Life in Crisis tells the story of Médecins Sans Frontières (Doctors Without Borders or MSF) and its effort to “save lives” on a global scale. Begun in 1971 as a French alternative to the Red Cross, the MSF has grown into an international institution with a reputation for outspoken protest as well as technical efficiency. It has also expanded beyond emergency response, providing for a wider range of endeavors, including AIDS care. Yet its seemingly simple ethical goal proves deeply complex in practice. MSF continually faces the problem of defining its own limits. Its minimalist form of care recalls the promise of state welfare, but without political resolution or a sense of well-being beyond health and survival. Lacking utopian certainty, the group struggles when the moral clarity of crisis fades. Nevertheless, it continues to take action and innovate. Its organizational history illustrates both the logic and the tensions of casting humanitarian medicine into a leading role in international affairs.
Life in Crisis The Ethical Journey of Doctors Without Borders
A Time of Crisis
Our action is to help people in situations of crisis. And ours is not a contented action.
MSF, Nobel Peace Prize acceptance speech, 1999
The Nobel Dream
On October 15, 1999, the Norwegian Nobel committee announced the last Peace Prize of the twentieth century. It would go, the committee proclaimed with customary fanfare, to the organization Médecins Sans Frontières. Known in English as Doctors Without Borders and in the acronym-friendly aid world as MSF, this group was, strictly speaking, focused on medical humanitarianism rather than peace. Nonetheless, the committee noted the distinctive independence MSF brought to disaster settings. By intervening swiftly and calling public attention to abuses of power, it suggested, MSF's action inspired at least a glimmer of a brighter future. "In critical situations, marked by violence and brutality, the humanitarian work of Médecins Sans Frontières enables the organization to create openings for contacts between the opposed parties," read the citation. "At the same time, each fearless and self-sacrificing helper shows each victim a human face, stands for respect for that person's dignity, and is a source of hope for peace and reconciliation." The award hardly came as a complete surprise. MSF fit a long lineage of humanitarian laureates and had received nominations for a number of years. Indeed, given that the founder of the Red Cross movement had shared the very first prize in 1901, it seemed fitting to end the century on a parallel note. What better way to frame a bloody, violent era than with variants on the red and white symbols of medical care?
As usual with the annual Nobel ritual, a flurry of news reports, mostly laudatory, profiled the committee's choice. Since MSF originated in France, the French press went into a particular paroxysm of celebration. To the annoyance of MSF's current members, considerable attention was focused on Bernard Kouchner, one of the group's founders who had subsequently become a significant European political figure. Many reports emphasized Kouchner's signature issue-the doit d'ingérence, or right to intervene on humanitarian grounds-a concept that his successors at MSF had increasingly disavowed even as variants materialized in international precedent. Alongside gauzy allusions to peace and hints of civilizing redemption, the accounts predictably emphasized national pride: this was France's great gesture of civil society, its response to Britain's Amnesty International and Switzerland's Red Cross. At the same time, the reviews skirted more controversial moments in the group's history, including the still-raw wounds of Rwanda. As congratulatory letters poured in, celebration, not controversy, was the order of the day. For its part MSF basked in the attention, worried about how to respond appropriately, and debated what to do with the prize money.
December saw an award ceremony in Oslo, where representatives of the organization frantically drafted a final version of their collective address and donned special T-shirts to silently protest the Russian bombing of the Chechen capital Grozny. The speech sought to outline MSF's humanitarian vision and concerns, drawing a sharp distinction between MSF's actions and those of a state. "Humanitarianism occurs where the political has failed or is in crisis," it proclaimed, rejecting humanitarian justifications for political agendas. MSF's action was a struggle, and its independence included a right to witness and speak out. The T-shirt protest and subsequent march to the Russian embassy sought to exemplify this at a moment of heightened exposure. Although the small gesture drew no immediate response, the BBC subsequently announced that the Russian government had extended an ultimatum in the conflict, expressing concern about civilian suffering. As for the prize itself, MSF decided to invest the funds in its new initiative to combat neglected diseases and its campaign for greater access to essential medicines worldwide. The celebratory mood continued though the final midnight of the year, when a young doctor from the group officially dropped the ball in New York's Times Square, ushering in a new millennium.
For all its obvious and sanctimonious pomp, the Nobel moment marked a watershed for MSF. Once considered a youthful and ragtag oppositional movement, the organization had grown into a fixture of international relief efforts and garnered official approval. Le monde, France's most established daily, described the group's mythic trajectory out of Nigeria's Biafran uprising as "the challenges of a generation." Other reports cited Paris's own turmoil in 1968, while Montreal's English-language Gazette, decrying the "humanitarian occupation of Third World countries," offered a more biting formulation: "Medical hippies go mainstream." At the opposite end of the spectrum a cartoon in a French satirical publication showed a young doctor returning to his stuffy, bourgeois parents, who wondered why he couldn't have received the medical prize instead. Nearing thirty, MSF had clearly come of age. What was less clear was whether or not the group would experience some sort of midlife crisis, growing complacent, as some of its adherents feared, or preserving the status quo, as some of its critics charged. Had humanitarian action-even in its outspoken and independent form-grown routine?
At the time of the Nobel announcement I was already curious about Médecins Sans Frontières. Like many people I was familiar with the group's fundraising efforts, having received its solicitations from time to time. I also knew people who had worked for them. The name intrigued me, since the phrase "without borders" had grown synonymous with global mobility. Moreover, the humanitarian focus on saving lives suggested a universal appeal: minimal morality through emergency care. At the same time, MSF practiced medicine. The group's members not only spoke, but also acted, mounting complex missions in diverse settings. Their collective work combined technology and morality with a practical form of anthropology, defining and contesting a sense of humanity worldwide. This was indeed an attempt at global medicine.
Memoirs aside, much of the writing about nongovernmental organizations I could find at the time dealt with the topic from a methodological or theoretical remove. Some analysts surveyed a range of groups to create comparative models. Others positioned the recent prominence of civil society and the NGO form within a larger framework of neoliberal reform and privatized welfare. I sought a view closer to the ground, one involving historical detail and the loose ends of experience, albeit one more systematic than an individual memoir. For an anthropologist of my generation and orientation, what people did mattered as much as what they said. I knew MSF was venturing into new areas, such as the above-mentioned pharmaceutical campaign, and a major effort to treat AIDS. Before addressing those developments, however, I wanted to grasp the group's traditional customs and habits. The first task of studying this NGO, then, would be to examine its call to arms and vision for action.
In the Nobel address, MSF defined its mission as helping "people in situations of crisis," quickly adding that this endeavor was not "contented." Beyond a general principle of the alleviation of suffering, then, the group's version of humanitarianism clearly depended on a concept of crisis. The life that MSF sought to save was not an ordinary one, in the sense of being burdened by everyday complaints. Rather it was the life located in an exceptional state of risk. Indeed, a persistent sense of urgency infused all of MSF's rhetoric and work. Although the group may have devoted its prize money to a new initiative for pharmaceutical equity, the Nobel citation reflected MSF's central public image: an emergency room team, on call worldwide. As I soon discovered, the details beneath that image proved more complex: the group included volunteer nurses, engineers, and administrators alongside doctors, relied on an army of local employees to perform a considerable part of the actual labor, and had grown to conduct a diverse range of missions. Nonetheless, the emergency idiom captured the organization's essential ethos.
