Médecins Sans Frontières imagines no countries

This article is adapted from a university essay evaluating aid providers, for a subject entitled ‘Global Aid and Development: Challenges and Prospects.’

Globally, there are gross inequalities between national healthcare systems. According to the World Health Organisation (WHO), there is a 36-year gap in life expectancy between countries: a child born in Malawi can expect to live for only 47 years while a child born in Japan could live for as long as 83 years.[1] Médecins Sans Frontières/Doctors Without Borders (MSF), as an independent international NGO, endeavours to even up these inequalities by providing emergency medical aid in crisis situations to vulnerable people. But how well does, and can, MSF achieve this?

About MSF

MSF is an independent non-government organisation providing free essential medical services to people who need it, without discrimination, in armed conflicts, epidemics, famines and natural disasters.[2] MSF was created in 1971 after some volunteer medical staff in Nigeria, during the Biafran War, parted with the Red Cross (ICRC) over differing principles of humanitarianism.[3] The ICRC had withdrawn aid benefitting rebel sides, yet MSF founders differed on this, believing “all people have the right to medical care regardless of gender, race, religion, creed or political affiliation, and that the needs of these people outweigh respect for national boundaries.”[4]

Today, MSF continues a policy of independence, impartiality and neutrality in conflicts, will treat people from both sides of the conflict and go where they are needed most.[5] Over 90% of MSF is generated by small donations by members of the public. This ensures MSF’s ability for quick mobilisation in emergencies without having to wait to be allocated official funds.[6] It also ensures the independence of MSF, ensuring it doesn’t further governments or businesses commercial, political or military goals and can remain neutral and impartial.

MSF provides assistance in nearly 70 countries and has over 36,000 staff worldwide. MSF has 5 operational centres in Europe and the US, 4 logistical centres in Europe and East Africa, and stocks of emergency materials are stored in Central America and East Asia.[7] This ensures, that within 24 hours, planes can be loaded with essential equipment and flown into a crisis area anywhere in the world.[8] In 2010, more than 27,000 MSF aid workers served patients in over 60 countries.[9] The total number of national staff is around 22,640 people, and they fill approximately 92% of all field positions (2006).[10]

Evaluation

Contradictions between the principles of ‘bearing witness’ and political neutrality

MSF promotes political impartiality and neutrality, but has achieved this with varying success. MSF-published book ‘Humanitarian Negotiations Revealed’ examines the controversial methods the organisation uses to gain access to patients in conflict-affected areas.[11] It’s policy of ‘bearing witness’ to atrocities and speaking out against perpetrators often conflicts with it’s ‘impartiality’ policy, and these competing principles must be balanced with consideration to achieve secure access to people in need of medical care. MSF staff explicitly stated mental health issues in Palestine were a direct consequence of Israeli oppression, and by doing so attracted Israeli government antagonism.[12] Israeli government-sponsored website ‘NGO Watch’ state in response that “MSF consistently abuses its status as a humanitarian organization to launch venomous anti-Israel political campaigns.”[13] MSF USA Director Jason Cone states, “Pro-Israeli and Pro-Palestinian groups have criticized MSF throughout the 20-plus years of its operations in the West Bank and Gaza. We have, essentially, satisfied none of the parties with our actions or with our speaking out. In essence, this is a true testament to our principle of independence.”[14]

Medical care without discrimination is a founding principle of MSF, the basis of it’s original split for the ICRC. However, MSF has struggled to determine what constitutes an acceptable compromise with local political and military figures to gain access to patients.[15] To continue their work, MSF and other NGOs are often forced to negotiate deals with groups and regimes which abuse human rights, and sometimes accused of prolonging conflict through aiding and alliances with warring parties.[16]

MSF has pursued conflicting approaches in humanitarian negotiations across the organisation, and differing policies of national sections have complicated its work.[17] For example, in Odagen, Ethiopia in 2007-08, Swiss sections of MSF criticised Ethiopian government for lack of humanitarian access while other national sections remained quiet.[18]  In Yemen, 2009, in order for MSF to continue it’s work it was forced by the Yemini government to publicly withdraw it’s ‘biased’ critique of the state-created humanitarian crisis, and accordingly deny that access to healthcare was being restricted.[19]

