Keywords

Provocateurs of the Humanitarian Sector

Few organizations in the humanitarian field elicit such strong reactions as Médecins Sans Frontières (MSF), also known as Doctors without Borders. MSF was started by a handful of doctors and journalists in the early 1970s. Almost 50 years later, it has become the second biggest non-governmental organization in the world with 21 national and 17 branch offices, an annual budget of 1536 million euros, and 47,318 staff (MSF 2019b).1

MSF is different from other humanitarian organizations. What sets this organization apart is its defined technical and operational expertise, combined with a fundamentally different interpretation and implementation of the so-called neutrality and independence principles. Based on their interpretation of these principles, MSF has developed an ‘ethics of refusal’ (Redfield 2005: 342) that has made the organization withdraw from numerous humanitarian crises, disconnecting itself from governments and humanitarian organizations. Their critical attitude towards the humanitarian sector and, increasingly, to itself, has earned MSF the reputation of an ‘outsider’ and ‘maverick’ among the general public.

MSF has gained notoriety as a provocateur with little inhibition to deviate from presumably common norms and standards (Bortolotti 2004). This nonconformity never seems to have harmed MSF’s reputation. On the contrary, their controversial acts triggered revisions of valuesand practices, creating an image of MSF as the ‘conscience of the humanitarian world’ (Rieff 2002: 83). The organization remains well-known and highly respected by the general public and is often portrayed as a paragon of aid provision in the media.

Interpreted by some as a sign of arrogance, MSF’s strict autonomy and reluctance to submit to coordination efforts is not without criticism among fellow humanitarians. Yet, at the same time, MSF has impacted the way humanitarian organizations operate today in multiple ways. MSF provided an alternative to the sector’s originally strong adherence to neutrality in aid provision and thereby a different way of ‘doing humanitarianism’. Operationally, the organization has impacted humanitarian aid practices via contributions to the fields of humanitarian supply chain management, emergency medicine and psychosocial care.

This chapter explains how MSF evolved into a public guardian of humanitarian values and thrived as a humanitarian organization, while acting as a principled provocateur in its organizational niche. We explore how the organization was successful in assuring a firm legitimacy base while simultaneously capitalizing on a nonconformist attitude, whereas internally it navigated through ‘growing pains’ and conflicts. We draw on secondary sources and MSF sources for our analysis.

MSF as an Institution: A Distinctive Identity and Unique Competence

MSF provides medical assistance in areas affected by conflict or natural disaster. It operates globally with teams composed of both expatriate and national staff. MSF was founded during the Cold War, an era in which superpowers used humanitarian and development aid—and the prospect of progress and modernity this was assumed to bring as an instrument to lure African, Asian and Latin-American countries into one of the two Cold War camps. Non-state humanitarian actors had little room to stay away from these political dynamics. The founding of MSF was a reaction to these Cold War politics, as we will show.

MSF belongs to the category of so-called ‘non-governmental organizations’, often defined as not-for-profit, self-governing organizations aiming at improving the life of vulnerable groups (Vakil 1997). MSF is labelled an international NGO, since it operates in countries beyond the country where its headquarters are located. In this category, MSF is characterized as a so-called emergency humanitarian organization, together with the ICRC (Barnett 2011), and NGOs such as International Medical Corps and International Rescue Committee. Since MSF aims to reduce immediate suffering, it is an operational NGO: it sends out medical, logistic and other expatriate staff to provide medical aid. At the other end of the spectrum there are the so-called ‘alchemist’ humanitarian organizations that aim to address the roots of suffering by providing long(-er) term aid, sometimes accompanied by short-term emergency aid. They do this predominantly through partnerships with local organizations (Barnett 2011). Examples of such INGOs are Oxfam and World Vision.

In 2018, MSF had an annual budget of 1536 million euros, was responsible for aid projects in 74 countries and employed 47,318 staff (84% national staff, 8% expatriate staff and 8% headquarterstaff) (MSF 2019b). Even though employing a highly diverse workforce (Reijn 2008), medical staff is the prominent group in the organization.

The organization consists of 21 sections plus 17 so-called branch offices (MSF 2019a, see also Table 9).2 Five operational centres manage operations and have decision-making authority over which projects to initiate. Sixteen partner sections contribute to operations via arranging staff and funds, and raising awareness. Some sections have opened branch offices to facilitate their work more regionally.

Each section and centre is connected to an association, with (former) MSF staff as its members. Each association choses a board of directors and president during a General Assembly and can provide input on MSF’s social mission. There are currently 25 associations, 21 associated with the sections and centres, one with branch office East Africa, and three regional ones in West and Central Africa, and in South Asia.

All associations are represented in MSF International where association representatives meet annually in the General International Assembly (IGA). The IGA elects the president of MSF International and is ‘responsible for safeguarding MSF’s medical humanitarian mission, and provides strategic orientation to all MSF entities. It delegates duties to the International Board, and holds the boardaccountable for those tasks’ (MSF, n.d.b). The international board consists of a mix of representatives of the Operational Centres and elected members from the associations (Table 11.1).

Table 11.1 MSF’s international organizational structure
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Distinctive Identity: A Truly Independent Organization “Bearing Witness”

The fundamental purpose of all humanitarian activity is the global prevention and alleviation of human suffering (Calhoun 2008; Barnett 2011). This duty is referred to as the humanitarian imperative. Whereas such purpose suggests that humanitarian aid is void of power or politics, historical accounts of the sector show that the various interpretations of humanitarianism are closely related to historical, economic and political developments (Barnett 2011).

All humanitarian organizations claim to adhere to a set of humanitarian principles that guide their actions. The most basic ones are outlined in the International Committee of the Red Cross Code of Conduct and thus originate from the era of imperial humanitarianism (ICRC 1994):

  • The impartiality principle refers to the allocation of aid based on need alone, irrespective of nationality, race, political affiliation, religion, etc.

