Conclusion

Chapter 9. Conclusion

Throughout our conversations for this research, we heard repeated concerns about documents that lead nowhere in MSF. Several interviewees spoke of their experience of writing and sharing reports only for them to be ignored. For example, one employee early in their MSF career, deeply troubled by what they had witnessed on assignments, said: “I wrote a 20-page report with all the details of everything I observed, and I was expecting that in my debriefing we’d have a detailed discussion on this, and nobody even cared.” Few among the group, they concluded, had even looked at it. Another employee with decades of experience in MSF, whose reports were addressed to the highest level of the movement’s leadership, was equally deflated: “I had another shot at passing the same messages and it still goes nowhere. It goes nowhere.”

We heard about agreements that do not change behaviours, studies that do not produce results, ‘lessons’ that are not ‘learned’, reports that ‘sit on a shelf.’ Indeed, these documents are part of the proliferation of initiatives aimed at some degree of ‘improvement,’ that do not lead to change. There were concerns that this research would join them.

Some interviewees linked this phenomenon to emergency culture, in which “people are not readers. If you bring a 50-pages document you have very, very few chances that anyone would read it.” One even considered MSF to be an “anti-intellectual setting” in which there is “the thinkers and the doers duality, and you are MSF if you are the doer kind.” Others suggested this was linked to limits in the ability or willingness to make use of analysis or critique. Criticism then becomes “a masking agent.” One person said:

“At the moment in MSF we are in a stage where we are good, that once we see a lesson-learned document, we rather praise ourselves to say, ‘Hey, we are open enough to do research and identify our weaknesses,’ and we accept our mistakes. The problem is it only stays or reaches that level.”

Another felt the attitude was: “We have to listen to it; we don’t have to do anything with it.” Ultimately, these testimonies challenge whether the ways in which MSF cares about the realities of a majority of its employees is beyond what is stipulated by the contractual obligations in HR policies.

In this environment, some people seized the opportunity to speak up about their experiences. One locally recruited employee affirmed: “These are the concerns of many staff members here. Sadly, not everybody dares to say it.” Because of this, many locally recruited interviewees working in MSF projects actually wanted their views, and indeed their names, communicated as part of the study: “Tell them I said this. Write that, don’t worry. Be clear, do not hesitate, write my name, I don’t mind. I like change, and it matters to me that our headquarters OCA make changes.” For researchers who collect such testimonies, there is a question of responsibility. As one person who had conducted research in MSF said, after describing a defensive management reaction to the critical conclusions they developed in collaboration with a diverse group of staff: “I wasted these people’s time and it means so much to them to have their voices in that, and I wasted their time.”

This study has focused attention not simply on the challenges that OCA, MSF, and their staff face, but on the power dynamics that shape how they approach these challenges.

Approaching change

OCA employees shared great concern about how to make meaningful change that was not simply tokenism, or artificial. On the one hand, initiatives that focus on attitudes, discrimination and bias, were considered artificial, because they did not make the necessary structural changes. Here again a tension between thinking and action emerged: “Sometimes you get tired, so many guidelines, so many papers and so many analyses. I say, ‘Guys, great, but can we move on in the practicalities?’” A different person asked: “even if you are debating things, how much does it really change?” Taking the example of recent DEI and anti-racism debates in OCA, they described the fundamental structural inequities that remained in place: “We are just good at talking, talking, talking about it without any proper action.” This was also seen as a top-down dynamic: “We saw a lot of changes at HQ level, but where it actually happens, all the work with the patients and beneficiaries, people barely even know about these kinds of topics that got debated.”

On the other hand, there was concern about how even reform efforts aimed at more structural change still did not address underlying power hierarchies. For instance, former locally hired staff in coordination posts for the first time described how even though they had the same “responsibilities” they “still don’t have the same level of trust” as international colleagues. Instead, this nationalisation was described as “just for appearances.” More broadly, there were concerns that the current debate was too inward looking or narrow, missing the opportunity to question the paternalistic interventionism of MSF: “Many of us say that we don’t have a voice. Just imagine the ones who we engage, serve, treat. If we say we don’t have voice, what do they have? They’re the last in the rank. They’re voiceless.”

Clearly, informal and formal inequalities are interconnected and interact in complex ways; they cannot be addressed separately. For instance, efforts to combat racism also need to be accompanied by structural change that enables more people of colour to occupy positions of influence and shift the organisational culture from one centred around whiteness to one representative of the diverse range of staff who make up MSF. At the same time, as the experience of locally recruited coordinators shows, merely changing who occupies different posts does not solve inequalities between different staff when the attitudes and prejudices that underpinned and justified their prior exclusion in unequal structures remain. Instead, this research illustrates how informal power dynamics justify formal structures of inequality, and how an organisation still structured by such stark structural power inequalities reproduces racist and discriminatory tropes and imaginaries which continue to exclude certain people.

