Diagnostic Disconnects

Chapter 8. Diagnostic Disconnects

Introduction

This chapter examines how members of OCA and MSF understand the organisation’s ability to conceptualise major change and react to it. It offers a series of diagnoses, put forward by interviewees, about why – in the views of those cited – the organisation struggles to act on its stated ambitions to change power dynamics. These diagnoses are not coherent. There are contradictions both between some of them and within some of them. That is, in some cases, even when the diagnosis is similar, the logic or the conclusions that are drawn can pull in different directions. This chapter thus highlights disconnect in OCA and MSF more widely – disconnects that reflect the scale and complexity of the movement. Despite the imagined unity of MSF, in reality, these disconnects in how its concepts, ideas and policies are understood and experienced are fundamental to how components of the movement relate and how staff experience their work and associative engagement.

The chapter explores a widely and strongly stated opinion that MSF is “glacially slow” – in the words of one senior manager – to address problematic power dynamics and inequalities. In some places, mechanisms such as employee representation and union delegations have helped staff to raise awareness of problems, but major issues were described as, to quote a locally recruited staff member, being “either addressed with years of delay or hardly addressed at all.” Observing the fallout from the increased debate about inequality in 2020, an employee commented how slow the response was: “There’s a lot of time taken investigating to say if this is actually what is happening, or did this actually happen?” Similar critiques were made about relationships with the individuals and communities among which MSF works:

“There’s been some ways in which it’s been operationalised quite well, but that no-one would even go back to La Mancha and say, ‘But where’s the accountability of the beneficiaries?’ It gets looked at every now and then, and people just say, ‘We can’t do it’.”

This study asked for people’s views on power and inequalities, subjects that lend themselves to critical assessments. In MSF and in the humanitarian sector more widely, this is a moment when the penitent mode is extremely influential; in public forums, narratives that identify major shortcomings are far more acceptable than those that portray problems as minor, which risk being labelled ill-informed, prejudiced or self-serving. It is potentially difficult to meaningfully dissent from the near consensus in MSF that ‘nothing has changed,’ though some interviewees did. Indeed, this very emphatic line of argument should not be taken too literally: many things have changed, but there are also profound continuities in some of the problems perceived as most important, most tied to MSF’s identity and values. The vast majority of interviews had critical views, which we have organised into a series of discourses to allow their effects to be considered both individually and collectively.

These discourses in themselves hold power. As the previous chapter showed, influence derived from institutional legitimacy can be used to encourage or discourage a focus on different potential priorities. Michael Barnett and Duvall (2005) refer to the ‘productive power’ held by those in a position to generate or mould concepts and discourse, and they point to the power of discourse itself as a determinant of action. At the same time, these discourses have the potential to be disjointed or contradictory. They reveal disconnects within the organisation, between values, incentives, access to information, and ways of working across different parts of the movement and the places it works.

This chapter introduces five narratives about MSF’s nature:

1. Paternalism
2. Cultural ‘others’ and othering cultures
3. Lack of vision for change
4. Lack of appetite for change
5. Action-oriented

Each section shows how employees of OCA and other parts of MSF illustrated these dynamics, or used them to explain slowness of change, with reference to major internal agendas in two spheres. The first of these spheres concerns relationships between the organisation and the people it aims to serve. The second concerns experiences and treatment of staff members within the organisation. While it is beyond the scope of this study to document how these diagnostic discourses have impacted specific choices, this approach allows us to draw attention to the weight that discourses can carry within the organisation.

8.1 Paternalism

As outlined in Chapter 3, there is a pronounced power imbalance between humanitarian organisations and the ‘communities’ they aim to ‘serve’, as well as between providers of care and their patients. Analyses of the colonial dynamics of aid date back decades, and critique of the paternalism inherent in humanitarianism has intensified markedly in the past 20 years. While by no means a consensus within MSF, this understanding of humanitarianism remains key to debates about the organisation and its work. Paternalism among MSF’s employees is one of the key themes in critiques within the organisation of the limits of its willingness – and even ability – to give up power.

Paternalism was described as an elemental challenge for MSF. An interviewee with a medical background made this point:

“You can be diverse and inclusive and still perpetuating a particular type of humanitarianism that is deeply problematic, because the power that we haven’t really talked about [in the interview so far] is the power that manifests between MSF staff and the people that we purport to support. That’s the gravest imbalance of power, really, that we still have a very paternalistic, very prescriptive, kind of, imposition of a certain way of seeing the world and a certain way of conceiving of an active humanitarianism that precludes the involvement of those people in the care they receive.”

This is described as reflected in the skills and competencies that MSF employees hold. When asked whether MSF was good at listening, one health advisor said that “we are very bad at it […] people find it very intimidating to sit down and to ask open questions, and to hear, because we don’t know if we can solve everything, but we also don’t have to.” Even when the listening happens, another said, it does not necessarily translate into “doing things differently.”

MSF communications has been critiqued both within and outside the organisation for paternalism and racialised images of suffering. Scholars of humanitarianism going back decades have drawn attention to the use of racialised and paternalistic tropes in the public messaging of NGOs, concerns that have also been recognised within the humanitarian sector through initiatives such as codes of conduct (e.g. Benthall, 1993; Burman, 1994; Boltanski, 1999; Franks, 2013; Chouliaraki, 2006; Benton, 2016b). A series of controversies around awareness-raising and fundraising campaigns has recently shone a spotlight on problematic practices by different parts of the MSF movement (e.g. McVeigh, 2020; Batty, 2022). At the heart of the disconnect in communications is a clash of values and expectations, between an organisation that – in principle – has committed to ethical approaches to how it represents crises and people affected by them, and target audiences of potential donors in the Global North who tend to respond more generously to emotive, paternalistic and racialised imagery than complex information. One interviewee identified this as pressure to cater to “what our donors are telling us. […] They don’t want to hear about, as they would call it, ‘fortune seekers’ crossing the Mediterranean: ‘We want the mother and child health in Chad. We want the babies’.”

While this situation arguably does create incentives for the use of white saviour tropes in the name of fundraising, some in MSF are concerned that such tropes also reflect internal attitudes to the people among whom the organisation works (and therefore also to the majority of MSF employees). As one interviewee observed, communications constitute “the public-facing aesthetic of MSF, so it’s often exposed to internal and external critique, but comms is just a window into how humanitarians and how MSF sees the world that it operates within.” Repeated signs of failure to “respect people’s dignity and agency,” in the words of a recent institutional apology for violating a child’s rights to privacy (Christou, 2022), lend credence to this view.

