Leviers d'influence

Chapter 4. Currencies of Influence

Introduction

The previous chapter outlined MSF’s emergency culture and operations, and described the environment in which employees work. This chapter examines what this means for people within the organisation – how is MSF experienced and navigated? Previous scholarship on values-based organisations has highlighted the informal powers and privileges (or disadvantages) of certain individuals, position-holders, or social groups (Hopgood, 2006; Benton, 2016; James, 2022; Kothari, 2006). Research on MSF has shown that norms within parts of the movement reflect different forms of cultural capital and intersect with social and political hierarchies and inequalities (Rambaud, 2009; Shevchenko and Fox, 2008; Souley Issoufou, 2018). Histories of MSF highlight the role of key individuals in defining, expanding, transgressing, and subverting formal structures, further valorising and mythologising the role of individual agency in an emergency culture where improvisation is often more important than institutionalisation (Vallaeys, 2004; Davey, 2015; Redfield, 2013).

Interviewees pointed to the importance of considering informal powers – and the related dynamics of discrimination – beyond formal hierarchies. One experienced MSF member described the limits of formal power: “for, me it is about four things that are interlinked and which the distribution in our organisation is extremely skewed. It’s power, it’s influence, it’s privilege and opportunity.” What matters is: “can I get people on board for what I truly believe is the right course of action?” Another who had worked across programme, OCA headquarters, and international roles argued that informal power is “related to the position but also to the personalities of people who are more powerful and influential than others […] There is always a way to influence, in one way or another.”

We use the term ‘currency of influence’ to describe some types of informal power that people invoke or draw on when trying to exert influence or seek authority within MSF. Currencies can become a means of advancing professionally and bring the ability to set and shape MSF’s agenda. When speaking about these topics, MSF employees used various terms, often referring to factors such as personal profiles, backgrounds, behaviours, assets, or identity traits. Currencies of influence are not necessarily stable, differing between geographical or professional contexts and changing over time. They represent informal forms of power, but some have become codified in formal structures and powers.

The first section maps some of the most frequently referenced inequalities within MSF, which both reflect and reproduce broader structures of inequality. The remaining sections examine six major ‘currencies of influence’ frequently raised by MSF employees: time in the field; friends in high places; whiteness; English language skills; masculinity, and medical expertise. Throughout the chapter, we use examples to illustrate how these interacting currencies may look in practice. This chapter thus documents what different employees see as contributing to some people being more able than others to operate, rise, and influence inside MSF.

4.1 Axes of inequality

ideas of ‘universal humanity’ can reproduce post-colonial power relations between the Global North and Global South (Duffield 2008), as well as inequalities between the populations they are meant to help (Bardelli 2020; Ticktin 2011), and between humanitarians themselves (Fassin 2007; Peters 2016; Benton 2016). A growing literature on MSF has documented racialised inequalities among its staff (see overview in Chapter 1). It has been argued that understanding these dynamics is important because “the structure of the work itself influences the outcome” of such interventions (Fechter and Hindman 2011, 2). Paradoxically then, humanitarians reinforce hierarchies of humanity.

This section briefly outlines several axes of inequalities around which MSF is structured. These axes of inequality are developed in further detail throughout the research so this section acts as an overview for the reader. Crucially, for this study, we did not define ‘inequality.’ Instead, we asked participants to describe the inequalities that they saw and experienced in the organisation, or the key structures of inequality that shaped MSF’s work. As one senior OCA employee put it: “inequality would be an absolute defining characteristic of MSF.” The organisation is, in effect, structured around inequalities: power imbalances between ‘patients’ and ‘humanitarians’, ‘volunteers’ and ‘employees’, remain integral to how the organisation was established and continues to operate.

Humanitarian subjects and agents

As the anthropologist and sociologist Didier Fassin (2007) articulated, humanitarianism is a ‘politics of life’; it gives specific meanings and value to human life, distinguishing lives that may be risked, and lives that can be sacrificed, despite its egalitarian aims. This has implications for the people that humanitarian organisations aim to serve and for their employees. The power inequality of who is able to shape this politics of life was recently highlighted in a research paper by Tammam Aloudat, President of MSF Holland, arguing that the ‘subjects’ of global health institutions – or the ‘health subaltern’ – cannot speak (Aloudat 2022; Spivak 1988). He described how the ‘beneficiaries’ of global health institutions have no place in the discourse, nor in the decision-making processes, that determine their fate.

Humanitarian medical intervention is structured by a power imbalance between the intervenor and the intervened upon. Some employees argued that MSF’s focus on saving lives encouraged a paternalistic interventionism, where patients are subjects to be acted upon, imagined to be without expertise or agency. An experienced nurse said that “we come with this idea of providing assistance and aid, and helping other people, with this idea that they can’t help themselves,” speculating that this may come from “our foundations of medicine, as a profession, which is paternalistic in many ways,” and historically is “a very middle-class profession, a very male profession and a very white profession.” 

This fits with a broader post-colonial critique of international humanitarian aid and global health which describes its imperial traces (Affun-Adegbulu and Adegbulu, 2020; Abimbola and Pai, 2020; Khan et al., 2021; Chaudhuri et al., 2021; Hirsch, 2021a; Hirsch, 2021b) embedded in the imaginary and treatment of the suffering ‘other’ (Ticktin, 2011; Abu-Lughod, 2013). The idea of responding to an emergency suggests the need for decision makers from outside, to come to help an overwhelmed population; an emergency is an exceptional time, legitimising exceptional measures; so, according to this logic, in some cases hierarchy and decision-making by outsiders is necessary.

As many employees reflected, MSF’s work to ‘save lives’ during ‘missions’ in countries predominantly in the Global South is a product of colonial history and a reflection of post-colonial global inequality. That “people from the Western world can afford to go to other countries and care for people there” is “just thinkable because there are these power imbalances in the world,” one stated. Another employee suggested that MSF’s hierarchical mode of operating is a product of both colonial history and medical paternalism:

“Globally, there is a power imbalance between the healthcare staff and patients, or communities. That is reflected, I think, in MSF as well. We’re not any different to that. I guess, for us, it’s complicated even more so, or worsened, by the kind of colonial roots that we have, as well. I don’t think we’ve perhaps, reflected enough yet on just how imbalances and inequality and the power that medicine, the medical profession has.”

Yet, as the previous chapter described, appealing to a focus on speed and urgency means that MSF consultation with communities is often minimal or contained within a narrow scope. Despite the project cycle featuring several steps that eventually culminate into project implementation, the community is often only able to influence the implementation phase. Other consultations may happen but they are more of a tick box exercise. Many times, MSF has already decided on what they want to do. One programme staff member said: “MSF bring[s] their decision and to give it like the water ‘Okay, take it now and drink’, without taking care about observation of beneficiaries.” The conclusion drawn is that “ultimately we [MSF] want to keep that power, the power of choice.” 57

Additionally, when attempts for consultations with ‘communities’ are made, it is the leaders who are often consulted. A doctor working as locally recruited staff has shared a probable explanation for this approach:

“People who are not leaders, they have no influence on the community. If you choose someone who is not a leader, it cannot give any influence on the community and so we need to choose the people who are going to understand what we are talking about and make a change with them and then they can go in the community and speak to the community or to us who have been discussing and then the message can be very well understood.”

On the flip side, “community leaders and a lot of the context where we speak are already the power holders in the community.” Hence the approach taken by MSF risks a perpetuation of already existing power imbalances within the community.

However, despite a heavy imbalance of power, all is not lost – people still retain some degree of power in their dealings with MSF at both individual level and community level or even national level. This most commonly presents as refusal of treatment, according to a Nursing Activity Manager: at individual level, as people “refuse medication sometimes if they don’t feel that it is okay for them, they refuse,” or refusal of an intervention altogether at community level. They further shared:

“Maybe that we think that we are in power a lot in our health facility, and in the programmes we run, but on the other side when the community really doesn’t want something, I think then you also see we are just visitors. They have a lot of power also.”

The power dynamics inherent in the medical work of MSF, and the interactions between healthcare workers and patients, feature in several places throughout this research.