Both crisis and emergency are native terms for MSF. Whereas the first indicates a critical condition or conjuncture, often including social and political contexts, the second references a more specific set of problems requiring rapid medical response. In this work I will largely adhere to MSF's distinction. Moreover, I suggest that the line that distinguishes emergency from the more fluid concept of crisis raises unsettling questions about the group's humanitarian rationale and purpose. While emergency missions may no longer be the norm, they still represent a self-consciously "classic" form of action within MSF. Not every member may dream of being "eight to a tent in the Congo," as one veteran put it to me in Kampala in 2003, but such dramatic conditions remain romantic points of reference for the collective, and a sense of urgency courses through most of the group's rhetoric. To quote another of its former adherents, MSF "couldn't survive without the word emergency." At the same time, the organization addresses a wider field of problems, not all of which fit into an ambulance. As I detail later, AIDS and pharmaceutical equity are certainly crises from MSF's perspective, but they are not exactly emergencies. Both terms, however, prioritize the present over the past and the future. Moreover, they suggest a state of rupture and through it an imperative need for action: something must be done and done quickly. In this sense disaster-not development-lies at the heart of the organization. "We are much more attached to the notion of crisis," the French section's communications director told me in 2003, describing the group's particular niche in the wider aid complex. "A community has developed in its own particular way, encounters a moment of crisis, so we help them face it and then move on." In this formulation at least, humanitarianism has come to define itself through exception.
Life in Crisis
In the fall of 2000, MSF brought a traveling exhibit to several sites in greater New York and Los Angeles. Part of a special publicity campaign on behalf of displaced people entitled "A Refugee Camp in the Heart of the City," it featured a model camp that could be moved and displayed in any public venue. At each stop the exhibit also served as a de facto reunion for former aid workers, who came together both to raise public awareness and to see old comrades and like-minded souls. Staff at MSF's New York office assured me it would make for an excellent entrée into their world. Thus on a beautiful September morning I found myself in Central Park, the light clear and bright as it filtered through the buildings. A small group of MSF veterans milled about before a temporary enclosure, white shirts emblazoned with a bright red insignia. Throughout the day, they issued identity cards to a growing stream of visitors, shepherding them through a circle of structures representing a simulated refugee camp: tents and prefabricated huts, a mobile clinic, and a mock latrine.
This was a year before New York itself would experience the immediacy of disaster and five years before Hurricane Katrina would strike New Orleans. The images of panicked, fleeing people appeared comfortably remote, a problem of elsewhere. The camp here was a model, after all, meant to convey the gist of the humanitarian labor involved in caring for displaced populations to those who had only encountered glimpses of such things on television. Led by aid workers, including some former refugees, the tours offered another experiential reminder of human suffering and need through a display of the materials used to respond to them. In the name of research, I went on several tours over the course of the day. Although each varied in detail and emphasis according to the background and personality of the person leading it, the general pattern remained. The first section of the exhibit illustrated basic needs: shelter in the form of simple tents adapted to different climates, water purification in the form of a giant bladder dispensing five gallons per person per day, food in the form of compact bars providing 2,100 calories, and finally hygiene in the form of a latrine (the "VIP version") that was equipped with both a folk painting about hand washing and an ingenious method of trapping flies. To one side hung a small poster about mental health and trauma and beyond lay the medical zone, featuring a model clinic, a weighing station and vaccination center, and finally a cholera exclusion area. The tour closed with a depiction of land mines and a photographic testimonial to the plight of refugees.
As the press release for the event noted, the core of the exhibit emphasized "basic elements" of refugee existence. Here was a panorama of survival, in all its measured essence. When confronted by emergency, people's lives shrank to elemental, species-level needs: a place to stay, some means of sustenance, and collective cleanliness. Without these they would suffer, fall ill, or even die. At moments of crisis, the exhibit made clear, life itself was on the line. Humanitarian concern, therefore, focused on providing temporary substitutes for immediate necessities. Longer-term issues, although recognized, remained on the sidelines.
The choice of a refugee camp for MSF's publicity campaign was far from arbitrary. Rather, it reflected the setting within which the group had emerged and subsequently developed much of its equipment, experience, customs, and mores. As a medical organization it focused primarily on health concerns. Although MSF might offer shelter, food, or water if conditions required, its real expertise lay in the clinical areas of camp life, assessing nutrition, offering basic treatment, and dispensing health advice. Even if the group's activities now extended well beyond camp settings, its sensibilities remained those of urgent care. Medicine here centered on patients with pressing needs and prioritized rapid treatment. Although the patients experienced common conditions, they remained individual in the sense that one could not simply be substituted for another.
The official press kit for the exhibit provided ample and graphic evidence of the refugee experience. Beyond images, testimonial accounts, and a fact sheet, it offered a sample emergency nutritional biscuit and a swatch of the plastic sheeting commonly used in camps. It also included one of MSF's simplest instruments-a thin paper strip that the attached publicity card dubbed "The Bracelet of Life." As the card explained, the strip could be used to measure the middle upper arm circumference of children below the age of five. When looped and pulled tight it gave a quick indication of nutritional health, expressed both as a numerical measure and a declining gradation of colors: green, yellow, orange, and red. Inexpensive, easily replaced, and simple to use, it was an elegant tool for triage and assessment during famine. The bracelet appeared a fascinating triumph of design. It also rendered most acutely a central dilemma confronted by MSF and similar organizations. Life, on this strip of paper, became most visible at the red end of the spectrum. There, existence itself was on the line. By contrast, the green reading indicated the absence of just one form of stress, not a secure childhood. Existence might be safe from starvation, but the significant gap between distress and happiness remained a cipher.
At the close of the 1950s the political philosopher Hannah Arendt suggested the term life might have more than one meaning. She drew a distinction between the cyclical life shared by all species, in which birth and death occur in repetitive patterns, and the linear life narrated by humans as a directional story, in which birth and death mark beginning and end. Citing Aristotle, she suggested that the gap between them reflected two Greek terms for life, zoe and bios, the respective roots of the contemporary English terms zoology and biography. Decades later other thinkers would take up Arendt's distinction and elaborate on the broader problem of life and politics. We will return to some of these elaborations shortly. For the moment, however, the key thing to note is that MSF's bracelet belongs more to the cyclical realm of existence than to the narrative realm of life beyond it. "Saving lives" surely addresses living in the sense of biological survival, but not always life in the sense of living well or, as the expression goes, "having a life."
Although measuring a state of zoe far more than bios, the Bracelet of Life still tells a story of sorts. MSF members often cite nutritional work as an example of gratifying humanitarian experience, since children who remain above a threshold of survival recover with satisfying regularity once carefully fed. But they also describe frustration, recalling instances when patients would return for a second visit, their bodies withered anew by the same conditions that brought them to therapy in the first place. MSF cannot offer a happy ending, only sporadic attention to cruelly thin arms and the potential for short-term gain in the shape of specially formulated foods. It may be better than nothing for the chosen few, certainly, but hardly an ideal basis for a full life. Even recent initiatives to widen the availability of therapeutic foods define themselves against present realities, not future utopias. Humanitarianism of this sort is a stopgap gesture, as MSF's Nobel address sought to stress. It remains troubling work precisely because it responds to failure without offering a comprehensive solution. Lives are sustained and prolonged, more than they are "saved" in any final sense. Survival, after all, is a perpetually temporary outcome.
The facts of survival often prove uncomfortable-even undignified-when viewed outside of urgent contexts. Of all the exhibits in the model refugee camp, the sanitation equipment evoked perhaps the strongest response, at least in a country known for lavish lavatories. This was exemplified by one reaction I witnessed:
Two young men join the same group that I do. Their appearance and behavior exude an air of cool indifference. A simple concrete block, molded to include the impressions of two feet and a hole for a wooden pole captures their attention, however. The purpose of this artifact begins to dawn on one of them even before our guide launches into describing the dynamics of a temporary pit latrine. "No way," the young man says loudly, staring at it in incredulity. Absorbing the rawness of physical need that it reflects he then steps backward, one hand raised in emphatic rejection. "No way!"