  • Independence relates to humanitarian organizations’ ability to revise and implement activities without being influenced by governments.

  • Neutrality refers to the refusal to take sides in a conflict.

  • Accountability evokes the responsibility of providers of humanitarian aid to account for their actions towards their donors and their beneficiaries.

  • Efficiency and effectiveness concern the sensible and transparent usage of available funds in relation to the outcomes of humanitarian responses.

  • Borrowing the words of the Hippocratic Oath, Anderson (1999) formulated an overarching dictum of all relief efforts: do no harm.

How impartiality, neutrality and independence relate to one another and how these principles are best achieved in operational practice has been a recurring topic of debate (Kanter and Summers 1987; Slim 1997). While providing a common frame of reference for legitimation, the principles leave room for re-interpretation and experimentation (Schneiberg and Lounsbury 2008; Zietsma and McBright 2009).

MSF’s mission statement or ‘charter’ offers a first insight in its position vis-á-vis the humanitarian principles. The mission specifies the goals and values of the organization through four principles (see Box 11.1): medical ethics, independence, impartiality and neutrality (MSF, n.d.c). These principles overlap with the core humanitarian principles of neutrality, impartiality, and independence and thus largely align with the moral code of the humanitarian sector. MSF also promises accountability and transparency and, critically, adheres to the principle of bearing witness:

Neutrality is not synonymous with silence. Our proximity to people in distress implies a duty to raise awareness on their plight to ultimately help improve their situation. We may seek to bring attention to extreme need and suffering, when access to lifesaving medical care is hindered, when our teams witness extreme acts of violence, when crises are neglected, or when the provision of aid is abused. (MSF, n.d.c)

Witnessing refers to the act of speaking out about experiences and observations during aid operations in order to bring abuses and atrocities to public attention, thus advocating on behalf of the aid recipients. Witnessing is a way of showing solidarity with groups in dire need. This conflicts with the humanitarian principle of neutrality that implies not taking sides in hostilities or to ‘engage at any time in controversies of a political, racial, religious or ideological nature’ (IFRC, n.d.).

Box 11.1 MSF’s Charter

Médecins Sans Frontières provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict. They do so irrespective of race, religion, creed or political convictions.

Médecins Sans Frontières observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance and claims full and unhindered freedom in the exercise of its functions.

Members undertake to respect their professional code of ethics and maintain complete independence from all political, economic or religious powers.

As volunteers, members understand the risks and dangers of the missions they carry out and make no claim for themselves or their assigns for any form of compensation other than that which the association might be able to afford them.

We can further analyze MSF’s distinctive identity and unique competence through distinguishing between a normative and an operational dimension. As summarized by Redfield (2005: 333): ‘On the one hand, MSF embodies the moral insistence of a human right to health and the dignity of life that goes with it. On the other hand, MSF represents a technical apparatus designed to implement basic health care quickly over great distances and under extreme conditions’.

MSF’s inception was by itself a rebellious act: several French doctors were frustrated with the established humanitarian system in general and the International Committee of the Red Cross, their employing organization, in particular. This frustration was caused by witnessing severe atrocities among civilians during the late 1960s Nigerian civil war and being forced to remain silent about these under the principle of ‘neutrality’. Keen to ‘speak out about the plight of victims, and seeking an independent, impartial way to provide care where they saw the greatest need’ (MSF Association, n.d.), these doctors, together with a group of journalists, formed MSF France, in 1971 (Fox 2014).3

MSF thus emerged from a fundamental break with the most prominent and central humanitarian organization (Dijkzeul 2004: 219; Barnett 2011) and the principles it represented. Re-evaluating the old (neutrality) and devising new principles (witnessing), MSF from the very start developed and applied its own interpretation of humanitarianism and thereby introduced a new way of ‘doing humanitarianism’. This ‘revolution’ constitutes the founding myth of the organization (Fox 2014) and is prominently featured in, for example, the ‘About us’ sections of the homepages of different national MSF sections.4 James Orbinski, president of the MSF International Council in 1999, also emphasized this ‘founding myth’ in his lecture given upon reception of the Nobel peace prize in December 1999:

We began formally in 1971 as a group of French doctors and journalists who decided to make themselves available to assist. This meant sometimes a rejection of the practices of states that directly assault the dignity of people. Silence has long been confused with neutrality, and has been presented as a necessary condition for humanitarian action. From its beginning, MSF was created in opposition to this assumption. We are not sure that words can always save lives, but we know that silence can certainly kill. (MSF 1999)

Some argue that speaking out about human rights abuses is a political act, since it can be interpreted as choosing sides, which contradicts the fundamental nature of humanitarian organizations as neutral aid providers (Derderian et al. 2009). Facing such criticism, MSF argued that it is the responsibility of humanitarian actors to advocate on behalf of their beneficiaries as an act of solidarity and to draw public attention to intolerable situations, even if consequences are harsh (Captier 2005). MSF (n.d.e) boldly states that ‘silence [can] kill’, thus making those that [watch] complicit in the atrocities. In this interpretation, adherence to the neutrality principle can increase suffering, whereas reporting about observed atrocities might reduce suffering.

In order to be able to uphold the witnessing principle, MSF argues that complete independence from other humanitarian actors is needed. MSF developed a particular interpretation of the independence principle. As a result, MSF refuses to participate in sector-wide efforts of coordination, standardization and fundraising. To the dismay of other humanitarian organizations, MSF has not signed up to common operational standard agreements of the humanitarian sector such as the Sphere Project’s ‘Humanitarian Charter and Minimum Standards in Disaster Response’ and has rejected the idea of ceding control to collective coordination efforts like the ‘Inter Agency Standing Committee’ or the ‘Steering Committee for Humanitarian Response’ (Tong 2004; Stobbaerts 2007). MSF also does not participate in the ‘Consolidated Appeals Process’, a collective fundraising mechanism (OCHA 2011).

