Culture de l'urgence

Chapter 3. Emergency Culture

Introduction

In 1999, MSF won the Nobel Peace Prize. In his acceptance speech, the President of the MSF International Council explained: “Wherever in the world there is manifest distress, the humanitarian, by vocation, must respond” (Orbinski, 1999). He described humanitarianism as “an immediate, short-term act” that “aims to build spaces of normalcy in the midst of what is profoundly abnormal” (Orbinski, 1999). This focus on saving lives appeals not only to the idea of immediacy, but also to the allure of the moral clarity offered by the urgent preservation of human life. A former Head of Mission summarised the spirit of MSF: “We, as a population of this world, we have a responsibility not to accept these sorts of realities, we have to do something about it, and we can.”

This chapter sets the scene for the rest of the research by examining MSF’s ‘emergency culture’. The first section describes how MSF’s work is shaped by the idea of a sudden, unpredictable break from normality that requires urgent and immediate action. This has important material consequences: the framing of a situation directs some actions, while precluding others. The second section reviews the healthcare delivery process within MSF through the ‘emergency’ lens. The third section describes particular elements of the sans-frontièriste identity developed over time, notably its emphasis on exceptionalism and debate. Finally, the fourth section examines how an ‘emergency imaginary’ shapes MSF as a workplace. Ultimately, the focus of emergency relief work is directed towards urgency and speed, with a short-term vision that is concerned with the here and now. This encourages a particular form of interventionism: in a context of exceptional need, exceptional measures are considered necessary, with external decision makers needing to make decisions quickly and urgently.

3.1 Emergency imaginary

MSF’s work is shaped by the idea of an ‘emergency’: a sudden, unpredictable break from normality, which requires urgent and immediate action to ‘restore normality’. As an experienced European Operations Manager put it, emergency is “the DNA of the organisation.” The term evokes a site of largescale human suffering. But what is an emergency? Rather than an objective reality, the term emergency is an ‘imaginary’ with important material effects (Calhoun, 2010). Emergencies are exceptions: a threat to the norm which is seen to be something worth protecting (Rubenstein, 2015). The term frames an event as sudden and unpredictable, brief and exceptional, against a background of supposed normality.

This framing is important because it dictates the understanding of an event or situation and the appropriate response to it. Labelling something as an emergency communicates a moral imperative to act. It focuses attention on the immediate event rather than its longer-term causes, or the voices of those affected (Calhoun, 2010; Redfield, 2013; Rubenstein, 2015). Unlike development, emergency relief is not transformative; intervention is conceived as short term and limited. Emergencies necessitate speed and include the hope that human agency can stop harm to something that has been deemed of value (Rubenstein, 2015).

This emergency imaginary remains central to MSF’s culture and identity; responding to an emergency remains the organisation’s raison d’être. In an ethnography of the organisation, Peter Redfield (2013) concludes that MSF’s work is a form of “minimalist biopolitics”; the organisation tackles threats to biological life by intervening directly with a technical capacity, but without addressing the root causes of social breakdown. The organisation’s sophisticated logistics infrastructure, universalised medical and logistical kits, reliance on the hyper-mobility of internationally mobile staff, are all designed with immediacy in mind: “We can provide assistance quickly, when and where the need is greatest,” the website explains. In theory, MSF seeks to offer a “minimal and temporary response,” not the “basis for a new regime” (Redfield, 2013, p. 21). The organisation addresses political problems through a medical prism, focusing on bodily rather than social breakdown. This “pathos of minimalism” involves a categorical “concern for life and suffering” (Redfield, 2013, p. 237).

The idea of emergency enables MSF’s work but also shapes how it unfolds in practice. The ability to act rapidly, mobilising significant resources, is highly valued. The nature of this study and the culture of criticism within MSF both contributed to a heavy emphasis on critique during interviews, but employees also acknowledged the positives of an ‘emergency culture’: “When it lines up well, MSF can be absolutely brilliant, right? You know, I can sound negative, but it’s a brilliant organisation. When you need surge capacity in a meningitis outbreak, don’t go to [another organisation].” Yet, as interviewees described, the idea of ‘emergency’ is not just a trigger for MSF’s work, it affects how that work is carried out. Despite the long-term nature of many projects, planning remains fixed on a one-year cycle:

“There is a very short-term attitude going on because next year, we might be doing something else because we’re an emergency organisation […] So, you’re 20-30 years in one place, in one hospital, still you do annual budgeting because next year, you might be leaving.”

Employees described how this focus on emergencies means that the organisation does not plan for the future, nor consider what will happen once it withdraws. An interviewee based in MSF South Asia, one of OCA’s contributing sections, described:

“We go in with the highest level of care, and the moment we step out, it drops ten times below. So, with sustainability, MSF has been very clear about it. We’re not there to do that. But […] on average, our project life is between seven and ten years. And we still deny the fact that we need to talk about sustainability. Ten years treating the disease, and after ten years, we’re still back to ground zero.”

Even if MSF has been working in certain countries for decades, this is framed as ‘temporary’. According to a perspective from the Amsterdam office, “there is a very short-term attitude going on because next year, we might be doing something else because we’re an emergency organisation.” This has been set against the viewpoint of affected people: “MSF has a very crisis emergency-oriented response,” a psychosocial specialist commented, “but in fact, the people in places where we operate are not seeing the experiences they have as crisis. It’s their life, and often it’s long term and protracted.” As one emergency coordinator explained, MSF’s attitude is “we just do today, and then tomorrow we see.” Emergency framing, therefore, circumscribes MSF’s interventions:

“I think we’ve found a good way out in an ethical dilemma […] short-term, medical, tangible, impactful […] for us we just do today, and then tomorrow we see. So, I think in that sense it’s good to be able to defend the accountable and defend what you are doing every day but as I’ve worked in more long-term development issues, the reality is more complex. So, I think we’ve found a good way out. Not fully way out […] because then we call emergency even when we are 30 years in the same place, and there’s still emergency.”