MSF is regularly targeted by military violence, arguable due to it’s policy of speaking out against injustices. Attacks severely hinder MSF capacity and operational security on the ground. Under the Geneva Convention, warring parties are supposed to respect the Red Cross on the roof of a hospital, yet this is rarely followed in practice.[20] On the 2016 bombing of MSF hospital in Kunduz, Afghanistan by the United States military, Director Stewart Condon stated, “The hospital in Kunduz was the only one in the area available to patients with traumatic injuries. The cost to staff is horrific but the impact on the community is huge too.”[21] MSF defends the contradiction between political neutrality and ‘bearing witness’ by making the distinction between military power, which ensures the long-term interests of the community and sacrifices human lives, and humanitarian action, “which is on the side of losers, whose lives it seeks to protect here and now while questioning the reasons for their sacrifice.”[22]

Organisational development and reform needed:

MSF (and WHO) took on sweeping reforms to emergency response processes in wake of the Ebola crisis, yet the requirement of nothing short of a global epidemic to ignite some organisational progression is concerning and points to inadequate internal evaluation.[23] MSF’s decentralised spread over 5 operational centres (Paris, Brussels, Amsterdam, Barcelona, and Geneva) complicates the integration of lessons from past projects, thwarting better preparedness and decision-making in the future. Lessons from project evaluations aren’t effectively absorbed into MSF policy, meaning the same mistakes are being made multiple times over during different projects.[24] Furthermore, MSF planning is determined by conditions and epidemiologic patterns in the location of past MSF missions, rather than diverse global situations.[25] For example, MSF were ill-prepared in Kosovo (1993-2000) to treat chronic, non-communicable diseases in middle-income settings, such diabetes, heart disease, and epilepsy. MSF had instead traditionally worked with infectious diseases, in low-resources settings in sub-Saharan African states.[26] Despite a post-Kosovo evaluation highlighting this oversight, emergency-preparedness stocks were not updated for middle-income settings until 2011, and MSF saw repeated struggles in treating non-communicable diseases in Iraq, 2003, and in Haiti, 2010. MSF requires a main evaluation, processes and decision-making centre in place of a critique system spread across the 5 operational centres. Policies should avoid ‘one-size-fits-all’ strategies characteristically befalling SAPs and development programs, but ensure swift integration of knowledge across MSF. MSF has made some effort to centralise evaluation and policy reform, but clings to an informal method of peer-critiquing among operational centres, which allows pitfalls to be missed.

MSF doesn’t improve public health system development:

MSF tasks itself with the impossible mission of provide global emergency medical care in absence of an international public health care system. It goes above the role and capacity of an independent NGO to take on the work of a global health provider. MSF’s independent and flexible funding, preparedness to mitigate risks and logistics capacity, experience with filovirus outbreaks, positions the organisation as one of the fastest responders to health crises, leading global emergency health service-delivery.[27] Yet, it is a ‘band-aid for a broken leg’, patching the holes left from a fledgling World Health Organisation (WHO) that is incapable of building and improving strong national health systems.[28]

It’s independent funding structure makes it the strongest NGO to respond to medical emergencies, globally. During the 2014-2016 Ebola epidemic in West Africa, MSF worked “beyond standard emergency operational role, starting to trained other organisations, lead role in strategic decisions at national levels, and conduct clinical trials on experimental drugs.”[29] However, MSF’s six-pillar Ebola Management approach came under strain due to size and geographical spread of the Ebola epidemic, and MSF had limited resources compared to size of scale.[30], [31], [32] Limited resources are an inevitability of an independent NGO, and this issue is more indicative of inadequate national health systems.

MSF struggles to meet the health needs of too many populations without adequate public health infrastructure. WHO proclaims itself to be the guardian of global public health, stating that “underpinning all we do, is a shared effort to build strong health systems and achieve universal health coverage.” It’s agenda including the goal of “enhancing national health systems, moving towards universal health coverage.”[33] Yet it doesn’t nearly have the capacity to meet this goal. In 2014, WHO’s budget decreased from $469 million in 2012-13 to $228 million for 2014-15, 300 jobs were cut, as well as 50% of its crisis response funding.[34] WHO was not prepared for a ‘global pandemic’ and has little real emergency health response capacity. Post-Ebola, WHO is beginning to improve emergency preparedness and capacity, but it’s aims don’t go far enough to protect against pandemics in fragile states and its funding requirements for necessary emergency response reform will not be met.[35] MSF’s mission to supplement for WHO is an impossible goal and requires immense cross-institutional collaboration to be realised.