In recounting this anecdote to academic audiences, I discovered they too could find latrines disturbing. The technical considerations of what to do with human waste, although an urgent problem in the case of a sudden influx of people in an emergency, fit poorly into discussions of the lives of political subjects. Moreover, they resonated awkwardly in portrayals of parts of the world frequently associated with suffering and material lack. A latrine was not-at this level of discussion, at least-"empowering." It required delicate positioning to be mentionable, let alone a point of focus.
Humanitarian organizations such as MSF do care deeply about something they call "dignity." They refer to it frequently as a fundamental aspect of humanity, gesturing to it as a rhetorical ideal and denouncing its absence in particular contexts. Life for them thus certainly involves more than survival. A spirit of urgency, however, fuels their actual interventions, which therefore continue to foreground immediate existence. Outbreaks of infectious diseases like cholera haunt crowded settings with poor hygiene, resulting in predictable deaths. Sanitation therefore remains a fundamental part of most aid projects with a public health focus. MSF's ideal might be the VIP latrine, enclosed and free of flies. But if necessary its members are prepared to construct an open pit, shifting its stations, digging and backfilling repeatedly until a better system can be constructed. Survival, in this sense, is ever primary. Dignity remains a secondary consideration, a deeper matter of human recognition that might endure temporary, superficial embarrassment.
The construction of modest artifacts like latrines might appear well removed from the grander terrain of politics. However, modern forms of government actually devote considerable attention to such details. A contemporary state faces implicit and explicit expectations regarding the welfare of its population. Beyond projects such as roads or canals, public works now involve a much broader range of oversight, planning, and regulation. Even most poor and weak governments produce statistics about the well-being of their respective populations, and if they do not, then others do it for them. Birth rates, death rates, infant mortality, life expectancy, and health expenditure all find their measure. So too do more complex statistical artifacts, such as the disability-adjusted life year (DALY), an effort to indicate relative disease burden and compare conditions by calculating "the loss of the equivalent of one year of full health." Infrastructure grows painfully visible when absent, particularly health infrastructure and the availability of care for treatable maladies. Life, in the sense of zoe, biological existence, has become a subject for constant accounting. Moments of crisis are thus not only readily apparent but find articulation through a language of health. The frame of a refugee camp both circumscribes a displaced population and reanimates its political significance through an economy of needs.
To situate MSF's work within this larger field of expectations, I extend an element of theoretical framing. Shortly after the organization was founded, the French thinker Michel Foucault underlined the growing significance of life processes in politics. He introduced the term biopower to describe the manner in which facts of existence became the focus of specific operations of government in eighteenth- and nineteenth-century Europe. Birth rates, public hygiene, and the regulation of sexual acts emerged as potential affairs of state and soon became the preoccupation of new cadres of experts. As Foucault famously summarized the shift: "One might say that the ancient right to take life or let live was replaced by a power to foster life or disallow it to the point of death." The tools of politics, in other words, would now include finer instruments than a sword.To govern, and not simply rule, any legitimate sovereign needed a growing cadre of experts.
To the extent that MSF provides for basic needs-supplying shelter, food, water, sanitation, and medicine, urging a population to practice better hygiene-its work involves contemporary functions of governing, if on a minimal, immediate scale. In Foucault's formulation the group is fostering life, and thereby participating in the form of politics that such an endeavor entails. At the same time, however, MSF does not seek anything like sovereignty and rejects conventional claims to power. Like most nongovernmental organizations, it operates to one side of politics, claiming ethical motivation and justification for its work. In MSF's case the group's members frame their humanitarian response to suffering as what the Nobel speech termed an "ethic of refusal." In this formulation, action responds to outrage and derives from indignation as much as pity. Unequivocal and antagonistic, such action rejects any justification for either cruelty or neglect. Its adherents view it as an exceptional undertaking, a rejoinder to political failure that resists both the assumptions of charity and the temptations of rule. The goal, as the Nobel speech summarizes it, is to "build spaces of normalcy in the midst of what is profoundly abnormal."
In this respect the group echoes the classic appeal of a humanitarianism rooted in war: responding to a moment of suffering that appears both exceptional and gratuitous. For Henri Dunant, the devout prophet of the Red Cross movement, it was groaning men on the battlefield of Solferino as they expired from lack of water, loss of blood, or a scavenger's knife. For some founders of Médecins Sans Frontières it was emaciated children, caught in the dwindling rebel enclave during the wretched excesses of the Biafran revolt in Nigeria. An immediacy of revulsion reverberates through this humanitarian stream, implicating both the suffering itself and the conditions that allowed it to occur. But this very immediacy also limits political range. The Red Cross effectively sought to civilize war, not end it. MSF may strive to enable individuals to "regain their rights and dignity as human beings," but it prescribes no particular path for doing so. In both instances the emphasis rests on exceptional suffering. The lives in question are those currently in danger, not the legacy of ancestors or the prospects of future generations. The present thus expands to fill time forward and backward.
Recently, the Italian philosopher Giorgio Agamben has extended questions about life and politics to issues of sovereignty and legal exception. Modifying and redirecting Foucault's vision with a central element from that of German political theorist Carl Schmitt, Agamben suggests that the state of exception provides a key form for sovereign rule. As he writes, the exception constitutes a "no-man's-land between public law and political fact, and between the juridical order and life"-a productive limit intimately tied to civil war, insurrection, and resistance. In keeping with Schmitt's dictum, it is precisely this limit that reveals sovereign power, since the one who designates the state of exception stands beyond law. Agamben returns to Arendt's distinction between Greek terms for life, and focuses on the lower threshold of human possibility: naked, formless existence. Tracing a lineage from Auschwitz back to ancient Roman law, he perceives a seed of violence buried deep within the very political tradition that sought to define civility: the designation of those living in exception, whose killing does not constitute a sacrifice. From this perspective, Agamben suggests, we should contemplate anew Walter Benjamin's famous dictum that "the 'state of emergency' in which we live is not the exception but the rule."
Agamben's intervention resonated widely enough to provoke considerable commentary, both positive and negative. Within anthropology it contributed to an upsurge in interest in topics like citizenship and sovereignty. As I suggest throughout this work, such political categories fit imperfectly against the actual conduct of a transnational NGO. MSF focuses quite emphatically on life rather than death. Likewise it defines itself through ethics rather than politics and displays only a reluctant and partial variety of mobile government. Still, whatever the relative merits of Agamben's larger argument and the terms it favors, his intervention highlights a critical axis of concern for this study: the complex contemporary politics of exception and the ambiguities of survival. It is in that spirit that I reference these themes here. Questions of survival and exception indeed lie at the heart of contemporary humanitarian action, particularly in its emergency medical form.
Recall that what MSF seeks to save is, most literally, life in crisis. Some crises are more urgent than others, and the most sudden and dramatic ones demand an emergency response. But in all cases the group perceives the recipients of its care to be people threatened by "times of difficulty, insecurity and suspense" in the phrasing of The Oxford English Dictionary. This sense of crisis is not that of ancient medicine (the turning point of a disease) nor the essential instability of capitalism outlined by Marxist economics and celebrated by technological optimists. Rather it designates a more general but categorically exceptional condition of threat. To borrow another of MSF's now well-worn designations, crisis describes the experience of "populations in danger." In responding to their needs the group displays a lavish commitment to health standards and geographic scope, together with a minimal assurance of continuity in place. Given that war exemplifies the political state of exception, to the extent that MSF views its own existence to be exceptional-a reflection of the needless suffering in the world-one might say that the organization is perpetually at war.
