1. How did the idea for Life in Crisis: The Ethical Journey of Doctors Without Borders came about? What inspired you?
I had friends who had worked for Médecins Sans Frontières (MSF) so I’d heard about them for some time. I thought it would be an interesting subject in part because the phrase sans frontières — “without borders” — later became a tagline for globalization. Historically this is the group that popularized that expression, if with rather different aims than to open markets. The organization’s core movement in France began to engage a “borderless” world of sorts in the early 1970’s, imagining that doctors should be able to reach patients anywhere, overcoming all barriers. I wanted to look at what it means to practice medicine with this global ambition in mind: How to take biomedicine (i.e. the sort of healing taught in medical schools) and move it anywhere in the world and try to make it work.
I’d also just finished my first book and started to teach at UNC. I was meeting a lot of undergraduates who wanted to do something good in the world — to make a difference, to live a meaningful life. Whether they were actively thinking about it or not, many of them were likely going to work in the world of NGOs, nonprofits, etc. So I wanted to look at such engagement once you put it in practice, into motion. What happens when your great idea actually takes off?
While there have been lots of things written about MSF in French, at the time there was little in English, even at a journalistic level. There was not a great deal of analysis in an anthropological sense (although now there is much more). Over the last dozen years, global health has emerged as a key term. Even the School of Public Health changed its name! Looking at MSF is a way to try and think about global health, or one version of it in practice. To see it in motion over time, to see what it means to try to be global in the most literal sense of direct cross-border mobility as opposed to having “international” relationships in the nation-to-nation sense. Historically, one of MSF’s claims (which is exaggerated but has a kernel of truth) is that the group can go anywhere in the world in 48 hours. That’s the kind of infrastructure for emergency response they sought to realize, and to a certain extent they succeeded. They can go to most places in the world relatively quickly, and as long as everything cooperates — all the people and things — they can set up an operation. There’s a similar conception of the “global” in global health, which tends to focus on particular projects and campaigns as opposed to general system building in a given nation state (unlike the older international health). It likewise generally shares MSF’s secular, medical focus on “saving human lives”. This notion of biomedicine as a response to human suffering reveals complex technical and ethical issues, particularly when cast at a global scale.
I should also note that MSF is no longer really a French organization; it became European in the 1980s and has increasingly grown transnational. Indeed the French part is a minority at this point. The dominant language across MSF has increasingly become English, which is also the dominant language of aid, trade etc., often in an asymmetrical way. At the same time most people involved with the group believe strongly in human equality, value diversity and don’t want to mimic colonial empire. So there are several kinds of globalization at work, not all of which neatly line up. That’s anthropologically interesting.
2. In undertaking the research, what were the practical and intellectual challenges you found when engaging with MSF?
I encountered the general challenge of trying to do any ethnographic work about a large-scale problem. Ethnography traditionally focused at the village level in face-to-face societies, where a single person could get to know some representative sample through personal engagement. This is much harder to do when talking about any spatially dispersed phenomenon. So how to get what is valuable about ethnography — a sense of depth and perspective that runs deeper than surveys or other kinds of methodologies? Even figuring out where to begin was a challenge (there’s an article by George Marcus on “multi-sited ethnography” that discusses some of these issues). I decided to make MSF the central object of study, given that its organization takes a global form. That was the unit I would use to decide what was “in” and what was “out” of field of research. It was still very broad, but it was helpful. Next, I would try to look at the group historically and through time, which was possible through oral histories and documents. The main problem was that I still had too much potential information, so I continually had to figure out how to limit it. The third challenge was where to go, amid all the possibilities on MSF’s map? I started visiting some of their main offices, in New York, Paris, Brussels, Amsterdam, Geneva…and then I went to visit field projects in Uganda.