As discussed in box 3, this framework of work impacts on what MSF leaves when it closes programmes.

BOX 3: WHAT DOES MSF LEAVE BEHIND?

There was concern among employees about the impact of MSF’s projects in the long term; for instance, how MSF’s presence can create ‘dependencies’, or can impact on the relationship between leaders and community members by changing people’s expectations. They linked this to short-termism in MSF’s emergency culture – as an advisor put it, speaking of general tendencies: “We are definitely destabilising a lot of communities by: ‘It’s a short-term activity, it’s a small project, it’s not going to impact anything.’ No, it will impact a lot of things.” This point appeared to be illustrated by the experiences that a former Project Coordinator (PC) gave of a rushed project closure. They described having to act on a “very directive, dictative” closure decision by OCA headquarters, which they felt did “not even think about the wider consequences […] and how we could stagger our exit so it doesn’t look like we’re just leaving people in the lurch.” From their perspective the top-down decision to close “wasn’t a discussion and there was no room.” The allocated timeframe went from six months to four and a half, and then “we were out of there, but it was so messy. We didn’t take into account the environment, the other actors, the gaping hole that we’re going to create and how it could have been better managed.”

This may or may not be a representative case, but it draws attention to the power dynamics at play. It also suggests that short-term mindsets are exacerbating the inherent challenges of decisions about withdrawing from a given setting or prioritising between shifting needs and access. This was illustrated by one of the clinicians who reflected on their experience of setting up a new project: “There wasn’t a proper long-term thinking of: ‘When do we say we have reached our goal and when is it okay, then, to […] walk back, then what would be the next step?’” They argued that a lack of consultation fed into a lack of strategic thinking about goals – even in instances when the project was not a rapid response, ‘lifesaving’ initiative as is understood medically. Ultimately, the closure of the project happened with neither predictability nor rationale, with consequences described as destabilising for participants in its programmes.

This is particularly important given that, as discussed below, MSF provides its services free of charge. Interviewees in this study attested to predictable, undesired impacts of when short-lived free healthcare eras end. MSF’s standards are difficult to attain for many national governments where MSF operates and there is evidence that economic and medical turbulence follow when the population can no longer access free healthcare (Abu Sa’Da, 2012). Some OCA projects are engaging directly with these questions: with a more consultative approach, a team in Chad learned that, to prepare for MSF’s eventual departure, community members preferred to have a system of payments for community health worker services that would contribute to sustainability over time. The open approach and the resulting feedback about payment both represent challenges to established processes. The Project Coordinator there wrote: “We dare to admit that our old methods created and contributed to a power imbalance here. And that, whilst many lives were saved, at times this approach had unintended, negative side-effects” (Cornelissen, 2022).

Discussion of humanitarian action’s intended and unintended impacts goes to the heart of how the movement defines its mandate. Some interviewees argued that it was not MSF’s role to be building health systems or ‘local capacity’. Others criticised the limits of an emergency approach. For instance, some highlighted the way it reserved key roles for internationally mobile staff, crippling efforts at capacity building:

“How many years has MSF been working in South Sudan? […] at least 40. What would be left in terms of infrastructure if MSF left South Sudan tomorrow? […] I’ve heard people say, ‘Do you know? We should have set up a medical training college instead’.”

The impermanency of MSF, some argued, was used to rationalise inaction or non-engagement on local staff concerns about salaries or health coverage:

“I just remember a lot of: ‘Yes, but this is not an MSF thing.’ A sort of: ‘This is not open for discussion’. Or if people wanted certain things, then we might be told something like: ‘Yes, but MSF is not a permanent employer, it’s not what we’re here for,’ and ‘MSF leaves.’ Whatever it is that you do, always remember that MSF leaves. So, you might hear things like: ‘If you do find a job somewhere, we encourage you to apply, because MSF is not really here to stay’, which is odd and I find very rude.”

There were concerns about the impact on locally recruited staff when future plans for projects are not clearly explained. Lack of information, even when staff members are directly asking about the plans for the mission, creates uncertainty and anxiety. This encourages people to adopt self-protective positions, anticipating “what I can do just to save myself,” and “when you are in that position, you cannot give the best of yourself […] which is not good for the life of the mission.” This can also affect Ministry of Health personnel working with MSF as so-called ‘incentivised’ staff (see Chapter 4). Short-termism therefore creates an unsettled workforce preoccupied with the possibilities of sudden job loss, with impacts for recipients of care, as may be seen with attempts at achieving long-term goals. One clinical colleague concluded: “The motivation to bring about long-term change is not there if they don’t know that they’ll be in the job maybe the next day or the next week or the next month.”

The reality, as many acknowledged, is more complex than the emergency imaginary. Emergencies are not sudden and brief, but cyclical, and embedded in longer term processes of crisis (Vigh, 2008; Lees et al., 2022). In practice, the moral clarity of responding to emergency wavers when faced with the complexity on the ground. Despite the focus on impartiality and alleviation of suffering, organisations like MSF must in practice determine where to respond (Krause, 2014). These decisions are influenced by organisational priorities, existing networks, individual decisions and personal interpretations (Brauman, 2012).