While willing to cooperate and share expertise, MSF will not submit to the authority of other humanitarian agencies. In large-scale emergencies involving various humanitarian actors, MSF ‘will coordinate, but won’t be coordinated’ as one presenter put it during MSF’s introduction course, because, as Stobbaerts (2007) argues, ‘the best service for populations in need will come as a result of independent action rather than participation in an integrated effort’.

In line with the independence principle, MSF aims for a high degree of financial independence, obtaining 95% of its income from 6.3 million non-state funders, such as individual donors and private foundations, thereby keeping government influence at arm’s length. As a comparison, Oxfam’s 2018 income consisted of 42.6% of institutional funding by governments and international organizations, whereas, International Rescue Committee’s 2018 income consisted of 73% of institutional funding (Oxfam 2018; International Rescue Committee 2019).

Since its foundation MSF presents an alternative means to achieve the humanitarian imperative that they argue to be more effective. Although not widely shared among humanitarian organizations, it has come to be accepted as one interpretation of humanitarianism, and as a prominent and distinguishing feature of MSF (Hilhorst and Schmiemann 2002).

Unique Competence: Experts in Emergency Medicine

Operationally, MSF’s expertise lies in providing short-term medical aid within 48 hours after deciding to become operational (Redfield 2005). This is possible because the organization has its own humanitarian supply chain, with four logistical centres in Europe and East Africa. The supplies range from medicines, vehicles and water processing facilities to standardized kits to tackle specific diseases such as cholera (MSF, n.d.f). Especially regarding (the development of) standardized response kits, MSF has gained a solid reputation (Redfield 2013). Furthermore, in the field of emergency surgery, the organization can quickly deliver and make ready inflatable tents with up to three operating rooms, postoperative wards and an intensive care unit (Chu et al. 2010).

MSF also is an important contributor to the development of expertise in the fields of humanitarian logistics, emergency medicine and psychosocial care (Redfield 2005). MSF staff contributes to these fields through developing and adjusting guidelines, writing publications and collaborating with academic institutes such as the London School of Hygiene and Tropical Medicine. Regarding emergency medicine, MSF founded Epicentre (Redfield 2005), an NGO that ‘conducts field epidemiology activities, research projects and training […]’ of which the results are published publicly online (Epicentre 2019). With regards to logistical matters, the organization works with academia to improve its supply chain, the results of which are made accessible to others (see, for example, Van der Laan et al. 2016; Vega 2018). MSF also has a track record in implementing psychosocial care interventions and innovations (see for example, Mooren et al. 2003; De Jong and Kleber 2007; Van Ommeren et al. 2011).

In recent years, the organization has taken up a new role as an advocate for particular issues. For example, MSF widely advocated for lowering the prices of HIV/AIDS drugs and for re-thinking investments in medicine development for diseases that disproportionally affect vulnerable groups through launching a campaign titled ‘Access to Essential Medicines’ (Redfield 2005; MSF Access Campaign, n.d.). This campaign—paid for with the Nobel Prize money—has led states and companies to comply with some of the campaign’s demands (Wong2012).

MSF’s operational approach has been subjected to criticism, also by MSF staff (Chen 2014; Redfield 2013; Barnett 2011: 39). MSF has been accused of neocolonial tendencies, because through sending out expatriates to manage aid projects it reproduces images of Western domination over the non-Western world (cf. Redfield 2005). The choice for short-term emergency aid has been met with accusations of providing ‘band aids’ only. The inclination to criticize and refuse cooperation with others has also led to criticism. MSF’s sharp condemnation of the international Ebola response drew rebuke, especially when MSF later had to admit its own mistakes (Reuters 2014).

Despite these criticisms, MSF has maintained a solid reputation with the general public. Few organizations enjoy the standing that MSF has within the field of humanitarian aid provision.5 David Rieff (2002: 83), a well-known humanitarian aid expert, describes MSF as ‘the most important humanitarian [organization]’ and, precisely due to their critical approach to normative standards, as the ‘conscience of the humanitarian world’. Charity Navigator awarded MSF 95 points out of 100 and the maximum of four stars, and its partner GuideStar has awarded the organization with a so-called ‘Gold Seal of Transparency’ (Charity Navigator 2020). Public recognition was also evident when MSF was awarded the Nobel Peace Prize in 1999, ‘in recognition of the organization’s pioneering humanitarian work on several continents [italics added]’ (Nobel Media, n.d.).

Institutional recognition is reflected in the Framework Partnership Agreement with the Humanitarian Department of the European Union, which presupposes that the partner organizations meet quality standards concerning their ‘internal control mechanisms and risk management, financial strength and procurement rules’ (ECHO 2008a: 1; 2008b). Finally, MSF´s legitimacy is also reflected in its sound financial resource base (Dijkzeul 2004). As the 2018 State of the Humanitarian System report stated (ALNAP 2018: 103): ‘MSF remains the largest humanitarian NGO in terms of operational expenditure and is now the largest humanitarian entity of any kind in terms of staff size, outstripping even the largest UN agencies in the number of staff dedicated to humanitarian response’.