The bracelet example cited above suggests the limits within which MSF operates, as well as the tension between its ideals and the means at its disposal. A colored ribbon might indicate the line between life and death for small children and suggest something about the nutritional state of a population, but it hardly encompasses the causes of human suffering. Often, as I try to suggest in these pages, MSF's general project has proved a work of minimalism, finding and highlighting varied and repeated threats to survival. Although particular interventions can appear extravagant, they remain circumscribed and attenuated, a "minimal biopolitics," if you will. The label fits uncomfortably, as this is action conducted in the name of an ethical rather than political vision. Its larger aims remain diffuse and open. The group's rhetoric routinely denounces threats to human dignity and occasionally suggests life as a longer arc. It does so, however, by claiming an exceptional, humanitarian ground, at once overarching and rigorously specific. The humanity of "populations in danger" remains ever embodied, not an abstract figure. Nonetheless I retain the reference to biopolitics here, not only because of the equipment and expertise MSF deploys (along with its effects), but also because of the form of political conscience it reveals. By responding to perceived state failures, the group asserts a strikingly clear vision of what any functioning state should do: foster life.
Designating MSF's activity as minimal biopolitics suggests a simultaneously attenuated and affirmative variation on the theme of Foucault's biopower. Such action constitutes itself negatively, directly resisting the sovereign right to kill. Rather than seeking control it demands governance by others, even as it provides a limited form of medical care. Unlike the emerging nation-state or Agamben's transcendent sovereign, MSF never names an enemy who must die to save the population, nor does it designate any death as being beyond sacrifice. If rebellious in attitude, it resists the violence of revolution along with the responsibility of rule. The only aspect of sovereignty the group claims is the Schmittian capacity to define an exception, in the sense of independently determining who is in crisis. Responding to those in crisis, it cannot deploy the full panoply of experts and technologies now associated with wealthy states; its action remains limited as well as medically focused. Yet it also marks a baseline, a minimum for moral legitimacy. That is the extent of its politics. In effect MSF dreams of a warmly nurturing state, one that would not designate exceptions or differentiate between those who should live or die. It would extend this dream worldwide to include all populations, sans frontières. But the group's own action does little to achieve such a utopian vision, beyond highlighting its continuing absence. It seeks to remain a minimal and temporary response, not the basis for a new regime.
Judging from its self-conception, MSF remains singularly untroubled by contradiction. The sociologist Rénee Fox aptly describes its overall vision as a "nonideological ideology" loosely based on the French legacy of the Rights of Man but directed against both abstract idealism and the existing order. As we will see in the next chapter, the term ideology may imply a greater degree of coherence than the historical record. The he group has grown, shifted, and fragmented, has often been riven by dispute, and has at times reversed course. However, two constants remain: a deeply realist geopolitical perspective and a categorical moral conscience about suffering. Its perspective combines anti-utopian skepticism with a near-utopian sense of engagement, implying close links between reason, emotion, and action. If MSF perceives a significant health crisis in any setting, be it an emergency such as a cholera outbreak among displaced people or a policy issue such as ineffective national malaria protocols, it tries to respond. Significantly, this response almost neverclaims to represent a comprehensive solution or to conform to conventional utilitarian rationales of public health. The majority of its operational programs justify themselves through moral legitimacy rather than through cost effectiveness. By demonstrating what is possible, the MSF doctrine suggests, a technically efficient project can highlight the failures of political will behind inadequate health care and remove the excuse that "it can't be done." Nonetheless, members of MSF rarely suggest that their work will directly build a better social order or achieve a state of justice. The goal is to agitate, disrupt, and encourage others to alter the world by practicing humanitarian medicine "one person at a time."
Before proceeding further with this analysis, I turn to from MSF's theory to its practice and the more complicated terrain of the field. When responding to an exceptional state-even an emergency-the group must first determine whether one exists, and if so, what manner of reaction it warrants. Just as the clarity of conflict fades amid the fog of experience, the certainty of crisis can likewise prove elusive.
A View from the Land Cruiser
A few years after visiting the model camp, I find myself in the back of a white Toyota Land Cruiser, bumping down a dirt track in northern Uganda. The classic transport of international aid organizations, the vehicle carries with it a small store of supplies, a team of field workers, and a connection to a wider world. A large radio antenna sways with each rut in the road, and team members clutch cell phones, checking the fading signal as we travel away from our base and into the countryside. MSF's red and white logo adorns the sides of the vehicle as well as the flag fluttering from the antenna. Another decal shows a rifle inside a slashed circle, emphasizing the unarmed nature of our business. Fittingly enough, this is an exploratory foray of sorts. Over the preceding months, a resurgence of violence in the country's long-simmering war has driven a new wave of people from their homes. MSF responded by launching a new mission in the region. Now that conditions have begun to stabilize in the regional center and a neighboring camp, MSF representatives are moving out to visit and evaluate more remote settlements. In this case we are following rumors of a poor water supply and a trail suggested by cases of bloody diarrhea. Although little fighting has been reported recently, security remains tight. The Ugandan military restricts travel to daylight hours, and MSF is relatively unusual in declining to travel in convoys. Nonetheless, members of the team monitor the airwaves, call in at regular intervals, and keep an eye on the horizon. A few burned-out buildings by the roadside break the monotony of tall grass and scraggly trees. Otherwise there are few visible scars of war.
Traveling with me are an Australian nurse who serves as team coordinator, a Japanese doctor, and two Ugandans, our driver and a logistics assistant. En route we notice a growing stream of people joining us on the road and stop to query a man riding a bicycle. He informs us that the camp ahead of us is scheduled for a food distribution today. By the time we arrive a large crowd has gathered in front of an administration building. Stacks of large white and brown burlap bags line the field, marked with "USA" in large letters and containing a corn-soy blend. At a table in front of the building our coordinator, Mary, meets with the camp leader and a representative of the United Nations World Food Program (WFP). After a few pleasantries they get down to business while assistants in blue smocks wait impassively for direction. The camp leader and WFP representative disagree over the current population. The leader claims that well over 27,000 people live there at present; he's done a survey himself with the head of each camp cell. The WFP representative appears unimpressed and sticks to the number he has received from the Ugandan district administrator, which is closer to 21,000. Mary argues with him, pushing for more service, as she's heard that people return from the distribution without food. The WFP representative remains impassive; to alter anything he would "need to have figures and truth." If there is a discrepancy it is the district's responsibility to furnish new official figures. An informal community survey does not count. Noting that he is an experienced administrator, he intimates that he must guard against any attempt inflate a settlement's numbers. He asks the camp leader to sign that the food has been received in good condition and then returns to his large UN car. Originally from South Asia, he has been in this post for three weeks.
As the distribution begins, our team divides up to get the lay of the land. The doctor will visit the health clinic and the cemetery to gain a sense of health services and death rates. The logistics assistant will inspect the latrines and water supply. Our driver will go shopping to check prices at the local trader. Meanwhile Mary and I begin an impromptu, thoroughly informal nutritional evaluation. Unlike the planned assessment I witnessed earlier at another site, we make no attempts to impose order. As the crowd presses in we walk against its flow, and she simply takes the arm of any passing child, measuring the middle upper arm with the multicolored bracelet. I record the results on a clipboard, filling in small bubbles on a sheet according to the color. Most are a healthy green, but as we walk further we find infants whose measurements are orange and red. In those cases Mary gestures to the bracelet to explain: "Orange getting very sick; red very sick," she repeats loudly in English when relevant. She knows little of the local language and we have no interpreter, but those who have been to school should have had some English instruction and may understand. She tells the mothers to find the MSF car and ask for a small food supplement.