‘Person-centred care’ (PCC) was another subject of critiques of MSF’s paternalism, specifically the difficulties in relinquishing decision-making power. In OCA, based on our interviews, PCC is perceived as a new ambition. It was not mentioned in OCA’s 2015-2019 strategic plan, although the plan states that one of OCA’s values is to “look at the whole person, not just their disease” (MSF OCA, undated, p. 9) – “looking at” the person being, of course, very different from involving them. In contrast, PCC features prominently in OCA’s 2020-2023 strategic plan, which makes “a PCC approach across all MSF OCA projects” a core goal (MSF OCA, 2019, p. 20). Another OCA document provides the following explanation:

“Whereas person-centred care is commonly understood as focusing on the individual seeking care (the patient), a person-centred approach encompasses these clinical encounters and widens it to also include attention to their families, networks and communities and the crucial role of communities as part of the health system.” (Hoetjes, undated)

Person-centred care encompasses patients and communities (see Harding, Wait and Scrutton, 2015), spanning the entirety of the movement from “our senior leaders, to our doctors and nurses, to the guardians who welcome people to our gates,” as it was captured in one MSF-wide conversation. Participants with a range of roles were insightful about PCC in ways that suggested it was meaningful to them. One medical programme colleague described it as “focusing on the individual engagement to make sure that what we are doing is according to that individual’s needs and said by that individual that they would want their care to be that way.” A PCC ambassador said that at its fullest this agenda meant “looking at the people more than just patients,” in a way that includes staff as well as patients, so that the “style of the mission” overall is more about people. The examples they gave included changing the ways that healthcare worker-patient consultations and assessments are conducted, how meetings are run, or how decisions are taken. By definition, one interviewee in headquarters said, there cannot be standardisation: “It looks different because we’re working in different projects, in different contexts, people with different cultures, values, perspectives, and so forth.” Another interviewee pointed out that monitoring progress on PCC “should be not us defining that what we’re doing is patient-centred” but rather understanding the views of those affected.

Nonetheless, person-centred care was sometimes described as more talk than action. One MedCo argued: “The talk about being person-centred versus the reality of the projects and the places we work in are very different.” A former Project Coordinator said:

“I’ve heard a lot about it [PCC], but in terms of implementation, again, because it’s done in a very ad hoc, piecemeal, unstructured manner I’ve not seen a lot of implementation. I think that also comes down to the lack of follow-through we have for patients.”

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These views may reflect the difficulties of trying to implement an agenda of such high ambition across the large scale of OCA’s projects. At the time of research, there were six country programmes formally implementing PCC initiatives at operational level. These initiatives, which are often in ‘piloting’ mode, have varied: from co-design of a project in Syria for people living with non-communicable diseases, which began with interviews with some people in this group as well as their caregivers; to plans in Sierra Leone to use exit interviews with patients to understand their experiences; to initiatives in partnership with communities in Chad to promote sustainable health services. Yet the discourse of PCC has been applied across OCA, with the 2020-2023 strategic plan calling for “all MSF OCA missions and projects” to have contextually appropriate PCC approaches (OCA, 2019, p. 20). While there are other smaller-scale or more ad hoc steps being taken, the apparent gap between discourse and implementation may lead staff members not based in participating programmes to question the extent or sincerity of OCA’s commitment to its stated goal. This implementation gap is further sustained by the resource pressures in many of the settings where MSF works. According to interviewees, because of the vast need in many of the settings, there is an ever-present dilemma on how to distribute resources – including time, supplies and labour – necessitating a trade-off between quality and quantity. In some situations, the demands placed on MSF clinics create practical challenges, as one locally recruited employee described:

“The fact of the free charge for MSF taking care of the population, everyone has to come to benefit from free of charge. Everyone comes, most of the patients. With several patients, there is no room, no space for everyone. They don’t have the time to ask the patient to give his wish and the person also doesn’t have the time to participate in that decision making. On that fact, there is no patient-centred care because the person doesn’t have time to participate in the decision making.”

Participants were also concerned with power dynamics within the implementation of person centred care (see box 7). Some argued that paternalism shaped internal power dynamics more broadly, discouraging power sharing and shaping interactions. One person argued that the gratification derived from helping others feeds a paternalistic approach across different levels of the organisation:

“You want to follow the path of power always. Where you find a place where you’re at a critical juncture where you might cede power, it is always in favour of people maintaining power. I don’t think these are people who are power hungry. I think these are people who have an addiction to contributing to saving the world.”

In the name of this contribution, as discussed in Chapter 3, individuals may permit themselves behaviours that appear to be at odds with the values of the organisation.

While paternalism in the medical profession is widely acknowledged, there was significant emphasis on the additional effects of the legacies and geographies of colonialism within MSF. “We come with this idea of providing assistance and aid, and helping other people, with this idea that they can’t help themselves,” one nurse reflected. An employee from Afghanistan said: “MSF itself is a Western ideology, it’s a Western organisation, that’s where the idea came about, that’s where it started.” Interviewees saw this as going beyond MSF specifically to the historical legacies inherent in the humanitarian endeavour itself: “If you see the history of the humanitarian sector, you can see this is something that came from Geneva, from Switzerland, after a war in Italy, Solferino. You have these human principles, that you name it and you choose the words according to your own thoughts. You were not giving a tour in Africa or in Southern Asia or in Latin America to ask people what they think about it.”

However, it is important to note that not everyone in OCA agreed with the notion that this implicates humanitarian gestures in racialised power dynamics. One interviewee pointed to the non-partisan aspect of the humanitarian imperative to explain why “humanitarian action as it is defined and how MSF has defined it […] has very little to do with any colonial heritage […] it was two countries at war and a neutral party in between, and that was the humanitarian action.”

BOX 7. POWER DYNAMICS IN PERSON-CENTRED CARE

Like DEI efforts (see below), the institutional push for person-centred care has seen the attribution of dedicated posts or duties. In addition to a lead at OCA headquarters level, some country programmes have PCC ambassadors. These are sometimes dedicated positions and sometimes a role added to an existing position – either way these roles are usually undertaken by locally recruited staff.

Some interviewees highlighted how ideas of authority and expertise can be used to justify paternalistic approaches. A PCC ambassador said that when they initially brought feedback from patients to staff meetings, “people start[ed] laughing, and they said, ‘Those patients, they don’t understand. We are the medics.” It was difficult, they argued, for MSF staff to “involve the other side” – a choice of language that reflects the assumed distance that this staff member was seeking to bridge. Another argued that difficulties with PCC revealed paternalistic assumptions in “what we read as beneficiary and patient”:

“We all go to the doctor. We will all have health issues. This should be a very universalising thing, but, in fact, the categories we put, and the ways that we see expertise, are communicated so clearly.”

Interviewees described how these dynamics interact with internal power inequalities. Reflecting on OCA’s experiences of promoting PCC, one interviewee spoke of dynamics with negative implications both for the individuals involved and for the overall goal:

“It is very hard to get, as a medic, to get feedback that you’re doing something wrong. And in the meantime, we’re educating patients, we’re trying to empower patients. But then we also need to really work on getting our staff ready to receive feedback and they need to receive the feedback that the patients said: ‘Okay, no, you gave me 2 pills but I’m supposed to only have 1 pill.’ And the same I’ve also seen with the PCC ambassadors, that our roles where we’re really trying to make them speak up and make a bridge between the community and MSF, and sometimes also really give reflections of: ‘The community thinks that.’ That is sometimes very critical feedback that comes out and perspectives on how we do things, which I think is really good but we are not always ready for this in our organisation. And then, with these person-centred care ambassadors, unfortunately it really depends which international staff is standing next to that as a colleague. And there are international staff that embrace and that are very happy, and there are international staff that can totally put someone down.” 

Currencies of influence related to expertise and contract type (tied in with ideas of MSF identity, see Chapters 4 and 6) are both at play here. The interviewee suggested that PCC ambassadors are “not always in a safe position” and can have their loyalties or motivations questioned when they relate critical feedback – affecting their safety at work and creating additional barriers for ‘community voices’ to be heard. This offers a particularly striking illustration of how power dynamics within MSF can affect the organisation’s social mission.