MSF’s Institutional Development

How did MSF evolve into the organization it currently is: thriving as an organization, highly respected externally, even if it is often criticized for its outsider position and controversial behaviour in the sector? MSF’s organizational history shows that this did not happen overnight, or without internal tensions and conflicts. Below we present a concise institutional history of MSF related to the above questions.6

The 1970s and 1980s: Ideological Battles and Organizational Splits

MSF emerged from a cooperation between a group of French doctors, who criticized the ICRC’s modus operandus in the Biafran war, and a group of journalists. The doctors, led by Bernard Kouchner—who later would become Sarkozy’s minister of Foreign Affairs (2007–2010)—had initiated GIMCU (Groupe d’Interventions Medical and Surgical d’Urgence) to send medical teams to victims of war and disaster (Fox 2014: 258). However, the teams lacked resources and had little impact (Redfield 2005). The journalists were affiliated with a medical journal called Tontus, which had a journalist who co-authored an article with Kouchner in Le Monde on the Biafran war. In this same journal, the founding of Sécours Médical Francais (SMF) was announced, an initiative of doctors and health professionals to provide aid. Kouchner also joined this initiative. Given the many similarities in approach and principles, and the shared need for both resources and publicity, the two initiatives decided to join forces in 1971 and Médecins sans Frontières was born (Barnett 2011: 144).

The witnessing principle was an important topic of debate when the two groups merged. Kouchner and his colleagues argued that this principle had to be upheld under all circumstances, whereas the Tontus colleagues pleaded for a more controlled use of the principle. In the end, it was agreed that the witnessing principle could only be exercised if explicitly approved by higher management (Barnett 2011: 144).

In 1974, Kouchner challenged this agreement and sent out a team to help Kurdish fighters in Iraq, against the wish of the Tontus colleagues (Barnett 2011: 146). In 1975, during the Cambodia and Vietnam conflicts, internal tensions further increased, especially about the question whether MSF should also provide longer term aid and whether the organization should professionalize. Kouchner argued for a continued focus on short-term medical relief, whereas others argued that the work in the refugee camps in the region required a longer term approach. Kouchner won this battle.

Some MSF staff members—led by a medical doctor named Malhuret, who had worked in the camps—criticized MSF’s dominant focus on media attention and pointed out MSF’s lack of professionalism. This criticism especially focused on Kouchner’s proposal to arrange ‘a boat for Vietnam’, as the media campaign was called to help Vietnamese boat refugees (Fox 2014: 46). As Barnett summarizes the debate at that time (2011: 151): ‘Would MSF be an organization that made noise and saved lives in the process, or an organization that saved lives and occasionally made noise’?

Kouchner argued that professionalization and bureaucratization would harm the organization’s soul and its inclination to speak out, whereas Malhuret and colleagues claimed that the organization should move away from its strong focus on media attention and the well-intended amateurism associated with it. Instead, it should train its volunteers and develop a ‘machinery’ to operate effectively (Barnett 2011: 152). In 1978, Malhuret was elected president of MSF and in 1979, the MSF Assembly defied Kouchner by adopting Malhuret’s plans for professionalization. Moreover, the Assembly decided that ‘witnessing’ could not be a solely individual choice, as Kouchner always argued; it was an organizational responsibility. The outcome of the Assembly made Kouchner decide to leave MSF. He founded a new organization: Médecins du Monde (Fox 2014: 48).

Whereas MSF’s founders mostly had a leftist political orientation, MSF’s new leaders moved closer to a liberal interpretation of human rights. One of them—Rony Brauman—introduced a plan to bring together both leftist and rightist political groups to combat all forms of totalitarianism. He and his colleague Malhuretsucceeded in doing this in early 1985, with support of the MSF Assembly, by initiating a new NGO: Liberté sans Frontières (Barnett 2011: 155; Fox 2014: 48). When Liberté sans Frontières was founded, MSF Belgium opposed this decision, claiming that this organization was politically motivated and violated MSF’s Charter. Consequently, MSF refused to financially support the organization. In 1985, MSF France took MSF Belgium to court, arguing the latter could no longer use the name MSF because of this refusal. The court ruled that the aims of Liberté sans Frontières were indeed political and therefore in conflict with MSF’s Charter. MSF Belgium could thus not be expelled from MSF (Fox 2014).7

One of MSF’s leaders Brauman adopted a contrarian position when aid agencies lined up to relieve the suffering of millions of malnourished Ethiopians in the wake of Bob Geldof’s 1985 Live Aid project. It soon became apparent—just as in the Cambodian case—that the Ethiopian government used humanitarian aid for its own political purposes. It withheld aid to separationist areas, so that its inhabitants had to move out of the region in order to survive. The government forced them to re-settle elsewhere and work in labour camps. Brauman decided to speak out about this in the media, stating that humanitarian organizations had become the helpers of an authoritarian regime (Barnett 2011: 147). He challenged the Ethiopian government to evict MSF from the country, which indeed happened (Fox 2014: 56). The other aid agencies decided to stay in the country.

By the end of the 1980s, MSF had expanded from one to six branches: France, Belgium, Spain, Luxembourg, Holland and Switzerland (MSF, n.d.c). The discussions about MSF’s mission were as alive as 10 years ago. For example, in the Dutch section, debate arose about the time horizon of MSF projects, as had happened 10 years ago in MSF France. Some projects had become long-term public health interventions, such as HIV/AIDS projects in the Soviet Union. In 1990, it was decided to re-focus the projects of the Dutch section on short-term medical relief interventions. For the longer term public health interventions a strategy familiar to MSF was applied: a new NGO was founded, called Health Net International (Heyse 2006).

The 1990s: Increasing Recalcitrance

With the end of the Cold War, not only the nature of conflict changed, but also the nature of humanitarianism. It marked the start of the era of ‘Liberal Humanitarianism’ (Barnett 2011) in which assuring international security was key, in a world characterized by a multitude of internal conflicts, such as in Somalia, Rwanda, Bosnia and Kosovo. Unique to these years was that the UN—for the first time—acknowledged a universal obligation to intervene in internal conflicts to protect those suffering. The UN implemented this decision, starting with Somalia.