The question of the sustainability of MSF remains whilst it operates as a short-term service-delivery organisation providing emergency relief rather than transformative social justice and sustainable development programs. MSF’s emergency programs have no room for empowering recipients, and could merely perpetuate a cycle of dependency on external actors.[36] MSF’s publicity campaigns often portray the populations it seeks to help as desperate victims, negating their agency.[37] The cycle of dependency not only highlights the problems of poor governance and institutional capacities but non-sustainable program design.[38]

MSF handover to national health systems post-crisis is often inadequate. As mentioned above, MSF is moving towards more holistic approaches and integrated medical action, including non-communicable disease treatment, and whilst doing so it is shifting from providing basic care for many to treating fewer people more comprehensively.[39] As it does this, it will be required to improve institutional ties with national health systems and WHO, or risk hindering the integration of public health infrastructure. MSF is an outspoken critic of WHO, yet WHO’s (and global public health’s) capacity is mired by UN member-state apathy and its over-reliance on voluntary donations.

In conclusion, MSF is the strongest-placed NGO globally to provide international medical care in emergency situations, yet it’s limited by some internal and external barriers to success. It’s organisational structure with decentralised accountability and decision-making chains complicates effective policy in crisis response, emergency-preparedness, and humanitarian negotiations. It’s dual policies, of neutrality and remaining outspoken against atrocities, are not easily reconciled. Most significantly, MSF relief operations in regions absent of basic health infrastructure, in a world of horrific health inequalities, are impossibly challenging. Inadequate international action on long-term health development ensures that an independent NGO like MSF is “a band-aid for a broken leg.”[40]

Endnotes

[1] Word Health Organisation, ‘World Conference on Social Determinants of Health: Fact file on health inequities’, 2012, accessed 14 August 2017

[2] ‘Where We Work’, Medecins Sans Frontieres,n.d., accessed 21/08/2017

[3] Independent, Neutral, Impartial, Medecins Sans Frontieres, n.d., accessed 21/08/2017; Christian Hall, P., ‘The Crisis Caravan: Charity’s Road to Hell?’, The Huffington Post, 25 May 2011, viewed 14 August 2017

[4] Medecins Sans Frontieres UK, ‘Founding of MSF’, 22 September 2016, viewed 21 August 2017

[5] Independent, Neutral, Impartial, Medecins Sans Frontieres, n.d., accessed 21/08/2017

[6] Independent, Neutral, Impartial, Medecins Sans Frontieres,n.d., accessed 21/08/2017>

[7] Parry, A., ‘Doctors without Borders’, South Yarra, Melbourne, Macmillan Education, 2005, p. 7

[8] Ibid, p. 5

[9] M McHarg, ‘Learning the Lesson is not enough’, Admitting Failure, 12 January 2012, viewed 23 August 2017

[10] Chen, Jau-Yon, ‘A Paradigm of Medical Humanitarianism: The Case of Médecins sans Frontières (Doctors without Borders) in Africa’, Online Journal of African Affairs, 2014, Volume 3, Issue 6, p. 92

[11] Magone, C., Neuman, M., Weissman, F., ‘Humanitarian Negotiations Revealed: The MSF Experience’, Hurst Publishers, London, 2012

[12] ‘Mental Health in Palestine – we were mainly dealing with the consequences of the occupation’, Medecins Sans Frontieres, 6 February 2017, accessed 21/08/2017

[13] ‘Medecins Sans Frontieres’, NGO Monitor, 2 February 2017, viewed 14 August 2017

[14] Cone, J., ‘Doctors without Borders Denies Institutional Anti-Semitism’, Forward, 29 June 2016, viewed 14 August 2017

[15] Beaumont, P. ‘Médecins sans Frontières book reveals aid agencies’ ugly compromises’, The Guardian Global Development, 21 November 2011, accessed 20 August 2017

[16] Ibid.