Uganda was not a country that I knew much about, as I had not trained as an Africanist. However, I chose it because I had good connections there outside of MSF, friends who could help me navigate and make sense of the general milieu. Serendipitously, Uganda proved a good choice. I wanted a broad view and it borders many issues in MSF’s world. Geographically the country is located in the center of sub-Saharan Africa. When you look at humanitarian aid statistically, this is the core region in all kinds of complicated ways. Unlike some of its neighbors, however, Uganda does not have one obvious crisis. Rather, it has multiple potential ones. During the early years of the last decade there were probably more than a million people living in displacement camps in the north. At the same time Uganda has a big profile in the HIV/AIDS world. It has emerging disease like ebola, as well as classic ones like malaria and sleeping sickness. MSF was doing epidemiological work there, as well as running a whole range of clinical programs.
Uganda was also relatively stable and an easy place to travel, which is one reason there are so many aid programs there. The primary language of exchange and education is English — in different regions people speak different languages — so I could follow a lot more of what was going on (I could also speak and understand French, which was essential for other parts of the project). Language is important for ethnography. One of the down sides of global health, from the perspective of medical anthropology, is that it often pays too little attention to language or history. Now short-term intervention can make sense in a true emergency context; if someone is bleeding out you need to act quickly to keep that person alive. But it’s a poor metaphor for health in general. Care, even biomedical care, requires communication to be effective. Yet all too often now there’s a devaluing of long-term knowledge, extended engagement and language skills. Whether or not you can communicate and how you communicate — these should be essential questions for any global health project. Especially once you get out of privileged settings to marginal populations, it’s particularly important to learn the language and develop a sense of history to really grasp the worldview. I say all this with a degree of irony, since that was beyond my abilities here. I was following this group, and trying to learn about the aid world, concepts of crisis, the history of humanitarianism etc. So there were limitations to what I could do. As a consequence one thing largely missing from the book is the perspective of people who are at the receiving end of these efforts. The patients I heard from most were in AIDS projects, which is a particular kind of care. Of course it would have required a team of multilingual people to present a really global set of voices.
Actually MSF recently sponsored its own study along these lines (http://www.doctorswithoutborders.org/publications/book/perceptions/). Anthropology teaches us that not everyone sees encounters the same way, and indeed that’s what they found. For example, MSF is a secular organization and its members often have long, complicated ethical and political explanations of why they are doing what they are doing. However, many people in the world view human motivation through religious cosmologies. They thus see the actions of aid workers as involving other forces of the universe, not just human intentions. It came as a bit of a shock to MSF to realize how little of its elaborate reasoning translated. From the perspective of anthropology that’s actually an encouraging development.
3. What was the most fun part?
We commonly dissociate fun from work, forgetting that work can be fun in its own way, even when difficult or challenging. That was much the case here. In some respects I was actually surprised by how easy it was to pursue this research. MSF has a tradition of being critical about what it is doing, and many of the people who work with the organization clearly embrace that. They have lots of critical things to say, and it wasn’t hard to gather material. I had some initial connections to start with, and the people I met introduced me to still others (the fancy term is “snowball sampling”). So along the way I had many thoughtful and detailed conversations. They also generate tons of documents and were quite generous in sharing them.
At the same time the topic itself was rarely easy. Almost everyone in MSF is troubled in one way or another. That’s no surprise, since it’s often troubling work and the situations where they find themselves are by definition frequently chaotic. These are places where people are dying unnecessarily, dying because as one person put it, “because other people decided they are expendable.” If you’re continually facing that on a frontline it can be quite disturbing. The world is not always a very happy place, and when you confront these issues seriously it only gets harder, as there aren’t simple solutions in practice. And yet this is precisely what inspires many people who want to study health professions, not just a desire to have a recognizable career, but wanting to make a difference. It’s a trite phrase, but still means something. Many of the people who work for MSF and similar organizations choose this path because it seems more real to them, not just focusing on ways to make money, but providing medical care. That’s a simple, compelling moral vision. It has dangers of romanticization, of course, and when people find themselves unable to simply fulfill it they often grow frustrated. There’s a lot of dark humor in the aid world, which is funny and tragic at the same time.