International/National

The most frequently cited inequality among MSF staff was between ‘internationally mobile’ and ‘locally recruited’ employees. Some MSF employees have referred to a ‘two-tier system’ (Majumdar, 2020; Campbell and Kardas-Nelson, 2021); others used the notion of a ‘caste system.’ One locally recruited employee said:

“From the first day I joined MSF, I felt there were two camps: The nationals camp, and the expats camp […] I asked [my supervisor] about it. I told her that I didn’t get it, that we had principles defining the organisation. I wanted to know why there were two camps, a camp for people like me, the locals, and another one for people like her, the expats. So, she looked at me and told me she did not know what to say, but that was just the way it was.”

The vast majority of MSF’s employees work in their country of origin – around 80% in recent years.3 They have remained largely invisible in the organisation’s public discourse and organisational narratives – instead, the focus remains on topics “which concern less than ten per cent of our population,” in the words of one senior manager. The split system is embedded in policies, creating what one interviewee condemned as an “ingrained inequality”:

3 In the past, locally recruited staff in programmes represented over 90% of MSF’s workforce. In 2021, they were 78% of the total number of employees (Cragg and Linna, 2022, p. 18), a proportional decline that can in part be explained by the growth of headquarters over time. Headquarters staff are now also described as ‘locally recruited’, although not all are nationals of the countries in which they are based.

“The intention is not that, but very plainly put it’s basically putting a different value on different people’s lives. That’s just not acceptable, and it’s hurtful, and it contributes to […] ingraining in people that we are different and that we should be valued differently, even in very subtle things it still sends that message.”

This ingrained inequality permeates the organisation to influence the healthcare giving processes at the level of clinical work. Many by virtue of their ‘international’ status will come in automatically as supervisors irrespective of their previous experience or inexperience of management. A locally recruited staff member observed:

“I witnessed this myself on a project that included a local nurse that had great experience and work ethic. There was also an international unqualified nurse who was promoted to the Head of Mission and supervised that local nurse. There was no valid reason for that, it was just the mentality that said, ‘can national staff supervise international staff?’ It is a matter of perception, the fact that someone from the international side is coming to supervise national staff without proper experience.”

Additionally, there were concerns that a perception of requirement for ‘international’ supervision was creating redundancy and inefficiency. A manager working in health said that “We are bringing NAMs [nursing activity managers] in higher salaries and higher positions and they’re just here for mentoring and sometimes they’re just doing just nursing work, doing cannulas, and they’re not even taking part in doing rosters [as expected] of the supervisor.” Conversely, their locally recruited counterparts sometimes have to work in positions lower than they are qualified for simply because of the prevailing unemployment within their countries. One hospital coordinator support shared the plight of a colleague:

“He applied for it, there was only a vacancy open for clinical officer, and he qualified for the position. He has a bachelor degree in medicines and surgery. So, that was the outcome, he’s a medical doctor recognised in the country. He chooses to work here, give him the position of medical doctor, instead of maybe bringing someone from [elsewhere]. He’s from the community, let him work.”

The position of locally recruited staff in the organisation has long been a subject of concern. In 2006, the La Mancha Agreement (MSF, 2006) committed to: “provide fair employment opportunities for all staff based on competence and commitment rather than mode of entry into the organisation (either through national or international contract).” However, the fundamental structure has remained the same: a group of foreign mobile staff in senior positions and a pool of personnel recruited in-country with a different contract type (Redfield, 2012; Pechayre, 2017). This results in an ever-shifting powerbase – “all the high-level positions, it’s for international,” as a focus group participant said – made up of individuals who are constantly on the move.

Locally recruited personnel have faced difficulties progressing beyond a certain ceiling, largely because of bars preventing them from occupying senior roles; as Chapter 5 explores, this is an ideologically grounded barrier based on the idea that outsiders are neutral in a way that ‘locals’ cannot be. Thus, in the six years from 2016, although the number of locally recruited staff in coordinator positions increased, in four of five operational sections, they remained below 20% (Cragg and Linna, 2022, p. 41). In OCA, notably, they rose from 16% in 2020 to 21% in 2021 (ibid., p.42; see figure 1), potentially reflecting the impacts of travel restrictions due to Covid-19 which some interviewees alluded to anecdotally. Even more striking is the percentage of full-time equivalent (FTE) coordination positions held by locally recruited staff in the recently founded West and Central Africa Operational Directorate (WaCA), the only MSF entity with operational authority to be based outside Europe – an outlier at 34%. Across the movement, nonetheless, 95% of Head of Mission FTEs and 92% of Medical Coordinator FTEs were held by internationally mobile staff (ibid., p. 44).

Figure 1: Evolution of locally recruited staff coordinator FTEs by Operational Centre, 2016 to 2021

Source: Cragg and Linna, 2022, p. 42

There also appear to be obstacles to locally recruited personnel being hired onto international contracts. In 2021, across the movement, only 5.6% of people recruited to work as internationally mobile staff (by headcount) came from the pool of (former) locally recruited employees (Cragg and Linna, 2022, p. 47). In practice this meant that MSF recruited only 167 people who had previously worked on local contracts, and of these OCA recruited the fewest: seven. OCA also had the fewest ‘detachments’ (secondments of up to three months) of locally recruited staff to a programme in another country: 18 out of a movement-wide total of 358 (ibid., p. 46).

In interviews, there were perceptions that the goal of ‘saving lives’ had come to present, or could be deployed to create, obstacles to greater investment in local personnel. “Our money is going towards saving lives, not that hump of bullshit of building national capacity,” was how one experienced employee captured the attitude. Indeed, this reflects MSF’s historical stance on ‘localisation.’ In 2016, the UN Secretary General argued at the World Humanitarian Summit that humanitarian action should be “as local as possible, as international as necessary” to remedy North/South power imbalances (Bennett, Foley and Pantuliano 2016, p. 46). In response, an MSF report emphasised “reservations” with the idea that “international actors should make themselves redundant by building local capacity and enabling local actors to run their own response” (Schenkenberg, 2016, p. 3). Instead, that report argued that “building local capacities is not an objective for MSF per se” as it would “diminish” humanitarian assistance’s “essence” and the “specific role it plays in conflict settings where a distinct and principled approach is required” (Schenkenberg, 2016, p. 9).

The two contract types determine vastly different relationships between employee and employer. As explored in subsequent chapters of this research, MSF’s split systems reflect and sustain power dynamics and have material consequences across a range of areas. This includes differential access to opportunities, leadership positions, and mobility, different pay and per diem policies, but also (as discussed in Chapter 5) a hierarchy of trust that imagines foreign workers as neutral, and local staff as entangled in particularist attachments. Locally recruited employees have differential access to healthcare and health referrals, and to MSF’s security apparatus and evacuation procedures. Fassin (2007) argued that through its unequal security provisions, MSF makes a distinction between lives with higher value (internationally mobile humanitarian workers), and those that can be risked (locally recruited staff).

Interviewees spoke in extremely strong terms about the social segregation between locally recruited and internationally mobile staff. Several people reported being shocked during their first international assignment by what one described as the “impression that there was a total apartheid between the expatriates and the national staff,” such as separate eating and sleeping quarters. While conducting short-term or exploration trips, Congolese employees who were brought into an area described being lodged in cheap hotels, when their international colleagues were placed in expensive hotels with better security. Some sites have separate toilets, as described by this internationally mobile employee:

“You go to the expat area and it’s […] not fancy, but nice and very well taken care of. And you go to the area that the local team is using, and it’s a project which is active for more than 10 years, and the toilet and the shower that we prepare for our team is made of plastic sheets. […] Nobody ever questioned this. [… The] water supervisor, who is responsible for water sanitation, making sure the toilet’s working, he’s the one taking care of the expat area. So, this guy [is] going and taking care of all the nice toilets for expats. And then he himself [is] using this toilet made of plastic areas and what message are you sending him?”

Many internationally mobile staff working in MSF were uncomfortable about inequalities with their local colleagues: “it’s one big thing that I’m ashamed of.” This structural inequality between locally recruited and internationally mobile staff is a thread that runs throughout the rest of the study, as we unpack how it manifests in particular settings, and is reproduced by particular organisational logics and assumptions.