Moreover, a great deal of MSF’s work does not fit the imaginary of emergency response – but instead focuses on more complex, ambiguous and longer-term processes of crisis. A clinician said that across most MSF Operational Centres there are different types of programmes: “You have a lot of these long-standing programmes that have been going on for years and years, and you also have programmes that are for research, and you have programmes that are very vertical for certain issues.” In many contexts, MSF is faced with a chronic ‘emergency,’ taking on more and more responsibility within a dilapidated health system. In some areas, MSF has been supporting hospitals for over a decade – creating access to care that did not exist before and will not exist after the organisation leaves. MSF’s presence is therefore not temporary, but instead “something of a tradition” (Redfield, 2013) – the organisation has become a permanent institution in the local political economy, reshaping access to healthcare and local job opportunities (James, 2022). Often, MSF is not a ‘lone actor’ but works in partnership with domestic institutions (Healy et al., 2020). MSF has focused on chronic diseases, HIV/AIDS, and processes of ‘social exclusion’ (Véran, Burtscher, and Stringer, 2020; Hanrieder and Galesne, 2021). Its work thus has an “expansive horizon” that illustrates “the elasticity of the concept of crisis and its increasing extension beyond medical understandings of emergency” (Redfield, 2013, p. 26).

The idea of emergency has important material effects in practice: the framing of a situation conditions the range of possible interventions. As Roitman (2013) argues, epistemological claims (such as ‘this is an emergency’) render certain interventions ‘knowable’ and ‘thinkable,’ while precluding others. What is communicated is the moral imperative to act, urgently, to do something to restore things to normal. Yet the idea of normality itself is predicated on global political structures. For MSF, the moral imperative is most often cast as an imperative to ‘save lives and alleviate suffering.’ This drives processes of prioritisation in the organisation, helping to justify exceptional measures and particular (unequal) intervention structures. Yet defining which lives to save, from what, is contested and defining what constitutes ‘suffering’ can be extremely complex. One MSF employee illustrated this complexity:

“Mental health is a good example. Is mental health part of a first, initial response? […] I still don’t even know, myself, because at the end of the day I’m not going to sit around doing counselling with people if they need to get out and be evacuated.”

In situations characterised as a medical emergency response, some employees argued that some aspects of power – such as hierarchies – can be indispensable. For example, a Project Coordinator argued, in some settings power inequality “can be a positive […] it’s not necessarily a bad thing.” During a mass casualty incident, for example, “where we activated the plan and we want to respond to it efficiently, categorising patients and attending to their needs according to severity, it’s important that these power dynamics exist.” As they explained, this applies not only to the structures of formal decision-making authority but to informal power, because: “that’s a moment of tension, stress and everyone’s overwhelmed.” Staff will seek guidance from certain leaders:

“You may have three MDs [medical doctors] on shift at that time or responding to the mass casualty, but maybe one of the three is the informal leader generally, and then he’s recognised or she’s recognised and they go tell us what to do and we’ll do.”

Similarly, a staff member in South Sudan said that “in an emergency setting, you need somebody to say: ‘This is how we’re going to do it.’ You can’t have everybody question that all the time because it’s not going to work.” As another Operations colleague pointed out, such dynamics can make it difficult to sift through “what should be equal and not?”

At the same time, some MSF employees argued that the myth of emergency was a means for the organisation to avoid confronting certain challenges or potential changes to its approach. One employee said the recourse to ‘emergency’ was used to justify ignoring diverse needs and realities on the ground:

“In MSF, we always say: ‘We are an emergency organisation.’ […] but about 50% of programmes are much more long term, TB [tuberculosis], HIV/AIDS, and those projects are absolutely not in a context of emergency […] So the argument ‘There are emergencies so we can’t do anything’ is not very valid because […] emergency is a minority of our projects. So to take these kinds of project as an argument to say ‘we don’t do anything’ for me is completely wrong.”

A range of examples of this mindset emerged in interviews. An internationally mobile employee said that a short-term approach to structural issues meant that MSF does not engage with ‘local communities’ to think about prevention:

“When you talk about things like measles, that comes back every few years. That’s a revolving disease. You can’t really treat it like just an emergency. It is a structural problem. So I think it’s worth looking at it with a bit more of a mid-term, long-term view, and looking also at it maybe more with a prevention view of what role the communities can play.”

Another example given was of attitudes towards disability inclusion. A colleague leading disability inclusion explained:

“Some people really told me, ‘But you know MSF it is an emergency organisation, I mean you have been in the field, you know the pressure. Think about all these missions where there is emergencies, there is war. Do you think people will have time to think about inclusion of persons with disabilities?’”

That colleague’s observation was that this argument was more likely to come from internationally mobile staff or headquarters. Indeed, not everybody shared this position – even some of those from ‘the field’ themselves. Another interviewee described the insistence that MSF leaves “as soon as the emergency’s gone” as an outdated conception of MSF’s role that inhibited proper project design, saying that “this space we work around also has evolved a lot. So, the attitude around how we start off our projects and our missions also needs to adapt to this.” Finally, as explored further in Chapter 8, employees described the way that an emergency culture in MSF inhibited consideration of longer-term or strategic issues, such as the environment. For example, a manager expressed their surprise at the fact that in 2021 “for the first time, MSF went to Glasgow for these climate summits. Sustainability is a long-term thing. We’re in emergency aid.”

Discourses that emphasise or even overstate the importance of ‘emergency’ may persist because it is so important to the organisation’s identity, as well as because of the potential to use this discourse, in a self-serving way, to justify or rationalise certain choices. These dynamics are explored in the following sections.