Overall, many people in OCA expressed a desire for discussions around inequality, change and reform to be explicitly reoriented towards fundamental self-questioning of the organisation’s work, and the inherent hierarchies and exercise of power this involved. In effect, they were frustrated at the idea of a zero-sum game: how DEI had become pitted against operations, when discussions about power hierarchy were inseparable from MSF’s operational work. As one interviewee summarised in relation to existing debates around anti-racism and DEI:

“The topics are seen as too associated with HR. I struggle, even in a space with activists like Decolonise MSF, I struggle a lot on bringing it back to the operations and problematising ourselves […] I think it’s because it’s so deeply uncomfortable, even for people who are allies on the topic, to really recognise the harm we may be doing, and letting go of the successes and joys we felt in our time, even if there were good things. It’s hard for everybody, and that’s even among people already more bent towards the cause.”

One employee said that “patients, communities, our staff” in countries of operation are “really doing all the difficult work. These people are there – if they weren’t, MSF wouldn’t exist […] and we don’t listen to them most of the time.” To meaningfully change MSF’s work, this interviewee suggested that the shift needed to be epistemic as well as structural. This would require not just diversifying who carries out MSF’s work, but also giving people the power to shape and conceptualise what it is fundamentally about. How inequalities in MSF are conceptualised and spoken about is as important as whether they are a topic of debate. A lot of personal pain can hide behind terms such as ‘power hierarchies’ or ‘structural inequalities.’ It is up to those in power to be vulnerable enough to recognise this and act on it. Another employee put this in terms of “who formulates the narrative,” arguing that if you “claim to want to be diverse, then you have to be open to the idea that expressions will come in many different ways, a lot of it not acceptable to you, but you have to sit and listen.” When discussing patients, communities, and staff across the world, the previous colleague concluded:

“The way they see the world, the vision of the world, is not the same, and it shouldn’t be. And we are not really integrating this element in our daily basis activities. This is DEI to me. Not having a big mission with people from 30 countries. That can be great, and for sure you’ll have more interesting and fruitful discussions, and more creative solutions in that specific mission. But when you have locally hired staff with an amount of information and richness that are not enjoyed and integrated, you are missing a lot. So, DEI is not necessarily about the principles, it’s a way of how to respect people, of how to really share power with them.”

What happens now, and how reform efforts move forward, remains to be seen.

Love and dismay

What appears more certain is that people in the ‘MSF family’ will continue to try. Throughout the study, people we spoke to – whether they still worked with MSF, or not – expressed strong attachment to the institution. There were genuine stories of social mobility and lives changed, such as one locally recruited employee who had started as a daily worker and is now in one of the most senior programme positions, whose “love” of the organisation came not just from the work, but “because I was able to grow.” “We never say, ‘It’s perfect’,” another employee said. “Of course, there are things to do, but I think at the end of the day, we know that MSF is good.”

Strikingly, affirmations of love and loyalty often came either before or after stark critiques of the organisation. An employee in Syria described how, in a context of personal loss, “MSF, for me, is very really family, and I do love them and I like to defend them,” but experiences of facing criticism for speaking up made them “really feel regret that nobody is caring about your pain” and ask “why is the power in those people’s hands?” Another interviewee captures the combination of faith and dismay evoked by many:

“It’s difficult because it’s an organisation I love so much and I don’t want to work for anyone else. At the same time, too, it could be so much better and – trying to reconcile the two because it’s very difficult – how can I love something so much and be so passionate about it when it’s also so broken? But it works somehow. There’s a touch of magic somewhere that makes it all work.”

At the end of the day, “the touch of magic” making it all work is people’s willingness to continue working for MSF, but also their structural inability to leave. Employees’ views of MSF weighed the institution against its own values as well as the world in which it seeks to intervene:

“I think MSF is essentially a neo-colonialist organisation, probably, and that’s really uncomfortable to hear and to think as a part of it. I still am part of MSF because I believe in universal free access to healthcare, which is an increasingly diminishing resource in the world, and MSF provides it in places where it really doesn’t exist, so on the scales of my soul, I still balance working for MSF as better than not.”

By tracing the power dynamics at work in OCA and more widely MSF, among staff and between staff and patients, this study has exposed some of the causes of dismay, hurt and frustration. It has shown how people drive forward the movement’s medical humanitarian action, by acting on the powers the organisation has granted them, by mobilising influence within the organisation, and by working around the obstacles that organisational and operational contexts present. It offers a portrait of the organisation, providing an analytical resource for those seeking to bring about change in MSF, and showing why they continue to try.