4. What questions does the book answer what what questions does it raise?
If you decide that human life is a valuable thing, all over the world, then what do you do? One response, the one given by medical humanitarianism, is to try and prevent people from dying needlessly, of “stupid things” as MSF (or Paul Farmer) would say. Politics and everything else aside, ethically you can say that some kid should not die because they were born in a poor place, or because of a lack of medication, or being randomly hit by a bullet etc. Ethically this is unjust and unfair, right? And that’s the basic motive for this form of humanitarianism, the notion that people should not suffer unnecessarily. The book follows a group that takes this perspective — that human life has fundamental value — and seeks to “save it” around the world in crisis settings. Anyone, anywhere who needs a doctor should have one. That’s a beautiful, simple idea.
Saving lives also seems concrete and immediate. In an unjust world you can try to change things through grand projects in the name of utopian goals, and movements for social justice. If you look at political history you’ll find many inspiring and noble visions. But they don’t always succeed, and even if they were to, they’d be unlikely to help people stuck in the present. Conversely, you can try to ameliorate some human suffering directly, right now. Your response then may be limited — very limited! — but it feels tangible and immediate. That’s part of the appeal of humanitarianism, and also of medicine. The reason why MSF started was that a number of doctors and journalists in France were searching for a meaningful way to engage the world. They had different backgrounds and motives, but shared a sense of disillusionment with the status quo. This was the early 1970’s, following a period of great change and upheaval in much of Europe as well as elsewhere. Many of them had been politically engaged but had grown frustrated with leftist politics, and others had worked for the Red Cross and wanted a different kind of humanitarian organization. The details are more complicated than the version of the myth I’m giving you, but the myth is still telling. Medicine offered an alternative that appeared morally clear. You could respond to some of the problems of the world, the problems that year after year weren’t being solved, by being a doctor. A doctor “without borders.” It wouldn’t fix everything, of course, but if you were a doctor and unafraid to both act and speak the truth, then at least you were doing something good. You had technical knowledge, so you could intervene in defense of human life. All of this frustration and saving lives seems like a pure and appealing idea. How can you be against it?
But then what happens to that beautiful idea in practice? Well, it opens up a lot of complications. There are both ethical and technical challenges in trying to practice medicine worldwide. At a technical level biomedicine relies on a lot of equipment, background infrastructure as well as medical machinery. There are a lot of expectations built in to protocols that may not apply in other parts of the world. Technically, how do you face these challenges? At the same time there are even more ethical complications. If you have general capacity to provide care, then what do you do and what don’t you do? Where do you choose to work? If you are going to be “sans frontières” where do you go? What problems do you respond to? And at what point do you stop responding, even if the work isn’t all done, because there’s another problem that you feel is worse?
Navigating between all these questions isn’t easy. Do you focus on emergency conditions? For most of its history emergency response provided MSF with its main rationale. They saw themselves as working in conflict settings or in response to disaster, running clinics in refugee camps and the like. Emergency provided moral clarity — in theory at least. In an emergency you need urgent action. But what about all the other forms of needless suffering? What about HIV/AIDS, for example? For a long time MSF avoided AIDS work. But then in the late 1990s they decided they would be part of a larger movement to show that antiretroviral medications could be used worldwide. Now they have some 200,000 people on ARVs (http://www.msfaccess.org/our-work/hiv-aids). That sort of treatment has a very different timeline than a classic emergency, and an even less clear exit strategy. Where do you open a project? Where don’t you open a project? When do you close one? How do you decide what happens with this beautiful simple idea of saving lives in these constantly complicated situations, where you have to make choices and face many demands at once?
There’s also the question of how you pay for things. Any operational organization needs to think about this, whether state, profit, or non-profit. MSF now has a budget of around a billion dollars a year, most of it raised from personal donations. Over time they decided to focus on raising money from the general public rather than taking money from states so that they would be more independent and less compromised by state politics, especially in conflict settings. By and large they’ve been very successful with this strategy. However, it means you have to be able to convince the general public to contribute, over and over. For the most part MSF and similar groups do so by focusing on emergencies, since people respond to them. Natural disasters in a scenic part of the world that affect children are particularly good. The best advertisement you can use is the sad-eyed child. Everyone involved in this knows that this is a very complicated thing, but it’s effective. It’s really hard to raise money with long, complicated explanations or pointing at problems that seem ongoing. And if you want to keep programs going, you need money.
