The sound of silence in humanitarian work

Witnessing” and speaking out (témoignage) are important aspects of the work of Médecins Sans Frontières. As MSF celebrates 40 years of “independence,” this book also discusses the “sound of silence,” the necessary compromises MSF has made with repressive governments to allow it to do its humanitarian work. Eighteen contributors reflect self-critically on the costs and benefits of difficult choices using stories and clear helpful regional reference maps from Sri Lanka, Ethiopia, Yemen, Afghanistan, Pakistan, Somalia, the Gaza Strip, Myanmar, Nigeria, India, South Africa and France.

The ethical questions explored include: What principles should be open to negotiation? And how can MSF protect the organization’s mandate to judge for itself the “blurry but very real line beyond which assistance for victims imperceptibly turns into support for their tormentors”? At times, different branches of MSF have justified different choices. In Myanmar, the French left and the Dutch stayed on, changing their name to do so, and treating one million patients with tuberculosis, AIDS and malaria in one year. The Swiss spent four years getting permission to work in one region in Myanmar, then left the work to another nongovernmental organization when they discovered they had insufficient patient volume.

This book also provides an important context for international aid. The fact that malnutrition among infants and children under three is increasing in India in spite of increases in per capita income, shows social inequities persist and demonstrates the fragility of health progress in that sociopolitical climate. Even more delicate are the negotiations in frankly political situations such as the Gaza strip, Darfur and corrupt states in Nigeria.

Image courtesy of C. Hurst & Co. Publishers Ltd.

This highly detailed book outlines the evolution of MSF’s underpinning ideology from neoconservatism to liberal internationalism, and the evolution of all of us working in international health. MSF’s position at the interface of these developments, including its political roles (lobbying for access to cheaper antiretroviral drugs) and crisis management (such as responding to natural disasters), is carefully critiqued.

Many of the stories are fascinating and compelling; this is clearly an insider’s look at history. However, I found much of the argumentation too long and the historical minutiae too intimate to maintain even a committed reader’s interest. In part, this may relate to the fact that much of the book has been translated. In addition, only an e-book was available to the reviewer, and given the dense and intense content, I would have preferred a print version. That said, this is an important book and reveals a high level of self-criticism within the organization, which is welcome.

The book comes at a time when MSF has just withdrawn from many years of engagement in southern Sudan. Reading this book I found it possible to imagine the behind-the-scenes negotiations that must have led to this difficult decision.

I would have liked to have seen more linkages to the comparable choices that all of us engaged in global health have had to make. When do development partners cut off aid if corruption is uncovered? Does this harm the innocent poor while those responsible may go unpunished? Do sector-wide supports to health make it more difficult to target priority spending and to engage non-state actors such as churches and non-government organizations? The world of MSF doesn’t delve into broader equally important negotiations, with male governments for women’s health, for example, or with dominant cultures for ethnic minorities’ rights to services.

I hope that this careful documentation will be a signpost for others to assess their tough choices. The leadership MSF has shown in making decisions so it can best serve its target groups is important given that many others engaged in the international arena are juggling their own political and economic self-interests in their humanitarian negotiations. This adds complexity to the choices that have to be made. This book helps to define and to highlight the true humanitarian space that primarily addresses the needs of others. It’s a welcome change.