Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières

By Ren é e C Fox. Baltimore, Md:
Johns Hopkins University Press, 2014. ISBN 9781421413549

Médecins Sans Frontières (MSF) has become the most successful and best-known apolitical, humanitarian endeavour of our time. Founded in 1971 by a small group of French doctors in response to the tragedies and atrocities of the Nigerian Civil War (1967 - 1970), it is now a worldwide movement responding to a wide spectrum of human-made and natural disasters. By 2013 its over 32 500 personnel provided hope and medical assistance to suffering people in more than 67 countries with an annual budget of more than 600 million euros (over 90% from private, non-governmental sources).

MSF’s driving principles include ethical medical practice, independence, impartiality and neutrality, bearing witness and being accountable. All its activities are taken without consideration of race, religion, gen­der or political affiliation (although often with political implications), and with priority given to those in the most serious and immediate danger – currently people threatened by the Ebola epidemic.

Through her participant/observer involve­ment with MSF for almost two decades, Renée Fox, a doyenne of medical sociology, has harnessed her sociological skills and extensive access to MSF documents to portray many insights into this impressive humanitarian movement. She illustrates its global scope, the complexity of its operational methods, its idealistic motivating forces, the internal dilemmas associated with its self-critical attempts to deal with complex (often paradoxical) aspects of humanitarian activities, and the external challenges arising from seemingly endless demands.

The book begins with ‘voices from the field’ (blogs) that the author analyses to record the passionate, courageous and insight­ful attitudes of many MSF workers. A description follows of the origins of the movement, its growing pains and crises, and the controversies associated with the imperfect struggle between humanitarianism and the inextricably associated politics. The symbolic and practical importance of the number, severity and variety of humanitarian disasters with which MSF deals, and the many individuals whose suffering it attempts to alleviate, cannot be underestimated in a world scarred by ongoing tragic mani­festations of human belligerence and vio­lence. Given the impossibility of covering all MSF’s field activities, Prof. Fox has chosen to illustrate these by recounting in detail its work in South Africa (SA) and Russia.

MSF’s decision to ‘take on’ the HIV/AIDS pandemic in SA was vindicated by the Khayalitsha project (driven by Dr Eric Goemaere with the support of many activists, and later by the Western Cape Department of Health), which demonstrated the successful application of affordable long-term antiretroviral therapy in resource-poor contexts. By 2013, almost 2 million South Africans were benefiting from enhanced quality of life and improved life expectancy. Advocacy for and successful implementation of such a programme stimulated the growth and influence of MSF worldwide, and led to the establishment of MSF South Africa to extend MSF’s ‘witnessing’ role and the spirit of SA’s struggle into other parts of Africa.

Together with Olga Shevchenko, MSF’s involvement in post-socialist Russia is explored with a focus on work with the homeless and street children in Moscow, and on the problem of rampant tuberculosis (TB), including the multidrug-resistant variety, in Siberian prisons where, despite atrocious conditions, nearly 7 000 successes were achieved among 10 500 patients treated for TB.

An important contribution of this book is the explication of MSF’s deliberations on its internal culture and its self-critique, which are characterised by introspection and participatory democracy, accompanied by humility. These qualities are evident in the description of events leading up to the 1999 Nobel Peace Prize award ceremony, the discussions on what should be included in the acceptance speech, the democratic process for deciding who should speak on behalf of MSF, the impact of its powerful message delivered by James Orbinski, then President of MSF, and the decision to allocate its award money to developing drugs for neglected diseases.

The story of how MSF Greece was ostra­cised for unilaterally deciding to enter Kosovo, and its subsequent reintegration into MSF International after eight years of critical analysis, debate and negotiation, sheds additional light on MSF’s organisational values, governance structures and methods of implementing its humanitarian principles.

Prof. Fox’s description of the 2004 ‘La Mancha’ process (named after Don Quixote’s allegorical encounter with powerful forces) portrays deliberations aimed at better defining the basic raison d’etre of MSF and how it should be governed. This process, tog­ether with the consequent La Mancha Agreement, confirmed MSF’s values (as documented in the 1995 Chantilly Agreement), consolidated its mode of operation, and documented its shortcomings and future challenges.

The book concludes with an account of MSF’s 40th anniversary celebration, the reun­ion with some surviving founders, reminiscences about its past activities, and visions for the future.

Prof. Fox’s carefully researched and elo­quently written epic book, remarkably com­pleted and published in her mid-eighties, is a treasured and monumental depiction of MSF’s courageous and persistent commitment to millions of people in distress. Like many volunteers whose lives have been transformed through their work with MSF, those who read this book will be similarly inspired.

Solomon Benatar

Bioethics Centre, University of Cape Town, South Africa, and Joint Centre for Bioethics, University of Toronto, Canada

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