The ethical journey of Doctors Without Borders
Peter Redfield, Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press, 2013. Paperback, 338 pp., €23.99. ISBN: 9780520274853.
There is a growing body of anthropological work analysing humanitarian organizations (see Fassin, 2010). Life in Crisis: The Ethical Journey of Doctors Without Borders,by Peter Redfield, is aligned with this body of work. Drawing on Marcus’s (1995) construct of multisited ethnography to study the international nongovernmental organization (NGO) Médecins Sans Frontières (MSF), or Doctors Without Borders, Redfield pursues the organization across various field sites and office locations. Life in Crisis chronicles the journey of MSF since its formation as an offshoot of the Red Cross Movement in France, to its engagement with saving lives in crisis and emergency situations, to its work with chronic diseases and longer-term humanitarian work in the field. Life in Crisis lays bare MSF’s ethical confrontations: defining whom to save, deciding when to wrap up and leave the field site, and determining what constitutes a crisis or an emergency.
Life in Crisis is divided into three parts. In part one, ‘Terms of Agreement’, Redfield examines how MSF defines its involvement in the field missions that it undertakes. Chapter 1, ‘A Time of Crisis’, illustrates how MSF defines a crisis and its rationale for engaging in particular missions. The award of the Nobel Peace Prize to MSF in 1999 marks a significant episode for the organization and the activities in which it subsequently engages. MSF’s work, like that of other humanitarian organizations, takes place ‘where the political has failed or is in crisis’ (p. 12). While MSF’s work should not be seen as substituting what the state should be doing, by salvaging life, however, and restoring dignity, MSF reinstates the survivor’s ability to choose and demand action from the state. Chapter 2, ‘A Secular Value of Life’, examines how MSF moulds and defines its missions. Redfield describes how ‘witnessing/témoignage’ and ‘speaking out’ slowly take root in the organization, and how MSF attempts to define itself accordingly.
Part two, ‘Global Ambitions’, scrutinizes MSF’s reach and spread worldwide, and the concessions and challenges that MSF makes and faces when implementing its work. MSF’s mobility takes centre stage in ‘Vital Mobility’, chapter 3. MSF distinguishes itself by deploying missions on ‘short notice’ in response to a crisis or emergency. However, mobility necessitates apt preparation, for which MSF formulated and utilizes a universal kit, as well as (mobilizing) sufficient (independent) capital to fund these operations. Like Redfield, anyone employed with or observing MSF will immediately see this ‘aid-in-a-box’ operational on location, whether MSF is caring for maimed refugees or attending to malnutritioned children. Although instrumental for pressing health conditions, the kit is inadequate for expanded assignments. Likewise, devoid of transportation or human resources, MSF is limited at mission sites. In ‘Moral Witness’, chapter 4, MSF is confronted with the moral duty of speaking out against the horrors, injustices, and inhumanity it witnesses at its mission sites. While witnessing, témoignage, is MSF’s collective duty, and speaking out an individual choice, Redfield notes that ‘the entire logic of MSF’s approach to aid revolves around … [MSF]’s operational presence in the field’ (p. 114). In chapter 5, ‘Human Frontiers’, Redfield retraces and recounts MSF’s ability to navigate physical and bureaucratic borders to reach people and transport supplies, because ‘the movement of people and things remains a profoundly public matter’ (p. 128). It is not surprising, then, that encounters with economic dissimilarities between, and within, MSF’s home countries and its mission countries accentuate the chafing and expectations amongst its staff.
Part three, ‘Testing Limits’, encompasses the nitty-gritty of MSF’s ethical labyrinth. MSF grapples to clarify its moral identity given the sheer number of victims needing salvation. Reluctantly, MSF has to make choices, where not all lives can be saved, not all people can be reached. Fittingly, chapter 6, ‘The Problem of Triage’, explores how MSF wrestles with the issue of death. In humanitarian organizations death is viewed as a failure of their work rather than a natural end to life. To die means to not have been selected to be saved, a bitter pill for MSF to swallow. To intervene, MSF occupies what it calls ‘humanitarian space’ (p. 162), an exceptional neutral space in which to offer aid beyond political authority or country borders, creating a catch-22 position for MSF. In chapter 7, ‘The Longue Durée of Disease’, MSF moves uncertainly from one type of emergency to another. MSF essentially engages in short-term missions, yet its reasoning for not engaging with longer-term missions grows indefensible with the breaking of the AIDS crisis with its endless, cureless casualties. Chapter 8, ‘The Verge of Crisis’, describes the (historically) ceaseless obstacle course of ‘near-events’ (pp. 206, 228) by which MSF rationalizes its longer-term missions in Uganda. Longer-term missions also bring members face to face with the country’s history, which was categorically ignored during short-term missions, but one that now must be considered and engaged with when making operational decisions. In chapter 9, ‘Action beyond Optimism’, Redfield questions whether there is more to life than just saving it, in both a rhetorical and literal reflection on MSF’s perpetual dance around hope or detachment, crisis or chronic engagement, complacency or action. Finally, Redfield concludes that MSF remains in perpetual motion, physically and morally.
Life in Crisis brings up questions for which MSF may not readily or unequivocally have the answers. Would national missions within national borders be (more) sustainable if expatriates were not involved? Didier Fassin (2010, 244) makes a more pointed critique of humanitarian organizations, and of MSF in particular, for its ‘claim (to) the sacredness of all lives’ while simultaneously distinguishing between ‘them’ and ‘us’ in a persistent asymmetry of relations between expatriates and national workers. Fassin (2010) describes MSF’s swift departure from its Iraqi mission without having saved a single victim’s life, concerned only with the lives of its two abducted expatriate staff while neglecting that of its employed Iraqi national who had also been abducted. ‘The anthropology of development’, as does Life in Crisis, ‘raises core anthropological questions about human similarity and difference, Western modernity, and the terms of economic (and historical) and cultural integration’ (Mosse 2013, 228).
This links MSF with neocolonial and neodevelopmental organizations, making Life in Crisis a thick description residing distinctly in the present. Skilfully put together, I was rewarded with a rich fabric of concepts and themes. Life in Crisis is a book that will appeal to a wide audience, not only the anthropological. It is an important book for scholars in development studies, perhaps even a prerequisite reader on humanitarianism, philanthropic development studies, globalization, and the anthropology of organizations. I would also recommend it to scholars interested in the breadth and depth of multisited ethnography, not as a methodological script but as a conceptual text.
Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam
Fassin, Didier. 2010. Inequalities of Lives, Hierarchies of Humanity: Moral Commitments and Ethical Dilemmas of Humanitarianism. In In the Name of Humanity: The Government of Threat and Care, edited by I. Feldman and M. Ticktin, 238–55. 1sted. Durham, NC: Duke University Press.
Marcus, George E. 1995. ‘Ethnography in/of the World System: The Emergence of Multi-sited Ethnography’. Annual Review of Anthropology 24: 95–117.
Mosse, David. 2013. ‘The Anthropology of International Development’. Annual Review of Anthropology, 42: 227–46.