While measuring, Mary also takes note of any other obvious disorders. She sees plenty of scabies, several signs of ringworm, a harelip, and possible cerebral palsy. At times she sacrifices efficiency for attention to specific cases; a child arriving only with her sister poses a problem, since the mother would need to be present to receive food. Mary urges the sister to find the mother, while telling her that vaccination is very important. We continue down the road meeting and greeting all available babies, really looking for the most vulnerable. As well as measuring their arms, Mary presses their feet to check for edema related to malnutrition. She catches a little boy who tries to wriggle off while a larger child in a blue shirt stands and stares. She meets a former patient from MSF's clinic in the trading center, calling her by name, and the two chat briefly. Cattle move among the people and an overloaded bicycle totters and crashes, to the amusement of passersby. The crowd streams on and on, and yet these are only a few of the camp's many residents. At last we reach the meeting point and find our vehicle. The other team members arrive and give their reports.
The driver informs us that there is a small market in the camp, its modest supplies selling at a markup. Informal transport leaves to a larger settlement once a day, but the high fare renders it a luxury for most residents. The settlement has four wells, but the chairman of the water association charges people to use them. When people cannot pay or the lines are too long or the water runs out, then they walk to the water hole, which is free but contaminated. Action Aid apparently works with the WFP here and UNICEF supports the health center, but otherwise the camp has received little international and even less governmental assistance. The doctor adds that the health center sees 60-70 patients a day, more than a quarter suffering from malaria. There are also reports of vomiting and gastrointestinal problems; and he announces with some satisfaction, "We have found our bloody diarrhea place." He and the logistics assistance both concur that water supply is a serious problem here. We all walk to the water hole, which proves to be little more than a muddy roadside puddle. Nonetheless, we find a throng of people using plastic cups to fill their jerry cans. The team takes photographs to use as evidence and on the way back to the car discusses the possibility of intervening. Water and sanitation are clearly the priority; perhaps MSF might assist WFP with a supplemental feeding center or work in the clinic, but only if the evidence supports it.
We return to the site of the food distribution, which is still in progress. People stand patiently in line to receive maize, oil, beans, and salt. Several of the mothers Mary enjoined to see us show up for their child's supplementary ration. Others crowd around the car, some with requests or complaints, others silently watching. A woman from a neighboring camp has somehow managed to get food at this distribution and looks hopefully for a ride. The driver ignores her. MSF will only carry patients and allows no one to clamber up on the roof. Mary does offer one mother transport funds to bring her severely withered child to the clinic. The logistics assistant advises another former patient to go to the local clinic. Our limited supplies are quickly exhausted and we head for home.
On the way home the doctor rests in the corner of one seat, closing his eyes and listening to music on earphones. Mary and the two Ugandans (who happen to share the same name) strike up a bantering conversation. The somewhat disjoined exchange-between bounces and over the roar of the engine-goes something like this:
Jonathan 1: Look! That bird there, you can't kill that one or there won't be rain. That's what our people say.
Jonathan 2: But we lost all our culture, thanks to you whites.
Mary: Hey, that wasn't me, that was nineteenth-century missionaries!
Jonathan 1 [flashing smile]: It's OK, I would choose to change.
Jonathan 2: But there was no big killing then. People rarely died. [pause] Before we didn't eat salt; there are all these new things for our bodies.
The Jonathans go on to tell Mary that there are rumors about the supplies included in food distributions. People only eat yellow corn because they are desperate, and some believe that it is part of a family planning effort to decrease the number of Africans. At another camp there was a riot when the corn-soy mix arrived. People were hungry but refused the mix, saying it caused diarrhea. The WFP switched to whole grain and that was better. Still, distrust lingers like it does with AIDS, which some rumors here ascribe to a foreign experiment. The camp mood remains suspicious, they assure her almost jovially.
The two Jonathans laugh frequently during this journey and like to point out incongruities on the road, such as a priest riding a motorbike illegally without a license plate (many soldiers do as well, one of the Jonathans adds). Such signs of double standards and political corruption are clearly a favored topic of humor. Indeed, the previous evening the entire team had carried on a running commentary about an ambulance donated by the Japanese government to the district hospital. The ambulance, it appeared, now sat idle for want of fuel, while the hospital director's motorcycle never seemed to run out. At one point someone pointed out gleefully that since the doctor was a Japanese taxpayer, he should simply go over and repossess the ambulance! Like most such humor, the joke aired a deeper frustration: the immobility of the hospital vehicle was a sore point for MSF staff, international and Ugandan alike. Routine medical transport fell under the hospital's purview, not theirs. And yet in the absence of an official ambulance, they faced continual requests for rides, which organizational protocol for nonemergency situations and insurance concerns forbid.
Mary has heard much of this before and wants to talk to WFP about encouraging a labor program, providing incentives to build latrines and improve sanitation; otherwise everyone focuses on food. She is clearly disturbed by the conditions in the camp we have just visited and wants to advocate with MSF's higher administration to start a project there. Back in the field office, she and I tabulate the results from our bracelet screening. She calculates the figures generously, rounding up and including all borderline cases, as if seeking support for intervention. The results are indeed discouraging but not obviously dire. In any case this is just a preliminary, informal impression. A convincing case will require a good deal more evidence. Among the many displacement camps in Uganda-let alone worldwide-why should MSF select this one? A grandmother with a full nursing career behind her, Mary has ample perspective and growing skepticism about the larger aid industry. She has already worked for MSF in South Sudan, where, as she puts it, "There's a whole generation that thinks shopping comes from the sky." Her time in Uganda is winding down, and soon she will find herself back in suburban Australia. Yet already she knows that once there, its material affluence will disturb her anew. Health care waste, disposable equipment, an everyday detachment from what she now sees as the real world will all prove unavoidable. Even worse is the display of ravenous consumption that now frightens her in supermarkets. The previous evening she had summarized her last return as a grotesquerie of surplus. "South Sudan didn't even have a plastic bag blowing around," she said. "I went home for Christmas and was horrified. What to give the grandchildren? They have everything." Once summoned to mind, this vision of excess lingers in our conversation. It contrasts starkly with MSF's relatively spartan office, which in turn appears munificent compared to its surroundings. This morning on the way to the camp we had passed little traffic other than a cotton truck, and as Mary observes, you can't eat cotton. Looking at the measurement numbers again, she sighs. "Today," she remarks softly to herself, "makes you want to stay."
Viewed from a field site rather than a model camp, the clarity of MSF's action wavers, overwhelmed by a distraction of details. Even basic needs can prove complex to calculate and reveal an assortment of varied interests. The population of a camp becomes a point of political tension between its leader and the official representative of international aid. Hints of corruption appear in the form of an idle ambulance or a missing license plate. The head of the local water association seeks to profit from controlling a basic resource. History appears in the form of offhand references to tradition and colonial rupture. Rumors circulate among camp residents, who prove to have strong opinions about what is and what is not edible. Moreover, "aid" involves many discrete activities, and organizations rarely work in isolation. Entrepreneurs and traders move along the same roads that carry state officials, soldiers, and relief workers. MSF's representatives fumble their way through this varied array, gathering information and dispensing advice, whether requested or not. They follow procedures but also improvise. They also have significant capacity on a local scale. In the above case, should MSF commit to the project, the team could easily alleviate the camp's water supply problem by building a system of pumps and storage bladders. Team members could set up a supplemental feeding center to treat small children at risk of starvation. They could staff the clinic and provide excellent medical care or support and train such personnel as are already there. But at the same time, they have limits. They recognize that their organization cannot provide such assistance to every camp in the country, let alone the world. And the longer they stay in place, the more they risk becoming a fixture and fueling dependency. Even as they contemplate intervention, they know their organization will eventually seek to get out. All in all, the question of whether and how to act looks considerably less certain on the ground.