The UN intervention in Somalia put humanitarian NGOs—with their strong adherence to principles of neutrality and impartiality—in a difficult position. They needed armed protection to reach groups in need, but this made them lose their impartiality. Whereas MSF for the first time in its history had decided to pay for armed protection by local groups to get aid delivered in Somalia, the UN peace enforcement operation was one bridge too far: MSF decided to pull out because it did not want to be connected to a UN operation in which violence was used to provide aid (Barnett 2011: 174).

In 1995, MSF once again withdrew from a country in war, namely during the refugee crisis in the Great Lakes region. This time, the organization challenged the most fundamental of all humanitarian principles—the humanitarian imperative. Faced with the dilemma that aid was abused by perpetrators of the Rwandan genocide, who used the refugee camps as bases to reassemble and launch further attacks, MSF, together with 15 other humanitarian organizations formulated an appeal to the UN Security Council to separate known war criminals from actual refugees. This appeal was ignored and the UN High Commissioner for Refugees continued treating criminals as refugees.

As a result, MSF made the controversial decision to terminate their activities in the region (Passant 2009). Claiming a ‘right of abstention’ from crises in which effective relief cannot be implemented, MSF de facto qualified the universality of the humanitarian imperative (Rieff 2002). Eventually, some other humanitarian organizations such as CARE Canada followed MSF’s example, whereas others like Oxfam and the UNHCR contended that ‘the rights of refugees to receive aid superseded the problems derived from supplying it’ (Terry 2013: 201).

MSF was strongly criticized for having abandoned their humanitarian mandate in the Great Lakes region. MSF argued that any engagement in the camps would do more harm than good, since their humanitarian assistance helped the perpetrators of the genocide to recover and continue with the violence. Later that year, all MSF sections gathered in Chantilly, France, to discuss MSF’s core principles. This led to the signing of the Chantilly agreement. All sections reconfirmed MSF’s original principles, and especially the witnessing principle, and that ‘the actions of MSF are first and foremost medical’ (cited in Fox 2014: 102). However, based on recent experiences in the field, being present without speaking out was also accepted under certain circumstances (Fox 2014: 46).

In 1999, NATO launched a military operation in Kosovo. This time, MSF did stay on the ground but refused to coordinate its operations with NATO, contrary to other NGOs (Barnett 2011). In October 1999, during the aftermath of the Kosovo conflict and internal reflections on MSF’s principles, MSF—now consisting of nineteen sections (Fox 2014: 150)8—was awarded the Nobel Prize. This illustrated that MSF had become an established and respected actor in the humanitarian sector. This not only sparked joy within MSF. First, the nomination led to heated internal discussions as to who was the legitimate MSF representative to accept the prize, laying bear a lack of consensus and communication between the nineteen sections (Fox 2014: 63). In the end, it was agreed that the president of the International Council would receive the prize. Second, especially the Belgian section wondered whether its rebellious character now was being ‘Nobelized’ and therefore ‘normalized’. They organized a debate around these questions titled: ‘Nobel or Rebel: A Nobel without a Cause’? (quoted in Fox 2014: 61).

As the Nobel Prize illustrated, MSF had become an established actor in the humanitarian sector. In the 30 years of its existence it had expanded from one French section to 19 sections spread all over the world. It was developing into a full-fledged multi-national professional organization, meeting the objectives expressed by the MSF Assembly by the end of the 1970s.

The Early 2000s: Professionalization and Internal Criticism

The 9/11 attacks on the Twin Towers in New York in 2001 and the resulting military operations in Iraq and Afghanistan defined the nature of humanitarianism in the new Millennium. Humanitarian organizations could often only reach groups in need with help of Western military forces, often as part of military strategies to ‘win the hearts and minds’ of local groups. Simultaneously, the world was confronted with a devastating AIDS/HIV pandemic, especially in Africa.

In these years, MSF’s professionalization process continued. A study into the development of formalized human resource management policies of the Dutch section of MSF illustrates how MSF developed into a professional employer (Korff 2012). The first steps towards formalizing the employee-employer relationship were already taken by the end of 1990s, as Fig. 11.1 shows.

Fig. 11.1
A line graph of number of formal H R M documents created per year between 1992 and 2008. The value is below 10 from 1992 to 1997, later it increases above 20 from 1998 to 2000. It increases from 2001 to a maximum of 76 in 2006and then drops to 35 and 24 in 2007 and 2008, respectively. Values are approximated.

(Source Korff [2012: 57])

Number of formal HRM documents created per year

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However, from 2001 on, the production of HRM documents steeply increased: whereas in 1992 only a few HRM formal documents could be counted, in 2008 there were about 425 (see Fig. 11.2), focusing predominantly on outlining rules and procedures regarding rewards for services, but also on topics such as employee well-being, and leave and absence (Korff 2012: 53). In addition, the organization developed a full-fledged training program for its staff, ranging from an introduction and socialization training for new staff (Korff 2012) to management trainings, and specialist trainings in medicine and logistics (Visser 2015).

Fig. 11.2
A bar chart of accumulation of formal H R M documents over time in M S F Holland from 1992 through 2008. There is an increasing trend, the value reached from 2 in 1992 to 425 in 2008. Values are approximated.

(Source Korff [2012: 56])

Accumulation of formal HRM documents over time in MSF Holland

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In the midst of this, internal criticism on the ‘personality’ and governance of MSF grew. The question arose whether MSF could be both a ‘movement’ and ‘an organization’ that was professionalizing and formalizing its operations (Fox 2014: 107). Could one ‘bureaucratize a good Samaritan’ (cf. Waters 2018) without losing the volunteer and humanitarian ‘spirit’ so key to MSF?