3.2 Emergency and paternalism

The social settings where MSF works are shaped by existing power structures, those particular to the period of ‘crisis’ as well as deeper ones. Locally recruited staff working for MSF claimed that the organisation’s presence was seen as reassuring: “Even without giving anything, only the fact of [MSF] being there is a relief.” Locally recruited medical employees contrasted this initial welcome with the public when decisions are made to close projects with the “jubilant celebrations as if it [is] a festival” when projects are re-opened. This image of opposing emotions encapsulates the power inequality between MSF and the people it finds on the ground, of which employees are strongly aware: “Clearly there’s a huge imbalance between the power MSF wields just in its ability to either provide the service or not.”

Nonetheless, being welcome does not remove the need for power negotiations so as – in the words of one Head of Mission – “to create a protected space where you can plan activities, missions, projects, et cetera.” Representatives of the organisation thus make an effort to find the right footing, with implications for clinical care and resource management – human or otherwise. The nature of negotiations also depends on the structures and relationships in place. Staff claimed that, in instances where MSF is acting independently, at least at the health facility level, “MSF has full control of what we need to do in the project.” Yet, as an OCA study (Healy et al., 2020) pointed out, MSF is no longer the “lone ranger” of its self-image, with over 70% of projects involving collaboration with a Ministry of Health (MoH). Interviewees described collaborative work as confronting MSF with additional considerations:

“When we work with MoH, there tends to be a lot of struggles, different struggles with MoH. There tends to be differences between MoH and MSF staff in terms of competency, in terms of benefits, in terms of salaries, respect et cetera, which can create conflicts between MoH and MSF. Management issues can’t be directly addressed with MoH staff et cetera. So when you have quality of care issues, you have to go through MoH management, which is not necessarily the same as being able to directly manage something yourself.”

As this quote indicates, for some members of MSF staff, MoH-linked projects tend to be characterised by greater turbulence and less enforceable hierarchies. This is suggestive of the potential for paternalism to also shape interpretations of the relationships between MSF and the government structures with which it collaborates.

Once present, MSF delivers a service to people who in their own eyes may sometimes perceive themselves as powerless, especially in comparison to MSF. In these settings, including beyond its own clinics, MSF is a powerful machine. As one patient said: “No hospital can have that capacity of treating without the support of MSF. Many medicines in boxes are provided by MSF.” Supplies are key – and not just any supplies but free and high-quality supplies.

The importance of supplies and services being provided free cannot be emphasised enough, as interviewee after interviewee echoed the same mantra. According to a clinician in Uzbekistan, this offer was widely understood, and provided incentives for people to access MSF’s services:

“The general population have understanding about MSF […] they understand that whatever services we provide, we provide for free of charge. This is one of the leading indicators why people always try to get, as much as possible, the services we provide because they don’t have to pay from their own pocket. They understand the humanity, from a humanitarian point of view, that our basic ideal goal is treat, care, cure and stuff like that, not to make business on people.”

Another doctor, from DRC, linked the provision of free healthcare to patients’ willingness to engage, seeing it as “making the patient very confident with us, and they could discuss with us regarding any matter.” Participants who had used MSF medical services expressed gratitude to the organisation: “MSF has been good for me. It’s a miracle. Without MSF, passing seven days in intensive treatment, I wouldn’t have been able to pay.” Another said:

“If MSF could not be here, the lives of people here can be very bad. Because very many people, especially with kids, they obviously admitting here in the ward. It can be very bad if there’s no MSF here. So MSF, people are grateful with MSF.”

Considering that free healthcare is welcome at all times, how much more welcome can we expect it to be in the circumstances in which MSF often operates? The provision of free healthcare is often characterised by a power shift in favour of the ‘giver’ of the service; provision of free healthcare is an important form of power and leverage for MSF. This is the double-edged sword that free healthcare represents, at least as far as power is concerned. One operational leader summarised:

“When you think about communication with beneficiaries, in a lot of places – and South Sudan is a great example of that – where healthcare infrastructure is poor and weak, MSF is a Godsend, essentially. We deliver free quality healthcare but that comes at this price, which a lot of people I think sometimes don’t acknowledge, which is that MSF then has power over the community through the act of delivery […] When we say something to the community sometimes, they may be receptive or seem receptive and accept what we’re saying. That’s not really because they accept it; maybe they do, maybe they don’t. But that’s also partially because us are the ones who hold all the power, the ones who give the healthcare, the ones who save the children.”

The focus on speed and urgency means that the organisation often does not consult local communities when designing an intervention, or only minimally. Instead, external intervenors act quickly, and implement their programmes as fast as possible with the aim of saving lives. For instance, one locus of emergency imaginary in OCA is the Emergency Desk (the E-desk), which sits in Amsterdam and manages the Emergency Support Department teams across MSF projects. One former E-desk member said: “The emergency team makes a lot of things happen” but “sometimes they can also really overwhelm existing missions or even really ignore the fact that we need to, even in emergency situations, consult the population we’re working with.” One employee described the doubt they had encountered within MSF that a more collaborative approach could be integrated into emergency programming “where we have to be quick.” They argued that it was possible: “It’s just about taking a minute before we start and listening, and asking people, what do you think your community needs now?”

This question is not only about prioritisation, however, but necessitates confronting the limits of MSF’s action and, more fundamentally, how people both outside and inside MSF view the organisation and its role. The perception of MSF by communities has been studied in detail in research instituted by Operational Centre Geneva (Abu-Sa’Da, 2012); in interviews for the present study, patients noted that MSF tends to do different things at different times, though did not always differentiate between different Operational Centres. These conversations revealed a complex set of expectations, which often fell beyond MSF’s actual intentions and outside of its medical mandate. For instance, one patient explained their requests to MSF: “To give food, flours, for children suffering from a lack of food. They don’t have an appetite, children don’t have an appetite, food to provide, to provide energy.” A Health Promoter described common requests on the part of local populations to MSF: “Safe drinking water, hygiene, and also healthcare, and also, surgical things. So these are the four things they want, and the community needs, from MSF.” Reflecting on such requests, a Project Coordinator said: “They always ask us to do more and more and more, and we tend to refuse.” But patients and community members are not the only ones questioning the limits of MSF’s chosen roles. Among employees within projects, there was some debate about the limits and possibilities of MSF’s medical action. While some argued that MSF does not do enough, in South Sudan, there was an impression that space should be made for other actors to take responsibility and fill in different services. These discussions parallel wider debates, with the approach of attending to only a particular set of needs contrasted with that of attending to the many needs that may present alongside healthcare, as for example in the ‘Partners in Health’ model (Farmer, 2013).