An Expansive Horizon
So far I have focused on emergency response and MSF's classic venue in and around refugee camps. At the time the group received its Nobel prize, it was also embarking on two ambitious and interrelated ventures: a commitment to offer treatment for victims of AIDS and an effort to advocate for greater access to medicines worldwide and foster pharmaceutical research on unprofitable diseases. Both the new AIDS program and the Access Campaign would alter the organization's profile and test its assumptions and procedures. They also illustrate the elasticity of the concept of crisis and its increasing extension beyond medical understandings of emergency. The HIV virus or an inadequate drug supply could certainly threaten a population and create what appeared to be exceptional circumstances. But neither fit easily into a delimited timeframe or invited techniques of rapid, mobile response. Here the crisis affecting life proved patently chronic and even structural in its scope.
The inclusion of nonemergency work in MSF's portfolio was not itself novel, but rather an alternative path present from the outset. As the group grew, it stressed innovation and took on fresh concerns. Unlike the Red Cross, it had no specific mandate or legal status beyond its internal charter and articles of incorporation. Led by an ever-shifting array of personnel and deeply infused with an oppositional ethos, the group's organizational structure fostered never-ending experimentation and critique. Many initiatives would prove short-lived, withering with the departure of key visionaries or eclipsed by later events. But over time MSF came to sponsor missions far beyond classic emergency responses to war or natural disaster. Although emergencies continued to define the group's public profile and sensibility, its definition of what constituted a crisis expanded to include problems such specific diseases and disenfranchised populations, conditions unlikely to be resolved quickly, cleanly, or conclusively. The Belgian section of the organization, in particular, flirted with sponsoring development projects, and even the French took on what they euphemistically called "longer-term" missions. Initially skeptical of offering mental health care, the group as a whole increasingly included it into its operations and later followed the aid world trend of drawing attention to gender and sexually based violence. MSF's sense of humanitarian crisis proved readily expansive.
MSF's Activity Reports provide a sense of the group's broader practice, so to situate the field anecdote above I turn to the 2003-2004 edition. As usual the volume contains not only a country-by-country synopsis of all projects, but also a world map, organizational statistics, a number of reflective and critical essays on humanitarian issues, and a carefully selected array of black-and-white images featuring aid workers and afflicted populations. It reflects, in this regard, what the sociologist Craig Calhoun terms "the emergency imaginary." As the essays in the report indicate, at the time MSF recognized a series of significant challenges. These included the rise of military humanitarianism, which the group blamed for the recent death of five staff members in Afghanistan; an increasing focus on cost recovery, which it suggested favored macroeconomic theory over human life; and the emerging disaster in Darfur, to which it responded with a massive operation and publicity blitz, if stopping short of calling the situation genocide. In addition, the report highlights regional issues related to HIV/AIDS in Africa, tuberculosis control in Asia, and the plight of recent immigrants in Europe.
Alongside these general concerns, the statistical record suggests both clear patterns of geographic concentration and a considerable variety of topical focus. MSF's projects stretch worldwide and go well beyond emergency response. In 2003-2004 the group maintained a presence in seventy-seven countries: it had thirty-two missions in Africa, twenty-one in Asia, thirteen in Europe and the Middle East, and eleven in the Americas. The prevalence of Africa grows even clearer in monetary terms. The continent accounted for nearly 70 percent of the organization's program expenditure that year and four of its five most expensive programs, led by the Democratic Republic of the Congo and Sudan. Of the twenty-two programs with expenditures over three million euro, only six lay outside Africa: in Afghanistan, Chechnya, Iraq, Myanmar, Cambodia, and Russia. Not all of these major programs, however, concentrated on immediate emergency relief. In post-conflict settings like Angola, MSF treated malaria patients while lobbying to change government protocols, and in Liberia and Burundi it had begun new initiatives aimed at combating sexual violence. In Kenya and Malawi it focused on AIDS, providing antiretroviral therapy. If not matching the scale of operations in the Congo or Sudan (each of which involved over two hundred foreign and several thousand local staff), in the aggregate, nonemergency programs constituted a majority. Outside Africa, missions tended to be smaller and the projects even more varied. For its efforts to combat AIDS and malaria in Thailand and Cambodia, MSF deployed only a tenth of the personnel it had in Sudan. In Nicaragua it targeted Chagas disease, and in Uzbekistan multidrug-resistant tuberculosis. In Burkina Faso and Guatemala it sponsored psychological counseling for street children.
Even this quick survey of MSF's worldwide activity underscores the extent to which the organization's sense of crisis extends well beyond the refugee camp. A similar expansion of concern is evident in the American section's annual list of top ten "underreported humanitarian stories." Released every year since 1998, these lists match entries for specific countries with general problems such as cholera, street children, AIDS, drug resistance, access to medicine, neglected diseases, and malnutrition. Such issues reflect MSF's advocacy priorities and its increasing involvement in efforts to alter health policy and even pharmaceutical research. Although stopping short of full political engagement-let alone utopian ideals-such efforts extend beyond the immediacy of charity that David Rieff identifies with Brecht's apt phrase, "a bed for the night." If MSF's annual reports and lists constitute snapshots of an emergency imaginary, then they reveal contours that stretch into longer-term ambitions and structural problems of inequality. Reading several in a row only further clouds the clarity of crisis itself. Missions open and close, problems reappear, dire predictions sometimes do and sometimes do not come to pass. The larger ensemble of MSF offers an empirical map of ethical turmoil related to humanitarian intervention.
There were many sites on MSF's map I could have chosen for my research, some more or less significant by one historical measure or other. I came to focus on Uganda largely through serendipity and old connections. But the choice proved ultimately fortuitous for thinking about crisis, precisely because the term floated uncertainly there, suspended between memories, relative states, and an array of potential problems. For someone of my middling generation, Uganda evoked the name of Idi Amin, who cast an oversized media shadow in the 1970s as the postcolonial cannibal king. His regime might have been long gone, but the country still bore scars, sometimes revealed by continuing conflict in the north. Although Uganda itself had subsequently achieved a measure of stability, it remained surrounded by conflict, in Sudan to the north, Rwanda to the south, and the Democratic Republic of the Congo (formerly Zaire) to the west. Uganda further served as an epicenter of health research in Africa, in part due to its early prominence in HIV/AIDS. An astonishing number of international organizations fielded teams there, their four-wheel-drive vehicles struggling through the dense traffic of mopeds and minibuses on Kampala's central roundabout. Uganda, then, appeared a crossroads of African aid, at the intersection of both space and time.
Most writing about contemporary humanitarianism-by practitioners, journalists and academics alike-focuses on dramatic episodes of extreme emergency and human tragedy. Major disasters like the Ethiopian famine and the Rwandan genocide inspire ample commentary, analysis, and recrimination after the fact. Their significance established, they then serve as landmarks for humanitarian chronology, orienting subsequent problems within a lineage of inhuman events. In this manner they constitute classic forms of crisis, moments that appear as decisive turning points, while collectively suggesting the limits of humanity amid extreme conditions. Nonetheless, a great deal of actual practice by humanitarian organizations responds to less spectacular forms of suffering and more ambiguous contexts, ones that might or might not represent states of emergency. As in popular portrayals of medicine, the spectacular overshadows the routine, suggesting a world of active remedies rather than tentative trials and passive waiting. At the same time, even routine medicine can acquire a virtuous glow when practiced in settings with a surplus of suffering. To treat poor people, especially poor people living in poor countries and afflicted by curable conditions, now exemplifies the moral essence of medicine.