Money also enters into the picture with respect to human relations. People who work for MSF tend to have egalitarian desires; they want everyone to be relatively equal. Collectively the organization questions itself, and yet when you look at the patterns there is a lot of inequality. In effect you have expats who circulate and local staff who are hired to a job in their national country. What are the different motivations? How much do you pay someone? If you pay too much it becomes a lucrative job, which can appear ethically dubious. But if you don’t pay someone anything at all for volunteering, then only people who are wealthy enough can do it. This becomes all the more complicated at a global level, when you have people crossing economies. A modest stipend in one setting can be a nice salary in another. Alternatively if you don’t move people, only funds — sending donations “directly” — then where do you send them? To whom? How do you know who’s trustworthy? That anything actually gets done? This can be particularly tricky in emergency settings, which was MSF’s formative environment. Their organization reflects a certain logic. But at every turn, how do you know that this is the right thing to do? How do you know you are not causing more problems than you are solving? At the same time you constantly have to make decisions. So as you see there are lots of questions, and few simple answers! It’s a messy world.
At the very end of the book, I try to think about hope and what that might mean looking at an organization like this. MSF is not a cheery happy go lucky kind of group by any means. Their collective vision of the world is fairly dark, and yet they also insist on doing something. Often when you talk critically about issues or point out difficulties, people will say “oh, it’s too depressing!” and throw up their hands. But MSF is dedicated to action — indeed their ethics are all about action. So what does action look like when it’s NOT about optimism, when it doesn’t paint a rosy picture of the world? That’s the story I try to tell, using the perspective of this one organization.
5. This idea of hope is something that people can relate to. So who was your audience(s) and how did you write for them?
Originally I wanted to write a book that undergraduates could read. I also wanted something at least partly accessible to aid workers and health care professionals who are interested in doing volunteer work for any organizations. It’s an academic book and ultimately the questions are quite philosophical. But I’ve always cared about writing, and wanted to provide a way in for anyone concerned about the issues it addresses. MSF has a commitment to critical reflection — that’s one way it’s an unusual organization — and I saw this project as reflecting that. I had the luxury of being an academic with a position outside the organization. I could do this project slowly and think about things that are hard to think about if you’re caught up in rushing around delivering aid. Why do we want to save lives, for instance? What motivates this? Not that I’m against trying to reduce human suffering, mind you, but if you consider medical humanitarianism as an anthropologist it becomes pretty clear it’s not timeless, or the only way to engage the world. In places like the U.S. we talk so much about life and death as a way of indicating value. But how do we imagine these lives? What do we mean by saving them? What does it mean to “save” a life, but not provide someone with the means to live a life afterwards? How did we come to focus so much on medicine and health? If you’re in an organization like MSF, it’s harder to ask such questions. They seem like abstract concerns when facing particular problems and particular people. But at the same time this sort of humanitarianism gets caught up in all kinds of grand, abstract discussions of the good and the bad. It’s on the edge between politics and ethics. It embodies moral feeling and religious tradition, even if it’s secular and medical.
This brings me to another audience I had in mind, academics who are thinking about activism and engagement. MSF sees itself as acting under the name of ethics, not politics, even though it responds to political failures and has a lot of political implications. The group insists it offers no political solution, just an ethical response. But whatever else it’s a form of action, very direct public action. So my goal was to look at humanitarianism in practice, that is to follow it ethnographically rather than arguing about it abstractly. Also with regard to anthropology and people who study science, technology and medicine, I wanted to write about how biomedicine travels. Which kinds of treatment move more or less easily and what sort of equipment does it take? I had to take several detours in this project to investigate parts of the background of MSF, for example the history of emergency medicine as relatively recent norm, largely coming out of the longer tradition of military medicine. Now we have emergency rooms and emergency kits all over the place, reinforcing this notion that you can intervene very quickly and fix something. There is absolutely nothing wrong with band-aids or first aid kits, of course, but it’s always important to recognize they aren’t saving the world — just patching up little bits here and there. In any case, following MSF in detail makes it clear how complicated it can be for medicine to move, and that “biomedicine” itself is a complex, plural form.