Several OCA projects have recently tried a new ‘community co-design’ approach, involving the local population in the design from the onset. An interviewee involved in one said:

“There’s this imagination or assumption that, in an emergency, immediate action is required, and MSF has the expertise of doing that, and the means. I think the step we miss there is: what expertise and what means do the community have? I think that is a lot more than MSF usually assumes it to be.”

These employees argued that a focus on saving lives in an emergency encouraged a paternalistic interventionism, where patients are subjects to be acted upon, and treated as if without expertise or agency (see especially Chapters 4 and 8). Yet, there was also concern about how elements of saviourism might be reproduced within MSF. MSF still relies on a model of internationally mobile staff who are brought in from abroad, and too often considered to be ‘experts.’ As one partner section staff member reflected:

“Our staff come with big cars, places with fences […] quite isolated from the local population […] And of course, we still do represent the white saviour pattern, with our fundraising, also with our communication. This is somehow unavoidable. I guess there is an awareness about the structural similarities [with colonial history], and we try to not fall into some traps, or at least be more diverse and more aware.”

Another interviewee at OCA headquarters described the problem of “mindset” in MSF among young medical graduates from Europe or North America who are brought to contexts where they consider themselves to have more skills than local medical staff, when this is clearly not always the case:

“But that’s not the picture we paint on our advert in Europe, so of course the junior doctors and nurses want to go and save lives. Whereas he or she should go to help others to do a better job to save lives, to manage, train or coach them. Again, except the 5% primary emergency, where we really need to go and stop the bleeding, but that’s a small part at the end of the day-to-day work that we do.”

To highlight the saviourism in the emergency medical culture, one interviewee described how they often asked during internal debates: “Could a patient be a General Director of MSF? Could a patient be on the board? Could a patient be a Head of Mission?” They argued that, although “we all go to the doctor, we will all have health issues,” the potential for this to be a “universalising” point of connection between staff and patients is undone by a reliance on placing people in what they called “categories” that carry assumptions and judgements. In the logic of these categories, there would be no value in having patients serve on a board or in an executive function. These propositions about patients are a provocation, and they have limits when applied in practice – any given patient is no better placed than any given employee to become a General Director; not all are suited to it. Where they help is in highlighting how certain imaginaries within MSF limit action, with implications for the organisation’s stated goals and commitments, such as to person-centred care (see Chapter 8). These imaginaries are also shaped by MSF’s history and culture.

3.3 Emergency mavericks

While the imaginary of emergency is important across the humanitarian sector, within MSF it is particularly tied to the organisation’s origins (Vallaeys, 2004; Brauman, 2006; Davey, 2015). Two traits in MSF’s emergency culture interact to create an image of MSF as the ‘mavericks’ of the aid sector: a sense of exceptionalism – the idea of doing work that no one else is – and the idea of the movement as an association.

A perception of MSF’s operational distinctiveness seems to be one of the main reasons why people want to work for the organisation and, if they stay, develop strong loyalties to it. One locally recruited employee who had worked for multiple non-governmental organisations (NGOs) valued MSF differently because “it’s only MSF that can give you access or that have the zeal to go and reach the people who are in need, no matter what difficulty they are facing.” Another said: “I’m lucky to be with MSF, because wherever there is a dangerous challenge, MSF never hesitated for support.” A senior colleague in Operations at headquarters similarly explained that “MSF offers me opportunities to respond to an emergency in a way that no other organisation will.” MSF’s financial independence, secured through its strategy of fundraising from private, individual donors rather than taking public money, is an enabler of this ability to take action. Employees valued MSF’s “independence on decision-making and money” and “independence on all levels” in making it resistant to pressure. Loyalty was often cast in the language of ‘love’ and speaking of MSF as ‘family’.

Conversely, the sense of exceptionalism was also presented as one of the biggest impediments to change. The organisation maintains an attachment to doing things differently because MSF is different from other organisations. OCA employees described a sense of scepticism towards ‘external’ experience, that might be too muddied by politics or ‘development’ agendas. These views came from long-standing OCA employees as well as more recent arrivals; from colleagues in operational, communications, and health roles; in executive positions and governance roles. “MSF is really insular, and people look inwards,” one said, while another noted “it is amazing how people simply don’t appreciate that somebody comes with something new.” Another described how “MSF has this bit of rebel spirit still that sometimes makes us a bit sceptical” about what others are doing. This rejection of the outside was described in one interview as enhancing “the cult-like nature of the organisation,” a characterisation arguably also seen in another’s critique that “we do not want to mirror ourselves to the outside world. The outside world doesn’t understand that we are different.”

This sense of self-reliance may lead to benefits for staff, with one locally recruited Health Advisor explaining that MSF is regarded as a powerful “training ground” for developing professional knowledge: “If you need training, come to MSF.” (They went on to say: “If you need money, go to another organisation.”) However, it also appeared to have indirect manifestations related to a sense of internal closure and lack of accountability. For locally recruited staff who were often excluded from strategic decision-making, they described how there was “always a reason for things to be done a certain way,” but that these reasons were rarely explained at project level to those affected.