8.2 Cultural ‘others’ and othering cultures

As many employees pointed out, MSF’s approach was imagined to be universal, but in reality, proved to be ethnocentric and specifically centred around white European cultural normativity. This argument was made in relation to operations, professional and organisational standards and norms, and how the organisation supports its staff. It was made using a variety of terminologies and vocabularies. Most of these were used to describe a sometimes fixed, sometimes shifting, cultural and racialised ‘other’, although only very few participants used exactly the terms ‘cultural’ or ‘racialised.’ While a majority of respondents spoke about ‘culture’ rather than ‘race’, it is important to point to the ways in which descriptions of human difference have increasingly moved from being grounded in racial difference to being explained through culture (Lentin, 2006). As interviewees described the implicit and explicit hierarchies expressed through this ethnocentrism, their language showed that these could be characterised in different ways: as a European dominance, as a Global North dominance, as a racialised hierarchy. These categories must be approached with caution, as the binaries they imply (European/non-European, North/South, centre/periphery, headquarters/field) and their application to different groups risk perpetuating reductive generalisations that dehistoricise and essentialise cultures and societies. However, this only adds to the importance of considering their prevalence and effect within the organisation and the often-coded languages used to describe them. On some level, there is potential common ground in the various critiques, which all single out practices they see as disrespectful, counter-productive, and inequitable. Yet they can also represent strongly divergent diagnoses of ‘the problem’ with different implications for how to resolve it.

While there was acknowledgement of a will to adapt to different settings, participants in the study questioned the extent to which white Western ethnocentrism in MSF operations has been addressed. Like other humanitarian organisations, OCA began to employ anthropologists, who are seen in MSF to have a role in addressing ‘biases’ in MSF’s programming (Véran et al., 2020). There have been broader debates about the role of anthropology in medical emergency response, with concerns that anthropologists are positioned as ‘translators’ or ‘cultural brokers’, there to decipher ‘the culture’ of the ‘Other’ with the aim of increasing ‘acceptance,’ rather than re-directing the critical ethnographic gaze towards the intervenors themselves (for this debate, see for instance, Lees et al., 2020; Benton, 2017; Enria and Lees, 2022). In any case, some staff questioned how far such changes went, arguing that, despite superficial changes such as women wearing headscarves or travelling in different cars from male colleagues, “certain things in the principle we don’t adapt, we don’t adapt to the context.”

There were numerous comments about ‘Western bias’ in operational standards, and racialised ideas about ‘professionalism’ – the markers of doing a good job or being good at one’s job. Expectations of how things should be organised can sometimes be “too European,” an experienced employee commented, using the example of a vaccination campaign: “people queueing up and everybody has his turn […] a typical international staff member maybe sees it as that is the way to organise it, but it may also be that something which looks ‘unorganised’ is actually still working.” Another employee argued that the production of standards and guidelines involved subject matter experts in their area being “all white, Global North, writing guidelines and standards for black and brown [staff] with black and brown patients.” The lack of representation was perceived as linked to potentially inappropriate or poorer quality of care for black and brown patients.

Observations about biased standards were frequently presented to explain (at least in part) why locally recruited staff struggled to access opportunities. In these narratives, there were certain fixed ideas about ‘Western culture’ being posited as the norm. An internationally mobile staff member reflected that “what we’re valuing in terms of work output is people responding to emails quickly,” describing this as “a very Western value in terms of our work culture and our idea of what it means to be a good staff member.” Similar reflections were applied to “how we appreciate evaluations done by certain nationalities different from other nationalities” and to staff learning and development, where there were comments about the need for greater attention on different cultures of learning because “the learning psychology that we use and therefore the learning methodologies that we use […] are very, very Western in their approach.” Other interviewees discussed other forms of professional development, such as whether MSF’s “concept of coaching” is a “Western concept.”

Staff members criticised biases in the conception and provision of psychosocial support structures in MSF, which were described as modelled on the experiences and needs of internationally mobile staff. For example, one programme employee talked about the visits of psychosocial experts, whom they saw as not reflecting gender, racial, or cultural diversity: “Nothing against white women, but I think it would be more beneficial to the communities that we’re working in […] to have a more diverse – regionally, linguistically, culturally – to have that team be a bit more diverse and a bit more present in real life.” This staff member was thus concerned about the perceived imposition of a white ethnocentric positionality and a sense that this created a gap in support, specifically through its aspiration towards a non-racialised universality. Another staff member argued that the problem was the denial – not the extension or imposition – of common standards. They described this as resulting from unrealistic, historically-grounded, racialised expectations of local staff:

“What we expect some of our nursing teams do, the hours that they work, the under-resourcing, I mean, honestly, for some of our midwifery teams and some of our paediatric teams, if you had that many patient deaths in a week, I mean, that is just unrecoverable […] I think, we fall guilty to the strong black woman trope, if I’m honest.”

While these critiques thus have slightly different logics, they portray a lack of institutional investment in tailoring psychosocial care to different staff. As highlighted in Chapter 4, MSF’s institutional structures result in different levels of support for internationally mobile staff from different countries. When awareness of gaps in support for locally recruited staff is combined with awareness of reduced support for internationally mobile staff from (predominantly) Global South countries, the national/international division appears less important than other ways of drawing lines between different staff groups, leading some staff to draw conclusions that MSF is ethnocentric, Eurocentric, ‘institutionally racist,’ or ‘white supremacist.’

The accessibility of support when faced with inappropriate behaviour from other staff was also questioned. In OCA, complaints about staff conduct are handled by what is known as the Responsible Behaviour Unit (RBU), which was established in 2019 as part of an overhaul of the ‘integrity system’ following an independent review. Although there are now multiple channels through which to reach the RBU, several interviewees described access as inequitable. Issues raised included language and challenges around ensuring confidentiality in isolated locations. How widespread these challenges are is unclear. Records kept by the RBU show an increase in reporting of harassment and discrimination, but this is still believed to under-represent the frequency of incidents. What is clear, however, is that perceptions of bias and exclusion persist and are strongly held, undermining confidence in the system. One employee said: “it’s known that MSF doesn’t punish anyone, even if he does something wrong, they just send him to another mission, a different position, which is really painful.” In the words of one person: “I find it hard to say anything can work if you have people it doesn’t work for.” There is a strong emphasis on practicalities in some of these questions: do the systems operate in a way that means some people can’t access them?

More profoundly, there is a tension between universalism and ethnocentrism that affects the very way ‘appropriate’ behaviour is defined and how violations are identified and handled. Internal attention on these issues was heightened during the period of research for this study due to the issuing of a revised Code of Conduct for OCA staff. Members of the RBU drafted the new Code of Conduct in 2021-22, with the process including consultations and several rounds of revisions. The RBU began the process of rolling out the new code in 2022.12 This process has re-exposed the challenges the organisation and it staff face in navigating different social and legal norms. These challenges present under many guises. Sharing information about the code can be difficult: an interviewee based in Yemen described how the country office was having to seek advice on “how we can take some of the topics that make more sense to the mission, because staff on the mission don’t accept some of the topics which is related to the culture, to the religion.” Specifically, sections of the Code of Conduct that deal with sexual activity (including the prohibition of exploitation, abuse and harassment as well as intimate relationships between staff members or between staff members and patients) were described as culturally inappropriate to discuss at a workplace, especially with both men and women. Translating the code into policies is also fraught. For example, in some contexts the code’s rejection of ‘child marriage’ presents challenges: not all countries consider anyone under 18 to be a child (as the code does) and in some cultures marriage below this age is considered normal. Does MSF have the right to pressure its staff not to enter relationships that are both legal and culturally acceptable where they live? Should employees already in such relationships be removed from their jobs for a breach of the code?