Intersecting axes of inequality

MSF employees also discussed other axes of inequality (beyond ‘international’ and ‘national’) which are too often overlooked. Notwithstanding this lesser attention, the institution is certainly aware of the importance of “non-professional criteria, including nationality, skin colour, gender and religion” within its workforce, as these are the basis of the practice known as ‘profiling,’ undertaken when security threats target specific kinds of staff (Duroch and Neuman, 2021). The categories need to be deconstructed, as does the assumed internal coherence of these labels, to instead examine the experiences of different humanitarians from an intersectional perspective (Martin de Almagro, 2018).

Some interviewees described how the organisation reproduces hierarchies between the Global North and Global South. Despite claiming an international identity, MSF remains headquartered in Europe, with its senior decision makers in headquarters predominantly from the Global North, intervening upon populations in the Global South. This overlaps with the structural power imbalance embedded in the way MSF’s operations are managed: decision-making power remains concentrated at headquarters in Europe, among former international staff members who are predominantly from the Global North. In effect, this means decisions about programmes and strategy remain in the hands of individuals based in the Global North, while the majority of MSF employees (and those who receive MSF aid) remain excluded.

These dynamics are reflected in recent Staff Data and Trends reports. Across the movement, in 2009, 74% of internationally mobile FTE staff positions were filled by people with the nationality of a country in the Global North (Cragg and Jager, 2021, p. 35).4 In 2021, for the first time, more internationally mobile staff FTEs were filled by people with the nationality of a country in the Global South than the Global North (Cragg and Linna, 2022, p. 38; see figure 2). That said, numerically speaking there are still more internationally mobile staff from the Global North; this combination reflects the length of assignments that each group undertakes and is suggestive of some of the dynamics shaping access to posts. As internationally mobile staff can have preferences about length of assignments, an interviewee noted that: “the nice cherries of the short missions, sometimes also the priority goes to certain people, all the time.” Though they did not comment on the nationalities of people in that group, according to movement-wide data the shorter an assignment is, the more like it is to be held by a staff member from the Global North. Specifically, 63% of assignments of less than 1 month are undertaken by personnel from the Global North but only 36% of those over 12 months, with the percentage gradually dropping as the length of assignment increases (Cragg and Linna 2020: 33). Further, staff from the Global North continue to dominate powerful coordination positions such as Head of Mission, Deputy Head of Mission, and Project Coordinator. Leadership positions in the medical line appear to be more open to staff from the Global South, who represent 67% and 77% respectively of Medical Coordinator (MedCo) and Deputy MedCo FTEs, raising questions about whether factors that have shaped this pattern can be applied to promote diversification of leadership in other lines. This also raises the question whether staff from the Global South are more entrusted with work requiring more technical decision-making.

4 For the list of countries considered Global North and Global South, see Cragg and Linna (2022), p. 64-65. 59

Figure 2: Distribution of senior role FTEs between internationally mobile staff from the Global South and North in 2021

Source: Cragg and Linna, 2022, p. 45

Despite this, many interviewees said that inequalities remain between people on the same contract type. This began from the offset for people who are recruited from a country that does not have an MSF office: “If you’re international staff recruited from anywhere beyond those 19 countries, you are in the Bermuda triangle.” Interviewees also pointed to the difficulties of obtaining visas for some nationalities to come to Europe. This is a major disadvantage when access to networks of influence and therefore opportunities (see currencies of influence, below) is considered:

“I don’t have scientific studies, but observation over the years is that if you are not from northern Europe or for whatever chance able to relatively regularly call into the headquarters, your career is progressing much slower. […] And just picking DRC, if you’re a DRC national working as an international member of staff, you miss a Schengen visa for the briefing or debriefing, you miss really out on your career.”

While the granting of visas is beyond MSF’s control, the concentration of formal power in Europe amplifies the impacts of these external inequalities. There was also discontent about how pay is calculated; the fact is that people occupying the same position are paid differently, depending on their country of origin. This is part of the salary structure known as IRP2 (for International Remuneration Project, version 2), which pegs salaries of international staff to rates in their countries of origin.5 While its first aim was to “attract, motivate, and retain international staff,” IRP2 has the effect of creating differences between the pay of national and international staff, and between the pay of international staff from different countries (Désilets and O’Brien, 2017). In essence, those from higher-income countries are paid more than those from lower- and middle-income countries. As a result, if the lens of Global North and South is once again applied, the impression of a privilege or bias in favour of internationally recruited staff from the North is reinforced. Simply stated, being ‘international’ alone is not enough to determine conditions or experiences, one’s exact origin is equally important.

These inequalities also manifest more indirectly. One internationally mobile staff member from the Global South described how “institutionally, our policies are very much influenced by the setup of Europe or the setup of the developed countries.” These policies disregard unequal government welfare provisions between countries in the Global North and South which influence MSF internal career choices and trajectories. They described “the insecurity of not having anything to provide for my family” in-between missions:

“To some extent it is impossible to give something in-between the mission for the expats but if I have said I am available to go in three months, I am planning myself that I have enough money to cover my finances and provide for my family for three months. After the three months if I am just waiting for another three months then I have nothing.”

This forced them to make difficult choices, accepting compromises that others may be able to avoid: “Even though that decision I would pass it and take something else but I don’t have the liberty to do so.” They persisted because: “I don’t want to jump into another boat and leave MSF” – another example of the loyalty that we often heard expressed towards the institution even when staff perceived it as contributing to or exacerbating challenges in their own day-to-day life.

5 At time of writing, IRP2 was being examined through a process known as the Rewards Review, which “aims to develop a new rewards framework for the whole MSF global workforce” to help the movement “better meet operational needs” and to “contribute to MSF becoming a more equitable, just and diverse global organization” (MSF International, 2023, p. 1).

Other interviewees said that these inequalities are not just shaped by nationality, but also by race. As Adia Benton (2016, p. 268) points out, while critiques of humanitarianism focus on power, they have not explored how humanitarianism is organised “along racial lines, alongside those of national citizenship and class.” The Black Lives Matter Movement in 2020 renewed critical discussion around structural racism in MSF, both in headquarters and in locations of intervention (see e.g. Aizenman, 2020; Al Jazeera, 2020; Caramel, 2020; Parker, 2020; Stewart, 2020). Interviewees for this study likewise described the varied ways that racial inequality was reproduced within MSF’s everyday structures. This is another key thread that runs throughout the research and is examined in further depth in the following section on how whiteness operates as a currency of influence in the organisation.

MSF employees pointed to the ways that gender and class intersected with race and nationality to produce situated forms of inequality in MSF’s organisational structure. As discussed in Chapter 7, the spirit of volunteerism that underpins MSF’s vision of its workforce is can be exclusionary with regard to different socioeconomic backgrounds. First-hand testimonies of MSF employees in headquarters and different countries of operation also revealed the complicated ways that gendered power dynamics shape MSF’s everyday work. Crucially, as explored below in the section on masculinity, gender intersects with race and nationality to produce forms of privilege, power, distance or disadvantage (Roth, 2015; Martin de Almagro, 2018; Read, 2019). The position of women in the organisation looks radically different at different levels of OCA. As an employee working in HR explained, staff data reveals a high percentage of women among internationally mobile staff from the Global North and even more at headquarters level. However, there are far fewer women from the Global South working as internationally mobile staff (see Cragg and Linna, 2022, p. 48). Similarly, there are far fewer women working as locally hired staff: “Our gender ratios are poor and the lower down the level you go, the worse they get.” This means that as MSF focuses on ensuring that the internationally mobile staff pool is more diverse, expatriating more locally hired staff from countries in the Global South: “the gender ratio is getting worse.” In WaCA, women represent 27% of internationally mobile FTEs, compared with between 37% and 46% for the other OCs, OCA representing the highest proportion (Cragg and Linna, 2022, p. 48).