A Real Doctor
During lunchtime at an MSF project in Uganda, one of my companions told a story about a successful plastic surgeon in Southern California. With the national trauma of September 11, 2001, this man apparently underwent a moral epiphany. Recognizing there were more important things than wealth and artificial beauty, he abruptly quit his practice and signed on for a field project with MSF. For the first time, he declared, he "felt like a real doctor." After returning from his first mission he launched into lower-income work at home and continued to volunteer periodically for humanitarian missions abroad. The story sounded second or third hand, and its particularities may have been apocryphal. Nonetheless, the tale captured a core sentiment I encountered again and again, both among people involved in aid work and those dreaming about it. Humanitarian medicine-whatever its realities, frustrations, or technical details-was fundamentally authentic in a way that wealthy suburban practice was not.
Claude, a French physician, had assured me of as much just the previous evening. "In Africa you see real problems," he said authoritatively, "not like in France." We were sitting at the table in his residence, eating dinner after a long day at the AIDS clinic and reflecting on the state of the world. "There it is all much more psychosomatic or small things overblown," he continued scornfully. "In developed countries people enlarge small problems." Life in suburban Europe was too easy, he felt, and as a consequence most patients there had forgotten how lucky they were. Claude waved his fork at the lantern that flickered dimly on our table, his tone hovering between wonder to disgust: "There you just turn on a switch and have light."
A deep sense of moral authenticity pervades MSF and similar aid organizations. Part of it entails a romantic rejection of material comfort and the illusions it generates. As Claude noted, people in wealthy countries ignore the ordinary miracles in their lives, forgetting to wonder at electricity or running water. Moreover, constant surplus dulls their perspective about what a real disruption of life might be like. By contrast, people focused on survival are rich in such awareness and know a real problem when they see one. Their visits to the hospital are more likely to involve matters of life and death, desperation as much as hope. A medical focus only amplifies this sense of touching reality: why treat the pampered and mildly sick when others need urgent care? Practicing humanitarian medicine offers moral liberation to health professionals trained amid excess. "You feel like the essence of a doctor," an American surgeon told me at the outset of my research in New York. Facing a conventional career in the United States, including the need to pay back school loans, she looked back on her experience as a volunteer with wistfulness as another, and perhaps more honest, education. Faced with limited resources, she had learned to rely on her intellect, not equipment. She had also found herself called upon to do everything, not just one specialized task. "It's pure medicine," she concluded, "not defensive, anti-lawsuit, documentation- and court-driven medicine."
The romance of medical authenticity takes many forms in individual lives. But at a collective level it defines the very core of common purpose for many adherents of MSF. A veteran Dutch nurse I met on my first visit to the Amsterdam office confessed that he had actually first joined the group simply to see the world. Over time, however, he had gradually transformed into a true believer: "What is MSF about for me? That people don't die of stupid things ... Kala azar [visceral leishmaniasis] in Sudan, example: a black-and-white disease with a simple treatment. Malaria, cholera, sleeping sickness. Not only wars, but also simple things; this is the essence of refugee health care. Whatever the political issues, if people flee they shouldn't die of malaria."
I would encounter the phrase "stupid things" many times, both in MSF and throughout the world of international health. Whatever else humanitarianism might signify for medical professionals immersed in it, it stood for the possibility of bringing need and care more closely in line, treating the treatable, and rejecting other considerations that might interfere. In MSF's case the adjective stupid bluntly delineated a terrain for action, sites where a minimal biopolitics of care might achieve immediate effects.
The degree to which the group identifies with both the possibilities and limits of the medical profession becomes equally clear in moments when the prospect of clinical attention redefines the situation. As a prominent figure within the French section of the organization suggested to me, medical personnel can claim a privileged perspective when it comes to facts of life:
Doctors can diagnose causes and states. They are the ones who can measure. In Rwanda it was clear we couldn't protect the population during genocide. We were told at a checkpoint, you can fetch the wounded and we'll kill them here. But afterward, in prisons, life expectancy was six months, while the wait for trial something like ten years. So you had death before trial. Now who can get into prisons? Those who work there and those who work in health. So medical personnel can perform a diagnostic of a situation. It's a different angle than that of "they're all génocidaires" (which many were, of course). We can view each of them as individuals, talk of people and their life chances, pathologies, and so on. It's a way of medically objectifying the political situation of why people are not living. It's about human facts, and not questions of philosophy, law, and the like. The doctor can speak of the sick, of a precise person and not in generalities. It's always individual-not talk of [abstract] desirable things, but of life and death. Doctors can talk in mortality rates.
Although not a doctor herself, she saw that professional legacy - particularly the clinical tradition of focusing on specific cases and the precision of health measures - playing a central role in the group's collective persona. Claiming medical authority permitted not only access, but also a means of speaking that could redefine a situation by objectifying it, placing the ethical focus on considerations of individual existence.
In this sense the organization's name ultimately proves revealing. The complicated material and rhetorical assemblage of Médecins Sans Frontières does translate into an enacted statement of sorts, loosely characterized as "doctors yes, borders no." Such a statement distorts even as it reveals: the group's operations involve far more than doctors, and the original name intended to imply liberation from boundaries, not their eradication. However, the claim "doctors yes, borders no" also reflects the core motivation for MSF's volunteers and supporters: the opportunity to participate in the moral essence of a medical career. What could seem purer, more certain than responding to obvious need?
The Allure of Simplicity
Crisis is seductive in its very conception. The term descends from a Greek root for "discrimination" or "decision" and implies a condition of instability or a moment of decisive change. Within crisis, time contracts and one inhabits the present as intimately as possible-the "immediate present." Language likewise reduces to the imperative mood, with exclamation: Do something! In this respect, crisis is the purest environment for a technical expert, a context in which expertise can and clearly mustengage with the immanence of problems. It is also the natural habitat of a moral witness, who acquires the capacity to give testimony by virtue of presence. One can both act and know by being somewhere at just the right moment.
For MSF, emergency missions go straight to the heart of crisis. Within the temporary shelter of a refugee camp, the group can (in theory at least) reach those near the edge of existence and provide them with urgent care. The appeal is vivid and direct: obvious suffering, critical need, a world of "black-and-white" diseases with simple treatments. Amid a world of political failure, disillusion and disappointment, the time of emergency offers moral clarity. Facing obvious rupture and lives at risk, medical action appears a natural and noble response. Like legal refugees-who are not just displaced, but have crossed a border-emergencies stand apart from everyday life, delimited from other problems. In real refugee camps such a distinction proves far less clear. We should not forget the small, complicating facts that linger even in the direst circumstances: the little treasures still secreted by those who "lost everything" at an earlier point in their story; the traces of memories that outlive bodies; the babies born during wartime. Moreover, as lives continue they quickly reacquire their complexity. Studies conducted in refugee settings suggest the power of the camp to both retain and sharpen moral political narratives and foster transformations over time. When examining experience in detail, displaced people are rarely reduced to a pure state of merely living. Nonetheless, it has grown increasingly easy to imagine them in precisely such terms. Emergency provides a broad template for the political framing of problems, even as states co-opt the rhetoric of humanitarian appeals.