12 Consultations were held with seven country programmes (managed by coordination-level staff), headquarters departments, partner sections, and association representatives, and individuals with relevant roles. The Code of Conduct also went through review by the OCA Management Team, its Works Council (a body required under Dutch employment law), the OCA Council, and the latter’s Duty of Care Committee.

In this context, while some employees criticised the imposition of universalist norms, others described racialised notions of ‘cultural difference’ as shaping responses to behaviour that contradicts MSF’s stated values. One staff member said that “some of the conversations I’ve listened to, particularly around domestic violence or intimate violence,” included comments along the lines of “‘oh, it’s a cultural thing’ […] this word ‘cultural difference’ I think, is used quite a lot, but incorrectly.” The focus on ‘culture’ also serves to distance debates around responsible behaviour or DEI from whiteness, that is to say from people holding on to the most power within MSF. This raises questions about how far the institution can reach into its employees’ private lives. OCA’s Code of Conduct officially applies to conduct outside working hours or locations “to the extent that it has a demonstrable negative impact on MSF-OCA’s stakeholders, work or reputation” (MSF OCA, 2022, p. 2), and employees are also expected to comply with the MSF movement’s “behavioural commitments,” which include the commitment that “MSF staff members and operational partners shall not abuse anyone physically (i.e. physical violence, sexual aggression or other forms of physical abuse) or psychologically (e.g. bullying, abuse of power, harassment, discrimination or favouritism)” (MSF, 2018, p. 1). While domestic violence was not a frequent topic in interviews, comparable concerns can be seen in other issues, such as whether MSF should offer services that may be contentious (such as abortion) or – as discussed below – how to support queer communities and staff in countries where homosexuality is stigmatised or criminalised. These suggest complexities of understanding, conceptualising and responding to the perceived ‘differences’ that the organisation encounters in the course of its work. Responsible behaviour tended to be seen as something that would help adjust non-European behaviours to European standards and not the other way round, thereby perpetuating MSF’s power imbalance between headquarters and ‘the field.’

Similarly, issues around ethnocentrism were also prominent in discussion of the DEI agenda. While “responsible behaviour” frameworks are concerned with individual incidents, DEI is conceived as addressing systemic issues. A manager with an intersectional role observed:

“Doing DEI in an organisation that, say, works in the UK when all of your staff are UK residents, that’s very different from having discussion on DEI and racism within an international organisation that has not only 25 different offices but also thousands of staff employed in over 70 different locations. Then it becomes so much more complicated, and everything could be tied to DEI.”

From this perspective, some of the concerns already raised (such as exclusionary professional expectations, culturally specific conceptions of care, or inequitable access to support) could be considered within the remit of DEI.

Almost everyone we spoke to – in every setting, at every level, and in all types of roles – rejected the idea that ‘DEI’ can be universally applied, offering critiques of Western ethnocentric and top-down approaches. Yet locally recruited staff, in particular, emphasised the risk, in practice, of DEI becoming another concept imposed from elsewhere. In the words of one local programme manager: “We have to be careful about this, because it can be frustrating for locals who feel that we [MSF] want to impose international beliefs and trends locally.” In DRC, for example, sexuality was raised in relation to the notion of imposition of outside norms:

“I can give the example of homosexuality here. It is a complicated matter to deal with on a local level. And such matters can make locals think that we are trying to introduce these trends and cultures. This can create problems. These are things we should look into to evaluate where resistance will be. What are the sensitive topics, and how should we frame them?”

For some locally recruited staff, there was a concern not simply about the values being imposed, but also the categories according to which these values are structured. Congolese employees described disconnects between the framing of DEI, and questions of equality and difference specific to eastern DRC. One person said:

“DEI should definitely be adapted to the environment and the context. For example, if we are talking about diversity and inclusion in regards to the Congolese, are they selecting a specific category of people and tribes? Are we ready to deal with that by establishing quotas? MSF should think of this when launching projects, and structure strategies and mechanisms in a way that it doesn’t create additional difficulties.”

Conversely, there was also concern that DEI in ‘the field’ was focused on real (or imagined) divisions among locally recruited staff based on ethnic categories, rather than structural inequalities within the organisation itself. Such questioning contributes to concerns about the level of institutional commitment to change, discussed below.

Another staff member, based in Amsterdam, argued that the prevailing way of talking about the institution is “too much European and North American driven” and revealed disconnects between headquarters and countries of operation:

“If I just look at how much attention, it’s what I call the flavour of the day, and mainly in headquarters, we go from MeToo to Black Lives Matter, to institutional racism and so, and then it’s almost like if there’s a new thing, a new flavour of the day, that we forget the other one. It’s all the discussions are focused around headquarters and people in headquarters and their opinions about what is happening in the fields, without otherwise having much clue over what is really going on.”

Disconnects between implementation of DEI in different parts of MSF and OCA can be profound. Thus, while some interviewees expressed frustration at DEI being treated as another universal framework, imposed from headquarters, others criticised what they saw as a failure to stand up for these very same values. This dynamic was vividly captured by comments related to a campaign for inclusive toilets at the Amsterdam office, presented as a motion in the association’s General Assembly. This episode was cited as an example of the privilege of headquarters staff: “Of course, there will be people sitting in the Netherlands, that’s the amount of problem they have, they don’t have a gender-neutral toilet in the office.” According to the interviewee who raised this concern, the “two hours of debate and discussion” on the Amsterdam toilets during the General Assembly marginalised association members from other countries and reflected the structural issues that prevented them from putting issues on the agenda. From the perspective of Amsterdam-based staff members who supported the motion, however, this was described as an issue of inclusion and accountability. For example, one interviewee expressed frustration that, after the refurbishment of the building and an associated consultation process, “the redesign was finalised, and there was no gender-neutral toilet, and there were only three accessible toilets for a six-floor building.” Using the associative route allowed staff to express their support for what they saw as a commitment to inclusion, setting “an example to the rest of MSF,” and to “future-proof” the building by making it welcoming for all.

Reckoning with the tensions produced by encounters between MSF’s values and principles, often assumed to be universal, and different norms, cultures and value systems is complex. While the imposition of outside norms poses problems, so too does the prospect of reinforcing inequalities. The dynamics perceived to be influenced by Western ethnocentrism are also multiple, and responses to them could therefore take a variety of forms. Employees’ observations then inform their readings of the institution, so that different perspectives on perceived ethnocentric biases in the treatment of staff, whether in terms of care or discipline, may result in diagnoses of the institution as (among other things) hypocritical, uncaring, indecisive, inconsistent, insensitive, or overbearing. As the following sections explain, interviewees expressed doubt about the potential for these challenges to be addressed.