In MSF structures, the emergency function of the executive is contrasted with the debating role of the association. The association is an important part of MSF’s governance and identity, reinforced in the Chantilly Principles of 1995 which tie associative life to “a capacity for questioning ourselves.” In brief, the association is a set of membership-based governance structures in which individuals vote for representatives and motions; their representatives can then take the motions to higher levels of movement governance. Once a person has worked for MSF, they have the right to join various associative bodies, and can remain a member of them even after they have left. ‘Debate’ is foregrounded as key to the association. For example, a training course for locally recruited staff on ‘MSF: An Association’ presents the association as the part of the movement that “defines MSF’s identity, principles, ethics and orientations,” is “democratic” and “about debate and discussion.” The executive, in contrast, is presented as the part that “translates ideas and plans into action in [the] field,” is “hierarchical” and “is about getting things done.”

Interviews with locally recruited staff highlighted the importance placed on the association for people’s sense of belonging in the movement. For example, a long-standing staff member who had joined MSF not knowing much about the organisation said that the fact that it “gives people the opportunity to speak up” became “something that makes me want to continue working with MSF […] It’s not something that other organisations across the world offer.” They described the association as a forum where the hierarchy of executive roles gives way to greater democracy: “The ideas of the Head of Mission, of the guard, of the cook, they all matter.” Another interviewee said: “Any changes that are coming to MSF are coming from the associations […] That’s why we are MSF. MSF always are looking for the motion. If you raise it, you can look at it, then agree or not agree on it.”

The power of initiative offered to individuals within these collective spaces converges with an image of MSF as an “organisation of mavericks.” A range of interviewees highlighted the importance of “charismatic people” and “outspoken individuals” in pushing the organisation to think differently. A locally recruited colleague summarised that “the will of some individuals,” particularly those who “refuse certain things,” can be a “catalyst” of change within the organisation.

The idea of charismatic, somewhat contrarian leaders driving an anti-establishment organisation taps into the story of MSF’s origins and early years. NGOs have origin stories that narrate their past in ways that serve agendas in the present. In MSF’s case, the importance of individualism has been reinforced through repetition of a story that situates the seeds of MSF’s creation in the act of French doctors who ‘spoke out’ about what they had seen during the Nigeria-Biafra war (Desgrandchamps, 2011-2012). In the early years of the founding French section, leaders sought to capitalise on media attention and built a tradition of written analysis, reflection and testimony (Davey, 2015). In the 1980s, employees from other parts of Europe established sections in their home countries, so that the movement benefited from, but also perpetuated, the influence of individuals who galvanised others into action. By the end of that decade, the internationalising network had developed a paradoxical image as “an informal movement with a culture of debate that nonetheless acted decisively, an organization of swashbucklers with technical expertise that spoke with equal parts brazenness and sophistication” (Bortolotti, 2004, p. 14).

The role of outspoken individuals within the organisation mirrored the role of an assertively independent organisation within the humanitarian sector and on an international stage. The concept of témoignage (sometimes translated into English as ‘speaking out’ or ‘bearing witness’) plays an important role in the organisation’s culture. It is enshrined in the current Charter, the Chantilly Principles, and the La Mancha Agreement, the preamble to which declared that “the separation of the concept of témoignage from operations has disappeared” (MSF International Council, 2006, p. 1). Despite its centrality, however, témoignage has no agreed definition (Gorin, Guevara and DuBois, 2021, p. 30). It connotes “notions of humanity and solidarity” and “encapsulates a medley of ideas: proximity with people living through crisis; the intent to listen to them; the swelling anger at their plight; the desire to change their situation; and calling out the manipulation of humanitarian action” (Claire, 2021, p. 47; see also Redfield, 2006; Givoni, 2011). Some of the ways témoignage has been described resonate with the depiction above of how individuals can make their mark within the movement, hinting at the value placed on exceptionalism within the MSF culture.

Institutionalisation and bureaucracy have been presented as a threat to the movement’s ability to maintain this spirit of openness to question. The maverick spirit is pitted against the “institutional thickening” (Fox, 2014, p. 5) that has accompanied MSF’s growth. As one employee said:

“If you’re awarded a Nobel Prize you become part of the system. With hindsight we should have refused it. Simply for the statement of it, ‘No, we don’t want to be part of the establishment. We want to remain outsiders, kicking and pointing at the fact that the emperor is naked.’ And now we became part of the naked reality of the emperor.”

This is not, as one senior manager explained, simply a question of institutional scale but of changing expectations:

“Now you can’t be so rebellious any more or you don’t have access to patients, so that generates a lot of tension between the spirit of the founding fathers, or the cowboy spirit, and the compliance standards which we have today. They can’t co-exist with the cowboy spirit. One says: ‘we are without borders and we go wherever’ and the other one says: ‘you don’t have a registration, you don’t do anything – period’.”

Historicised narratives about MSF’s identity also shape perceptions of what is possible in the present. A former General Director in the movement captured how the place of history in MSF’s emergency imaginary is both meaningful and somewhat mythical:

“You are running to a country to save lives because that was basically the image of the 70s. That has changed a lot, let us be honest, but the perception is sometimes still very present. […] Because the French medical thing is not so much French, not so much medical, and not so much running alone there in the field.”