In November 2004, this led to the launch of the so-called La Mancha process which aimed to gain more consensus about MSF’s governance model and mission in times of militarization of aid and AIDS/HIV. The process was titled La Mancha in reference to Don Quichote (a man with ‘a sense of ideals, but mad’) and Sancho Panza (a man with ‘a sense of reality, but no ideals’) (quoted in Fox 2014: 103). The organization started to collect staff views on MSF’s principles, key characteristics and future, but also of external actors, as preparation for a General Assembly to be held in March 2006. The results were published in a four-hundred page book titled My Sweet La Mancha (Fox 2014: 103).

Not long after the start of the La Mancha process, a tsunami hit South-East Asia, after which MSF exhibited a particularly fierce interpretation of the independence principle. Within days, millions of Euros in funds were raised to support the emergency response in the affected areas. Numerous humanitarian organizations encouraged and accepted the contributions (Telford and Cosgrave 2007). MSF, in contrast, took a perplexing step: after receiving sufficient funds for the foreseen emergency response within days, a statement was issued on the international MSF homepage discouraging further donations earmarked for the tsunami affected regions. The humanitarian community and the media accused MSF of undercutting the flow of donations by giving the impression that further funds were superfluous (Bennhold 2005). Instead of conceding to such criticism, MSF contacted private donors to request their approval for making the allocated funds available for less prominent and underfunded crises, such as Darfur.

MSF’s rejection of tsunami-earmarked funds was justified by efficiency and accountability concerns. Seeing their emergency response plans sufficiently funded, MSF argued that in order to honour donor intentions and to maintain an exclusively needs-driven approach, forestalling further donations was a necessary move. By doing this, MSF indirectly criticized other humanitarian organizations for being dependent on their donors and for not following a needs-driven approach. The New York Times and the Sydney Morning Herald critically discussed this decision as ‘[setting] off [a] storm’ (Bennhold 2005) and described MSF as ‘deluged with money’ (Norrie and Pryor 2005), overall expressing concerns that MSF’s stance would undercut the wave of giving to the region (cf. Deephouse 2000).

MSF’s reputation seemed to have benefitted from the decision, with later accounts even going so far as to claim that ‘[al]though misunderstood at first, Doctors Without Borders’ bold decision to stop accepting tsunami-relief donation could help revive public trust in nonprofits’ (Barbagallo 2005). Also MSF’s own post-tsunami financial overview (2005) showed that the rejection of earmarked funds did not decrease the overall budget. Moreover, the evaluation of the tsunami response lent support to MSF’s decision (Telford and Cosgrave 2007), revealing the arbitrary nature of emergencyfunding and the lack of needs assessment in the humanitarian response.

In March 2006, the anticipated General Assembly started in which more than 200 MSF representatives participated to decide on the outcomes of the La Mancha process. One important realization was how much MSF had changed from a predominantly Western expatriate organization to being dependent on national staff who had unequal employment and salary conditions compared to expats. All sections vowed to work towards a more associative international form of governance, acknowledging the need for decentralization, increased quality of interventions, equal employment conditions for all staff, and being transparent and accountable (Fox 2014).

A first step in this direction was taken in November 2006, when MSF South Africa was recognized as an MSF branch office, after extensive internal discussions, since MSF as a whole lacked procedures for dealing with the new MSF ‘entities’ that had been established in this decade, such as MSF Brazil, East Africa and Latin America (Fox 2014: 186–187, 250). MSF South Africa differed from the other branches, in that it had been established with the aim to address the HIV/AIDS crisis in the country, which implied long-term medical aid, not emergency medicine. The acknowledgement of MSF South Africa, an office that was non-Western European and focused on long-term medical interventions, marked MSF’s intention to become more inclusive and international.

From 2010 Onwards: More Provocative Acts

MSF maintained and extended its rebellious, outsider position. It applied the strategy of withdrawing from countries where MSF’s work or security was compromised such as in Somalia (2013) and areas occupied by Islamic State (2012) (MSF, n.d.c). In 2014, MSF provided input for the preparation of the World Humanitarian Summit with a research paper titled ‘Where is everyone? Responding to emergencies in difficult places’. In this report MSF heavily criticized UN agencies and INGOs, as stated in the foreword of the document:

…problems remain with the scale up of the UN and INGO response, which is characterized by bureaucracy and risk aversion….

…We also put the choices made by INGOs, our peers, in the spotlight: to profile themselves as emergency responders, but without building the technical and human capacity to respond quickly and effectively; to work as implementers for the UN agencies, and become trapped in their bureaucracies; to avoid risk to the extent that they won’t work where people most need them; and to become dependent on the geopolitical interests in play in various conflicts and crises. (MSF 2014: 4)

Once again, MSF criticized others for losing their independence and not meeting the humanitarian imperative. The report received much attention and was criticized for its flawed methodology, bias and lacking accuracy. Bob Kitchen, director of the emergency preparedness and response unit at the International Rescue Committee (IRC), argued for example in a blog titled ‘Where is everyone? We are right beside you’ that IRC did not hesitate to work in difficult settings, such as in Somalia ‘a country so violent that MSF itself has withdrawn, while many other aid groups continue to stand and deliver in the face of chaos and mounting humanitarian needs’ (Siegfried 2014). MSF also received support for its claims. As Abby Stoddard—a well-known humanitarian expert—stated in The Guardian:

Médecins sans Frontières (MSF) created some welcome upheaval in the international humanitarian discourse recently, with their compelling Where is Everyone? report, lamenting the scarcity of humanitarian agencies operating in difficult environments. As an organization forged from righteous anger, MSF has never reserved criticism for governments and warring parties alone. Often its barbs are directed horizontally at humanitarian counterparts, and this one clearly stung. (Stoddard 2014)

During the World Summit in 2016, MSF applied its well-known strategy by pulling out, calling the summit a ‘fig leaf of good intentions’ and claiming that ‘the summit neglects to reinforce the obligations of states to uphold and implement the humanitarian and refugee laws which they have signed up to’ (Jones 2016).

