather than deliberate policy. To continue their humanitarian work, the doctors decided to remain silent.

The transfers became more authoritarian in early 1985, and the violence more frequent. MSF members witnessed roundups of hospitalized persons, noticing that no efforts were made to keep families together. Many persons died in transfer. The areas in which those being transferred were settled were frequently without adequate facilities or assistance, and the Ethiopian authorities had established food quotas in Addis Ababa. Furthermore, the transfers diverted many resources from the MSF rescue operations.

By autumn of 1984 it became clear that there was a political and ideological motivation behind the transfers, carried out with the twofold aim of weakening the guerrilla movements in the north (in Eritrea and Tigre) by removing their grass-roots supporters and of putting these populations in villages in order to bring them ideologically in line with government policy. Under this scheme, humanitarian aid was used to attract villagers and blackmail them into going along with the program. After lodging many fruitless protests with the Ethiopian authorities, MSF decided in November 1985 that, regardless of the consequences to its ability to remain in the country, the organization could no longer remain silent. If it did so, MSF could appear to be condoning the brutality of these transfers, already responsible for more deaths than the famine (100,000 victims, according to MSF reports).

The presence of a host of aid organizations in Ethiopia made it less difficult for MSF to denounce the transfer practices in public and enabled MSF to take the risk of expulsion. A few days after officially requesting the discontinuance of the transfers, MSF was expelled from Ethiopia. MSF immediately briefed the media on the diversion of aid, used to oppress instead of help. A few days after MSF's expulsion, the EEC and the United States decided to make further aid conditional on the discontinuance of these forced population transfers. Thus pressured, the Ethiopian government announced in early 1986 that it would cease its resettlement programs.

Despite a commitment to speak out in the face of massive human rights abuses, the leaders of MSF have limited their public declarations. The process of bearing witness, however, occurs on an ongoing basis with the intention of improving conditions for populations in danger. MSF field volunteers participate in witnessing by serving as an international presence in crisis areas and by raising public awareness about the populations they serve. In extreme situations, the witness process extends to openly criticizing or denouncing breaches of international conventions. This is a last resort used when MSF volunteers witness mass violations of human rights, including forced displacement of populations, forced return of refugees, genocide, crimes against humanity, and war crimes.

MSF in the United States

In 1990, Médecins Sans Frontières was introduced in the United States, where it is known as MSF. With its headquarters in New York City and an additional office in Los Angeles, its purpose is to raise funds for relief projects conducted in the field by MSF, to recruit American medical and non-medical professionals to volunteer in the field, and to increase public awareness of populations in danger.

As a nonprofit charitable organization, MSF in the United States focuses its fund-raising activities on contributions from individuals, foundations, corporations, and U.S. institutions. Since its founding, the U.S. organization has attracted 160,000 individual donors, who in 1997 provided $8.4 million to support projects ranging from aid to Rwandan refugees to the treatment of Kashin-Beck syndrome ("big-bone disease") in Tibet. These private funds strengthen the international organization's capacity to develop projects with full independence from government influences. The establishment of a U.S. section has also enriched the organization's pool of relief workers; in 1997, nearly 100 American volunteers participated in field projects. The U.S. organization also negotiates U.S. government funding for emergency and refugee operations for the international MSF network. Finally the U.S. organization has been a focal point in MSF advocacy efforts with the United Nations, the U.S. government, and other relief organizations. In recent years, MSF was, on several occasions, invited by Congress to testify on current humanitarian issues such as the 1994 genocide in Rwanda and subsequent refugee flight, the land mine crisis in Afghanistan, and the 1996-97 refugee crisis in Congo (former Zaire). In 1997, MSF joined several other organizations in a historic presentation to the U.N. Security Council on the refugee crisis in Africa's Great Lakes region.

Challenges of the 1990s

With a yearly budget of about $250 million and 2,500 volunteer departures to the field each year, MSF has become one of the world's leading private medical emergency assistance organizations. Much of MSF's recognition derives from its missions in Afghanistan, Ethiopia, Iraqi Kurdistan, Somalia, Rwanda, and Congo (former Zaire) which were widely reported in the media.

Although MSF's work is conducted in many of the same places today as in past decades, the activity has changed considerably in keeping with the changing global environment. While many countries such as Angola, Thailand, and Afghanistan are still dealing with the effects of large population displacements, the issue has been complicated by changes in the status applied to refugees and by the repatriation-both voluntary and forced-of several populations to their original countries. Although refugees remain an important focus for MSF (particularly in Africa's "Great Lakes" region), the organization increasingly is facing the challenge of new health care crises. Those challenges include the re-emergence of once-controlled diseases, such as sleeping sickness and tuberculosis; the emergence of new epidemics and especially the AIDS epidemic; lack of access to health care for excluded populations; failing health systems in the former Soviet Union; and the need for medical assistance in MSF headquarters' own backyards. At the same time, MSF and other aid organizations are facing previously unknown difficulties in maintaining a presence and ensuring the safety of its volunteers in the face of warring parties that neither recognize the neutrality of, nor protect, humanitarian aid workers.