8.3 Lack of vision for change

Another prominent line of argument among interviewees was that MSF struggles with large scale visions for change. This argument was made regularly in relation to the movement’s relationship with political issues and frequently in relation to internal dynamics. This implicates MSF’s emergency culture: as Chapter 3 described, MSF’s focus is on the immediate, urgent problem at hand. Restoring ‘normality’ has generally been seen as the priority, rather than long-term structural issues, but whether this constitutes a sufficient political vision is disputed. This means that for some, critiques are not simply incorrect but entirely misplaced – MSF, by this counter-argument, has reached its current status not by shying away from vision but by defending and expanding its original goals. Like other debates, therefore, discourses around ‘vision’ also reflect MSF’s scale and the disconnects that come with being such a large and dispersed movement. Put simply, with many people come many opinions – in MSF’s case, most of them strongly held.

So, how good is MSF at thinking big? Some senior figures argue that its ability is limited. One argued that the movement has “trouble formulating coherent positions on big issues of our time, on migration, climate change, populism, all of the political changes that are going on, and how to operate within these big changes that are happening.” For instance, on climate change, another interviewee said, “a mountain went into labour and gave birth to a mouse”:

“Instead of saying, ‘What sort of MSF will be able to address, not 70 million displaced people but potentially 500 million displaced people, in 20 years? How should we look like, where should we exist, to be relevant in 20 years?’ the question becomes, the evolutionary question becomes, ‘How do we reduce our footprint?’ And even that we cannot agree on.”

The Access Campaign is sometimes seen as an exception to a culture of short-termism, although it may today be better considered symptomatic of the challenges. The Campaign for Access to Essential Medicines launched in 1999 to advocate for the development of new drugs and improved access to treatment, identifying ways to fill gaps in access to medical products and seeking to “humanize” relevant intellectual property rules (see Binet and Saulnier, 2019, pp. 201-02). That year, MSF received the Nobel Peace Prize, investing the money in this new policy advocacy unit, with then International President James Orbinski declaring in his speech: “What we as a civil society movement demand is change, not charity.” The Access Campaign website uses this quote at the top of its ‘about us’ page, emphasising its ambitions for political impact. However, only a couple of sentences earlier, Orbinski (1999) had said: “If civil society identifies a problem, it is not theirs to provide a solution,” delineating the limits of that ambition.

This tension continues to shape attitudes towards the Access Campaign today, which has been the subject of a difficult internal discussion. Weighing the potential gains or losses of campaigns on root causes is daunting. Reflecting on the need to reassess, one interviewee said:

“We may have been able to shift the needle on certain things, but the forest continues to burn […]. So, in this new landscape, where there’s been a pandemic, certain things have come to light, and all of that, what is our new political analysis? And what are the structural barriers we want to tackle, and what is the new Access project? We don’t have that analysis.”

There are other examples of sustained campaigns that seek to go beyond emergency response. The Drugs for Neglected Diseases initiative, for instance, dates from the same era as the Access Campaign (indeed, it also benefited from the Nobel Prize award). As an example of a vertical initiative, OCA has been driving MSF’s campaign for greater recognition and improved treatments for noma, for which it runs a specialised hospital in northern Nigeria. Despite the life-changing impacts of the hospital’s work for survivors, staff members recognise the limits of the emergency response approach. A nurse working in the hospital wrote:

“Right now, MSF is trying to go into preventative mode. It’s very challenging, because how do you prevent noma? One of the contributing factors is poverty. How do you alleviate poverty? Can MSF do that singlehandedly? No. That is why the world needs to join in.” (Emeh, 2021)

An application to the World Health Organization to have noma placed on the list of neglected tropical diseases is part of the campaign to bring ‘the world’ in. To further this goal, OCA staff members have contributed research to help improve awareness and understanding of the disease (e.g., Farley et al, 2020a and 2020b), supported the production of a documentary about noma by an external team, and publicised the existence of noma in mass media (Johnson, 2021).

Despite these examples, discourses critiquing the organisation’s ability to formulate political positions take a range of forms. Some highlighted the limits of MSF’s role in sounding an alarm, a lack of appetite to engage with providing solutions that reflects the organisation’s emergency response culture. Limiting itself to an emergency lens, we heard, means that MSF “can tell you the story of what we’re seeing” but when asked what should be done about it “there is no answer because we’re not stepping into that.” Or, as another said: “all we do is tell the world again how shit everything is, and we’re not mature enough to actually start putting solutions on the table.”

This idea was raised as compromising MSF’s ability to influence others to take action, although it is also an important part of the moral underpinning of the concept of témoignage. The relationship between advocacy and témoignage is complex, especially as people may hold various working definitions of these terms. Nonetheless, to the extent that témoignage can take the form of “the cri du coeur, a moral outrage being expressed” (Gorin, Guevara and Du Bois, 2021, p. 29), it does not require the act of speaking out to include a prescription on what should be done. This is not the case for advocacy, which as a contemporary practice is generally considered to require a defined end goal and a ‘theory of change’ indicating how to influence other actors to act.

Disconnects created by the movement’s size were also cited as a key factor limiting politically informed visions of MSF’s potential roles or actions. The institution’s growth has brought “splintering and atomisation” as well as bureaucratisation. An institutional culture that emphasises debate and participation – even if these are in practice limited by power dynamics and inequities – also contributes. “We are a consensus-based organisation, at the bigger scale of our governance, which comes with its own limitation.” This means that, when parts of MSF do seek to push for a particular vision, action, or proposed solution, it is “watered down” (in the words of an interviewee with experience of international collaboration) due to the need to find agreement across a complex and competing set of actors. Protection and advocacy expert Arjun Claire (2021, p. 51) has argued that “speaking out for MSF has also carried moral significance, where remaining silent in front of grave human rights violations was seen as an act of complicity.” This means that arguments over what position to take can easily shift from a tactical register to a moral one, increasing the potential for internal confrontations.

However, the challenges are not just about sheer size – they also reflect differences of opinion and perspective on fundamental issues facing MSF. For some, the focus on emergency programming (at least in principle) remained the defining characteristic of the organisation: “Our task is bringing back the normal for the most vulnerable groups.” This is, in itself, a vision of refusal of the suffering of others and a vision for MSF’s place in the world (Davey, 2015). For others, questions such as ‘Where do we see ourselves? What is our social mission?’ are more open for discussion:

“Are we simply just a healthcare provider in humanitarian settings? Or given the size that we are, given the influence that we have in the world, do we have an obligation, […] is there a role that we play as an influencer in, for example, what the global systems [are] that have that negative impact on the work that we do and in the countries that we work in?”

The tensions between these two positions go to whether MSF’s identity and role are fixed or – as the logic of the associative structures would suggest – have the potential to evolve.

The idea of a lack of vision was a prominent theme in the discussion of how OCA and MSF approach efforts to address discrimination and inequalities. Indeed, these efforts are often formulated as a reaction: as a desire to “tackle institutional racism,” for example. OCA personnel spoke in a range of ways about this vision gap. One observed there was no “lighthouse on the horizon” for institutional change efforts, without which the movement is left “drifting in all kinds of different directions” and individuals faced with a given action “sense that it might be the right thing to do, but they don’t really have a frame for why we are doing that.” As if to illustrate their point, an OCA employee posed the question: “The end goal is often we want to be a diverse and inclusive organisation but then what does that mean?” OCA does have a “staff vision,” however no interviewees referred to this document.