Meanwhile, Europe was confronted with an increased refugee influx. Especially Syrians were finding their way to EU countries, via Turkey and the Greek isles, but also the number of migrants who crossed the Mediterranean Sea from North Africa increased. MSF was already providing aid to the latter group on the island of Lampedusa since 2002. In 2015, MSF decided to launch a search and rescue operation in the Mediterranean Sea, after the Italian government decided to terminate Operation Mare Nostrum, which aimed at rescuing boat refugees from Northern Africa. Although MSF had never engaged in such activities before, they chose to do so on the basis of the humanitarian imperative and the witnessing principle:

As a humanitarian organization, we believe our presence is needed to save lives, as well as to witness and speak out about the human costs of the policies and politics at play in the Mediterranean Sea. (MSF, n.d.g)

Again, MSF was confronted with criticism, this time from European governments that argued that such rescue operations encouraged refugees to cross the sea and, through this, NGOs would stimulate (paid) human trafficking. MSF responded by deciding to no longer accept any EU funding for its operations anymore (MSF, n.d.c). When, in 2017, the Italian government asked NGOs with search and rescue operations in their waters to sign a code of conduct that would restrict NGOs’ freedom to approach refugees, MSF refused where others signed (Smith 2018). When other NGOs took the initiative to formulate and sign a voluntary code of conduct somewhat later in 2017, MSF again did not join (Smith 2018).9

In this decade, MSF seems to add a dimension to its role as critic of the humanitarian sector. In the report for the Humanitarian Summit, MSF did not spare itself and also discussed its own actions critically (MSF 2014: 20). Later, in 2015, MSF admitted to having made mistakes in the Ebola response, which was painful since it had first criticized other international agencies for their failed response (Hussain 2015).

How to Remain a Well-Respected Provocateur?

This chapter has tried to answer the question how MSF could evolve into a public guardian of humanitarian values and thrive as an organization, while at the same time acting as a provocateur. We explored how the organization was successful in maintaining its reputation, capitalizing on a nonconformist attitude, while internally navigating through growing pains and conflicts.

Nonconformity as an Institutional Characteristic

We posit that MSF’s controversial acts have in fact become integral part of its reputation. Selznick (1957) coined the term ‘organizational character’ to refer to the institutionalized expectations stakeholders hold regarding an organization based on the organization’s evolution over time and the commitments it made to its constituents. Unconventionality is deeply engrained in the organization’s character. Their founding history remains a crucial reference point for MSF, as stated by Vickie Hawkins, current director of MSF UK in an interview with The Independent (Laurence 2014):

Our roots are in radicalism. Our founders were activists who wanted to shake up the humanitarian aid system. They wanted a form of action that was more challenging to governments. It is still very much part of our ethos.

MSF’s radicalism, expressed through the fundamentally different interpretation of the witnessing and independence principles, was the result of fundamental choices in the establishment of the organization and had lasting effects: they constitute ‘irreversible commitments’, decisions that are so central to the identity of an organization that any reversal would substantially alter the nature of the organization and could potentially lead to crisis (King 2015). Building on this core commitment, subsequent decisions to act controversially have contributed to a perception of MSF as an organization that will ‘go where others don’t’, that MSF is different from other international aid organizations, and that MSF is willing to transgress and even affront if it so deems sensible.10 Engrained in MSF’s character, these notions have become institutionalized as expectations among its fellows and stakeholders within the humanitarian field. Thus, when MSF rejects or challengescommon practices of the humanitarian field, it does not defy, but, in fact, meets stakeholders’ expectations.

Looking back, MSF’s viability as an organization might seem surprising, given the many internal struggles it went through (and still is going through). MSF’s inclination to be the critic of the humanitarian world is also part and parcel of its internal dynamics. Much of the internal debates revolved around the question whether MSF could be both an organization and a movement. The organization was (and still is) navigating pressures for professionalization as an organization and calls to uphold the ‘volunteer and humanitarian spirit’ of MSF as a movement. Furthermore, the time horizon of MSF’s work has been a recurrent topic of discussion: how short-term should emergency relief be, if refugee camps exist for decades and diseases are only treated once they are diagnosed, whereas prevention would be more effective?

Our concise—and obviously incomplete—history of the organization revealed some patterns in MSF’s strategies to accommodate these tensions. In the early years, MSF ‘resolved’ internal disagreements by means of organizational splits and establishing new organizations. Attempts to expel the Belgian section in 1985 were not very successful. Instead, the organization expanded into the multi-national organization it is nowadays. This increasingly required MSF to find ways to include and take serious the variety in opinions, positions and ideals of its members. Quite successful attempts seemed to have been the Chantilly and La Mancha agreements of 1995 and 2006. More generally, the elaboration of MSF’s international and associative nature and structure seem to have at least partly accommodated the organization’s ‘culture of debate’ and inclination for critical self-reflection (Fox 2014).

At the same time, MSF has embarked on a path of professionalization and formalization. Although recognizing the risk of bureaucratization and rationalization of humanitarianism, MSF also seems aware that its credibility as provocateur is at stake if the organization does not perform well itself (or at least: is perceived not to perform well). Development of technicalexpertise in the fields of supply chain management, emergency medicine, psycho social care and AIDS/HIV has been crucial in this respect.