The binary of national/international overlooks another group of employees: ‘delocalised’ staff, or ‘in-pats’. Whereas ‘locally recruited’ staff originate from near the project site itself, and ‘internationally mobile’ staff have been brought there to work from abroad, in-pats sit somewhere in the middle; they are nationals who have been ‘in-patriated’ from their region of origin to work elsewhere in their own country (James, 2020). In-pats described the difficulty of falling between two categories of staff. For instance, evacuation procedures for in-pats have been developed over time, with the conclusion that because in-pats were brought in, they should be taken out in times of emergency. However, interviews revealed this was not always the case. At some projects, in-pats are evacuated alongside foreign staff, however at other sites, they were not. In-pats argued that OCA treated them tactically as local, “to avoid worrying about our fate when there is a problem.” One interviewee described how during an exploratory mission with international colleagues: “we worked on the project, and we all lived in the same house,” but when approval came to officially start a project, “that meant that we had to operate as local staff and leave the house […] our contract would change, and that we were no longer entitled to evacuation […] They [internationally mobile staff] told me that I’m on my own.”

In-pats often have to cover their own costs when leaving or returning to a project once employed. There is no global policy on the issue of in-pat compensation. In cases where OCA has actively sought to recruit outside the local area, relocation expenses may be offered to incentivise applications. However, interviewees argued that not providing in-pats with support to cover ongoing travel expenses was unfair, because the organisation pays for the travel of international staff, who are paid more, and because in-pats often had to travel to nearby cities to access their salary at a bank. In locations where travel was expensive, these problems became more acute. For instance, at a project in eastern DRC (Walikale), in-pats must pay for their own plane ticket to travel to and from the project. An employee explained: “MSF knows that I was recruited from Goma. I did the whole process by Skype. I came to Walikale on MSF planes […] But the organisation tries to ignore all this.”

Another category of staff that complicates the picture of ‘local’ and ‘international’ is that of ‘MSF incentivised’ staff, who constitute a distinct group within MSF. This category is the result of MSF’s collaborations with Ministries of Health. According to a manager in one of these collaborative sites, these people are “supposed to get a salary from the Ministry and then a salary top up from MSF.” On the whole, human resource management pertaining to this group is in the hands of the MoH. Based on interviews for the present study, MoH incentivised staff – which are numerically important but have been an “underanalysed” group (Harvey et al, 2019) – appear to occupy an ambivalent position. The institution appears to be less able to exercise control over this group. A quantitative survey in 2019 indicated that OCA had limited control over incentivised staff and struggled to address poor performance, although overall country offices reported that projects are still able to meet set objectives (MSF OCA, 2019b). An experienced programme employee said:

“If I ask something of the MoH staff, they can just listen from here and [it] just [goes out the other side] away from there. Because they are not afraid, they have nothing. Because they know we couldn’t terminate them. But if you have an MSF staff, they have strongly conducted their work.”

This led them to conclude that “if the MSF is working alone, it will be better.” As shown in Chapter 5, the construction of MSF identity opens the door for judgements about the motivation and level of commitment of different groups, judgements which were applied harshly to MoH staff. At the same time, MoH staff experience different, often more precarious, conditions from other staff. In DRC, it was noted that despite these staff being employed primarily by the MoH, should MSF leave or stop paying incentives “many of these staff will lose their jobs as well because the government without support of other partners will not be able to continue many of the services being offered.” MSF employees were confident that “many of them would like to work as MSF staff.” There are some glaring system “distortions” (Harvey et al, 2019) facing incentivised staff, including in remuneration. An MSF employee who had worked in Tajikistan recalled commenting on the programme having many challenges, and being told that an MoH doctor was paid 1,300 somoni per month, while an MSF nurse was paid 5,000 and an MSF doctor 9,000; this “pay differential” was presented as “part of the reason why this dynamic doesn’t work.” There are thus inequalities between this group and the rest of the MSF staff, yet they are held to MSF standards when it comes to their duties. One Activity Manager said:

“I think there’s some quite challenging things about […] the difference in privilege between MSF staff and between Ministry of Health staff, even if they are effectively doing a very similar job and were recruited from the same place. The MSF staff have healthcare guaranteed, they have a reasonably good salary, they have access to training, et cetera. And then, meanwhile, the Ministry of Health staff have none of that, but we’re pushing them to work in the same way.”

Overall, the categories explored in this section are not static or immovable. Rebecca Peters (2016) illustrates how the ‘local’ is socially produced: aid workers may strategically position themselves as ‘local’ within institutional hierarchies in order to access employment and to further personal interests (see also Heaton Shrestha, 2006; James, 2022). Rather than employees positioning themselves as ‘local’, in one of situations described above, MSF management strategically positioned in-pats as ‘local’, despite having facilitated the mobility of this group of employees. In a further subclassification of the local, we find the MoH incentivised staff come in at the bottom of this ‘caste’ system yet can be closest to the MSF patient when MSF works within the MoH structures. Ultimately, the labels ‘local’ or ‘international’ may obscure, rather than describe, the complex social positions of people working for humanitarian organisations.

BOX 4: ETHNICITY AND RECRUITMENT

When discussing inequality, locally hired staff in different contexts described concerns about the way MSF’s presence interacted with, or exacerbated, existing structures of inequality. Many of these concerns were articulated with the language of ‘ethnicity’ – staff were concerned that MSF’s recruitment processes might be interacting with existing societal cleavages. Patients, too, make observations, as seen in an interview in South Sudan, where a patient’s concerns about unfair treatment were attributed to ‘clan level’ as a basis for segregation. Humanitarian agencies are powerful actors in the political economy and their resources and employment become entwined in local power contests. Recruitment, then, is not simply a human resources process, but becomes an arena where people contest who has a right to the resources MSF’s presence brings. Who gets to represent and work for an NGO is a fraught issue.

In Syria, OCA works in an area controlled by Kurdish self-administration. There were tensions about how MSF’s presence and recruitment interacted with existing social dynamics between Kurdish and Arab communities. One Syrian employee said: “we Kurd staff often feel that there are some expats who rely, trust, or have a good relationship with the Arab staff rather than the Kurds.” Some employees argued that this “leads the strategy of the project,” with a focus on Arab areas rather than Kurd areas: “then the community, the authorities, ask ‘why […] is it all going to the Arab area?’”

In eastern DRC, there were concerns locally about ‘tribalism’ in recruitment processes, with frequent perceptions that some groups were being favoured over others. This was a priority for DEI efforts in the country. MSF must navigate historically laden conflicts and highly politicised notions of belonging about who is considered ‘autochthonous’ to a particular place. Autochthony is a slippery concept, politically manipulated and itself a colonial import, that operates at several levels (Jackson, 2006). At a territorial level autochthonous groups were pitted against speakers of Kinyarwanda, and MSF was sometimes accused of favouring one group over another. Sometimes, this was expressed in ethnic terms. At a provincial level, where supposedly ‘authentic’ provincial identities have become increasingly politicised, MSF faced criticism for the ‘importation’ of in-pats from other provinces. Even the term ‘local’ was highly contested. Employees indicated that perceptions of “favouritism or partiality” were the “cause of many security problems” for MSF in the region.

4.2 Currencies of influence

This section identifies and unpacks the key currencies of influence that emerged through our interviews. While it indicates some of the complexity inherent in these currencies, highlighting variations, intersections and contradictions in different settings, more detailed and nuanced discussion of their impacts comes in the chapters that follow. The currencies of influence we heard most about were: time in ‘the field’; friends in high places; whiteness; spoken English; masculinity; and medical expertise.

These currencies will not all be treated in the same way. Some were discussed more frequently than others, in stronger terms, or with more specificity. For example, there is discomfort around talking explicitly about racism. This reflects a broader issue in that, as one interviewee commented: “It’s going to be really hard for you to talk about stuff that people don’t know how to talk about. They don’t have the lexicon for it and there are […] quasi-visible or invisible barriers to even thinking about this.” They cited the word ‘effective’ as an example of how terminologies also hold currency in MSF’s emergency culture, justifying certain choices and masking or dismissing their impacts, ultimately making it more difficult for underlying issues to be explicitly recognised.