Some interviewees at headquarters level – particularly those with extensive or high-level experience – expressed beliefs that such ambitious changes to the way MSF works were difficult, or undesirable, or both. Discourses about whether the institution or its top leadership are able to change are thus entangled with discourses about whether they are willing to do so.

8.4 Lack of appetite for change

The idea that MSF lacks appetite for change is closely related to claims that it lacks vision, but distinguishing these two narratives allows a clearer view on the extent to which a lack of trust of high-level leadership is shaping current discourse. Compared to the vision narrative, the views about appetite for change are less likely to speak of ‘culture’ and more likely to speak of ‘leadership’ or ‘management,’ Although, as seen especially in Chapters 6 and 7, interviews captured a general lack of confidence in those ‘higher up,’ the critiques under consideration in this chapter reflect a very strongly held view that those in perceived positions of power, whether formal or informal, want to maintain their dominance. The lack of appetite for change therefore relates specifically to change that would address internal inequities and injustices. Given that DEI is the dominant frame through which issues around power and inequalities are approached, this was the topic that most often provoked such reflections. Throughout the organisation, staff members are drawing their own conclusions based on what they see as a gap between rhetoric and practice. In the words of a locally recruited staff member in Nigeria: “We are discussing it at the top, HQ. All the HQ are discussing it. Why is the real implementation not in the place?”

During interviews for this study, staff with a range of perspectives portrayed the organisation as being unable to face fundamental and structural reforms. One person who argued that MSF’s organisational culture was ill-equipped for difficult, ethical and strategic discussions gave the example of conversations about how operational teams might be composed to illustrate the reticence. Another gave the example of resistance to moving the bulk of Human Resources structures from headquarters offices to countries of operation, despite the fact that the latter are where the majority of personnel are from and are based. Similar dynamics were raised when interviewees spoke about disability inclusion. Locally recruited personnel in multiple sites were critical of perceived inaction from headquarters. For instance, one locally recruited employee said that in 12 years with MSF, with different OCs and despite seeing different “missions” and attending international trainings: “I have never seen an employee with a disability. Are you trying to say that a person living with disability is not capable of working with MSF?” This may not reflect an unqualified reality but captures the perception of exclusion and lip service. Employees in multiple countries expressed frustration at inaction from the executive despite associative engagement. One summed up:

“We discussed that aspect in particular at the international level of MSF, we even voted on motions stating that MSF has to include people living with handicaps. But when is that going to be applied? That’s the problem of that DEI.”

Arguments that the institution was avoiding structural or more complex issues often underpinned claims that there was no appetite for change. For example, Congolese employees described how English language requirements remained a barrier in OCA. In describing their attempt to apply for a senior position, one employee explained:

“Weirdly, in the written test, there were questions in English and questions in French. So, for us who are weak in English, the questions in English had to be left out, and we did not even make it on the list of people who were getting an interview. When I spoke to a colleague who had the chance to get an interview, he told me the interview was entirely in English. So, I told him it was going to be tough, if that is how DEI is implemented. Because these obstacles are set up by the same people at the headquarters who are pretending to be implementing this DEI in the missions. They are the ones setting up these obstacles. What kind of DEI is it if you are still blocking out people because of language? What type of DEI is that?”

There was a sense that change needed to begin higher up. “I am telling you that the headquarters are a part of the problem when it comes to the DEI because they do not want to change. They want the change, but they do not want to change themselves,” a locally recruited employee concluded.

Supporting staff with issues related to sexual orientation and gender identity was another area raised. Recognition that in some countries where humanitarian organisations operate, homosexuality is either taboo or criminalised, has contributed to something of a ‘don’t-ask-don’t-tell’ culture in the sector. Within OCA, a study found that lesbian and gay staff members managed information about their sexual orientation differently in headquarters and on assignments, and that organisational support for staff navigating such choices was limited (Rengers et al, 2019). One interviewee said that “sometimes we find a more conservative approach in headquarters, more than in the field,” based on the “patronising” idea that “we have to protect them [programme sites] from something that apparently is too crazy as an idea that there can be LGBTQ people in the field, or beneficiaries, or the local population.” In their view, the claim that it was necessary to “prioritise” certain issues over others was a cover for an unwillingness to tackle a subject that, as already described above, raises issues of ethnocentrism and can have implications for acceptance and access – even though it is also important for the inclusion of different groups within communities. They concluded: “I don’t feel that it is authentic. Or you take diversity or you don’t take it, but don’t pick and choose.”

Finally, interviewees raised the exclusion of locally recruited staff from senior positions in their country of origin (see Chapter 5). Institutional responses to this issue illustrate the challenges of undertaking reforms that will have direct operational consequences across such a large and diverse movement. Although there have been some changes, in the past approaches have focused on diversifying access to international contracts. Mobility offers opportunities for development and ultimately progression through the organisation, and the rising proportion of internationally mobile staff from the Global South was repeatedly cited during interviews as a sign of increasing inclusion. However, while greater access to mobility may improve the outlook for individual employees, it does not address systemic issues at the collective level for locally recruited staff, nor does it move locally recruited staff into positions of power and seniority within MSF. Indeed, the limits of expatriation as a form of career progression were already recognised at the time of La Mancha, with a review noting that “expatriation has been, for many national staff, the only way of participating to MSF’s decision-making” even though “expatriation of national staff does not contribute stricto sensu to the access of national staff to positions of responsibilities with MSF” (Dollé, 2006, p. 68). As Chapters 3 and 4 described, MSF’s form of emergency intervention is built upon a two-tier system in which foreign decision-makers intervene quickly and pick the people they consider best to do the work they have set out to do. As a result, tackling these issues means questioning what one interviewee summarised as an operational model and culture based on “making decisions on behalf of people, about their own lives.” Many staff expressed doubt about the willingness and ability to question the model.

Interestingly, the sheer volume of initiatives has not convinced sceptical staff members that leaders of the institution are committed to change, even less that they are able to achieve it. At the time this study was conducted, there were numerous large institutional efforts active: the ‘MSF We Want to Be’ conversation, for example, intended to enable collective reflection on how the movement should evolve; a ‘Rewards Review’ examining remuneration; a review of representation in the International General Assembly; and an entire funding scheme known as the Transformative Investment Capacity (TIC), which funds projects across the movement to “bring forward new ideas that can change how we work to better meet the evolving needs of our patients.”13 Yet there are also criticisms of these processes and impatience with their pace and, at least for some employees, a sense that ambition was lacking. One interviewee argued:

“The two horrifyingly bad metaphors that are used regularly are: ‘MSF is an oil tanker not a boat and turning takes time,’ and, ‘don’t throw the baby out with the bath water.’ Those are, sort of, in my mind, emblematic of the stagnation, of the justification of the position as it is.”

13 https://msf-transformation.org/

Some of these concerns are held by people in leadership positions. Senior managers in OCA as well as in other parts of MSF criticised how DEI had been ringfenced as an ‘HR issue,’ avoiding a more fundamental self-questioning about the organisation’s ways of working. Yet there were concerns from others that DEI was increasingly becoming a comfortable frame for the organisation specifically because it was not equipped, as one former employee argued, to “really address those fundamental criticisms.” They said:

“It can very easily just be reduced to: ‘We need to diversify the workforce’ and ‘we need to make sure that people don’t experience discrimination in the workplace.’ All of which are absolutely important things, but they don’t actually necessarily require that you disrupt systems of power and influence.”