In addition, some limits of MSF’s independence strategy to share its expertise while refraining from coordination with other humanitarian agencies have emerged. This became especially clear in the Ebola crisis when MSF had to admit mistakes, after it had first harshly criticized other international agencies. By publicly acknowledging its own fallibility through explicit exercises of ‘self-criticism’—while continuing to criticize others—MSF seems to aim for a balance of being controversial but also credible, both as an organization and a movement.

The Viability of Nonconformity

MSF’s challenge has always been to remain different in order to maintain its reputation as an unconventional organization. For an organization to sustain a positive reputation while chancing its legitimacy through defiance of conventional norms is difficult, if not impossible in the long-term (Rao 1994). We argue that MSF could achieve this due to two interrelated reasons: the strong value orientation of the humanitarian sector, and the possibility of framing controversial acts since values are paramount, yet ambiguous. Framing refers to the conscious and strategic effort of fashioning shared understandings (McAdam et al. 1996), with the purpose to garner acceptance and supportfrom stakeholders. MSF’s justification of their controversial acts exhibits such efforts to reframe interpretations and modify observers’ perceptions. MSF’s controversial acts are not excused, played down or even defended as inevitable, as has been often observed (e.g. Sutton and Callahan 1987; Coombs 1998, 2007; Martins 2005; Rhee and Valdez 2009). Instead they are presented as deliberate and justified decisions, based on the same set of values—the humanitarian principles—that they are said to violate.

MSF’s framing of controversial behaviour is grounded in the inherent ambiguity of the value system of the humanitarian field, which allows simultaneously challenging and embracing core values of the humanitarian field without ever forsaking the common frame of reference. In challenging standard interpretations of humanitarian principles and motivating this nonconformity by reference to other principles, MSF is able to defy normsand practices of the humanitarian sector—i.e. act unconventionally and controversially—while signalling commitment to the core values of the field, thus remaining a legitimate and respected guardian of humanitarian value.

This strategy seems only viable if MSF is able to uphold its reputation as a well-performing and professional organization and to accept a willingness to acknowledge its own fallibility through institutionalized self-criticism. In the past decade, MSF has worked hard to ‘speak truth to power’ through a delicate balancing act of speaking out, being independent, criticizing others, facilitating internal debate and being effective as an organization. Such balancing act inhibits risks: too much internal criticism may lead to new splits or organizational paralysis, and potentially to declining donor support; too much criticism of others may spiral back if MSF would fail to be effective itself; and frequently pulling out from crises and coordination efforts may isolate MSF to the extent that it can no longer do its work. With its current size and challenges, internally and externally, only the future can tell whether MSF will be able to continue to walk this tightrope.

Questions for Discussion

  1. 1.

    One way for a whole field of organizations to institutionalize might be through widespread copying of the strategies of leading organizations in that field. What would happen if other humanitarian organizations would decide to copy MSF’s strategy of an ‘ethics of refusal’? Will this enhance their legitimacy or not, and why so?

  2. 2.

    The chapter states that ‘MSF’s framing of controversial behaviour is grounded in the inherent ambiguity of the value system of its field, which allows simultaneously challenging and embracing core values of the humanitarian field without ever forsaking the common frame of reference’. Explain how this ambiguity helps MSF to legitimize its controversial behaviour and to stay respected as a humanitarian organization.

  3. 3.

    To what extent is this ambiguity in value system a trait of any given policy sector or organizational field, or are there sectors or organizational fields where there is less ambiguity? If the latter, name an example and think through what would this imply for the viability of an ‘ethics of refusal’ in such a setting.

  4. 4.

    How might an organization that prides itself on its value set and moral exemplarship function and be perceived by others as a peer and as a partner in networks and collaborations? How, in other words, can MSF avoid getting caught in a trap of institutional arrogance and aloofness?

  5. 5.

    MSF’s founding leaders played a decisive role in the early phases of institutionalization. They also became controversial. Does this mean that the different phases of institutionalization might require different types of leaders and leadership?

Notes

  1. 1.

    NGO Advisor (n.d.). No. 1 in this ranking is BRAC, an NGO from Bangladesh.

  2. 2.

    This paragraph is based on MSF (n.d.a).

  3. 3.

    These doctors were not the only ones to speak out; Oxfam, for example, publicly supported the rebels (Barnett 2011: 135).

  4. 4.

    See for example MSF (n.d.d).

  5. 5.

    Organizational reputation refers to the collective perception and comparative assessment of an organization’s quality and prominence within its field (Walker 2010; Fombrun 2012; Rindova et al. 2005). Actual performance in the sense of the quality of outcomes is, of course, hard to measure, particularly in the civic sector where, despite ongoing efforts to institutionalize performance evaluation, no standardized metrics exists (Powell et al. 2014; Hall 2014).

  6. 6.

    For more extensive histories and analyses of the organization, see among others, Barnett (2011), Redfield (2013), and Fox (2014) that were also input of this chapter, but also accounts of MSF as an organization as well as its staff, such as the many works of one of its former leaders Rony Brauman.

  7. 7.

    During its short life, Liberté sans Frontières gained a reputation of being anti-Soviet, pro-American and pro-Israel, which went against the political beliefs of many MSF staff. In 1989, when the Cold War ended, the organization ceased to exist (Barnett 2011).

  8. 8.

    These sections were in Australia, Austria, Belgium, Canada, Denmark, France, Germany, Greece, Holland, Hong Kong, Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, the United Kingdom and the United States (Korff 2012).

  9. 9.

    The search and rescue operation was terminated between December 2018 and July 2019 based on the accusation that MSF and its partner SOS Mediterranee were dumping toxic waste illegally at ports, something the two NGOs denied. As of July 1019, MSF managed to get back into action together with SOS Mediterranee.

  10. 10.

    This core characteristic of the organization has even become institutionalized in the form of a blog and debating website called MSF-CRASH (http://www.msf-crash.org/en/) that has criticism and debate at its core mission.