A senior employee described the weight of this legacy in thinking about personnel on assignment. Within MSF’s particular ideology of emergency humanitarian intervention, they said that “the makeup of the staff” and “the idea of sans-frontièrisme” are “essential to the identity of the organisation.” This places limits on the ability to discuss issues such as team composition in a nuanced and context-specific way:

“We could probably recruit most, if not all, of the expertise that we need within the country. But MSF has said very clearly that we don’t want to have just local teams even in contexts where we could do, because we think that the international nature of our teams is really important and it brings a really important added value and it’s essential to the identity of sans-frontièrisme. But what we haven’t done is defined what that means.”

Several interviewees described such issues as blockages, dynamics that are explored in later chapters.

3.4 Emergency as a workplace

Employees described the ways that MSF’s emergency imaginary – the combined pressure of urgency and importance – and the legacies of its history impacted their experiences of MSF as a workplace.

The focus on a fast and urgent response to immediate need created a work culture whereby “MSF becomes a bit your life.” For instance, international employees often live together, are considered constant representatives of the organisation and must act accordingly, while security measures restrict their ability to spend time beyond the logistical infrastructure of the organisation. Meanwhile, all employees work long hours and described MSF as a demanding part of their life. A medical programme employee said that in her experience:

“Sometimes you have, like, 70, 80 patients which you have to see them, alone by yourself. So, of course, we were so dedicated to that, we were doing that. And though it was a workload, we did not realise, because we also like our work. So, you will do all the rounds on this patient, and still be able to offer them some of the care you can give. Because, of course, we know very well that not everybody will get the quality care. But of course you can be able to end up seeing them all, making plans for them. But the workload within MSF of course can not be talked about. It is the usual thing.”

Indicating the value placed on work itself, one interviewee commented: “I think a lot of the people we work with are quite overwhelmed and overworked because there is so much to do. And if there’s not much to do, they make themselves a lot to do.” A Health Promoter reflected on how this culture affected the collective ability to think outside of current conditions (see also Chapter 8):

“I think it could be the fact that it’s an emergency and there’s always a lot of work. […] There’s never an opportunity for people to sit around and say, ‘Okay, what are we going to do next?’ There’s always like, ‘Go, go, go’.”

‘Being MSF’ required a degree of personal sacrifice, which was understood as central to the ‘volunteer spirit’. As one employee said: “Because we work in emergency, we expect our staff to be responsive and dedicated 24/7 to what we’re doing. That doesn’t necessarily align to what’s best for their day-to-day lives, or ours, for that matter.” Experienced fieldworkers described receiving limited support from managers: “I just think people are busy and people have different ideas about what good management is or how much of their role they feel like they need to offer to the management responsibilities.” Locally recruited staff described working long hours, which they often have to juggle with other responsibilities and pressures. One employee in Syria described:

“We work from eight to five, then when we go to family, from five we have our home tasks […] Sometimes we work after work time […] a silly question that we get from international staff, they say: ‘How do you spend your weekend? Did you go somewhere, did you travel, did you go to a restaurant, did you go somewhere celebrating?’ We are just laughing. Because I spent all weekend to fix something at home and to work on the pending home tasks. So, we never have a rest.”

Among some employees, there was concern about the burnout rate, and an organisational culture that prioritised doing whatever it takes in the context of emergency. These also reflect one of the themes to emerge from interviews, distrust or lack of confidence in management:

“We were trying to share with the higher ups saying: ‘How do we ensure we have less of a burnout rate? Because we’re losing a lot of good people. Our contracts say we work 40 hours. We actually work 100 hours. The 100-hour people continue with the organisation, because they can handle it, but […] we’re losing retention on this amazing group of people’. […] And we brought this up to the general direction some years back, and we were told: ‘That’s MSF. We like people to continue working with us who have the passion’. And it’s an undertone that this is the way you work. You learn or you burn.”

Attempts to manage burnout risk through short-term assignments can create problems of continuity. A member of the Operations Department in Amsterdam explained: “We fix the length of missions for some positions for very good reasons. If it’s active, front-line work you have external stress, which after certain time the exposure is damaging, so we need to limit it.” A colleague described the problem of high turnover, as each Head of Mission came in and tried to implement new ideas:

“We get a HoM or Project Coordinator who is in for three months and says: ‘Hey, we need to do this’, but we’ve already tried it three times. Or […] we know the long game on that doesn’t play out in the way that would be beneficial for the population.”

In some settings, it was argued, it should be possible to reduce turnover, yet the emergency DNA of MSF takes over: “we manage things with a short-term mindset, and […] we also justify it when it shouldn’t [be the case].” The high turnover of what were often described as top-down decision makers has implications for the constructiveness, or otherwise, of the workplace. One clinical staff member explained:

“Let’s say I spend four years in a project and every six months you have to change supervisor, for you have not much power, you have not much authority to do anything other than to follow what the supervisor wants you to do […]. So, of course when today somebody comes and tells you, ‘let us do A’; another comes tomorrow and says, ‘no, A doesn’t work […] let us do B’; another comes and says, ‘let us do C’. You know how this person is going to be very confused, you know. So, he’s going to be completely confused and there’s nothing he can do other than just to follow, do this, he will do that and do that, yes – but when you pull people together and treat them as a team, when there is decision making to be made they are also involved, I mean, I think it will give them that much interest to work.”