One experienced MSFer said that “let’s do DEI” had become the response to two problems of MSF: “discrimination, racism, gender inequality and so on in the organisation,” and “how MSF as an organisation acts upon people it serves,” and concluded: “this is not going to be solved by diversity and inclusion.”

The institutionalisation of DEI efforts has been criticised for its lack of radical ambitions and its failings to shift power substantially within the organisation (see also Hirsch, 2021a). Without those shifts, movement-wide DEI efforts risk becoming little more than window-dressing: a way of affirming an organisation’s willingness to tackle inequalities without redistributing power and responsibility. Given MSF’s structural divide between headquarters and ‘the field’, institutional narratives about DEI and in particular their focus on cultural norms seem to increasingly be drawing attention away from MSF’s centres of power. MSF is not the only organisation facing such critiques, nor is it the only movement in which considerable investments in DEI coexist peacefully with a deep-seated desire to maintain the status quo – to the detriment of the global majority.

Staff throughout OCA therefore questioned the sincerity of the stated commitment to addressing injustices perpetrated within and by MSF. Depending on the speaker’s position, this could reflect their perceptions of attitudes in headquarters generally or their impressions of senior management, or both. Many people who had been involved in grassroots efforts within OCA described a feeling of being held at a distance or kept out of discussions since the reinforcement of formal DEI structures. A former board member pointed to the lack of attention to the impact of activities, leading to the conclusion that activities were “just to show that we reacted.” These perspectives echo Sara Ahmed’s argument that institutional DEI commitments are not designed to address deep-seated inequalities, and do not commit the institution to doing anything. Instead, making commitments or naming the problem comes to stand in for action: “as a result, naming can be a way of not bringing something into effect” (Ahmed, 2012, p. 117). At the same time, the existence of these institutional mechanisms insures the organisation against accusations of inaction, and allows them to ignore complaints brought forward through other pathways. An Operations colleague said:

“There are countless examples like this one, where we have expressed an intention but we cannot seem to cut the Gordian knot of our own rules and regulations. As a consequence, little of substance appears to be happening while I know for a fact that there is genuine intention […]. But the inability to cut through the bullshit means not enough is moving, not enough is being felt by staff in field positions and […] disbelief at the intentions is starting to emerge. Because of course people doubt – how hard can it be to just allow somebody to just do a job they are qualified for in their own country? And apparently it’s really hard.”

In sum, frustration and mistrust reflect a view that DEI risks oiling the system, rather than changing it – and a view that these are two different things. “I don’t think we need a more palatable version of the status quo,” one interviewee said, arguing that DEI was “being co-opted and instrumentalised to serve the exact opposite of its announced purpose.” This affects the dynamics within which leadership must act. One member of the Operations Department said: “I agree with the problem, I disagree in how we address it” and argued that Operations had actually “done more things to remove some of these barriers” than official DEI initiatives. Another person said that they felt “sceptical” because “I don’t see much action. I see a lot of doc[ument]s, but what does it mean?” The dominance of this discourse is a source of concern to some who have taken part in or witnessed efforts to introduce change:

“I think it would be really unfair for some people to say, ‘Okay, nothing is happening.’ And that’s what I hear now, a lot. And I’m tired of that discourse that nothing is changing, nothing is happening, it’s the same status quo […] it’s not true.”

In the end, “people get disenfranchised,” a programme colleague noted, and withdraw their participation from surveys, consultations, and research.

Nonetheless, notwithstanding critiques of insufficient actions at both OCA and intersectional or international level, it is not clear that a more imposing approach by senior leaders would be acceptable to staff. As the examples above and in the previous chapter show, there are widely ranging views about the types of leadership action that are acceptable and about the legitimacy of current officeholders. ‘Debate’ and participation are valued – even if they are not inclusive or equitable – in part because of MSF’s associative make-up. One-size-fits-all approaches hold little appeal and opposition to anything that presents as ‘bureaucratic’ can also be strong. One of the results of all this is that staff take action of their own.

8.5 Action-oriented

As outlined in Chapter 3, individual initiative is an important part of MSF’s identity, and this places value on a history of charismatic leaders who have challenged the organisation – and the humanitarian sector – to do ever better. People speak of MSF as ‘personality-driven’ or ‘person-driven.’ This appreciation of individuals who drive change is an important exception to critiques of leadership, though people need not be in positions of formal power to be perceived as leaders in this sense. The emphasis on individual initiative underpins the idea that “you need people who’ve got the conviction and passion to just really keep pushing on a topic.” Interviewees described an organisational culture that is strong on reaction or improvisation, but weak on approaching structural issues. In this action-oriented organisational culture, people develop their own strategies and tactics for driving forward the issues that they see as important.

The power of initiative is reflected in some of MSF’s formal structures and spaces as well as how staff approach their work. MSF’s associative structures are intended to encourage this way of thinking and provide a forum for members’ initiatives and agendas (see Chapters 3 and 5). The power of initiative has also been reinforced institutionally through mechanisms like the Transformative Investment Capacity scheme. Outside these institutionally sanctioned formats, too, ideas lead to new actions. Interviewees described a culture of developing workarounds, helping people working ‘towards’ their goals. One person commented: “When you hit roadblocks and obstacles, the easiest strategy – and maybe not only in MSF, because we see it in the sector – is to make and dig your own silo.” Another member of staff involved in collaborations across the movement explained how they looked for “people of goodwill, people who want to do things, people that are interested, people who understand the issue.”

However, the flourishing of ideas and actions appear to be also adding to a feeling of being overwhelmed and a sense of a lack of discipline. Day-to-day, the institution generates a large workload for its personnel. OCA programme staff described an “unrealistic” succession of agendas that inflate their workload:

“Things are very ad hoc and very piecemeal and quite unstructured. […] At one point it’s patient-centred care, at another point it’s employee engagement, at another point it’s the climate, and so things are trendy and then, for that trend and that hype, we do a lot of talk […] but when it comes to […] structured implementation, we lack that a lot.”

Another said that “OCA is very good organisationally at putting ourselves in an in-between position that dooms us to fail.” They described a pattern as follows: “We pick a priority, we agree it’s a priority, and it requires support to put in place.” Confronted with the costs of doing this comprehensively – hiring new implementers and trainers, updating all training courses, continuing training and socialisation process for years, and so on – the choice is made to instead hire a small number of advisors. The idea is that “people in projects can reach out to them through their line manager, through their Head of Mission or LogCo, their MedCo” – note the involvement of the filtering positions (see Chapter 6) – but “nobody calls, nobody goes to seek out that assistance because they’re too busy, because they’re slapped in the face every day with work […] And so they cannot prioritise that priority because when everything’s an emergency nothing’s an emergency.” The entire model of decision making, which concentrates power acutely in some areas and requires others to exert influence, is implicated in this critique, as well as the way that resources are allocated.

Parallel commentaries were made at movement level. With the emphasis on problem-solving, one person who had been involved in multiple high-level initiatives said: “it all gets started and loads of people working on loads of different stuff and then it quite often stalls because there’s not enough political will to push it forward because there’s too much happening.” Such accounts dovetail with a recent movement-wide analysis that was critical of “the duplication of functions and projects, the permanent expansion of existing units, and the permanent addition of new initiatives without any counter-balancing closures” at headquarters level, noting that on the one hand, “it is hard to believe that they all systematically deliver their promises and must be maintained forever” and on the other “very few projects we manage reach their goals and eventually close” (Levery, 2019, p. 5).