Time in ‘the field’

References to ‘the field’ in MSF can mean a lot of things: a location juxtaposed to headquarters as the place where MSF’s medical humanitarian work is carried out, or a body of personnel (‘we want to hear from the field’). Stellmach (2020) found that in MSF, the field was a receding horizon depending on perspective – from programme countries to project sites, to places beyond the clinic. This field imaginary as exotic and strange is rooted in colonial history (Gupta and Ferguson 1997), invested in “old fantasies of remoteness and otherness” (Andersson 2016).

Time in ‘the field’ is a pre-eminent currency of influence in MSF. It gives you “street credibility,” it’s what gets you “the stripes on your shoulder” that legitimise you to represent MSF externally and “join the conversation” internally. The depth of this experience is important. As one headquarters employee commented: “Gap fills are not really considered field experience; I think field experience is six months or longer in a project location.” Geography also matters, reflecting the importance of certain large and long-running country programmes within MSF and the humanitarian sector in general (Taithe, 2016). Interviewees linked ‘field experience’ to MSF’s emergency culture and the production of the ‘MSF family’: “When you spend times in the most difficult situations with a group of people, you form certain connections, you form certain bonds that stay with you.”

Moving into a headquarters role after international operational experience is a common trajectory, meaning that MSF offices include employees with twenty, thirty, or more years of experience in the movement. Interviewees have referred to this as a phenomenon of “lifers”, “veterans”, and – with an air of playfulness, from someone who considered themselves as not qualifying quite yet – as “MSF dinosaurs.” In an organisation where “the years in the club count very much for your legitimacy,” a person with external experience noted “every conversation starts with: ‘I have been short with this organisation. I’ve only been here for eight years, so I’m really new’.” In this environment, an employee in OCA’s Operational Support Communications, Advocacy, Reflection (OSCAR) noted, “the longer you’ve been with MSF, the more weight you have.”

However, as Chapter 5 describes, the length of service of locally recruited staff does not carry the same weight. One interviewee said:

“We have been trying to send people to the field, first missioners, who could work under senior locally recruited staff. But the mindset is as such, and the informal curriculum is as such, that by default when they get to the country, they believe they’re the supervisor.”

A former locally recruited employee who has since worked abroad described how: “For expats, it’s usually the first mission you work with a peer, the second mission, you’re automatically a manager.” For former locally recruited staff, they suggested, there is often a criterion that “you have been a manager or supervisor for a whole team.” Indeed, a person will be considered a ‘first missioner’ on their first international assignment, even if they have come to that appointment following extensive experience as a locally recruited employee. Being ‘from’ the field does not represent the currency that having visited it does.

For all staff, MSF operational experience also holds currency over ‘external’ experience (Harvey and Delaunay 2018, p. 5). This was seen across various routes into the organisation and roles. When locally recruited staff take on international assignments, notwithstanding the attitudes to length of service described above, broadly speaking, interviewees found these experienced staff easier to live and work with than the ‘first timers’ who came in directly through the international route. Staff with prior MSF experience elsewhere thus remained the preferred option. This was also the case within the circuits of internationally mobile staff and headquarters staff. One employee described how starting at MSF can feel like joining an “odd cult” because of the way that:

“Anything that you take with you is disregarded, almost very explicitly, even. When you’re just having salary negotiations, there’s an actual grid that you have to fill out with HR, like, ‘What kind of positions have you had?’ Then you get graded on percentage: ‘How relevant is that to MSF?’ so things like you’ve worked in X, Y, Z countries. Sometimes that can be considered fully irrelevant.”

This applies to people who join MSF after experience elsewhere in the NGO sector. As another commented: “All my experiences of working with other organisations, other NGOs in the humanitarian sphere were never seen to have any weight, and do not provide me with any seniority or recognition within the organisation.” That these attitudes can coexist with the apparently contradictory placement of trust in newly recruited internationally mobile staff and not their more internally experienced locally recruited counterparts suggests just how powerful the ‘mindset’ and ‘informal curriculum’ are, not just in the assumptions of new international recruits but in the organisation’s systems and structures. These are explored further in Chapter 5, while dynamics at headquarters level between staff members with different professional backgrounds are considered in Chapter 7.

Friends in high places

Being well connected, in particular with senior international decision makers at headquarters, is another key currency of power in MSF: “The organisation, historically, has been one where, if you have a strong network and you have a strong set of interpersonal relationships across the organisation then, obviously, that works in your favour.” An internationally mobile staff member who had worked for different Operational Centres commented that in MSF – and OCA specifically:

“Things are down to influence and things are down to personal connections and not necessarily merit. So, it’s not about how well you do your job technically, managerially, how we can weigh you against indicators and professional competencies. No, it’s not about that, it’s about who you know, what influence they have, what influence you have with them, the strings you can pull, and I think that goes a lot into power, and that affects at all levels – team within a project, department within a project, the entire project, the entire mission, OC in between missions.”

Having friends in high places enabled people to construct themselves as legitimate and important. For example, an interviewee described how those with connections “would want to show that they have [power] not actually related to the position that they are holding but related to the connections that they have” concluding that “they feel that they have power over anyone who is not connected to that.” As one former Head of Mission explained, social dynamics in MSF could be summarised as “discrimination by proximity.” According to this logic, your ability to access different opportunities is determined by “how close you are to the decision-making body, and how many people you know.” As shown in Chapter 6, because of their position as filters and circuit-breakers, people in coordination positions play a key role, although they are far from the only conduits for this form of influence. Suggestions that this might be changing were far outnumbered by examples that showed these networks at work in OCA.

For example, employees in Amsterdam described the importance of personal networks in placing internationally mobile staff on postings: “I’m not proud of it, but I think the informal information sharing is way heavier than the formal side of it,” one interviewee explained, describing the importance of the “usual suspects list” of people “that you already work with and that you know can deliver.” Personal recommendations could get someone onto this list: “One good recommendation from a trustworthy source would be enough […] it’s only that. It’s a WhatsApp, and sometimes, especially for detachments, I really try and create opportunities for that.” Therefore, being well connected shaped access to different postings, and for locally recruited staff, a recommendation from the right person could facilitate opportunities. Similarly, friends in high places can facilitate access to particular postings, such as family missions: “If someone has been working for a long time for MSF and wants a family role, it will be easier for him to negotiate because he is close to someone.”

Being well connected can also determine safety and access to support. For example, personal networks shaped who had access to different duty of care committees to bring up specific cases of staff needing protection. The instances where locally recruited staff were evacuated or taken out of high-risk contexts were sometimes the result of “individual informal initiatives” led by internationally mobile staff:

“It is a matter of proximity. The better you know the people the more you will do something for them. […] There is a lot of distance between the top and the bottom and that’s structural […] Individuals can easily create proximity whereas the institution cannot break that distance.”

These testimonies suggested that informal paths are needed to overcome inadequacies in MSF’s formal structures and solve problems. In improvising responses to systemic problems affecting their colleagues, people feel that they are overcoming structural discrimination rather than perpetuating a different kind of discrimination. The fact that there is a significant margin for discretionary decision making allows the organisation to be responsive to the complex and rapidly evolving situations in which it works, while also opening up space for this system of “institutional favouritism,” in the words of one senior manager, to operate.

Whiteness

Some MSF employees described how whiteness continues to operate as a marker of power and competency in the organisation. During our interviews, ‘expat’ was often equated with whiteness. In fact, several terms seemed to stand in for whiteness during our interviews: expats, international staff, internationally mobile staff, Western, or European. In this context, the change in MSF’s institutionally preferred terminology from ‘expatriate’ to ‘internationally mobile staff’ recognises that ‘expat’ is not race neutral (Kothari, 2006). Yet it was noticeable that most concern with such terminology came from headquarters staff, while locally recruited staff focused their comments on the manifestations of inequality.