Although the total number of registered refugees was reduced in the 1990s, MSF encountered a crisis of tremendous dimensions when one million people crossed into the Democratic Republic of Congo (former Zaire) from Rwanda in the aftermath of the 1994 Rwandan genocide. The crisis continued to escalate when a cholera epidemic broke out in the refugee camps of eastern Congo, prompting the largest intervention in MSF's history. Over the next three years, ongoing ethnic tension in the region and the failure of the international community to take action led to more violence, particularly when the camps were attacked in 1996 sending hundreds of thousands of refugees back into Rwanda and Burundi and further into Congo. Those refugees who did not return to their home countries faced massacres, starvation, and disease. Military forces blocked aid and manipulated relief workers, using their presence as bait to attract and eliminate refugees more easily. MSF teams, blocked in their effort to reach and assist the refugees, spoke out against these abuses and, along with three other humanitarian agencies, was invited for the first time directly to address the U.N. Security Council on this issue.

The most significant geographic novelty of this period has been MSF's recognition of humanitarian needs in Europe. With the collapse of communism in Eastern Europe, MSF began to participate in the effort to restore the public health systems in Romania, Bulgaria, and a number of republics of the former USSR. The deterioration of the Soviet Union has posed a particular challenge even to MSF's most seasoned volunteers. These medical professionals were used to working in countries with little healthcare infrastructure and few doctors, but they were not accustomed to working in countries where infrastructures and doctors existed but in which the public health structures did not function adequately. The rise of epidemics in the former Soviet bloc forced MSF quickly to develop new expertise, and in the mid-1990s, the organization launched an AIDS-prevention project in Moscow, a tuberculosis treatment project in Siberia, a massive polio vaccination campaign in Albania, and a variety of public health programs in Uzbekistan, to name just a few projects.

With continued economic uncertainty in Western Europe, MSF has turned its attention to the steadily increasing number of people who for a variety of reasons are not adequately served by their public health systems. In such countries as Belgium, France, and Spain, MSF has undertaken project addressing those societies' most vulnerable populations including drug addicts, people with AIDS, immigrants and asylum seekers, and other under-served communities.

The rapidly moving political and economic events of the post-Cold War period have increased the complexity of the environment in which MSF works and forced the organization, at times, to balance the needs of civilians against the negative consequences of aid and the growing dangers to humanitarian workers.

On October 19, 1991, MSF sent a humanitarian convoy to evacuate casualties from the besieged Croatian city of Vukovar. Several previous rescue attempts had failed, and the convoy was allowed to proceed only after protracted negotiations with the Yugoslav Army and the Croatian authorities. The twelve-vehicle convoy successfully evacuated an estimated 109 wounded soldiers and civilians. As it headed out of the city, however, one of the trucks struck a mine, and two MSF nurses sustained serious injuries. Concern for the safety of volunteers placed MSF in the difficult position of having to rule out any attempts to rescue the remaining wounded in Vukovar's hospital.

This incident occurred despite the strictly humanitarian nature of the operation and despite assurances of safe passage from both sides of the conflict. Worldwide conflicts in which the impartial provision of humanitarian aid is less and less respected are becoming more common. In 1989 a missile destroyed an Avions Sans Frontières airplane in Sudan, killing two MSF members on board. In 1990 an MSF logistics expert was assassinated in Afghanistan, and in 1997, an MSF doctor was murdered in Somalia. The organization has faced kidnappings in Ingushetia and Sierra Leone. MSF has also faced serious safety problems in Iraq, former Yugoslavia, Liberia, Chechnya, Rwanda, and Congo (former Zaire).

Experiences in the 1990s have also taught MSF important lessons about working alongside military-humanitarian operations. The first such operation took place in Kurdistan, where a largely U.S.-led military force provided the logistics for a massive delivery of aid materials. While the latter experience taught the value of what military logistical capacity could add to an emergency aid operation, MSF's experience in Somalia, where peacekeepers became embroiled in the escalation of violence to the point of attacking civilians they had come to help, showed the pitfalls of such collaboration. Following the Somalia debacle, the U.S. in particular has been less quick to act, and MSF has voiced concern that, too often, peacekeeping operations make it their job to bring humanitarian aid, such as food distribution, while protection of civilians from attack is forgotten.

At the end of the twentieth century, the world has begun to resemble a global village connected by fax, phone, and internet, where what is said and done in a remote part of Africa can appear simultaneously on television in New York. In previous eras, lack of action could have legitimately been blamed on ignorance. Today, in the face of so much information, it would be easy to assume an accompanying increase in interest and sympathy. Yet it continues to be difficult to arouse this sympathy toward people who are still seen as faraway and unfamiliar. The globalization of media will not solve this problem, and it will be the role of humanitarian agencies to keep these issues in the forefront of public awareness.

For MSF greater awareness should lead to a greater sense of responsibility. That sense of responsibility has driven the organization to embrace the values of independence and impartiality, the ethic of volunteerism, and to seek and confront the greatest challenges in our midst. As MSF enters the twenty-first century, the pursuit of these values in a drastically changing world environment will continue to guide the organization's mission and work.

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