These dynamics are visible in how staff members spoke about workplace injustices. An employee in one of OCA’s partner sections commented that “there are a lot of measures” but “I don’t know if you can call it a strategy” (a similar analysis is given in Schenkenberg van Mierop and Harvey-Dehaye, 2020). In recognition of the difficulty of addressing structural issues, several interviewees referred to the possibility of “quick fixes”, “quick wins” or “low-hanging fruit” in relation to inequalities within the movement. This appeared to be another reflection of emergency culture. While they did not always believe that these opportunities had been taken – indeed, they were frequently critical of what they saw as failures to act on them – there was a sense that quick wins existed and could be contrasted with more challenging structural issues. In contrast with the issues described in the previous section, certain problems were considered to be in a “comfort zone” of being easily identifiable or approachable as technical or ad hoc adjustments, such as “revisiting our duty of care, our existing internal regulations and HR policies and procedures based off of how the context has shifted.” In contrast, others criticised the “quick wins” mentality as a sign of a bureaucratic organisation that, instead of allowing DEI to meaningfully confront major issues, dragged it into “the big machine of MSF” and a “conservative approach.” Yet others questioned whether “quick wins” exist at all.

Staff perceptions of blockages and an emphasis on the power of initiative encourage the proliferation of actions. In OCA, for example, the Kaleidoscope Network and the Rainbow Network were both formed by small groups of staff members based in the Amsterdam office. Staff members involved in these groups described feeling like it was necessary to “take matters into our own hands” as a response to perceptions of “absolutely nothing happening on the part of the [Management Team] whatsoever.” They emphasised a desire for impact: “We don’t want to be another guideline or paper or DEI discussion or committee, we want to provoke change in the organisation in a very practical way,” with ambitions that go beyond their immediate area of work: “We wanted to be something that worked for the improvement of MSF, overall.” These can contribute to positive steps, but also risk increasing the burden on individual staff in an already demanding workplace.

The creation of the Decolonise MSF group arguably also reflects the power of initiative in MSF, operating both within and outside the movement. Decolonise MSF, which exists as a WhatsApp group with some 1,300 members and on Facebook, offers something that institutional forums do not. One internationally mobile staff member described the importance of encountering Decolonise MSF after the destabilising impacts of what they described as “apartheid” structures in their first two assignments with MSF. Previously questioning whether they had been “too emotional,” they described the feeling of relief when “I understood by reading the testimonies of others that I was not crazy. […] I finally understood that these things are repeating again and again with the same pattern.” When asked what engagement with the group offered, another said:

“I think I was feeling really frustrated and angry about a lot of the power structures that I was seeing in MSF and a lot of the internal racism and this colonialist divide between ex-pats and national staff […] I was looking for an outlet to share my frustrations and also hear from others to try to see if there were places that we could be useful to try to push for a little bit of change.”

A former OCA board member summarised this as a “group of people that just don’t feel seen, don’t feel heard, don’t feel included.”

Yet, although its creation reflects disconnects between staff members and perceived institutional positions about necessary change, Decolonise MSF is not exempt from disconnects of its own. Decolonise MSF also faces challenges due to the range of different opinions it accommodates, from people “openly venting about MSF” to those “who are not necessarily there because they believe in the group, but they’re there to watch what’s happening.” More broadly, there remains a lack of consensus about what ‘decolonising’ means, with growing concern in the humanitarian sector that it has become a metaphor, another “comfortable buzzword” for Northern actors and institutions (Tuck and Yang, 2012; Khan et al., 2021; James, 2022). As a result, in MSF, Decolonise MSF has sparked a conversation in the organisation about what structural change is possible, while still remaining ‘MSF.’ In short, what would ‘decolonising’ MSF look like in practice? Is ‘decolonising’ through reform possible, or would this require disbanding the organisation altogether? One person who had signed the 2020 open letter, for instance, now described the group as “not helpful”, “populistic” and “just trying to pull down MSF.” Another employee reacted to arguments within the group:

“What you’re describing isn’t MSF. What you want is a new organisation. To enact the changes that you want would destroy MSF as it currently exists, which is fine. Then don’t work for MSF, or work really hard to change it.”

This situation can also create cognitive dissonance: one Decolonise MSF member said that, if the institution is opposed to radical change and even hostile to those who call for it, “you wonder if you are not a hypocrite for wanting to continue to work with MSF.”

Conclusion

Throughout this study, power and inequality have been conceptualised differently in different places. This reflects both scale and diversity: with multiple generations and different political, social and professional cultures coexisting, MSF – like other humanitarian organisations – accommodates a wide range of views about its own role and purpose. Despite the imagined universality of the MSF movement, there are fundamental disconnects in how its concepts, ideas and policies are understood and experienced. Many staff members have their own interpretation of what these disconnects reveal about the institution or those at its helm.

While criticism dominated the views shared for this study, there were also some cautious, qualified observations that expressed hope for the prospects of improvement. A reflection from a former Head of Mission is worth quoting at length for how it captured the prevailing tone of self-criticism, directed towards the institution as well as the positionality of individuals, and for how it articulated the major change that the apparently small demand of being ‘decent’ requires. They said:

“I think perhaps where OCA is in a positive sense is that improving our internal culture and being more decent isn’t now seen as a tick-box activity. Decent, that makes it sound like something we should be doing, you know what I mean. And again, it’s easy because I’ve always been the privileged person in the room that I can just say: ‘Yes, sure we should just be doing it this way, come on guys, let’s go.’ […] There is not a hope in hell that I would have reached where I am now in this organisation if I didn’t come from the background that I do, if I didn’t look the way I do, and if I hadn’t had the opportunity, before MSF, right? With the opportunity of having a very comfortable childhood, good access to education, and not worrying about anything. And then add to that how I’m perceived and trusted as an authority, [without that] I wouldn’t have ended up here. So, it’s easy for me to say it’s just about decency, it’s clearly about much more than that, but I think at least where we are inside OCA is that increasingly people, and people who need to be party to changes, recognised that these are not tick-box activities, that these are actually integral to our ways of working and are directly aligned with our principles. It’s just that we’ve always looked at those principles as being things we’d apply to other groups of people rather than to embody internally. I think we’re getting through that.”

If there is indeed a shift underway, or momentum building, efforts to foster it will need to confront not only the practical obstacles to structural change but also institutional and attitudinal ones. This includes the narratives according to which people understand MSF and the forces that shape its practices. These narratives play into internal power dynamics, favouring certain positions and discouraging others. They are constitutive of the environment within which MSF employees and leaders make choices and shape the relationships between different groups within the organisation.

The different diagnostic discourses outlined in this chapter may be persuasive to staff and others familiar with MSF, or they may meet with doubt. Some may align closely with individuals’ experiences of working for MSF on particular activities or campaigns; others may appear more like received truths, myths, or generalisations. Some views may be held strongly in certain circles and not represented among others. They may or may not reflect official positions. But all are circulating amongst MSF and to at least some degree among OCA staff. They are important to recognise and heed, both as insights into the evolution of MSF to date and as influences upon its future.