Interviews gave examples of white entitlement within the organisation ranging from conceptualisation to implementation: “It’s only just recently that, for the nursing group, we were all white, Global North, writing guidelines and standards for black and brown nurses with black and brown patients. Like, it needs to look different, and it needs that diversity of just thought and experience.” We were told how a white employee without any medical training “tried to impose his point of view on a midwife who was Ivorian, who works in the maternity ward. What is a laboratory technician doing in the maternity ward?” Whiteness is a “configuration of power, privilege and identity consisting of white racialised ideologies and practices, with material and social ramifications” (Zyl-Hermann and Boersema, 2017, p. 652). It needs to be understood beyond the physical: whiteness is also a socio-political and economic order, which involves a set of cultural practices which are wrongly considered to be universal. Crucially, whiteness is not a static or uniform category; the boundaries of whiteness shift and change in different localities, but also over time (Roediger, 2005; Twine and Gallagher, 2008). Mills (2007) concludes that whiteness is also an epistemic position, a form of Eurocentricism that wilfully ignores centuries of conquest, colonisation and enslavement and their continued impact on the present.

Employees described forms of racist thinking that marked certain staff members as ‘Other’, not neutral, or not MSF. While some of these examples were drawn from several or even many years ago, they were positioned as being relevant to understanding the ideologies of the institution and the deep-seated attitudes to different staff. For example, one employee remembered “sitting in on a discussion about, for example, Congolese national staff who were being expatted” wherein the conversation turned towards deciding what the “cap” should be on the number of Congolese who could have international assignments because “we wouldn’t want to have too many.” They described a feeling of disbelief, looking back at such conversations, reflecting the gap between such attitudes and current values: “Did this actually happen?” The same colleague described having a colleague who “wore a hijab, and people discussing it, like: ‘Whoa, she’s never going to be able to go to the field, because she’s not going to be neutral. She’s not going to be perceived as neutral, because she’s wearing a headscarf’.” As further examined in the section on gender, this suggests that access to MSF identity is predicated on conformity to a cultural type identified with whiteness, Europeanness, and atheism or covert religiousness. As one employee of colour recalled, “the first year, a lot of the experience I had with other staff members was really terrible. I was even told: ‘You’re not MSF.’ Implying, you know, that my almost non-European presence or engagement was not MSF enough.” There remains a racialised image of the humanitarian worker, with whiteness still operating as a marker that signals belonging to MSF identity.

Many participants in the study described how imaginaries of authority, expertise and competency were racialised in MSF. Access to senior roles was one area of attention. In DRC, for instance, Congolese employees described: “The majority of department heads are Westerners. Other races weren’t well represented. Even the heads of projects were mainly Westerners.” This echoes findings from a 2017 study in OCA of a “strong belief that there is a glass ceiling for people of colour, or for people who are not perceived as belonging to the ‘majority’” (Adatia, 2017, p. 10). Several interviewees commented on the lack of racial diversity of leadership across the MSF movement. 77

As described in different sections of this research, inequalities between national and international staff are often racialised, but MSF employees also described racial thinking that cut across the national/international division. In country programmes, interviewees described how black internationally mobile staff were viewed as less qualified. For example, locally recruited employees described how when a Project Coordinator was evacuated because of Covid-19, a white employee said that “there was no one capable of taking over whilst the manager was away,” despite the presence of the experienced local team and black African employees. In the end, “the person who came to replace our manager didn’t even stay for four days. Because they felt that we were sufficiently qualified to manage on our own. They assigned a substitute who was a Kenyan to take over.” Scholars writing on development and humanitarianism have criticised the colour-blind stance of the aid sector which ignores how authority, expertise and knowledge remain racialised (Adeso Africa, 2020; White, 2002; Crewe and Fernando, 2006; Pailey, 2020; Kothari, 2006; Benton, 2016). Robtel Pailey (2020, p. 16) describes how Western whiteness remains “a signifier of expertise” in aid work and the “referent of power, prestige and progress”, while Adia Benton (2016, p. 270) describes how African expatriates work in an infrastructure where “assessments of their expertise, mobility and professional success are racialised.” In short, certain types of body are thought to possess superior levels of knowledge and experience.

Indeed, interviewees reflected that when staff members of colour occupied decision making positions, they had less authority than white Western employees. In Syria, for example, there was an impression that “expats have more power” when they are from Europe or North America, “not Africa or Asia.” A Syrian employee described how African expatriates did not wield the same influence as “if you’re Dutch, for example, or […] European”:

“I really notice that some Africans, and I have two Africans that were my line managers before [as Medical Team Leaders] and when I asked them, like: ‘I have this problem with the MedCo. Can you speak with them?’ […] they are not enabled and empowered from the MedCo and they feel scared as well from the MedCo. They really say, like, ‘You are protected more than me. You can speak with the MedCo’.”

While some of these comments reflected perceptions of relationships between programme colleagues, others were about who was perceived to be influential in relation to headquarters. In DRC, black internationally mobile staff were placed closer to Congolese staff in a racialised hierarchy:

“If we have an African supervisor, a dark-skinned supervisor, whether he’s African or American or from anywhere else in the world, his decisions are not considered in the same way a Westerner’s decisions are […] This generates some lack of trust within MSF OCA.”

This hierarchy was described as extending into a racialised politics of life (Fassin, 2007; Hirsch, 2021b) in other areas of practice. For instance, several employees perceived different treatment of black and white internationally mobile staff:

“I also noticed discrimination among the international staff. Because I have realised that when it’s an international dark-skinned staff that is evacuated for treatment, it’s done at the last minute but when the health of a white person deteriorates, the procedure is quickly set in motion. They are evacuated in no time […] There was a black employee who got Covid […] At the same time, by coincidence, there was also a white international staff member who got sick, but we were told to keep checking on him as much as possible.”

What is creating such situations can be difficult to assess given the range of possible variables (nature of illness, health conditions, evacuation route, and so on), however it was clear from interviews that people base their conclusions of bias on a web of observations and stories, not any one incident. Given this racialised hierarchy in MSF, there was some concern about challenges facing employees of colour in influencing roles: “With their African and Asian nationalities, I am not sure Westerners will appreciate all they do.” Here racialised hierarchies can interact with the national/international divide, as for instance DEI leads and person-centred care focal points in country programmes are often locally recruited colleagues.

Comments from staff who had worked in a range of countries suggested that black African staff were considered to embody a higher degree of otherness. For instance, interviewees described staff from South Asia or the Middle East as more competent, or ‘closer’ to Europe than “contexts where we normally work.” This speaks to the continued perceived hierarchies anchored to a European and white standard; those with greater proximity to this standard are perceived as more able and capable (Pailey, 2020). Another interviewee described how Indian staff were more trusted with responsibility:

“My last Head of Mission stint was three years in India, and it was totally different. I mean the relationship with national staff was much more equal in many ways than it would have been in Chad or in CAR [Central African Republic]. And where does it have to do with it? I find it hard to describe, is it education? Is it exposure? I don’t know, I can’t really name it, but there were differences between the different settings, and the different, yes, backgrounds of people that was clear. Yes, I definitely didn’t see the same level of, let’s say, maybe hierarchies […] as when I was Head of Mission in Chad and CAR.”

Racialised colonial imaginaries of Africa as lacking competency and expertise appeared to justify continued and increased power inequalities in these settings. When discussing the fact that duty of care was discussed much more in relation to Syria than other regions in conflict, another interviewee said:

“There is a racist component [and] I don’t think MSF was special in that. If you look at any humanitarian organisation, the way they treated Syrian staff was completely different from the way they treated African staff and I use ‘African’ in the racist sense, if you want. But those wouldn’t even be individual decisions or conscious aspects. It’s really just structural biases in our mind.”

While leaders at international, Operational Centre, and section levels have recently recognised the existence of ‘institutional racism’ within MSF, many staff are still waiting for signs that related steps have had an impact and, as Chapter 8 documents, are sceptical about the likelihood of change.

English

The ability to speak English was identified as a route for accessing positions of power in OCA. English has become the lingua franca of the aid world (Roth, 2019). OCA’s working language is English, and the MSF movement’s international working languages are Arabic, English, French and Spanish. To borrow Silke Roth’s (2019) term, the ability to speak English has become an important form of “linguistic capital” in MSF that intersects with other axes of inequality. While this section focuses on OCA, comparable dynamics are likely to be present in other parts of the movement.