Similar dynamics of short-termism were described in the conditions for locally recruited staff despite these positions not being identified as requiring turnover to avoid burnout. Locally recruited staff raised concerns about being shuffled between projects and sections, with contracts described as often being short-term and subject to renewal despite many locally recruited staff working for the organisation for decades. These accounts may reflect inconsistencies in approaches at a range of potential levels, as from a headquarters HR perspective, OCA’s standard approach (adapted to meet national employment law requirements) should be to offer an open-ended contract after 24 months of continuous employment. According to OCA data, 57% of the Operational Centre’s locally recruited personnel were on open-ended contracts as of April 2023.2 Beyond formal contract issues, short-termism was described as shaping the organisational approach to its personnel: “Being an emergency organisation, the idea is you go in and you [go] out. By design, you’re not supposed to be a really good employer, right?” As one senior manager explained, the focus on saving lives “also means that you’re not investing in society around it or trying to give capacity to local staff because: why would we?” Locally recruited staff argued that the short-term postings of senior in-country decision makers reduced the responsibility that these managers feel to think strategically about the longer-term vision of the organisation’s projects, or to solve structural problems that affect their colleagues. Here again, in a different form, a lack of confidence in management is visible. One local employee explained:

By way of comparison the proportion of open-ended contracts in the Netherlands-based headquarters staff was 67%. Data provided to the authors, May 2023.

“That is another issue with MSF: the fact that they bring international staff for two, three, six, or nine months, and then they leave. Then, someone else comes for the same amount of time, and they do not feel responsible for anything. Everybody tells you they do not know why things are this way and what can be done about it.”

Many interviewees argued that the institution’s willingness to offer poor employment conditions and its tolerance of poor behaviour was a product of its emergency culture. A senior manager criticised the organisation for systematically “paying people badly” due to this culture, summarising the logic as: “we need to save money for saving the world, and because you are so lucky you can work with us, and it’s so fulfilling for you to work with us, we are okay with not paying a proper salary.” Some implications of this attitude are discussed in Chapter 7. Another interviewee put the stakes even more starkly: “I think the organisation recognises that it offers this amazing opportunity, but also leverages this in playing off of you. So, I could easily walk away, but I choose to be here, and I choose to be abused.” Locally recruited staff described how discussions around per diems, pay grades or medical benefits seemed to be approached as a distraction from the medical mission of MSF. Narratives on this issue are often strongly presented, reflecting what employees describe as a failure to make meaningful progress on issues that many see as fundamental to the movement’s integrity (see Chapters 5 and 8). One interviewee with experience of advocating for improved conditions, especially for locally recruited personnel, said:

“HR and MSF is just a nightmare. It is a nightmare even though the people are what gets the job done. It isn’t okay in MSF to think about what individual people might need or what they feel or what brings them to being valuable contributors to the MSF thing. You’re very much a cog in the wheel of operational service. Everything is a slave to Operations basically. So, trying to fight against that is one of the hardest jobs in MSF.”

Reflecting on different aspects of their workplaces, employees described the strength needed to build a career in MSF. Some evoked a stereotype that they found in the organisation, an attitude of “I can be very shit to my colleagues and it’s fine because I’m doing something good, because I’m a humanitarian.” Interpersonal communications can become hostile, with some “using the word of emergency” to put other views down. The culture was described as at times “oppressive”, “toxic”, “abusive”, ill disposed towards discussion of vulnerability, and making people “reluctant to engage with one another’s criticism.” This echoes earlier studies of the movement that have highlighted how: “The ‘social mission first’ imperative can be used to justify or accommodate disrespect or neglect toward others” (Harvey and Delaunay, 2018, p. 9). Some interviewees had the impression of different styles or tones of communication across the offices of OCA and partner sections, although not sufficiently to temper the idea that strength and confidence is required to speak within MSF and that if you experience a problem “you’re supposed to kind of work through it.” This is also a part of being an “organisation of mavericks,” as one person said: 

“There’s a way to move up the ranks to be heard, to be known, to make your mark and it’s very much about seizing sort of the moment when you run against the current […] because you just put it out there at the right moment when the debate has to happen and it’s all a mess and you need somebody to walk into the middle of it and say, ‘This is what we need to talk about’.”

This culture was identified as resting on privilege and interacting with the material privileges that create favourable circumstances for an engagement based on the spirit of volunteerism. A person of colour reflected that:

“Whether it is white privilege or privilege for people like me, privilege is clearly at play. It’s who you have access to, whose ears you have, the ability for you to travel, the language you are able to speak, the education you’ve had, all of that and maybe much more; the confidence, a certain sense of confidence that you have, that you can challenge, and you can engage, and you can be heard, and without your ego getting too bruised, or you recover from that bruising. All of that is privilege, right?”

Conclusion

MSF’s work is defined by an aim both minimalistic and expansive: to save lives. While appealing to moral clarity, this emphasis on emergency is more complex in practice, and shapes the organisation’s work and culture in specific ways. As this chapter outlines, emergency culture in MSF redirects the organisation to the here and now, responding with urgency and speed in the short term. At least in principle, the focus remains on short-term intervention, rather than longer-term processes or questions of sustainability. The organisation’s intervention structures, and the inherent inequalities they reproduce, are justified by the moral appeal to save lives in an emergency. Emergency programming, MSF argues, often requires external intervenors, who act quickly, sometimes with little input from local populations or patients in the design of projects. However, by not thinking about health and the political contexts in which it intervenes sustainably, MSF contributes to a mode of short-term emergency planning that leaves the door open for ever more emergencies, thereby reaffirming global relevance and legitimacy for outside interventions.

MSF’s emergency culture is a thread that runs throughout the rest of this research. The power dynamics inherent in the organisation’s relationship with the people it aims to serve is another theme, including the approach to healthcare which is underpinned by the mantra of saving lives in an emergency context. These dynamics are inherent in the way that locally recruited staff are positioned, as Chapters 5 and 6 show, with their assumed proximity to communities where MSF works, sometimes treated as an asset and sometimes as a risk. Chapters 7 and 8 describe in greater depth how an appeal to ‘emergency’ shapes what reform initiatives are deemed possible. The next chapter introduces some of the currencies of influence that hold sway within this culture and how they interact with inequalities within and beyond the MSF movement.