[17] Beaumont, P. ‘Médecins sans Frontières book reveals aid agencies’ ugly compromises’, The Guardian Global Development, 21 November 2011, accessed 20 August 2017

[18]Binet, L., ‘Ethiopia: A Fool’s Game in Ogaden’, Humanitarian Negotiations Revealed: The MSF Experience, eds. Magone, C., Neuman, M., Weissman, F., Hurst Publications, London, 2012, p. 35

[19] Allie, M., ‘At any price?’, Humanitarian Negotiations Revealed: The MSF Experience, eds. Magone, C., Neuman, M., Weissman, F., Hurst Publications, London, 2012, p. 1

[20] Condon, Stewart. ‘Kaleidoscope’ [online]. Independent Education, Vol. 46, No. 1, Mar 2016, p. 5

[21] Ibid, p. 5

[22] “Not In Our Name”: Why Médecins Sans Frontières Does Not Support the “Responsibility to Protect”’, 2010, Criminal Justice Ethics, vol. 29, issue 2, pp. 194 – 207

[23] Pagano, H., & Poncin, M., ‘Chpt 2: Treating Containing, Mobilising: The Role of Medecins Sans Frontieres in the West African Ebola Epidemic Response’, Global Management of Infectious Disease After Ebola, eds. Halabi, S., Gostin, L., Crowley, J., Oxford University Press, 2017, no page number, p.1 of chapter 2

[24] M McHarg, ‘Learning the Lesson is not enough’, Admitting Failure, 12 January 2012, viewed 23 August 2017

[25] Ibid.

[26] ‘MSF in Kosovo’, Medecins Sans Frontieres, 7 August 2000, viewed 20 August 2017

[27] Pagano, H., & Poncin, M., ‘Chpt 2: Treating Containing, Mobilising: The Role of Medecins Sans Frontieres in the West African Ebola Epidemic Response’, Global Management of Infectious Disease After Ebola, eds. Halabi, S., Gostin, L., Crowley, J., Oxford University Press, 2017, no page number, p.1 of chapter 2

[28] Kelland, Kate, ‘Doctoring WHO: The World Health Organisations Critical Challenge: healing Itself’, 8 February 2016, Reuters, viewed 22 August 2017

[29] Pagano, H., & Poncin, M., ‘Chpt 2: Treating Containing, Mobilising: The Role of Medecins Sans Frontieres in the West African Ebola Epidemic Response’, Global Management of Infectious Disease After Ebola, eds. Halabi, S., Gostin, L., Crowley, J., Oxford University Press, 2017, no page number, p.1 of chapter 2

[30] Ibid, p.1, chapter 2

[31] ‘MSF-Supported Research on Ebola’, Medecins Sans Frontieres Operational Centre Brussels, March 2016, p. 7

[32] Philips, M., ‘Dying of the Mundane in The Time of Ebola: The effect of the Epidemic on health and Disease in West Africa’, The Politics of Fear: Medecins Sans Frontieres and the West African Ebola Epidemic’, eds. Au, S., Hoffman, M., Oxford University Press, New York, 2017, p. 112

[33] World Health Organisation, “the Global guardian of Public Health”, 2016, viewed 25/08/2017

[34] Youde, Jeremy, ‘Can the World Health Organisation Lead? Do we want it to?’, 8 August 2014, The Washington Post, viewed 25 August 2017

[35] Doucleff, Michaeleen, ‘‘WHO Aims To Reform Itself But Health Experts Aren’t Yet Impressed’, National Public Radio, May 25 2016, viewed 24 August 2017

[36] Chen, Jau-Yon, ‘A Paradigm of Medical Humanitarianism: The Case of Médecins sans Frontières (Doctors without Borders) in Africa’, Online Journal of African Affairs, 2014, Volume 3, Issue 6, p. 92

[37] Debrix F., ‘De-territorialized Territories, Borderless Borders: The New Geography of International Medical Assistance’, Third World Quarterly, 1998, vol 19 issue 5, p. 842, found in Chen, Jau-Yon, ‘A Paradigm of Medical Humanitarianism: The Case of Médecins sans Frontières (Doctors without Borders) in Africa’, Online Journal of African Affairs, 2014, Volume 3, Issue 6, p. 91

[38] Chen, Jau-Yon, ‘A Paradigm of Medical Humanitarianism: The Case of Médecins sans Frontières (Doctors without Borders) in Africa’, Online Journal of African Affairs, 2014, Volume 3, Issue 6, p. 93

[39] McHarg, M., ‘Learning the Lesson is not enough’, Admitting Failure, 12 January 2012, viewed 23 August 2017

[40] Brown, D., ‘Band-aid for a Broken Leg: Being a Doctor with no borders’, Allen & Unwin, Melbourne, 2013.

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