Research elsewhere has shown that linguistic skills can create ambiguous dynamics among the humanitarian workforce, potentially increasing a person’s utility to an organisation, while reducing the range of opportunities for which they are considered and contributing to hierarchies between ‘local’ and ‘transferable’ knowledge (Hassemer and Garrido, 2020; Garrido 2017). One Syrian employee said: “There are lots of really vulnerable staff that they cannot speak, share, defend their ideas, defend their rights, because they don’t speak the language, because nobody’s asking them, nobody thinks that they know something. So they keep silent, and their rights are gone, you know?” In DRC, English was described as a key barrier for staff trying to progress in the organisation. Without English, Congolese employees described being blocked from decision-making posts, expatriation or training that was only provided in English. One locally recruited employee described their difficulty working in a post that required contact with Amsterdam. “I was judged worthless because I did not know English,” they said, continuing:

“In OCA, you need English to advance. You can even say that English is the most important skill. Even if you don’t have any other skill required for that decision-making role, if you speak English, you can easily be given that role […] that is crazy. It doesn’t make sense that English is such an important factor. For us Congolese, when we debate about this, we think it is a form of colonialism within MSF.”

Additionally, the organisational dominance of English presented as extra work to the locally recruited staff who have to attend to their own tasks and also carry the unpaid task of translating: “We were in a survey in the field one time, and I had my supervisor. He didn’t talk in French. I became at the same time the interpreter, and also the supervisor of the team, because he didn’t speak French.” Looked at from another perspective, given that only a limited proportion of OCA’s internationally mobile personnel have French language skills, those who do may find it easier to access opportunities in programmes in Francophone countries. Arabic was also cited as one of the “prestige languages” at headquarters and valuable when seeking positions.

English as a currency of influence interacts with axes of inequality around nationality and contract type, which are seen as double standards. In the words of one Congolese employee: “To be expatriated, you need to speak English and French. But then expats come here, and they don’t even speak French!” Language was described as a barrier in other programme sites, too. An employee involved in medical research highlighted how the dominance of English affected clinical discussions:

“Something else that was spoken about a lot in terms of barriers around access to roles, access to clinical roles, but also, like, who has authority to speak up in certain situations, was on the basis of who spoke English, which I thought was fascinating in countries where, you know, the predominant languages would be Russian maybe, and then actually regional languages, like Tajik and Uzbek, but even in Uzbekistan where in the north you speak Karakalpak. […] So, that is another barrier that it’s like, ‘Well, you can’t possibly participate in this case discussion because the supervisor or the medical team leader doesn’t speak Russian, or Uzbek, or Karakalpak.”

As this example illustrates, dynamics are further complicated when taking into account the existence of vernacular and regional languages, even less likely to be spoken by internationally mobile staff than European (and former colonial) languages.

Interviewees suggested that when OCA accepted a lack of language skills among internationally mobile or headquarters staff, while using lack of language skills as an “excuse” not to give locally recruited staff opportunities, this was evidence of a “racist” double standard. For instance, one employee described “international staff in Francophone missions that could not speak a word of French […] could not understand what was happening around them or understand other staff,” yet were given high levels of responsibility and remuneration. Another noted that advisors at headquarters level were not expected to be able to speak the language of programme staff that their roles are designed to support. Multiple interviewees made a link with security. For example:

“They had a Project Coordinator who is the highest level of person in the project, responsible of security, who […] didn’t speak French or Swahili. You’re putting someone with zero language skills as the highest level of security responsible. Then please don’t give me a reason that the language is the reason that you’re not giving the opportunity [to locally recruited staff].”

These practices limit the pool of originally locally recruited staff within the internationally mobile community, with implications for OCA’s leadership cohort and the ability to shape OCA from the top.

They also implicate MSF’s social mission, with employees raising questions about “our ability to actually connect with the people we’re working with, and also to connect with the population that we’re working with.” Although some MSF projects do have professional interpreters (or ‘cultural mediators’), and some positions (notably Project Coordinator Assistant) officially include translation roles, such staff are not necessarily present in all projects or available in all situations. The choice to invest in translation is case-by-case; there is no official guideline. Other research has found that it is often taken for granted that local staff can translate and communicate with patients (Peters, 2016; James, 2020). Interviews for this study revealed a mix of negative consequences deriving from this presumption, whether based on perceptions or experiences. Some participants felt that locally recruited clinical staff were not best placed to serve as interpreters, citing issues of insufficient mastery of language, mistrust by patients, distortion of message, and implications for the confidentiality of healthcare worker-patient interactions. A patient raised concerns about when staff are expected to translate patient’s speech for their colleagues, saying: “it’s never a correct translation. Some of it will be missing because they don’t know how to translate to English.” Preferences for certain treatments can lead patients to challenge the translations, according to one locally recruited healthcare worker during a focus group in DRC:

“When the medication was prescribed, how people only trust when they were given an injection, what they like. If they’re given oral, they said, ‘Maybe you didn’t explain it well.’ So this is another issue we [healthcare workers] also face when we are translating.”

Participants in the same focus group reflected that patients’ willingness to disclose sensitive information can also be affected if they “do not trust the one who will be doing the translation. Yes, if there’s someone you trust, yes, he would tell you everything.” On the other side of the exchange, English-speaking employees described realising that the message they were trying to pass on was not being accurately represented:

“I had a conversation with the mother via a nurse translating. I couldn’t exactly [make out] what was being translated, but it definitely had absolutely no resemblance to what I said. He was saying all these positive things about how she would be cured, and I was saying, ‘I think there probably won’t be a cure.’ And in the end, I went and found somebody else to translate who was more honest, but I think that just shows that people are terrified to give the bad news. But then that just gives families the impression that people aren’t being honest with them, because they’re not.”

Ideas about expertise and authority strongly inflect these accounts, which show that concerns are influencing behaviour even when no wrongdoing or error is apparent. The clear impression throughout is that in non-Anglophone countries, the working language is determined by the smaller number of senior staff who speak only English rather than the vast majority of staff and patients whose mother tongue is often something else.

Masculinity

Masculinity, and sometimes even the ability to perform or occupy a particular macho persona, was described as another currency of influence in MSF. In Amsterdam, interviewees of different genders referred to an “old boys’ clique” (despite the presence of women) and to a retreat at the end of the day to the Eik en Linde (the bar next door to the Amsterdam office) to talk shop. Interviewees described the difficulty of challenging “the conventional wisdom or the old guards, the old boys’ networks,” especially for women, and especially for women who had joined headquarters from outside MSF. Interviewees cast aspects of emergency culture in gendered ways, and described a particular type of macho masculinity as rewarded and respected. For instance, one former OCA employee described:

“Women who have to, every day, act more aggressive […] to be seen as legitimate in their roles […] The ops is the guys who act with their guts. Guys as in men and women […] It is the most gendered thing I’ve ever seen. It is like the masculine traits are what gets you into ops successfully. The feminine traits, like being self-doubtful [are] not seen as something you do if you’re in ops.”

With strong attention in recent years on women’s experiences of aid work, some of which directly implicated OCA (Martin, 2018; see also Riley, 2020), gendered experiences may be evolving. There was a sense of improvement over the last decade or so, “when a lot of women went into these positions of desks,” often coupled with recognition that it was “not easy for them, some of them were becoming heroes, some of them were leaving.” Nonetheless, one experienced female colleague reflected that, overall, “the informal culture of the organisation to my mind is quite macho and it’s not easy.”

Masculinity as a currency of influence interacted with whiteness and a form of Eurocentrism in MSF, where secularity and whiteness were seen as ‘neutral’ (see Fernando, 2014; Beanmann, 2018). The imaginary of the MSF humanitarian worker was shaped by gendered and racial histories (Ticktin, 2011): it was imagined to be a young, European, atheist, white man. This was linked to leadership. One interviewee said that “power in MSF is Eurocentric, white and mainly male […] We do have more and more female white leaders within MSF […] but this is still a very male, white, European oriented organisation.” They reflected: “no one wants to give away their own power.” While this was less explicit in most interviews, it is highly likely that this imagined worker also reflects a heteronormative idea of male identity.