So I wanted to write in an accessible language for several audiences, while at the same time talking about serious issues. That’s not always easy, since professional language is full of specialized terms that seems like jargon when you’re outside of it. That’s why you go to medical or law school, after all, to learn a technical language, and it’s true with any subject. So it’s difficult to write in a way that is accessible and at the same time deal with complicated issues as understood by the professionals who study them. In writing this book my ambition was to try and juggle all this through description. That’s why I decided to tell the story of MSF as a sort of coming of age story, one organization’s coming of age while trying to engage world. As to whether or not that worked, well, readers will have to judge!
6. What advice do you have for current and future humanitarians and activists?
Anthropologists are never very good at answering questions like that, except with complicated evasions and footnotes. Anthropology doesn’t equip you to give very general advice; you can give very specific commentary about a particular locale, issue, or problem or you can raise general questions about the assumptions that frame them.
But since at the moment lots of people want to respond to problems in the world by creating an organization I’ll try to say a few things. First, as well as thinking about a problem, try to think also about its limits. Part of the lesson of MSF is that if you call yourself “without borders” it means you’re going to have to find your own, because where do you stop if there is not a border? You need to define some limit precisely so that you know where to go. The phrase sans frontières is often read as expansive ambition, but in actual practice it produces a continual debate about what is or isn’t appropriate to do. So pay attention to limits on ideas, projects, responsibilities, ambitions as well as the possibilities they open up. In any project where do people refer to larger moral ambitions? And where do they insist on practicality? Neither is simply a given. Second, before you go somewhere do try to learn about it, rather than assuming you know what’s going on. Even when you are being global, you are always somewhere. Even when you are living the most ex-pat of expat lives with the fewest connections to a locale you’re still there! Again, one of the most important legacies of anthropology is the insistence that things like history, language, and place matter even if they aren’t immediately obvious. Medical anthropology deals not just with esoteric issues at the edge of contemporary medicine, but also ones that are central to it and its anxieties. So it’s a great place to start if you’re interested in global health. Technical skills are essential if you want to get anything done, but they’re never sufficient for understanding what you’re actually doing or why it might or might not be a good idea. Third (although maybe I should have this first!) keep in mind you may not be the first person to engage with this problem. Look to see if there are existing organizations, and a history of action and intervention rather than assuming nothing has come before. There’s no shortage of problems by any means, but sometimes there’s also no shortage of efforts to respond to them. So engage as seriously as you can, find out as much as you can, work as hard as you can, and think as critically as you can, including about your own assumptions.
7. With all of these lessons learned, what happens now? What is next for you?
I’ve started doing a bit or research on humanitarian design, that is efforts to try to create something to improve the world at the very basic level of fostering human survival. There are lots of new gadgets emerging for resource poor settings (to use a favored euphemism) — for poor people in poor places. For example, building an incubator that you can run on solar power, or a low budget water filtration system. It’s an effort to solve problems at a small scale, with a magic bullet. Like any anthropologist, I’m skeptical and want to insist in the importance of history and politics, in what we call context. But I’m also interested in what magic bullets actually do, the sorts of technological visions they represent and their effects in practice. Some of this is an older dream of appropriate technology, but there are new twists. In particular I want to focus on medical or quasi-medical aspects of infrastructure. What do you feed children who are suffering from malnutrition? How do you deal with sanitation or water systems? How do you deal with these aspects of life that involve basic terms of public health? I want to follow some of these efforts to see how people are imagining problems and responses in ways that may differ from the past, and then look at what emerges in the messy world of actual experience.
I’m also hoping to do some of this in a collaborative fashion. If there’s one thing I learned from writing this MSF book, it was the limits of one person trying to study far-flung contemporary issues! There are lots of topics where exchanges and collaboration can be very fruitful, especially if trying to examine something seriously and critically, but without dismissing it out of hand. Ultimately I see anthropology in general as a collaborative project.