Even if medicine enjoys no monopoly on emergency, it provides a critical frame for its contemporary definition. At present it is hard to conceive of the term, or associated ones like accident, without expecting a response. In a society that measures health through risk and produces first-aid kits for even small calamities, life-threatening events naturally demand medical attention. However, neither the hospital emergency room nor the civilian ambulance, let alone the vast complex of artifacts we now associate with them, is all that old. Indeed, the concept of medical emergency itself may only have crystalized during the First World War, when the crushing reality of that destruction brought a complex of associated concepts into alignment: accident, ambulance, asphyxia, reanimation, resuscitation, shock, sudden death, and trauma. The ambulance was an older instrument in warfare, named for the "flying" version of battlefield treatment pioneered by France's chief surgeon during the Napoleonic wars, Dominique Larrey. If operating under a different conception of medicine, Larrey nonetheless advocated for the paramount importance of timely response, establishing a template for urgent care. During the long end of the nineteenth century ambulance societies began to respond to everyday problems in the industrial landscape. Only in the later decades of the twentieth century did organizational forms from military medicine translate into systems of emergency services common to wealthy countries. An ethos of war entered civilian life, as it were, through rapid medical care.
The advent of Médecins Sans Frontières marks the extension of such an emergency sensibility worldwide. The group is hardly alone in pursuing this goal, of course, but it embodies the fundamental principles of urgency and action and seeks to provide global response. At its most fundamental level of justification it operates under an ethic of crisis, pursuing the good during moments of exception. The organization further expresses an ethos of crisis with its imperative atmosphere and an aesthetic of crisis with its breathless imagery. Most significantly, it refocuses political and economic problems through a medical prism. When doing so it both participates in the tendency of the larger historical moment and struggles to distinguish its particular form of response within it.
Although some of its elements may be very old, the configuration of "humanitarian crisis" now common to international affairs appears more recent. Like the discourse of human rights, it emerged with new force in the 1970s. While more utopian framings for political history eroded-notably class struggle and anticolonial liberation-suffering appeared as a new point of moral reference. The articulation of a private humanitarian conscience within international affairs promises simplicity and certainty. By recognizing suffering and finding it unconscionable, groups like MSF assert moral clarity amid the grayer realm of politics. "If someone's drowning, you save them," one adherent told me in Uganda, describing her own conversion to humanitarian work. If uncertain about the universality of human rights, she knew she cared about the dying. The stark line of existence offers lucidity. Unlike utopian dreams it proves directly relevant, while providing a grounds for judgment as well as action. One can distinguish between positions and policies in terms of the effects they have on life and death, and-once properly equipped-respond to ameliorate them. MSF's version of humanitarianism frames its work in an anti-heroic mode ("It is a depressing world," another member told me in Amsterdam. "We do this because we don't know what else to do"). Nonetheless, the group's forceful tone and emphasis on action cast it in a heroic role. Faced with intolerable conditions it endeavors to respond directly, refusing to stay silent or to sacrifice the present to a longer perspective.
Moral clarity, however, can come at a price, particularly if unaccompanied by reflection or doubt. Functioning as politics, amid political expectations, humanitarianism's moral force threatens to erode into reactive moralism.Divorced from a particular sense of knowledge, it is easily co-opted and its rhetoric redeployed by established interests. As Didier Fassin astutely observes, humanitarian intervention can dispense a soothing balm of self-satisfaction, the intoxicating assurance of being humane. Its most concentrated form can justify military adventure, not simply as part of a longer lineage of moral crusades and just wars but as a political and legal claim to a post-sovereign norm in international relations. Much like the language of humanitarianism itself, a right to intervene can serve as a principle for the expression of power as well as a source of moral opposition to that power's inhuman effects.
The Problem of Critique
Here etymology again proves instructive. The root term for crisis, Reinhart Koselleck reminds us, once included the act of rendering judgment, as much a subjective exercise as any recognition of objective reality. An ethical perspective, then, should recognize the claim of crisis around emergency, involving critical reason alongside reaction. Critique too has a history, which Koselleck strongly identifies with the European enlightenment response to an absolutist state and the rise of bourgeois society. In that context the critic could stand apart as a moral sovereign and appeal to utopia. The results were not all salutatory in Koselleck's larger analysis, resulting in a division between moral and political spheres, to the detriment of the latter. An unreflective critic now spoke to the political world by passing judgment, without enduring conceptual risk. Amid the continual crisis of modern conceptions of history, such judgments secured themselves in the future, forever exempt from the imperfections of present action. Turning points and choices might punctuate time, but the critic judged at a safe remove, detached by certainty.
By contrast, conceptual risk requires not only recognizing the burden of decision inherent in claims to crisis but also remaining troubled by it. To illustrate I will add a historical thread to my earlier theoretical allusion. Despite expressing frequent misgivings about the category of the intellectual, Foucault clearly functioned as one in the French terms of his era. A central expectation of that role was to speak at moments of crisis-events of apparent political significance. The turbulent atmosphere of the 1970s offered many opportunities for such public performance: marches, statements, study groups, letters of protest, and expressions of solidarity. It also, however, introduced a greater measure of reflection and doubt. Following the abortive upheaval of 1968, decolonization, and the increasingly obvious impurities of state socialism, it grew harder to maintain inherited categories of ideological struggle. Foucault's later writings on ethics indicate a restless desire for continual interrogation, a politics capable of animated skepticism. Discussing a volume entitled The Age of Ruptures in 1979, he called for an "ethic of discomfort" in the face of revolution as well as rising conservatism. Beginning with Immanuel Kant's confrontation of enlightenment, the text closes with a nod to Maurice Merleau-Ponty, suggesting that the essential philosophical task is "never to consent to being completely comfortable with one's own presuppositions."
The son and grandson of surgeons, Foucault's connection to medicine ran biographically as well as conceptually deep. Most tellingly, he wrote about life and politics in the same milieu within which Médecins Sans Frontières emerged. Like a number of prominent French intellectuals of the day, he joined several of Bernard Kouchner's public campaigns during the period, notably traveling with him to Poland to deliver medicines in support of the Solidarity movement. Shortly before his untimely death, Foucault apparently expressed a desire to go on a mission with Kouchner's successor organization, Médecins du Monde. Noting such connections is not to collapse significant differences between the two men (the latter of whom fully and fatefully embraced the life of a politician), let alone between a practice of critical thought and that of humanitarianism. However, it does underscore a certain confluence of desire-the desire to act, to tell truths, to find virtue in opposition-as well as theme. In an era of ruptures and disintegrating certainty, medicine became an influential referent for politics.
MSF too pronounced its own ethic of discomfort of sorts in accepting the Nobel Prize. This discontent may fall within the narrower limits of evaluating the good relative to a humanitarian precept of life. Nonetheless, it seeks a form of moveable action, if not moveable thought. In an effort to provide a minimal definition of humanitarianism at the end of the cold war, the group pointed not only to the preservation of life and human dignity but also the need "to restore people's ability to choose." Framed in the language of liberalism, this statement posits autonomy and choice as natural conditions, if not necessarily individual ones. The assertion also places the legitimate center of politics elsewhere, beyond the reach of a humanitarian organization. If the stakes of crisis are ultimately those of assessment and decision, MSF refuses a full wager. "Humanitarian action comes with limitations," the Nobel address warns repeatedly, adding, "It cannot be a substitute for political action." Just what form this politics might take-beyond preventing genocide-the group cannot say. Medicine offers an array of temporary specific measures, not a lasting, general prescription. Over time it might also have to adjust to its own effects.
MSF prides itself on fostering an internal culture of reflection, debate, and critique. Publications that circulate in-house regularly feature confessions and denunciations as well as jokes and cartoons. One of my favorite drawings addresses the group's reputation for arrogance and knee-jerk opposition. In it a young woman asks a grizzled aid veteran how MSF manages things. "Oh, not like that!" he replies airily. "Not like that either! No, no, not like that!" When she repeats her question he finally responds, "Well, not like that but better! Another question?" The humorous deferral reflects a deeper tension: within a world of crisis and an ethic of refusal, it is hard to say more.