Masculinity was also raised as a factor in day-to-day experiences across different parts of the organisation. A man of colour working at headquarters described gaining a new view of the culture in Amsterdam after moving to a different entity within MSF:

“A few years later, someone who had difficulty in OCA told me in no abstract terms, ‘You bought a white guy’s ticket to OCA.’ And by that she means I am non-religious. I am an atheist. I drink alcohol. […] She was a woman of colour, a Muslim with a hijab and she said, ‘You know what? All stuff happened in the Eik [en Linde]. All relationships were built around beer and boy’s clubs’ – including women’s participation in the boy’s club didn’t make it less of a boy’s club – and she said, ‘This wasn’t open to everybody but you found a ticket in’.”

Or, as another interviewee described, masculinity interacted with a form of “cultural proximity.” “If you don’t have the same culture, a distance is created.” The MSF volunteer, then, is imagined to be highly mobile, free of social responsibility at home and acquiring few attachments in the field (Redfield, 2012). This is a product of the fact that the MSF volunteer was built around the social position of young men in France in the 1970s. As a result, as a woman who has occupied senior Operations positions in the MSF movement for years explained:

“It’s a man’s world really in MSF. I mean the whole staffing model which is around people going for extended periods of time away from their family and the fact that those are the people that do the senior jobs, that of course means that women with families are automatically at a disadvantage.”

This was highlighted by women working as locally recruited staff. For example, when asked whether she would like to be expatriated if presented the opportunity, one Congolese woman explained that this would only be possible if she had a posting where you can bring family, which she was unlikely to get: “If I had a family mission, it would be nice. Then I wouldn’t have to leave my daughter for nine months, who is about to turn one. She would forget me. […] It is difficult being a working mum.” As the same interviewee described, in DRC, men had an advantage in expatriation processes: “You will never see a father asking to take his children with him. He leaves them at his mother’s, or at his sister’s.” The ability to secure a family mission was perceived as subject to the currencies of influence of length of service, and friends in high places.

Locally recruited staff highlighted gendered power dynamics in country teams. For instance, when asked about inequality in MSF, one experienced nurse said: “Well, firstly, the problem is that there are not lots of women!” Indeed, the privileges afforded to masculinity find fertile ground “in some places [where] there are just no women because women aren’t given the same access to education and jobs for whatever reason, so all of the medical staff will be men.” The majority of female locally recruited staff “are in either housekeeping or caregiving. Men occupy all the other positions.” Congolese women described how internal power dynamics in MSF reproduced gendered norms in DRC. Despite the fact that this experienced nurse is a supervisor: “In meetings, it is the men who like to speak […] because women shouldn’t speak in front of men, they should let men speak.” She described an example where a colleague told her that “women can’t supervise men.” Drawing attention to the different authority afforded female internationally mobile staff, she added: “it is mostly national staff women who experience this, there isn’t much we can do and we are not listened to.” Male staff also observed these dynamics, with gender differences coming through the clinical practice stage:

“The paediatrician, she is specialised. She is more experienced and more capable of taking decisions when it comes to paediatric cases, but she meets more resistance than I do with some male clinicians, and that’s just because of gender, I think. This is also being shown in the patients’ perspective.”

Existing gendered dynamics were reproduced within MSF’s organisational structures. For instance, some women described a closed circle of men who occupied senior national posts, and seemed to control the circulation of information about opportunities:

“I noticed that certain opportunities such as detachments and expatriation were only accessible to men from certain groups […] We are not in a world where we should have to push women forward any more. It’s just about giving them the liberty to choose what they would like to do and have access to information.”

This also had repercussions on project management: “I remember a couple of years ago we closed a project in [country] that was a sexual violence project. The team making that decision was a male team.”

Medical expertise

Medical expertise was described as a key currency of influence in MSF, which enabled people to exert influence and set and shape agendas. The name Doctors Without Borders, one nurse has explained, “suggests the hierarchical importance of a single role to the apparent exclusion of others,” of which employees have long been aware (Carrick, 2020). This overlooks the importance of nurses in the organisation’s medical programmes, as well as the crucial role played by a broad range of other employees at operational level and elsewhere. Of course, the medical side of MSF is far from homogenous, with medical hierarchies between, for instance, nurses, generalists, and specialists such as surgeons and “power struggles even within the medical line and medical team.” Many of these reflect encounters between different forms of expertise, which may be embodied in personnel, clinical guidelines, short-term trainings such as workshops, or institutions such as the MSF Academy for Healthcare.

In Amsterdam, interviewees described a “deference to medical expertise.” As one interviewee summarised: “that’s one thing that gives you a lot of credentials: if you come in and you’re a medical doctor.” MSF employees said that pointing to a lack of medical expertise could be used to “undermine” some critiques, sometimes citing the positioning of different departments (particularly the Public Health Department’s relationships with others) and sometimes interactions between individuals. They described how those without medical or health expertise could be the subject of commentary to the effect of: “Oh, they just don’t get how it works. They’re not medics, so they don’t get it.”

In some cases, medical expertise is institutionally recognised and given a privileged position. For instance, OCA’s statutes require at least half of the Board to have a medical background and the President of the Board must come from their ranks. This is intended to safeguard and support the organisation’s medical and health work. In others, the structures do not favour the medical line. In OCA headquarters, much as medical expertise may appear as a currency of influence, the medical department as a whole is not the locus of decision-making power. As discussed in Chapter 7, this lies with the Operations Department. Yet this was also considered to interact with individual attributes:

“There’s a certain stereotype within MSF where it’s not only the fact that the operational line has probably more decision-making power than the medical line, but it is also the case that stereotypically, you’ve had stronger people in the operational line who have not necessarily used that position in the most constructive and collaborative way.”

While it is normal that different roles come with different remits, in operational settings, some interviewees described how “respect” could be tied to individuals’ professional areas. A former international health advisor observed that often:

“The doctor is way more important than the cleaner, and […] the nurse is way more important than the guards. […] I think it’s an art to have your door open for people. To not only greet the doctors in the morning, but to also greet the rest of the staff, to have your chat with the cleaners, to appreciate our cooks. And that takes effort, but it also makes it better. Because I think that a group of people who do the job, and that is from drivers to the MedCo, is as strong as the weakest link. So that respect, that mutual respect, is something I always wanted, when I visited, or wanted in my missions. But of course, that’s not always the fact.”

Across the board, different currencies of influence overlap and intersect with axes of inequality within the organisation. As an example of how medical and health hierarchies interact with MSF’s internal dynamics, an employee with a nursing background commented that tendencies of “medical doctors, especially surgeons, really feeling that they have so much education and are higher than others and thinking that they should be served” are exacerbated by the difficulty in securing this expertise for MSF projects, meaning that “due to scarcity, people get very much served in doing very short missions and then you have high overturn, and they can just demand whatever they want.” These dynamics then interact with nationality, length of service, and racism in the organisation. To illustrate this, a doctor with MSF described an anecdote:

“We have one example where you have one medical doctor who has worked with MSF for quite some time […] He went out and came back to MSF. He is supervised by a Medical Team Leader who happens to be a nurse, and who happens to be of African origin. And he happens to be from a European origin. So, he was using the power of, one, being from where he comes from, two, of having worked with MSF for a long time and also some time ago, and now again. So, he was always looking down upon his Medical Team Leader who is a nurse, and who is also of African origin. Because some of the things that he would mention were like: ‘this African medical team leader and other African colleagues were only with MSF because of the benefits’.”

Conclusion

This chapter described several key structures of inequality in MSF, and currencies of influence that enable certain people to exert influence or obtain legitimacy within MSF. Among these structures are demographic factors like race, gender, ethnicity, which are a reflection of wider societal structures. In such circumstances, MSF will play either an accentuating or alleviating role depending on the stance it takes. Other structures (time in the field, friends in higher places, medical expertise and spoken English) are inherent within – if not unique to – MSF’s systems and cultures, reflecting the scale of the movement, the setup of its structures, and the medical work that characterises MSF’s primary duty. These currencies of influence act as threads in the following empirical chapters.